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Se Eusoti:‘tbutions to the Diagiosis of Empyema, with

Cases. By Roper L. Mac Downe LL, Licentiate of the
Royal College of Surgeor reland ; Demon tor of Ana-
tomy in the Medical School, Park-street.
“—.m
Tens is not, perhaps, a subject connected with the’progress of
modern medicine more remarkable than the fact, that the sources
from which the diagnosis and treatment of some of the most
important diseases are derived, have had their origin from one
or two isolated but well observed examples of these particular —
affections. And in some instances, no doubt, they were recorded,
rather as being curious and interesting in themselves, than with
the expectation that they would throw light upon the obscure
class of diseases to which they belonged. Thus, for instance,
our knowledge of the diagnosis of Abdominal Aneurisms, dates
from the publication of the case of Mr. M, recorded by Dr.
Beatty ;* we knew nothingof the positive diagnosis of Pericarditis

* Dublin Hospital Reports, volaw.

VOL. XxV. NO. 73. B
2 Mr. Mac Donnell’s Contributions to the

previous to the appearance of Dr. Stokes’s paper on the subject,*

though Collin and Latham had previouslymentionedthe very signs
upon which the diagnosis is founded. We were equally igno-
rant of the symptoms and signs peculiar to Cancer of the Lung
until Dr. Gravest recorded his interesting case. Our familiarity
with diffuse inflammation, phlebitis, and that particular category
of affections, commenced with Dr. M‘Dowel’st memoir on Puru-
lent Periostitis; and our knowledge of the phenomena of Glan-
ders in the human subject had its commencement in Dr. Elliot-
son’s§ paper. Many more examples might be quoted in illus-
tration of this view, and it is to be hoped that the cases I am
about to detail, will form the nucleus, around which others of a
similar nature will be gathered, so as to constitute an additional
feature in the diagnosis of thoracic affections, particularly those
presenting the symptoms of Empyema or of Encephaloid dis-
ease of the lung.
The opportunities I have possessed, both as a student and
practitioner, for some years past, of investigating chest com-
plaints, have been very considerable; - a great portion of
that time I have beenengage clinical assistant to my kind
friends, Drs. “‘Gtaves and Stokes, in ibe medical wards of the
Meath Hospital, where, in the practicee of theformer gentleman,
many of the cases occurred, upon which the observations to be
met with further on, were instituted, and I am indebted to his
well-known liberality for permission to lay them before the pro-
fession. As these observations are not based upon theory sup-
ported by ingenious argument, but are the result of careful
bed-side investigation, it is hoped that their claims to be con-
sidered as “‘ contributions to the diagnosis of empyema” will be
submitted to the same test.
Though I am well aware of the great inconvenience arising
from the introduction of new names into medicine, and from
atl gd Soha LOU a eS eee

* Dublin Journal of Medical Science, vol. v.

+ Ibid. vol. iv. ¢ Ibid. vol. ili.
§ Med. Chir. Transactions, vol. xvi.
 Diagnosis of Empyema. 3
the frequent changing of those already in use, yet I do not think
that any other would accurately convey an idea of the nature of
the three first cases than that of ‘ Pulsating Empyema of Ne-
cessity,” which both expresses the great peculiarity of each,
and with the exception of the word pulsating, is merely the
revival of a term, which until very lately was employed to ex-
press the bursting of an empyema outwardly.
Case —Pulsating Empyema of Necessity. 4 large Tumour
appears in the Cardiac Region, which after pulsating for
some time, becomes red, tense, and shining, and then bursts,
giving Exit to large Quantities of Pus; Death; Post
Mortem. |
A woman, aged 28, of dissolute and abandoned habits, was
admitted into the Meath Hospital Sept. 6. It appeared from
her statement that she had been labouring under symptoms of
acute pleuritis for two months, for which she was actively treated.
When admitted she was greatly emaciated, suffered from pain
in the left side a little below the mamma ; she had cough, with
bloody streaks through the expectoration, and inability of lying
on either side, decubitus being for the most part on the back.
Her pulse was 108, small and weak. The physical signs were
dulness of the left side, commencing a few inches below the
clavicle, and extending downwards both before and behind;
the left lateral region was likewise dull; total absence of res-
piration all over this dull portion; the upper part of the left
side, both before and behind, was clear on percussion, with
bronchitic rales accompanying the respiratory murmur, The
lower half of the sternal region was completely dull, and here
the sounds and pulsations of the heart were more intense than
in any other situation. The whole of the right side of the chest,
both before and behind, sounded clear, and the respiratory
murmur was loud, puerile, and free from rale. There was no
dilatation of the side observed on her admission.
For the next fortnight there was very little change observed ;
on the 21st however the cough again became very troublesome:
 we
4 Mr Mac Donnell’s Contributions to the

and was accompanied by a copious muco-purulent expectora-

tion, and her breath became intolerably foetid; pulse 106, weak
and feeble; respiration 25, and very laboured. She complained
of slight tenderness a little below the nipple, but there was no
discoloration or cedema of the part. On the 26th a small tu-
mour became perceptible, every time she coughed, in the si-
tuation of the pain; it was soft, and exquisitely tender to the
touch, but not discoloured or cedematous. On the 28th, bron-
chitic rales were very intense in the right lung, and those in the
top of left lung were much increased; the expectoration had
become quite purulent. When she reclined to the left side the
tumour became greatly enlarged, but receded when she lay on
the right, and had a distinct fluctuation. On the 30th the tu-
mour had extended considerably, and the expectoration was
still purulent, and very copious. Pulse 108, and weak,
From the lst of October till the 15th, she suffered severely_
from incontrollable diarrhoea, and was reduced to such a state
that her stools were passed involuntarily. The tumour had
greatly increased, and was now about the size of an orange, it
was red, shining, and fluctuating, and had a strong diastolic
pulsation, which did not convey the idea of being tilted forward
by a pulsating body, as occursin the case of tumours lying on ar-
teries, but it was of an expanding character, and in every part the
pulsation was equally strong. Though frequently examined
with the stethoscope the least trace of bruit de souffiet was
never discovered ; nor had it. the peculiar thrill so frequently
felt in aneurisms. On the 2lst she expectorated about a
pint of green pus, and the bowel complaint received a notable
check. ‘The tumour was still more red, tense, and pulsating,
and on the following day it burst, and gave exit to about
three quarts of extremely foetid pus, and she becameexceedingly
weak. After the evacuation of the pus the sound on percussion
assumed a clear tone. On the 24th the respiration in the right
lung was again healthy, and free from rale. The tumour had re-
ceded, the respiration in the affected side was just audible, but
 *

Diagnosis of Empyema. 5
without rale. All the metallic phenomena, except tinkling and
amphoric breathing, were present, and the sound on percussion
was quite tympanitic. When the aperture was uncovered a pe-
culiar rustling or whistling noise was perceived at each inspi-
ration. From this time she began to rally, her strength in-
creased, the diarrheea ceased, and the purulent expectoration
diminished, and she was able to sit up all day, the pus con-
stantly trickling from the fistula which remained open, and for the
next six weeks she had periodical discharges to the amount of
two or three quarts every ten days or so. At last her strength
again failed, the cough increased, the pulse became quick, but she
remained free from sweating. The clavicle and spine of scapula
of the affected side became gradually dull, accompanied with
feeble respiration, mixed with crepitating rales. The day be-
fore her death, which occurred on the 15th of December, a dis-
charge of nearly three quarts of green and foetid pus escaped
from the fistula.
Post Mortem Examination.—The right lung was in every
respect healthy, zot the least evidence of bronchial inflamma-
tion in any part of it. On the left side of the chest being
opened, the lung was found bound by adhesions to the ribs, for
about two-thirds of the pleural cavity, and the remaining third
i. e. between the compressed and shrivelled lung and diaphragm,
was an empty cavity. ‘The lung was also bound down to the
spinal column by two strong bands of adhesion, and its inferior
lobe was found red and carnified. The sac of the abscess passed
behind the lung also, to a considerable distance; it was coated
with a thin layer of organized lymph. The upper lobe of the left
lung was the seat of numerous tubercles, beginning to soften, the
anterior part of lower lobe was healthy, but the posterior, as be-
fore stated, was solid. The fourth rib was quite carious near its
cartilage, and the sixth was in a similar condition, and the perios-
teum covering both was in a sloughy state. Externally the in-
teguments around the fistula were separated for a couple of
inches from the subjacent muscles. The liver was enlarged to
 *

id

6 Mr. Mac Donnell’s Contributions to the

nearly half its normal size, engorged and full of blood. The
intestines were examined with the greatest care, but no trace of
disease could be discovered.
Case Il.—Pulsating Empyema of Necessity ; two Tumours
appear in the lower Part of left Side, presenting Fluc-
tuation and Pulsation; on being opened purulent Matter
escapes in large Quantities; Death.
About the middle of June, 1842, I was requested by my
friend Dr. Graves to visit A. B., Esq. From the history of the
case it appeared, that three years previously he was attacked
with pain in the left side, cough, and difficulty of breathing.
These symptoms he referred to influenza, which was then very
prevalent, but as they continued longer than he expected, and
left him in a weakened condition, he came up to Dublin, and
placed himself under the care of Dr. Graves, who immediately
discovered that he was labouring under empyema of the left
side. He remained in town for some time, and appeared to be
greatly improved, when urgent business obliged him to go down
again to the country, where, from change of air, and perseve-
rance in the treatment advised, his strength increased, his spirits
became good, and he was so far recovered as to be able to fol-
low his usual pursuits, which were those of a country gentleman,
and even to engage in field sports. For the next two years his
health was sometimes good and at others bad: the cough fre-
quently returned, and the difficulty of breathing and pain in
the side occasionally annoyed him. For these symptoms he
often consulted medical men in his neighbourhood, but it
does not appear that he made them fully acquainted with his
condition, for the remedies employed consisted chiefly of simple
cough mixtures; nor indeed were his habits such as to lead his
medical attendants to suspect him labouring under serious ill-
ness, for, according to his own statement, he used to join in
various amusemeuts, particularly hunting, and frequently has
felt the fluid moving in his chest when going over a leap. So
 Diagnosis of Empyema. 7
little was there in his appearance to excite alarm, that he suc-
ceeded in getting a medical certificate on one occasion, when it
was necessary to have his life insured, for the examination was
confined to the upper and front portion of his chest, and in this
way his actual condition eluded observation. From that pe-
riod till May, 1842, he enjoyed pretty good general health. He
now began to suffer from many of the constitutional symptoms
of phthisis, and was greatly alarmed by the appearance of two
tumours on the affected side, which we shall describe more par-
ticularly farther on, and determined on coming to Dublin and
placing himself again under the care of Dr. Graves. He was
not long in town before I saw him, and his state was then as
follows :—He was greatly emaciated, pale, and haggard; his
pulse was quick and feeble; he suffered greatly from night
sweats; he had aslight cough, without expectoration; difficulty
of breathing, and inability of lying, except on the back. He
was extremely nervous, and, in short, had all the usual symp-
toms of hectic, save diarrhoea.
On examining the chest, two large tumours were observed,
one situated in the spot usually occupied by the apex of the
heart; the other was situated posteriorly, and appeared between
the tenth and eleventh ribs, about two inches from the spine.
Both of these tumours were alike in the following particulars:
they were large (about the size of a Seville orange), soft
and fluctuating, not discoloured, but having a few large and
varicose veins coursing about their bases. They first made their
appearance in the intercostal space, and at the time I speak of,
they both possessed a strong diastolic pulsation, quite visible,
and as strong as that ofan aneurism of equal size, but without
bruit de soufflet or thrill. It was also easy to perceive that a
communication existed between them, for by placing the hand
on one, fluctuation could be felt when the other was tapped:
The integument in the neighbourhood was not inflamed or
oedematous, nor did he suffer any pain from handling the tu-
mours or the parts in their vicinity. Previous to their first
8 Mr. Mac Donnell’s Contributions to the

appearance, he suffered considerably in the above-mentioned

situations, from a constant pain, increased on pressure, or when
the waistband of his trowsers was buttoned ; but this after some
time diminished, and two small tumours, about the size of
hazle-nuts, became perceptible, and soon attained the size
above described. At first they did not possess any pulsation,
nor was it until they were about the size of a turkey egg that
this peculiarity was observed. So much as regards the tumours.
The affected side was not at the time I saw him increased in
size, when measured at a distance from the tumours, nor had it
the well-known barrel shape so common in empyema. It was
completely dull on percussion over its entire extent, except for
about two inches below the clavicle in front, and to the middle
of the scapular region behind. In these situations the respira-
tion was loud, and free from rale, but in every other part of
this side, it was completely absent. The heart had left its na-
tural position (now occupied by one of the tumours), and was
pulsating strongly and visibly to the right of the sternum under
the corresponding mamma. There was no egophony or friction
sound heard over any part of the diseased side.
In consultation with Mr. Cusack and Doctor Stokes, it was
judged prudent to make an exploratory puncture into the
front tumour, the result of which proved that it contained pus.
The opening was now enlarged, and about a breakfast-cup
full of matter drawn off, from which the patient experienced —
considerable relief, and the wound was then closed. For
the next three or four days nothing worthy of note occurred.
Mr. Cusack again saw him in consultation, and on this occasion
the tumour at the posterior part of the chest was likewise punc-
tured, and was found to contain pus of the same character as
the other. He appeared but little improved, his hectic conti-
nued, and an irritative cough annoyed him, and at each cough
a gush of matter took place from the tumour. The pulsation,
though greatly diminished, did not altogether disappear, and
was very perceptible even in the collapsed sac of the abscess.
 Diagnosis of Empyema. 9

The tumour in front, which had been punctured first, was now
as large as before, and presented a pulsation quite as strong.
and it was observed that pressure made on it, tended to empty
that placed behind; poultices were applied for about one
month, during which time it continued to discharge at least a
large breakfast-cup full of good pus daily. The constitutional
‘symptoms, which before were very alarming, now abated; his
appearance improved; the pulse fell down to the natural stan-
dard; the sweating stopped; the appetite and general strength
gradually increased; and his nights were passed without rest-
lessness or uneasiness of any kind, The change in his appear-
ance was not more remarkable than that which took place in
the physical signs. The left side of the chest from the level
of the cardiac region upwards, became less dull, though by no
means perfectly clear, and from being void of respiratory mur-
mur, now presented it, in a tolerably intense degree, accom-
panied both before and behind by a loud rasping frottement,—
so intense, that the patient himself was quite conscious of its pre-
sence, and suffered considerably from it, at each inspiration.
In a few days all this portion which I have this moment stated,
remained rather dull, became almost tympanitic, and from
the fact of a metallic resonance of the voice and cough,
and Hippocratic succussion being likewise noticed, it might
have given rise at first to the suspicion that the untoward acci-
dent of an opening into the lung had taken place, but he had
neither the symptoms which characterize the sudden formation
ofa pneumothorax from perforation,* nor those which indicate
the bursting of an empyema into the lungs; so that it was clear,
that the air which now occupied the place of the pus in the

* «©The symptoms commonly observed are the following: a sudden, new,

and violent pain, with a sensation as if something had given way, is felt in the
lower portions of the side; followed by dreadful dyspnoea, suppression of expectora-
tion, extreme anxiety and general collapse. In addition to these there may be loss
of voice and impossibility of lying on one side.” — Vide Srokzs on Diseases of the
Chest, p. 528,
VOL. XXV. NO, 73. Cc
 10 Mr. Mac Donnell’s Contributions to the

pleural cavity had entered through the external orifice. The

heart, which was, as before stated, completely towards the right
side, had moved to midway between the mammary regions, and
its apex was beating behind the xyphoid cartilage. So far,
every thing was going on well, when unfortunately his landlady
put damp sheets on the bed in which he and his wife slept.
The next morning he had all the symptoms of an acute attack of
pleurisy of the affected side, pain, stitch, difficulty of breathing,
acceleration of the pulse, and the physical signs of an extensive
effusion were again manifested, and the discharge from the open
abscess, which had been gradually diminishing, became again
profuse.* Under appropriate treatment these acute symptoms
were relieved.
For the next six weeks [ was in daily attendance on him,
and I shall content myself with mentioning, that at the end of
that time his health was so much improved that he could dis-
pense with medical care, and was about to return to the country,
when he was arrested for debt, and imprisoned in the Marshalsea,
At this time the effusion was almost removed; the discharge
from the posterior tumour had nearly ceased; the affected side
was beginning to contract, and the inferior angle of the scapula
was considerably tilted out. The sound on percussion was still
somewhat dull, but the respiration was loud, and the heart
occupied the space behind the sternum. The upper part of both
lungs was examined with the greatest care, without discovering
the least evidence of the deposition of tubercle, and as there
was complete absence of pyrexia, a recovery, with of course the
contraction of the side and the usual amount of deformity, was
expected.
Before long, the confinement ofa prison produced symp-
toms which but too clearly showed that phthisis had set in, and

* His wife, who slept in the same bed, was on the same day seized with symp-
toms of violent pleuritis, and notwithstanding that she was treated most actively from
the commencement by Dr. Graves’s advice, she died at the end of a week, with all
the signs of extensive effusion into the left side of thechest, and pneumonia of right
lung.
 Diagnosis of Empyema. 1]
after a residence there of four months’ duration, he was dis-
charged to die of the disease. From the period of his arrest till
his death he was attended by my friend Mr. Newland, who has
kindly furnished me with full details of the course of the dis-
ease; but as these notes have already extended to a great
length, I shall pass them over, merely mentioning that he suf-
fered from hectic in all its varieties. His friends refused per-
mission to make a post mortem examination.
By a strange coincidence, I had an opportunity, at the same
time, through the kindness of Dr. Graves, of examining a some-
what similar case in a gentleman who had been twice under the
care of that distinguished physician. I shall quote the history
of his illness as published by Dr, Croly of Mountmellick.
Case HI.—Pulsating Empyema of Noressity.—Two large
Tumours appear in the lower Portion of the left Side of
Chest, presenting Fluctuation and Pulsation. One of them
is opened, and the Pus escapes in large Quantities; Death ;
Post Mortem.
Case of Jones, Esq. (abridged from Dr. Croly’s ac-
count in the 8th volume of the ‘‘ Medical Press,” p. 138).
He had laboured under an attack of bronchitis, pneumonia,
and pleuritis with effusion. The urgent symptoms were very
much relieved, and he was enabled to resume his usual avo-
cations ; still, however, he suffered from febrile exacerbations
at evening, and his pulse remained quick.* A few months
before I saw him his strength again failed, and his fever in-
creased. ‘The following, according to Dr. Croly, was his con-
dition immediately before he came to Dublin. “ There was pal-
pable evidence of empyema. The side was obviously enlarged,

* Dr. Croly thinks the quick pulse was kept up by the unnatural position of
the heart. In this view I cannot agree, for I have seen numerous cases in which
the heart was under the right mamma, and yet the pulse was quite natural, and
there were neither bruit de soufflet, palpitations, nor other morbid phenomena present.
In this case it indicated the deposition of tubercles.
12 Mr. Mac Donnell’s Contributions to the

with protrusion of the intercostal spaces, more particularly be-

tween the tenth and eleventh ribs anteriorly and posteriorly, the
integuments of which were oedematous and painful, with an
erythematous blush, and conveyed to the touch a sense of fluc-
tuation. Even the patient himself at times experienced the
sound of fluctuation in the chest. He was unable to lie on the
sound side, his usual position in bed being either on his back
or on the diseased side. Respiration was partially audible at
the posterior part of the left lung, along the side of the verte-
bral column. This, however, was rather bronchial respiration
than the respiratory murmur, or vesicular respiration. The
sound on percussion of the same side was dull or tympanitic,
according as the patient assumed the horizontal or erect pos-
ture, varying with the situation of the contained fluid. I dis-
tinctly recognized metallic tinkling on applying the cylinder
beneath the clavicle. This, with the sound of fluctuation on
succussion, were proofs that air as well as matter were contained
within the sac of the pleura; that in fact pleuro-pneumothorax
existed.” Dr, Croly also found that the heart still occupied the
right infra-mammary region ; and the left lung sounded well on
percussion, and remained free from rale. Such was his condi-
tion before his arrival in Dublin.
About the middle of June, 1842, Dr. Graves requested me
to visit this gentleman, whose case bore so strong a resemblance
to that of Mr. B. just detailed. He was then extremely emaciated
and pale, his countenance anxious and haggard, and he was bathed
in profuse perspiration. His pulse was 120, small, and weak;
his respiration 30, laboured. He was sitting up in bed support-
ed by pillows; any other position was sure to induce intolerable
dyspnoea. He complained of the excessive difficulty of breath-
ing, and earnestly intreated that the operation of paracentesis
should be performed. On examining the chest two tumours,
each about the size ofa hen-egg were observed, one occupying a
situation a few inches below the nipple, the other presented itself
between the tenth and eleventh ribs about two inches from the
spinal column. They were rather tender to the touch, a few
 Diagnosis of Empyema. 13
turgid veins surrounded their bases, the integument covering
them was discoloured and reddish, and they both possessed a
well marked fluctuation and a distinct, perceptible, and diasto-
lic pulsation. ‘This latter peculiarity was not only evident to
the touch, but quite perceptible to the eye; and as was noted in
the two former cases, these tumours were completely devoid
of thrill, or bruté de soufflet, and the pulsation had all the
characters that were observed in the two others. The lower
two-thirds of the left side, both before and behind, was com-
pletely dull on percussion, the upper-third was quite tympa-
nitic. In no part could the respiratory murmur be distinctly
heard. When he spoke, or coughed, the metallic phenomena
in the upper portion of this side became painfully developed, but
I did not hear metallic tinkling, and, of course, in his condition,
the experiment of succussion was not repeated. The heart,
both by percussion and auscultation, was discovered to occupy
the right infra-mammary region. The sound on percussion was
quite clear all over the right lung, both before and behind, and
the murmur was in every part puerile and without rale. As be-
fore stated, the operation was urgently demanded by the suffer-
ing patient; and though the case was so unfavourable that a
successful result was not to be expected, yet it was deemed
necessary, as he was almost suffocated, and anxiously looked
forward to relief from its performance. An opening was ac-
cordingly made into the posterior tumour, and a large quantity
of odourless pus was discharged, the entire amount was not,
however, drawn off, and the wound was closed with adhesive
plaster, and soon united. When next examined, the tumour
was found as large as before, and again presented the pulsation
as well marked as ever. From the operation he experienced
great relief for a few days, but again the urgent symptoms obliged
Mr. Morrison, his regular attendant, to make a second opening,
and as soon as the matter began to flow he got ease from the sense
of suffocation. For a little while the patient appeared to im-
prove, but he soon fell a victim to distressing hectic. The body
was examined by Drs. Croly and Hanlon ; and I shall extract
14 Mr. Mac Donnell’s Contributions to the

from the account furnished by the former gentleman all the fea-
tures of interest which the dissection revealed.
Post Mortem Examination.—On raising the sternum, bands
of lymph were seen passing backwards to the right side. An
immense cavern presented itself in the left side of the chest, so
that nothing was to be seen, except about a quart of sanguino-
lent matter lying at the bottom. The sides of this cavity were
lined with a thick coating of lymph, and gave to it the character
of the sac of an immense abscess, across which several bands
of lymph stretched from one side to the other. At first the left
lung could with difficulty be discovered, but it was soon found
lying against the bodies of the vertebrae, compressed, shrivel-
led up, and bound down. It was studded with tubercles
througout every portion of its structure; they had not com-
menced to soften, and no communication could be traced be-
tween any of the bronchial tubes and the cavity before alluded
to. The heart lay to the right of the sternum, its apex being
opposite to the fifth and sixth ribs. A strong band of lymph of
a ligamentous appearance, arising from the anterior mediastinum,
attached itself to the right lung; this, with the adhesion of the
pericardium to the diaphragm, fettered the heart to its abnormal
position. The pericardium was universally adherent to the heart
so closely and intimately, that it could not be separated without
removing the muscular fibres of that organ, whose structure
was pale and flabby ; the valves were all healthy. The right
lung was found quite healthy, not a tubercle was discovered
in any part of it. Dr. Croly accounts for not being able to
trace a communication between the bronchial tubes and the
cavity of the pleura, by the fact that the lung was so much dis-
organized as to prevent a careful examination, It is to be re-
gretted that he did not inflate the lung while under water, by
means of a bellows connected with the left bronchi.

REMARKS.

The three preceding cases are no less interesting than im-

portant, and, as far as I have been able to ascertain, are per-
 Diagnosis of Empyema. 15
fectly new in the history of empyema, there being no mention
made of such cases in any of the recent writings on the disease.
It is worthy of notice that in all three, large tumours presented
themselves in the sftuation usually occupied by the heart’s apex,
and in all, the heart itself was dislocated to the right of the ster-
num; there cannot then be the least doubt as to the source from
which the pulsation was derived, and the manner in which it
was communicated to these abscesses. The heart, pushed out of
its normal position, pulsated strongly and equally against their
walls, and their contents being fluid and of equal density, a uni-
form and diastolic impulse was communicated to all parts
of their surface, more intense, of course, in those situations
nearest the source of pulsation. This accounts for what was no~
ticed in the three cases, that the pulsation did not resemble that
so often observed in tumours lying over large arteries, in which
the motion consists in a mere tilting forward, nor was it like
that which is seen in ordinary abscesses lying on an artery in
which the pulsation occurs, generally speaking, along the line of
the vessel, and is scareely perceptible in any other part ofthe tu-
mour; but it was uniform, expanding, and strong. In the two last
cases, the tumours behind either derived their pulsation from the
heart or from thethoracic aorta, and were from theirsize, situation,
and feeble pulsation, more likely to lead us into error than those
in front. What are the affections with which these cases might
have been confounded by a person ignorant of the actual state of
our knowledge respecting thoracic disease, or who, unacquainted
with their history, had only seen them for the first time? ‘Tho-
racic aneurism, and pulsating cancer of the lungs immediately
present themselves to our view, and on examination we shall |
find that they possess some features in common. When com-
pared with aneurisms we have, in both cases, tumours occurring
in patients, who fora length of time complained of pain in the
side, difficulty of breathing, cough, inability to lie but on one
side ; whose constitutions were exhausted by the protracted and
distressing nature of their complaints, and in whom the outward
progress of the disease was marked by severe pain at a particu-
16 Mr. Mac Donnell’s Contributions to the

lar point, in which, after a time, a small tumour, of a soft

and yielding nature, is observed, which gradually increases in
size, is totally devoid of pain, and presents well marked dias-
tolic pulsation. But, on the other hand,*the history of the
last two cases was that of pleurisy with effusion; their duration
also (three years) was greater than the average length of time
that patients with thoracic aneurisms live,* and at no period did
they experience those dreadful, tearing, and lancinating pains pe-
culiar to the latter disease; and, in addition, many of the usual
symptoms of the affection were absent, such as dysphagia, the
peculiar aneurismal cough, a bruit de soufflett on placing the
stethoscope over the tumour, and a thrill sensible to the hand ;
and as far asI have been able to ascertain, aneurism of the tho-
racic aorta has never presented itself externally in two situations
so widely separated. They were also distinguished from aneurism
in the following particulars: the greater portion of the affected
side was dull, and without respiratory murmur,f yet the pulsa-
tion was only felt in the external tumours, in this respect dif-
fering essentially from aneurisms, in which the pulsation, thrill,
and bruit de soufflet (when present) are most intense at the point
of maximum dulness ; and though by pressure on a bronchial
tube, aneurismsmay prevent the entrance ofair into the part ofthe

* Patients with thoracic aneurisms seldom live beyond two years, and accurate
statistics would probably show that they rarely last out so long. I have seen one
case in which the disease existed seven years. The patient was under the care of
Professor Porter, by whose judicious treatment his life was no doubt prolonged.
In this instance, the immediate cause of death was extensive hydrothorax, the ef-
fect of pressure on the large venous trunks by the aneurismal tumour, and not from
the rupture of the sac.
t Iam aware that bruit de soufflet is not a constant sign of aneurism; many
cases have come under my notice in which it was either absent or intermittent.
At present we are ignorant of the peculiar circumstances which determine its pre-
sence or absence in aneurisms.
¢ Dr. Greene has given the details ofa rare case of aneurism, in which just be-
fore death the entire left side of the chest became dull, owing to rupture of the sac
and extravasation of its contents.—‘* Dublin Journal of Medical Science,” vol. x.
Pp: 362,
 Diagnosis of Emypema. 17
lung to which the tube leads, and thus produce absence of mur-
“mur, yet this portion of lung will yield a clear sound on per-
cussion, thus presenting phenomena altogether different from
those observed in my cases.
These cases, however, establish the fact, that ‘empyema
of necessity” is liable to be mistaken for aneurism, particularly
(as in the first case) when it occurs in the form of one large pul-
sating tumour, and an accurate knowledge of the characteristic
features of the two affections isnecessary, in order to avoid com-
mitting the grievous error of pronouncing an empyema to be an
aneurism, or vice versa. But we do not anticipate so much diffi-
culty in distinguishing between these two diseases as between such
cases as I have detailed, and “ cancer of the lung and medias-
tinum.” At the very outset of ourinvestigation a great difficulty
presents itself, for we cannot avail ourselves ofthe aid derived from
the history of the disease, for in many of the most accurately re-
corded instances of cancer of the lung, the patients evidently suf-
fered at the commencement of their illness from pleurisy excited
by ordinary causes, and followed by empyema, and in other in-
stances where the existence of empyema was not actually disco-
vered, the history of the cases resembled in many particulars
that of ordinary pleurisy. But this fact will be more apparent
by laying before the reader a brief outline of some of those ex-
amples of cancer of the lung, which during life were the most
minutely observed, and after death the' most carefully exa-
mined,
The first on record, which can be of any use in assisting
us in laying down rules of diagnosis, is described by Doctor
Graves.* This was followed by some interesting cases from Hey-
felder,t+ and lastly, Dr. Stokes has contributed others of extreme
value; and in his paper will be found the actual state of our
knowledge, both as to the pathology and diagnosis of this dis-
ease. In some of these cases, there are many symptoms which

* Graves’s Clinical Medicine, p. 792.

+ Archives Générales de Médicine.
VOL. KEV. NO. 7S. D
18 Mr. Mac Donnell’s Contributions te the

are not only common io both affections, but which, before the
appearance of these I have now brought forward, were con-
sidered as exclusively belonging to encephaloid disease of
the lung. In that described by Doctor Graves, the patient
at first laboured apparently under pleurisy ; and this view of
the case seemed confirmed by the following symptoms: “ de-
cubitus on the affected side (the right)—fixed condition of that
side—stitches on drawing in deep breath. The physical signs
were universal dulness, with bronchial respiration all over the
right lung; no rale; no resonance of the voice, diminished
vocal vibration, At the post mortem examination, the whole
right lung was converted into a mass of encephaloid matter ;
pleura greatly thickened and dense. In Heyfelder’s case, the
patient was attacked twice with acute pleuritis. When he first
saw him he was labouring under acute pain in the left side ; stitch
on deep inspiration; inability to lie in any position but on the
affected side. The left side was fixed, and was likewise dilated.
The physical signs were complete dulness all over the left lung,
with absence of respiratory murmur. No cegophony over this
side. The heart was dislocated to the right of sternum; and in
the situation usually occupied by it, there was a soft, elastic
tumour the size of two fists. 'The right lung sounded clear on
percussion, and in every situation, the respiration was puerile,
and without rale. At the post mortem examination, the left
lung was found converted into a white lardaceous mass, sof-
tened in the centre. The external tumour had sprung from
this, and proceeded outwards between the ribs; it was also
softened in the centre, and a direct communication existed
between these two points of softening. Inthe remarkable case
of Mr. J , detailed by Dr. Stokes, the symptoms were at
first, solely those of pleuritis, attended at the commencement by
dulness, occupying only the lower half of the pleural cavity,
but which after some time extended all over the right side; and
this side, which at first was of equal size with the left, soon be-
came dilated to the extent of two inches. In addition to these
symptoms of empyema, he was affected with oedema of the right
 Diagnosis of Empyema. 19
side, and the peculiar varicose condition of the veins of the same
side, upon which Dr. Stokes lays such stress, became very evi-
dent: he lingered on for some time, and died in great pain. At
the post mortem examination, a large quantity of pus, amount-
ing to three pints, was found in the pleura. ‘The lung was con-
verted into a “ solid, heavy, fibro-cartilaginous mass of abrilliant,
white, brain-like colour, interspersed with black spots, of the
diameter of a six-pence each, contrasting singularly with the
white portion.” The liver was “sound, but somewhat enlarged,
and projected about three inches below the cartilages of the
ribs, and at the point of contact with them, presented a very deep
sulcus, such as Dr. Stokes has described in his observations on
the diagnosis of empyema—a condition of the organ evidently
the result of congestive engorgement.
From the short description of these three cases of cancerous
degeneration of the lung, we may observe that they all began
with symptoms of pleurisy. In all, decubitus could not be borne
on any, but the affected side. The physical signs were ex-
tremely like those detailed in my cases; and in one(that by Dr.
Graves) a soft elastic tumour presented itself behind, very close
to where a tumour appeared in two of my cases; and in
Heyfelder’s, a large soft, elastic, tumour appeared in the infra-
mammary region of the affected side, a position which, in my
three cases, was occupied also by soft, elastic tumours. Now,
supposing that these encephaloid tumours (for such they were
found to be) had possessed the pulsation, which every-day’s ob- -
servation shews, that tumours of the kind are extremely likely
to enjoy, how could such a case be distinguished from either
of my two last? The grounds of diagnosis could not be derived
from the history of the cases,—from the sufferings of the patient,
—from the physical signs,—or from the nature of the tumours
(presuming the encephaloid masses had pulsation),—or from
their position, for an empyema may point, and an encephaloid
tumour may form, on any part of the thorax. Nor could the
comparison of the physical phenomena of the two sides of the
chest afford much assistance; for in two cases of the malignant
20 Mr. Mac Donnell’s Contributions to the

disease, and in two of the empyemas, the dulness and loss of re-
spiratory murmur were confined solely to one side. The other
lung possessed clearness of sound on percussion, pure respira-
tory murmur, and freedom from rale. In the third case of
malignant disease, and the first case of empyema, the physical
signs of bronchitis were evident in the lung of the unaffected side,
and dislocation of the heart observed in my three cases was
also present in the example of encephaloid disease by Heyfelder.
But even in these apparently obscure cases, considerable advan-
tage will be derived from an attentive consideration of the points
laid down by Dr. Stokes, as diagnostic between encephaloid
diseases of the lung, and the ordinary affections of that organ.
We have not, for instance, in empyema, the very remarkable va-
ricose and tortuous condition of the venous system, accompanied
by cedema of the chest and arm, occurring only on the affected
side. For though it ismentioned that varicose veins surrounded
the bases of the tumours in two of the foregoing cases, yet such a
condition of the veins is widely different from that alluded to in
Dr. Stokes’s paper, and not likely to mislead the observant phy-
sician. Nor have we the remarkably persistent bronchitis noticed
in the cases by Dr. Graves and Dr. Stokes, and the peculiar ex-
pectoration resembling black current jelly, from its admixture
with blood. In the case by Dr, Stokes, these symptoms were not
noticed at the time the affected side was dilated, but appeared
after it had returned to its natural dimensions ; and the liver was
found protruding beyond the ribs for nearly three inches, though
the sides were symmetrical—a circumstance not as yet observed
in ordinary empyema ; but to this latter phenomenon I shall re-
turn in another place.
These two latter circumstances proved an obstruction to the
intra-thoracic circulation: the return of the dilated side to its
natural dimensions shewed a decrease in its fluid contents, con-
sequently, the obstruction must have been caused either by a
tumour pressing on some of the large vessels, or by an important
alteration in the structure ofthe lung itself.
The next feature from which information, in doubtful cases,
 Diagnosis of Empyema. 21
may be obtained, is the appearance of soft, elastic, and painless
tumours in different parts of the body. These were observed
in three of the cases described by Dr. Stokes, and presented
themselves at a period long subsequent to the thoracic affec-
tion; and ina beautiful specimen of cancer of the lung, exhibited
at a late meeting of the Pathological Society by Dr. Law, a soft
and large tumour of an encephaloid nature appeared above the
right clavicle, shortly before death. From what has been said,
the occurrence of such tumours on the affected side, would
greatly embarrass the diagnosis ; but the situation in which they
form appears to be quite accidental. In Bayle’s and Dr. Law’s
cases, they were situated above the clavicle ; in Dr. Graves’s, one
was attached to the ramus of the jaw, one to the epigastrium,
and one to the posterior part of the thorax ; in Heyfelder’s, one
appeared at the infra-mammary region, and another under the left
clavicle; and a fifth instance of this coincidence of cancer of the
lung, with the appearance of soft, elastic tumours on the different
parts of the body, will be found in Forbes’s “ British and Foreign
Review”—No. xxxii., p.384. The case is extracted from Kerst’s
“ Pathology,” and is a remarkable instance of the latency(?) of
thoracic cancer.
“« The patient was a soldier, nineteen years old, who said
that about three weeks before his admission, as he was walking,
he felt a sudden pain in the ham, and on reaching home, felt a
swelling there, which, in twenty-four hours, increased to the size
which it presented on his arrival at the Infirmary. At this time,
the left knee was much enlarged, but the pain had not increased.
There was swelling as large as a goose-egg in the ham, partly
compact, partly fluctuating, and on a moderate pressure, dis-
tinctly pulsating. Under the notion that it was a false aneurism,
compression was employed for some time; but as the swelling
increased, and the cedema of the leg came on, the femoral ar-
tery was tied; after the operation, however, which in itself was
successful, the tumour continued to grow as rapidly as before:
the patient began to cough as iffrom organic disease of the
22 Mr. Mac Donnell’s Contributions to the

lungs, and gradually sunk. On examining the body, the inter-

nal organs were found healthy, except the right lung, which was
completely converted into a brain-like mass. The tumour in
the ham was fifteen inches long, and twenty-four inches in cir-
cumference, and adhered firmly to the periosteum of the femur
and tibia. On its surface were five sacculi, holding between five
and six ounces of a sero-sanguinolent fluid.” Suffice it to say,
that the tumour presented a well-marked example of encepha-
loid disease, and was curious from the fact that the artery ran
over it, lying imbedded between two of the saccull.
The presence of cancer in any of the other viscera will, like-
wise, it is hardly necessary to say, afford most valuable assistance,
and the persistence of bronchitic rales, not removable by treat-
ment, and continuing after the affected side has returned to its
natural dimensions, constitute a point of dissimilarity of extreme
value; for in every case of empyema I have seen, in which
bronchitic rales existed, they always disappeared as soon as the
effusion began to be absorbed, except in some rare cases, where
the deposition of tubercle was rapidly progressing.
PURULENT EXPECTORATION IN EMPYEMA.

The case first detailed differs in some points from those which
followed, and presents features which demand a separate con-
sideration. The disease ran an unusually rapid course, if com-
pared with those instances, where the matter of an empyema
makes its escape outwards, but particularly rapid when compared
with the slow progress of the other two cases, which extended
over a period of between two and three years each. This cir-
cumstance may be accounted for by the difference in the habits
and constitutions of the patients. The health of the woman,
previous to the attack of pleurisy, was irreparably destroyed by
hardship, syphilis and mercury, and in her cachectic and ex-
hausted condition, any acute affection would, no doubt, have
exhibited unusual virulence.
Three weeks after her admission into Hospital, she began to
 Diagnosis of Empyema. 23
expectorate matter ofa decidedly purulent character ; and bron-
chitic rales were heard throughout the right lung. A few days
after, diarrhoea set in, and resisting every kind of treatment,
ceased spontaneously on the bronchial flux becoming greatly in-
creased, for we find it noted on the 2lst of October, that she had
expectorated a pint of greenish pus, and that the bowel complaint
had received a notable check. The post mortem examination
proved that the bronchial membrane was in a perfectly healthy
condition, and no trace of a communication between the sac of
the empyema and a bronchial tube could be discovered. The
tubercles in the left lung were in a crude, unsoftened state, so that
the pus expectorated could not have proceeded from them. We
are, therefore, compelled to consider this case as one of those in
which the mucous membrane of the lungs and (as occurred also
in the present instance) that of the intestines take on a vicarious
action, by which an evacuation of pus, either by absorption and
secretion, or some other process, is effected, which, as it ad-
vances, a corresponding diminution in the empyema is noticed to
take place. How the process of absorption and removal of the
matter of the empyema and its elimination from the mucous mem-
brane of the bronchial tubes, intestines, bladder, or vagina, is per-
formed, remains an undecided question. Certain it is, that from
a very early period of medicine, the process has been familiar to
physicians, though overlooked by many late writers on the disease
in question. I must not, however, omit to mention that my friend
Professor Greene has again directed attention to this subject,
in his admirable paper on “ Empyema,” in the 17th volume of
this Journal. He details the particulars of four cases of the
disease, inall of which copious purulent expectoration wasa promi-
nent symptom ; and in all there were external tumours, which it
was deemed prudent to puncture. In these instances, it was ob-
served that as soon as the matter got exit by the external opening,
the quantity of purulent expectoration diminished, and the same
circumstance occurred in the case now mentioned. Dr. Greene
adds—* the first explanation I heard offered as to the nature
24 Mr. Mac Donnell’s Contributions to the

and cause of this expectoration, was suggested by Dr. Hutton,

in a consultation held on one of the cases detailed. He ob-
served, that he had frequently seen the expectoration to sub-
side and lose its character when an opening had been made
for the collection, and had consequently come to the con-
clusion, that in many cases of empyema, the expectoration was
the result of an effort of nature to free the system of purulent
deposit through an external outlet, which in these instances was
effected through the bronchial tubes.”
The paper of Dr. Greene must be regarded by every physi-
cian as one of the most useful that has appeared for many years.
We learn from it that though a patient present all the symptoms
of extensive empyema of one side, with bronchitic rales or gurg-
ling in the opposite lung, and copious purulent expectoration,
the case is not to be despaired of, nor are we justified in giving
a positive diagnosis of the existence of pulmonary abscess.
Whilst acting as Clinical Assistant to my friend Dr. Graves,
a patient was admitted into the medical wards of the Meath
Hospital, with the following symptoms
Cass IV.—Acute Pleuritis, followed by Empyema, copious
purulent Expectoration ; Recovery.
He had been in Stevens’ Hospital for an attack of acute
pleuritis, was treated in the usual manner, and, after some
time, was dismissed cured. He again caught cold, and being
unwilling to enter hospital, remained at home without any
treatment. After a month or six weeks, he and his friends
became alarmed at the quantities of purulent matter he expec-
torated, and he determined on entering the Meath Hospital.
He now presented the usual well marked symptoms of empyema
of the right side; his pulse was weak, about 90 ; his breathing
rather difficult; his countenance anxious; he had cough, with
copious purulent expectoration, but no sweating or othersymptom
of hectic. ‘The two inferior thirds of right side were completely
dull on percussion, with absence of respiration. The intercostal
 Diagnosis of Empyema. 29
spaces were dilated, and this side was nearly two inches greater
in circumference than the other, in addition to which, he had
depression of the liver, and loss of vocal vibration all over the
dull portion of the chest. The left side of the chest sounded
clear on percussion, and the respiration was free from rale in
every situation, except about the situation of the large tubes,
where there was occasionally heard a loose bronchitic rale, in-
variably removed by a paroxysm of coughing, attended with
expectoration of the purulent matter.
I was glad to find that on the patient’s being examined by
Dr. Graves, he immediately declared it, as one of those to which
Dr. Greene had drawn the attention of the profession ; a con-
clusion at which I had already arrived, for reasons which shall
be mentioned hereafter. It was determined to do no more than
assist the efforts of nature by supporting the patient’s strength,
and as he had been greatly reduced by his previous illness and by
the privations he had endured before his admission into the Meath
Hospital, a generous diet and small quantities of wine were allowed
him. He had not been under this treatment a week before his pulse
became full and fell down to the natural standard, he lost the
anxious expression of countenance,
his breathing became easy,and
he began to gain both flesh and strength, and yet he continued
to expectorate daily two large sputa-cups full of thick, yellow,
‘well concocted” pus. I do not recollect a case that afforded
me greater pleasure in observing, or from which greater infor-
mation was to be derived. At each morning visit we found our
patient perceptibly improved ; from being haggard and emacia-
ted he became fat, ruddy, and strong; and at each visit his
sputa-cup was found full of pus of the character I have men-
tioned. ‘The progress of the case was most satisfactory, even
more so than in those detailed by Dr. Greene, for in his, para-
centesis was resorted to, but in our’s the entire of the empyema
was removed by expectoration. Atthe end of six weeks the
patient was discharged without a symptom of his complaint re-
VOL. XXv. NO. 73, E
26 Mr. Mac Donnell’s Contributions to the
h, or difficulty
maining, his right side perfectly clear; no coug
of breathing; pulse natural; strength restored.
us
Case V.—Acute Pleuritis, followed by Empyema, copio
purulent Expectoration ; Recovery.
in the last
The following case came under my observation with
from my
four months, and I shall extract briefly the notes of it
, was
case-book. A woman aged 30, mother of five children
acute pain
attacked about two months before she came to me with
in a
in the left side, difficulty of breathing, stitch on drawing
itis.
deep breath, and the other usual symptoms of acute pleur
was
She applied for relief to a medical man in this city, and
bled by him and got some opening medicine. From the loss
of blood she experienced some relief, but neglected all medical
advice till she came to me, when, in addition to the symptoms
already detailed, I found the lower third of the left side com-
pletely dull and without respiratory murmur, and all over the
middle third behind, a loud and rough friction sound could be
heard. ‘The dulness extended round under the axilla to the
g
left infra-mammary region; the heart was felt and seen pulsatin
to the right of the sternum, and its sounds were louder and more
distinct under the right nipple than in any other situation.
They were not accompanied by any abnormal bruit. ‘The left
side was equal in dimensions to the right. When the hand
was placed over the dull part behind, no vocal vibration could
be perceived; when carried up over the middle third, the friction
could be most distinctly felt, and also immediately under the
left axilla, but in every other part of the left lung and all over
the right, the sound on percussion was clear, and the respiratory
murmur was loud, puerile, and without any kind of rale; yet
she complained of frequent cough attended with considerable
purulent expectoration, which she used to collect in a tea cup
for my inspection on every occasion she visited me. This last
symptom, together with the state of the pulse, 108, weak and
soft, and night sweats, led me to make frequent and most
 Diagnosis of Empyema. 27
accurate examinations for phthisis, but I could not discover
the least trace of tubercular deposition, nor did the previous
history of the patient warrant the supposition, for except the
present attack she had always ‘enjoyed good health. There
was no enlargement of the liver. I considerd the purulent ex-
pectoration as the result of the peculiar action of the bronchial
membrane before alluded to, but the weak and feeble condition
of my patient did not warrant me, I conceived, in leaving the
evacuation of the effusion to the unassisted efforts of nature; I
therefore placed her under a mild mercurial treatment combined
_with expectorants, blisters to the side, and a generous diet with
the cautious use of wine. This was a plan of treatment against
which strong arguments, grounded on the presence of purulent
expectoration, sweating, and quick pulse, would have been urged
some years ago, with all the appearance of experience and sound
judgment for their authority; but through its agency, and the
efforts of nature, the entire quantity of the effusion was removed,
and the patient was restored to health in about a month from the
time she first presented herself to me. After the mercury had
slightly touched the gums, I placed the patient on the use ofin-
fusion ofbark, as I did not consider the use of iodine necessary
in her case. I have purposely omitted an account of the changes
in the physical signs during her recovery, as they differ in no
material point from what is ordinarily observed in such cases.
Before the appearance of Dr. Greene’s paper, these cases
would have been considered as hopeless examples of pulmonary
abscesses, or at least of empyemas bursting into a bronchial tube.
This leads me to make a few remarks, suggested by the close
observation of some cases of empyema, which have terminated
by purulent discharges from the bronchial tubes. There are
two modes by which this process is effected ; in one, the mem-
brane takes on a vicarious action, by which large quantities of
pus are discharged without any distinct evidence of inflamma-
tion being set up in the membrane, or communication being es-
tablished between the bronchial tubes and the sac of the abscess.
28 Mr. Mac Donnell’s Contributions to the

In the other form, a direct communication exists between the

bronchial tube and the sac of the empyema. They are both
efforts of nature to get rid of the purulent collection and effect
a spontaneous cure, but as the means adopted are so widely dif-
ferent, an equally opposite train of symptoms, may naturally
be expected to attend these processes, and such we find to be
the case.
In the examples detailed by Dr. Greene, and in those which I
have given, the expectoration was thrown upin small quantities
at each paroxysm of coughing, and though it amounted to a con-
siderable quantity during the twenty-four hours, yet what fol-
lowed each paroxysm of coughing never occasioned any distress
to the patient, or alarm to his attendants, and was excreted
gradually and regularly, without producing any violent or
distressing symptom to the patient; and the removal of the
empyema, as shown by diminution in the extent of the dul-
ness and return of respiratory murmur in the affected side,
was equally gradual and progressive. But, in the second class
of cases, where a direct communication has been established, we
have, in addition to the rapid development of the physical
signs denoting the accident (such as the sudden removal of the
dulness, with metallic phenomena of the voice and cough, and a
tympanitic sound over the portion of the chest previously dull),
a violent and sudden paroxysm of coughing, usually accompa-
nied with expectoration of a large quantity ofpus,so great asin
almost every instance to produce themost alarming symptoms of
suffocation, and not unfrequently even death from this cause.*
This is followed by relief for a time, but a second and third ac-
cumulation of the matter takes place, which is again got rid of
in the same way; and on each occasion the patient’s life is in
imminent danger from asphyxia.
I have now seen three instances of empyema terminating in

* See Hodgkin’s Lectures on the Morbid Anatomy of the Serous and Mucous
Membranes.
 Diagnosis of Limpyema. 20
this manner, and the particulars ofa fourth have been com-
municated to me; and though a pretty frequent, it is by no means
a very desirable mode of cure.
In myfirst case, the expectoration, though copious, purulent and
foetid, wasnever thrown up in the manner indicative ofa direct com-
munication with the pleural cavity, nor was any such communica-
tion discovered at the post mortem examination, neither was
there evidence of bronchial inflammation, and, as beforestated, the
tubercles being hard and crude, could not have supplied the pus
so abundantly expectorated; the conviction, therefore, is forced
on us, that, in this particular instance, we have a direct confirma-
tion of the doctrines advanced by the ancient physicians, and
more recently enforced by Drs. Hutton’ and Greene; and
were evidence wanting, it is supplied by the occurrence of the
uncontrollable diarrhoea, which, resisting every kind of treat-
ment, received a decided check on the purulent expectoration
being established; and it isalso remarkable, that the inspection of
the intestines afforded no explanation for the occurrence of this
latter formidable symptom. Heretofore,
the efforts of nature in
this woman were unavailing, and, as an additional one,she endea-
voured to procure the evacuation of the fluid by an external
opening; but the shattered and broken down constitution of the
patient was unable to bear up against processes so slow and
wasting, and she fell a victim to the disease in spite of the great
exertions made by nature for her recovery. The post mortem
examination showed that the layers of lymph, lining the opposed
surfaces of the pleura, were exceedingly thin; and this will ac-
count for a circumstance in which this case differed from the
two which follow it, viz., that after the evacuation of the fluid of
the empyema, the sound, from being dull, immediately became
clear. Many treatises on auscultation assert that after the re-
moval of the effusion, the sound becomes clear. ‘This is not
strictly true; for if the layers of lymph be unusually dense, the
sound will still remain somewhat dull, and Dr. Stokes has shown
that in empyema of long standing, the ribs become hypertro-
30 Mr. Mac Donnell’s Contributions to the
phied—thus constituting another cause for dulness. In our case,
the clearness of sound was explained by the small quantity of
lymph found lining the sac of the abscess.
The mode by which the matter works its way externally has
not been sufficiently investigated. In some instances an abscess
forms in the integuments, which opens both inwardly into the
pleura, and externally through the integuments. But in other
cases, there is no such abscess, and the process commences on
the inner surface of the costal pleura. Thus Dr. Hodgkin*
thinks, “ that in some cases, the process resembles one which
more frequently occurs in the peritoneum ; viz., that when a con-
siderable quantity of the inorganizable product of inflammation
is collected, ulcerative absorption takes place in that part of the
serous membrane with which it is in contact, and that, by a com-
munication of the same process, the external opening is effected.”
In our case, the lymph was uniformly diffused, and in no part
was it collected in any considerable quantity; and, as far as
one instance goes, it confirms the observation of Laennec, who
considers that it is by means of gangrene and ulceration of the
pleura, that the fluid works its way outwards, and that destruc-
tion of the periosteum and caries of the ribs, are frequent accom-
paniments of the lesion.

METHOD OF DIAGNOSIS IN EMPYEMA WITH COPIOUS PURULENT

EXPECTORATION.

It may be useful to investigate the grounds of diagnosis in

cases like those detailed by Dr. Greene and myself, which pre-
sented some of the symptoms of pulmonary abscess and bronchi-
tis; for it is evident, that without clear and distinct views on
this subject, no useful conclusion can be arrived at, and our
prognosis must be devoid of anything like certainty, or even
probability.

* Op. cit. vol. i. p. 113.

+ See Forbes’s Translation of Laennee on Diseases of the Chest, 4th Ed. p.
406.
 Diagnosis of Empyema. 31

In the first case detailed by Dr. Greene, except the abundant

purulent expectoration, “ no sign of pulmonary abscess or fistu-
lous communication with a bronchial tube could be discovered.”
In his second, the symptoms likely to lead to an erroneous diag-
nosis, were the following :—* On applying the stethoscope under
the spinous process of the scapula, and towards the root of the
lung, a loud gurgling sound was heard; the resonance of the
voice, also, was so loud and clear in this situation, as to amount
to imperfect pectoriloquy, while percussion yielded a very dull
sound. All these phenomena were the more striking, as con-
trasted with the voice and respiration on the opposite side.
These signs, combined with the profuse, purulent expectoration,
led me to suspect that the pleuritic effusion might be complicated
with some structural disease of the lung—probably witha pneu-
monic abscess.”* In his third case, we find no symptoms which
could lead us to suppose the existence of a pulmonary abscess,
except the copious purulent expectoration. ‘The lung of the
unaffected side yielded a clear sound in every situation, and the
respiratory murmur was in every part puerile, and free from rale.
So that we have nows?zz cases of empyema, in all of which co-
pious purulentexpectoration formeda prominent symptom; infour
of them there were xo physical signs whatever to account for this
phenomenon, not even those of bronchitis.t In one, we are told,
a loud gurgling sound was heard towards the root of the lung; but
it is not mentioned whether this sound was persistent, or, if remov-

* Dublin Medical Journal, vol. xvii. p. 275.

+ Lam notignorant of the fact, that in some rare cases of phthisis, the consti-
tutional symptoms may continue for a long time, before the slightest trace of the
physical phenomena of the disease become manifest, owing, most probably, to the
morbid processes being confined to the central parts of the lung. 1 have now
seen many such cases, and have observed in some of them a peculiarly fatid odour
from the breath after coughing, and from the expectoration, The diagnosis in these
obscure cases rests upon the want of correspondence between the presence of all the
symptoms of phthisis, and the total absence of the physical phenomena, We are
not, however, in such cases, left long in doubt, for very soon the lesion becomes
discoverable by auscultation and percussion.
ao Mr. Mac Donnell’s Contributions to the

able by a paroxysm of coughing; there were also “ imperfect

pectoriloquy,” and “ a very dull sound.” “ Gurgling,” “ imper-
fect pectoriloquy,” “and avery dull sound,” are then the only phy-
sical signs likely to mislead the physician; and in the present state
of the science,and possessed aswe are of the facts disclosed in Dr.
Greene’s paper, we do not anticipate much difficulty on these
points. The gurgling was but a larger degree of the rale no-
ticed in my second case, and would probably have been com-
pletely removed, or at least greatly modified, by coughing, fol-
lowed by expectoration. The presence orabsence of the ‘ 1m-
perfect pectoriloquy,” by itself, must be considered of no value
whatever as a sign to be relied on, either for or against the ex-
istence of pulmonary abscess in any part of the lung, and, above
all other situations, of least value at the root of the organ, for
here there is naturally an increased resonance of the voice, which
some term bronchophony, and others may, with as much reason,
call imperfect pectoriloguy. The dulness of sound was caused
either by the deposition of thick layers of lymph,the result of the
previous pleuritic inflammation, or by a still existing effusion in
the part—a condition by no means irreconcileable with the fact,
that gurgling was heard over the seat of this dulness, for Andral
distinctly states that an effusion of fluid between the lungs and
the ribs does not prevent our hearing sounds generated in the
bronchial tubes,*
The history of this case, the situation (the root of the lung)
in which the phenomena occurred, and the paucity and valueless
nature of the signs, could hardly mislead any one at the present
time, particularly when we bear in mind that pneumonic abscess

* «When the bronchi are full of mucus, the interposition ofa liquid between
the lungs and the ribs does not prevent the different rales from being heard, to
which the accumulation of this mucus may give rise. This remark is not devoid
of importance, for the existence of these rales may incline one to think, that the
lung is in immediate contact with the ribs, and consequently may occasion the
disease to be mistaken.”’— Clinique Medicale, by Spillan, p. 603.
 Diagnosis of Empyema. 33

is one of the rarest lesions met with in the lungs,* and almost
always occupies the base of the organ, whilst tubercular abscess
is situated in the apex. The reason why pneumonic abscess so
seldom occurs, has been accurately pointed out by Dr. Stokes 5+
and a moment’s reflection will shew, that it is next to impossible
an abscess of this nature could form at the root of the lung.
These circumstances, taken in conjunction with the fact,
that true pneumonic abscesses are not accompanied with very
copious expectoration ; but, on the contrary, are found to con-
tain an exceedingly small quantity of pust, will enable the
observer to arrive at a correct diagnosis in a similar instance.
ae ae ae eee eer
oe) Meats Neg)
* <¢ At the period when Laennec published his work on Auscultation, puru-
lent collections were found but five or six times in the inflamed lung; they were
yet very small. The largest abscess met could scarcely admit the ends of the three
fingers joined together. As for ourselves, it has not fallen to our lot more than
once to see a real abscess after a pneumonia, at the La Charité.”,—Andral’s Cli-
nique Medicale, by Spillan, p. 382.
He alludes to another example of abscess of the lung after pneumonia, pre-
to be
sented to the Royal Academy of Medicine by M. Honoré, These two appear
the only cases Andral has met with.—Op. cit. p. 382,
+ ‘ But itis in the anatomical structure of the lung that we find the true ex-
planation of the point in question. If we compare the viscera, with respect to the
of the
liability to form abscess, we find that in those in which the earlier products
In the
inflammation can be got rid of, there is the least liability to abscess.
of inflammation ;
brain, which has no excretory duct, abscess is a common result
more so than that
abscess of the liver is less common than that of the brain, and
scale, and that of the
of the lung; abscess of the kidney may be placed next in the
lung decidedly the last in the order of frequency. Considering the bronchial
the viscera, the lungs have
tubes as excretory ducts, we must admit, that of all
it in a vital or me-
the most extensive apparatus for excretion, whether we consider
chanical point of view. From the first, the products of irritation are got rid of by
ation of the matter
expectoration ; and even in the suppurative stage, the accumul
on Diseases of
is prevented by the universal permeability of the lung.” —Stokes
the Chest, p. 313.
abscess in the lung
{ «The rare instances, in which what may be regarded as
idated by inflam-
really takes place, occur when aportion of lung has been consol
of the lung sup-
mation, obliterating the air-cells. In such consolidated portions
the character of
puration may take place, and produce a collection of pus having
VOL. XXV. NO. (3. F
 = +

34 Mr. Mac Donnell’s Contributions to the

In one of the cases I have detailed, the bronchitic rales

were diffused all over the sound lung, and yet no trace of in-
flammation could be detected at the post mortem examination ;
in the other, a few mucous rales were heard occasionally at the
root of the lung, which disappeared after each fit of coughing,
attended with purulent spitting, and were unaccompanied by
any fever or distress of breathing which could legitimately be
ascribed to bronchitis.
We are therefore warranted in deducing from the foregoing
cases the following rule. That purulent expectoration in em-
pyema, though attended by quick pulse, sweating, emaciation,
and other hectic symptoms, is not indicative of tubercular or
pneumonic abscess, unless accompanied by unequivocal physi-
cal signs of these lesions ; but, on the contrary, it ts to be re-
garded as the consequence of an effort of the constitution to
get rid of a large collection of purulent matter, by one of the.
ordinary emunctories.
Since the above was written, Dr. Stokes has informed me
of the particulars of two cases, in both of which there were ex-
tensive empyema of one side, and copious purulent expectora-
tion, but without any of the usual signs of abscess or chronic
bronchitis. These two cases, froma physician of such accurate
observation, strengthen, in an essential degree, the position upon
which the diagnosis, above announced, is grounded, and confirm
the conclusions to which I have been led.
Andral also details the particulars ofa case of empyema,
in which, before death, purulent expectoration took place,
“which seemed to come from a tuberculous mass; but at the
post mortem examination no cavity was detected in either lung,
some crude tubercles were found in the upper portion of the
right one. In his remarks on the case, he says, “ we shall also

abscess. The pus so fcrmed is neither very pure nor very copious. I do not know
that I have seen above a drachm collected in such a cavity, and in most of the
instances which I can call to mind, there was also present, gangrene of the lung,
which had produced some slough or eschar.”—Hodgkin’s Lectures on the Morbid
Anatomy of the Serous and Mucous Membranes, vol. ii. p. d.
 Diagnosis of Empyema. 35
direct attention to the nature of the expectoration, similar to
that yielded by large tubercular cavities, and which was merely
the product of the bronchial mucous membrane.” The mucous
membrane presented no trace of disease.*
CONDITION OF THE SOUND LUNG IN EMPYEMA.

There is, however, aérue bronchitis of the sound lung which

occurs inempyema, where the lungof the affected side is so com-
pressed and bound down by adhesions as to be unable to take
any part in the respiratory process. In four cases which I
have witnessed, the disease was ushered in by accession of
fever and increased difficulty of breathing, and no satisfac-
tory cause could be assigned, save the additional duty im-
posed on one lung by the useless state of the other. In these
instances the expectoration was not purulent, nor did it differ in
any respect from what usually attends acute bronchitis, and in
all, the affection disappeared on an amendment taking place in
the opposite side of the chest.
Such cases are not likely to be confounded with those in
which the mucous and gurgling rales are produced by the
quantities of pus in the tubes, the result of vicarious secretion.
But there is also another condition of the sound lung in em-
pyema, which, though it has escaped the notice of writers, it is
necesssary we should be familiar with, inasmuch as our over-
looking it, or, on the other hand, attaching too much impor-
tance to it, will lead us into error, namely, congestion of the
mucous membrane, producing physical signs of bronchitis, or
some ofthe stethoscopic signsof pneumonia. This is by no means
an unusual complication of empyema. I have observed it now
in several instances, and have no doubt that many cases, pre-
senting the physical signs denoting these conditions of the sound
lung, have been recorded as examples of empyema of one side,
with bronchitis or pneumonia of the opposite. A little atten-
tion will enable us to distinguish this state very readily from an

* Vide Clinique Medicale, by Spillan, p. 566.

36 Mr. Mac Donnell’s Contributions to the

acute bronchitis, or a pneumonia, supervening in the sound lung

during the ‘progress of the empyema, for though we may dis-
cover bronchitic rales all over the back part of the sound lung,
in which the respiratory murmur had previously been puerile
and free from rale; or we may often hear a loud, large, and
loose crepitus (such as is commonly heard in typhoid pneumonia)
yet we do not find the du/ness on percussion, and characteristic
sputa of pneumonia on the one hand, nor, on the other, the in-
crease of fever, exacerbation of cough, or great difficulty of
breathing which almost invariably accompany an accession of
bronchial inflammation. On the contrary, neither the general
symptoms, nor the feelings, nor the appearance of the patient
indicate the supervention of a new disease. I am disposed,
therefore, to attach very great importance to the absence of these
latter symptoms as diagnostic signs between this affection of
the lungand true bronch foriti rable experience and close
consides,
observation of thoracic disease have convinced me of the truth
of the doctrine long since advanced by my friend and respected
preceptor, Dr. Stokes, that these symptoms are a measure of
the irritation, rather than of the obstruction in the lung.
It is unnecessary to point out the errors in treatment and
prognosis, into which a neglect of the means of distinguishing
between these complications of empyema, will lead the practi-
tioner; the patient will be harassed by cupping, blistering,
and other local applications, and his apprehensions awakened,
and the alarm of his friends excited, by the intelligence that
his sound lung has become engaged, for we all know how fondly
both patients and their friends look forward to a recovery so
long as only one lung is diseased, and the error is not confined
merely to those imperfectly acquainted with auscultation, it
is daily committed by many, otherwise very familiar with the
science.
There is no difficulty in accounting for congestion of the
sound lung in empyema, if we reflect fora moment on the fol-
lowing circumstances, whichI have long considered as quite
 Diagnosis of Empyema. 37
explanatory of the phenomenon. First. It occurs for the most
part in those cases, where, from some unusual cause, the patient
cannot lie on the affected side, but prefers reposing either on
the sound side, on the back, or assumes the position termed by
Andral diagonal decubitus, or, as more frequently happens, he
lies altogether on the diseased side, In any of these situations,
it is evident that congestion in particular parts of the lung ts fa-
voured by the position of the patient. Secondly. A still more im-
portantand efficient cause is owing to the circumstance that in con-
sequence of the compressed, collapsed, and impermeable condition
of one lung, the whole quantity of the blood circulating through
the body, is driven into the sound lung for aeration and oxy-
genation, and its sojourn in that lung is prolonged beyond the
period which in health is necessary for the purification of only
half the quantity; and, as a natural consequence, congestion
from this cause depends on the greater or less degree of permea-
bility enjoyed by the lung of the affected side. The disappear-
ance of this condition of the lung is one of the first symptoms
which indicate the absorption of the pleuritic effusion, and
proceeds in direct ratio with the gradually increasing expansi-
bility of the compressed lung.
CONDITION OF THE LIVER IN EMPYEMA.

In connexion with this subject I may be permitted to allude

to the condition of the liverin empyema. For the most ample
and accurate observations we possses respecting that organ in
the affection under consideration we are indebted to the re-
searches of Dr. Stokes; but, besides the observations detailed
in his celebrated work, there are many points worthy of atten-
tion, which have hitherto been left uninvestigated.
It is generally supposed that the only way in which the liver
is engaged in this disease, occurs when an extensive empyema
of the right side depresses it mechanically ; its condition in em-
pyema of the left side has been altogether overlooked. Some
time ago I met with a case in which an effusion into the left
38 Mr. Mac Donnell’s Contributions to the

pleura, producing dislocation of the heart, was also attended

with a perceptible tumour in the right hypochondriac and epigas-
tric regions, which I concluded was an ordinary enlargement of
the liver, and I was confirmed in this opinion when the tumour
diminished under the use of mercury given for the pleurisy. I
have since seen the same phenomenon in cases of empyema of
the left side, in which no symptoms of derangement of the liver
preceded the pleuritic attack, and in which the disappearance
of the hepatic enlargement was too sudden and too complete to
be confounded with the ordinary enlargement of the organ from
chronic hepatitis. In some instances this enlargement is attend-
ed with pain on pressure ; and this symptom has often led to the af-
fection being considered as hepatitis. Now I have no doubt that
besides mere mechanical depression of the liver, there is another
agent of a vital nature, still more efficient in the production of the
hepatic tumour, for were we to rest satisfied with the usual ex-
planation, we should expect that the appearance of the hepatic
tumour, only occurred in empyema of the right side, so ex-
tensive, as to produce not only depression of the liver, but like-
wise protrusion of the intercostal spaces of that side. But the
fact is not so, it is not confined to effusions into the right pleura,
but occurs likewise in cases where the left cavity is the seat of
the disease, and many of those examples of empyema of the left
side, in which tumours in the epigastrium and towards the umbi-
licus were noticed, and which were considered as depression
and displacement of the spleen, were in all probability exam-
ples of this enlargement of the liver.* And on the other hand
an hepatic tumour is frequently observed in cases where there
is no protrusion of the intercostal spaces, although there exists
considerable impediment to the respiration. Let us inquire
into the nature of this enlargement of the organ, for such I have
no doubt will be found to be the true nature of the alteration in

* See the works of Piorry and Raciborski. We need not be surprised at this,
for I have often seen an enlarged left lobe of the liver mistaken for enlarged spleen,
and vice versa.
 Diagnosis of Empyema. 39
many cases, though I am far from denying that in empyema of
the right side, the viscus is also depressed mechanically by the
fluid within the thorax, This increase in size, then, seems due to
acongestion or engorgement of the liver analogous to what takes
place in cases of morbus cordis and diseases of the lungs, at-
tended with imperfect aeration of the blood. In these diseases
it has long been known, that the liver takes on a supplementary
action, by which a quantity of carbon is eliminated from the blood,
which the impeded state of the circulation through the heart and
lungs renders them unable to accomplish.* These enlargements
are of very frequent occurrence in the class of cases I have men-
tioned, and every one must have been at times surprised, by
their rapid disappearance as soon as the respiration was re-
lieved, and the circulation through the heart and lungs became
less obstructed. Morbid anatomy shows us that no material
change in the structure of the organ takes place; it is found
considerably enlarged, and always gorged with blood, which
flows out in great profusion, on an incision being made into its
substance, whose consistence is somewhat softer than natural, and
darker in colour. But as this peculiar state of the liver does
not invariably attend obstruction of the circulation, from morbus
cordis or disease of the lungs, even when considerable; so like-
wise, it is not an invariable attendant on effusions into the
pleura, but when the hepatic tumour és perceived, we must,
I think, admit of the explanation now offered (in conjunction
with mechanical depression, when the effusion occurs on the right
side)—a view of the subject, not based on theory, but grounded
on the well-known physiological laws which regulate the com-
bined functions of the heart, lungs, and liver.t
a a ee
*The researches of Tiedeman and Gmelin, as well as those of Elliotson
and
Liebig, have now clearly established the truth of the above doctrine.
} In the case ofa gentleman, whom I attended along with my friend Mr. New-
land, for morbus cordis and incipient phthisis, and who had been for many
years
affected with asthma; every paroxysm of the latter disease was attended
with a
remarkable enlargement of the liver, which used to protrude to midway between
&

40 Mr. Mac Donnell’s Contributions to the

the view Itake
Though this peculiarcondition of the liver,and
not been no-
of the hepatic tumours occurring in empyema, have
their accounts of
ticed by writers on diseases of the chest, yet, in
is frequently men-
post mortem appearances, this state of the liver
by Dr. Stokes
tioned incidentally, Thus, in a paper published
he gives the case
many years ago, upon the diagnosis of empyema,
yema of the
of a patient, in whom, besides the appearances of emp
s tts natural
right side, the liver was found “nearly three time
we cannot suppose
size? As no other alteration is mentioned,
have been omitted
that any was observed, otherwise it would not
And again, in
by a writer of such acknowledged accuracy.*
to a case of
his work on the Chest, we find him alluding
was softened and
empyema of the right side, in which the liver
in his
engorged.t Andral also remarks, in a casual manner,
yema of the right
description of one of his fatal cases of emp
gorged with
side, that the liver was found enlarged and
case, “ the liver was
blood ;¢ and at the post mortem of my first
orged, and full of
enlarged to nearly half its normal size, eng
side; and had my
blood,” though the empyema was on the deft
ect, there can be
attention at that time been directed to this subj
ld have been
no doubt that such an extensive enlargement wou
what I have since
readily detected, and we should have had then,
t, with the
frequently seen, effusion into the left side of the ches
occurrence of a large hepatic tumour.
pe-
I could quote several other cases mentioned in different
a gee ee re
Pee ee ies
This enlargement generally
the ribs and umbilicus, and into the epigastric region.
nce was almost always at-
subsided under leeching of the anus, and its disappeara
observed the same thing to
tended with relief to the pectoral symptoms. I have
me suddenly enlarged in mor-
occur in many other cases, where the liver has beco
used to increase
bus cordis. During the illness of the late Mr. Colles, the liver
, during his paroxysms of
to nearly twice its natural size in twenty-four hours
as soon as he obtained
dyspnoea, and used to disappear with equal rapidity,
relief in his breathing.
* Op. cit. p. 503.
57.
+ Vide Dublin Medical Journal, vol. iii. p.
¢ Vide Andral’s Clinique Médicaleby, Spillan, p. 515.
 Diagnosis of Empyema. 4]
riodicals, where this enlargement of the liver from engorgement
was found, at the examination of fatal cases of empyema. I am,
therefore, confident that we are not justified in considering the
hepatic tumour in these cases, as produced by a mechanical de-
pression alone, for, according to the best observers, this depres-
sion is always either preceded or accompanied by a protrusion of
the intercostal spaces, and the same explanation has been offered
for the occurrence of the two symptoms. But in the case of cancer
ofthe lung and empyema, published by Dr. Stokes, the liver was
found much enlarged and engorged with blood, though for a
long time previous to death, the right side had returned to its
usual size, and all appearance of intercostal protrusion had long
before disappeared. The enlargement, therefore, was the result
of the same cause which produced the varicose condition of the
veins, namely, the impediment to the free circulation through
the lungs, whereby a supplementary duty was imposed upon
the liver, and, as always occurs in such cases, the organ was
found not only enlarged but engorged, and its texture much
darker than natural, from its containing a larger quantity of
blood.* It is, therefore, natural to expect that, as in chronic
bronchitis, emphysema and phthisis, morbus cordis and cancer
of the lungs the liver supplies the place of the inefficiency of
the lungs in purifying the blood, that it will act in a similar
manner when one of these organs is compressed and rendered
useless, by an extensive pleuritic effusion into either side of the
chest, and this is proved, not only by my observations in cases
that have recovered, but also by the appearances revealed at ne-
croscopic examinations of empyema, recorded by writers who had
neither a theory to support,nor a series of observations requiring
confirmation, and whose testimony is, therefore, entitled to the

* As in the account of the autopsy furnished to Dr. Stokes by Dr. Carroll of

Waterford, it is merely stated that the liver was enlarged, I took the liberty of
writing to that gentleman, to ascertain more accurately its precise condition, and
the above account is extracted from the answer which he very kindly forwarded
to me, k

VOL, XXV. NO. 73. G

42 Mr. Mac Donnell’s Contributions to the

highest consideration. I shall now throw into the form of pro-

positions, the points discussed in this paper.
1. That in Cases I., II. and TIL, we are presented with a
new form of Empyema, which may be termed “ Pulsating Em-
pyema of Necessity,” exhibiting some features common to that
form of empyema and to thoracic aneurism, and encephaloid
disease of the lung.
2, That it may be diagnosed from thoracic aneurism, by
a. The history of the case.
b. The dulness extending over the whole side, the
pulsation being only felt in the external tumour.
c. The absence of thrill.
d, The absence of bruit de soufflet.
e. The extent and nature of the fluctuation.
3. That it may be distinguished from encephaloid disease of
the lung and mediastinum, by
a. The absence of the expectoration resembling black
currant jelly.
b. The absence of a persistent bronchitis,
c. The absence of a varicose condition of the veins and
oedema of the side affected.
d. In cancer of the lung the situation in which the ex-
ternal tumours form, is not invariably confined to the
thorax.

4, That copious purulent expectoration in empyema is not

always indicative of cavities in the lung; but, on the contrary,
is of frequent occurrence in this disease, and seems to be the
result of an effort of nature to get rid of the purulent collec-
tion by the nearest and readiest outlet.
5. That this symptom, when it results from the above cause,
is not attended with the usual symptoms either of abscess of the
lungs, or inflammation of the bronchial mucous membrane.
6. That a ¢rue bronchitis of the sound lung frequently com-
plicates empyema.
 Diagnosis of Empyema. 43
7. That still more frequently the sound lung becomes con-
gested, and presents some of the ordinary signs of bronchitis and
pneumonia, from both of which it may be distinguished by atten-
tion to the rules laid down in the previous part of this commu-
nication.
8. ‘That in addition to depression ofthe liver, from mechani-
cal causes, that organ is likewise enlarged from engorgement
with blood in empyema.
9. This enlargement is not confined to empyema of the
right side, but occurs also when the disease is seated in the left
cavity of the chest.
10, That this enlargement is identical with that which takes
place in other affections of the lungs and heart, where, in con-
sequence of their functions being impaired, an additional duty is
imposed on the liver, viz., that of eliminating carbon from the
blood, as proved by the researches of Tiedeman and Gmelin,
Elliotson and Liebig; and as occurs in the former cases, so like-
wise we observe in this, that the increased size of the organ is
due to an additional afflux of blood, whereby its structure be-
comes engorged, softer in consistence, and darker in colour.
11. ‘This condition of the liver has been observed by myself
as proved by dissection (see Case I.), and its presence detected
in other cases that have recovered. It has also been mentioned
by many writers in their accounts of the appearances noticed at
the autopsies of cases of empyema, who have recorded the fact,
though unaware of its connexion with the subject under discus-
sion, and it must now be considered as constituting an addi-
tional feature in the diagnosis and pathology of empyema.
12. This condition of the liver, when it occurs in the ordi-
nary diseases of the heart and lungs, has been observed to dis-
appear as soon as the obstruction to the circulation of the blood
and want of proper aeration, which gave rise to it, had ceased.
So likewise in empyema, its disappearance is one of the first
signs which indicate the removal of the effusion, and the return
of the compressed lung to the performance of its functions.
44 Dr. Doherty on impending Dissolution and
I cannot conclude without availing myself of this opportunity
of returning my thanks to Dr. Graves for his extreme kindness
and liberality in permitting me to make use of the cases upon
which the foregoing observations are founded.
10, Lower Fitzwilliam Street.

Art. II.—On impending Dissolution and Nervous Affections

in young Infants. By Ricaarp Douerty, M. D., Honorary
Member and Secretary of the Dublin Obstetrical Society.
[Read before that Society, Dec. 4, 1843.]

Tur risks to which children are exposed at birth admirably

exemplify the three modes whereby, according to Professor
Alison’s able analyzation of the causes of sudden death, a pe-
riod may be put to existence in after-life; namely, by Death
commencing at the Brain, Death commencing at the Lungs, and
Death commencing at the Heart.* And as, whilst each of these
catastrophies is impending, a train of convulsive actions may be
established in the adult, so in the child just born, these condi-
tions may exist contemporaneously.
Death, commencing at the brain, may be induced in two
ways; firstly, as in compression, when the respiratory function
is the first to suffer; and secondly, as in concussion, when the
heart’s action is directly arrested. The first mode, or that by
coma, is frequently a cause of children being still-born ; and, as
in individuals of a more advanced age labouring under apoplexy,
there is venous turgescence, bloated features, slow and impeded
respiration, so in the infant, which has so suffered, those pecu-
liarities are observable. It is quite a common circumstance, for
the face, when expelled, to assume a purple hue; which colour,
it the labour be quickly finished, soon disappears: but if from
delay or any other cause the return of the blood from the

* Outlines of Physiology and Pathology, by Wm. P. Alison, M.D, Lon-

don, 1833. Page 326.
 Nervous Affections in young Infants. 45
head be prevented, the external engorgement continues to in-
dicate a similar condition within the cranium, and, although when
delivery is completed the heart continues to beat for some time,
respiration is with difficulty, or not at all established. The same
consequences may be induced if the head be subjected to long-
continued pressure from the action of the uterus, or squeezed
through the outlet of a narrow pelvis; and they not uncom-
monly result from the compression produced by the forceps.
After recovery from the immediate effects of this condition, a
congestion of a minor degree may persist, giving rise to con-
vulsions, or paralysis, if the proper remedies for its removal
be not adopted. I shall give examples of the different de-
grees of this affection. Thus the first is a case of simple con-
gestion; the second, congestion with convulsions easily re-
moved, and so on.*
Case 1.—M‘Bride’s child, her first, born Sept. 2, 1839,
after an eight hours’ labour, lay at evening visit dark-coloured,
moaning, and with imperfect and gradually diminishing respi-
ration. ‘Two leeches were applied over the anterior fontanelle,
and a warm bath given, after which the child breathed more
freely, and was next morning quite well.
Case I1.—The child of Farrell, a woman who was re-
ceived on the 7th Sept. 1839, in the last stage of phthisis, was
at birth, which took place an hour after admission, ofa purple
colour throughout, and immediately fell into a convulsive fit.
Some blood was allowed to flow from the cord, and it quickly
recovered.
Case III.— Higgins was delivered on the 26th June, 1839,

“ I would premise, that all the cases I am about to relate were noted by me
during my connexion with the Dublin Lying-in Hospital, in which magnificent
Institution they occurred; and I owe the permission to make use of them to the
kindness and liberality of Dr. Evory Kennedy, the then Master, who indeed has
shown himself, in his ‘* Essay on Cerebro-spinal Apoplexy and Paralysis in In-
fants,’ a successful cultivator of this very field.— Dublin Journal of Medical
Science, vol. x. page 419.
46 Dr. Doherty on impending Dissolution and

after a lapse of eight hours. The head was allowed by the at-
tending pupil to remain expelled for above five minutes before
the further progress of the child was aided. Its face was then
purple, and great difficulty was experienced in resuscitating it.
In a few hours it became affected with spasmodic twitchings.
A leech was immediately applied to the fontanelle, and a bath
given, Next morning the child appeared improved, but there
was still some clonic motion of the muscles of the face. A leech
was applied to the occiput, and blue pill given, followed by
castor oil and turpentine. On the subsequent day it sucked
freely, and ultimately recovered.
Case IV.—Lawlor, being three hours in labour on the 21st
August, 1838, the funis came suddenly down before the head,
which had at that time almost arrived at the perineum, Efforts
to return the cord being unavailing, and its pulsations gra-
dually ceasing, Dr. Kennedy sent for the forceps, but before
it arrived, managed to extract the head by introducing the
fingers of one hand behind the pubis, and those of the other
at the sacrum. The child was with difficulty brought round
by means of the warm bath, bleeding from the cord, and an
injection. When visited in a few hours it was reported by
the nurse to have been very restless since birth; its thumbs
were then closely approximated to the palms of its hands, and
it showed a general tendency to spasm. Some hydrargyrum
cum cretA was given after the usual purgatives, and it gradually
recovered,
Case V.—Gaffney’s labour had, on the 4th August, 1838,
continued for four hours, when the membranes ruptured; the
funis then descended, followed rapidly by the head. ‘The pul-
sations of the cord ceased during the uterine action, and returned
in the intervals. At length they failed altogether, but as the
head was on the perineum, and the pains were strong, the birth
was permitted to be effected without assistance. On the ex-
pulsion of the child some blood was drawn from the funis, and
by the usual means continued for an hour animation was re-
 Nervous Affections in young Infants. 47
stored. ‘Three days after this child was attacked with spas-
modie contraction of the muscles of the jaw and of the ex-
tremities, with clenched hands, passingoff in tremulous motions.
Occasional aperients were alone made use of, and it recovered.
Case VI.—Bardon was admitted at 11 o’clock on the night
of July 14, 1839, in labour of her first child. At 10 a.m. on
the next day the os uteri had completely disappeared, and the
head entered the pelvis in the third position. At noon it began
to change into the second, and at 8 p.m. it had perfected its
semi-rotation. From that period it continued to descend, but
it was not till 7 o’clock next morning she was delivered, labour
having lasted thirty hours. The child was permitted to remain
for a few moments longer than was judicious half expelled, and
the cord, which was tightly coiled round the neck, ceased to
beat before efficient assistance arrived. Resuscitation was accom-
plished by the usual means, Next morning, July 17, it was re-
ported to have been moaning throughout the night; it was
easier then, and swallowed freely; its bowels had been moved
by calomel, followed by oil, On the morning of the 18th it
had frequent convulsions, and the fingers were strongly clenched,
evacuations green. A leech was applied to the back of the
neck, and a grain of blue pill given, followed by oil; the bath
and counter-irritation were also employed. Throughout the
day, however, the convulsions grew more frequent, and during
them its features assumed a livid hue, and its fingers were
spasmodically turned into the palms of the hands. At 4 o’clock
it seemed much exhausted, and died at 10 that night. On
post mortem examination the vessels on the surface of the
brain were distended with blood; there was subarachnoid
effusion, and the brain itself was unusually vascular,
Case VII.—After a labour rendered tedious by an un-
dilating condition of the anterior lip of the os uteri, and a dis-
proportion between the sizes of the pelvis and the foetus, which
descended throughout in the third position, Skinner was deli-
vered on the 9th July, 1839, of her second child. When the
48 Dr. Doherty on impending Dissolution and
head was expelled a very large tumour was found over the su-
perior angle of the anterior part of the parietal and frontal
bones of the /ef¢ side; thus marking the unusual position in
which the child had passed through the pelvis.* ‘The forehead
having remained as at the commencement of labour turned to-
wards the pubis, was much compressed, and a broad red mark
extended around it, having its convexity towards the nose.
After the upper part of the child had escaped, the cord having
suddenly ceased to pulsate, the expulsion of the remainder was
quickened, and as no attempt at respiration ensued, and the
heart’s action could not be detected, the cord was cut, and the
body immersed in a warm bath. The heart soon began to beat
slowly and unequally; an ounce of blood was allowed to flow
from the funis, and friction with hartshorn sedulously maintained
over the chest and spine. In about a quarter of an hour the
child began to gasp. A large quantity of tenacious mucus was
removed from the nares and throat, and half an hour elapsed
before breathing could be satisfactorily established. Even then
it could not be made to cry loudly, and it still presented as at
birth, contraction of the muscles of the lower lip, ptosis of the
right eyelid, and a permanently open state of the left, the pupils
being unaffected. A leech was applied to the anterior fonta-
nelle, and failing to draw a sufficient quantity of blood, a second
was put on, and the bowels were rapidly freed; after which it
fell into a calm sleep, and awoke in three hours, free from all
nervous symptoms, and capable of sucking. The child weighed,
with its clothes on, nine pounds andahalf.
It remained well for ten days, when it was reported to be
unable to suck. It could open its mouth freely, but when the
nipple or the finger was introduced, closed it convulsively. It
clenched its fingers now and then, but had no other spasm.

* Out of 1210 deliveries, Naegelé met 359 in which the head presented in
the third position, and in ninety-six of these he observed the head to come through
the external passage with the face upwards and forwards but three times.—Essay
on the Mechanism of Parturition, translated by Rigby.
 Nervous Affections in young Infants. 49
The discharges from the bowels were very foul and green. A
grain of blue pill, two grains of chalk, and one of compound
powder of ipecacuanha, were divided into two parts, one of which
was given immediately, and the other in three hours, followed
in four hours by an oil draught. The child was also immersed
ina bath. That evening the oil was repeated, with twenty drops
of turpentine, and three hours afterwards a turpentine and assa-
foetida enema was thrown up. This treatment proved of great
service. ‘The remainder consisted of calomel alternated with
oil occasionally, and the child recovered.
This case appears to me to illustrate, firstly, a primary apo-
plectic attack, resulting from pressure on the brain and funis;
and secondly, what I shall afterwards have occasion to speak of,
a congestion of the nervous centre, sympathetic of irritation on
the intestinal mucous membrane.

With respect to the other species of death commencing at

the brain, Chossat’s experiments have shown, that in injuries to
that organ, sufficient to produce concussion, and particularly
when the spinal cord has been severely injured below the neck,
the circulation in the capillaries has appeared for some time
even more affected than the heart’s action, although it is by the
gradual failure ofthe circulation that such cases prove ultimately
fatal.* This, then, seems the mode of death when the foetus,
having been exposed to strong uterine action, or its head
driven with shocks against resisting points, such as incurvated
spines of the ischia, is at length expelled, of a pallid hue,
with relaxed limbs, and the cord pulseless, or beating feebly;
and also in cases of breech-presentation, when in consequence
of powerful efforts to withdraw the head, injury is inflicted
on the spinal marrow. It will be perceived I do not now
allude to cases, in which the child is born delicate in its na-
ture, but I refer to those, by no means rare, wherein, although,
aan oa: rnne memmeemeee=eeeemen
* Influence du Systeme Nerveux sur la chaleur Animale. Dissert, Inaug.
Paris, 1820.
VOL. XXV. NO, 73. H
50 Dr. Doherty on impending Dissolution and
ng motions
in consequence of the mother’s account of the stro
of the foetal pul-
she has felt in her child, and the loudness
ion, we had every
sations, before the commencement of parturit
nt,—yet owing to
reason to expect the birth of a vigorous infa
pale in colour, of
a tedious or a violent labour it comes forth,
, makes but puny
a low temperature, and if not quite dead
illustrate this con-
efforts at respiration. Such cases, 1 think,
res; and if the proper
sequence of injury to the nervous cent
quickly prove fatal
mode of assistance be not rendered, they
in a short time of
from exhaustion, or become the subjects
spasmodic action. For example:
ne on the 18th
Caspr VIII.—The child of Abby Kelly, bor
ve hours, appeared pale
of October, 1838, after a labour of twel
ion was with diffi-
and cold, and feeble at birth, so that respirat
menced screaming
culty established. Shortly afterwards it com
convulsive move-
in a low, whining tone, and was attacked with
immediately placed
ments of the face and extremities. It was
when reaction set in
in a warm bath, wine whey given it, and
. Next day it was
a leech was applied to the nape of the neck
movements of the
much better, having only slight spasmodic
given, followed by
limbs. On the 20th some calomel was
charges from the bowels
magnesia mixture. On the 21st the dis
pronounced conva-
had become yellow, and on the 22nd it was
lescent.
vered for the first
Casz IX.—So in the case of Keegan, deli
ur of twenty-four
time on the 17th of August, 1839, after a labo
in consequence of
hours, by the fingers employed as a forceps,
cending so as to
the head having remained for six hours des
receding on their
distend the perineum during the pains, and
d by the ischiatic
departure, owing to its progress being oppose
child’s debility, to
spines, it was necessary, on account of the
ion to revive
employ the warm bath and artificial respirat
or oil was given,
*t. The usual dose of calomel and cast
ral convulsions. A
but next morning it was seized with gene
m bath again re-
leech was applied to the head, and the war
 Nervous Affections in young Infants. o1
sorted to. Half a grain blue pill, mixed with aromatic water,
was followed up in three hours by a draught of turpentine and
oil, and small doses of blue pill and Dover’s powder given every
third hour. The following day spasmodic twitchings and
screaming existed; there was considerable strabismus, and saw-
ing of the right hand and arm. The child died convulsed
during the night.
Case X.—In the case of Banks, delivered at 5 o’clock on
the morning of the 16th June, 1839, the child presented with
the foot, and considerable difficulty was experienced in bringing
away the head, It was pulseless at birth, and its life was with
difficulty saved. At the usual visit at 10 o’clock on that morn-
ing the hands were clenched, the thumbs being grasped by the
fingers; there was a tremulous state of the lower jaw, which,
though moveable, was drawn somewhat downwards. The mouth
was turned to the left side, and deglutition was difficult. A
leech was applied to the back of the neck, wine whey given
at intervals, and the usual purgatives administered. On the
17th the child had passed a very restless night; the mouth
presented a natural appearance, but there was strabismus,
and now and then spasmodic twitchings of its arms and legs.
A leech was applied to the spine, followed by a stimulating
liniment. Three grains of calomel, two drops of laudanum, and
five grains of sugar, were divided into six powders, of which one
was given every third hour, and the wine whey was persevered
in, ‘These remedies were successful, and next day the child
was well.

In the two species of impending death depicted in the fore-

going instances, it is obvious the treatment will require to be in
some degree different. In the former, or apoplectic form, the
remedy which should be first resorted to, is evidently the ab-
straction of blood from the cord, to relieve the turgescent ves-
sels, with the warm bath and friction, to quicken the circulation
in the extremities, and cold applied to the head to relieve the
52 Dr. Doherty on impending Dissolution and
determination there. If after those means have been successful
in maintaining the vital principle, a congested appearance should
still remain, or respiration be feeble, benefit will result from the
application of one or more leeches to the fontanelle, and active
purgatives, alternated, if necessary, with wine whey or other
stimulants, until the balance of the circulation is established.
If convulsions set in, as they indicate a state closely allied to, if
not altogether one of meningitis, and at all events liable to be-
come so, the same remedies must be pushed still further,and aided
by calomel, counter-irritation to the neck, and cataplasms to the
feet. In this particular form, although medicines which rapidly
free the bowels are of great service, my own impression is, that
injections with turpentine, so indiscrimately resorted to in all
spasmodic affections in children, are not judicious. ‘They ap-
pear to me to react injuriously on the head, and therefore their
use ought, in my mind, to be restricted to other forms of the
disease. In cases such as I now speak of, Billiard has pointed
out, that besides the congestion of other organs, there is also a
congestion of the intestinal mucous membrane, which may give
rise to bleeding from the bowels and other bad consequences.*
For its removal it may be necessary to apply a leech to the epi-
gastrium, or anus also, and adopt other measures, peculiarly
suited to this complication. It is well to refrain from putting
such children to the breast for some hours longer than usual;
meanwhile a little milk and water sweetened will be sufficient.
When, on the other hand, the child comes into the world
pale and feeble, with symptoms resembling those arising
from concussion, blood-letting must not be resorted to in
the first instance. The warm bath, at a high temperature,
not continued, however, too long, as it would then tend rather
to depress the powers of life, frictions to the surface, ammonia
applied to the nostrils, mustard to the feet, and the injection
‘into the stomach of a little wine whey, to which a few drops of

* Billiard on the Diseases of Infants; translated by James Stewart, M. D.,

London, 1839 ; page 285.
 Nervous Affections in young Infants. 53
ether have been added, must constitute our immediate re-
sources. In throwing into the abdomen a stimulating fluid,
there is one point we should recollect, that too large a quan-
tity may act injuriously, by preventing the descent of the dia-
phragm. A want of unanimity exists amongst authors as to the
best mode of employing water for the resuscitation of still-born
children. My own opinions I cannot better express than by
quoting the following passage from M. Hall’s last work. ‘“ The
most important of all our remedies in congenital asphyxia is
the sudden and forcible impression of cold water on the face
and general surface. The quantity of the water should not be
great, but it should be applied suddenly and with force. The
temperature should not be lowered ; on the contrary, the dash-
ing of the cold water should be alternated with a warm bath,
succeeded by warm flannels. These too may be applied briskly
and suddenly. The efficacy of the remedy is in proportion to
the suddenness and the energy of the alternation.—The infant
may be placed in a warm bath, and be afterwards rubbed with
warm flannels. The sudden dashing of cold water will then
especially be doubly efficacious.”* In these directions, which
have my fullest accordance, Hall differs from Kdwards ofParis,
and Scholler of Berlin.j But independent of having witnessed
the best effects from this mode of treatment, I consider | am
justified, even in a theoretic point of view, in rejecting as inap-
plicable to the present subject, Edwards’ excellent experiments,
whereby he demonstrated, that an animal in a state of asphyxy
will die much more readily, if immersed in hot, than in cold
water ;t because, as I shall just now show, the still-born condi-
tion is markedly dissimilar from that of asphyxia, though nom1-
* New Memoir of the Nervous System, by Marshall Hall, M.D., page 64,
London, 1843.
+ Scholler recommends the infant to be placed in a bath of cold water, and
gives cases in which it proved efficacious.—Medicinische Zeitung, 28th April,
1841.
t} Del’Influence des Agens physiques sur la vie, Par W. F. Edwards, D, M.
Paris, 1824. Page 175.
oA Dr. Doherty on impending Dissolution and
nally called so. The propriety of cutting the cord under such
circumstances constitutes another point, upon which there is a
discrepancy amongst writers. Observation leads me to side
with those, who think, that once the funic pulsations have
ceased, the cord can be no longer of service, but will only in-
convenience us in employing the bath, and other appropriate
remedies. I place no reliance on the possibility of the circula-
tion recommencing at the placenta, for which Chaussier con-
tends; nor can I agree with Baudelocque that the blood still
flows through the vein, although the arteries may have ceased
to beat. In both classes of cases, and particularly in the latter,
wherein the heart’s action directly fails, it may be necessary,
from the delay in the establishment of natural breathing (which
we know is an agent in effecting a circulation of the blood), to
resort to artificial respiration, but it is a measure, which should
be reserved for a last resource, and never adopted until other
means are evidently inadequate.* I have seen in such in-
stances, benefit result from passing shocks of galvanism through
the cardiac region; however, it is very seldom that remedy can
be made available, as the apparatus will rarely be at hand at the
moment. It often becomes necessary even in these latter cases,
for instance, where a tendency to convulsions is manifested, to
apply a leech to the head, before the circulation will become
adjusted; but it should be at a comparatively later period, and
accompanied by the use of stimulants to support the vital powers.

The term Asphyxia, as applied to impending death in new-

born infants, has been very generally misused. We constantly
hear of children coming into the world in a state which is so de-
signated; but this is manifestly incorrect. The word, in its proper
pathological signification, only implies a condition, the conse-

* It is curious how long insufflation will maintain the heart in action, even in
cases in which the nervous system never recovers the injury it has received, in ac-
cordance with Sir B. Brodie’s well-known experiments, wherein he was able by
that means to sustain the circulation after the head had been cut off.
 Nervous Affections in young Infants. 55
quence of a cause, which directly arrests the supply of pure air
that should enter the chest. Now, in the foetus at birth, no such
cause exists under ordinary circumstances. The child is then
surrounded by an atmosphere of healthful quality, whose ingress
is prevented by no mechanical impediment ; and breathing, if
it remain unaccomplished, is so, not from any fault in the lungs
and its appendages, but from a defect in the stimulus of nervous
influence, upon which the muscular actions constituting respi-
ration depend; and for this reason we should, as I have ob-
served, resort to other measures, rather than artificial inflation,
in the first instance.* There is this difference too, which has
not been alluded to by writers on this subject, to be observed
between a child still-born, and a person of more advanced age,
who has fallen into asphyxia, namely, that the latter has been
accustomed to the circulation of arterialized blood, while in the
former, that fluid has never, as yet, been perfectly decarbonized.
In the adult, the chain of events by which death is induced,
when it commences at the lungs, may be stated to be: firstly,
a suspension of the respiratory function, while the heart’s action
continues ; secondly (the circulation being thus maintained), the
contact of venous blood with the nervous centres, by the delete-
rious qualities of which their sensibility is depressed; and
thirdly, a stagnation in the lungs, through which such blood
soon ceases to be transmitted. It is evident, under these cir-
cumstances, life may often be preserved, if we reverse these con-
ditions, by substituting for natural inspiration an artificial cur-
rent of air, by which there may be effected in the pulmonary tis-
sues those changes in the blood, necessary to enable it to traverse

* In stating that no mechanical impediment to the entrance of the air exists at

birth, it is of course presumed, that the membranes, and the mucus which blocks
up the nares and throat, have been removed. Independently of these, however,
it should be remarked, that in cases of universal congestion, the inordinate quan-
tity of blood with which the lungs are loaded, may, perhaps, offer direct opposition
to inhalation (Billiard) ; but it is evident this state is removeable, not by artificial
distention of the air cells, but by withdrawing some of the superabundant fluid,
56 Dr. Doherty on impending Dissolution and
them, and by which it may be purified of the noxious constituents
that are acting as a poison on the system. By thus temporising,
an opportunity, which speedy dissolution would otherwise deny,
is afforded for the employment of remedies capable of removing
the comatose condition, and in this way the vital principle may
be resuscitated and sustained.* But in the child which has never
breathed, things are differently circumstanced. In it the nervous
apparatus has not yet been supplied with blood which has un-
dergone the process of aération ; for although some alteration
is certainly produced in it, by the action of the placenta and foetal
liver,t and perhaps the thymus gland, during intra-uterine ex-
istence, it preserves throughout those characters, which are
denominated venous, and “ both in the arteries and veins, differs
in no perceptible respect from the venous blood of the adult.”’t
In the child still-born, therefore, it is not necessary to take into
consideration, as an element in the production of a fatal event,
the destructive effects of black blood, if conveyed by arterial
vessels, so apparent in after-life; (otherwise there could never be
such an occurrence, as the unaided revival of an infant, twenty-
four hours after being laid aside for dead§) ; and on that account
the circumstances are not so urgent as to require us to imme-
diately adopt measures for its purgation, by beginning our
efforts for restoration at the lungs, but they should be directed
rather to the brain and its peripheral extremities, whose blunted
sensibility is the canse of the non-performance of respiration.
Then, indeed, it may be useful, if breathing be delayed, to
blow into the lungs, as experiment has proved, that expansion
and contraction of the chest, and the vital actions consequent
thereon, directly aid in the circulation of the blood. But this

* On this principle, artificial respiration is worthy ofa trial in certain cases of

apparent death from apoplexy,
+ See a paper on the Functions of the Foetal Liver, by Lee and Prout, in the
Philosophical Transactions for 1829.
+ Miller’s Elements of Physiology, vol. i. p. 337. London, 1840.
§ Lancet, vol. xv. page 686.
 Nervous Affections in young Infants. 57
process, at such a time, may be aptly compared to touching the
pendulum of a clock, which has been wound up, but still remains
at rest; it gives the impetus, whereby the machinery—ready to
maintain its own actions, once it is set a-going—is thrown into
motion; whereas, to commence with artificial inflation would
more resemble making the pendulum vibrate, before the other
parts of the apparatus are in a condition to perpetuate the move-
ments thus begun. I dwell on this point, because I believe that
the latter mode of treatment is much more frequently adopted
than it ought, owing, in a great measure, to the term asphyxia
being thus incorrectly used—an error, which may probably be
attributed to the foetus before birth being immersed ina fluid ;—
and I have no doubt, that injury is often, by this operation, in-
flicted on the texture of the lungs, so delicate in infancy.
Case XI.—Thus in the case of M‘Mahon, admitted 2lst
May, 1839, in labour for the first time, when the os uteri was
but one-third dilated, a coil of the funis descended before the
head, then only entering the brim of the pelvis. The cord was
returned, and maintained so by the introduction of a large piece
of sponge; and two hours and a half afterwards the child was
expelled. It was still-born, and required the abstraction of
blood from the umbilical vessels, the warm bath, and ultimately
artificial respiration, toreanimate the vital principle. By those
means it was in some measure restored ; but, in spite of treat-
ment, expired about eleven hours subsequently. On inspection,
the lungs, notwithstanding that the operation had been per-
formed with the utmost care, presented extensive appearances of
emphysema, and points of extravasated blood. The lungs,
heart, and thymus gland, conjointly floated, when thrown into
water.
One of the chief defects of artificial breathing is, that in it
the chest is expanded by the pressure of the injected air, where-
as, in natural breathing, the air enters in consequence of its
spontaneous enlargement. But, besides the local injury which
VOL. Xxv. NO. 73. I
58 Dr. Doherty on impending Dissolution and
may be thus done, I am confident resuscitation is in many in-
stances actually arrested by resorting to mechanical insufilation,
instead of being aided thereby ; for Leroy d’Etoiles has shown
by experiment, that although inflation of air into the lungs after
submersion, is one of the best remedies for restoring life, still if
it be not managed with great skill, restoration may be prevented
by the very means used. Whatever be the remedies we feel our-
selves called on to employ, they should be assiduously persevered
in, as wonderful recoveries are sometimes made, even after all
reason for hope has apparently vanished.*
Death commencing at the lungs, therefore, or what should
alone be termed asphyxia, is mot of frequent occurrence in
young infants. It is principally observed in the event ofa wo-
man, either accidentally, or by design, overlaying her child, or
from its birth taking place unperceived; an occurrence, I would
observe, peculiarly liable to happen during the stupor which
attends puerperal convulsions. The relaxing treatment adopted
in this complaint, renders the soft parts so yielding, that the
foetus sometimes slips away, without almost an effort on the
part of the uterus. This happened with a case I was myself
appointed to watch (Flood, admitted 24th May, 1839); we
should, therefore, at such times, be on our guard. In the fol-
lowing instance, however, it occurred while the woman was in
the perfect enjoyment of her senses.
Case XII.—Tighe’s fifth child was born on the 18th of
June, 1839, unknown to the attendants, and without any outcry
on the part of the mother, who supposed it was only a motion
from the bowels she had had. It lay for some time under the
clothes, so that when discovered, it was with difficulty revived.

* Desormeaux complains of his want of success from inflation of the lungs,

even when carefully employed, and places more dependence upon means calcu-
lated to excite the respiratory muscles to contract.—Art. Nouveau-né, Dict. de
Médécine, ou Repert. Gener. des Sc. Med. Tom. vingt-uniéme, p. 154, Paris,
1840.
 Nervous Affections in young Infants. 59
A few hours after it appeared very feeble and dark coloured ;
heart beating irregularly. Some wine whey was given, by
which it seemed to be revived; during the day, however, it
was attacked with convulsions; a leech was applied to the oc-
ciput, and three baths at intervals given it. Next morning it
appeared more lively and able to suck; its bowels had been
freed by means of calomel followed by oil. On the following
day it was quite well.
Case XIII.—In an instance I lately saw in the North Dub-
lin Poor House, with my friend Dr. James Duncan, a child, a
few hours after its birth, and while in good health, was placed
lying in its mother’s arms in bed. Twenty minutes afterwards
it was discovered, that, probably through inexperience, for it was
her first, she had allowed it to turn on its face under her side;
when taken up it was quite dead. On inspection, there was a
purple red colour of the skin; the lungs and heart removed to-
gether, floated when placed in water; the lungs were congested
throughout, the lower lobes of both quite solid, as if unexpanded
by respiration; about an ounce and a half of serum in the peri-
cardium; the heart was healthy, its right cavities full of blood;
thymus very large; head not examined.*
We should remember, that in cases of suffocation the heart
retains its irritability for some time after the circulation has
ceased, and we should not, therefore, be dissuaded by that cir-
cumstance from resorting to artificial respiration, and diligently
employing other means for restoring suspended animation. Con-
vulsions, if they occur during, or after the struggle for life, will
require to be treated by local depletion, and the other measures
already pointed out.
When an infant comes into the world, the mouth and
ct
Ni tie a
* On the occasion at which this paper was submitted (in a more condensed
form) to the consideration of the Obstetrical Society, Dr, Evory Kennedy re-
marked, that in cases such as the above, death seemed sometimes to be produced,
not by the mouth being covered, but by the neck bending upon itself, in conse-
quence of the child’s head slipping off too high a pillow on which it had been
placed.
60 Dr. Doherty on impending Dissolution and
pharynx are generally clogged by mucosities, which, if not re-
moved, may impede the entrance of air, and produce asphyxia.
The same consequence sometimes results, as first pointed out
by Héroldt of Copenhagen, from the trachea and bronchial
tubes being filled with liquor amnii, a fluid that the observa-
tions of Leclard tend ‘to prove is actually respired, instead of
air, by mature embryes.*
Case XIV.—Lynch’s child, born in the Lying-in Hospital
on the 8th October, 1838, was for three hours ina very perilous
condition, almost suffocated by viscid mucus which had been
permitted to remain in its throat. In this case fremissement
was distinctly felt all over the thorax. By removing the mucus,
which was withdrawn in strings of great tenacity, by rubbing
the chest, and keeping the child lying on the lap with the head
depending, it was with a great deal to do brought round toa
satisfactory state.
Case XV.—August 9th, 1839. Dunn’s child, born last night
at 11 o’clock, after a natural Jabour, is this morning dark-co-
loured and purplish, a tint, which is more marked on the face
than the body; pulse 80; respirations 36 in the minute, irre-
gular; first sound of the heart prolonged, interval considerable.
It could never be made to breathe freely, and it died next day.
On examination, the viscera of the chest and abdomen were
found healthy. The foramen ovale open, but not large; lungs
but little distended; air passages much obstructed by fluid.
The vessels on the surface of the brain greatly distended; some
effusion of blood and serum at the posterior part and base of
that organ. In the substance of the choroid plexus was a por-
tion of adhesive yellow fibrine, resembling adipose substance,
but more firm.
Such cases require the careful removal of whatever mucus
may be within reach, either by the finger, or more easily, ac-
cording to Gardien, witha pledget of lint dipped in a solution of

* Muller’s Archiv. p- 340. 1841.

 Nervous Affections in young Infants. 61
common salt. When the trachea is blocked up, it is proposed
by Schéele to withdraw the fluid by means of a flexible tube,
to which a pump is attached.* A more feasible method is to
keep the head dependent, rub the thorax, and, if these measures
fail, we may administer a gentle emetic. After apparent reco-
very, they must be carefully watched, lest they fall into what
may be termed secondary asphyxia.
Under this head should be included death from spasm of
the glottis, but to that disease I shall only allude, as Iam una-
ble to thaow any additional light on its pathology. I have seen
eases of the affection, irrespective of that, which may complicate
local inflammation, wherein were discovered after death either
enlarged glands, as described by Ley, or the thymus of inordi-
nate size, to which attention has been drawn by Kopp and
Hirsh of Konigsberg, and by Dr. Montgomery; but in many
I believe the opinion of Sir Henry Marsh to be perfectly cor-
rect, that it is merely a functional disease at first, but when
it increases in severity, and when general convulsions arise, the
brain and its membranes have become involved.+

* Bibliothéque Germanique, tom, ill.

+ I shall here relate an interesting case, by permission of Dr. James Duncan,
under whose skilful care, at the N. D, Poor House, 1 witnessed it, as it is allied
to the disease under consideration.
Lawlor, a middle-aged woman, nursetender in one of the hospital wards of
that institution, was affected with hoarseness, apparently the result of cold, about
the beginning of the month of August, 1842. She was not confined to bed till the
18th, when she presented the following symptoms. Urgent shortness of breath,
and great anxiety of countenance; points to the top of the sternum, where, she
says, there is an obstruction to her respiration; little cough, occasionally expecto-
rates large lumps of black matter; heart’s action loud, and tolerably strong; bruit
de soufflet ; a set of dilated veins over the front part of the sternum, where, and
particularly under the right clavicle, some fulness is perceptible. Nostrils feel
stuffed.
19th. Was very ill last night, and unable to lie down; Jost her voice, and felt
as if something sticking in her throat was choaking her; thirst, but she is afraid
to drink, lest she should suffocate in the act; no obstruction, once the ingesta pass
the top of the larynx, nor has she ever felt as if the bit stopped in the passage ;
62 Dr. Doherty on d:npending Dissolution and
But there seems yet another mode, in which death, com-
mencing in the respiratory organs, may be produced in the
young infant. As death beginning at the brain results from
tedious labour, so a birth of unusual rapidity may be the cause
of death, commencing at the lungs, apparently by not giving
them time to prepare for the performance of their new function.
We are indebted to Joerg of Leipsig, for first pointing out
the injurious consequences to the child of too speedy a deli-
very. He conceives that in such cases, in consequence of the
inferior degree of compression to which the placenta is sub-
jected, a sufficient tendency is not given to the foramen ovale to
close, nor is a necessity for respiration felt by the system. After
birth then, a portion of the lungs alone becomes filled with air,
while the remainder continues in a foetal state, a condition to

there is a raucous sound on inspiration, expiration free, breathing quick; chest

sounds well, and the air cells are fully distended; epiglottis does not feel thick-
ened, no tenderness externally; heart’s action feeble and frequent, some souffle
with the first sound, but it is doubtful whether it is persistent: spit up some black
matter last night; epistaxis from left nostril, which she felt had the effect of clear-
ing it; expression still anxious; aspect pale and cachectic ; tongue dry and brown.
20th. Considerably less distress ; slept well lying down; breathing less fre-
quent, and more equal ; less stridor ; complains of rawness of the throat; sputa
brought up by an emetic consisted of inspissated mucus with some blood and
black matter. MHeart’s action more tranquil, 92; still slight souffle with first
sound, epistaxis returned; tongue as before; no difficulty in swallowing; back
of the pharynx presents streaks of a dark colour; neither uvula nor palate swol-
len.
2st. Suffered greatly from dyspnoea during the night; rather less stridor,
9, p.m. Sleeping constantly and heavily, notwithstanding that she has been bled
and cupped; blood drawn cupped and buffed; can scarcely swallow; chest is
very much contracted and expanded at each respiration; expiration, as well as
inspiration attended with a loud sound, like that heard in tracheotomised cases;
pulse 96.
22nd, Dyspnoea is rather less urgent; is constantly falling asleep; ‘inspira-
tion accompanied by a loud noise, expiration whistling, both forcible. Is very
reluctant to swallow ; sometimes a drink will only get as far as the pharynx, when
it is rejected.
 Nervous Affections in young Infants. 63
which he has given the name of atelektasis, and which may,
amongst other ill consequences, give rise to apoplexy, depend-
ing on the want of duly oxygenated blood.* For example:
Case XVI.—Murray’s child, born 16th August, 1839, after
a labour, the entire of which occupied only an hour, respired
very imperfectly at birth. An attempt was made to distend the
lungs artificially, which, with the aid of the warm bath and
galvanism, was partly successful. The child, however, continued
very feeble, although stimulants were applied, and two days
afterwards was seized with convulsions. A leech was applied
to the head, and blue pill with James’s powder given ; it died
at four o’clock next morning.
Casz XVII.—June 5th, 1839. Kelly’s child, her eighth, born
three days ago, after a labour of only half an hour’s duration,

23rd. Died at 4 o’clock this morning, after much dyspnoea succeeded by

convulsions.
Post Mortem.—Body plump; layer of subcutaneous fat very thick; conside-
rable congestion of lungs, which were throughout healthy, except at the anterior
partof the base of the left lung, where was the remains ofan old cavity, filled with
Ccrustaceous matter. Thyroid gland very large, and its third lobe much more develop-
ed than natural ; epiglottis a little thickened, some punctuated redness on the mu-
cous membrane of the larynx and trachea; no other morbid appearance about the
rima. On removing the parts, a tubercular appendage was found growing from
the sixth intercostal cartilage, rather to the right of the median line; it was about
the size of a large pea, and close to it was a mass of tuberculous deposit, as large
as an ordinary lemon, which in a great measure surrounded the trachea, and must
have encroached considerably upon its calibre. In the foregoing case then it
would appear, that the pressure of this mass, and probably of the enlarged thyroid,
upon the nervous trunks, was capable ofproducing a difficulty, both in the ingress
and egress of air at the top of the larynx, and thus gave rise to sounds corres-
ponding with those heard in spasm of the glottis in infants. It is, I think, a par-
ticularly interesting case, as neither Ley nor his commentator (Dublin Journal
of Medical Science, vol. ix. p.303), whom from the initials affixed to that excellent
review, I presume to be Mr. W. H. Porter, the distinguished author of ‘* The
Surgical Pathology of the Larynx,” has ever seen laryngismus stridulus thus
produced in the adult,
* Joerg Die Fotuslunge im gebornem Kinde, &c. Grimma, 1835,
64 Dr. Doherty on impending Dissolution and

has continued since birth of a dark colour; skin cold; breath-

ing difficult; a tendency to spasm, particularly when drink is
given to it; discharge of a greenish colour from the mouth,
which is thickly coated with muguet ; sounds of heart normal.
A leech over the sternum; wine whey. Next day the child
appeared declining; colour of skin not so dark ; great diffi-
culty in swallowing, the pharynx being apparently thrown into
spasmodic action, the fluid can only make its way a short dis-
tance down when it is regurgitated. Stimulants were continued,
but it gradually lost the power of swallowing, and died on the
10th inst., apparently in great pain. On post mortem examina-
tion, the lungs were only partially permeated by air, the re-
mainder maintaining their original state; the foramen ovale
continued pervious; the vessels of the brain much distended.
In cases of this kind, and indeed in all, there is one ge-
neral rule to be observed, never to tie the cord as long as
pulsation exists in it, until respiration is well established;
and never to rest satisfied in any case, until the child by its loud
cry, the “ vagitus intra muros” of the Scotch law, convinces us
that its lungs are fully able to perform their function. At a later
period, in instances such as those I have recorded, our treat-
ment must consist in the use of stimulants internally and exter-
nally, together with remedies directed against the apoplectic and
inflammatory consequences to which the brain and lungs are
both liable. In detracting blood from the chest, the best situa-
tion to apply leeches is under the axilla, as the subcutaneous
venous plexus there communicates directly with the vessels of
the thoracic cavity, a remark which has been made by Bil-
liard.

Instances we sometimes see, in which, after birth, the heart

of the child is laboured and tumultous in its action, and appa-
rently oppressed by the blood that flows upon it; and, in such
cases, congestion of the surface, convulsions, and even death
may ensue. They probably arise from a tendency to closure of
 Nervous Affections in young Infants. 65
the former channels not being established (for it does not appear
necessary they should be actually closed for some days), or from
a feeble condition of the heart itself. The same symptoms are
often, in the hands of inexperienced attendants, induced by ap-
plying a ligature to the cord the moment the first gasp is ob-
served, and before the respiratory function has come sufficiently
into action to open a new course for the circulation.* They re-
quire leeching over the cardiac region, &c., for their removal.
But syncope, or death commencing at the heart, in the newly
born as in the adult, is best exemplified by the effects of loss of
blood. Hemorrhagic discharges from the uterus during ges-
tation or labour, may, it is well known, be a cause of death and
premature expulsion to the foetus, or of deficient vitality in the
child at birth, even if carried to the full time. We are not to
suppose this result is produced by a direct detraction from its
system ; for experience proves these beings, though in such close
coaptation, to possess circulations so independent of each other,
that although the parent may bleed even to the extinction of her
life, the foetal vessels are not thereby deprived of their contents;
a fact first demonstrated by Wrisberg in his experiments on cows
in calf.t It is strange, therefore, to find so distinguished a
writer, as Marc, assert, that in cases of detachment of the pla-
centa, and of ruptured uterus, the foetus becomes bloodless.t
But Ladmirault has proved that in the former case, this morbid
condition ought not to be attributed to an empty state of the
vessels, for in his post mortem inspections, on opening the heart
and great vessels, a large quantity of blood flowed from them.

* The injurious consequences of tying the cord too soon, are noticed by Eberle
in his ‘‘ Treatise on the Diseases and Physical Education of Children,” Phila-
delphia, 1837, p. 86.
+ See also Rigby in Tweedie’s Library of Medicine, vol. v. page 34. London,
1841.
¢ Dans ’hémorrhagie ombilicale produite par le décollement total ou partiel
du placenta, par la rupture de la matrice, le foetus présente tous les signes de
Vanémie.” —Art. Infanticide, Dict. de Med. ou Repertoire Gen. des Sc. Med. tom.
vi. p. 383.
VOL. XxVv. NO 73. K
66 Dr. Doherty on impending Dissolution and
It should rather be referred to a deprivation of that peculiar in-
fluence, (which some, without sufficient reason, have denominated
the power of oxygenation,) exercised by the placenta on the fluids
earried to it by the umbilical arteries. In the latter instance too,
this, which may be looked on as a spurious asphyxia, must be the
cause of death, when the uterine contents escape into the abdo-
men ; but even when the foetus remains in utero, the fatal event is
not referrible toa drainage from the vascular, but apparently to a
shock upon the nervous system, possibly transmitted from that of
the mother, extinguishing the vital powers, by whose means the
blood is moved, just as occurs in concussion ; and thence arises the
pale, flaccid appearance of the body. On this account, we can-
not, with strict propriety, include in this section the still-born
condition, if consequent on profuse metrorrhagia, nor following
laceration of the womb. But if we are of opinion, as indeed is
proved almost beyond a doubt, that the office of the placenta
is, not to be a medium of continuity between their circulatory
organs, but to transmit from the one individual to the other,
andelaborate in their passage, nutrient particles, we may readily
admit, that the feeble, puny, almost lifeless state, in which the
infant so frequently comes forth,—in cases, wherein the placen-
tal function has been interfered with by hemorrhage in smaller
quantity but frequently repeated,—does approximate to true
syncope, the consequence of the offspring having been exposed
to what may, without inaccuracy, be termed starvation.
To syncope we may also, with much probability, assign the
imminent danger which impends over the foetus, when it presents
by the feet. Under such circumstances, it is apparent the cord
is very liable to suffer such compression, as will instantaneously
put an end to the transmission of blood through it; even more
so, than when the head being engaged in the vagina, the pelvis
is sufficiently roomy to permit a coil or two of it to prolapse.
Now, the consequence of the funic circulation being suddenly an-
nihilated, must be, that the supply of blood to the left side of
the heart is at once cut off, just as if in the adult the pulmonary
 Nervous Affections in young Infants. 67
veins were rendered impervious, and those cavities, continuing to
contract, speedily empty themselves of their contents, and are
then disabled from maintaining any longer the normal amount
of pressure on the brain. While, though the escape of blood
from the system is at the same time equally arrested, the vis a
tergo being no longer in action, the capillaries do not become
sufficiently distended to give more than a livid tint to the sur-
face. The child at birth, therefore, presents all the appearances
of a deep faint; and on opening such bodies, the blood is
found to have deserted the left side of the heart, and accumu-
lated in its right cavities and the great trunks. But we have
already seen that in other cases of funic presentation, the infant
exhibited all the signs of congestion. Those were instances
in which, from the cord being subjected to only a mode-
rate or an intermitting force, its pulsations could be felt in the
vagina becoming more and more laboured, until they ulti-
mately ceased. There seem then to be two modes whereby
compression of the navel-string may prove detrimental to the
foetus; firstly, resulting from a total obliteration of its vessels, an
almost instantaneous suspension of life, beginning at the heart;
and, secondly, a comatose condition, slower in its approach, hav-
ing its seat in the brain. In the same way, too, it would appear,
that artificial delivery of a footling, if not dexterously per-
formed, is fraught with a double danger to the child. Attempts
at extraction, made at an improper time, may be attended by a
perilous failure of the heart, and from force, indiscreetly applied,
may arise a concussion of the spinal marrow, equally deplorable
in its results.*

* Intra-uterine life is sometimes accidentally extinguished by the mother lean-

ing against the edge ofa table, for instance, and thus obliterating the funic
vessels, if exposed to pressure, in consequence of the cord encirling a limb of the
foetus. They are cases in which the funic souffle would have been audible with
the stethoscope. A tight knot on the navel-string may have the same effect, as no-
ticed by Smellie, Osiander, and others. See Hannay’s case, Lond. Med. Gazette
vol, xxvii. p. 122.
68 Dr. Doherty on impending Dissolution ana
But death, having the heart for its salient point—as indi-
cated by paleness and collapse of the countenance, cold extremi-
ties, pulse becoming gradually imperceptible, while respiration
continues to the last—is still more plainly exemplified by cases
wherein, either from inattention at the birth, bleeding from the
cord occurs, or when the same accident attends ulceration at the
umbilicus, after the navel-string has dropped. Inan instance which
occurred to myself some years ago, I used a rather broad piece
of tape to tie a cord, which was very thick and gelatinous. Be- .
fore I left the house, I fortunately went to look at the child,
which, after being dressed, had been laid in a cradle, when I
found it blanched, and in a state closely bordering on convul-
sion. The cord having quickly shrunk, the string had slipped
off, and bleeding to an alarming extent ensued, without attract-
ing notice. By the aid of cordials, and sedulously maintaining
the heat of the body, the child gradually came round; but the
occurrence gave me, at the time, a great fright, and impressed
upon my mind a lesson never to be forgotten. I now always, to
make assurance doubly sure, apply two ligatures to the foetal
end of a very thick funis, pressing out, at the same time, the
gelatinous matter, and I never neglect the precaution my old
preceptor, the late respected Professor Hamilton, used to re-
commend to his class, namely, while handing the child, after
its separation from its mother, to the nurse, to desire the latter, in
a voice which can be heard by others as well as herself, to ex-
amine frequently that all is right with the navel.
The treatment such cases will demand, whether attended or
not by convulsions, will be similar to that, which, under parallel
circumstances, would be required in the adult ; the observance of
the horizontal position, the application of heat, and the use of
stimulants (with opiates in some instances), and of appropriate
sustenance, being the chief indications. Very much the same
plan should be adopted when the infant comes into the world,
feeble from deficient nutrition; but when still-born from this
cause, I apprehend we can entertain less hopes of recovery,
 Nervous Affections in young Infants. 69
than in other forms of apparent death. However, we should
instantly attempt it by means of external warmth, stimulating
frictions, wine injections, and other measures calculated to recall,
if possible, the vital spark. Artificial inflation may here be
given an early trial, but I fear will not often be found of much
avail. In arrested circulation from pressure on the cord, a
much better prospect of success attends the performance of the
operation, and this is just the case in which its timely and conti-
nued use is likely to be followed by the happiest results, owing
to its power of unloading the venous trunks, and renewing the
contractions of the heart. But it need not be resorted to, till
we have tried slapping the buttocks, dashing cold water on the
surface, and other such measures.*
ree ae meet an eS SS ee Se Eee eee
* To show how indiscriminately the term asphyxia has been used to signify the
still-born condition, regardless of the function primarily engaged in its production,
thus making the absence of respiration, a mere symptom, the generic characteristic
of the morbid state, I shall quote the following passage from a work of acknowledged
excellence. ‘‘ L’Asphyxie des nouveau-nés,” observes Savary, ‘* succéde ordinaire-
ment a un accouchement laborieux, et dans lequel la mére a essuyé des pertes con-
sidérables. L’enfant vient alors au monde ex-sanguin, pour nous servir de l’ex-
pression du célebre Baudelocque. Mais ce n’est pas le seul cas o& cet accident
se présente; il peut tenir a la constitution délicate du foetus, et depend souvent,
ou presque toujours, suivant M. Freteau, de la compression du cordon ombilical
pendant ]’accouchement; aussi est-il plus commun lorsque l’enfant vient par les
pieds. Dans cet état l’enfant est pale, ou livide, ses chairs sont flasques, ses mem=
bres souples, et sans mouvemens; il ne respire point; on ne sent point de battee
mens le long du cordon ombilical, ni 4 la région du cceur; tout, en un mot, semble
indiquer, que l’enfant a cessé d'exister.”” This author, however, more correct than
many others, has properly distinguished the condition here depicted from that of
apoplexy.—Art. Asphyxie, Dict. des Sciences Med. tom ii. p. 369.
Gardien, in his chapter entitled, «‘ Soins a donner a l’enfant nouveau né,” one
of the few elaborate articles on this subject, has fully exposed the impropriety of
using the term asphyxia, but with little more accuracy he has referred the symp-
toms usually classed under it, in every instance, to Syncope. In so doing, it ap-
pears to me, he has fallen into several errors ; firstly, throughout his arguments he
has assumed that the maternal and foetal circulations are continuous ; his words, in
speaking of cases of profuse hemorrhage from the uterus, are: ‘ L’état ex-sanguin
dans lequel nait l'enfant dépend évidemment de ce qu’il n’y a plus de proportion
70 Dr. Doherty on impending Dissolution and
We have already shown that injury inflicted on the spinal
marrow during delivery may extinguish life by directly arrest-
ing the heart’s action; and we have now to notice, that as
the brain is liable to be the seat of congestion in the child
newly born, so may the medulla spinalis in a similar way
be deranged. The consequence of such a condition must be
to paralyse the organs of respiration, for the medulla oblon-
gata is the source from which the nervous influence for the res-
piratory motions is derived, and the spinal cord is, as it were,
the trunk of the nerves which arise from it.* Ollivier in-
deed states, that this function is entirely dependant, at least in
mammiferous animals, on the spinal marrow; and Wilson’s expe-
riments have proved, that the action of this portion of the ner-
vous system on the heart, is not so direct as on the function
of the lungs. After this morbid state has been in a great mea-
sure removed by treatment, a minor degree may persist, or may
at a somewhat later period arise, from which, as from its conge-
ner in the brain, injurious consequences will result. Indeed,

entre le sang qu'il regoit de sa mére, et celui qu’il envoie au placenta :” secondly,
while he shows the fallacy of the opinion entertained by Chambon, Capuron and
others, that total obliteration of the cord gives rise to apoplexy, he does not recog-
nize the difference in the mode of death in that case, and when it is only partially
compressed: ‘si, dans le cas,” he observes, ‘‘ ot le cordon accompagne la téte
enfant présente quelquefois le facies, propre a celui qui est apoplectique, c’est
que la téte a ete comprimée en méme temps que le cordon, et avant que la pres-
sion fit assez forte sur ce dernier pour y intercepter le cours du sang;” not per-
ceiving, that it is in cases of large pelvis, and when the head is consequently
exposed to actually the least degree of pressure, prolapse of the funis is most
liable to occur with that presentation: and thirdly, he makes no allusion what-
ever to death from concussion, nor to a morbid state of the spinal marrow. In
the following sentence he is decidedly incorrect: ‘‘ Jamais on n’a vu l’enfant
naitre pale, decolore, parce que la téte, en traversant les détroits du bassin, a été
soumise & une pression plus ou moins forte.”—Traité d’Accouchemens, tom. iii.
page 130-152. Paris, 1824.
* Muller’s Elements of Physiology, vol. i. p. 364, 2nd edit. London, 1840,
tOllivier Traite de la Moelle Epiniére, &c. vol. i. p. 64. Paris, 1823;
Wilson in Phil. Transac. for 1815,
 Nervous Affections in young Infants. ‘al
Ludwig and Frank* have pointed out, that even in a state of
health the absence of valves in the spinal vessels, and their pe-
culiar distribution on the surface of the cord, must predispose
to a remora of the venous blood in the adult, particularly as
that fluid must ascend in opposition to gravitation. The vessels
too are equally pressed on by the cerebo-spinal fluid; but any
cause, which tends to increase or diminish its normal quantity,
may readily be conceived to favour venous congestion.t These
conditions exist equally in the infant after birth, and in it,
therefore, engorgement of the spinal canal is by no means un-
common. Cases of this kind, from the violent spasms which
attend them, frequently bear a great resemblance to that more
fatal malady, trismus nascentium ; but they differ from it in pre-
senting a moveable condition of the jaw, and a power of deglu-
tition in the intervals of the fits. The following was probably
a case of simple spinal apoplexy.
Case XVIIL—Doyle’s child, a full grown infant, was born
in the street while its mother was on ber way to the hospital, at
1 o'clock on the morning of the 14th November, 1838, and on
its admission immediately afterwards, appeared ina very weakly
state. It was nearly motionless; its breathing slow; the sur-
face cold and blue. By the application of heat an improvement
in its circulation was effected, but still it did not cry out. A
grain of calomel was given, followed by oil, and brought away
copious evacuations of the usual black colour; wine whey was
administered occasionally. It remained pretty nearly in this state
with occasional low whining till the next morning. It was then
unable to suck, and assumed the yellowish tinge seen in infants
about this period. About 12 o’clock it was first observed to be
convulsed, The fit set in with a low screech, which was suc-

* Ludwig Advers. Med. Prac. tom. i. p. 711, Leipsig, 1770; Frank Delect.
Opuscula, tom. xi, de vert. column. 1792,
T See Ollivier, Op. Cit. vol. ii. page 448. Magendie’s experiments on the
effects of drawing off the cephalo-rhachidian fluid will be found in the Lancet, vol,
xi, page 725,
72 Dr. Doherty on impending Dissolution and
ceeded by alternate spasmodic contraction and relaxation of the
limbs; the fingers were alternately extended and drawn spas-
modically into the palms of the hands, with the thumbs strongly
flexed over them; the body was bent forcibly backwards. During .
its continuance the respiration became much slower, the surface
of the body and face livid, and the eyelids were alternately
opened and shut. These paroxysms, each lasting about five mi-
nutes, continued in rapid succession, with a gradually diminish-
ing interval, until at length a fewseconds only intervened. As the
fits became more severe and frequent, the surface lost its yellow
tinge and became pallid. At half past | o’clock, a.m., the suc-
ceeding day, the convulsions appeared to subside alittle, but they
were followed by an increased degree of exhaustion, and the
child expired at 2 o’clock immediately after the cessation of a
paroxysm.
In the following example in which cerebral and spinal con-
gestion were combined, the resemblance to trismus was still
more striking, but yet it did not present the firmly closed jaw,
nor the angles of the mouth drawn directly backwards, so cha-
racteristic of the latter disease.
Cas— XIX.—Reilly was in labour of her third child for
an hour anda half on the 11th September, 1838, when the funis
prolapsed. As it was pulsating, and the head pressing strongly
on the perineum, no artificial assistance was rendered. On the
birth of the child its vitality was with difficulty restored, nor
did it appear perfectly revived for above two hours. At 5, a. M.,
on the 12th September, fifteen hours after birth, it was seized
with clonic contraction of its limbs, ushered in by a scream, the
hands and feet being strongly flexed and remaining so through-
out the paroxysm ; mouth widely open, lower jaw firmly fixed in
that position; complete oposthotonos ; respiration impeded, the
whole surface ofa dark colour. Warm baths, leeching the back
of the neck, calomel, and assafcetida injections were employed.
4, p.m. Has had many convulsions during the day, the inter-
val between them being generally only of five or ten minutes du-
 Nervous Affections in young Infants. 73
ration. During the fits, which commence with a tremulous mo-
tion of the lids and eyes, the features become black, the mouth
is forcibly opened, and the child works strongly with the feet
and hands. At present, a paroxysm having just ceased, the
hands are closely shut, the thumbs overlapping the extremities
of the first two fingers, and the forearms are strongly flexed. A
tremulous turning of the head from side to side exists, and
twitchings of the muscles of the face, accompanied with opening
and shutting of the mouth, which is occasionally drawn to the
right side. The child can swallow only half a teaspoonful
at a time, and the injections are not retained for a moment.
9, p.m. It is now lying in a state of quiescence; the con-
junctivee are much injected; on the approach of a candle the
pupils act, but the infant does not appear sensible of the light;
the arms are not so firmly drawn up, and though fits occur oc-
casionally, the intervals are more prolonged. A draught of tur-
pentine, oil, and tincture of assafoetida administered, and calo-
mel continued in doses of half a grain every third hour. Next
morning (the 15th) convulsions still existed, and the child died
during the course of that day.
Post Mortem made 28 Hours after Death.—Great and ge-
neral lividity of the surface; rigidity of the limbs ; hands firmly
clenched. On cutting through the dorsal muscles a conside-
rable quantity of fluid blood escaped, and still more was infil-
trated into the cellular tissue about the dura mater of the cord ;
this membrane was itself congested, and the vessels in the spinal
eanal, and particularly those described by Breschet, between the
dura mater and the posterior surface of the vertebra, were
gorged with blood and presented a beautiful appearance.
There was some serous effusion into the theca, but the spinal
marrow was itself apparently natural. The sinuses of the brain
were distended with fluid blood ; blood mostly fluid was effused
betweenthe dura mater and the two parietal bones, detaching the
membrane extensively from them. A small clot of blood lay
upon the arachnoid, covering the posterior part of the middle
VOL. Xxv. NO. 73, L
 74 Dr. Doherty on impending Dissolution and
lobe of the right hemisphere: the vessels of the pia mater
were also much injected, and the brain throughout presented,
when cut, more bloody points than natural. All the cavities of
the heart were full of blood; the ductus arteriosus was wide
open, and no effort had apparently been made to close it, or
the communication between the auricles. The lungs were much
congested. The liver was black from the quantity of blood
it contained; the gall bladder distended with bile; the ductus
venosus shrunk, but not obliterated ; the other viscera healthy.
It is curious that in infants we scarcely ever find circum-
scribed cerebral haemorrhage. Effusion, when it does occur,
- is almost always on the surface of the membranes, which per-
haps may account for the infrequency of permanent paralysis in
cases, which survive the apoplectic seizure. I shall now contrast
these cases with two of pure Trismus, that occurred in the hospi-
tal about the same time, and of which I was able to obtain
post mortem inspections.
Case XX.—Tankard’s child, born on the 16th of August,
1838, after a natural labour of three hours, was quite well up to
3 o’clock, a. M., on the 21st, when it began to whimper. About
4 o’clock the nurse observed its jaws firmly closed, and it was
unable to suck. It had a bath and calomel powder, after which
it slept till 6 o’clock, when it awoke in a scream. At 10 o’clock
visit, the jaws were closely approximated, the lines upon the
chin, arising from contracted muscles,’ distinctly marked; the
lips compressed against the teeth, the corners of the mouth
being drawn directly backwards, and the depression naturally
existing in the centre of the upper lip thus obliterated; the nos-
trils were widely open; the lids half closed; the eyes some-
what turned up, half the cornea being concealed under the up-
per lids, but the eyes themselves moveable; hands and arms
flexible; the back of the neck stiff. There was an unhealthy
appearance of the umbilicus, from which the cord had sepa-
rated the day before. One grain and a half of calomel was ad-
ministered, and a bath. At one o’clock all those symptoms
persisted, and the rigidity had affected the upper extremities
 Nervous Affections in young Infants. 75
also, the thumbs being buried in the palms of the hands. The
bowels had been once moved by the medicine ; dejections dark
green; abdomen distended. Following out the treatment re-
commended by Dr. O’Beirne, who indeed saw this case, a tube
was first passed up the rectum to bring away flatus (an opera-
tion, which did not prove as difficult, as the apparently spasmodic
state of the sphincter would have led one to expect), and a short
time after, there was injected through ithalfof an infusion, made
with three grains of tobacco to eight ounces of boiling water.
On visiting the child an hour after this enema, the fingers
were still clenched, it was constantly and loudly moaning, but in
a hoarse tone. Spasm had then attacked the lower extremities
also. The eyelids usually remained half open, and, on an attempt
being made to separate them still more, closed spasmodically ;
the eyes were not affected. The child made now and then mo-
mentary efforts to throw itself backwards—efforts, which seemed
to be made with the head and spine simultaneously; the arms
being, at the same instant, drawn spasmodically towards the me-
dium line of the body, and the fingers and thumbs more firmly
clenched.
7 oclock. Has just had a strong tetanic fit, in conse-
quence of the nurse endeavouring to make it swallow. She says
it sometimes lies for twenty minutes, when undisturbed, without
having one, but the moment a drop of fluid is put into its mouth,
all its extensors are thrown into action. The last, she describes,
as the most violent it has yet had. The pulse is scarcely per-
ceptible. Extremities cold. The remainder of the injection
was thrown up.
At 9 o’clock,it appeared somewhat better. It certainly could
open its mouth rather more, and the upper extremities were,
perhaps, less rigid; but the hamstrings were just as tense, and
the big toes turned as forcibly upwards and inwards. The child
was pale, pulse very weak. The tube was again passed, to bring
away flatus, and some chicken broth thrown up. It died, how-
ever, at 4 o’clock next morning.
Post Mortem made eight Hours afterwards.—In the spinal
76 Dr. Doherty on impending Dissolution and
column was found a considerable quantity of fluid blood, effused
into the cellular tissue around the dura mater, which was itself
healthy. The vessels beneath the arachnoid appeared little more
distended than usual; spinal marrow unaltered. Rather more
distention of the cerebral sinuses than natural, no extravasation ;
brain not particularly engorged; ventricles healthy; falx and
tentorium very vascular.
Case XXI.—Leary’s child, born on the 21st August, 1838,
was attacked with trismus on the 4th September, at four o’clock
in the afternoon. In this case, the treatment recommended by
Dr. Breen was adopted, namely, small doses of laudanum with
calomel, followed by castor oil and turpentine ; but it died at
five, P. M.
Post Mortem made next Day.—Great and general lividity
of the surface, especially of the extremities, which were in a
state of semiflexure, and exceedingly rigid ; the fingers firmly
clenched, and the thumbs closed on the palm. There was great
rigidity of all the muscles, and even some degree of opisthotonos
remained, the loins being raised for some distance from the flat
surface, upon which the child was laid ; the jaws were not quite
closed, but firmly fixed; the umbilicus was not healed, though
the cord had dropped off, and there was slight oozing of sero-
sanguineolent fluid, from the orifice of the umbilical vein. ‘This
vessel, however, was not inflamed—a condition, I would observe,
I have seen distinctly marked in one case. The whole tract of
the spine was occupied by semi-coagulated blood, effused in
great abundance into the cellular tissue, surrounding the dura
mater; less copious within the arachnoid, the vessels beneath
which membrane were also much distended. The dura mater
of the brain was healthy, but there was considerable effusion of
blood into the sac of the arachnoid at the base of the brain; the
vessels on the surface were congested ; the brain itself vascular.
The pleure, and substance of the lungs, presented a congested
appearance; all the cavities of the heart were full of blood, and
the foramen ovale and ductus arteriosus were both open, nor did
there appear to have been any attempt to close them. The vis-
 Nervous Affections in young Infants. 77
cera of the abdomen were healthy; umbilical vein pervious ;
ductus venosus contracted, but not obliterated.
Rachitic congestion, then, is characterized by convulsions of
the limbs, and sometimes of the face, and more particularly by
tetanic spasms, generally assuming the form of opisthotonos.
It requires the same remedies for its removal as congestion
within the head, namely, local abstraction of blood, counter-
irritation, calomel, probably combined with James’s powder, &c.
As to the nature of trismus, it is not my intention to offer any
remarks, nor shall I canvass, at such a moment, the correctness
of the opinion, advocated by our much-to-be-lamented friend,
Dr. Colles,* that it is actually traumatic tetanus, originating in
unnatural separation of the funis. The cases, I have given, show
how similar are the symptoms, and how close a resemblance
exists between the post obit appearances presented, by in-
fants, who have died of that disease, and of mere ordinary
cerebro-spinal congestion; and I own myself altogether inca-
pable of determining, why it should be, that the latter is amenable
to treatment, while the former is invariably fatal.t+

* A fatal termination to the illness, with which that distinguished surgeon and
exemplary man had long been afflicted, had taken place a few days before the even-
ing, upon which this paper was read to the Obstetrical Society.
+ Some post mortem examinations of cases of trismus are given in the 15th
volume of the Edin. Med. & Surg. Jour. by Dr. Labatt, but in it he confines his
observations to the state of the navel, to controvert Mr. Colles’s opinion above al-
luded to, It appears to me, that it is from not attending to the distinctive cha-
racters I have poiated out, some authors have been led into the belief of the cura-
bility of trismus. But it will be found, that in the disease which is remediable,
the mouth, instead of presenting the peculiar features of a firmly closed jaw, and
angles of lips drawn directly backwards, is either widely opened, or drawn to one
side, or if clenched by spasm, can with very little force be opened, as in the case
ofa child seven days old, recorded by Abercrombie, in which, after death, a long
and very firm coagulum of blood was discovered, effused between the bones and
the membranes of the cord on the posterior part, and extending the whole length of
the cervical portion of the spinal canal (On Diseases of the Brain and Spinal Cord.
Edin. 1834, 3rd edit. p. 358). And 1 am fully borne out in my statement, that
Trismus Infantum has hitherto resisted every mode of treatment, by Dr. Collins,
in the Dub. Jour. of Med. Sc. vol. ix. page 83. The result has attended various
modes of treatment adopted by Finckh. See his interesting Memoir published in
78 Dr. Doherty on impending Dissolution and
I have now gone through what may be termed primary con-
vulsions, or those directly dependant upon an unnatural condi-
tion of the great vital organs, the brain and medulla spinalis,
the lungs, and the heart; and I shall now offer a few illustra-
trations of disorders of the nervous system, which may be called
secondary, or sympathetic, still confining my observations to in-
fants shortly after birth. It is a well-known fact, that the irrita-
tion caused by offending matter in the intestines, whether from
retention of the meconium, or the use of aliments which disagree
(amongst which the most common is thick victuals), is a very
fertile source of such affections. From analysing cases of this
description, it would appear, that gastro-intestinal derangement
may not only produce spasmodic movements, co-existing with
evidence of cerebro-spinal congestion; but it may also affect the
distribution of nervous influence—of course by a reflex action—
but without any disordered condition of the nervous centres ca-
pable of demonstration. Examples of these different states I
shall now give. The following were two cases of threatening
apoplexy from this cause:
Casé XXII.—May 26, 1838. Penrose’s child, now three
days old, was griped throughout yesterday; this morning it has a
tendency to fits, and presents a paralytic condition of the right
side of the face. It was given blue pill, followed by oil and tur-
pentine, and as the tendency to convulsions still continued, a
leech was applied to the fontanelle, and it was immersed in a
warm bath. Next morning it was quite well.
Case XXHI.—A child, the name of whose parent I ne-
glected to note, born in ward 7, bed 70, on the 27th April,
1838, and brought up by the spoon, was observed on the tenth
day, its bowels having become deranged, to lie in a soporose con-
dition, with tremulous motions of the lower jaw,the left angle of
the mouth being drawn downwards. A leech was applied to its

Hecker’s Annalen, vol. iii, No. 3, in which be gives the post mortem appearances
in twenty cases. Darwin entertained the curious idea, that Trismus with the
mouth open is most usual in newly born infants ; but the opposite is the case in
those who have already begun to masticate hard substances (Zoonomia, vol. v.
p. 50).
 Nervous Affections of young Infants. 79
head, the bath used, and calomel given, followed by oil. Next
day it was more lively, but feeble, and in pain ; some aromatic
spirits of ammonia, in carraway water, was given at intervals, and
an injection of a grain of carbonate of ammonia, and two drops
tincture of opium, ina little camphor mixture, thrown up. On
the following morning it was much better. It had lost the drow-
siness and tendency to spasm in the muscles of the face.
Dr. Parrish, one of the physicians to the Pennsylvania Hos-
pital of Philadelphia, has drawn attention to the fact, that in-
fantile convulsions often arise from spasm of the intestines. In
one case, five months’ old, he found after death more than half
of the small intestinesirregularly contracted. In some places, for
more than an inch in extent, the bowel was reduced to the size of
a goose-quill; in others, it appeared as if tied with a thread, its
calibre being almost obliterated. The omentum was closely
folded up in the form of a small cord, and lay on the arch of the
colon.* In the following case, convulsions were produced by an
inability to discharge the contents of the abdomen, in conse-
quence of one of the bowels not being developed beyond a ru-
dimentary condition.
Case XXIV.—July 11, 1838. Tench’s child, born on the
7th, has had no discharge of meconium since birth, notwithstand-
ing the use of purgatives and injections, A little jelly-like fluid
alone was expelled, and even that has ceased since yesterday. It
is now jaundiced, cold, feeble, with a tendency to fits, still ca-
pable of swallowing; but what it swallows it throws up. No
treatment was effectual in moving the bowels, and it died con-
vulsed, the following morning at one o’clock.
Post Mortem made next Day.—Body emaciated, and gene-
rally ofa yellow colour. On opening the abdomen, the liver
appeared healthy, the ducts pervious, and the gall-bladder full
of green bile; the stomach and duodenum were distended with
air, and contained a yellowish, thick, creamy fluid; in the ileum,
were several masses of green, rather hard and dry feecal matter,
at irregular distances from one another, but the mucous mem-

* North American Medical and Surgical Journal for January, 1827,

80 Dr. Doherty on impending Dissolution and
brane in contact with them, was not infamed ; the arch of the
colon was very defective in size, being little more thana narrow
flat band ; the descending colon and rectum natural.
The two following cases exemplify the rapidity with which
convulsions, the result of intestinal irritation, may produce death.
In the second, not only the brain, but the spinal marrow appears
to have been engaged.
Case XXV.—Rafter’s child, born on the 3lst May, 1839,
was spoon-fed, in consequence of its mother becoming affected
with peritonitis. It seemed thriving up to the 8th June, when,
its bowels becoming disordered, it was seized with fits, for the
relief of which, turpentine enemata, the warm bath, and wine
whey were directed, Next morning it appeared in a state of
collapse; it was pulseless, cold, and blue; breathing by gasps,
occurring at long intervals, but not affected with spasms. The
warm bath was again resorted to, and a stimulating liniment
rubbed to the spine, and wine whey, with other remedies calcu-
lated to bring about reaction ; however, it never rallied, but died
the day following.
Case XXVI.—M‘Donald’s child, born on the 20th Fe-
bruary, 1839, was cross on the 24th, its stools being unnatural ;
an enema was given, and at bedtime, a quarter of a grain of
Dover’s powder. About an hour after she fell asleep, and in
a short time was seized with a convulsive fit. ‘The heart
beat feebly, and sometimes intermitted; breathing at times
almost suspended; body cold; pupils contracted ; now and then
the child clenched its hands, drew up its arms, and threw its
body backwards. A stimulating liniment was assiduously rubbed
over the heart; the body was immersed in a warm bath, while
cold water was thrown on the head; wine whey was freely
administered. By these means the infant was restored, and
was left breathing freely, and crying loudly. Two grains
of carbonate of ammonia were ordered every halfhour. At ten
o’clock visit next day, it appeared very weakly, and lay with
little signs oflife,save slight motion of the alz nasi, and a feeble
beating of the heart, at the rate of eighty-four in the minute.
 Nervous Affections in young Infants. $1
The former means were again resorted to, and at twelve o'clock
it appeared much more itself, breathing freely, and having its
eyes open. ‘The same remedies were continued throughout the
day, together with a leech to the head, and a mustard cataplasm
to the spine, notwithstanding which it died about two o’clock.
The body was removed without examination.
To enter fully into the treatment required by cases such as
these, would extend this paper to an inordinate length. I shall
therefore rest satisfied with the general statement, that the con-
vulsions will demand almost the same measures as before alluded
to, graduated of course according to the previous condition of
the little patient; and that besides medicines, which tend to
correct the unnatural condition of the alvine discharges, we
should be particular in supplying the infant with wholesome
diet. Ifthe child be spoon-fed, a healthy nurse should be im-
mediately obtained; and if brought up on the breast, the milk
of another woman should be tried; nor should we be content
with one alteration, but again and again should the nurse be
changed, unti] milk is found, which will agree with the infant.
With respect to the use of opium in infantile convulsions, I
would observe, that although, while congestion prevails, it must
not be employed; after that state 1s removed, it becomes a re-
medy of great utility, as it allays the irritability, and breaks
through the habit, upon which the continuance of convulsions
frequently depends.*
The attention of the profession has been but lately called to
the fact, that paralytic affections in children may exist, uncom-
bined with any indication of cerebro-spinal disease. Under-
wood was aware that serious disease of the brain was not always
present, and Marshall Hall has given a few observations on
paralysis depending on dentition: but it is in the papers of my

* Upon this subject North’s work on Convulsions may be advantageously

consulted. He dwells particularly on the injurious effects of indiscriminately re-
sorting to the abstraction of blood in such affections.
VOL. XXV. NO. 42. M
82 Dr. Doherty on impending Dissolution and

friends, Dr. Henry Kennedy of this city, and Dr. Charles West
of London, that the most elaborate consideration of this subject
is contained. To their communications I must refer,* and con-
tent myself with merely noticing two cases of this nature which
I have met with.
Case XXVII.—In the case of a lady, whom I attended on the
21st Oct. 1841, of her fifth child, a girl, the labour was ren-
dered somewhat tedious, in the first stage, by a slow dilatation of
the os uteri, but the second stage was completed rapidly, and
the child was born naturally. It cried loudly, and showed every
symptom of being vigorous, nor was any complaint made re-
specting it till the third week, when it was pointed out to me
that the left arm was completely paralysed. In all other respects
the child was in perfect health, if we except the existence of
greenish evacuations, attended by abdominal pain, but not of
greater amount than we so commonly see in infants. What
prognosis to give in this case puzzled me very much, forI could
not satisfactorily ascertain from the attendants, whether it ever
had had the power of moving that limb; and I feared it might
be an instance of congenital paralysis, owing perhaps to defi-
ciency in the nervous endowment. However, as that arm was
as warm, and fully as well formed, as the other, and as sensation
remained, I held out expectations of amendment, and imme-
diately set about correcting the only deranged function I could
detect. Mercurial alteratives, and antacid purgatives, with the
warm salt water bath, constituted the first remedies I employed.
I then directed the douche to the affected limb, and the fre-
quent use of stimulating liniments; and when the intestinal se-
cretions were rendered more natural, I followed up the advan-
tage gained, by the exhibition of chalybeate tonics. Under
this regimen I had the satisfaction to observe the paralysis dis-

* H, Kennedy on Paralytic A ffections in Children. Dub. Med. Press, vol. vi.

p. 201. West on some forms of Paralysis incidental to Infancy and Childhood.
Lond. Med. Gazette, Sept. 8, 1843, p. 829. See also Colmer on Paralysis in
teething Children. Lond. Med. Gaz. Ap. 21, 1843.
 Nervous Affections in young Infants. $3
appear, andthe child has now as perfect power over that limb
as over the opposite. Purgatives, followed by tonics, must then,
I think, be the line of practice we should adopt in such cases,
combined with free scarification of the gums, when at a later
period than that, to which I have confined myself in these ob-
servations, teething is, as it appears not unfrequently to be, the
cause of this paralysis. The affection, indeed, appears to me
very much to resemble neuralgia, arising from a similar source
in the adult, only that a different series of nerves is engaged ;*
and as in the one, so in the other, the tonico-purgative treatment
appears the most beneficial. Amongst the tonics to be em-
ployed in either case, iron is to be preferred, and of all prepa-
rations I think the solution of the citrate, as manufactured by
Mr. Bewley of this city, most deserving of a trial. Its taste is
so little disagreeable, that any child will take it, and it is emi-
nently efficacious. The following case was most probably an
instance of the same affection:
Cas—E XXVIII—Lawlor, whose child I have already ad-
duced as an example of transient apoplexy, resulting from pres-
sure on a prolapsed funis, and which left hospital on the usual
day in a perfectly healthy condition, as far as was ascertained,
returned with it a year afterwards, stating that it had never
been able since birth to hold up its head. It had, when brought
back, the power of rotating the head when supported ; but
when placed in the erect posture, it was unable to prevent it
falling backwards, nor could it well restrain its motions forwards.
In other respects it was in perfect health, nor had it ever had
convulsions since it left hospital. Now, I think I am justified
in assuming, that this was a case of paralysis, arising from the
cause | have mentioned, and appearing very shortly after the
* They both illustrate the now recognized law, so well enunciated by Ductor
Graves, that ‘impressions made upon any portion of the nervous extremities may
be propagated towards their centres, and thence bya reflex action transmitted to
the nerves of other and more distant parts, so as to give rise to morbid phenomena,
analogous to those, which are produced by disease, originating in the central parts
themselves.”—Clinical Medicine, Dub. 1843, p. 406,
84 Dr. Doherty on impending Dissolution and
tem-
child was discharged; and not either the remains of the
con-
porary congestion of the brain at birth, or resulting from
it had
genital deficiency: for although the mother asserted,
that the
never had power over its head, it 1s not to be supposed,
could
experienced nurse of the ward, under whose care it was,
ut de-
have handled and dressed it for eight or nine days witho
show, I
tecting this, or even a slighter deficiency. It should
and
think, that such cases, if neglected, may become chronic,
probably at length irremediable. The mother would not re-
main to allow the effects of treatment to be observed. I may
remark, I have lately seen two cases of a more advanced age, in
whom limping apparently arose from a disordered state of the
tinence of
bowels; in one of them it was combined with incon
urine. But to enter into their consideration would be over-
stepping the bounds which I have laid down for myself on this
occasion. *
eee

t
* This disease differs materially from the paralysis, which follows remitten
n
fever in children, of which a curious example was admitted into the Lying-i
Hospital on the 21st April, 1839. She was then twenty years of age, and the
account she gave of herself was, that when ten years old she had had fever, suc-
ceeded by complete loss of power over her lower limbs. Twelve months after,
when she was quite hemiplegic, she said she was brought to St. John’s Well (a
holy well, formerly in great repute for miraculous cures, near Dublin), and bathed
in it; the consequence of which was, that although she could not even stand when
she went there, she immediately acquired sufficient power to walk about the adjoining
field. However I fear the poor girl’s anticipations were not fulfilled to the extent
she expected, for when in hospital she presented the following deformity. She
had power over the left thigh, but not over the right one; the former therefore
was well developed, the latter shrunken and flaccid. The right foot she could
bend on the ankle, the left she could not; the right leg was muscular, the left

wasted and small. The left foot was very much arched; the right flat, the big
toe of the latter being turned over the dorsum of the first and second ones. When
she walked it was principally on her inner ankles. She was able to raise the toes
of the right foot sufficiently to prevent their touching the ground; but to avoid
tripping with the other, she was obliged to elevate the knee considerably. The
latter foot she turned very much outwards. ‘The paralysis, considerable as it was,
did not extend to the generative organs, for she became pregnant, and was deli-
vered on the day mentioned, aftéra labour of ordinary duration.
 Nervous Affections in young Infants. 85

The subject would scarcely be complete if I did not allude

to the fact, that infants in many instances appear to be pre-
disposed to convulsions, by the state of the mother during ges-
tation and labour. However we may find a difficulty in demon-
strating a vascular and nervous communication between the pa-
rent and the offspring she carries; proofs are not wanting of
mental impressions and contaminations of the blood being
transmissable from the former to the latter individual. At all
times, in the female, the circulation in the abdomen and uterine
system manifests a great liability to be deranged by shocks, act-
ing on the nervous system ; and thus it is probably, that a fright
to the mother, while pregnant, may be the means of producing
nervous disturbance in the child, after their connexion has been
severed. Thus Gdlis relates, that in 1809 most of the children,
born after the bombardment of Vienna, were seized with con-
vulsions twenty or thirty days after birth, and died. Mr, Reid
had under his care in St. Giles’ workhouse a woman affected
with chorea, of which the mother gave the following history :—
She said, that having borne children, she was in the fourth
month of another pregnancy, when there was thrown upon her
bosom a frightfully disgusting object. She was for two months
in a state of extreme nervous illness from this cause; but she re-
covered, and went her full time. She remarked, however, that
the child was extraordinarily lively in the womb, so that at times
she was overcome by the sensations she experienced. The child
at the instant of its birth displayed the writhing motions of
chorea; they had continued up to that time, when she had ar-
rived at thirty years of age. Her head was then remarkably
small and narrow; she was thin and worn, and the mind very
little removed from complete idiotcy.* Convulsions also fre-
quently ensue in the children of those, who have themselves
had convulsions during gestation or labour, if they chance
to survive their birth. Diseases of the parent, too, by which
the foetus can be contaminated, may be a source of infantile con-
vulsions, by depressing the powers of life; it is in this way many
* London Medical Gazette, vol. xvi. p. 287.
86 Dr. Doherty on impending Dissolution and
cases which present a syphilitic taint arrive at a fatal termination.
In the same way, medicines administered during pregnancy may,
as is well known, affect the foetus in utero ; and it is strange, that it
is not always those, which require to be given to infants with great
caution. Thus children bear mercurial preparations well, and
they may be long continued, even at an early age, with impunity;
but if exhibited to the parent, so as to exert their specific action
during the latter months of pregnancy, are very liable to destroy
intra-uterine life, or, as I am led to think from a case, in which
mercury became necessary to arrest peritonitis before delivery,
they predispose to convulsions, if the offspring be born alive. On
the other hand, opium, which so easily affects infants, may be
given during gestation with the utmost safety. Ihave heard
Dr. Collins state that he had a patient, to whom he gave a grain
of opium three times each day, for three months antecedent to
labour, and yet the child did not suffer.

It only remains for me to mention, that spasmodic affections,

or paralysis of certain muscles, merely local in their nature, may
result from injury done to a nerve during labour, either by pres-
sure against a resisting point in the pelvis,—as is particularly liable
to occur in face presentations, in which, however, the distortion
must not be confounded with that arising from tumefaction,—or
by the application of the forceps to the head, or the blunt hook
to the groin. Examples of paralysis of the seventh pair of
nerves, consequent on the use of the forceps, are given by Kilian,
Dubois, Evory Kennedy, and Landouzy, and in explanation of
this occurrence, an observation made by the last named author
deserves to be quoted. In the adult, he remarks, the projec-
tion of the mastoid process, of the external meatus of the ear,
and of the sterno-mastoid muscle, renders compression of the
seventh pair, at its exit from the cranium, almost impossible;
but in the infant at birth the reverse condition of these parts
easily admits of injury in that situation.* Of this affection

* Gazette Médicale de Paris, Aug. 10, 1839.

 Nervous Affections in young Infants. a,
I have myself only two cases to bring forward. One was
that of Doyle, delivered with the forceps on the 4th May, 1838,
after a labour of twenty hours; the foetal head was very large,
and the temple was indented by the instrument. The angle of
the mouth was drawn down, and to one side; there was ptosis of
that eye, and when the child cried the whole face became dis-
torted, Shortly after, evidences of cerebral congestion, pro-
bably the result of the long labour, appeared, and required
leeching for their removal. In the other, that of Elkington, de-
livered with the same instrument on the 23rd October, 1839,
after twenty hours’ labour, there was a wound behind the left
ear at birth, with paralysis of the side of the face. In both
the muscles were daily regaining their power, when, probably in
consequence of the same cause as determined the existence of
puerperal peritonitis, then prevailing, phlegmonoid erysipelas of
the scalp occurred, and they died.

Art. Tff.—Ewxamination of the Question—Is the Chyle inci-

pient Blood? By Joun Atpriver, M. D., Lecturer on
Chemistry at the Park-street School of Medicine, Dublin.
In the progress of modern organic chemistry it has been ren-
dered extremely probable, that the essential constituents of the
blood of animals, the albumen, and fibrine, are taken into the
stomach, ready formed, and that digestion consists simply in
their solution; and that when this process is effected, and they
are absorbed, they at once constitute blood, fit for the purposes
of nutrition, and not requiring to undergo any further change.
If this doctrine should ultimately prove true, it will intro-
duce an extreme simplicity into a department of physiology
that has been hitherto full of obscurity and complexity. The
arguments in its favour, as stated in M. Liebig’s late work on
Animal Chemistry, are very powerful; and it therefore deserves
the most careful consideration, not only on the part of those who
are interested in the perfection of chemical science, but of all
88 Dr. Aldridge’s Examination of the Question,
who seek to understand the intimate phenomena of organic
functions.
But this doctrine is opposed to all our preconceived notions:
we have been hitherto taught in the schools that blood is
gradually formed; that there are a succession of steps in its
production; that the process of hamatogenesis 1s a very com-
plicated one; that after digestion (in itself a series of stages,
chymification, and chylification), and subsequently lacteal ab-
sorption, the chyle has to undergo assimilation; and the
coats of the vessels, the conglobate glands, the lungs, liver,
&c., are all organs accessory to the completion of the blood-
making act. Now the consideration of this new chemical doc-
trine, of the blood being taken into the system ready formed,
involves a complete revision of all these cherished theories. It
is necessary that physiologists and chemists shall re-examine the
data upon which the former hypotheses were founded, in order
that they may rest assured, whether or not the deductions they had
heretofore received were legitimately drawn. This reason has
led me to investigate the facts that have been hitherto disco-
vered with respect to the chyle, and to see whether those facts
justify the conclusion which has been almost unanimously ar-
rived at by physiologists, namely, that chyle is blood in an in-
cipient stage of its formation: and I think it may be useful ‘to
the Profession to recall these facts to the recollection of its
members, so that they may be able to judge whether they are
warranted in continuing to entertain this opinion.
The common theory, as regards chyle, is, that it is the nu-
tritious part of the food, in a stage of assimilation. This theory
is supported by the following facts: it is found in streaks
through the ingesta within the intestines; the lacteals after di-
gestion are found distended with it; diseases of the mesenteric
glands are accompanied with marasmus; ligature of the thoracic
duct is generally followed by death; the coagulability of chyle
increases in its progress through the vessels; the chyle of the
large lacteals contains more coagulable matter than the lymph
of the lymphatics; the contents of the thoracic ducts have some-
 Is the Chyle incipient Blood ? 89
times a reddish tint; the iron in the chyle is present in a diffe-
rent state from what it is in the blood, being easily detectible
after the addition of nitric acid. These appear to me to be all
the arguments that have been brought forward to prove that
chyle is incipient blood. I have not thought it necessary to
mention the names of the discoverers of these facts; they are
now the property of science; and the authorities upon which
they rest can be easily ascertained by referring to any of the
standard works on physiology, especially Miiller’s admirable
compilation.
Before examining of what value these facts are in the sup-
port of the prevailing theory, let us see what are the relations of
the contents of the lacteals, lymphatics, and blood-vessels, when
the intestines are empty, and when the liquid in the first class of
these vessels is uninfluenced by the process of digestion.
‘The lymph has been examined by Reus and Emmert, Las-
saigne, Miller, and Nasse, &c.: it appears in all its properties
when drawn from any of the large lymphatics, to be identical
with the “liquor sanguinis,” except in the proportion of its
constituents, being much more dilute: thus when allowed to
stand in a glass vessel, a coagulum of fibrine separates from it;
and the remaining serum contains albumen, together with the
ordinary salts of the blood. Scemerring, who found it in lym-
phatic varices, says that this lymph did not coagulate; Miller
throws doubt upon this latter observation, as he regards coagu-
lability as an essential character of lymph; and yet he tells us
that when frogs are kept several days out of the water in sum-
mer, their lymph loses its coagulability. Miller and Nasse
have discovered scanty globules in the lymph of man and other
animals, smaller than the blood globules, granulated upon their
surfaces, and containing one or more nuclei, the latter being
rendered more apparent by acetic acid.
The blood consists of liquor sanguinis, with innumerable red
globules in suspension. In reference to the relations of lymph
and blood, Miller says, “ the lymph must, in its composition, be
VOL, XXV. NO. 73. N
90 Dr. Aldridge’s Examination of the Question,
exactly identical with the fluid portion of the blood, or “quor
sanguinis, and the blood itself must consist merely of lymph
and red particles.” The blood contains a few of the lymph
globules, besides its proper globules.
The lacteals in the intervals of digestion contain a fluid pos-
sessing all the ordinary properties of lymph. Tiedemann and
Gmelin found that in a fasting horse the liquid of the thoracic
duct contained somewhat more albumen than the lymph, and
was of a reddish colour,—redder than it was ascertained to be
after a meal; from whence they very rightly deduce, that this
tint could not proceed from a process of assimilation, but rather
from the presence of some of the colouring matter of the blood,
which they proved by the reaction of sulphuretted hydrogen.
In fact, these observers have proved that the red colour of the
chyle when present (which is rare) is most marked in fasting
animals, and least so the more nutritious the food. They,
moreover, found that the contents of the thoracic duct coagu-
lated more firmly in fasting animals; and that the liquid con-
tained in the large lacteals contains more fibrine than the lymph
of the large lymphatics of the pelvis. They consider that this
fibrine is yielded by the conglobate glands; and therefore they
conclude that the mesenteric glands afford more fibrine than the
glands of the lymphatic system. Miller prefers considering
the fibrine to proceed from a transformation of albumen effected
by the walls of the vessels: he maintains that the vessels have a
power of changing the constitution of their contents; and quotes
the experiments of Emmert, who found that the application of
Augustura virosa (bark of Strychnos nux vomica), or prussic
acid, to a wound in the inferior extremities, did not poison when
the abdominal aorta had been previously tied: from hence
Webber had deduced, that the lymphatics have a power of de-
composing or altering the substances they absorb. But surely
this deduction is not warranted; for it remains to be proved that
the lymphatics are capable of absorbing these poisons. Iixpe-
riments appear to lead to the conclusion that the lymphatics
and lacteals reject certain matters, and refuse to absorb them.
 Is the Chyle incipient Blood ? ol
And even if the poisons are capable of being absorbed by the
lymphatics, it remains to be ascertained the rate at which the
absorption is effected, and the rapidity with which lymphatic
circulation is carried on. These circumstances would neces-
sarily very much influence the effects produced. The rate at
which the lymph and chyle travels has not been accurately as-
certained, but compared with the blood, it is evidently very
slow. Lymph and chyle are both alcaline, but less so than
blood.
Miiller says: “ The lymph of the intestines, when it contains
matter just absorbed from the digested food, is always more or
less turbid, and has a yellowish gray, or whitish colour, arising
from the presence of a great number of globules; it is then
called chyle.” ‘The chyle globules are for the most part very
small (7755 of an inch in diameter,—Prevost and Dumas), but
according to Miller and Wagner there are some the size of the
blood corpuscules, or even larger, opaque ; and to these they
attribute the turbidity of the chyle during digestion. These
larger globules cannot be lymph globules, for the latter are
much smaller than the red particles of the blood; nor are they
blood globules, for they are white, and different in form; nor
are they the nuclei of blood globules, for they are as large, or
larger, than the red particles themselves. The smaller globules
are admitted by all observers to be nothing but drops of oil,
and can be extracted from the chyle by ether. The globules,
whether larger or small, are evidently derived from the food,
for they are only present in the chyle when the aliment has been
just digested. Both kinds of globules are found in the very
minutest lacteals.
The chyle, after digestion, is not milky in birds; it is not
very turbid in herbivorous mammalia; it is not milky in car-
nivorous mammalia, when fed on liquid albumen, fibrine, ge-
latine, cheese, starch, or gluten ; many of these substances being
highly nutritious. Majendie, Marcet, Tiedemann, and Gmelin
all agree that the turbidity of chyle is in proportion to the fatty
nature of the food. In general,” says Berzelius, “the fat is
92 Dr. Aldridge’s Examination of the Question,

the sole substance which is found more abundantly in chyle

during digestion, than in the state of intestinal emptiness. ”
From these facts it is evident that the chyle globules, whether
large or small, opaque or transparent, are nothing but fat de-
rived from the food.
The chyle in the first lacteals, previously to passing through
the ganglions, is not coagulable; whilst a clot separates from
that taken from the larger trunks, This clot is more consider-
able than what is obtained from the lymph of the larger lym-
phatics; but this is in part explained by Miller, by the involve-
ment of globules in the coagulum. Whether this fibrine be
derived from the glands, or from the conversion of albumen,
according to the hypothesis suggested by Tiedemann and Gmelin
on the one side, and Miller on the other, and which I have
already alluded to, when speaking of the chyle in the intervals
of digestion, it is evident that this increase of coagulability is no
argument for a transition of chyle into blood; for if so, it would
only occur in the chyle of digestion. We have seen that in a
fasting animal there is more albumen in the chyle than in the
lymph; during digestion there is, on the contrary, less.
The fluid contained in the lacteals is not, as we have seen,
invariably milky during digestion, ‘Tiedemann and Gmelin
ascertained that, first, after the use of butter the chyle became
superabundantly charged with fat ; and second, that after starch,
they found sugar in the chyle of a dog.
Let us now turn our attention to the source of this milky
fluid, to which the name of chyle is given. “ The fat,” says
Berzelius, “ which is a part of the aliment, swims in the stomach
in a melted state on the surface of the chyme, but after mixture
with the bile and pancreatic liquid, becomes converted into a
fluid, having the appearance of an emulsion, which becomes
disseminated in milky strize through the chyme. This milky
fluid is afterwards absorbed by the lymphatics, through the
parietes of which its white colour can be perceived, and these
vessels are from this circumstance called Jacteals.”
Sir B. Brodie ascertained that when the ductus cholodochus
 Is the Chyle incipient Blood? 93
was tied, the contents of the lacteals were no longer milky;
from whence he concluded that bile was necessary to the forma-
tion of chyle. Berzelius remarks, that the reason of this it is
now easy to see; the alcaline bile being absent, the fat of the
aliments could no longer assume the form of an emulsion.
Here then are the results: that during digestion some fat
or sugar, as the case may be, is added to the lymph contained
in the lymphatics of the mesentery ; neither fat nor sugar con-
tain the elements out of which blood can be formed ; and chyle
cannot therefore be incipient blood.
No doubt that the iron contained in the chyle serves in part
for the formation of the blood globules; no doubt the fat con-
tained in the chyle undergoes numerous changes afterwards in
the circulation ; but the albumen and fibrine, the essential ele-
ments of nutrition, emphatically the blood, are not formed out
of any thing contained in the chyle.
Dr. Graves has well shown that the lymphatics may be con-
sidered the veins of the white tissues: it is not wonderful that
the mesentery should be freely furnished with them: the ab-
sorbing power of the lymphatics, as well as that of the veins, has
been demonstrated by many observers: we can therefore un-
derstand that many of the more fluid results of digestion may
easily find their way into these vessels, without considering them
the only channels through which the blood can receive its new
supplies. So contrary is the fact, even as regards the milky
emulsion called chyle, that Tiedemann, Gmelin, and Mayer
have found it in streaks in the blood of the intestinal and portal
veins. And that true aliment may be absorbed by the capil-
laries, is proved by the serum of the blood of sucking kittens
and puppies being frequently found milky, by Schlemm, Ru-
dolphi, Miller, Mayer, &c.
I will not spin out this article by dwelling on the possibility
of the marasmus which accompanies mesenteric disease, being
the cause of the latter, or what is more likely, an effect of a
catise common to both; nor by pointing out the fallacies attend-
ing such operations as ligature of the thoracic duct, an operation
94. Dr. Bird’s Remarks on Dr. Aldridge’s
after which, by the way, the animals did not always die; nor,
by appealing to the want of likelihood, that a liquid so scanty
in its quantity, and so slow in its motions as the chyle, should
be the sole source from whence nutrition and secretion derive
their supplies. Iam satisfied with pointing out the insufficiency
of the proofs hitherto depended on, in support of the opinion
that chyle is incipient blood.
There is nothing new in the facts brought forward in this
paper : all that can be considered as original is the point of view
under which the subject is presented. I have not omitted any
that appeared to be opposed to the conclusions to which I have
been led; nor have I distorted any to suit my arguments. In
conclusion, it is to be remembered that all the foregoing data
have been established by the supporters of the prevailing doc-
trine.

Art. 1V.—Remarks on Doctor Aldridge’s Communication on

Urinary Diseases. By Gotpine Birp, A. M., M. D., As-
sistant Physician to, and Lecturer on Materia Medica at
Guy’s Hospital.
TO THE EDITOR OF THE DUBLIN JOURNAL OF MEDICAL SCIENCE.

Str,—The perusal of Dr. Aldridge’s paper in the last num-

ber of your excellent Journal, has induced me to offer a few
brief remarks, for the insertion of which I must rely on your own
sense of justice.
Dr. Aldridge describes (p.460) a case in which he discovered
a deposit in the urine, consisting of square plates, with a circu-
lar hole in the centre of each; these he very correctly supposed
to consist of oxalate of lime. After indulging in certain specu-
lations regarding the origin of this deposit, and the connexion
between the oxalate and carbonate of lime, he concludes by re-
marking, that the ‘question is one of mere curiosity.” The
detection of the oxalate is announced in the light of a discovery,
and no reference is made to the labours or observations of
 Communication on Urinary Diseases.
95
others, except to M. Rayer, who figured the
microscopic ap-
pearance of the oxalate artificially precipitated
by oxalic acid
from urine; and to M, Donné, who has desc
ribed the presence
of crystals of the oxalate in urine after the inge
stion of sorrel.
In Guy’s Hospital Reports, No. XIV. p. 211,
published in
April, 1842, I announced the frequent presence
of crystals of
oxalate of lime in the urine, and gave drawings
of their micro-
scopic appearances, including the curious opti
cal illusion pre-
sented by the flattened rhombic octohedra
of the oxalate seen
When examined in a dry state. They then
resemble black tables
perforated by a square aperture (not a circ
ular one, as stated by
Dr. Aldridge), with sharply defined angl
es. In the London
Medical Gazette (July, August, 1842) I
published a series of
cases characterized by the abundant pres
ence of oxalate of lime
in the urine. The existence of this salt
is there shown to be
connected with severe irritative dyspepsia,
and often with a
highly irritable condition of the genito-urina
ry organs. In my
lectures delivered at Guy’s Hospital in January,
1843, I again
drew attention to this very important subject;
and in the Re-
ports of them, published in the Medical Gaze
tte, engravings
were given of the microscopic appearances pres
ented by the dif-
ferent varieties of the oxalate.
A further account of my observations has
appeared in Mr.
Braithwaite’s valuable retrospect, and in Dr.
Hoskin’s transla-
tion of Professor Scharling’s work on Vesical
Calculi; the mi-
croscopic figures have moreover been copied in
the last edition
of Dr. Prout’s elaborate work. So that I thin
k Dr. Aldridge
can hardly plead ignorance of the literature of the
subject as an
excuse for tacitly claiming the discovery ofthe oxal
ate in urine.
I trust, Sir, I shall not be deemed guilty of
egotism in thus
venturing to claim the credit of the discover
y ofoxalate of lime
in urine in a crystalline form, as the investig
ation of this very
serious pathological state of the urine cost me
months of labour
in a large field of experience.
In another part of Dr. Aldridge’s paper (p.
466) some very
96 Dr. Bird’s Remarks on Dr. Aldridge’s
interesting remarks on diabetes occur, in the course of which
much importance is deservedly attached to the remarkable re-
lation borne by the composition of sugar with ammonia to
albumen, and a formula is given illustrative of these views.
direct
Now, Sir, without wishing to charge Dr. Aldridge with
rs
plagiarism, I would wish to direct the attention of your reade
ced
to the fact of this relation having been pointed out, and addu
four
‘n favour of the treatment of diabetes by ammonia, nearly
s
years ago, by my friend and colleague, Dr. Barlow, in Guy'
Hospital Reports. In January, 1844, Dr. Aldridge, after a
ine
formula, showing the relation of sugar and ammonia to prote
i-
(the base of albumen), remarks: “ Now, if the essential const
and
tuent of albumen is capable of being formed out of sugar
why
ammonia, with loss of water and oxygen, there 1s no reason
ated
sugar and ammonia should not be capable of being gener
out of albumen, by combination with oxygen and the elements
of water.”’*
In October, 1840, Dr. Barlow published a formula, which
differs only from Dr. Aldridge’s in the relation between sugar
with ammonia to albumen, being shown by their per centage
composition, instead of an empirical formula: adding, “ Thus
we find that when the numbers which represent the atomic
composition of ammonia and sugar are added in certain pro-:
portions, we obtain a result which exactly coincides with the
numbers representing the atomic constitution of albumen, in-
creased by certain equivalents of carbonic acid and water, sub-
stances which are continually excreted from the body.”
Whatever merit may attach to these views,—which have at
least in many cases led to a satisfactory treatment of a most for-
midable disease,—must be conceded to Dr. Barlow.
At page 468, Dr. Aldridge gives a useful practical hint for
the detection of albumen in the urine by nitric acid ; he states,
SID ITnEWass Dn sencnmvnenonnira nnn nn
* Dublin Medical Journal, January, 1844, p. 466.
+ Guy’s Hospital Reports, 1840, p. 287.
 Communication on Urinary Diseases. 97
“ Nitrate of albumen is soluble in excess of urine; if nitric acid
be added in small quantities to albuminous urine, the precipitate
at first formed is capable of being re-dissolved by agitation.
This proves that nitric acid isa bad means of detecting small
quantities of albumen in the urine.”’*
This “ practical hint” has been particularly pointed out by
my friend Dr. John Griffith in the London Medical Gazette in
1842: “ When a few drops of nitric acid (sp. gr. 1.5) are added
to urine containing a small quantity of albumen, a cloud is im-
mediately formed, which by agitation is immediately redis-
solved.” ‘ Therefore the formation of a cloud by heat soluble
in a drop or two of nitric acid is no proof that albumen is ab-
sent, &c.’’+
The only novelty in the last quotation from Dr. Aldridge’s
paper is the use of the term nitrate of albumen, whichI do not
think will receive the sanction of chemical authorities.
There are several other parts of Dr. Aldridge’s paper equally
destitute of originality, to which it is unnecessary to refer, as it
is quite possible that physicians engaged in similar pursuits may
arrive at the same conclusions by different paths, and indepen-
dently of each other. Those which I have ventured to point
out, your talented correspondent must be too well read in the
literature of medical science to be quite unacquainted with.
In conclusion, I regard Dr. Aldridge with respect, as a fel-
low-labourer in the difficult field of chemical pathology, and
feel sure that his character will not stand less high, nor his re-
putation suffer, by practically remembering the motto, ** seem
cuique.”
I remain, Sir, your obedient Servant,
Gotpine Birp.
Myddleton Square, London,
January 4, 1844,

* Dublin Medical Journal, 1844, p. 468.

7 London Medical Gazette, 1842, p. 112.
VOL. XXY. NO. 73. O
98 Mr. Wilde on the Causes and Cure of

Art. V.—Observations upon the Causes, and the Operations

recommended for the Cure of Entropium and Trichiasis.
By W. R. Witpr, M.R.LA., Lecturer upon the Diseases
of the Eye and Ear in the School of Medicine, Park-street,
and Member of the learned Societies of Paris, Vienna,
Berlin, and Athens.

Sir Paiuie Crampton, in his most admirable Essay upon the

Inversion of the Eyelids, has with great justness observed, that
“the Entropeon is wonderfully common among the lower orders
of the Irish ;” and this opinion will, Iam sure, receive confirma-
tion from all those practitioners of this country, who may hap-
pen to be much occupied with the diseases of the poor, particu-
larly in large cities. Some idea may be formed of the preva-
lence of this affection, when I state, that of 1056 cases ofdiseases
of the Eyes, of which 748 were original applications, treated at.
the Frederick-lane Dispensary during the year ending Septem-
ber, 1843, no less than 27 were instances of inversion or irregu-
larity of the cilia, requiring operation.
The symptoms and history of this disease (under which I
include the inversion, irregularity, and morbid growth of the
eye-lashes) have been so well described in all the modern
works upon ophthalmic surgery, that it is unnecessary to enu-
merate them in this short statement, the chief design of which
is to throw, if possible, some light upon the causes of the inver-
sion—to remark upon the applicability of the different methods
of cure to the several varieties of this disease—and to exhibit
the ill effects of certain operations upon the subsequent condi-
tion of the eye and lachrymal appendages.
Those who have observed these morbid states of the cilia
and the margins of the eyelids, will recognize the following va-
rieties :—Entropium, the zzversio palpebrarum of the ancients,
which may be divided, according to its locality, into superior
or inferior; or into its extent, as when it occupies, which it fre-
quently does, both lids together, when it may be termed com-
 Entropium and Trichiasis. 99
plete; and when it takes place on a portion of the lid only,
partial, Neither of these terms, however, of partial or com-
plete, refer to the progress or duration of the disease, but to
the moiety of the lid or lids affected by it. In all these, the seé-
ting (to use an artistic expression) of the eyelashes remains unal-
tered, while the tarsal margin isso viciously bent inwards towards
the globe of the eye, that the hairs lie upon, or are in contact
with the conjunctiva cornez et scleroticee; nay, in some cases,
as when the disease affects the lower lid, the cilia absolutely lie
between the globe and the palpebra. When the disease occurs
in the upper eyelid, the inversion is almost invariably increased
by turning the eye upwards. The effect of such an unnatural
position of these parts will be manifest ; and will present the
symptoms of irritation, pain, nictitation, the sensation ofa foreign
body in the eye, incessant winking, epiphora, chronic inflamma-
tion of the conjunctiva, a granular state of the lids, vascularity
of the cornea, photophobia, spasmodic action of the orbicularis
palpebrarum and corrugator supercilii muscles: the head being
inclined downward and generally on one side, and the shoulders
elevated ; to these succeed redness of the tarsal margin, and often-
times cedematous swelling of the eyelids, followed by opacity of
the cornea, which, having gone through the various stages of pan-
nus, has been not inaptly likened, by the graphic Saunders, to the
appearance of a macerated ligament; and finally, total loss of
vision ensues—the pain, irritation, and intolerance of light de-
creasing as the transparent cornea becomes white and thickened
and the conjunctiva insensible, perhaps cuticular.
This is generally the result of the extreme inversion of the
ciliary margin of the upper lid. In cases, however, where the
lower lid is alone affected, and this form of the disease occurs
most frequently among females advanced in life, the symptoms
seldom amount to the degree of severity I have just detailed,
and the lashes, which are usually finer and shorter on the
lower than the upper lid, have a slight inclination towards
the external canthus, as well as inwards, and lie along the
100 Mr. Wilde on the Causes and Cure of
junction of the cornea and lid, while the external integument
is almost invariably lax, smooth, and shining.
Another form of this disease is where a portion only of
the tarsal margin, with a normal row of cilia, becomes in-
verted; the most marked cases of this description generally
occur in the outer half of ‘the margin of the upper lid. Jn
an instance of ‘this description which lately came under my
notice, In a young lady from Edinburgh, ‘one-half of the
superior palpebra, with its cilia, was completely turned in-
wards, without the slightest ‘alteration in any other part of the
palpebral opening ; the irritation of the cornea was in part got
rid of by an effort of nature, marked ‘convergent strabismus of
that eye having taken place since the supervention of the entro-
pium. In another well marked case ofpartial inversion ofthe lid,
without trichiasis or distichiasis, it occurred congenitally. The
child, which was placed under my care by Dr. R. L. Nixon, ‘was
remarked a few days after birth to:have sore eyes, and ‘was said to
‘be constantly crying and excessively irritable. I saw ‘it when one
month old, and then the margin of the outer half of the right
superior lid was completely inverted; and young as the child
was, it scarcely ever, when awake, removed the back of the hand
from the affected eye, which was kept spasmodically closed, and
had all the appearance of strumous ophthalmia. Enitropium has
been divided by authors into traumatic, and acute‘and ‘chronic’;
with these, however, we donot at present ‘particularly deal.
A\t times, without ‘any inversion of the lid, ‘some of the cilia
themselves will turn inwards in an tnnatural manner, and cause,
ina modified and less degree, the symptoms attending entropium ;
these irregular growths, or to speak more strictly, ‘irregular cur-
vatures or directions of the hairs, may occur in ‘patches of three
or halfa dozen in one spot, or take place in single hairs all round
the eyelid’; or again, be in connexion, as'they often are, with
complete or partial inversion of the ‘lid (entropium). I have
remarked in ‘this country, that this particulariform of the affec-
tion more frequently occurs in the lower than’ the upper 'lid, and
oftener in light haired than in dark-complexioned persons, and
 Entropium and Trichiasis. 101
also that the -hairs are generally finer in quality; in some in-
stances they are so very delicate as'to be with difficulty discovered
without the aid of a magnifying glass and a good light. A
thickened and irregular nodulated state of the tarsal margin
of the lids, generally accompanies this form of the disease, to
which has been applied the term Trichiasis.
The third form of the abnormal condition ofthe eyelashes:is
that denominated Distichiasis, and consists of a preternatural or
supernumerary development -of hairs, .called pseudo cilia; «in
fact, a double row of eyelashes internal to the normal -row.
This may exist with or without inversion of the cartilage ; it may
be partial, or confined to a spot from a line to half an inch «in
length, or these new hairs may be irregularly scattered along
the whole palpebral aperture. The same general symptoms
which mark the entropium, in ‘intensity commensurate with ‘the
extent of the disease and ‘the violence of the irritation, attend
this affection. he fact of'an additional growth of hairs has'been
denied, and it is asserted, that “although they issue from ‘the
wrong iplace, and grow inva wrong direction, they are not new
productions, but merely natural cilia, the bulbs of which have
been displaced by disease affecting the border of the eyelid);”’*
and had I not several preparations in ‘my possession, which
show an undoubted additional growth of these hairs, I should
be very slow in differing from ‘this, one ‘of the highest living
authorities upon ophthalmic surgery. ‘In these cases, however, I
not only examined ‘the tarsal margins'minutely after their remo-
val, but counted'the cilia, and they invariably amounted to more
than what occurs in health ; although it*must be acknowledged
that the number ‘varies even in a healthy or natural ‘condition.
Preternatural growths of‘hair from other parts ofthe ‘eye
(the conjunctiva for instance) where they didnot originally exist,
are not unknown to ophthalmologists. Mr. Lawrence acknow-
ledges that “there is a partial series of cilia produced on the
inner margin of the lid, in addition toithe natural row.”
* Mackenzie on Diseases of the Eye.
102 Mr. Wilde on the Causes and Cure of
Let this brief description suffice to remind the reader of the
most prominent symptoms, and the varieties of these diseases of
the tarsal margins and the eyelashes, more detailed accounts of
which will be found in the special works upon diseases of the
eye. Ihave observed more of this disease in Ireland than any
country I have ever visited, except Egypt; and I believe that a
granular condition of the conjunctiva palpebrarum will also be
found to exist more frequently in a given number of diseases of
the eye, in this kingdom, than in any other. In Vienna, the
great centre of attraction for diseases of the eye, and the great
school of ophthalmic surgery, these diseases are rare in compa-
rison with their frequency here.
The endurance of, or the indifference of the Irish people, to
such severe suffering as the complete entropium causes, is really
astonishing; it is not unusual for cases to present themselves for
the first time for advice, and that, too, before the cornea has be-
come nebulous or insensible, as we know it will after long conti-
nued irritation, when the disease has been from six months to
two years’ duration. Many ofthese cases, occurring chiefly in
middle aged females in the very lowest walks of life, who re-
side within the city, were content to remain in this lamentable
state for the length of time I have mentioned; merely employing
to use their own expression, “a drop of eye water,” and clipping
the inverted eyelashes with a scissors from time to time! ! very
few of these people availing themselves of the palliative means of
plucking out the offending hairs with a forceps or tweezers.
This disease, or rather the disease which produced it, is one of
very frequent occurrence among that class of poor women who
sit in the streets, under archways, or at the openings of lanes
and entries, selling fruit, fish, confectionary, and articles of that
description ; and who are, by their occupation, exposed to all
the hardships and vicissitudes of our variable climate, with no
other external covering than a threadbare grey cloak ; their feet
being protected only by a pair of thin, broken slippers; sitting
upon a handful of damp straw; and their heads covered by an
 Entropium and Trichiasis. 103
habiliment that seems the almost invariable attendant of “ sore
eyes, —the remains of an old black beaver bonnet.
As regards the causes of entropium, I believe, in most in-
stances (not traumatic), it will be found to result from inflam-
mation, in some form or other. Without entering into the
history of the opinions put forward by the ancients, which will
be found enumerated at length by Mr. Guthrie, in his Opera-
tive Surgery of the Eye,I think the modern notions on this sub-
ject may be divided into,—relaxation of the external integu-
ment; unequal muscular action; ulceration and contraction of
the tarsal margin of the lids; anda contracted state of the folds
of conjunctiva forming the external and internal tarsal ligaments,
by which means the levator palpebree muscle acts on the lower
portion of the cartilage, and turns it in, as stated by Sir Philip
Crampton; but this can only apply to the upper lid. Others
ascribe the inversion to a vicious turning in of the cartilage,
without advancing any remote or proximate cause for such.
General contraction of the conjunctiva lining the lids has also,
among other reasons, been advanced by writers; but this solu-
tion of the question has not been advocated with that firmness,
which, in my mind, it seems to deserve.
Upon some of these hypotheses most of the operations devised
for the cure of this disease have been grounded ; and no doubt,
cases will be found to support each of these opinions, in whole or
in part, and also requiring each of the operations recommended.
But it is of that particular form of inveterate entropium, especially
of the upper lid, where the inversion takes place in a chronic
form, and where there is no more inflammation of the eye-ball
than that produced by the irritation and unnatural condition of
the cilia, to which I would more particularly call the attention
of my readers.
The idea of the relaxation and swelling of the integuments
of the lids being a constant cause of inversion of the lids is now
nearly exploded, and it is evident that it cannot produce those
partial turnings in of the tarsal margin which are frequently met
104 Mr. Wilde on the Causes and Cure of

with in practice, nor can it in anywise cause either the trichiasis

or distichiasis. But that it sometimes conduces to the acute
form of general inversion of the lids, which occurs in the severe
inflammations of the eye, we see numerous instances to support
the opinion. This has been well explained by Dr. Mackenzie ;
and that it assists in causing the chronic and atonic inversion of
the lower lid inold and relaxed people, when the subjacent fat
is absorbed, there is likewise, I think, little doubt. But I am
also of opinion, that even in such cases, there always exists a
cotemporaneous contraction of the conjunctiva lining the infe-
rior palpebra.
With regard to the supposed unequal contraction of the
orbicularis palpebrarum muscle, or the increased action of the
levator palpebrz, or indeed any action of this latter, it does not
appear that the case has been fully established ; and even if they
do exist in keeping up and increasing the inversion, it is only
as a secondary effect, after the cartilage has been already un-
naturally bent in by the contraction of the conjunctiva.
The assumed paralysis and relaxation of the levator palpa-
bree, as asserted by Mr. Ware, has been already tested, and will
not, I imagine, have many supporters in the present day. Al-
though ulceration and contraction of the tarsal cartilage, along
its free margin, may produce some partial inversion, and no
doubt produces dislocation or irregularity of individual hairs,
there is wanted proof of its being a cause of any very extensive
turning in of the whole upper lid. And that the disease does
not generally arise from the tightening and contraction of the
palpebral aperture, we learn from the fact, that in cases ofsevere
entropium, it will be found upon examination that the lids do not
fit more closely to the eye than natural, except so far as is pro-
duced by the spasmodic action of the musculus ciliaris; and that,
although they return to the inverted position immediately after,
still that they can with ease be lifted off the globe of the eye.
Again, if such was the case, why not have the disease always
occupying the entire free margin of the lids? why have it so fre-
 Entropium and Trichiasis. 105

quently in the upper lid? and how could partial entropium of

any one portion of it take place, the tarsal ligament acting
equally on the whole extent of the conjunctiva and cartilage?
Moreover, if it arose from a too tight condition of the margin
of the lid, why not have the puncta more frequently dislocated—
more frequently drawn outwards, or preternaturally inwards,
which is never the case.
From what I have observed of this affection, I am induced to
believe that in almost every instanc esevere chronic entropium (not
depending on accident) is the result of thickening and contraction
of the conjunctiva lining the lid, caused in limine by chronic
inflammation; and then, no doubt, the first turn or vicious bend
having been given to the tarsal margin of the lid by the mucous
membrane, which is there so intimately attached, that we might
say it was inserted into the cartilage, the muscular apparatus
attached to the appendages of the eye comes into play; and the
winking, which is so constant an attendant on this disease,
although at first a natural effort to rid the parts of the offend-
ing hairs, soon becomes, owing to the increased action of the
orbicularis muscle, not only a cause for keeping up, but also
for aggravating the affection.
Sir Philip Crampton was well aware, when he wrote his
essay,* of the part which the contracted conjunctiva played in
the formation of entropium ; and on a careful examination of his
views, one only wonders he did not follow up these opinions in
the line of treatment which he subsequently adopted, or adapt
his operation to the removal ofa pathological effect, of which
he was to a certain extent cognisant. He gives it as his opi-
_nion, that the loose folds of conjunctiva, reflected from the globe
to the upper margin of the tarsal cartilage, become in particular
states of disease contracted ; and he illustrates the effect which
such a condition would produce by the experiment, which any

* An Essay on the Entropeon or Inversion of the byelids—by Philip Cramp-

ton, M.D. London, 1805.
VOL. XXV. NO, 73. P
106 Mr. Wilde on the Causes and Cure of

one may perform upon themselves, by holding the lashes of the

upper lid, and drawing it downwards, and then rolling the eye
upwards, when the strain on these folds of conjunctiva will be
instantly felt. And in support of this opinion, he says: “ When
the contraction increases (and we know that a disposition to
contract is common to all secreting membranes), so that the folds
are not only obliterated, but that the internal membrane becomes
actually shorter than the external integument; the margin of
the tarsus deriving no support from without, and constantly
acted upon from within, readily yields, and becomes perma-
nently inverted.” ‘The contraction of the membrane, to which
I would, however, call the attention of my readers, is not to that
occurring in the upper loose folds of the reflected conjunctiva,
so affected) draw the whole lid upwards
which could, at best (if
and backwards, and could not exert any power on its free mar-
gin, but a contraction of the conjunctiva lining the cartilage,
and chiefly that part running parallel with and about the eighth
of an inch from the tarsal edge of the lid.
That acontracted state of the reflexion of the conjunctiva will
not cause inversion of the cartilage to which it is attached, [have
reason to conclude from several cases that I have lately witnessed.
In one of these instances now under my care, where, from the
effects of long-continued chronic ophthalmia,and a granular con-
dition of the lid, the folds so often referred to have been oblite-
rated, although the granulations have long since been removed,
the upper margin of the superior tarsal cartilage is bound in so
tightly to the eye, that it is with great difficulty the lid can be
everted ; and when the ball is turned upwards, the lid is forcibly
carried backwards and upwards also—yet here no inversion of
the margin has taken place.
Again, we daily witness cases of inversion of the lower lid, in
which, from the greater facility of examining, we can satisfy
ourselves as to the condition of the conjunctival reflection; and
we do not find any obliteration of the folds, which to a certain
extent exist there also; or any contraction of the membrane
where it passes from the globe to the lid, while we shall almost
 Eniropium and Trichiasis. 107
invariably observe a line of contraction running along the inner
surface of the lid, between its margin and the angle of reflexion,
similar in appearance to that which will be found upon the
upper lid. |
Since my attention was directed to the subject, I have made
it a rule, before adopting any line of treatment, to examine
with care the internal surface of the lids. In several cases the
conjunctiva was in a state of chronic inflammation, and fre-
quently granular, but this may be a consequence of the irritation,
and not a cause of the disease. In other cases, even in the very
early stage, and before much irritation had ensued, the lid, upon
being everted, exhibited a number of pale, shining, whitish-co-
loured lines scattered over the surface of the conjunctiva, but
chiefly running along its lateral extent, and resembling in ap-
pearance the cicatrices and contractions left upon this part after
the cure of granulations. The inner surface of the lid, moreover,
if carefully examined both on its plane aspect and in profile, will
be found to present an irregular, puckered appearance, and its
redness to exhibit a mottled character, varying in depth and in-
tensity in different parts—characters very difficult to explain in
writing, or even exhibit, without the aid ofa coloured represen-
tation. This contracted state of the lining membrane may take
place without any very apparent or troublesome inflammation
being present, and is often, I believe, a slow chronic process, of
which the individual is frequently unconscious. This action and
this effect may be local or general over the whole surface, and
thus produce the entropium ofa part or the whole of the lid ;
and when once the irregular turn is given to the cartilage, on
which from its close connexion it must act, the muscular appa-
ratus so often referred to in this paper, particularly that part of
the orbicular muscle denominated musculus ciliaris, comes into
play, and completes the inversion.
The frequency of entropium among the lower orders who
neglect their eyes, and its rarity in the upper walks of life, adds
strength to thisopinion. ‘‘ The consequence ofthis neglect,” says
Sir P. Crampton, ‘‘is excoriation and consequent contraction of
108 Mr. Wilde on the Causes and Cure of
the skin at the external angle of the eyelids, followed by a con-
traction of the fold of conjunctiva, which forms the internal liga-
ment of the tarsus.” From this, and the general tone and bearing
of his work, as well as from the principle of the operation which
he has introduced into practice for its removal, we gather that
he conceives the contraction of the membrane occurs in such a
manner as that the palpebral aperture is lessened in its extent,
or decreased from within outwards, whereas, with all due defe-
rence to this very high authority, I respectfully submit that the
contracting process takes place in almost every instance of inve-
terate entropium from above downwards, decreasing the breadth
and not the length of the lid. To our distinguished countryman
however, is undoubtedly due the credit of the first solution of
the problem as to the cause of entropium, namely, conjunctival
contraction in the first instance. This difference of opinion as
to the mode in which it acts, although apparently at first sight
of little value, is inreality of great importance in a pathological
point of view, for on it are to be grounded the operations for the
relief of this most harassing disease. Furthermore, the opera-
tions of Messrs. Crampton and Guthrie frequently fail, unless
these very contractions and tight, adhesive, band-like portions
of the conjunctiva are divided.
With respect to the causes of triachiasis (and perhaps the
same power may produce distichiasis also), I have in the first
instance to remark with Scarpa, that the cilia are not, as was
generally supposed, set upon the cartilage in a single row or
line; but that what upon a superficial view appears so, is in
reality an irregular triple line where they pierce the integument,
and ina kind of chevaux-de-frise manner they cross or meet
each other towards their extremities. From this it follows, that
the hairs cannot run parallel to each other from their roots to
their external appearance, and upon a close examination we
find that the bulbs of these hairs are not only very irregular, but
also diverge widely as they sink into the structure on which
they are placed. In psorophthalmia, and particularly in tinea
palpebrarum, when inflammation attacks the whole margin of
 Entropium and Trichiasis. 109
the eye-lid (especially the upper), and the cutis swells consi-
derably, while small abcesses form round the roots of the indi-
vidual hairs, and the entire surface in some cases presents a con-
dylomatous appearance, the interspaces between the cilia enlarge
from the unhealthy deposit in the part, so that the natural
position of these hairs is reversed, being then more divergent
where they pierce the skin than at the roots; and they likewise
exhibit a bushy, very irregular, and distorted appearance in a
well marked triple or quadruple row. Now, although the ori-
ginal disease that produced this state may be speedily removed,
still the fibrous deposit along the margin of the lid, which altered
the relation of these hairs, remains to a certain extent, and
keeps up their deformity or unnatural and distorted condition
in whole or in part, so as subsequently to produce the
disease called trichiasis, the apex of the line of hairs being
then at their roots along the cartilage, and the base at their fine
extremities. I have watched this process going forward so often,
that I have satisfied myself of its truth, and have had several
drawings made of the affection in its various stages to exhibit it.
It is possible that distichiasis may be produced in like manner,
and the inflammatory action may be propagated from the margin
to the inner surface of the lid, and thus producing contraction,
give rise to entropium—so frequently met with in connexion with
trichiasis. In such cases in particular, the granular, condyloma-
tous, hard and thickened margin of the lid is very apparent.
For the relief of the various forms of this disease (entropium
trichiasis and distichiasis), the operations and methods of cure may
be divided into the palliative and the radical: the former consist-
ing of the removal of the offending hairs as often as they require
it, or the temporary application of straps of adhesive plaster,
pads, glue bandages, and other mechanical contrivances to re-
tain the lid in such a position as that the cilia may no longer of-
fend the globe of the eye; as well as the sticking together by gum
and such other glutinous substances, small packets of the hairs,
whereby the normal ones support the irregular or inverted ones.
110 Mr. Wilde on the Causes and Cure of
Now although the relief by all such means is but temporary, yet
as many old or timid persons will not submit to the employment
of any other means, the surgeon should be well acquainted with
the varieties of these methods of treatment. The latter, the ra-
dical method, consists of such surgical operations as will either
return into its natural position the inverted cartilage, by remov-
ing a portion ofthe integuments of the lids, or acting on them
with escarotics, or by division of the tarsal margin of the carti-
lage, soasto free it from any preternatural tightening, as supposed
by some to be the cause of this complaint; and this modified by
various incisions, and such subsequent positions of it in the heal-
ing process as will make it retain the natural position ;—or by re-
moving in whole or in part the hairs and the substance in which
they are set.
It is not my intention to describe minutely, or to enter intoa
discussion of the relative merits of each of these methods of
cure; but to contrast the operations with their subsequent effects
upon the eye, recommended for the cure of entropium by Sir P.
Crampton and Mr, Guthrie on the one hand, and those per-
formed by Professor Jigerand Mr. Saunders on the other.
Those acquainted with the beautiful anatomical mechanism
of the eye-lids; their admirable adaptation to the eye-ball in all
its various positions—their action not only as curtains to shield
the globe from all extraneous substance, but also (the upper lids
in particular) by the thin stratum offluid which, if I may so say,
lines the external surface of the eye, preserving the necessary
moisture and polish of the globe—know full well the necessity of
preserving intact the proper position of the puncta lachrymalia ;
the adjustment of the margin of the lids to the surface of the
globe; the integrity of the tarsal ligaments and tendon of the orbi-
cularis muscle; and,above all, the preservation of continuity of the
edge of the lids, in order to keep in a healthy state the delicate
provisions of this most wonderful apparatus. Should it then
become necessary to interfere with these parts, in order to alle-
viate or remove disease, the surgeon should bear in mind not
 Entropium and Trichiasis. t1t

only the parts he has to deal with as regards their structure,

but also the functions which they are intended to perform in
this piece-of optical mechanism.
Mr. Ware, on the supposition that entropium arose from the
“ciliary edges” being “ not only inverted, but likewise contract-
ed in length,” advises the “ enlarging the circumference of the
ciliary edges,” and says, “this may be done either by an inci-
sion at the outer angle, or by a complete division ofthe cartilage
called tarsus in the middle.” Mr. Tyrrell and Mr, Wharton
Jones still partially adhere to this form of operation.
This method not succeeding, Sir P. Crampton devised the
operation so well known and so constantly practised in this
country, of dividing the tarsal cartilage at its internal and ex-
ternal extremity; the former incision beside the punctum, and
the latter at the external commissure, in order to include the
tarsal ligaments ; when, if the inversion (I write of the upper lid)
is not removed, these perpendicular incisions are united at
their extremities by a longitudinal one, running parallel with the
ciliary margin of the lid. The parts are held thus in an inverted
condition by a suspensorium palpebrarum, for some days, in
order ¢o restore to its natural position the inverted cartilage.
These are the principles of the operation; the subsequent
dressing and after-treatment are known to most students in this
city. In some cases, Sir Philip has been obliged, in addition,
to glue down the lashes to the integuments, and to apply other
mechanical means to bring back whatever deformity remained
after the incisions, This method of cure was first propounded
in 1804. In 1838, Mr. Guthrie writes: “ Mr. Crampton’s
operation, then, as above described, appears to have succeeded
perfectly in his hands; that it has been found insufficient in
that of others is equally certain, arising, I believe, from the un-
equal effect produced by the suspensorium, and from its not
acting in a sufficiently powerful manner, in the inveterate curva-
tures of the cartilage, on its bent extremities; and from his
attention not having been directed towards them, and the esta-
blishment of a countervailing force: all of which indications
142 Dr. Wilde on the Causes and Cure of
are necessary to be, and are, I believe, fulfilled in the worst
cases, by performing the operation in the manner I shall point
out.”
Two perpendicular incisions, of from a quarter to half an
inch in extent, or of a sufficient length to render the eyelid quite
free, are made through the lid, one close to the external angle,
the other at a short distance from the punctum lachrymale;
and these incisions are, he says, to be “continued, if necessary, by
repeated touches with the scissors, until that part of the eyelid
containing the tarsal cartilage is perfectly free, and is evidently
not acted upon by the fibres of the orbicularis muscle, which lie
upon it.” The portion of the lid included in these incisions
is now to be everted, and retained against the brow, when he
continues, “if any lateral attachment be observed acting upon
and drawing or confining the lid, it is to be divided, which is,
in fact, still elongating the incisions ;” but as these incisions,
extended as they are, will frequently fail in turning outwards
the incurvated margin of the cartilage, as is acknowledged by
Mr. Guthrie himself, he recommends the division of the car-
tilage along its whole length, from point to point of the lateral
perpendicular incisions, thus leaving the lid connected with
the surrounding parts merely by the external integuments,
and the fibres of the orbicular muscles. Not deeming this
sufficient, or the vicious turn of the lid still remaining,
he
advises “a fold of skin to be cut away from that part of the
eyelid included. between the incisions,” as close as possible
to the ciliary margin of the lid; three or four ligatures are
then passed through the divided edges of this latter inci-
sion, and made also to include the outer or lower edge of the
lid itself, which is then retained upon the brow by means of
these ligatures, fastened upon the foreliead by pieces of adhe-
sive plaster. “In order to prevent any attempt at union but
by granulation, or a filling up of the incision, the edges are
to be slightly touched with a saulphas cupri; a compress
and retaining bandage is then applied, but removed next day,
when any adhesion that may have taken place at the angles
 Entropium and Trichiasis. 113

of the incisions, is to be removed. On the third day the edges

of the incisions are again to be touched with the sulphate of
copper, the lid being still retained in its inverted position;
when “in a few days more,” continues the describer, “ and
especially by the continued elevation of the lid, the ligatures
cut their way out, during which period the eyelid is gradually
lowered, and by the time the incisions have filled up, it will
have resumed its natural situation, and the cure will have been
completed, with, however, two indentations in the ciliary mar-
gin of the tarsus, and it may be, the continued inversion of two
or three detached and irregular hairs.” This operation, it will
be seen, differs from that originally described and recom-
mended by Sir Philip Crampton, only in its magnitude and
severity ; in making the longitudinal incision of the conjunctiva,
as recommended by CHtius and Sir Philip, extend through the
cartilage, and in retaining the everted lid upon the brow, by
means of ligatures, with greater security than could be achieved
by the suspensorium palpebrarum. Mr. Guthrie very judicious-
ly cautions the operator to avoid the division of the punctum,
but observes, ‘‘ that the operation, accomplished with all the
care I have described, will still fail, if equal attention be not
daily paid to the subsequent dressing, on which indeed more
depends than on the operation itself ; so much so, indeed, that
I am disposed to consider inattention to it the most certain
cause of failure.”
Before I proceed to remark upon what appears to me the
defects of this operation, let us turn to that recommended by
Mr. Saunders, who, in recommending the complete removal of
the cilia, and in describing the sufferings induced by the ha-
rassing disease of entropium or trichiasis, most justly observes:
“ This picture which I have drawn, although melancholy, is not
overcharged. Considering that I am addressing men acquainted
with human misery, it may be deemed superfluous; but I am
anxious that this truth should be impressed on the reader's
mind, that the excision of the tarsus and roots ofthe cilia, how-
VOL. XXYV. NO. 73. Q
114 Mr. Wilde on the Causes and Cure of
ever severe and formidable in apprehension, is instituted for
the cure of a most excruciating disease, and that the occasion
demanding it is imperious.” With this rule, so admirably ex-
pressed, I fully concur.
Saunders performed his operation thus: having placed a
piece of thin horn beneath the affected eyelid, in order to afford
a resistance behind, as well as to guard the globe from injury,
he made an incision posterior to and along the whole length of
the cilia, and extending from the punctum to the external angle,
when the entire tarsal margin containing the eyelashes was dis-
sected off.* No subsequent dressing was applied, or deemed
necessary; and in a few days union took place between the in-
teguments and conjunctiva.
This operation was subsequently modified by Professor
Jager, of Vienna; and this I shall presently describe as that
which it appears to me is best suited to the removal of entro-
pium and trichiasis. When once a cartilage, particularly that
of the eyelid, has become distorted, and has remained so any
length oftime, I have always found it a matter of exceeding diffi-
culty to restore it by any artificial means to its natural position,
even although the original exciting cause may be removed.
During the Summer of 1842, I was assisted by Mr. Hamilton
and Mr. Grimshaw in two plastic operations, for the removal of
ectropium, the results of burn and ulceration. In both of these,
although the transplanted lid formed a perfect and sufficient co-
vering to the eye, yet for many weeks after, that portion of the
cartilage which had been most distorted, and was, if I may so
say, puckered by the original cicatrix returned, in part at least,
to its original position, and protruded at the palpebral aperture ;
nor could this defect be remedied till an incision was made, in
both instances, through the lid, from without inwards; and the
edges of the divided portion of cartilage having been drawn

* To Razes we are, I believe, indebted for the recommendation of the removal

by excision of the entire ciliary margin of the eyelid. See also Heister’s Surgery,
Part IL. p. 370.
 Entropium and Trichiasis. 115
through the external wound, and retained there by sutures, the
adhesion thus produced remedied the defect. And it is this
difficulty of turning back an old inveterate case of entropium
which often renders the operation by incision inefficacious, in
the more advanced stage, which might have been, in all pro-
bability, cured by it in the earlier period.
All practical oculists seem aware of the inveterate and
almost incurable bend or turn which the tarsal cartilage takes,and
of its continued liability to return, even long after the operation.
This was long since clearly proved by Saunders, who, in re-
marking upon the operation of incision, says: “although by
detaching it from the external and internal canthi, and by keep-
ing it everted for a considerable time, until the incisions be
healed, the ciliary margin may for a time be clear of the eye,
yet this flattering appearance, increased by the temporary relief
of the patient, together with the returning transparency of the
cornea, the friction being taken off, is but of short duration.
The altered state of the tarsus, preventing its accommodation
to the surface of the globe, is not corrected ; and so great is
the tendency of this diseased substance to incurvate, that the
inversion of the eyelid is very soon again confirmed.”
I offer no excuse for these lengthened quotations from Mr.
Saunders’ invaluable work; they are so just, so practical, and
it appears to me, so thoroughly based on long experience and
extensive observation of this disease, and his opinions are so
well expressed, thatI feel they must have more weight than any
thing I could offer on the subject. I was led to adopt views
similar to these, from being applied to at my dispensary by
numbers of persons who had been already operated on at various
periods of their lives, by different methods, and by different in-
dividuals, for the cure ofinversion and distortion of the eyelashes,
in which, although temporary relief had been obtained by each
surgical effort, still the unnatural condition of the cartilage and
eyelashes returned in whole or in part, and the distortion of the
margin of the lid, from the effect of the various operations, was
116 Mr. Wilde on the Causes and Cure of
not only disfiguring, but positively destructive to the mechanical
adaptation of the appendages of the eye. Let the following
case stand as an example of many.
Edward Connor, et. 31, a native of Belturbet, one of the
Society of Religious Brothers, applied at the dispensary in July
last, with both trichiasis and entropium of the upper lids, and a
few distorted hairs upon the right lower lid; the cornee nebu-
lous and vascular; the vessels running in straight lines, and
chiefly from above downwards, over that portion of each cornea
fretted by the cilia, which were thick, bushy, irregular, and
light in colour; the lids slightly oedematous, and their margins
thickened, red, and irritable. There are two gaps, about the
eighth of an inch in width, and a line in depth, in the margins
of both lids. He holds the head downwards, and complains of
greatirritation, heat, smarting, pain, and scalding in the eyes, with
profuse lachrymation. He is continually winking; his skin is cold
and clammy; has profuse night perspirations; the tongue is thick,
white, and clammy; complains of loss of appetite, thirst, and
restless nights. Upon the upper lids there are several scars and
cicatrices, distinguished by their whiteness from the surrounding
integument. The palpebral aperture does not seem contracted,
and the lids can be easily lifted off the eye, but a considerable dif-
ficulty is experienced in everting them, apparently owing to the
contracted state of the conjunctiva, which presents the mottled,
contracted, and irregularly lined appearance which I described
at page 107, and which I believe to be the cause of the inversion.
The history which he gives of his disease is to the following effect.
He states that about fifteen years ago, he was first affected with
that description of “sore eyes,’ > which, from the account he
gives, I believe to have been ophthalmia tarsi, and for this he
had an issue placed in his arm. Three years afterwards he was
placed under the care of a distinguished army surgeon, who
put a seton in the back of his neck, and applied caustic plasters
to his temples, At this time the lashes had begun to turn in,
and to remedy this, a perpendicular incision (I suppose that
 Entropium and Trichiasis. 117

recommended by Mr. Ware) was made through the right lid;

this affording but slight relief, the inverted lashes were removed
as often as they grew, and a strong acid was applied to the out-
side of the lids thirty-four times. He likewise underwent two
courses of mercury. By this time (1827), the irritation and
inflammatory condition of the eyes were so much removed, that
he was enabled to return to his original occupation, that of a
shoemaker; but he was obliged to remove the hairs with a
tweezers almost daily. In this state he remained till 1830,
when another army surgeon removed an elliptical portion of
integument from each lid ; but not finding it succeed, and
being told that enough had not been removed, he submitted to
a repetition of the operation about a month subsequently. ‘This
latter gave partial relief, and in this state he remained for about
six years, removing the lashes from time to time, but being liable
to attacks of inflammation from cold, increased growth of the
hairs, or any other irritating cause. In the year 1834, how-
ever, his vision and general health were so much impaired, that
he was obliged to give up his trade, and was received into the
Thurles Monastery as one of the lay-brothers. Distressed and
wearied with the constant irritation of his eyes, and with being
obliged to pluck out the lashes daily, he came to Dublin in
May last (1843), and was received into one of the hospitals,
where the operation advised by Sir Philip Crampton was per-
formed on both eyes. During the five weeks he remained in
the hospital subsequent to the operation, he was, to use his own
expression, “all but well ;’—the eyes, however, he states, have
watered much more since the operation than they did before;
and he says he feels the lid even tighter than it was previously.
On the 28th of August I removed the entire cilia of the
upper lids of both eyes, by Jager’s operation, and everted the
two curved cilia in the lower lid of the right eye, by cutting
down upon them, and applying nitrate of silver to their roots.
I have seen this man constantly from that period to the present;
the corneze have become quite clear; the pain, irritation, and
118 Mr. Wilde on the Causes and Cure of
suffusion of tears have ceased, and his constitution has become
‘quite repaired.” The margins of the lids were for some time
after the operation touched with sulphate of copper, and the
dilute citrine ointment occasionally applied at bed-time; and at
a more advanced period, the wine of opium was dropped into
the eyes every morning. The solution of the hydriodate of po-
tash, with tincture of iodine, was likewise administered inter-
nally. The integuments and conjunctiva have united; the
edges of the lids are perfectly smooth, and present a slight
pinkish appearance. None of the cilia have since appeared,
and although the cartilage is still partially inverted, it produces
no annoyance or disfiguration. The lids, with the exception of
the want of cilia, present a natural appearance, and the gaps
which previously existed in their margins, from the former
operations, are scarcely perceptible. Such was the relief which
this poor man experienced, that, when asked to-day how he did,
his answer was, “ oh, I am in heaven!”
‘<The operation proposed by Dr. Crampton,” says Saunders,
‘is highly successful, and, as I am inclined to think, unexcep-
tionable in the earlier periods of the disease, before an uncon-
querable inclination of the tarsus towards the globe is produced ;
but in this ultimate and inveterate state of the disease, in which
the contraction is often consequent on the cicatrization of the
tarsus itself, it is altogether inexpedient.” In commenting (I
must say rather severely) upon this opinion, with which I per-
fectly coincide, Mr. Guthrie writes as follows: “ But as the
alterations | have made in Mr, Crampton’s method render it,
in my opinion, equal to the cure of every stage of the disease,
and as so many more cases of it have come under my observa-
tion, and have been cured by the operation I recommend, since
the publication of the first edition of this work, I feel myself
bound to add, that any surgeon who shall mutilate his patient,
without having previously tried it, and failed, will be liable to
the severest reprehension.” ‘That, however, it will fail, even
when performed according to the plan, and to the full extent,
 Entropium and Trichiasis. 119
recommended by Mr. Guthrie, I have seen numerous examples :
—let the following suffice.
Eliza Haberlin, zt. 27, the appearance of whose eyes upon
the 4th of January, 1843, is exhibited in the accompanying en-
graving, states that she had weak eyes from childhood, and that

about seven years ago the lashes began to turn in, and the mar-
gins of the lids had become red and sore. After going through
the usual progress ofthe disease, and being affected with the usual
symptoms, the cornez became dim about four years ago. A
year afterwards, she came to Dublin, was received into hospital,
and operated on by Guthrie’s method; the lid was held up by
means of sutures and adhesive plasters, she says, for upwards of
ten days. By this operation the lashes were for a time turned
out, and she left the hospital with a promise, that the cornez
would soon clear. This, unhappily, has not occurred, for the
lashes, as will be seen by reference to the representation, still
lie upon the cornea as bad as ever, but the lid does not press
upon it with such severity.
Her appearance, and the character and condition of the
eyes when I first saw her, in the early part of January, in this
year, were as follows: both cornee were semi-opaque, whitish
like a macerated ligament, more conical than natural, and tra-
versed by several tortuous red vessels. The conjunctiva of the
globe was of a yellowish red colour; and around the cornea of
each eye there was an irregular circle offine pinkish vessels, while
the whole surface of the globe was remarkably insensible to the
touch, and almost approaching to xeroma, ‘The rime of both pal-
pebre were irregular, fissured, and considerably distorted, owing
120 Mr. Wilde on the Causes and Cure of
to the gaps left by the perpendicular incisions of the previous
operation; the hairs grew chiefly from the centres of the upper
lids, which were still inverted ; the hairs on the remaining in-
ternal and external portion of both upper lids, and particularly
near the margins of the wounds, were in that state denominated
trichiasis, growing, in fact, in every direction; the puncta
lachrymalium, in both lids of the eyes, were considerably dis-
torted; and the tears, which were secreted in great quantity,
and trickling down through the gaps in the cartilage, distilled
over the cheek, and very little of the lachrymal fluid seemed to
pass through the puncta; both lower lids were everted; their
cilia scanty, and irregular; the conjunctiva red, and velvety;
and the integuments beneath each lid were ostensibly tightened
and contracted. On everting the upper lids, the irregular,
puckered, and contracted state of the conjunctiva was apparent,
and such as I have already so frequently alluded to. The brow
was, as usual, corrugated; there was, however, little intolerance
of light, and she was able to find her way through the streets.
As a chance still remained of preserving some vision, and as
she earnestly requested to have the hairs completely removed,
I performed Saunders’ operation on both upper lids. This was
rendered necessary by the unnatural, distorted condition of the
cartilage, and the gaps or fissures already made in its margin.
A portion of the integument, with an irregular slip of cartilage,
and all the cilia were removed, from the punctum to the external
commissure of one eye ; the skin of the lid was then brought in
contact with the margin of the conjunctiva lining the inner
surface of the cartilage by a couple of fine sutures—cold water
dressing was used for the two days following the operation; and
on the third, the sutures were removed. The edges of the lids
have adhered by the first intention, and now present fine smooth
margins; the exposed surface of the under lid has been touched
with the sulphate of copper every second day, and the wine
of opium dropped into the eyes on the alternate ones. The
same course was adopted with the second eye.
Feb. 12, She has experienced the greatest relief since the
 Entropium and Trichiasis. 12]
operation, and says she can find her way much better. The
upper third of the cornea in the right eye has certainly become
clearer; the tears do not now run over the cheek, as before,
and the general appearance of the eyes and the countenance is
much improved. Should the cornea continue to clear at any
one spot round its margin, it is within the range of possibility
that an artificial pupil might afford further relief. But it can-
not be expected that any great or general improvement of the
opacity of the cornea will take place. Had, however, the opera-
tion of excision been performed in this most inveterate case, in
its early stage, I firmly believe that the only difficulty or de-
formity which this poor woman would now labour under, would
be the loss (if such it can be termed under these circumstances)
of the eyelashes, and an occasional redness of the tarsal margin
of the lids.
Again, let us examine into another circumstance, with regard
to this operation ofdivision,or perpendicular incision ofthe tarsal
cartilage, even when it succeeds in completely turning out the
lashes—namely, its subsequent effects on the mechanical adjust-
ment of the parts subsidiary to the organ of vision. This effect, it
is to be remembered, is not an immediate one; it is not to be
observed on the patient’s leaving the hospital, nor perhaps for
many months after. ‘This illustration will explain my meaning
better than words. This
drawing was made in
August, 1842, from the
eye of Michael Murphy,
et. 60, by trade a file-
maker, and residing in the
Liberties. He states that
six years before, he was
operated on for the turn-
ing in of his eyelashes;
and from his description of the operation it appears to have
been that recommended by Mr. Guthrie; for his lid was “ kept
VOL, XXV, NO. 73. R
122 Mr. Wilde on the Causes and Cure of
turned up for many a day after the cutting.” He states, that
he experienced considerable relief for several months after the
operation, only that “the eye was always watery ;” that towards
the end of a year or fifteen months, the upper eyelid began to
curl up, and the lower to fall down, till it assumed the appearance
delineated in this wood-cut ; that ‘the tears are now evermore
flowing over ;” that he is unable perfectly to close the lids; and
the eye, from being more exposed to the effects of his occupation
than natural, is continually inflamed and irritable. Such is his
story. The parts now present the following appearance: two
extensive gaps exist in the margin of the upper lid; one of
these will be observed at the outer angle, the other at the
punctum lachrymale, which the incision seems to have divided
obliquely; the cilia are all in a perfectly normal line with one
another, but do not turn outwards and upwards, but downwards
and forwards, owing to some remains of the entropium; the hairs,
however, do not touch the globe. The lower lid hangs downwards,
in an angular manner, and its conjunctiva is red, thickened,
and villous; he is unable, even by squeezing, to bring the lids
in apposition; the upper punctum is to be found in the edge
of the inner gap, and the lower looks forwards and outwards,
owing to the eversion of its cartilage. The cilia are loaded at the
roots with yellow discharge ; an erysipelatous redness exists all
round the eye, but particularly along the upper thickened por-
tion of lid included within the incisions, and about half an inch
below the inferior palpebrum, where the skin is smooth, ofa
pinkish white colour, and so tightly contracted, that it is not
possible to restore the lower lid to its natural position, even
with the finger.
At the external angle, a band of contracted integuments
drew it downwards and outwards, caused in all probability by
the irritation of the tears and the discharge which was constantly
flowing over it, the curtain power of the eye-lid being com-
pletely lost, and its adaptation to the globe destroyed. Surely
such a state of things as this eye now presents cannot be com-
 Entropium and Trichiasis. 123
pared with the trifling inconvenience resulting from the loss of
the cilia,
The objections which it appears to me, the operation by in-
cision is liable to, may be summed up as follows:—It does not
always remedy the inversion, and although it affords temporary
relief in many instances, still the disease, as acknowledged upon
all hands, is liable to return, owing either to the vicious and de-
terminate inclination of the cartilage, or to the original cause
not having been removed, Judicious and ingenious as the ope-
ration of Sir Philip Crampton is in the first stage of pure entro-
pium, without any irregularity of the lashes, it is totally ineffi-
cacious where any extent of trichiasis is present ; and ina vast
number of cases that I have seen after the operation, trichiasis
did exist, and therefore the intention of the inventor has neither
been fully understood nor acted upon. Sir Philip advises the
insulation and eversion of that portion of the lid in which the
inverted or irregular hairs are situated, but very frequently these
hairs are scattered at irregular intervals, all along the ciliary
margin, and each hair would require a separate operation for
itself; moreover, the trichiasis, either singly or in connexion
with entropium, does not depend upon an unnatural position of
the cartilage, but upon an irregular or vicious position of the
hair itself, and therefore, to remove the hair from the surface
of the cornea by means of any operation upon the cartilage,
must be to place it (the cartilage) in an irregular and unnatural
situation—all which objections are obviated in the operation by
excision or extirpation.
The eyelids appear to be held in their natural position by
the tendon of the orbicularis palpebrarum muscle, and also its
fleshy fibres spreading over its surface, by the external integu-
ment, and by the conjunctival lining, especially those portions
of it denominated external and internal ligaments. And upon
the correct and accurate position of the eyelids depends the in-
tegrity and mechanical power of those capillary, and perhaps
erectile-mouthed siphon tubes, the puncta lachrymalium. If,
124: Mr. Wilde on the Causes and Cure of
then, the margin of the palpebral fissure be divided, the sphinc-
ter power of the lids is lost; the lower lid, from want of the
support afforded it by the action of the orbicularis muscle, and
its attachment to the upper lid, after some time, droops and
causes entropium; the puncta, no longer held in their natural
position, do not take up the secretion thrown into the lacus
lachrymalis, and the tears, instead of being urged forward by
the action of the lids into that receptacle, distil over the eye
through the fissures in the lid, and irritating the cheek, increase
the eversion of the inferior palpebra. According to Mr.
Guthrie’s method, the portion of cartilage containing the inver-
sion is completely detached; and I have seen cases in which,
in three months after, it lay flat upon the lid, with the eyelashes
hanging downwards and forwards; and so much difficulty was
experienced in raising the lid, that the eye appeared to be
affected with ptosis.
The objections urged against Mr. Saunders’ operation I have
already spoken of. I believe the only valid ones are, that it
destroyed the Mibomian glands, and took away from the length
of the cartilage, forI do not think any one can consider the
removal of the cilia in trichiasis or entropium a loss in any way
commensurate with the benefit derived from their extraction.
Did not these cilia return with an almost hydrean force, who
would ever think of doing more than plucking them out for the
cure of any of the affections I have described? Who would
think of recommending the painful, tedious, and often insufficient
operation of making a double perpendicular incision through
the tarsal cartilage, each incision half an inch long, connecting
these by a longitudinal cut also through the cartilage, removing
an elliptical piece of the external integument, turning the lid
up upon the brow, and retaining it there for several days with liga-
tures and slips of adhesive plaster, and applying in the mean time
escarotics to the margins of the wounds, and often waiting for
weeks before a probable cure is effected? How many persons
pass through life comfortable and happy, and with very good
 Entropium and Trichiasis. 125

vision, without any eyelashes at all, or what they have, scanty,

and in no wise performing the functions for which these portions
of the lachrymal appendages were intended. Why, then, exclaim
with such warmth and severity against those who advise the
surgical removal of the eyelashes, without any interference with
the tarsal cartilage, either in length or continuity ofits margin;
The operation, which I have been in the habit of per-
forming for some time, the facility and good effects of which
have been witnessed by numbers of my professional brethren, I
will now describe; merely premising, that it differs from that
recommended by Professor Jiger only in one of its stages, and
in the application of ligatures instead of allowing union by the
second intention.
The surgeon should be provided, in the first instance, with
a variety of horn or ivory spatulas, such as those originally
described by Saunders, and figured in most works upon
ophthalmic surgery.* They should be made of different
breadths and curvatures, to fit the varieties of palpebral aper-
tures, and will be found much more convenient without than
with the wire retractor usually attached to them, and they
should be at least four inches in length. The patient being
settled in a high backed chair, or with the head resting against
the breast of an assistant, the spatula is to be inserted beneath
the upper lid, for at least half an inch of its length, and
held firmly in that position by the left hand of the operator,
which rests against the cheek of the patient; the assistant
then, with the fore-finger of his right hand, draws upwards
and presses against the superciliary arch the integument of the
lid, so as to put it completely on the stretch, and likewise evert,
as far as possible, the lashes, which the operator holds down
upon the spatula with the thumb nail of his left hand, Before
proceeding farther, the surgeon should make himself thoroughly
acquainted with the exact position of the punctum, in order to
keep clear of it in the subsequent incision. It may also be re-

* See Mackenzie, p. 507.

126 Mr. Wilde on the Causes and Cure of
marked, that the more the parts are put upon the stretch, the
greater will be the facility experienced in the subsequent stages
of the operation, and the more perfect will be its results; there-
fore, the spatula employed should be accurately fitted to the
extent of aperture in each individual case. With a small fine
scalpel, more curved than usual towards its point, and having a
small indenture in its back, towards the extremity, an incision
is to be made through the external integument, parallel with,
and about the eighth of an inch behind the ciliary margin of
the lid; commencing in the right eye at the external commis-
sure and ending at the punctum, and vice versa in the left. In
this incision, which may be varied in its extent from the edge
of the lid, according to the quantity of external integument
which it may be desirable to remove, the fibres of the orbicula-
ris muscle must be in part divided along their longitudinal
course, for the cartilage should be reached at one cut; and the
extremities of the incision should likewise curve abruptly down-
wards, in order to leave no nodulated or rugged margin to the
lid in the subsequent process of healing.
Considerable hemorrhage always follows this incision, the
parts being naturally exceedingly vascular, and rendered more
so by their diseased condition. Jager and most operators now
complete the excision of the tarsus by slanting the blade of the
knife downwards and inwards, and so slicing off, by repeated
slight incisions, that portion of the lid in which the cilia are
placed, and cutting on the spatula, which affords a firm resis-
tance behind as well as a protection to the globe itself. A much
simpler and more eflicacious plan will be found in throwing
aside the spatula, and laying hold of the external angle of the
margin of the lid with a fine toothed forceps, such as that which
I described and figured among the ear instruments in the last
number of this Journal, Then, standing, not in front but on
one side of the patient, so that the parts may be seen in profile,
with the knife held in that position that its blade crosses ob-
liquely the margin of the lid, from the external tegumentary
 Entropium and Trichiasis. 127
incision to a point a little internal to the centre of that flat sur-
face which the lids present to each other when closed, it is
made to traverse, with its back kept towards the operator, the
whole extent of the part to be removed, while the forceps re-
tained in the left hand draws forwards the slip containing the
eyelashes, till the incision is complete; the assistant still pre-
serving his original position. By this means there is nothing
whatever removed from the length of the cartilage, and the
cilia, by not being inserted in, but dying on the cartilage, are
completely removed, and by thus taking off the slip in profile,
we see exactly how much we are removing, and can also guard
with greater accuracy the punctum.
The whole of what I have now described need not occupy
above a minute, and the pain, though it is certainly very severe,
is in no wise equal to that experienced in the operation by inci-
sion, at least if the patient’s expression of feeling is to be taken
as a test of such. Upon examining the inner portion of the
surface removed it will be found studded over with the black
bulbous roots ofthe eyelashes, which are generally all removed
by the incision ; the excised surface ofthe lid, however, must be
accurately examined to see that no root remains, and until the
surgeon is assured of this he has not completed his operation.
The bleeding is, as I have said, very profuse, and in some cases,—
those which may be denominated vascular persons, two or three
small arteries, branches of the superior palpebral, pour out per
saltem. The surgeon must, however, wait patiently till all this
ceases, and the assistant should continue to keep the lid elevated
as by closure or turning in upon the eye the hemorrhage will
be decidedly increased ; a little cold water and the action ofthe
air will, however, soon arrest the bleeding, at least to an extent
sufficient to allow of such an examination as will enable the ope-
rator to observe the divided root of any remaining hair, which
is fortunately always of a dark colour, no matter what may be
the complexion of the patient. Such roots should be laid hold
of with a fine toothed or a ciliary forceps, and removed, along
128 Mr. Wilde on the Causes and Cure of
with some of the surrounding cellular substance, by the scalpel
or acurved scissors, for if these points are only plucked out
there is a possibility of the hairs growing again.
Many operators are now content with the application of water
dressing, and allowing the parts to contract and adhere as best
they can ; such was the mode of treatment adopted by Mr. Saun-
ders, who, however, adds: “ in all the patients on whom I have
operated, a fungus of considerable size has sprouted from the
centre of the section.” This induced me to employ two or three
points of suture passed by means of a fine sewing needle,* first
through the thin margin of the cartilage, and then including the
external integument which is thus brought in accurate apposition
with the conjunctiva lining of the lid. By inserting the central
one first, and, through its means, holding the lid slightly everted,
the two others can be passed with great facility; they are then cut
off close, and removed about the end of the third day, when the
wound is generally healed, and no further trouble isexperienced,
the cornea clearing, and the irritability, epiphora, winking, and
chronic inflammation of the parts gradually subsiding. I sel-
dom see the patient again till it is time to remove the ligatures
on the third day, but recommend the application of cold water
in the interim. The hemorrhage is generally very salutary, and
in thirty-six cases on which [I have operated no inflammation
worth remarking upon occurred.

* Heretofore there were no instruments so ill made, or so clumsily constructed,

as what were denominated ‘‘ Surgeons’ Needles;”’ they were totally inapplicable
to all delicate operations. None of the needles manufactured by the instrument
makers are ever so smooth, fine, or sharp, as the common sewing needle. These
latter can, however, be made applicable to any of the purposes of operative sur-
gery, by being softened in the flame of a candle, bent to the required position, and
then rehardened. And I am not sure that a triangular pointed needle makes its
way with greater facility than a well polished round one, although it is possible
that a large ligature may follow it with more facility.
+ Dr. Jacob, in the 5th volume of the Dublin Hospital Reports, states, that
without any incision with the knife, but ‘ by repeated clips of the scissors along
the eyelids, and at a distance of something more than a line from the margin,”’ he
 Entropium and Trichiasis. 129
A greater change, not only in the eyes themselves, but in the
whole appearance and expression of the countenance, cannot
possibly be imagined, than that produced in a very few days by
the operation that I have now described ; the offending bodies
being removed, the lids open wide, the head is held erect,
and the patient has in truth
‘¢ Smoothed his wrinkled front 3”

for the brow, before so rugous and contracted, has now become
expanded ; the frown has given way to a smile, and the whole
bearing of the individual is that of ease and cheerfulness, and
all this has been purchased with the loss of the diseased eye-
lashes! Yet this has been denounced as a “ most cruel pro-
ceeding,” a “ dreadful operation,” and a “ mutilation,” for which
the surgeon who has not previously resorted to the method of
Mr. Guthrie is deserving of the “‘ severest reprehension ! !”
This engraving faithfully represents the eyes of Margaret

cision for entropium of two years’ standing in September, 1842.

clips away the ciliary margin of the eyelid from the angle to the punctum, in-
cluding skin, cartilage, and roots of eyelashes. Vacca Berlinghieri, of Pisa,
makes a small flap of integument, so as to uncover the roots of the cilia in partial
trichiasis, and dissecting them out, or destroying them with acid, restores the por-
tion of integument. Dr. Rainy, everting the lid, extirpates with an extraction
knife that portion only of the cartilage in which the distorted hairs are placed,
leaving the external natural row. Sir William Adams performed the same opera-
tion as that recommended by him for eversion, the removal of a wedge-shaped
piece of the lid.
WOLS SEV: NOW (5, Ss
130 Mr. Wilde on the Causes and Cure of
At the period when this drawing was made, the right eye had
been operated on one month ; all the hairs had been completely
removed, and the lid presented a perfectly smooth, regular
margin.
The left eye was operated on a few days afterwards, and
with similar success. She remained in the Dispensary for about
six weeks, until the vascularity of the cornea had gone off. A
short time since I met her accidentally in the street; the lids
had remained smooth and natural ; the redness of their margins,
which remained for some time after the operation, had entirely
disappeared ; the edges of the upper and lower lids meet per-
fectly, and the inversion of the edge of the cartilage was scarcely
perceptible. This latter circumstance leads me to remark upon
an objection which I have heard urged against the operation of
excision—that though we remove the cilia, we do not evert the
cartilage. This is quite true, but the edge of the cartilage in no
way offends the eye, except by means of the hair set upon it ;
and it must be remembered that much of the eversion is spas-
modic and caused by muscular action, when once the vicious
turn is given to the cartilage; “the orbicularis palpebrarum,”
says Mr. Dalrymple, in his admirable Anatomy of the Human
Eye,* “contracts with a force altogether spasmodic, whenever
any irritating or foreign particle falls upon either the globe of
the eye or the inner surface of the eye-lids, and by sudden and
involuntary closure of the lids, guards this sensible organ from
the intrusion of such bodies.” This muscle is antagonized by
the levator palpebree superioris, which is inserted into the upper
margin of the tarsal cartilage, and whenever it acts, by drawing
the lid with its offending eyelashes over the surface of the
globe, it naturally increases the spasmodic action of the orbi-
cular muscle, especially towards its inner edge; but that it can
exercise any influence on the lower margin of the tarsal cartilage
in the first instance, I think it remains yet to be proved; for it

* The Anatomy of the Human Eye, by John Dalrymple, Assistant Surgeon

to the London Ophthalmic Infirmary. London, Longman, 1834.
 Entropium and Trichiasis. 131
is very dubious whether any of its fibres extend further than the
margin of the cartilage ; and should they even do so one would
be at a loss to assign any other reason for it than that of produc-
ing an entropium every time it elevated the lid.
Mr. Middlemore’s views coincide with mine, and strengthen
the opinion I have expressed as to the part which contraction
of the conjunctiva plays in the production of entropium: “ A
thickened, rigid, and granular state of the conjunctiva may,” he
says, “produce entropium—first, by the undue power of the
inner, as compared with that of the outer, membrane of the
eyelid—and secondly, by the ocular irritation it excites, whereby
a spasmodic action of the orbicularis muscle is produced, and
an increased tendency to entropium communicated. I have
examined the conjunctiva in this state after its division ; it ap-
pears to be shortened, and thickened, and indurated, and the
cellular membrane, with which it is connected to the palpebral
integument and the muscle beneath, is increased in quantity and
firmness, and is arranged in a laminiform manner: at all events,
if it be not increased in quantity, it is consolidated with adven-
titious deposition, so as to have acquired an augmented volume,
and a character of semi-cartilaginous firmness.” Mr. Middle-
more likewise adds, in speaking of Sir Philip Crampton’s claim
to priority in the assignment of conjunctival contraction as the
cause of entropium: “ the dependence of entropium ona dis-
eased state of the conjunctiva has been well known ever since
the days of Bannister” (1622); and the old operation of the
longitudinal incision of this membrance proves this; still Sir
Philip Crampton appears to have been one of the first to put
this forward in its proper light, although the contraction he
speaks of does not occur in the direction he supposes.
In conclusion, the advantages of extirpation, no matter how
performed, over all other operations for the removal ofinvete-
rate entropium, may be thus enumerated :—the complete remo-
val of the cause of irritation, there being no danger of return,
there being no deformity produced, no dislocation of the puncta,
132 Mr, Wilde on the Causes and Cure of
no subsequent stillicidium lachrymarum, no falling or eversion
of the lower lid, the integrity of the cartilage being preserved,
and the Mibomian glands, which Saunders must have cut across,
being for the most part left entire.
In three instances I completely removed the cilia in both
lids of the same eye, and with the most beneficial effect. The
lower, however, except when affected with severe trichiasis, can
be much more frequently cured by the removal of a portion of
integument, or the application of an acid, than the upper one.
When an elliptical portion of integument is removed, I have
only to remark that it is generally too small, and as far as my ex-
perience of this operation extends, unless some fibres of the
subjacent muscle are also removed with it, and the ligatures
made to include the muscle and the integument, by which
means an adhesion is produced that afterwards acts as a coun-
teracting force against the internal contraction of the conjunc-
tiva, little good will result. Furthermore, the upper edge of
this elliptical incision should be made as close as it possibly can
with safety to the ciliary margin of the lid: it is in general made
at too great a distance from it.
A single lash, or one or two lashes, will sometimes turn
in upon the eye and produce the greatest annoyance; the
patient gets tired of plucking them out, and applies for surgi-
cal relief. In such cases placing the horn spatula within the
lid, I make an incision with a small knife down to the root of
the inverted lash, and, having waited till the hemorrhage has
ceased, I apply a point of nitrate of silver by means of a
small port-caustic (such as I have already described among
the ear instruments), down to the bottom of the wound, and
then remove the lash; it seldom fails, but frequently it destroys
two or three of the neighbouring cilia. Partial distichiasis
also, or more extended trichiasis, may likewise be successfully
treated by the same means. In the operation of extirpation for
entropium, a single lash, or sometimes two or three, may escape
the notice of the operator, and will reappear in a few days after
 Dr. Osbrey on diffuse Inflammation, &c. 133
the operation, though not always in an inverted position. Such
cases may be treated by incision and the nitrate of silver, or,
what is simpler and less painful, laying hold of the surrounding
skin and cutting out a V shaped portion with the root of the
lash.

Arr. VI.—Remarks on diffuse Inflammation occurring in the

Exanthemata, with Cases, where the Vaccine Vesicle was
attacked by it. By Grratp Osprey, A. M. M.B., Licen-
tiate of the Royal Coilege of Surgeons, Ireland; Physician
to Mary’s Dispensary.
TO THE EDITOR OF THE DUBLIN JOURNAL OF MEDICAL SCIENCE. |

Str,—In your Journal for the month of November, 1843, I

find, in the review of Dr. Henry Kennedy’s work “ On the Epi-
demic of Searlatina which prevailed in Dublin from 1834 to
1842 inclusive,” that there are certain extracts from that work
in which allusions have been made to cases in my paper on
Diffuse Inflammations occurring during attacks of Scarlatina,
published in Dr. Graves’s System of Clinical Medicine. AsI
think that Dr. Henry Kennedy is in error with regard to some
remarks he has made on these cases, I shall feel obliged by
your inserting in your forthcoming Number this paper.
Your obedient Servant,
GERALD OsBreY.
Fertine deeply thankful to Dr. Henry Kennedy for the very
favourable notice he has taken of my paper, ! heartily hope
that he will consider the following remarks as made merely for
the purpose of correcting what I imagine to be an error, and not
in any way as intended to detract from the merit of his highly
instructive work.
The following are the passages which Iwish first to remark on:
—‘ Dr. Osbrey has alluded to three cases where sores on other
parts of the body closely resembled hospital gangrene; nothing
134 Dr. Osbrey on diffuse Inflammation
of this sort came under my notice: in every instance I saw the
edges were deeply undermined, so much so as always to fall in-
wards, and in this respect to makea marked distinction between
the two diseases. Were I to compare the process of sloughing
with any other I have seen, I should say it bore a very close re- |
semblance to the usual progress of cancrum oris.
«© Another remarkable complication which was seen by Dr.
Osbrey, was ina case where, together with the sloughing of the
neck, like hospital gangrene, sloughs formed on either cornea,
which rapidly extended, and involved the other textures of the
eye.*
From the latter of these passages, in consequence of a mis-
take in the location of the words, it would seem that I described
the sloughing of the neck as resembling hospital gangrene,
whereas it was the disorganized structure of the eye which I
stated presented the appearance of that destructive disease. In
the original passage in my paper in Dr. Graves’s work the words
are: “ In each of these three cases the appearance of the part,
when destroyed, closely resembled hospital gangrene.”+ This
mistake however is merely verbal. From the former passage,
however, it would appear that Dr. Henry Kennedy considers
the circumstance of the edges being undermined in the slough-
ing ulcers occasionally occurring in scarlatina, as constituting a
marked distinction between such ulcers and hospital gangrene.
By referring to Mr. Samuel Cooper’s Surgical Dictionary it will
be found, on the authority of that very learned and experienced
surgeon, that the edges of ulcers are undermined in the ad-
vanced stages of hospital gangrene; his words are: “ As the
disease advances the integuments are undermined and slough;
and hemorrhage from small vessels is a common occurrence.tf
Again, from the authority of the same writer, even if it be ad-

* Dr. Henry Kennedy on the Epidemic of Scarlatina, pp. 14, 112.

+ Dr. Graves’s System of Clinical Medicine, p. 930.
{ Cooper’s Surgical Dictionary; 7th edition, p. 761.
 occurring in the Exanthemata. 135
mitted, with Dr. Henry Kennedy, that the sloughing of the
neck may resemble in its progress cancrum oris, it does not fol-
low that it may not also resemble hospital gangrene. In the
commencement of the article by Mr. Cooper on cancrum oris,
there occurs the following passage: “ It is a perfect specimen
of phagedenic ulceration, and in its worst forms not unlike hos-
pital gangrene, as I have seen several deplorable instances of.”
Though I had opportunities of seeing in the year 1836, in
one of the largest hospitals of this city, several cases of hospital
gangrene, which exhibited itself in consequence of some obscure
and unknown cause, I have preferred quoting from the descrip-
tion by Mr. Cooper of that disease, now fortunately most rare,
to contradicting Dr. Henry Kennedy on my own authority; but
this much I can say, that so closely did the cases described by
me resemble hospital gangrene, that, as far as the appearance of
the disorganized structures was concerned, they could not be dis-
tinguished from cases of that disease. It is probable that the
rarity of the disease may have caused Dr. Henry Kennedy to
have fallen into the mistake he did.
The reason why the edges are always found undermined
when sloughing has attacked the integuments of the neck is,
that in such cases the sloughing of the cellular tissue has _pre-
ceded that of the tegumentary membrane, the latter being at-
tacked last in the order of succession. In the three cases
alluded to by me of sloughing occurring in other parts of the
body, the superficial tissues were those which were first attacked ;
consequently as in ulcers seized by hospital gangrene, the edges
were not undermined until the sloughs had separated.
Dr. Kennedy thinks that there is a close analogy between
the case in which I have described the eyes as having been ra-
pidly disorganized, and those cases of destructive inflammation
of the eye occasionally met with in puerperal fever noticed by
Lee.* In this opinion I coincide; it is probable that similar

* Vide Lee, p. 50.

136. Dr. Osbrey on diffuse Inflammation
states of the general system, producing a tendency to rapid dis-
organization of the tissues of the body, gave rise to both. In
the local appearances there was however this difference between
my cases and those of Dr. Lee, that in the latter there was in-
tense conjunctival inflammation, whereas in mine the conjunctiva
was not even red; the loss of vision was the first circumstance
which drew my attention to the eye previous to any sloughing
having commenced: this case must have differed from those
given by Dr. Gregory, and referred to in a note by Dr. Ken-
nedy,* as the inflammation in Dr. Gregory’s cases must have been
of a very sthenic character: bleeding, cupping, physicking, and
starving having been recommended by him for the cure of it.
To have had recourse to such practice in my case, so debilitated
was the young patient, would have been almost insanity on the
part of the practitioner. It is to be regretted that Dr. Gregory
has not more fully described the severe inflammation which he
states may seize the eye in scarlatina; he merely writes, in his
description of it, “The eye may become affected, and two
things may here take place both requiring your attention.”
«The eye itself may become affected, and this, if neglected,
may go on to actual destruction of one or both eyes.” “ But fur-
ther, the inflammatory action may lay hold, not of the eye, but
of the cellular substance within the orbits in which the eye lies
imbedded.”+
A mild form of ophthalmia in scarlatina, amounting to little
more than vascular congestion, and in scrofulous subjects as-
suming, on the decline of the disease, the form of scrofulous
ophthalmia, has been described by systematic writerst on the
eye, but there is no mention made by them, as far as I am
aware, of destructive ophthalmia supervening in that {disease.
ean) Dy es ential ae
wpeinettrecs PAT Surtomiinbh 15 oem
* Opus cit., p. 112.
+ Gregory on Eruptive Fevers, 5th edition, p. 128. It appears from a Re-
view in the Number of this Journal for July, 1843, that this work was published
subsequently to Dr. Graves’s work.
t Vide the works of Dr, Mackenzie and Mr. Lawrence.
 occurring in the Exanthemata. 137
Dr. Mackenzie, has in the interesting article on phlebitic
ophthalmitis in his work on Diseases of the Eye, published a case
headed “scarlatina, phlegmasia dolens, typhus fever, phlebitic
_ ophthalmitis, and death ;’* it will be found, however, on the
perusal of this case that the destruction of the eye was preceded
by an attack of genuine typhus. The case which I have given
is, [ think, of the same nature as those published by Dr. Mac-
kenzie as instances of phlebitic ophthalmitis. It is to be hoped
that Dr. George Gregory and other practitioners like him, pos-
sessing great opportunities for experience, when they meet with
destructive inflammation occurring in other exanthemata besides
variola, will give a full description of its nature. Since the
publication of Dr. Graves’ work, I have heard of a case having
been in one of the large hospitals of this city, in which both
eyes were lost during an attack of scarlatina, but Ihave not
been able to possess myself of its particulars.
While on the subject of the occurrence of unhealthy inflam-
mation in the exanthemata, I take the opportunity of giving two
cases in which very alarming symptoms presented themselves
during the progress of cow-pock, which, I think, in conformity
with the opinions of Jenner, Barron, and Ceely, must now be
allowed to be an exanthematous affection, Dr. Ceely having
proved, almost beyond a question, that it 1s modification of va-
riola. Dr. Labatt mentions, in his work on vaccination, that he
has met with cases in which diffuse inflammation supervened
during the progress of cow-pock, and has stated the treatment
which he found most beneficial in relieving them; his cases
do not appear to have been of quite so alarming a nature as the
two following.
The first was that of a female child, aged 5 years, who had
been vaccinated by a respectable practitioner in this city. ‘This
child was brought to me about three weeks alter it had been ino-

* Vide Mackenzie on the Eye, 3rd edition, p. 513.

VOL. XXV. NO. 73. T
138 Dr. Osbrey on diffuse Inflammation

culated. The arm was then greatly swollen, the swelling extend-
ing to the hand; the integuments of the upper arm were ofa
dusky leaden hue, and a large black slough occupied the si-
tuation of the usual crust of the vaccine vesicle. The child’s
pulse was weak and slow, not exceeding 64. The extremities
were cold; tongue dry and coated. ‘There was stupor almost
amounting to coma. There was extensive sloughing and he-
morrhage from the mucous membrane of the mouth. The in-
teguments of the cheeks adjoining the commissure of the lips
were of a livid hue. The respiration was very much hurried,
but no physical sign of disease could be detected in the chest.
These formidable symptoms, I was informed by the child’s pa-
h
rents, first presented themselves between the ninth and twelft
day from that on which it had been vaccinated. ‘The practi-
tioner who inoculated the child assured me that up to that pe-
riod the vaccine vesicle ran a healthy course, and that he had
vaccinated other children with the same lymph in whom the
course of the vesicle was perfectly regular.
This child was ofa delicate constitution, having been at
times under my care for attacks of scrofulous ophthalmia, pneu-
monia, and bronchitis. Its health I understood was good at the |
time it was inoculated. |
Complete recovery, though very slowly, was effected in this
case by the following means :—The child’s strength was sup-
ported by the exhibition of mild tonics and ofthe diffusible and
permanent stimulants. The arm was kept constantly poulticed
and fomented, until the sloughs separated, and was then dressed
with simple dressings. Muriatic acid, slightly diluted, was
occasionally applied around the sloughs of the mucous mem-
brane of the mouth; and at times small doses of opium were
given.
The second case was that of a male child, aged 18 months,
who was also vaccinated by a physician of character in this city.
About the twelfth day from the period on which it was vacci-
 occurring in the Exanthemata. 139
nated, the arm was attacked with severe inflammation of the
erysipelatous character, the vaccine vesicle, as far as I could
collect from the parents, having up to that day ran a regular
course. [saw this child on the sixteenth day. A dark slough, as
large as a shilling, then occupied the situation of the vesicle ;
the entire extremity was immensely swollen; the integuments
of the upper arm were of erysipelatous redness, and such por-
tions of them as were in the immediate neighbourhood of the
slough were quite livid. The attending fever was ofthe inflam-
matory type; the skin being hot, tongue furred, pulse rapid
and full, and the thirst great. Until the fever was subdued by
cooling and alterative medicines, and the local inflammation re-
lieved by the application of poultices and fomentations, the
sloughing spread with the most alarming rapidity. After the
sloughs had separated, the progress of the gangrene having
been arrested by the foregoing treatment, a large and deep
ulcer remained with undermined edges, at the bottom of which
the muscles of the arm could be distinctly observed; so exten-
sive was this ulcer, that it was not healed for three months,
though the case progressed most favourably in every respect.
The child, I was informed, -was in good health at the time it
was inoculated; and I saw other children who, I was told by
their parents, were vaccinated by the same matter, in whom the
vaccine vesicle ran a regular course. Dr. Francis Battersby,
one of the physicians to Pitt-street Dispensary for Diseases of
Children, saw both these cases with me. The second case was
also seen by Dr. Dwyer, likewise one of the physicians of that
Institution, and formerly assistant physician to the Lying-in
Hospital, Britain-street. .
It is obvious, if the accounts which I received were correct,
thai the unhealthy inflammation in the foregoing cases could not
have been produced by the inoculation of impure matter, as
other children were vaccinated with the same lymph without
any deleterious consequences: the period also at which the in-
140 Dr. Osbrey on diffuse Inflammation

flammation supervened militates against such a supposition.

Dr. Dwyer and Dr. Battersby, who, as I have just mentioned,
saw the last of these two cases, concurred with me in the opinion
that the very severe inflammation which attacked the arm must
have arisen from some peculiarity in the child’s constitution, or
from some local irritation. The fever and symptoms which
existed in the first case appear to have been very similar to those
symptoms which attend one of the malignant forms of scarlatina
described in Dr. Graves’ work, styled secondary fever in my
paper published in it, and aptly termed complicated malignant
by Dr. Henry Kennedy. There could have been no complica-
tion in this case with scarlatina, as the child had been affected
with that disease at a remote period from that in which it was_
vaccinated.
L have recorded these cases not with the slightest idea of
creating any prejudice against vaccination, which has proved so
eminently useful, but for the purpose of showing its analogy to
the other exanthemata, and with a view of rendering practitioners
cautious in the management of children whom they have vaccl-
nated, until all inflammation has ceased. There is a fatal case
of cow-pock given in Dr. Labatt’s work, and I have been in-
formed by a practitioner of great eminence in this city that he
knew of a case which terminated in death, though the child was
inoculated with pure matter.
I may appear to have dwelt too much on this subject; I
should not however have done so, but that it seemed to me that
these remarks, if they did not add to, they might at least, in
some respects, confirm the knowledge already possessed of so
important a class of complaints as the exanthemata, both with
regard to their pathology and treatment. The following con-
clusion I think may be deduced from the foregoing cases and
remarks.
That the unhealthy inflammations which occasionally occur
during the course of the exanthemata are, in some instances, of
a nature very similar to hospital gangrene.
 occurring in the Evanthemata. 141

That destructive ophthalmia may take place in scarlatina,

and possibly in other exanthemata, besides variola.*
That even in cow-pock, though very rarely, a malignant form
may occur from some individual peculiarity.
ee ee
that
* Dr. Mackenzie has quoted (Opus cit. p. 434) Mr. Marson’s opinion,
a se-
the destructive inflammation of the eye which follows small-pox is entirely
mem-
condary affection, and that it is analogous to the sloughing of the cellular
disease.
brane in other parts of the body, which is a frequent sequela of that
 BIBLIOGRAPHIC NOTICES.

Report of the Commissioners appointed to take the Census of

Ireland for the Year 1841.
Any one ever so little acquainted with the obtainingof statistical
returns, must be aware how very difficult it is to combine minute-
ness with accuracy. And also that the difficulty arises as much
from the machinery asthe subject. The late Rev. Caesar Otway,
in his travels through Erris, tells us that the mode adopted in a
former census was to employ persons who were paid in propor-
tion to the number of the population they made out! This
will, probably, explain why the numbers given in the present
census are so little above those obtained in the former, without
the necessity of assuming extraordinary causes to account for a
decreased population.
The present Commissioners—Mr. Tighe Hamilton, Mr.
Brownrigg, and Captain Larcom—having the police at their
disposal, arranged their plans with great care, and so as to
avoid all ordinary sources of error, and the result is one of
the most minute, ample, and satisfactory Reports we have ever
met. In it we have very full details of the persons, houses,
families, occupations, emigration (home and colonial), rural
economy, such as division of lands, plantations and trees, farms
and live stock, education and vital statistics, 2. e. births, mar-
riages, ages and deaths, as regards each county, and a general
summary of the whole.
The Report upon the table of deaths has been intrusted to
our distinguished compatriote, Surgeon Wilde, and we have no
hesitation in saying that it does him infinite credit, both as to
the mode adopted for obtaining accurate results, and the labour
and extreme care bestowed. It is with this department that we
shall occupy ourselves at present, as it has a more direct bear-
ing upon the profession, But it may not be uninteresting to
our readers—before we leave the general Report—if we lay
before them the portion which describes the plan adopted on
the present occasion :
‘“‘ Our first step was to procure from the Ordnance Survey De-
partment a map of every barony in Ireland, showing the boundaries
 Census of Ireland for the Year 1841. 145
and details of its several parishes and townlands, with classified
lists of these subdivisions. As the survey had been completed, ex-
cept in the counties of Cork, Kerry, and Limerick, we thus, for the
first time, possessed the advantage of a set of maps which not only
indicated correct boundaries, but exhibited every house upon
the face of the country. For those three counties the maps were
formed from less perfect documents, and exhibited, for the most
part, no more than the boundaries.
“It having been resolved that the constabulary should be em-
ployed for the enumeration, we next distributed the maps and lists
to the several officers and head constables of the force, selected by
the inspector-general for each barony. They again divided these
into districts of contiguous townlands, to each of which was as-
signed a superintending constable or sub-constable, or, in those
districts where the constabulary were not sufficiently numerous,
one of the coast-guard, or, where such assistance was not availa-
ble, a civilian selected by the superintendent. We were thus ena-
bled to mark on a general map the districts and stations of all the
enumerators, and the whole force thus marshalled was in readiness
before the arrival of the period fixed by the Act of Parliament for
the enumeration.
‘¢ In the mean time, having maturely considered the best mod
of ascertaining the various facts we had in view, we resolved to
adopt the course of sending a form of return to each family, to be
filled by its head, as less intrusive than requiring it to be filled by
the enumerator from viva voce inquiry. But we, of course, took
means to check the returns so obtained, and required from the enu-
merator a certificate that they were true to the best of his belief.
Another form was supplied to the ennmerator, in which he was
himself required to record the various particulars sought, as to
houses and matters ofa similar nature. The general distinction
we followed was, that the statement of all facts which were of a
personal nature, and only ascertainable by personal inquiry, was, as
far as possible, left to the head of the family, whilst that of all facts
which could be ascertained by mere observation was demanded
from the enumerator.
‘The Act required us to ascertain the age, the sex, the occu-
pation, and place of nativity of every person abiding in Ireland, on
the night of Sunday, the 6th of June, with such other particulars
as the Lord Lieutenant should direct. We accordingly made pro-
vision under the latter power for such inquiries as appeared likely
to illustrate or verify the information specifically required. Thus,
we asked the mame of every individual, as a proof of identity; and
the relationship, with a view to distinguish the members of the za-
tural family from the servants and other members of the establish-
ment, constituting what may be considered the social family. We
also demanded a return of absent members, which, together with
the measures adopted at the ports, to be described hereafter, we
hoped would obviate the danger of error from the lateness of the
season at which the census was to be taken. We also ascertained
144 Bibliographic Notices.

the dates of marriages and of deaths since the last census, in order
to institute a comparison of ages with the former returns, and, in
the absence of registries, test in some degree the correctness of the
enumeration.
‘The Act also required a return of the houses, distinguishing
those which were inhabited from those which were uninhabited, or
building; and by a similar extension of the inquiries into subjects
of a kindred nature, we sought to ensure a correct knowledge of
their state in point of accommodation; whilst, from the combina-
tion of these several returns with those before mentioned, we hoped
to throw some useful light upon the general condition of the com-
munity, as there can be no more obvious indication of the advances
and condition of a people than improvement in the comfort of their
residence. So, in an agricultural community, the quantity of land
held or tilled by each occupant, not only throws light upon agri-
culture as a branch of national wealth and industry, but by its in-
fluence on the condition of the people, affords a test of the relative
advantages of large and small farms. Again, the quantity of cattle
and other stock of every description, is necessary to a just estimate
of the productiveness of a country, and its influence upon the com-
fort of the inhabitants.”
For further details we must refer the reader to the Report,
and we can honestly assure him that he will be amply repaid
for the trouble of perusal.
Now let us turn to Mr, Wilde’s Report, which is divided into
five sections:—1. The mortality from disease and accident.
2. Coroner’s inquests. 3. Insanity and lunatics in jails. 4.
Hospitals and sanatory institutions. 5. A special sanatory report
on the city of Dublin. We shall notice a few points here and
there, leaving the fifth section fora future notice, premising that
this is the first attempt at a bill of mortality for Ireland. Dr.
Wilde observes:
‘¢ None of the ancient Irish works attempt to enumerate the dis-
eases of this country, to catalogue their names, or describe their
symptoms or fatality. The same deficiency in medical nosology is
apparent in those of more modern times; and in no instance has
any effort been made to draw up a general bill of mortality for this
kingdom until the present. The only conception of this kind arose
with Sir William Petty, who, in 1683, published a small tract of *‘ Ob-
servations upon the Dublin Bills of Mortality, MDCLXAXAXL,
and the State of that City.’ In the opening paragraph of this
essay, he says, ‘ The observations upon the London bills of mor-
tality have been a new light to the world ; and the like observation
upon those of Dublin, may serve as snuffers to make the same can-
dle burn clearer.’
‘¢ <The London observations flowed from bills regularly kept for
nearly onehundred years ; but these are squeezed out of six strag-
gling London bills, out of fifteen Dublin bills, and from a note of
a

Census of Ireland for the Year 1841. 145

the families and hearths in each parish of Dublin, which are all di-
gested into the one table or sheet annexed, consisting of three parts,
marked A. B. C., being the A. B. C. of public economy, and even
of that policy which tends to peace and plenty.’ These tables hav-
ing a more local interest, will be referred to in the Report upon the
mortality of the city of Dublin in particular.”
‘« The precise period at which ‘burials and births’ were first
recorded in Dublin has not been ascertained. They must have been
in existence long prior to the date of Petty’s tract (although they
did not specify the cause of death); for in his Table B. he com-
mences with the ‘ burials and births’ of 1666. May they not have
been introduced when Graunt’s ‘ Watural and Political Observa-
tions upon Bills of Mortality,’ in 1661, first drew particular atten-
tion to the value of statistical inquiries of this nature in England ?
I find in the Appendix to his 5th edition of ‘ Observations on the
London Bills of Mortality, published in 1676, a small imperfect
Dublin bill given without any observations, and headed thus—
‘ Dublin—A bill of mortality from the 7-6 of July to the end of
August, 1662.’ The registries in this document are—‘ flux, 7;
rickets, 0; ague, 4; feaver, 0; consumption, 8; small-pox, 1;
spotted feaver, 0; plague, 0; baptised, 145; died, 20.’ ‘This was in
all probability one of the first attempts at a registration of deaths
in this city.
‘‘These bills were obtained from the parish clerks, but must
have been very defective, from the circumstance of so many persons
being buried in the grave yards in the vicinity of the city, and also
from the fact of the births of dissenters not being registered. The
exact period over which these bills extended cannot now be accu-
rately determined ; Dr. Thomas Short, in his work ‘‘ Odservations
on the City, Town, and Country Bills of Mortality, 1750, thus
alludes to this tract of Petty’s :—‘ Major Graunt having taken no
notice of the Dublin bills of mortality, though the second city in
his Majesty’s dominions, an ingenious author in 1681 has published
a small schedule on them, with three short tables.’ This small bill
for 1662 must have escaped the notice of Short, or he consulted
only the early editions of Graunt’s work. In 1686, Sir William
Petty reprinted his original tract under the title of ‘ Kurther Obser-
vations upon the Dublin Bills ; or Accounts of the Houses,
Hearths, Baptisms, and Burials of the City.’ London, 8vo.,
1686.—The only additional matter inserted in this edition is one
small table for 1682, from which it appears that the houses were
6,025; fire-places, 25,369; baptisms, 912 ; and deaths, 2,259. In
a few remarks upon this table, he concludes that the deaths of the
metropolis were at that time 1 in 30—more according to an esta-
blished rule for forming proportions of mortality then in use, than
as the result of any actual calculation or observations of his own;
were this proportion correct it would increase the ratio of deaths to
the population, to 2,253 for that year. In 1684, Petty introduced
the subject of these bills before the Royal Society—(see Philoso-
phical Transactions). ‘After this’ (1648), says Short, ‘I meet
VOL. XXV. NO. 73. U
146 Bibliographic Notices.

with no other public account or notice of the Dublin bills till 1747,
that the worthy Dr. Rutty there procured me an annual abstract of
them from 1715 to 1746, only the birthsand burials of 1739 are want-
ing; because, before that year they ended their year with March 24,
but since then with December 25. These want also the christenings
of 1732, 37, and 38. Nor is it specified in these three years, the
particular numbers that died above and under sixteen years of age,
as is done in all the other years. Neither the old nor xew Bills
distinguish the sexes of baptized and buried, like other bills, nor
have either of them the marriages, which is a great want.’ One or
two of the Irish medical writers about the same date briefly allude
to them; but the most authentic record is that given by the accu-
rate and observant Dr. Rutty (already cited by Short), in his
‘Chronological History of the Weather and Seasons in 1770,’
and also his ‘ Vatural History of Dublin, in 1772.”
The population of the country, as ascertained by the returns,
is 8,175,124, and the total deaths for the ten years ending
June 6, 1841, amounts to 1,187,374, in the proportion of 100
males to 924 females.
The first object, of course, was to form a statistical nosology
which would embrace all the diseases specified in the returns,
and guard against errors arising from ignorance:
‘¢Tn order to embrace as much variety as possible in the local
terms for disease and death, I selected a town, and also a rural dis-
trict, consisting of one or two remote parishes, in each of the four
provinces, as well as a portion of the liberty, and some of the prin-
cipal streets and squares of the city of Dublin, and recorded the
names of all the diseases mentioned in these places. Many of these
names being mere local definitions, were entered as synonymes to
the term in most general use. By this means, I not only became
acquainted with the most frequent causes of death among the difle-
rent grades of the population, but also with the local and provin-
cial terms used to express either the same or analogous diseases in
different parts of the country. From this information I drew up
a list of fifty-two diseases, consisting of the most frequent causes of
death, and the names and symptoms of which are most generally
known to the lower classes of this country, and arranged them, not
according to their nosological grouping, but as far as possible with
reference to the age at which they occurred, commencing with those
of infancy and ending with those of senility, in order to facilitate
their subsequent registration. Opposite the name of each disease,
the various synonymes or popular and local terms, occasionally
used to express the same or some very similar affection, were enu-
merated. Thus, for pemphigus gangreenosus, a disease common in
many of the country parts of Ireland, the expressions ‘ black hives,
—mortifying hives,—burned holes,—aad black and white blisters,’
were used. And again, dysentery and diarrhcea were constantly
expressed by ‘ bowel complaints, lax, flux, purging, and bloody
 Census ofIreland for the Year 1841. 147

flux, &e.,’ the synonymes varying according to the rank, or cha-

racter, or education of the person who filled the return, or accord-
ing to the part of the country from which the information was de-
rived. A previous acquaintance with the state of disease, particularly
among the working classes in the remote districts of this kingdom,
materially assisted me in arranging and applying the general appli-
cation of the terms used to express disease; and I also communi-
cated, when any difficulty arose, with several medical practitioners
located in different parts of the country on this subject.”
The nosological table thus constructed stands thus. First
we have Epipemic, Enpemic, and Contacious Disgaszs, in-
cluding small-pox, measles, scarlatina, hooping cough, croup,
thrush, pemphigus, diarrhoea, ague, cholera, influenza, fever,
erysipelas, syphilis, hydrophobia, glanders. Then we have
Sporapic Disrasus, divided into Diseases of the Nervous
System, including hydrocephalus, inflammation of the brain,
apoplexy, injuries of the head, convulsions, paralysis, lockjaw,
epilepsy, delirium tremens, insanity. Diseases of the Respira-
tory and Circulating Systems, including cynanche, inflamma-
tion of lungs, bronchitis, consumption, spitting of blood, asthma,
vomiting of blood, diseases of the heart, water on the chest, aneu-
rism, emphysema, empyema. Diseases of the Digestive Sys-
tems, including teething, jaundice, worms, colic, gastric fever,
dropsy, diseases of the intestines, hernia, liver complaint, peri-
tonitis, inflammation of the bowels, marasmus. Diseases of the
Urinary Organs, including stone, stricture, extravasation of
urine, urinary disease, diabetes, diseases of the bladder, diseases
of the kidney. Diseases of the Generative Organs, including dis-
eases of childbed, prolapsus uteri, ovarian dropsy, cancer uteri.
Diseases of theLocomotive Organs, including rheumatism, dis-
eases of the bones and joints, hip disease, spine disease. Dis-
eases of the Tegumentary System, including ulceration, purpura,
fistula, anthrax, lepra. Diseases of uncertain seat, including
inflammation, phlebitis, mortification, wounds, heemorrhage, ma-
lignant fungus, scrofula, gout, cancer, tumour, abscess, fracture,
dislocation, debility, and old age. ‘To these are added Vio-
lent and Sudden Deaths, including burns and scalds, drowning,
intemperance, homicide, starvation, executed, poison accidental,
suicide, accidental unspecified, and a column where the cause is
not specified.
Under the circumstances, probably, no better classification
could have been made out; it could not be expected that mi-
nute accuracy could be attained as to the special cause of death.
Not the least interesting part of the table are the popular syno-
nymes, especially the Irish ones. Can anything be more graphic
than the terms * the eating disorder,” for pemphigus gangreeno-
148 Bibliographic Notices.

sus; “half dead,” for hemiplegia; “shrinking of one’s self,” for

phthisis; “ splitting of the bones” for necrosis: and many others
as good might be adduced.
But to proceed :
‘The next questions that presented themselves were, as to the
period over which our inquiries should extend, and the primary di-
vision to be made of the work. The length of time that had elapsed
since June, 1831, must necessarily have rendered the accuracy of
the census returns of deaths, in the absence of all other official and
authentic records, very defective as a whole; and this defect would,
as might be anticipated, become more apparent as we receded to-
wards the earlier years. Except in the first and last periods the
deaths were therefore registered in single years for the ten years
over which our inquiries extended; the first of these is therefore
understood to include the half year and twenty-four days from the
6th of June to the end of December, 1831, and also the entire year
1832 ;—and in the last is only included the five months and six
days from the Ist January to the 6th June, 1841.
‘¢ Regarding the local division of the registration,itwas thought
more desirable, more in accordance with the other branches of the
census, affording not only greater accuracy, but being also a more
limited and definite space on which to test the correctness of our
work, and if necessary to refer to for any more detailed object or
local information, to register the different counties in parishes. And,
as the laws of mortality are so much influenced by a crowded or
scanty state of the population—by the quantity and quality of their
food—geographical position—the condition of their dwellings—the
prevalence of epidemics—the existence of trade and manufactures of
different kinds, as well as the greater or less proportion of medical
aid and general sanatory relief, both in large towns and in the open
country ; the division into civic and rural districts became also ne-
cessary.
‘‘In order that each of the ordinary divisions of the country
might present this difference,and that at the same time those places
only which afforded a collection of inhabitants within such spaces
as might influence their mortality, should be distinctly specified, it
was arranged that the civic district of each county should consist of
all the towns of or above 2,000 people; and with one exception
(that of Leitrim) each county in Ireland offered one or more exam-
les of this description. Cities and towns of considerable magni-
tude (as Belfast) were registered separately, and not included in
the civic district of the counties to which they belong; but in all
instances the original parochial division was retained. Towns situ-
ated on the borders of counties, and portions of which extended
beyond the county boundary, have had each part included in the
civic districts of their respective counties, provided the entire popu-
lation of such towns amounted to 2,000. In this way a parochial
registration of the kingdom was effected, as complete as the returns
permitted, which amounted in all to 1,187,374 deaths. When new,
 Census of freland for the Year 1841. 149
or particular diseases, or those not set forth among the fifty-two al-
ready mentioned, were met with in the parish registration, they
were specified in the form of notes upon the registering books: the
particular cause of death in the case of accidents comes under this
head.
‘‘ Thus a registration was compiled of the causes of every death
given in the returns, the age at which it occurred, and the year in
which it took place.
‘The hospitals and sanatory institutions having been also fur-
nished with forms requiring a return of their deaths of a more de-
tailed and medical nature, and being aware of the greater impor-
tance and accuracy of those returns when properly attended to, I
undertook, with your permission, to collect from these establish-
ments such other additional information connected with their me-
dical statistics as their records could supply. The causes of death
afforded by the hospital returns having been furnished either by
the medical attendants or from the case books and registries of these
institutions, being in their definition much more accurate, and in
their numbers more extensive, I arranged separate tables of deaths
for the collected hospitals of each county in the kingdom. This,
added to the notes of particular affections in the parochial registry,
increased the list of diseases and causes of deaths to ninety-three.
‘‘ Owing to the length of time that had elapsed from the out-
break of cholera in 1832 and 1833—from the circumstance of so
many poor and destitute persons, as well as whole families, having
been swept off by that epidemic—from the universal panic that
then prevailed, and the general medical and surgical hospitals having
been closedagainst the admittance of persons labouring under Asiatic
cholera, the return of deaths from this disease, either in the A.
forms or in the hospital registries, was, as might have been antici-
pated, very defective. ‘To remedy this omission, a return of the
deaths from cholera, that occurred in 1832 and 1833, amounting to
25,378, was procured from the office of the Board of Health, and
the numbers specified therein, distributed among the deaths of the
different localities where they occurred.
‘¢ A record of the deaths, as well as the executions that took
place in the different gaols in Ireland, was also received and regis-
tered.
‘«¢ A return was received of the number and the date and cause
of death of the different coroners’ inquests in each county and city
in the kingdom for the ten years included in the census inquiry.
These documents having been statistically arranged, those violent
or sudden deaths which they specified, and which were not enume-
rated in the returns, were added to the general mortality of their
respective counties, for the years in which they occurred.
‘“‘ Finally, the number of deaths that occurred in each of the
public and private lunatic asylums, together with such other topics
of information as the records of these establishments afforded, was
registered, and the deaths added to their respective districts.
‘Thus while the hospital returns afforded more accurate infor-
150 Bibliographic Notices.
mation in a nosological point of view than the return of deaths in
the A. forms, the inquests and gaol returns filled up those blanks
in the general table of mortality, which it would have been impossi-
ble to have derived from either.
“< By registering all the information derived from these sources
upon properly arranged tables, we had acquired a knowledge of the
age, sex, date, locality, and disease of one million, one hundred and
eighty-seven thousand, three hundred and seventy-four deaths.
‘The parish registries being too voluminous to print in detail,
were next arranged im baronies ; separating the towns of 2000 inha-
bitants ;—and in these baronial returns the ages which had been
originally registered in single years, were, with the exception of the
first year, which was retained in months, and the following four in
single years, compressed into quinquennial periods. ‘Thus, the ba-
ronies of each county, including all the villages andminor towns
whose population did not amount to 2000 inhabitants, were added
together to form the Rural District ; and the towns of or above
that number of inhabitants, were added to form a Civic District ;
while the hospitals and asylums of each county were added, under
the title of Hospitals and Sanatory Institutions, and a General
Summary made of the whole.”
After thus classifying the causes of death, and arranging
these multifold tables, which reflect great credit upon Mr.
Wilde’s ingenuity and accuracy, he proceeds to notice the dis-
eases in detail, furnishing us not only with the statistical pro-
portion, but with much antiquarian information as to the preva-
lence, from early times, of peculiar diseases or epidemics. As
a specimen we will quote the section on fever:
«¢ Fever—The plague of Ireland, and from the earliest period
to which history refers, the most prevalent and fatal affection to
which this country has been subject. The Maculated or Spot-
ted Fever, the true Typhus Hibernicus, is recorded in the early
Irish MSS. under the term of Fiabhrus Morgaighthe, or the Putrid
Fever; and also Fiabhrus righin, the Lingering or low nervous
Fever. Although the former of these words is well known to all
Irish scholars, yet it is seldom used by the people, who express ‘the
fever” or “the sickness,’ as it is sometimes called, by the general
term Fiabhrus. * It is probable,” write Doctors Barker and Cheyne,
that “continued Fever existed in this island long before the era of
authentic medical records, Were we to hazard a conjecture respect-
ing the plagues, as they were called, which accompanied the two
great civil wars in Ireland—that in Queen Elizabeth’s time, and that
which commenced in 1641—it would be that those, strictly speak-
ing, were not plagues, but epidemic Fevers, such as have lately pre-
vailed.”
‘Gerald Boate, the first English writer who described these
Fevers under “ The Diseases reigning in Ireland, and whereunto
that country is particularly subject,” states that, “As Ireland is sub-
 Census of Ireland for the Year 18411. 151
ject to most diseases in common with other countries, so there are
some whereunto it is peculiarly obnoxious, being at all times so rife
there that they may justly be reputed for Ireland’s endemit morbi,
or reigning diseases, as indeed they are generally reputed for such.
Of this number is a certain sort of malignant feavers, vulgarly in Ire-
land called Irish agues, because at all times they are so common in
Ireland, as well among the inhabitants and the natives, as among
those who are newly come thither from other countries.” He like-
wise notices its epidemic nature, prevailing “in some years with so
great violence, that notwithstanding all good helps, some are thereby
carried to their graves; and others who come off with their lives
through robustness of nature or hidden causes, are forced to keep
their beds a long time from extreme weakness, being a great while
before they can recover their perfect health and strength.” All au-
thorities at present agree in regarding the “Irish Agues” of Boate
as the true Synochial and Typhus Fevers of this country, and not of
an intermittent character. Doctor Short states, that «In 1682 there
raged a Spotted Fever in Dublin; in that year died 2,262, a very
high bill.” «*In the year 1688, in the middle of May, a Fever be-
gan at London which spread over all England; and likewise over all
Ireland, in July. Not one of fifteen escaped, yet not one of a thou-
sand died; and it was observed, both in England and Ireland, some
time before the Fever began, that a slight but universal disease
seized the horses—viz., a great deflection of rheum from their noses.”
—(Rutiy). This was a modification of the sweating sickness (Sudor
Anglicus). And from the early part of the 18th century till towards
its close, we have the fullest and most satisfactory records of the epi-
demic Fevers of this country transmitted to us in the works of
O'Connell, Rogers, and Rutty, the medical historians of Ireland, to
which I have already referred, and which, say the eminent authori-
ties from whom I have just quoted (Doctors Barker and Cheyne),
‘¢ possess a permanent interest, and excite a feeling of regret, that
the physicians who succeeded those eminent men, by failing to imi-
tate so laudable an example, should have left a blank in the medical
history of their country which it is no longer possible to supply.”
“‘ It is probable that it has always been endemic; but the first
defined period of epidemic Fever in Ireland is that chronicled by
Rogers in Cork and its vicinity in 1708, and again in 1718-21, and
1728 to 31; and by O’Connell from 1740 to 1743. But as the an-
nals of disease left us by these authors are more or less local, it may
be well to mention, that ‘*when Typhus begins to increase notably
in the Dublin hospitals, we may rest assured that a nearly simulta-
neous increase of Fever will be observed in Cork, Galway, Lime-
rick, and Belfast.” (Graves.) “After the year 1721 there was
again an interval of good health in Ireland, so complete that scarcely
a case of Fever was to be met with.” The most fearful epidemic
of the last century, that in 1740 and 1741, is recorded by Rutty and
O’Connell. We have certain accounts of this Fever being general
throughout the provinces; and “in Galway,” says Webster, “in
1840 it fell little short of the plague.” Rutty says, that “in those
152 Bibliographic Notices.

years it was computed, though probably with exaggeration, that jone-

fifth of the inhabitants died of Fever.” O’Connell stated the num-
ber to be about 80,000; and again, in more modern times, it has
been asserted in the Select Committee of the House of Commons
(in 1830), that 65,000 died of Fever in 1817. How much reliance
can be placed on rough guesses of this description may be gleaned
from the statistics of mortality now recorded, which, whatever may
be their intrinsic value, have certainly been obtained from sources
such as were not, and could not have been had recourse to by the
persons who offered these conjectures—the whole amount of Fever
in Ireland for ten years, both in and out of hospital, not being much
above 112,000; and cholera in its three years’ progress, carried off
little more than 45,000.
« Rutty notices an epidemic Fever in Dublin in 1745, from
whence, to 1763 and 1764, the country appears to have been tole-
rably free from this malady. Sims mentions a violent epidemic
Typhus in 1771, and Cheyne another from 1797 to 1803, founded
upon “the monthly returns and reports made to Government by the
Army Medical Board of Ireland, the proceedings of the Governors
of the House of Industry, and the records of the Fever Hospital at
Waterford.” During the latter part of the last century, the health
of the army was considered a good test of the health of the commu-
nity generally; the soldiery being then principally located in billets
or temporary barracks, were cousequently liable to all the infectious
diseases of the lower orders. A slight increase in Fever took place
in 1810, and again in 1815, but it did not proceed to any great ex-
tent till the memorable years 1817, 1818, and 1819, when, say
Doctors Barker and Cheyne, ‘“ assuming the population of Ireland
to amount to six millions, it will be no exaggeration to state, that a
million and a half of persons suffered from an attack of Fever in the
time included between the commencement of the years 1818 and
1819. In the course of two years commencing with September,
1817, more than 42,000 patients were admitted into the hospitals.”
This scourge spared neither rank, circumstance, nor Jocality—town
or country. The total number of patients admitted into the hospi-
tals of Ireland (both temporary and permanent), during the preva-
lence of that epidemic, was 100,737, of whom 4,349 died. ‘These
authorities likewise mention the greater prevalence and fatality of
Fever among males than females; this supposition, formed upon the
returns of the Dublin hospitals, in the epidemic of 1817-19, is con-
firmed by the Census returns of 1841—the sexes being 60,206 males,
and 51,866 females; and this proportion holds equally good, in both
the districts, and in the hospitals and sanatory institutions. We have
no account of any pestilential Fever or other formidable epidemic
occurring in Ireland, until the arrival of cholera in 1832-3.
‘¢ The total deaths from Fever in Ireland, during the ten years
included between June, 1831, and June, 1841, afforded by the Cen-
sus returns, amount to 112,072—jin the proportion of 100 males to
86.14 females, being 1 death in 10.59 of the mortality from all
causes, and 1 in 3.4 of the deaths of the total epidemic class of dis-
eases.
 Census of Ireland for the Year 1841. 153
-« Compared with the general mortality, Fever has prevailed most
in the counties of Cavan, Mayo, Galway, and Clare, and the towns
of Belfast, Kilkenny, Dublin, Limerick, and Carrickfergus. During
the ten years comprised in this Report, an epidemic Fever of a very
malignant nature again visited this kingdom and the metropolis in
particular, as an accompaniment to the influenza of 1836-7. During
the latter year the deaths afforded by the Census returns amount to
17,280: in the two following years the mortality fell considerably,
but rose again in the year 1840, when 17,965 died. This increase,
however, independent of any epidemic outbreak at that period, may
be accounted for by the increased number of Fever hospitals es-
tablished of late years in Ireland ;—thus in 1840, we find the deaths
in hospitals to amount to 2,663, being double what they were in the
early part of the period over which our present inquiry extends—
(See Fever Hospital Statistics, pages 198 and 199), Cases of Typhoid
Pneumonia have no doubt been included in these returns; thus, says
Dr. Wm. Stokes: ‘ This disease, so frequent in Dublin, at times
indeed almost epidemic, has been long noticed under the names of
the putrid, bilious, typhoid, or erysipelatous pneumonia.” Fever
has spared no age, from 1 month to 90 years and upwards, but its
most fatal period has been from 15 to 50.
‘‘ The causes of epidemic Fever, and other epidemic or con-
tagious diseases, do not come within the province of this memoir ;
but it must strike the medical historian and statistician as remarkable,
that when the Irish records of this class of affections are accurately
examined, it will be found, that notwithstanding all that has been
written and asserted upon the subject of atmospheric influence, want
and distress, &c., conducing to the propagation and spread of disease,
Fever in particular has raged nearly decennially for the last one
hundred and fifty years. I do not mean to say, that it has become
epidemic or fatal exactly upon the tenth year ; but from the eighth
to the twelfth, with an interval of from six to eight years ; thus it
appeared in 1708 ; 1718-21; 1728-31; 1740-43; 1763-64; 177]
73; and 1817-21. In the years 1832-33 Cholera took its place,
but in 1837 it again appeared ; and the year 1842 has been marked
by a most fatal epizotic. Why those lapses of twenty years, or
whether our records are deficient for those periods, cannot now be
determined: this periodic invasion is nevertheless curious though
unaccountable: “ The wind bloweth where it listeth, and thou
hearest the sound thereof, but canst not tell whence it cometh and
whither it goeth.”
As every one would expect, the proportion of deaths to the
population is much greater in the large towns than in the open
country or small towns, being as | to 36.33 in the former, and
as | to 59.89 in the latter.
The Report on coroner’s inquests has been so largely no-
ticed by the newspapers and periodicals, that we shall merely
point out as curious, the periods of the year at which suicide,
murder, and infanticide prevail, and refer the reader to the novel
and interesting tables, p, 184.
VOL. xxv. NO, 73. x
154 Bibliographic Notices.
The section on insanity is very valuable, and highly credit-
able to the industry and care of Mr. Wilde. He has given us,
in a tabular form, the professions and occupations, the ages,
sexes, marriage, education, &c. of these (p. 200), which must
have cost an enormous amount of labour. ‘To the credit of the
proprietors of private lunatic asylums, we must notice that, with
the exception of names, all the queries were promptly and fully
answered,
On the other hand, to the disgrace of the country, it must
be stated that a number of pauper lunatics and idiots are con-
fined in the jails, the lunatic asylums being full. Of the 1800
thus committed during ten years, 96 died, 66 males and 30
females.
One would have anticipated more accuracy and satisfaction
from the records of hospitals than from any other section—here
at least, we ought to have accurate data, with entries of dates,
ages, occupations, deaths, cures, &c., on which a minute and
valuable Report might be founded. We really quote, with a [eel-
ing of shame, the following paragraphs:
‘It is much to be regretted that in 6,049 instances, 3,216
males and 2,833 females, the records of the two classes of institu-
tions under consideration, were unable to afford a return of the
cause of death, or that nearly one in every three cases occurring in
these public hospitals shonld be marked ‘ Not Known,’ or ‘ Cannot
Tell ;’ yet, manifest as is this deficiency in the public medical re-
cords of disease, it is one which, in many instances, was no doubt
unavoidable, particularly in the country parts, where post mortem
examinations (often the only means of acquiring a knowledge of the
true cause of death) are so objectionable to the people. But when
the records of the hospitals at large are unable tospecify the age at
which death took place in 8,764 instances, 5,191 males and 3,573
females, or about1 in every 5, the benefit of some general system of
hospital registration forces itself upon our attention. The total
deaths in infirmaries and general hospitals during the ten years was
19,039, as 100 males to 69.67 females.
‘The great majority of these hospitals have afforded a return of
their receptions and deaths for the entire period, the ten years end-
ing the 6th June, 1841, but several could not afford it for half the
time; some kept no record of the distinction of sexes, and some were
opened only lately.”’
Surely men who enjoy the advantages of hospitals, ought at
least to afford to the profession an accurate statistical record of
their experience:
‘The total amount of deaths in 86 fever hospitals, from which
returns were received for the entire, or portions of the ten years,
ending 6th June, 1841, is 15,988, as 100 males to 94.5 females;
 Census of treland for the Year 1841. 155
but from the defective state of hospital registries in Ireland, this
falls far short of the actual number of deaths for the period over
which our inquiries extend. The entire number of deaths from the
epidemic class of diseases was 15,339, 2. e., 7,849 males and 7,490
females, of which number 14,501 were deaths from typhus, or other
forms of epidemic fever, 7,465 males and 7,036 females. The other
deaths from epidemic diseases were, by small-pox, 49; scarlatina,
23; croup, 1; diarrhoea, 34; cholera, 716; influenza, 1 ; erysipe-
las, 13; and glanders, 1. 68 died of sporadic diseases of the ner-
vous system, 42 males and 26 females; 145 from diseases of the
respiratory and circulating organs, 77 males, and 68 females; 63
from diseases of the digestive organs, 40 males and 23 females. 4
males died of diseases of the urinary organs, and 6 females from
those of the generative organs, 5 of which were the result of child-
bed. 6 persons died from affections of the locomotive organs; 7
from diseases of the tegumentary system, and 30 died by the dis-
eases of uncertain seat, 19 males and 11 females. 12 violent or
sudden deaths have been returned by the fever hospitals; and in
308 instances, 172 males and 136 females, the cause of death was
not specified. It is, however, but just to remark, that 287 of these
deaths, where the cause of death was not returned, occurred in one
hospital, that of New Ross, in the county of Wexford. It may,
however, be fairly presumed, from the nature of the hospital, that
these were also cases of fever.”
As to the hospitals of jails, much the same unsatisfactory
result obtains; however we find a certain amount of informa-
tion given:
‘* The epidemic diseases, the most numerous of the entire, proved
fatal to 213 persons, 162 males and 51 females; of these fever car-
ried off 113 males and 29 females. Diseases of the nervous system
destroyed 82; @. e., 58 males and 24 females; of this class of affec-
tions, deaths from apoplexy were the most numerous, as might be
anticipated from the great change of life, habits, and pursuits of
persons on becoming confined in prison; it proved fatal in 22 in-
stances, 14 males and 8 females. 26 persons, 19 males and 7 fe-
males, died of insanity, and 14 of epilepsy, 10 males and 4 females.
Diseases of the respiratory and circulating organs, the second most
fatal class of affections in jails, destroyed 147 persons, 110 males
and 37 females ; of these, consumption caused death in 98 cases, 70
males and 28 females. Diseases of the digestive organs carried of
44 persons, 32 males and 12 females; of the urinary organs, 6
males; of the generative organs, 5 females; of the locomotive
organs, 4 males and | female; and of ulceration, the only specified
cause of death among the diseases of the tegumentary system, 2
males and 2 females. Diseases of uncertain seat proved fatal to 71,
2. €., 98 males and 13 females, of which number 43 males and 9
females are reputed to have died of debility or old age. The violent
or sudden deaths amount to only 14, 7. e., 10 males and 4 females;
156 Bibliographic Notices.
and the deaths where the causes were not specified to 72,2. ¢., 46
males and 26 females.”
We have thus given a slight sketch of this very valuable
Report; to have done justice to its merits and to have fully laid
before our readers the enormous mass of information it contains
would require a volume. It is creditable to the government to
have furnished the means, and to the commissioners who have
superintended its execution; and our readers, we are sure, will
echo our opinion, when we pronounce the Report we have brought
under their notice most creditable to the ingenuity, patient in-
dustry, and talent of Surgeon Wilde. In conclusion we shall
quote the last paragraph, and beg of our readers to consult the
work for themselves :
‘In conclusion, gentlemen, I have but to remark, that in ar-
ranging the following tables of deaths, and in drawing up the fore-
going Report, I have endeavoured to place in the clearest light, and
to display in the most concise and succinct mannner, the amount of
information contained in the documents which you submitted to my
inspection. And although I have ventured an opinion on the im-
portance and the character of each class of our materials, I have
cautiously abstained from drawing conclusions from premises which
may, perchance, be false ;—nor ventured on calculations unless for
the purpose of local comparisons, as in the tables of mortality,
which, though they do not express the actual amount of mortality,
or the actual average duration of life in Ireland, yet serve by compa-
risons to exhibit the relative healthiness or unhealthiness of parti-
cular places, or among particular classes, or of deaths caused by
particular kinds of disease ; and having in every instance stated the
premises, and in many cases given the actual numbers on which
such calculations were formed, I have, I trust, stripped them of an
assumption of authenticity which they in no wise deserve as a whole.
There is, however, independent of all calculations and deductions,
a vast collection of statistical facts put together in this portion of
the census, of which, no doubt, the statistician and political econo-
mist will take advantage. The records and tabularly arranged sta-
tistics of the public medical hospitals and sanatory institutions—
coroners’ inquests—lunatic asylums—jails, &e., are in themselves
of sufficient importance to lend character to this portion of our la-
bours; and until some better and more accurate registration of the
deaths of Ireland is effected, that which I now beg leave to submit
to you may be referred to.”

Descriptive Catalogue of the Anatomical and Pathological

Museum of the School of Medicine, Park-strcet. By Joun
Houston, M. D., &c.
TuoucH a catalogue does not, strictly speaking, come within
the range of our Journal, we are, in the present instance, iuduced
 Dr. Churchill on the principal Diseases of Females. 157
by the intrinsic merit of this publication, to depart from our
usual course. The museum of the Park-street School is well
known as one of the most valuable in this city. In the depart-
ment of pathology it is particularly rich, as it contains the most
valuable specimens of morbid anatomy which have for some
years been met with in Stevens’, the Meath, Sir P. Dun’s,
and the Fever Hospitals, in the practice of Mr. Cusack, Mr.
Wilmot, Mr. Porter, Sir H. Marsh, Dr. Graves, Dr. Stokes,
and many other distinguished members of the profession. In
the preface we are told that “ for the student it was written, and
to him it is addressed ;” but the practitioner will also find in it
much valuable information and food for deep and profitable re-
flection.
We cannot conclude without expressing our admiration of
the manner in which this little work has been laid before the
public by Dr. Houston, assisted by the talented and zealous
Curator of the museum, Dr. J. Hill.

On the principal Diseases of Females. By Frteetrwoop

CuurcuitLt, M. D. Second Edition, with Engravings.
As the first edition of Dr. Churchill’s useful work has been al-
ready reviewed in this Journal, we have only to inform our
readers that the present edition is published in a very conve-
nient form, duodecimo size, that it is illustrated by some excel-
lent wood-cuts by Bagg, from drawings by a talented artist of
this city, Mr. Nielan, and that the introductory remarks on the
pathology, diagnosis, and treatment of the diseases of the uterus
have been remodelled and contain much valuable new matter,
particularly on the subject of the different modes of examination
of the uterus, and the various forms of speculum in use. Like
Dr. Churchill’s other works it is remarkable for a clear, terse
style, and vast erudition; the notes, and references, and enume-
ration of the authors who have written on the particular subject
treated of, are of great value, and give a complete resumé of the
medical literature of all the diseases of females. Dr. Churchill’s
merits have not been appreciated in this country alone,a second
edition has been published in America, nor will it stop here, we
are sure, as for a clear, compact, and satisfactory description of
the diseases of females we know no work to compare to Dr.
Churchill’s,
158 Bibliographie Notices.

Natural History, Pathology, and Treatment of the Epidemic

Fever at present prevailing in Edinburgh and other
Towns. By Joun Rose Cormack, M. D., &c. &e.
We regret extremely that our limits will not permit us to lay
an analysis of this valuable work before our readers in this
Number, but we hope to be able to do so in our next. The
fever at present prevailing in some towns of Scotland differs
materially from the usual type, and presents many points of
resemblance to that observed in the epidemic which appeared in
Dublin in 1827, described by Drs. Graves and Stokes. These
eminent Physicians have given the details of several cases
presenting features exactly like the yellow fever of tropical
climates, and it is strange that in the epidemic now described
by Dr. Cormack, several cases of yellow fever have occurred,
presenting not only the symptoms, but the same pathological
appearances as were noticed in the Dublin fever. In our next
Number we shall enter more fully into these particulars.
Dr. Cormack has performed his task in a manner highly credi-
table to him; the cases are recorded most accurately and mi-
nutely, and the deductions drawn from them are rigid and
conclusive. We could not pronounce a higher encomium on this
record ofa very remarkable epidemic, than to say, that it deserves
a place beside CueyNne and Barker’s “ Report of the Epidemic
Fever in Ireland,” a distinction to which it is well entitled.

Elements of Natural Philosophy. By Goupine Biro, M. D.

Tue fact that a work of this kind was required for the student of
medicine seems evident from the circumstance that a second edi-
tion has been called for within a short time from its firstappearance.
It is unnecessary to point out the utility of such an undertaking,
for there is hardly a department of medicine or surgery which
does not require a previous knowledge of the general laws of
physics before it can be properly studied. Hitherto this know-
ledge has been acquired from different sources, as most works
are so encumbered with technicalities, and are so elaborate, as to
repel rather than invite the student, and consequently, few of
those readers, for whose benefit the present work has been
undertaken, have had an opportunity of acquiring any thing
like a useful knowledge of physics. ‘This deficiency has hitherto
been supplied, to a certain degree, by the lecturers on the
different branches of medicine, as for instance, acoustics is
usually spoken of preliminary to a course of lectures on diseases
of the chest; optics is touched on by the lecturer either on the
 Dr, Bird’s Elements of Natural Philosophy. 159
pathology or the physiology ofthe organ of vision; hydrostatics
by him who teaches the laws which regulate the circulation;
electricity, magnetism, polarization of light, and thermomics,
by the teacher of chemistry; and some of the principles
of mechanics must be explained by the lecturer on surgery,
Seeing then, that an acquaintance with the science is absolutely
indispensable, we feel pleasure in giving a favourable opinion
of the above Treatise to our readers. We do so the more
cordially, as we know Dr. Bird to be both a scientific and an
excellent practical physician, and we therefore recommend his
treatise as being not only one of the best on the subject, but as
the only one adapted for the student and practitioner of medi-
cine. The paper, type, wood-cuts, and “ getting up” of the
work, are entitled to the highest praise, and the style and
arrangement are both lucid and concise.
 SCIENTIFIC INTELLIGENCE.

PROCEEDINGS OF THE PATHOLOGICAL SOCIETY OF

DUBLIN.
Session 1841-1842.

Seventeenth Meeting, 19th of March, 1842.

ProressoR GREENE in the Chair.
1. Chronic Laryngitis; obstruction of the Rima Glottedis.—
Doctor Corrigan said he had received a preparation from his friend
Dr. Scott-of Kilkenny, which he considered of sufficient importance
to lay before the Society. It was a specimen of laryngitis of the
form denominated subglottal by Cruveilhier. There was no disease
of the cartilages nor of the lungs. The patient was a woman et. 40,
and of spare habit, who had been suffering from chronic laryngitis for
seven or eight weeks, during which various remedial means were
tried without benefit, when she applied for Dr. Scott’s advice. At
this time she was very weak, her respirati ons hurried, about thirty in
the minute, and accompanied by a loud crowing sound similar to that
of croup. The pulse was 120, quick and feeble. Nothing remark-
able could be discerned in the throat, and pressure on the larynx
caused no pain. There was no dulness in any part of the chest, nor
any stethoscopic phenomena, except occasionally some slight mucous
and sonorous rales. The croupy sound of the inspirations was heard
louder and more distinct when the stethoscope was applied to the la-
rynx. The patient died on the next morning. When the body was
examined it was found that the rima glottidis was almost completely
closed by two white, firm, mammillary bodies, situated immediately
above the arytenoid cartilages; a small blowpipe could barely be
passed between them. It was evident that but little air could have
passed through the glottis in this obstructed condition. The epiglottis
was healthy; the mucous membrane of the larynx and trachea was
red, and the larynx itself diminished in capacity. The trachea and
bronchi, even to their minutest ramifications, contained a frothy mucus.
The lungs appeared congested. Within the cranium the pia mater
was very vascular, and the surface of the brain congested. Dr. Cor-
rigan observed, that in this case the disease had probably commenced
as the cedema glottidis of Bayle, and that the swollen part had after-
wards become solidified. This change in the part appeared to have
taken place at the end of seven weeks from the commencement ofthe
 Scientific Intelligence. 161

disease. It was remarkable that there was no ulceration. The

white bodies obstructing the rima glottidis were, as the society would
perceive, very dense, and resembled fibro-cartilage. When laryngitis
occurred in the adult, the glottis is usually engaged and: the effusion
is submucous; in the child, on the contrary, the effusion is on the
mucous surface,
2. Prostate enlarged and inflamed.— Middle Lobe obstructing
Urethra.— Bladder inflamed and perforated by Abscess opening into
Peritoneum.—Peritonitis.—Mr. Smith said he had to communicate
to the Society a preparation, which, like the preceding, had been re-
ceived from Dr. Scott, and on which be would make some observations.
The preparation exhibited disease of the bladder and enlarged middle
lobe of the prostate gland. The subject of the case was a man 72
years of age, who had suffered for a considerable time from prostatic
‘disease. When his body was examined after death, the bladder was
found adhering anteriorly to the abdominal parietes, and there was in
this situation diffused pus among the deep muscles. When the
adhesions were broken down, a perforation of about an inch in dia-
meter was discovered in the bladder, which was ina sloughy state
round the aperture. The parietes of the bladder itself were enor-
mously thickened; interiorly it appeared corrugated and ofa greenish
colour, with some red patches here and there. In the upper and pos-
terior part the mucous membrane had sloughed, and there was an
abscess containing pus opening into the peritoneal cavity. Round
this opening the intestines were adherent to the bladder and to each
other, and the peritoneum in a state of inflammation throughout. The
ureters appeared healthy ; in the kidneys were several small abscesses.
The prostrategland was greatly enlarged; the right and left lobes
were each of the size of a hen’s egg, and the third lobe of that ofa wal-
nut; their surface was of a bright red colour, which was most obvious
on the middle Jobe. It projected forward into the bladder, obstructing
the orifice of the urethra. In this case the middle lobe had been
perforated by the catheter.
Mr. Smith having pointed out these particulars in the prepara-
tion, observed that the progress of the abscess was probably this;
first a hernia of the mucous membrane of the bladder through the
muscular coat, caused by the violent efforts made in passing water;
and then inflammation and suppuration within the protruded part,
bursting at last into the peritoneum. There was another subject he
mightmention in connexion with this case. The perforation of the
third lobe of the prostate had been recommended by some surgeons,
and there were some cases certainly where it had been perfectly and
permanently successful, of which Sir Benjamia Brodie had given an in-
Stance ; but on the other hand it had often proved fatal, both when per-
formed designedly as an operation, and when it had accidentally occurred
by unskilfulness in the use of instruments. Mr. Smith considered that
in almost every case of obstruction from enlarged middle lobe, the ca-
theter might by proper attention be introduced. In the preparation
VOL. xXV. NO. 73, Y
 tl

162 Scientific Intelligence.

then on the table, there was an immense third lobe, yet the urethra
was not so obstructed but that a catheter could be passed by raising —
its point, as Hey recommeded. Mr. Smith was of opinion that punc-
turing the bladder would be preferable to perforating the prostate.
3. Rima Glottidis closed by warty Vegetations from its Mar-
gin.— Doctor Stokes said the case from which he had the recent
specimens, which he then laid before the Society, was one of great
interest as connected with the performance of the operation of Trache-
otomy, and the circumstances which would indicate it to be necessary.
It was a case presenting the unusual circumstance of a fatal chronic
disease of the larynx, without disease of the lung and without the
usual symptoms of mechanical obstruction to the respiration. The
subject of the case was a house-painter, et. 34, admitted into the
Meath Hospital on the 10th inst. This man had colica pictonum
thirteen times, and his upper extremities had been paralysed three
times. His voice had gradually become very weak, and about eight
months ago he became troubled with a cough and expectoration of a
viscid mucus, but had neither heemoptysis nor pain in the chest. At
the time of his admission he was extremely emaciated, his countenance
pale, lips blue, mouth, teeth and tongue covered with sordes. His
aspect was altogether that of a person suffering from profound disease,
and whose constitution had completely given way. There was
difficulty of breathing. On looking into the throat nothing could
be perceived but general relaxation. The uvula appeared enlarged,
but there was neither ulceration nor cicatrix in the throat. The ep!-_
glottis felt healthy and was not enlarged. There was no dysphagia
and no tumour in the neck. The respiration was sometimes difficult,
sometimes easy and tranquil; there was never orthopnea. There
was occasionally stridor, but it was very slight, and only occurred
when the patient wasexcited. The voice wasvery weak. The respira-
tory murmur was almost inaudible, sometimes some slight bronchial rales —
would be heard in the chest, sometimes a very slight degree of dulness
might be perceived. The impulse of the heart was well de fined, and the
soundsnormal, When the respiration was suspended by voluntary effort,
the first sound of the heart became inaudible. To form a diagnosis
in this case, it would have been necessary to determine whether the
stridolous breathing was caused by a disease of the larynx, alone, or
complicated with tubercle of the lung; or whether it might not be
produced by the pressure of a tumour either malignant or aneurismal.
It was ascertained not to be caused by pressure; but it was not 80
easy to determine whether the lungs were engaged ornot. The vocal
phenomena were in fact useless in this case, and no useful result
could be had from the physical examination of the chest. ;
The difficulty of breathing increased, but there were no violent
paroxysms of it. The stridor would perhaps accompany three or four
inspirations and then intermit. At night there was some slight aber-
ration of mind, bat when roused he was perfectly intelligent. He.
had been despaired of from the time of his admission, and died im

z;|

;
 Scientific Intelligence. 163

about a week afterwards. After death, the body was examined. It

was then found that the glottis was completely obstructed by a growth
of warty vegetations round the lips of the orifice, which was so per-
fectly closed that water would not pass through into the larynx when
poured upon it. The disease was singularly localised. The epiglottis
was quite healthy. The trachea was free from disease. The lungs
were free from tubercle, and presented only a slight degree of san-
guineous congestion in the lower lobes. There was a frothy mucus
in the bronchi. There was no appearance of ulceration below the
obstruction, ‘The ventricles of the larynx were a little contracted,
and the thyroid cartilage in a state of ossification. There had been a case
some time ago in the Richmond Hospital, the symptoms of which were
great dyspnoea occurring in paroxysms, with stridulous breathing
and raucous voice. In that case the obstruction of the larynx de-
pended on the growth of excrescences about the glottis; it was con-
nected with syphilis and was relieved by tracheotomy. In the present
case there had never been any syphilitic affection. (Museum, Rich-
mond Hospital.)
Eighteenth Meeting, 2nd of March, 1842.
Mr. O’Ferrattu in the Chair.
1. Erosion of the Bodies of the Lumbar Vertebre.— Doctor
Kirkpatrick presented a specimen of disease of the lumbar vertebrae
and anterior surface of the sacrum, taken from the body ofa man who
had suffered for a considerable length of time from psoas abscess.
Denis Sweeny, the subject of the case, came under Dr. K.’s notice in
the Hospital of the North Union Workhouse. His age was about
28 years, he was by trade a comb maker, and when he came under
Dr. K.’s notice was lame, greatly emaciated, and of a broken down
constitution. ‘The account of his case, as well as it could be traced,
was, that about sixteen months ago he had been attacked with pain in
the back and in the right hip, for which having applied at the hospital
for relief, he was cupped both before and behind the great trochanter
of the affected side, and internally used hydriodate of potass. By
these means he was so much relieved that in a fortnight he left the
hospital and returned to his employment. At the end of about three
months a tumour was perceived in the groin, after which he was fre-
quently in hospital, and for several months was alternately at work,
and in hospital as a patient. At last the abscess opened, and he return-
ed to the Workhouse Hospital. On his admission he was found to
have a fistulous opening at the upper and innerpart of the right thigh,
about three or four inches below Poupart’s ligament; this opening
communicated with the cavity of the abscess. There was no symptom
of spinal disease, nor did he complain of pain in the back from his ad-
mission to his death. When the body was examined it was discovered
that there were two psoas abscesses, and there was also a chain of
small abscesses along the concavity of the sacrum. The bodies of the
last two lumbar vertebrze were eroded, but the inververtebral substance
remained unaffected. There was no curvature of the spine.
164 Scientific Intelligence.
2, Intus-susception—Mr. O’Ferrall produced the recent speci-
mens in this case, which he mentioned had been communicated to
him by Mr. O Keeffe. The patient was a woman aged 42, whose
abdomen had gradually become very much enlarged, in consequence
of which and the absence of the catamenia she imagined herself to be
pregnant. However the swelling of the abdomen continued after the
catamenia had re-appeared, and on examination a solid, firm tumour
could be distinguished in the region of the transverse colon. The
bowels were costive and at last became obstinately constipated for se-
ven or eight days, ileus and peritonitis with the usual symptoms su-
pervened, and in this condition death took place. When the body
was examined the usual results of peritoneal inflammation were found,
and the tumour which had been felt in the abdomen was found to be
caused by an intus-susception of the great intestines. The coecum,
a portion ofthe ileum, and part of the colon were included in the trans-
verse colon; part of the invaginated portion was sloughy, and, what
was very remarkable, the sigmoid flexure was enlarged in calibre,
below the obstruction, contrary to what usually occurs. This perhaps
might have depended on the assiduous employment of enemata to re-
lieve the patient during the last few days of life.
3. Enlargement of the Heart.— Thickening of the mitral Valves.
Dr. Bigger presented the recent specimens in this case, the subject
of which had been a soldier. His last illness commenced about two
months ago, when he was perceived to be affected with a disease of
the heart. The pulsation of the heart could be felt over a considerable
portion of the left side; its action was irregular; the impulse less
than natural; the pulse at the wrist was not synchronous with the
action of the heart. Near the left mamma was a distinct bruit de
scie audible over a well defined circumscribed space; the double
sound was very distinct opposite to the auriculo-ventricular opening.
This patient was mercurialized and treated with digitalis and other re-
medies. However dropsy came on, which for some time was alternately
in creasing and diminishing. He had then an attack of cholera, and for
four days passed no urine. Hecomplained greatly of want of rest and of
difficulty of breathing. There was now cedema of the lung with a sub-
crepitant rale. After being two months in this state he died very
suddenly, having got up out of bed for a few minutes and having just
strength enough to return into it before he expired. When the
thorax was laid open the lungs were found with the usual appearance
of oedema; in the lower lobe of the left lung were several spots of
pulmonary apoplexy. ‘The heart was of very large dimensions, being
nearly as large as that ofa heifer. The mitral valves were a little
thickened, but presented no remarkable morbid change: nor did the
aortic valves, these were still capable of closing the aperture. ‘The
pouches external to the valves were very large. From the examina-
tion of the parts very little light was thrown on the symptoms, which
it is extremely difficult to account for; there was very slight capabi-
lity of regurgitation. In the abdominal viscera there was nothing
remarkable.
 Scientific Intelligence. 165
4. Fatty Degeneration of the Liver.—Phthisis.—Dr. Stokes said
the specimen he had to communicate was a very well marked exam-
ple of the fatty degeneration of the liver, a very remarkable condi-
tion of that organ, and in the present state of our knowledge incurable.
The complications of coexistent diseases are of great importance, and
in no disease is this more observable than in phthisis. Dr. Mont-
gomery has already directed attention to the atrophy of the uterus,
which sometimes is observed in that malady; the present specimen is
an instance of another lesion, frequently found in subjects affected
with phthisis. This degeneration of the liver is not of frequent occur-
rence in this country; butin France it is very common, especially in
females, and, as Louis has remarked, in persons who were by no
means of dissipated habits. The specimen now produced to the So-
ciety was from the body ofa young man who had been addicted to
intoxicating liquors. Three months ago he was attacked by phthisis,
which rapidly proceeded to a fatal termination. All the muscles of
voluntary motion were exceedingly atrophied. The heart was very
small and was loaded with fat; the lungs presented the usual symp-
toms of ulcerous phthisis; the elottis and the chordee vocales were
thickened and infiltrated with fatty matter, yet there had been during
the illness no symptom referrible to the larynx; the voice had been
strong, and there had never been aphonia. The liver was very light,
its specific gravity much less than natural, and its entire structure
very greasy ; the fatty degeneration affected both lobes equally; the
mesentery and intestines were loaded with fat, only the stomach and
duodenum appeared healthy, and this was an interesting point in the
case, as Broussais connects this condition of the liver with disease of
the duodenum. The colon and ccecum were thickened, and in seye-
ral places were ulcerated. As to the symptoms by which this peculiar
state of the liver might be recognized during life, none are at present
certainly known. Louis infers its existence from enlargement of
the organ without functional disturbance. The same pathologist has
observed that in phthisis there is no other organic disease of the liver
along with this, The rapidity of its formation is also very remarka-
ble. It has been found in cases of acute phthisis, which had ended
in fifty days: in the present case the phthisis was of only three
months’ duration. The relation of this disease to phthisis deserves
investigation. It has been found in forty-seven out of forty-nine
cases, and in subjects at every age.
5. farre’s Tubercle of the Liver—Cancer of the Cervix
Utert.—Mr. R. W. Smith presented a specimen of cancerous tu-
bercle of the liver, from the body of a woman which he had examined
that day, shortly before the meeting of the Society. This woman
had been ill during the last six months: she was pale, sallow, and
emaciated; she suffered pain and bearing down, with purulent dis-
charge from the vagina. Some tubercles of the liver could be felt
through the abdominal parietes. In the liver, the tubercles were
both scattered through the substance of the organ, and also elevated
166 Scientific Intelligence.
above the surface. These tubercles had no central depression; in con-
sistence they presented variety; some were very soft, others beginning
to soften in the centre, in others this process had not yet commenced.
The hepaticstructure,iutervening between the tubercles, was ofnatural
appearance. This is evidently the disease known as Farre’s tubercle of
theliver. Inthis case they were not limited to that organ; the omentum
was also studded with them. In the left iliac fossa was a large tumour or
mass, of a cartilaginous hardness, but the artery and vein, though en-
veloped in this diseased structure, were still pervious, and evidently
unaffected as yet by the disease. In the pelvis the uterus was found:
to be as hard as cartilage; its cervix had been destroyed by cancerous
ulceration. Mr. Smith observed, that he had met with this tubercle
of the liver coexistent with cancer of various other organs, as well as
of the uterus: he bad seen it along with cancer of the breast, the py-
lorus, and the thyroid gland; perhaps most frequently with that of
the pylorus.
6. Ascites consequent on Scarlatina.— Compression of the Lung
by the distended Peritoneum.— Bright’s Disease in Kidney.—
Mr. O’Ferrall said, the specimens which he bad then to lay before the
Society were taken a few days ago from the body of a girl, six years
of age, who had become affected with ascites after scarlatina. She
had been only in St. Vincent’s Hospital, under his observation, for a
few days before her death. He observed that the ascites was large
and well marked, while there was but a slight degree of anasarca, and
that limited to the lower extremities. There was great difficulty of
breathing, and a severe pain in the left hypochondrium, which caused
the child to scream violently and frequently. Under these symptoms
she gradually sunk, and for seven or eight hours before death was
completely comatose. It was thought that some relief might have
been obtained by paracentesis of the abdomen, but to this operation
the child’s family would not consent. When the body was examined
after death, it was found that the abdomen contained a large quantity
of straw-coloured fluid, with which the peritoneum was distended, and
the viscera forced from their natural situations. The liver had been
driven upwards, as high as the fourth rib, by this aceumulated fluid.
As soon as the abdomen was laid open, and the fluid evacuated, the vis-
cera were observed to resume their normal situations, the liver descend-
ed. There was no lymphy deposition in any part of the abdomen. The
peritoneum throughout had the appearance of having been a long time
bathed in fluid. The liver was congested, and its serous coat opaque. A
very interesting circumstance was the existence of Bright’s disease in
the cortical structure of thekidney [which was well represented ina
drawing made from the recent part]. The distention of the abdomen
had diminished the capacity of the chest. The lungs had been so
compressed that they had the appearance of carnified lung, though
they were not quite so solid, and hence the great dyspnoea so obvious
in the latter stages of the illness. The remarkable features in the
case were these—the occurrence of Bright’s disease with very little

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 Scientific Intelligence. 167

anasarca, and the diminished volume of the lung, giving it, to a great
degree, the appearance of carnification.
Nineteenth Meeting, April 2, 1842.
Dr. O’Berrne in the Chair.
1. Aneurism of the ascending Aorta, compressing the Vena
Cava.—Doctor Law presented the recent specimens, and a coloured
drawing, exhibiting the appearance of the patient during his last ill-
ness, The subject wasa stout, athletic man, named Brown, aged 42,
whom he had seen on last Saturday, in Sir Patrick Dun’s Hospital.
His face, neck, hands, and arms were then of a remarkably deep livid
colour, as depicted in the portrait. This man had laboured. under a
slight cough during four months previous, and on the morning of last
Saturday felt a sudden fulness in the face, and great oppression in the
precordial region. Inthe evening he wasseen by Dr. Law, in the hospital.
There was then cedemia of the integuments over the thorax ; the superfi-
cial veins in the neck were hard and firm to the touch; there wag con-
siderable anxiety; the respiration was distinct, and there was no dul-
ness in any part of the chest; the heart’s action was, perhaps, too
diffused ; it was audible under the clavicles; the pulsations were re-
gular; the patient referred all his distress to the heart; the intellect
was unimpaired, and there was a slowness in replying to questions,
not, however, to any great degree. The most remarkable feature of
the case was the extraordinary venous congestion of the upper part
of the body, and the suddenness of its accession. Dr. Law referred
this to some obstruction in the descending cava, but what might be
the cause of this was involved in obscurity. The treatment adopted
was bleeding from the arm, and on Sunday, cupping over the situa-
tion of the heart; at the same time stimulants were administered in-
ternally. Considerable relief was obtained by these means. On
Monday he was quicker in replying; there was no appearance of
coma, and the pulse was very weak. The stimulants were continued,
On Tuesday, the pulse was still weaker at the wrist, but was very
strong in the femoral artery; there was no symptom of aneurism.
On Wednesday, the pulse at the wrist could no longer be felt; there
was increased distress, but no stupor, and he gradually sunk, After
death the body was examined. The beart was completely concealed
by the lungs; the opposite laminze of the pericardium were adherent
by effused blood; the right ventricle was filled with a yellowish cca-
gulum, extending into the auricle; the cava was narrowed; in the
ascending aorta was an aneurism which had pressed the sides of the
vein together; the coats of the artery, at this point, were thinner
than in the rest of its course, and were transparent ; the valves were
free. Dr. Law remarked, that this was by no means a common Case ;
Corvisart had referred to one somewhat parallel. In the present
case, the suddenness of the attack, and the difference between the
pulse at the wrist and ia the femoral artery were as yet unexplained.
168 Scientific Intelligence.
It might be mentioned, that a brother of this patient had died of a dis-
ease of the heart at the age of 27.
2. Pneumonia in a Child of Eleven Months.—Mr. Adams pre-
sented the recent specimens, taken from the body ofa child eleven
months old, which bad died of acute pneumonia. It lingered but
five or six days under this illness. The surface was very pale, yet
the skin was intensely hot, and there was a short, painful cough. On
the second day of the attack, the right lung was already solidified up
to the clavicle; the left was still permeable, and the respiration pue-
rile, On the third day, the respirations were 62, and the pulsations
170 in the minute. On the next day, the respirations were 72, the
pulsations 200. When the chest was laid open, after death, some
petechial spots were observable on the surface of the right lung, not
unlike those met with in purpura; the lung did not crepitate; it looked
more like spleen than lung; it sunk in water, and bed the appearance
and blue colour, as well as the density, of the foetallung. This was
a circumstance of importance to the medical jurist. Mr. Adams pro-
duced a drawing of a specimen of the same disease, that he had com-
municated ata former meeting. The subject in that case was a child
who had inhaled very hot steam from the spout of a kettle; oedema
of the glottis ensued. Tracheotomy was performed, and relief ob-
tained; but pneumonia, much resembling that in the present case,
came on, of which it died four days after the accident.
3. Warty Deposition in the Larynx.—Haemorrhage from an
Artery opening into a tubercular Cavity in the Lung.—Doctor
Lees presented the recent specimens, taken from the body of an
infant, that, about eight months ago, had been received into the
South Union Hospital. It was at that time about a monthold. It
had a slight cough, and the usual symptoms of tubercular phthisis,
but no stridor, no difficulty of breathing. Two mernings ago, im-
mediately after awaking, a cough came on which was succeeded by
a profuse vomiting of blood: it died soon afterwards. The examina-
tion of the body was carefully made by Mr. Jchnson. The chord
vocales and ventricles of the larynx were found covered with a fibrinous
deposit. In the left lung, at the supero-posterior portion of the inferior
lobe, there was a large irregular cavity, the interior of which had a gra-
nular appearance, not lined by any false membrane; there was coagulated
blood in this cavity. Three or four branches of the pulmonary artery
traversed the cavity; of these one only was pervious, and this one
had ruptured about the middle of the cavity. This lung was much
larger and more dense than that of the opposite side, which was also
occupied by tubercular deposition in an earlier stage of development.
In the bronchial tubes there was coagulated blood. Dr. Lees re-
marked, that Dr. Hodgkin had described tubercular cavities as
lined by a peculiar secretion, which Laennec had considered as a false
membrane; in the present case there was nothing of the sort. Dr.
Lees referred to his communication, at a former meeting, of a speci-
men, in which blood-vessels opened into a tubercular cavity, giving
rise to fatal heemorrhage. There was in the present case another re-
 Scientific Intelligence. 169

markable lesion, that of thelarynx. Dr. W. Stokes, at the last meeting

but one, had presented a specimen of similar vegetations about the
rima glottidis. As to the nature of this growth, there was a diffe-
ence of opinion among pathologists, some regarding it as a peculiar
morbid deposition, others as a hypertrophied condition of the natural
structure of mucous membrane, the effect of inflammation. If we
regard it as a result of inflammation, we must recognize it as a
special modification of that process, appearing to consist in a lesion
of nutrition more than of secretion, which occurs so frequeutly in
children, in the plastic form.
4, Pericarditis, with false Membranes in a State of extreme
Hyperemia.—Mr. O’Ferrall said the specimen he then presented
wastan example of pericarditis, with enlargement of the heart. The
subject was a boy of eleven years of age, who had sunk, at St. Vin-
cent’s Hospital, under repeated attacks of pneumonia, complicated with
irritable bowels, and whose strength had been previously muchexhaust-
ed, first from scarlatina, six months before his death, and afterwards
from acute rheumatism, two mouths previous to the same, from either
of which attacks he but imperfectly recovered. When admitted into
hospital, his looks appeared evidently cachectic; he had dulness and
frottement in the lower part of both lungs; there was no evidence,
however, of liquid effusion. He was relieved by treatment, but only
to suffer another attack of pneumonic inflammation; and, after a
series of these relapses, he died. Upon examination of his thorax,
the lungs were found in the condition that the physical signs would
lead to be expected. Besides this, the heart was enlarged, and the
surfaces adherent by bands of lymph, in the process of organization.
It was to the appearance of this lymph that Mr. O’F. wished espe-
cially to call attention: at the first glance, one would suppose it to
be composed of coagula of blood, so deeply coloured was it, yet the
small quantity of fluid contained in the sac of the pericardium did not
contain a single blood globule. Mr. O’Ferrall would remind the Society
ofa case of true hemorrhagic pericarditis, which he had presented to
them three years ago, and of which he now produced a drawing. In
that case the blood had evidently been effused along with the lymph;
but the present appeared to be a case where the organizing lymph
owed its deep red colour to excessive hyperzemia. It was impossible,
of course, to prove the truth of this position by injection, the greater
number of the highest pathologists having been hitherto unable to
trace the vessels of organizing lymph into the neighbouring tissues,
if indeed they reaily have any such communication; but it had been
ascertained, that channels for the conveyance of blood existed in the
lymph before the existence of vessels with proper coats; and from
the appearance of the lymph in this case, it was probable that the
hypereemia here existed in such channels.
5. Exfoliation of the Head of the Femur in Morbus Core.—
Mr. Adams presented the exfoliated head of the femur of a child six
years of age, which had laboured under hip disease for two years,
and had recovered after the exfoliation with a false joint. This spe-
VOL. XXV. NO. 73. Z
170 Scientific Intelligence.
cimen he had received from Mr. Allingham. Mr. A. remarked, that
where this exfoliation has occurred, the patients have recovered.
The present was the third instance of this occurrence which bad been
communicated to the Society.
6. Cerebral Apoplexy without premonitory Symptoms.—Stea-
tomatous Deposition in Arteries at Base of the Brain.—Doctor
Lees said the specimens he had to produce were taken from the
body of a man aged seventy, who had appeared well up to yesterday,
when he suddenly lost voice and sensation for two or three minutes,
and was then found to be paralysed at the left side. He recovered
the power of speaking, but talked incoherently; in an hour afterwards
became comatose, and died within four hours from the first attack.
There had been no premonitory symptoms, unless some disposition to
drowsiness, and slight incoherence in discourse during a few days
previous. When the calvarium was taken off, the brain externally ap-
peared normal. On cutting into it, a large recent clot was found ex-
tending into both ventricles. Inferiorly, there was an extravasation
extending from the pons to the spinal marrow. The arteries at the
base of the brain were the seat of steatomatous deposition. The left
ventricle of the heart was hypertrophied, and there was calcareous
deposition in the mitral valves, and to a slighter extent in the-tri-
cuspid.
7. Intus-susceptio.—Dr. Evory Kennedy communicated a speci-
men of intus-susceptio, that had occurred in a child four months old,
who had died in thirty hours from the commencement of the illness.
This child had been in perfect health up to last Tuesday evening. The
bowels were confined, and a dose of castor oil was administered, which
was followed after a few hours by another. On the next morning
there was a hemorrhagic discharge from the bowels, mixed with
feculent matter, and these discharges became frequent during the
day; there was also vomiting of a dark fluid, but this was not fre-
quent; none of the blood which was discharged coagulated; the pulse
was small and very rapid; acetas plumbi and Dover’s powder were
ordered in suitable doses, but without success, On Thursday morn-
ing the little patient died, and when the body was opened the intus-
susceptio was discovered, consisting of a considerable portion of the
colon, the coecum, and a part of the ilium: there was no peritoneal
inflammation. It was evident that the feeces which were discharged
must have been lying below the obstruction in the intestinal tube.
Twentieth Meeting, April 9, 1842.
Dr. Monrcomery in the Chair.
1. Dissecting Aneurism of the ascending Aorta bursting into
the Pericardium.—Dr. Lees exhibited to the Society a specimen of
an unusual variety of aneurism of the ascending portion of the arch
of the aorta. The subject from whom the specimen was derived was
a woman about sixty years of age, who was apparently in perfect
health on the day of her death, which occurred during the last week.
 Scientific Intelligence. 171
After breakfasting heartily, she suddenly screamed, fell back, and
expired in five minutes. On opening the pericardium a large quan-
tity of coagulated blood was found interposed between it and the
heart, which was adherent at several points to the pericardium, evi-
dently the result of a former attack of pericarditis. The heart was
hypertrophied. There was a rent about two inches long in the cel-
lular coat of the posterior wall of the ascending aorta. The longer
axis of this rent corresponded to that of the artery just where the
pericardium is reflected from the aorta on the pulmonary artery.
The external and middle coats of the aorta in this situation were se-
parated from each other for a considerable space by a quantity of co-
agulated blood, which reached superiorly as high as the junction of
the transverse with the descending portion of the arch, and inferiorly
as low as the base of the heart. The cellular coat having been slitup
anteriorly, there was brought into view a large transverse rent in the
internal and middle coats, not coinciding with the opening in the ex-
ternal coat. It was about an inch in extent, and was situated in the
anterior wall of the ascending aorta, at the distance of an inch and a
half above the heart. There was an atheromatous deposit in the mi-
tral and aortic valves, and also between the internal and middle coats
of the aorta and of the large vessels arising from thearch. Dr. Lees
remarked, that this unusual form of aneurism had been described by
Laennec, and that similar cases had been recorded by his friend Mr.
R. W. Smith in the 9th volume of the Dublin Journal of Medical
Science.
2. Benign Osteosarcoma of the Hand.—Dr. Fleming exhibited
a specimen sent by Dr. Cusack, of a disease of the bones, which has
been designated spina ventosa by some, by others, benign osteosar-
coma. Of this disease several specimens had been communicated to
the Society by the Surgeon-General and by Messrs. O’Ferrall and
Adams, of whom the latter had particularly described this affection
in his article on abnormal conditions of the hand, published in Todd’s
Cyclopedia. The subject from whom the present specimen had
been taken was a young lady of strumous habit, about twenty years
of age, and who had glandular enlargements in the neck. The dis-
ease of the bone involved the ring and little finger of the right hand.
It commenced nine or ten years ago as a small tumour on the dor-
sum of one of the phalanges, which slowly increased in size up to
twelve months ago, when, after a blow accidentally received by a
fall, it enlarged very much and became painful. The pain was not
confined to the tumour, but darted up the arm to the axilla. The in-
teguments were not discoloured, and were moveable over the tumour,
but all the prominent points on its surface became ulcerated. Am-
putation was found to be necessary, and was performed by Dr. Cu-
sack at the carpal joint. On cutting into the tumour the structure
appeared cartilaginous or fibro-cartilaginous within a very thin shell
of bone. A section of the tumour showed a cartilaginous material,
enclosed in a bony shell, which was remarkably thin. Mr. Fleming
172 Scientific Intelligence.
alluded to the cases of this disease described by Mr. Adams, at the
ninth meeting of the present session, held January 22nd.
3. Scirrhus of the Pylorus.—Cancerous Deposition in the
Mesentery and Intestines.— Dr. Greene presented a very well-
marked specimen of scirrhous pylorus from the body ofa man who
died in the Whitworth Hospital during the last week, The illness
of this patient was described to have commenced nine months pre-
viously with anorexia, thirst, acid eructations, and constipation.
There was no vomiting or nausea. After some time he began, in ad-
dition to the preceding symptoms, to feel pain, but not of a violent
character. It was felt over the umbilicus and in the epigastric re-
gion, and was sometimes like colic. When admitted into the Whit-
worth Hospital, he was labouring under intense jaundice. There
was a fulness in the epigastrium, but no defined tumour could be de-
tected. There was no vomiting. Dr. Greene, on examining the
patient, was induced to ascribe the jaundice to a mechanical obstruc-
tion. About ten days before the patient’s death, coffee-coloured vo-
miting came on, A week ago he became delirious, aud died in that
state. On opening the body the stomach was observed to be dilated,
but was not ulcerated. This coincides with what Andral has remarked,
and also with a case communicated to this Society by Mr. O’Ferrall,
in which there was coffee-coloured vomiting, but no ulceration of the
stomach. The pylorus in the present specimen was very hard, thick,
and firm. Its calibre was greatly contracted, the stricture being nar-
rowest towards the stomach. The ascending and transverse colon and
head of the pancreas were bound down into a cancerous mass, with
which the duodenum also was connected; the cystic and hepatic
ducts were both obstructed by the cancerous growth; they were both
much dilated above the strictured part. There were cancerous masses
in the mesentery, in several parts of the small intestines, and between
the rectum and the bladder. The coats of the gall bladder were
hypertrophied; its mucous lining was ulcerated in several spots, leay-
ing merely the peritoneal coat to prevent the escape of its contents;
there were no calculi in it, nor had there been any pain felt in that
situation during life.
4, Uterus softened and relazed.—Doctor Montgomery presented
the uterus of a patient that died in Sir Patrick Dun’s Hospital during
the last week. He regretted that the history of the case was defec-
tive, as the patient had been unable to detail it; but he had learned
some particulars of it from Dr. Henry Kennedy, amounting gene-
rally to this, that she had been delivered five weeks before her admis-
sion into Sir P. Dun’s; that after her recovery she had been at-
tacked by sudden and very profuse hemorrhage from the uterus,
after which fever set in, and she was brought to the hospital in the
last stage of typhus. The uterus, it would be observed, was not so
small as it should have beea at that period after parturition; and
there was a remarkable relaxation and softening of its tissue, the
effect of the hemorrhage. Within the cavity, the placental mark
was larger and more prominent than usual. There was a small tu-
 Scientific Intelligence. 173

mour depending from the Fallopian tube of the right side. The en-
tire of the uterus was very vascular, and the veins greatly enlarged.
There had been in this patient a peculiar soreness and tender-
ness of the entire surface after her delivery; this Dr. Montgomery
considers indicative of disease within the uterus. ‘The same symp-
tom is observable in another patient now in Sir P. Dun’s, a female
recently delivered, and in whom there is also an extreme quickness
of the pulse.
Twenty second Meeting, 16th of April, 1842.
Mr. CARMICHAEL in the Chair.
1. Stracture of cardiac Extremity of Gisophagus.—Scirrhus?
—Mr. O’Ferrall presented the recent parts and an illustrative co-
loured drawing of a case, where the cesopbagus was strictured at its
cardiac end, The subject was a man sixty-five years of age, who
had for a long time laboured under dysphagia, which progressively
increased. Mr. O’F. had only seen him in the last week before his
death. The patient at that time referred the difficulty in swallowing
to a point opposite the cricoid cartilage. He never had cesophageal
vomiting. Mr. O’F. pointed out in the specimen, how the muscular
tunic of the cesophagus became gradually thicker towards the cardiac
extremity; at the seat of the stricture all the tissues appeared amal-
gamated, and many lymphatic glands, some of which were soften-
ing, were enveloped in the diseased part, all together forming a
very hard tumour. Internally, the stricture was sharp and well-
defined, with many small spots of superficial ulceration at the
narrowest part. A longitudinal section displayed the thickening of
the coats and the glandular bodies included in the morbid part; the
texture of the thickened portion was explored, by carefully dissecting
off the mucous coat, when it was perceived that the submucous and
muscular coats were hypertrophied, and that the muscular had com-
pletely lost its natural appearance; at the point of stricture all the
tissues were lost and indistinct; the morbid condition might there-
fore be described as hypertrophy of the tissues, merging into a carci-
nomatous state at the stricture. From a horizontal section near the
stricture, and either above or below it, a creamy or cerebriform fluid
exuded, when the thickened parts were pressed firmly. It was for
the Society to consider whether this was a specimen of true cancer
or not,
2. Scrofulous Deposit on the Perrtoneum.— Communication
between the Uterus and Bladder effected by Ulceration. — Mr.
R, W. Smith presented several specimens of disease from the body
of a female of about thirty years of age, who, in last August, began
to complain of pain in the side, in the region of the liver. She was
treated for hepatitis, but without obtaining relief, and at last died of
peritoneal inflammation: she had no jaundice. On examining the
body after death, the usual results of peritonitis, both acute and chro-
nic, were observed, and also very extensive disease in the pelvis:
 if

174 Scientific Intelligence.

there were tubercles developed to a great extent in the false mem-
branes, particularly on the surface of the liver; in the pelvis, the ra-
vages of disease were very remarkable; the posterior wall of the
uterus was ulcerated and sloughy, in some parts quite broken down,
but no part of it had the hardness of carcinoma; an opening had
been effected by the disease from the uterus into the bladder, through
which there was a tubercle projecting; the bladder was in a state of
inflammation; the orifice of the right ureter was almost completely
obstructed, and that of the left in a less degree; the uterus was en-
larged, and was infiltrated with purulent matter, which extended into
the Fallopian tubes. The intestines and the mesenteric glands were
extensively affected with tubercle and scrofulous matter, in several
stages of development; there was no ulceration of any portion of the
intestinal canal. It was a question whether this disease of the pelvic
viscera was malignant or not. Mr. Smith inclined to the opinion
that it was rather scrofulous degeneration of the uterus. The case
had all the characters of struma, except that the lungs were unaf-
fected. He had not observed the Fallopian tubes filled with morbid
deposition in cases of cancer of the uterus.
3. Morbus Coxe ; luxation of the Head of the Femur.—Mr.
Adams said he had been requested by Mr. Shannon, the surgeon of
the South Union, to communicate to the Society a specimen of dis-
ease of the hip-joint in which luxation was produced, an occurrence
unusual in this affection. Besides the parts concerned he had also
sent a cast and a drawing. The subject of this case was sixteen
years of age; the head of the femur it would be observed was sof-
tened and dislocated on the dorsum of the ilium; the limb was
shortened and adducted ; abscess and suppuration had ensued, and
the patient had sunk under the continuance of hectic. The capsular
ligament had been completely destroyed.
A, Acute Gastritis —Mr. Robert W. Smith said he wished to
lay before the Society a specimen which was highly interesting in a
medico-legal point of view. The subject was a female, zt. 20, who
had been admitted into the Hardwick Hospital, in the last stage of
peritoneal inflammation; she had been a prostitute, and had given
birth to a child about a week before her admission; soon after par-
turition she was attacked with symptoms of gastritis and peritonitis,
which proved fatal within 24 hours after her admission into the hos-
pital. The child had been found dead, concealed under the floor of the
room in which the mother had been delivered. Upon examination
of the body, the anatomical characters of acute peritonitis were found,
lymph had been copiously effused; the stomach was ina state of
most intense inflammation: in some places the mucous membrane
presented patches of the brightest scarlet, the vessels being distinct
and arranged in an arborescent form; in others the membrane was
perfectly black, as in case of poisoning by sulphuric acid, but there
was no abrasion either in the cesophagus or stomach the most careful
chemical analysis (in conducting which, Mr. Smith had the valuable
 Scientific Intelligence. 175
assistance of Professor Apjohn) failed to detect the presence of any poi-
son, (Museum, Richmond Hospital.)
Twenty-third Meeting, 23rd of April, 1842.
Dr. MontGomery in the Chair.
1. Caries of the Vertebre.—Doctor Lees produced recent spe-
cimens illustrative of the pathology of this disease. The first case
occurred under his care in the Hospital of the South Union. The
subject was a child aged five years, which was brought under bis no-
tice for the first time about six months ago, in consequence of having
been observed to stand crooked or bent towards one side. On careful
examination of the spine a slight projection was discovered at the
lower part of the cervical vertebree. An issue was inserted in the
neck, and the usual remedies directed. However the child’s health
gradually declined, the pulse became greatly accelerated, and during
the last week it died, labouring under diarrhoea and lobular pneumonia.
{t had always complained of pain in the front of the chest, but never
of any in the back. There was paralysis of motion of the upper and
lower extremities without rigidity of the muscles. The feces and
urine were discharged involuntarily. The body was inspected after
death; the bodies of the five upper dorsal vertebrae were completely
carious and the intervertebral substance destroyed; the sixth and
seventh were quite black and rough; the body of the ninth was very
vascular; the intervertebral substance between the seventh and eighth
was quitesound. The theca of the medulla spinalis was quite thick-
ened, and very vascular; the medulla itself was quite yellow and sof-
tened. It was remarkable that in this case no abscess had been
formed, though so many vertebra were engaged. There was no de-
position in the diseased vertebrae, and no tubercles in any ofthe vis-
cera,
The next specimen Dr. Lees had to present was sent to him by
his colleague Mr. Shannon. The subject was a man of strumous
habit, who had died of phthisis; he was also paralysed; his lungs
were found to be loaded with tubercles; the three last of the dorsal
and the first of the lumbar vertebree were diseased; there was a
cheesy deposition in the substance of the bone and also between the
ligaments and bodies of the vertebrae; the spine in this situation was
bent to a considerable angle, and the canal was enlarged at the angle
of the curvature. This was a good specimen of the scrofulous form
of the disease.
2. Carcinoma of axillary Glands and Mamma.—Scirrhus of
the Head of the Pancreas and Ovaria.—Mr. R. W. Smith said he
had to lay before the Society several specimens of carcinomatous dis-
ease, taken from a woman thirty years of age. She had first ob-
served a swelling of the glands of the axilla, and this had existed
twelve months before she was seen by Mr. S. The disease com-
mencing in the axilla indicates, he observed, a more inveterate affec-
tion than when it makes its first appearance in the mammary gland.
176 Scientific Intelligence.
In this patient, there was a hard, rugged tumour in the posterior
part of the axilla, which was often affected with a lancinating pain ;
at a later period the mamma became affected. There were also tuber-
cles of the skin, scattered over the neck and chest; these were pale
and hard, and occasionally painful. These tubercles indicate a gene-
ral contamination of the system, and in such cases operation would be
worse than useless. The arm was swelled, and exhibited several ecchy-
moid vesiccations, filled with a discoloured fluid. In the progress ofthe
case there came on vomiting, epigastric tenderness, and gastritis; these
were succeeded by stupor, listlessness, dilated pupils, and a state of the
limbs like that of a patient in catalepsy. In a week afterwards, ob-
stinate constipation and jaundice ensued, after which she fell into a
state of coma, in which she died. The results of the examination
after death explained most of the symptoms, The jaundice was
caused by an obstruction of the duct produced by the head of the
pancreas, which was enlarged, scirrhous, and contained several dis-
tinct tubercles ; this compressed and completely obstructed the duct;
the gall bladder was dilated with bile. The constipation of the
bowels might be referred to the obstruction to the flow of the bile, and
to the compression made on the rectum by the ovaria, which were
scirrhous; there was scarcely room for the little finger to pass
through at this place; below it the rectum was inflamed. The cedema
of the arm was in like manner elucidated, by finding that the scir-
rhous glands in the axilla had compressed the axillary vein, the blood
in which was coagulated; the roots of the median nerve were sur-
rounded by a mass of scirrhous matter, but the nervous tissue itself
was not affected. A similar observation had been made by Cruveil-
hier. The mamma presented the usual structure of scirrhus; the
nipple was very little retracted. The head was not opened. Mr. 8.
remarked that disease of the pancreas was usually limited to the head.
Mr. S. thought it important that in every case of cancer of the
breast, with diseased axillary glands, the condition of the veins
should be examined. (Museum, Richmond Hospital.)
3. Ruptured Bladder in the Female.—Mr. R. W. Smith said
he had another specimen to lay before the Society, which was inte-
resting, as being one rarely met with. It wasacase of rupture of the
bladder, from the body of a female, fifty years of age, who had, while
in a state of intoxication, fallen across the edge of a tub, This acci-
dent is one of rare occurrence in the female, perhaps from the bladder
being in some measure protected by the uterus and the concavity of
the sacrum. The symptoms in the present case were syncope, vomiting,
and tympanitic distention of the abdomen. In three days after the acci-
dent she was sent intothe Richmond Hospital; a quantity of bloody fluid
was drawn off by the catheter; the countenance was anxious, and all the
features appeared collapsed. She lived five days after the injury.
The peritoneum was acutely inflamed; the rent in the bladder was
very large; it was transverse in its direction, and was situated in the
posterior and upper part of the bladder. Mr. S. observed, that rup-
ture of the bladder is almost always caused by direct violence; some-
 Scientific Intelligence. Eee
times it is produced by concussion, of which there is an instance re-
lated by Dr, Cusack, in the Dublin Hospital Reports, where it had
occurred in a person who had fallen from a considerable height, but
had lighted on the feet. Dr. Harrison had published several cases
of ruptured bladder in the Dudblin Journal of Medical Science; all
these had ended fatally, at periods of from five to eight days from the
receipt of the injury.
4. Thoracic encephaloid Tumour compressing the Vena Cava.—
Mr. O’Ferrall presented the recent specimen. The subject was a
female, thirty-five years of age, who was brought into St. Vincent’s
Hospital, labouring onder what she called erysipelas of the face and
neck. Her face was tumid and sublivid; her neck presented the
tippet-formed swelling; there was a degree of venous turgescence of
the whole of the upper portion of the trunk; there was orthopneea
and a very distressing cough; absolute dulness and bronchial respi-
ration under the right clavicle; below this point the chest sounded
clear, but the respiration was feeble. Posteriorly, the right chest
Sounded comparatively dull on percussion; respiration in the left lung
puerile. There was double bruit de soufflet at the base of the heart,
extending a short way up the sternum, and inclining a little to the
left of the mesian line; the right radial pulse was smaller than the
left; there was some difficulty of deglutition; she lived for five or six
days in the hospital; her breathing became stridulous before her
death. A consideration of all the symptoms induced Mr. O’F. to
diagnose the existence of some intrathoracic tumour pressing on the
Superior cava. His diagnosis was negative as regarded aneurism, on
_ these grounds:—first, because the extent of dulness posteriorly was
greater than he had ever remarked in aneurism of the arch; and, se-
cond, because, although there was a murmur, its greatest intensity
Was not within the limits assigned by percussion to the tumour in
front. He, therefore, inclined to the opinion that it was malignant
disease. On examination after death, a quantity of straw-cvloured
fluid was found in the right pleura, but there was no appearance of
inflammation. The lung felt solid to the touch; it was adherent to a
large morbid growth, occupying the anterior mediastinum. There were
numerous masses of the same morbid deposit in the substance of the
right lung; the whole was encephaloid. The malignant growth ex-
tended to the posterior mediastinum, surrounding the trachea and
cesophagus. The superior cava passed through the mass, and was
obstructed by it; a mammillary projection nearly closed the canal of
the vessel. The pericardium contained bloody fluid; the heart was
Mot enlarged ; the septum of the auricles remarkably thin ; the fora-
men ovale open to the size of asilver fourpence. The septum pre-
_Sented other minute perforations; the valves of the pulmonary artery
attenuated and cribriform. Mr. O’F. remarked, that the sudden in-
vasion of the symptoms might be explained by the perforation of the
_ Yena cava by the morbid growth. The connexion of the murmur
_ With the cardiac lesions deserved a separate consideration.
VOI, XXV. NO, 73, 2A
178 Scientific Intelligence.

Fourth Meeting, 30th of April, 1842.

Dr. MontGomeERy in the Chair.

1. Cryptogamic Vegetations on the mucous Coat of the Stomach

after Death.—Doctor Lees produced portions of the stomach and
upper part of the intestinal canal of a corpse that had been interred
three months ago, and exhumed during the last week for medico-legal
investigation. The mucous surface of the stomach was of a deep
chocolate colour, and on it were scattered numerous white circular
bodies, elevated at the edge and depressed in the centre ; some of these
were very minute, and had the appearance ofa white powder sprinkled
on the membrane. This appearance had been noticed by Orfila as
one of those which had been mistaken for arsenic. Buchner too had
mentioned a white granular substance containing fat, found lining the
stomach. The question arises, what is the intimate nature and origin
of these bodies? Are they fungi? they are certainly not calcareous
depositions. They are partially soluble in alcohol, and they melt
before the blowpipe. They have not been described as fungi by any
writer on medical jurisprudence that Dr, Lees was acquainted with.
The scales in tinea capitis were by some supposed to be of vegetable
origin. Christison and other writers might be consulted as to this
appearance.
2. Aneurism of the Thoracic Aorta, without Murmur.—Mr.
O’Ferrall produced the recent parts and an illustrative drawing
of a case of aneurism of the thoracic aorta, which was attended
with much difficulty in making the diagnosis. The subject was a
man forty-five years of age, whom he had been called on to see in
consultation. He laboured under great dyspnoea occurring in
paroxysms in which he was almost asphyxiated, constant dith-
culty of swallowing solids, and stridulous breathing; there was no
bruit of any kind; no dulness; no sigo of interrupted circulation;
the respiratory murmur was rather feebler on the left side, and there
was general bronchitis, but not to an extreme degree. The cause of
the urgent symptoms was a matter of doubt. Among the medical at-
tendants of the patient there wasa great difference of opinion both as
to the origin of the dyspnoea and the means to be adopted for its re-
lief. One proposed to excise the uvula, another to administer emetics
and mercurials. Thestridor was equally matter of doubt. It had
not occurred until the patient had for three months sufferred dyspha-_
gia of solids. The medical attendants considered it to proceed from
the rima glottidis, but Mr. O’Ferrall was of opinion that the obstruc-
tion, whatever it was, had its seat below. There was no positive evl-
dence of intra-thoracic tumour, but that such existed he inferred from
the rational signs and from the history of the case. paroxysms
The
of dyspnoea recurred every evening during three weeks, and it was ia
one of them that the patient died. In these attacks his face became —
black and the whole body cold and livid, the faeces were discharged
involuntarily, and consciousness was almost entirely lost. From this
 Scientific Intelligence. 179
state relief was obtained by the application of warmth and the use of
stimulants and counter-irritants. The stimulants were also useful in
relieving the bronchitic symptoms. When the chest was opened
after death it was found that there was an aneurism of the arch of
the aorta which pressed upon the trachea and the cesophagus. The
aneurism was situated at the central and posterior part of the trans-
verse portion of the arch, between the innominata and the left carotid :
there was a large opening into the aneurism from the artery. Mr.
O’Ferrall observed, that several of the symptoms in this case were
explicable by the aneurismal tumour and its relations to the neigh-
bouring parts, but it was not quite so easy to explain the in-
termissions which were so remarkable in the progress of the illness.
Two years ago, Mr. O’Ferrall had ascribed such intermissions to
alesion of one or both of the recurrent nerves. In the present
case the pneumo-gastric nerve at the lower part of the aneurismal
tumour spread out into a cellular web, in the situation where
the recurrent should have been given off. In some cases of thoracic
aneurism the voice is affected; that the aphonia is, at least in some
of these, attributable to the lesion here described may be inferred
from the present as well as from some former cases which he had
brought under the notice of the Society.
3. Aneurism of Thoracic Aorta bursting into the Pericardium.
—Doctor J. C. Ferguson presented the recent parts concerned in an
aneurism of the thoracic aorta. The subject was a man who
came into Sir P. Dun’s Hospital three months ago. The diag-
nosis was there made that he laboured under intra-thoracic aneurism.
On the day before yesterday he died suddenly in a state of syncope.
The aneurismal tumour lay to the right of the trachea on which it
pressed. The calibre of the trachea just above its bifurcation had
been diminished by the pressure, and during the progress of the com-
plaint stridulous breathing had been a very prominent symptom :
there had been neither aphonia nordysphagia. The tumour also press-
ed on the descending cava and was adherent to it. The innominata
was almost obliterated where it came off from the aorta. During life
there was a remarkable tumefaction of the veins in the neck, and
pulsation was absent in the right radial artery. These symptoms
were explained by the morbid phenomena. There was a copious ef-
fusion of blood into the pericardium amounting to more than a pint.
The rupture in the aneurismal sac was small.
4, Dislocation of the Head of the Femur in Morbus Cora.—
Mr. R. W. Smith presented a specimen of a morbus coxe with dis-
location of the head of the femur on the dorsum of the ilium. Mr.
Smith observed that the shortening of the limb in morbus coxz is
seldom the result of dislocation. It is most usually effected by an
absorption of the head of the bone, or by a widening of the acetabu-
Jum, or by an incomplete luxation. In the present case the progress
of the disease was very rapid. The subject was a boy fourteen years
of age, was only six months ill, and the dislocation occurred about
four months before his death. The head of the bone was protruding
180 Scientific Intelligence.
through the integuments which had sloughed. The acetabulum was
ulcerated, denuded of its cartilages, and the bony portions of which it
is composed had become detached almost completely from each other,
The epiphysis of the femur was separating. The joint was surrounded
by an immense abscess. The head of the femur was coated with
lymph, it was lying under the gluteus medius, between that muscle
and the gluteus minimus.— Museum, Richmond Hospital,

An Address delivered before the Dublin Obstetrical Society on

the Opening of their Sixth Session, on the 4th December, 1843,
by W. F. Montgomery, A. M., M.D.,M.R.1. A., Fellow and Pro-
fessor of Midwifery in the King and Queen’s College of Physicians
in Ireland, and one of the Vice-Presidents of the Society. —-GENTLE-
meN—Members of the Dublin Obstetrical Society—since, by a choice
which I cannot but regard as much more the offspring of your feelings
of partiality, than in accordance with the deliberate results of your
judgment, you have placed me in this flattering position, and devolved
on me the duty of addressing you on this occasion, the opening
meeting of your Sixth Session; I beg to assure you, that although
I cannot venture to hope that my performance of the task will be in
any way commensurate with either your, or my own ideas of the im-
portance of the subject, I have not been careless in its consideration;
and, in the first place, offer you my best acknowledgments for this,
the second honour which your kindness has induced you to confer
upon me,
I have next to congratulate you on the flourishing state of your
Society, the utility of which is, long since, fully established in public
opinion.
If there were wanted an additional evidence of the success with
which the objects of this Society have been accomplished, it is to be
bad in the interest with which your discussions have been listened
to, and your meetings attended by several of the senior members of
the profession, to whom, I am instructed by your Committee to offer
ithe best thanks of the Society for their frequent visits at the Meet-
ings, and the many instructive remarks and suggestions with which
they have, on many occasions, so ably and kindly illustrated the
questions under consideration, shedding the lights of their matured
experience over subjects, which, in less experienced hands, might have
been obscured by doubt and difficulty in their investigation; and
thus materially forwarding the success, and raising the character of
this Society by their countenance and support; while on the other
hand, for myself, I cannot avoid saying, that on very many occasions
indeed, I have heard, with no less surprize than admiration, the fand
of correct practical knowledge displayed in this room by the junior
members of the Society, to whom, I beg to premise, the observations
which I have this evening the honor to offer, are principally ad-
dressed; and if, while doing so, many of my remarks shall, to
our more senior brethren, who have this evening, as on many former
occasions, made us their debtors by their presence, sound trite or
 Scientific Intelligence. 18]
trivial, merely conveying to their ears matters which are already to
their minds ‘ familiar as a household word,” I hope they will, even
so, bear with me, considering the necessity of the case, and that they
will permit me to plead my apology in the words of Platner’s epi-
graph to his book :—
‘‘ Hoc autem velim omnes tenere et scire, me scripsisse tironibus,
non excellentibus in arte professoribus, nec peritis atque exercitatis
magistris ; quibus, in hoc libello, plura leviora et vix commemoratione
digna videbuntur; que, tamen, discentium in gratiam, repetenda
fuerunt.”
It is almost superfluous for me to tell you that midwifery is no
longer included within the narrow limits of the old definition, which
declared it to be only the “ Ar¢ of assisting women in labour.”
At the present day, the practitioner in midwifery, in addition toa
thorough knowledge of all the varieties of labour and the casualties
with which they may be complicated, is expected to be familiar, not
only with the anatomy of the uterus in its virgin and gravid states,
but with its physiological laws also; with the diseases to which it is
subject; with the nature of the organized products which may form
within it, or be expelled from it, with the symptoms which indicate
the existence of pregnancy, and the laws that regulate gestation and
its duration; the characters by which the age of the foetus may be
determined, and the many and important diseases of childbed and
early infancy, the treatment of which, gentlemen, I pray you observe,
is to be learned but in one way; and that is, by acquiring first a
thorough knowledge of anatomy and physiology, especially as regards
the female system, and then such an acquaintance with the general
practice of medicine, as will enable you to apply its principles to
those particular cases, with the peculiarities of which, your frequent
observation of all the circumstances of the puerperal woman has
made you thoroughly familiar.
This, you will say, is asking much. Be assured, that if you aim
at a high standing in this department of the profession, and its
accompanying rewards, you cannot do with less. Society now ex-
pects this knowledge of us, because they see and understand that
our line of practice and opportunities for observation, furnish us with
abundant materials for its acquisition—and in this, they come unques-
tionably to a right conclusion: and be assured, society wll have this
amount of knowledge in you, or it will not have you, without it.
Every day’s experience makes our opinions the tribunal, before
which, are decided questions that touch the dearest and holiest ties
that hallow our social relations; the fair fame of purity and virtue,
the fidelity of married life, the claim to legitimacy, and, as a conse-
quence, the succession to wealth and honorable title; and in some
instances connected with judicial investigations, as in cases of clan-
destine delivery, suspicion of infanticide, or in pleas in bar of exe-
cution, when a woman, condemned to death, pleads pregnancy to save
her from execution, life itself may depend on the accuracy of our
judgement.
182 Scientific Intelligence.
It is a well-known fact that a noble family in Scotland was
doomed to years of domestic misery and alienation, by the ignorance,
or want of caution of their medical attendant, who pronounced an
hydatid to be an early abortion.
Gentlemen, it may, at the present day, seem almost incredible
that there should have been those who maintained that practical
midwifery required no study, and denied its utility; asserting the
all-sufficiency of the powers of unassisted nature; yet such has been
the fact. But a doctrine so obviously futile requires now no formal
refutation: that it should have had its advocates, we cannot wonder
at, when we consider how happily it coincided with the fastidious
theories of the enthusiastic admirers of nature ; how conveniently it
suited the supineness of those who were averse from inquiry, or
indisposed to exertion; how effectually it apologized for ignorance,
and how plausibly it extenuated the evils arising from neglect, or the
want of the timely and judicious application of artificial assistance.
Far be it from me, to advocate any thing like indiscriminate inter-
ference in the process of natural labour. I know too well that nature
is as truly admirable in the preservation of the individual, as in the
perpetuation of the species. Isee that all the organs, with which
she has supplied the different classes of animated nature, the proper-
ties, with which she has endowed them, and the powers with which
she has enriched them,—all tend ultimately to this one great object.
The various instruments employed in the reproduction of the vege-
able and animal kingdoms, are but the different machines which
support the brilliant decorations of the organic world, and the process,
by which the humble acorn is developed, matured, and shed from its
calyx, or the unsightly chrysalis transformed into the rainbow beauty
of the butterfly, is, I feel assured, as worthy of Him, who “ measured
the waters in the hollow of his hand, and meted out the heavens
with a span,” as deserving of admiration in its contrivance, and as
perfect in its operation and accomplishment, as that which ushers the
infant monarch into life.
But, | also believe that the providence of nature effects its purposes
and intentions by universal laws, and that what we call the powers of
nature have their limits, to which they go, and no further, in the pre-
sent government of visible things. I cannot but remember the de-
nunciation, ‘I will greatly multiply thy sorrow and thy conception,
and in sorrow shalt thou bring forth children ;” and I know that the
sorrow, and the suffering, are permitted to be abridged in their dura-
tion, and alleviated in their degree by the judicious interposition of a
well-timed assistance ;—and while I unhesitatingly acknowledge that
in many, nay, in the great majority of instances, we are, and should
be, but the passive observers of nature’s operation, I must as distinctly
maintain and insist, that it requires no less judgment to determine
when we should be so, than when we are called upon to aid her, or
even take the matter altogether out of her guidance.
By the advocates of nature’s all-sufficiency, it has been objected,
 Scientific Intelligence. 183

that those cases of extreme difficulty and danger which require assis-
tance, are the result of artificial habits. Well, be it so—with the
cause we have nothing to do, as it is beyond our control—the effect
must be remedied, or the patient dies.
But the assertion is false in fact; for instances of deaths in child-
bed are recorded from the earliest periods of Scripture history, and
Lycurgus passed a law 884 years before the Christian era, forbidding
inscriptions to be put upon the tombs of women who died in labour;
it is, moreover, notorious to all, that even the lower animals, living
in a state of nature, unrestrained and unvitiated by art, occasionally
die in parturition; and to many who hear me, the fact is well known,
that when William Hunter attempted to reform the mischievous prac-
tice of the ancients with regard to the hasty extraction ofthe after-birth,
and taught that it might, nay, ought, to be left entirely to nature, and
practised what he taught, the loss of several human lives, owing to
the retention of that organ, was the result of that practice, and evinced
the necessity of adopting the more modified and more reasonable prac-
tice of the present day.
On the other hand, there have been, and still are some, who, al-
though they confess the necessity, and acknowledge the utility of
midwifery, yet accustom themselves to consider its study and its prac-
tice, as matters of such common-place facility, as to require little or no
attention, for the acquisition of knowledge in the one, or expertness
in the other. In those who are never to practise it, this in an error
to be lamented, but in those who are to adopt this branch of the pro-
fession, it is a fearful delusion—a truth, which they will find it too
late to learn, when practice bas involved them in circumstances of
such danger, or such peculiar delicacy, that on the one hand life or
death, and on the other, the happiness or misery of many are depend-
ing on the accuracy of their discrimination, and on the promptitude
and dexterity of their action, A. Leroy, amongst a thousand other
sneers, said, that all that was worth knowing in the whole practice of
midwifery might be written on the back of a playing-card. Of this
remark, I will only observe, that every man, who speaks his opinion
sincerely, speaks according to the amount of his own knowledge, and
Leroy, of all he undertook, never finished anything.
The emergencies of midwifery practice are often eminently urgent,
and admit of no delay to seek the opinion, or the assistance of others ;
fulfilling truly the poet’s description of the rapid issue of battle:
es Quid enim? concurritur, hore
Momento cifa mors venit, aut victoria leta.”
It would be tedious to enumerate all the different circumstances,
in which the truth of this assertion might be illustrated; it will be
amply sufficient in the way of proof, to allude to one or two, and |
believe I need only mention puerperal convulsions, presentation ofthe
placenta, and other forms of profuse haemorrhage, and rupture of the
uterus, and dispense with further comment.
Again, it is tobe recollected, that, while in the treatment of ordi-
nary cases, in medical and surgical practice, one life only 1s at stake,
 184 | Scientific Intelligence.

the practitioner in midwifery has always a double responsibility; and

it unfortunately, but too frequently happens, that the safety of both
intrusted to him is incompatible. Under such circumstances, he
will have great reason for joyful congratulation, if by the judicious in-
terposition of his best exertions, he be always able to preserve to soci-
ety the more valuable life of the mother, without having prematurely.
sacrificed that of the infant: for, I believe there is not, in the whole
range of medical or surgical practice, an occasion which demands
more mature deliberation, more precise knowledge, or a clearer judg-
ment, than are required to enable the accoucheur to determine, in cases
of tedious and dificult labour, how long he may trust to nature, with-
out compromising the life of the mother, or entailing on her an exis-
tence of misery worse, as far as we can judge, than death itself; or,
on the other hand, to fix—awful decision !—the precise time when he
is imperatively called on to sacrifice the child, for the safety of the pa-
rent. Poignant, indeed, and full of agony must be the feelings of the
man who, under such circumstances, stands self-accused and self-
convicted of having neglected, or presumptuously slighted the oppor-
tunity of acquiring the knowledge suited to such an occasion: and if,
while he stands vacillating in uncertainty and indecision, the doom
of the victim be sealed, and the mother of a family be consigned to
death, let him shudder at the name, with which astrict morality may
justly brand the part he has acted in the tragedy.
How little will the dark shadows of this picture be enlivened, if,
while life escapes, it remains only to be endured, but not enjoyed, and
a loathsome disease, and a childless bed are allotted as the sufferer’s
future inheritance. The feeling which prompted the exclamation of
the Scripture matron—‘ Give me children or I die,” finds its coun-
terpart in every woman’s bosom; and however incompatible it may ap-
pear, with the superiority of our mental, and moral constitution, how-
ever degrading it may seem to a mind accustomed to view human
nature only through the dazzling and deceptive medium of the lofty
speculations of a refined philosophy, still, it must be acknowledged,
that something less purified than the refinements of Platonic senti-
ment seems necessary for the cement of human affection, which but
too frequently droops and withers, when the hopes which, at first, in-
spired it, exist no more; and oh! how bitter must be the unavailing
remorse of the man who can look back to his ignorance, or mal-practice
as the first cause of a severed affection.
Even, under ordinary circumstances, the accoucheur will meet
with much to exercise his patience, and call for no ordinary degree
of calmness and self-possession, which a proper knowledge of his
business alone can confer : he meets his patient under circumstances,
which, however mild, or gentle may be her natural disposition, often
render her intractable, unreasonable, and impatient; vainly imagining
_that it is always in the power of her physician to diminish her
suffering’, or abridge the period of its duration; and, in proportion, she
solicits bis in¢anforanice! however premature or unsuitable it may be.
Along with her entreaties, he has to encounter the well-meant, but
 Scientific Intelligence. 185
officious and most vexatious observations and appeals of female friends,
who, from personal experience, consider themselves entitled to form
a judgment of the case, and of the course he ought to pursue, and
persecute him accordingly; but woe to him, if, with a polite but
dishonest compliance with such solicitations, he venture upon a pre-
cipitate and uncalled for interference, for let him be assured, that
even should his precipitancy be attended with success, he will not
get the credit of it; even his compliance will be remembered to his
disadvantage, his firmness will be doubted, and the confidence to be
reposed in him diminished or annulled: and should he fail, or be
unfortunate in the result, he may rest assured, that the very persons
who urged him, will be among the foremost to exclaim against, and
blame him, for his unmanly and temporizing subservience to the
opinions of those who were not qualified to influence, or direct him,
and whom he should not have regarded.
If there be one quality beyond another, of paramount value, even
in the well-educated accoucheur, it is judicious patience, under
whose influence we shall act ‘‘ neque temere neque timide,” by
which, I mean patience, regulated and limited by sound discretion
and judgment, which, while it effectually guards us against prema-
ture interference, will not induce us to fall into the opposite, but
equally dangerous extreme, of undue procrastination; and, without
which, no man can honestly discharge his duty to his patient, and to
society.
When the time has arrived, at which, patience is no longer pru-
dence, and we must interpose, I would earnestly entreat of you to
abhor the baneful notion, that haste proves skill, or that rapidity of
execution, and true dexterity, are equivalent terms; rather, be con-
vinced, that precipitancy and violence are ever the result of dishonesty,
or ignorance.
To my apprehension, an accoucheur, however accomplished, but
without patience, and who, on every occasion of inconvenient delay,
resorts to the use of artificial assistance, is more formidable than a
bedlamite with a drawn sword; the one puts us on our guard, and
we may disarm, or overpower him, but the other uses his weapon of
destruction under the sanction of his professional authority, and
maims, or murders, with impunity, perhaps with applause. Do not
suppose, that because you do not use instruments, you may not com-
mit violence ; it has been well, and truly said, that the thrust ofa
hand may be as fatal as the thrust of a bayonet; in point of fact, it
is likely to be much more so, since the extent, to which it will tear
and lacerate, is an hundred fold greater. I mean to be perfectly serious,
- when I say, that the man who measures his dexterity, or skill, by the
velocity and momentum of his efforts, would shew a sound discretion
in changing his profession, and seeking scope for his powers in the
construction of steam engines; or he might possibly acquire fame, as
a pugilist, but his qualities are awful for an accoucheur.
It is certainly true that our temper is sometimes sorely tried, and
we are made to wince, under the stings of unmerited reproach, or
VOL. Xxv. NO. 73, 2B
186 Scientific Intelligence.
smart with the irritation of insulting inuendo; but even so, I pray
you pause, and recollect that the sufferer is torn with agony beyond
all human endurance, her heart sick, with hope too long deferred,
and her fortitude exhausted, so that she is hardly conscious of what
she either does or says; recollect, that she is one of those, whose
power is in her weakness, whose strength is in her tenderness; to
whom we owe the watchful care of infancy and childhood, and to
whom we look, in manhood, for all the dearest consolations of do-
mestic life.
‘* The very first
Of human life must spring from woman’s breast;
Our first small words are taught us by her lips;
Our first tear quenched by her, and our last sighs
Too often breathed out in a woman’s hearing.”

Gratitude alone, then, demands from us the utmost stretch of our

forbearance, the utmost exercise of our gentleness, and indulgence,
such as we would be sure to experience at her hands, were we the
tenant of the bed of pain, and she beside us as mother, wife, or
sister; with what unwearied zeal, what anxious solicitude would she
watch, to anticipate our slightest wish, with what unfailing patience,
through many a tedious day and watchful night, would she smooth
down our weary pillow, console our sick-bed sorrows, and like a
ministering angel, ‘‘cheer with smiles the bed of death.” Do we
not daily see this fully exemplified, and with a full devotedness of
affection which realizes the picture of unshaken constancy so exqui-
sitely embodied in the words of Ruth to Naomi: ‘“‘ Entreat me not
to leave thee, or to return from following after thee; for whither thou
goestI will go, and where thou lodgest I will lodge; thy people shall be
my people, and thy God my God: where thou diest will I die, and there
will I be buried.” Shall we then forget our part, and because our pa-
tient is unreasonable, or perverse under agony, shall we be petulant, re-
sentful, or unmanly ? Need [ answer the question ? Need I remind you,
how delightful the consolation of knowing, that though heaviness
may endure for a night, joy cometh with the morning, and of feeling
that we have been instrumental in the delightful consummation
which realizes all the mother’s anxious hopes and fondest wishes,
and gives her a resting-place for all her deepest, and tenderest
feelings, for which, ‘‘she remembereth no more the anguish,” even
though, to use the strong language of the psalmist ‘‘ the pains of hell
gat hold upon her, and the sorrows of death compassed her around ¢”
I feel that it would be needless for me to suggest to gentlemen
educated as you are, that no consideration of rank or riches should
be suffered to weigh against, or disturb the working of our judgment;
difference of station makes no distinction in disease, or pain, which,
like the sterner influence of death, happens alike to all,
‘* AAquo pulsat pede pauperum
Tabernas, regumque turres.”
The duchess or the queen has no immunity, or privilege in labour
beyond the ragged beggar; and on our part, we are just as responsible
 Scientific Intelligence. 187
to God and man for the safety of the unborn innocent of the poor
and needy, as for the heir of a sceptre and a diadem.
it is said that when Napoleon Buonaparte was asked by the
accoucheur in attendance on Maria Louisa, how he should act, in case
of such, or suchan emergency, in the labour of his queen, his stern
answer conveyed a magnificent lesson in morality :—‘‘I expect, Sir,
that you will treat her, as you would the wife of a shopkeeper in the
Rue St. Martin.”
This was very noble, when we recollect the circumstances,—it
was better, for, it was in accordance with the great law of conscience.
How little can we judge of the importance of the being about to
enter life, by the circumstances attendant on its birth. How great
may be the destiny of him, whose nativity was cast in misery, whose
infancy was steeped in poverty and privation; a cot of bulrushes
received the chosen of the Pentateuch, and the Saviour of mankind
was cradled in a manger.
Even, if we take onlya mere worldly and self-interested view of this
matter, every day’s experience proves that the kindness shown to
the suffering pauper in her wretched hovel, is often acknowledged
in the mansions of the rich and noble, when we least expect it. Your
school-boy recollections will remind you, that it was in the silent soli-
tude of the forest cave, unseen of man, that the Dacian slave drew
forth the thorn from the lion’s foot, and relieved his pain; little dream-
ing of recompense; but what, and where was his reward? In the
presence of assembled Rome, and before his emperor’s face, while
the shouting thousands of the Circus Maximus hailed, with joy, the
sentence, that announced to him life preserved and liberty restored;
and where, and what shall be his reward, who, in obedience to the
command of Him who seeth in secret, but rewardeth openly; does
good to the least of all his brethren? his reward shall be conferred in
the great amphitheatre of heaven—before assembled worlds, in the
presence of the King of kings—and his recompense the glorious
liberty of the sons of God, and never ending immortality.
Now permit me to make a few suggestions, connected with the
nature and study of our branch of medicine.
I know that an idea prevails very generally, that attendance on
cases of labour is all that it is required to teach a man to practise
midwifery; delivery being but a mere mechanical operation, the moving
power of which acts without our assistance, and refuses to submit to
our control.
This is one of the many assertions, whose peculiar danger is, that
they embody just enough of truth to veil their falsehood.
{ think you might as well believe, that the man who had watched
for years, the operation of a steam-engine, or the motions of a pendu-
lum, would, therefore, be capable of regulating their action when de-
ranged, or adjusting their parts when displaced, although ignorant of
the laws of physics, and of the construction and relation of the several
parts of the machine; or that by nightly gazing on the countless
glories of the stars, he would learn the laws that regulate their motions.
188 Scientific Intelligence.
Be assured, there is a knowledge which you must acquire, before
you can hope to practise midwifery, as it ought to be practised,
that is, as a science, and before you can conscientiously venture to
approach the bedside of a patient, for, at that bedside, you never can
acquire it. You all know, gentlemen, that Levret was a man of very
extended knowledge and of great practice, and his opinion, on this
point, is given in these words: ‘‘ be not deceived, practice alone is not
sufficient to afford such information, for if we are not supported by
sound theoretical knowledge, it is in vain that nature is exhibited
plainly before our eyes: under such circumstances, we see her under
forms which do not belong to her.”
1. At the dissecting table and in the museum you must learn
the anatomy of the pelvis, its form, position, and dimensions; the
relations, structure, and connexions of the parts contained within if,
and their communications with those that are externally attached;
with this, should be conjoined, an intimate acquaintance with the ana-
tomy of the gravid uterus, and the structure of the ovum.
2. In your study and from books you must learn the physiology
of all these; that is, the uses to which they are subservient, and the
functions which they perform, under ordinary circumstances, the cha-
racter of their healthy action, and the sympathies which they display.
3. In the lecture room you should hear and see explained, the
changes made in those anatomical relations and functional sympathies,
whether by pregnancy, parturition, or disease; and you should have
laid before your eyes, the mechanism of delivery, in the several va~
rieties of labour; while in hospitals, and by other means, you should
acquire a competent knowledge of surgery and practical medicine.
When you have treasured in your mind, the information derivable
from these sources, you will possess the qualifications which alone can
fit you for commencing practice at the bedside; where you will, then,
and not till then, be prepared to apply to practice, the sound, the
unerring knowledge of unalterable principles.
Experience shows that the mere observation of facts, without
other modes of investigation, in matters connected with the opera-
tions of the animal economy, and especially as connected with our
subject, has disclosed very slowly some of the most ordinary, and yet,
most important facts connected with midwifery; one proof of which
may here suffice; 2f was not until the year 1742, that even an ap-
proach was made to a knowledge of the proper position and rela-
tions of the child’s head, in natural labour; and yet, on that know-
ledge, depends our power ofrectifying malposition, removing difficulties,
and effecting delivery under untoward circumstances; and it is grati-
fying to be able to add, that this important discovery was made in
this city, by our countryman, Sir Fielding Ould.
Alike distinct from medicine and surgery, individually considered,
midwifery embraces, and requires both, for its effectual and successful
practice. As natural philosophy is neither geometry nor metaphysics,
yet without a thorough knowledge of both, sinks from the dignity of
 Scientific Intelligence. 189
a science into the meanness of a technical system; the natural phi-
losopher, if such he can be called, who is unversed in these, may
solve problems and obtain true results, so long as these problems pre-
Sent nothing new, nothing that scholastic forms or collegiate exer-
cises have not already made familiar; but when he comes to orene-
ralize axioms, or from a series of complicated results to draw ageneral
inference, he ponders on to little purpose, until, at length, worn out
and ‘‘ weary of conjecture” he makes a desperate final guess, and
plunges into inextricable and fatal confusion.
The analogy appears so close, as to require no comment; but if it
should, it will be found fearfully set forth in the misdeeds of those,
who content with their obstetrical acquirements alone, have forgotten,
or neglected, to possess themselves of the advantages to be derived
from a proper knowledge of the sister branches of medical science.
Let us suppose a patient, after a short, easy, and natural labour,
suddenly seized with violent peritonitis, inflammation of the uterus,
pneumonia, or scarlatina, how will a man be prepared to act in these
trying emergencies, who has neglected to acquire a proper knowledge
of practical medicine ? or how is he who is altogether ignorant of
surgery to act, when his puerperal patient is seized with deep-seated
abscess, as, for instance, that which forms in the lateral appen-
dages of the uterus after labour? :
How many days of unnecessary agony will his patient suffer, if he
is either, too ignorant to discover its existence, or too unskilful to re-
lieve her with his lancet? How will he manage a mammary abscess;
a lacerated perineum; a thrombus, ora vaginal hernia? how will he
treat a fissured rectum, or remove a polypus, or an inverted uterus,
by the ligature, or knife? Oh, but some one will say, he can easily
find some one to do any of those things for him: very true; and with
the same facility, he may find some one who would cheerfully relieve
him of the trouble of ever again attending his patient, under any cir-
cumstances,
But don ot misunderstand me, and suppose that I would discourage
you from seeking assistance in cases of doubt, or ditiiculty; very far
from it; it is the mark of honesty to avow a doubt fearlessly, and the
better informed any one is, the more readily he will do so: none are
so vain of their knowledge as the slightly learned, none so reluctant
to receive advice; and it is, not only, wise and prudent, but a bounden
moral duty to seek the assistance of those more competent than our-
selves, whenever we think the welfare of our patient runs a risk of
being compromised, by our depending on ourselves alone. Iam only
anxious, that by being fully instructed in the different branches of
knowledge necessary for your practice, you should be prepared to do
the greatest amount of service, with the least necessity for assistance,
from others of your fellow-men; but, how gladly, would I anticipate
that every one here, and elsewhere, would feel bound, in every case
and in every circumstance of life, to seek for assistance from the great
Physician, by faithful prayer, and confident reliance on his support, —
190 Scientific Intelligence.
then might he feel assured that the same power which can cause the
‘“‘harren woman to keep house and to be a joyful mother of children,”
will be ever at his right hand, to guide and support him, and to crown
all his honest endeavours, with all the success which he can desire,
or they deserve.
I cannot leave this part of our subject without alluding to the
noble Institution within whose precincts we are now assembled;
which is, perhaps, the noblest monument of philanthropy ever left by
one man’s almost unaided efforts, which he prosecuted with an ardour
of benevolence unfortunately more commensurate with the lofty and
uncompromising spirit of genuine Christian charity, than with his
own resources. In 1757, Dr. Bartholomew Mosse completed this
grand object of his ambition (the first institution of the kind in the
British dominions); but, alas, sunk in the struggle, exhausted in
health and means.
Such heroic devotion in morals is little apt to be blazoned forth
on the page of history; but in the memory of all good men, will live
the praise of him, who with more than the patriot heroism of the
Roman Curtius, cast himself into the gulf, for the benefit of the
commonwealth; and among the many beneficial consequences which
have hence arisen to the public, a most important one is, that there
is here established a system of instruction which has, now, for many
years, conferred its advantages on the Profession, and, through them,
on society at large, and young men are no longer under the dangerous
necessity of trusting to learn midwifery by actual practice, and unas-
sisted by any guide.
This institution, in addition to an immense field of observation, in
the various forms, and contingencies of labour, and of those diseases
and accidents to which women are liable, has, at all times, afforded to
its pupils, the unusual advantage of an experienced guide constantly
resident within its walls, and, therefore, at all hours ready to impart
instruction, and direct the learner in all things belonging to his study.
On the qualifications of the gentleman, to whom that important duty
is, at present, intrusted, I would willingly expatiate were he not pre-
sent; but I refrain for many reasons. I know that my spoken eu-
logy, however high, would only be the imperfect utterance of your
thoughts, and my words of praise, you would have already learned
from the public voice; I may therefore be permitted to avail myself
of the apology once offered by Bishop Sherlock : ‘I am ill at com-
pliment, and do not choose to be every body’s echo.”
Permit me, here, to draw your attention for a moment to what ap-
pears to me a very important point for consideration, namely, that a
large store of theoretical information, even though combined with an
extensive observation of facts, may not afford a commensurate supply
of practical knowledge.
It is an observation as trite, as it is true, that ‘“ knowledge is
power,” and under no circumstance, is this more remarkably verified
than in the profession of medicine ; but I fear also that we are, of all
 Scientific Intelligence. 191
others, the most apt to fall into error on this subject, partly by mis-
taking the elements of knowledge, for knowledge itself; partly by sub-
stituting in our reasonings names in the place of édeas, adopting
theories instead of submitting to laborious investigation, and so pre-
ferring a sort of second-hand, or ready-made belief to the more tedious
and irksome labour of close examination, or careful induction.
As you collect facts, whether from observation, or reading, recol-
lect, they are only valuable, in proportion as you can draw from them
directions for future contingencies in practice, by reflection, compa-
rison, and arrangement in your mind: for, as food, however good, or
nutritious, will not afford nourishment, except it be healthily digested,
and its nutritive portions made our own by a healthy process of assi-
milation; so, the acquisition of isolated facts, or opinions, no matter
how great their number, or how valuable their quality, is not know-
ledge; nay, the very multiplicity of our ideas, if not carefully ar-
ranged, compared, and digested, may be absolutely a bar to it, a mere
cause of confusion: ‘‘ Learning, without knowledge,” says the ta-
Jented author of Pelham, ‘is but a bundle of prejudices; a lumber
of inert matter set before the threshold of the understanding, to the
exclusion of common sense.”
This did not escape the observation of our great modern painter of
the human character, Sir Walter Scott, who compares a mind so cir-
cumstanced ‘to the magazine of a pawnbroker, stowed with goods of
every description, but so cumbrously piled together and in such total
disorganization, that the owner can never lay his hands upon any one
article, at the moment he has occasion for it.” Knowledge, whether
in medicine, or philosophy, depends on the care, with which we exa-
mine and compare our ideas, not on the number of them; it is, in the
words of Locke, ‘‘the perception of their agreement, or disagree-
ment;”’ ‘where this perception is, there is knowledge; where it is
not, we may fancy, guess, or believe, but we fall short of knowledge.”
Thus, you perceive that our ideas may be numerous, and yet our
knowledge very scanty, nay, our ideas may be clear as it is possible,
and yet our knowledge be obscure, or even miserably deficient; and all
for want of reflection and examination. |fear this is remarkably dis-
played in the study of medicine generally, and of our branch of it, in
particular. How many among us are fully convinced that the obser-
vation ofa certain number of cases, with the recollection of their
Symptoms, and of the remedies suited to their treatment; the atten-
dance on a certain number of lectures, and the perusal of a certain
number of books, must necessarily confer on us a profitable know-
ledge of our subject; but how soon does experience undeceive us, and
teach us that we have adopted ‘a lame and impotent conclusion.”
Do not for a moment imagine, that J mean to undervalue the benefits
arising from attentive observation; very far from it; by such means,
and by no other, do we acquire ideas of particular facts of great value,
but, on our own mental exertion, in arranging and comparing these,
 ”

192 Scientific Intelligence.

must depend the degree and the clearness of the knowledge they
will supply us with: ‘‘ If our memories retain them well, we have in-
deed the materials of knowledge, but, like those for building, they
are of no advantage, if they are merely allowed to lie heaped up toge-
ther, a ‘rudis indigestaque moles.’”’ By observation and industry, we
may have thus, as it were, collected the marble and the cement; by the
working of our intellectual powers, must we draw the plan, and raise
the structure of the temple of wisdom. Our great metaphysician
Locke has expressed himself so admirably on this point, that I can-
not avoid availing myself of so powerful an auxiliary. Speaking of
the benefits to be derived from reading, he says: ‘‘ Those who have
read of every thing are thought to understand every thing too; but
itis not always so. Reading furnishes the mind, only with materials
of knowledge; it is thinking makes what we read, ours. We are of
the ruminating kind, and it is not enough to cram ourselves with a
great load of collections, unless we chew them over again, they will
not give us strength and nourishment. The memory may be stored,
but the judgment is little better, and the stock of knowledge not in-
creased, by being able to repeat what others have said, or produce the
arguments we have found in them.”
Gentlemen, ifI should happen to be heard by any, who feel their
spirits damped, and their exertions crippled by straitened circumstan-
ces, who are compelled to feel the truth of the maxim,
‘«¢ Haud facile emergunt quorum virtutibus obstat
Res angusta domi,”
let me assure them, they need not be discouraged. If they will look to
the history ofsome of the brightest ornaments of our Profession, as well
as of others, they will find, that they had to encounter similar difficulties.
Indeed, the early difficulties of eminent men form, perhaps, the most
instructive and animating portion of their biography. Linnzeus records
of himself—‘ Exivi patria triginta sex nummis aureis dives.” William
Hunter was under the necessity of deferring his third course of lec-
tures for a fortnight, from want of money, to pay for the usual adver-
tisements ; and Dr. Cheyne tells us, in his autobiography, that when
he settled in this city in 1810, after having been already fifteen years
in practice, during six months he received only three gueneas; but,
by the adoption of the course which I shall presently tell you of, in
ten years, his professional income amounted to £5000 a-year. Nay,
gentlemen, believe me, your days of struggle will hereafter be remem-
bered with interest and pleasure. Memory will scatter sunshine over
past moments, which did not illuminate them, when actually present;
even the gloomy periods of existence are sometimes reproduced by
recollection in an attractive form.
‘‘ Forsan, et hac, olim meminisse juvabit,”
was a part of the argument used by /Eneas, to cheer the drooping spi-
rits of his weary followers.
 Scientific Intelligence. 193
Hereafter, you will have to sacrifice a large portion of your happi-
ness in the pursuit and duties of extensive practice, and when thus
swallowed up in a vortex of overwhelming occupation, excluding,
perhaps, almost every pleasure except that of adding to your reputa-
tion and your wealth, you will look back, with fondness and regret, on
the obscurer days, in which you had leisure to enjoy existence ; when
life was young, and hope was fresh and buoyant, ever at your side
and pointing to promised joy ; and the mind’s eye will strain back to
trace the outlines of former pleasures, long since buried in the waters
of a sea of troubles; as the traveller seeks in vain to discover, in the
bosom of our northern lakes, the sunken towns and towers of a former
age.
It is true, that a sentence of one of our greatest English moralists
and philosophers, has been received, almost as a dogma, in our profes-
sion :—‘‘ A physician in a great city,” says Johnson in his life of
Akenside, ‘* seems to be the mere plaything of fortune ; his degree of
reputation is, for the most part, totally casual; they that employ him
know not his excellence; they that reject him know not his deficience,”’
and this statement is supposed to apply, even more pointedly, to prac-
titioners in midwifery, than to others.
But, be assured, this is a view of the subject as deceptive, as it is
gloomy and discouraging: be assured that in this, as in other pro-
fessions, industry and perseverance, if united with even moderate
ability, will enable you to reap a suitable reward. Be assured, that
although, in your struggles for advancement, disappointment may en-
dure for a time, if you walk uprightly, honestly and diligently, your
hour of triumph and rejoicing will come, sooner or later. No doubt
accident may favour one more than another, but if it be true, on the
one hand, that ‘‘ opportunity makes the man,” it is equally certain, that
the man of information, industry, and discretion can create the oppor-
tunity.
If you doubt the truth of these assertions, read the volume of the
** Family Library” entitled ‘‘ The Lives of the most eminent British
Physicians,” and assuredly you will be satisfied that the disheartening
observation of the great moralist must be received as pointing, not to
the rule, but to the exception; and that, generally speaking, in our
course of active life, asin others, the long labour of preparatory study,
anxious diligence of observation, and conscientious assiduity in prac-
tice, are crowned with all the distinctions which generous ambition
can aspire to reach. But above all, recollect the encouraging promise,
from a source that never failed, that if we are not weary in well doing,
‘*in due season we shall reap if we faint not.” But, if you are unwise
enough to rest your hopes of professional advancement on anything
but industry, and its natural consequence, knowledge, supported of
course by unvarying good moral conduct, rest assured you will be bit-
terly disappointed. Patronage or nepotism may invest a man with
place, to which he has no legitimate claim, and for the duties of which
he is unfit; or it may enrich him, for a time, with emoluments wrung
VOL. XXV. NO. 73. 2¢
194 Scientific Intelligence.

from the institutions of his country, and of which he is andeserving,

but can patronage bestow information, or obtain for its minion the con-
fidence of the public, and the approbation of society’ Believe me,
gentlemen, i¢ cannot,ztnever did. No man ever yet retained reputa-
tion except by his own merits. Accident or good fortune may invest
the ignorant or worthless blockhead with the robe of authority, or the
garb of knowledge, but the hand of experience and public examination
soon tears off the borrowed plumes, and bares to public scorn the un-
fledged fool; like the ass, in the fable, who assumed the lion’s skin,
but was found to be but an ass, after all.
Let your aim be, to establish your character on the solid pyramid
of public opinion, around whose base are the blessings of the poor and
needy, and those who have none to help them, and, on its apex, the
aristocracy of the land, the smiles of the great and opulent. This is
the foundation which will not sink away, when you least expect it, but
will stand firm, as a rock, under the feet of him who climbs it by his
own meritorious efforts. The public is your only safe and steady pa-
tron, and, for this strong reason, it is the interest of all to secure the
services of the man of real merit. You will find them astern, inflex-
ible, and generally an unerring tribunal;before whom it is unnecessary
to plead the cause of active merit, and useless to varnish infirmity, or
recommend incapacity. Friends may flatter and exaggerate, and
enemies may slander and defame, but the public at large will do
justice, because they are far removed from the sphere of personal
feeling, individual influence, and private prejudice. It is to this tri-
bunal, that you must appeal, if you wish for justice.
It was the playful boast of the most brilliant poet of the Augustan
age, that no extremes of climate could prevent him from loving and
praising his mistress; that, whether in the ice-bound regions of the
north, or under the glowing chariot wheels of the tropic sun, his
sentiments and feelings would remain unaltered: you recollect his
words:
‘¢ Pone me, pigris ubi nulla campis
Arbor estiva recreatur aura
Quod latus mundi, nebulz, malusque
Jupiter urget.
‘¢ Pone sub curru nimium propinqui
Solis, in terra domibus negata,
Dulce ridentem, Lalagen amabo
Dulce loquentem.”

But it is the Christian physician’s glorious privilege, that wherever

he may be, the great object of his love and praise is with him, about
his bed and about his path, and directing all his ways,—while there
exists no spot on the broad surface of the habitable earth, in which,
he cannot exercise his art for the benefit of his fellow-creatures; the
lawyer in a foreign country, a stranger to its laws and customs, finds
his knowledge foolishness; even the minister of God may fail to
interest, and may be unable to impress his divine mission on the
 Scientific Intelligence. 195
callous heart, or to make his “ tidings of great joy” intelligible,—
but
where is the man, civilized or savage, who will push back the hand
stretched forth to minister to his bodily comfort, and relieve his pain.
Disease and suffering are of every clime, and almost alike in all, and
surely we may truly exclaim with the Trojan exile, though in a
different sense,
‘* Que regio in terris, nostri non plena laboris 2”

It may be, that there are here, to night, some young men, who,
toiling eagerly onwards in the acquisition of professional information,
or its application to practice, have with ‘‘a zeal not according to
knowledge,” unhappily persuaded themselves, that all the seven days
of the week are but too little for all they have to do; and, so per-
suaded, use them all alike.
If there be here any such, I would fain say a few words in abate-
ment ofthe error, into which they have fallen, and endeavour to shew
them the necessity and advantages of keeping holy the sabbath day.
The first point, they will learn more appropriately, and far more
effectively, from those, whose sacred duty it is, to enforce the com-
mands of God; among which there is none more distinct, or cogent,
than ‘“‘ Remember the Sabbath day to keep it holy. Six days shalt
thou labour and do all thy work. But the seventh is the sabbath of
the Lord thy God.”
If now, you are satisfied, that those are the words of the same
God who said, ‘¢ Thou shalt do no murder,” which crime, no earthly
inducement could prevail on you to commit, and from the very idea
of which, you would recoil with horror, on what plea of reason do you
acknowledge and respect the one command, but reject and transgress
the other ?
But what are the advantages of keeping the sabbath holy? As
sure as God and man have spoken truth, blessings both temporal and
eternal await its due observance.
What says the Lord of all the earth? ‘If thou turn away thy
foot from the sabbath, from doing thy pleasure on my holy day, and
call the sabbath a delight, the holy of the Lord, honourable, and
shalt honour him, not doing thine own ways, nor finding thine own
pleasure, nor speaking thine own words:”
Then what is the consequence?
““Then shalt thou delight thyself in the Lord, and [ will cause
thee to ride upon the high places of the earth, and feed thee with the
heritage of Jacob thy father, for the mouth of the Lord hath spoken it.”
Let the sabbath-breaker tell where, on earth, he will find a
reward like this.
But, viewed even within the narrow limits of personal or profes-
sicnal advantages, my firm conviction is, that a due observance of
the sabbath accelerates, instead of retarding, the accomplishment of
all the legitimate and most desirable objects of our ambition, and saves
time, instead of wasting it.
 Bir

196 Scientific Intelligence.

It is a universal law of nature, that there should be certain alter-

nations of activity and repose, labour and sleep, day and night; and
in proportion as any man acts in accordance with this law, he will do
what he has to do, more efficiently, and continue longer equal to the
necessary efforts of both mind and body,
I may here be permitted to illustrate the apostrophe of the man
of Uz, “* Ask now the beasts of the field, and they shall teach thee,”
by calling your attention to a curious and interesting fact, stated at
the last meeting of the British Association by Mr. Bianconi, as one
of his reasons for not working his horses on Sunday: ‘‘1 found,” said
he, ‘‘ after several years’ experience, that a horse would travel eight
miles a day, on six days in each week, for a much longer time, than
he would travel six miles a day, every day in the week.” That is,
that 48 miles a week would impose less fatigue, with rest on Sunday,
than 42 miles a week, without any day of rest.
I am satisfied, we have but to change the name, and that the
same statement might be made, with perfect truth, of man, and with
this important addition, that the repose of the sabbath not only re-
freshes and restores his physical powers, but that the soothing
influence of its holy duties spreads a refreshing dew over his ex-
hausted mental faculties, by which they are rendered more clear,
active, and vigorous for the duties of the coming week,—thus, God
works secretly for our good, and shall we oppose him ¢
But you may ask, have we any evidence of all this before us,
among our fellow-men, and on satisfactory authority¢
To this,*I will answer by statements derived from two sources,
well calculated, as I conceive, to make a forcible impression on your
minds in reference to this subject.
The one is furnished by a medical man actively and successfully
engaged in practice, and the other is extracted from the life of an
eminent lawyer and judge.
The former, I shall now read to you, as written by himself:
«When | wasa young man,” he says, ‘just beginning my profes-
sion, | was very industrious and zealous in my attention to its duties.
1 neglected nothing which I thought, at that tame, would best promote
my advancement, forgot nothing that appeared likely to conduce to
success, but I did totally neglect and forget Him who has said: ‘ them
that honour me, I will honour.’ J entirely forsook public worship,
never went to church, partly, because | preferred devoting the time to
professional reading at home, or to some occupation connected with
my profession ; partly because I indulged in the silly and sinful affec-
tation of wishing to appear so busy, that J had not treme to go to
church ; and partly, because I thought, that by remaining at home,
and in the way, as it is said, 1 would be more likely to have the
advantage of chance calls to patients.
‘¢ In this kind of sordid, slavish, and sinful devotion to business
I continued for some years, my health gradually giving way, and
my mind always in a state of feverish anxiety, until at length I was
 Scientific Intelligence. 197
visited with deep affliction and a severe illness, which were to me,
the beginning of blessing and happiness. By God’s grace and
goodness, my eyes were opened, and I saw clearly the enormity of
the course of life [ had been leading, and was, by Him, enabled to
change it; and now, for some years, in addition to private prayer
and family worship, morning and evening, I have never failed, except
when actually detained at a patient’s bedside, to attend the services
of the Church on Sunday, both morning and evening, so that, al-
though in full business, I think1 might say truly, that 1am not
absent three times in a year; my mind is tranquil and happy, my
practice greatly increased, and | find that I can accomplish more, in
the six working days of the week, without fatigue, than ever I did,
when I profaned the sabbath; on which day, I have long made it a
rule, not to open a professional book, nor read any thing except works
suitable to the Lord’s sabbath.
‘Let me add, in conclusion, that while I traticked with the devil
for business on Sunday, it constantly struck me as singular, and I
now remember it with pleasure, that in no instance that I can bring
to recollection, did I obtain the chance advantages, on which I so
wickedly speculated, in misusing and misspending the sabbath; and
on the other hand, I can say with perfect certainty, that in no single
instance have | ever been obliged to neglect a patient, or omet any
necessary duty, nor have | ever sustained the slightest inconvenience,
or loss, by my attendance on public worship.”
Secondly, that distinguished ornament of the English Bench,
Lord Chief Justice Sir Matthew Hale, thus speaks: “I have ever
found, by a strict and diligent observation, that a due observance of
the duty of Sunday has ever had joined to it, a blessing upon the rest
of my time; and the week that has so begun has been blessed and
prosperous to me: and, on the other side, when I have been negli-
gent of the duties of this day, the rest of the week has been unsuc-
cessful and unhappy to my own secular employments; so that I could
easily make an estimate of my successes the week following, by the
manner of passing this day. And I do not write this lightly, but
by long and sound experience.”
Now Gentlemen, do not mistake me, or suppose that I intend
to advance any thing so monstrously absurd, as that you should
neglect your necessary and indispensable professional duties to your
patients on the sabbath day,—far be any such idea from me. You
have the authority of Him ‘‘ who spoke as never man spoke,” that it
is lawful “‘to do good and to heal, on the sabbath day,” as he did
himself, for, to use his own words, ‘‘ the sabbath was made for man,
and not man for the sabbath.”
It is not against the legitimate use, but the misuse and desecration
of it, that | have ventured to warn you.
Gentlemen, it is one of the painful distinctions of the profession of
medicine generally, and in our department ofit especially, that we have
no time, on which we can calculate as our own; the hours of rest, or
198 Scientific Intelligence.
meals, or social enjoyment afford us no immunity from interruption ;
emergencies, and those often of the most urgent and important kind,
come upon us, when we least expect them, and for which therefore
no medical man should ever be unprepared or disqualified, seeing
how imperatively they may require a steady hand, an acute eye, and
a clear unclouded head, all which may be essential to the welfare,
perhaps to the /2fe of those intrusted to our charge.
Let us then take care, that the public shall have cause to repose
in us, that entire confidence which Philip of Macedon felt in the vigi-
lance of his general Parmenio, when, at the festive board, even with
the enemy arrayed before him, he exclaimed to his guests, ‘‘ Come,
let us drink, my friends, we may do it with safety, for Parmenio
never drinks.”
And if there have been those who boasted that they prescribed
as well when drunk as when sober, while we must suppose that they
knew themselves best, and formed a correct estimate of the mode in
which they acquitted themselves in these different conditions, it must
be obvious, says Percival, ‘‘ that whether we consider the matter
physically, or logically, their boast amounts precisely to this, and no
more, that they prescribed no better when they were sober, than
they did when they were drunk,” which is surely no great subject of
congratulation, nor likely, if true, to redound to their reputation, or
advance their success.
There is no branch of medicine which brings the practitioner into
so close and intimate a relation with the most delicate feelings and
circumstances of society, as ours, none which affords so frequent an
opportunity of receiving confidence and exercising discretion—many
occasions occur in which the alternative between domestic happiness,
or disunion and alienation of affection rests upon the proper silence
and discretion of the accoucheur.
In the course of practice many instances will be presented to you,
in which the good and virtuous have declined, for a moment, from their
happy and exalted state ; can there be imagined any act more unge-
nerous and base, than the idle or mischievous levity of a professional
man, who, by his silly babbling, lifts the veil from off the only stain on
an otherwise pure and spotless character? Or, it may be, that cir-
cumstances have arisen, which, although in no wise faulty or repre-
hensible in themselves, may, notwithstanding, if disclosed to others,
sow the seeds of suspicion and discord; while he who thus offends,
may rest assured, that he has forfeited, most probably for ever, the good
opinion of the parties concerned. Nothing is more acutely felt, or
so certainly resented, as a breach of professional confidence.
“Secrecy,” says the celebrated Dr. Gregory, “is particularly
requisite where women are concerned. Independently of the peculiar
tenderness with which a woman’s character should be treated, there
are certain circumstances of health, which, though in no respect con-
nected with her reputation, every woman, from the natural delicacy
of hea sex, is anxious to conceal ; andin some cases, the concealment
 _ Scientific Intelligence. 199
of these circumstances may be of consequence to her health, to her
interest, and to her happiness.”’
There is another kind of discretion and honourable dealing, the
want of which has been too often complained of, and it is to be feared,
with too much reason; I mean that due regard and kind consideration
for the character and feelings of those who may be associated with us
in attendance, or who may have preceded us in the treatment of the
case,
Under such circumstances I would fain impress upon you this
truth, that the best means ever any man adopted to advance his own
interest, effectually and permanently, is to be tender of the reputa-
tion, and considerate for the interest of others. There is no surer
proof of an honourable mind and conscious integrity of purpose, than
a readiness to construe liberally the acts of others; to make allowances
for defects, which, after all, may be only apparent, and to palliate
errors in others, as far as that can be done consistently with truth,
and a due regard to the welfare of those committed to our care. As,
then, we value our own characters we should be tender of that of
others. It is surely wretched architecture to attempt to build a repu-
tation on the crumbling remains of that of another. What can be
expected of such a structure, but that it will tumble about the ears of
the builder, and perhaps bury him in the ruins, Rest assured, that
however secretly, or cunningly, any one may manage, ‘ ambiguas
spargere voces,” the uncharitable insinuation will be disclosed ; for such
things, stone walls have ears, or, to use the language of Solomon, “ A
bird of the air shall carry the voice, and that which hath wings shall
tell the matter.”
Be assured, sooner or later, those who follow this unworthy course
will experience the truth of the Persian proverb, which Says, that
“‘ Curses are like chickens, and always come to roost at home:” and
are not insinuations and detractions some of the worst curses of socj-
ety? Be assured of this, that the ladder, by which, you can most cer-
tainly and safely mount to a high reputation is the good opinion of
your professional brethren,
Dr. Cheyne, whose memory is still cherished with reverence by
all who knew him, has bequeathed us a memoir of himself well cal-
culated to arrest our attention, not only for the valuable truths it con-
tains, and the important lessons it conveys, but for the unpretending
simplicity with which it is written, and the spirit of pure Christianity
with which it is adorned. In this memoir, speaking of the principles
of action he adopted, and the means which first led to his advance-
ment, he says: ‘‘I endeavoured to become acquainted with the cha-
racters of those who moved in the highest rank of the Profession, and
to discover the causes of their success, and I ascertained that, although
a man might acquire popularity by various means, he could not
reckon upon preserving public favour, unless he possessed the respect
of his own Profession ; that if he would effectually guard his own in-
terests, he must, in the first place, attend to the interests of others;
200 Scientific Intelligence.
ue that
hence, I was led carefully to study, and liberally to constr
to-
part of medical ethics which regulates the conduct of physicians
limit
wards each other;’’ and again, having attained to the utmost
of success, he observes: ‘‘ by a good arrangemen t, punctu ality, atten-
brethren, and
tion to the interests and feelings of my professional
by prudence, the means which had apparently led to my advance-
life is
ment, I now tried to avoid those reverses to which professional
us
ever subject ;” and many here know the result, that when he left
in the autumn of his days, when ‘his way of life had fallen into the
sear, the yellow leaf,” he took with him “ golden opinions from ail
sorts of people’—and possessed, in rich abundance, what the guilty
monarch wept to anticipate the want of—
‘¢ As honour, love, obedience, troops of friends.”
And here, I feel persuaded, that it has already occurred to many
of you, that it were only necessary to change the name, and all these
sentiments of admiration and regard would equally apply to another,
who just now, “ after life’s fitful fever, sleeps well,” and if I speak
of one who, after a long life of honour and utility, carries with him
to the grave, the affectionate respect and reverence of all who knew
him,—one so entwined with our best and tenderest feelings and
recollections, that the poet’s exclamation will not appear extra-
vagant :-—
<¢ Ah quanto minus,
Versari cum aliis, quam meminisse tui.”
When, I say, I speak of such an one, I feel that your hearts antici-
pate the application of my words, and murmur the name of CoLLEs.
December 4th, 1843.
 THE

DUBLIN JOURNAL
OF

MEDICAL SCIENCE,
MAY 1, 1844.

PART I.
ORIGINAL COMMUNICATIONS.

Art. VI.—Contributions to Midwifery, No. V.—On. the In-

fluence of Ergot of Rye on the Fetus in Utero. By
Tuomas Epwarp Beatty, M.D., M.R.I.A., Fellow of,
and Professor of Midwifery to the Royal College of Sur-
geons in Ireland; Physician to the City of Dublin Hospital;
Consulting Accoucheur to the South Eastern Lying-in Hos-
pital; Vice-President of the Dublin Obstetrical Society;
and Honorary Member of the Obstetrical Society of Edin-
burgh.
[Read before the Dublin Obstetrical Society.]

Ir is not my intention on the present occasion to occupy the

time of the Society by any very lengthened observations on the
use of the ergot of rye; but I wish to lay before the members
an account of some effects of this drug, which during an exten-
tensive employment of it I have observed, and of which I have
not been able to find any notice in the authors who have treated
of the medicine. Since the revival of the use of the secale cor-
VOL, XXV. NO, 74. 2D
202 Dr. Beatty on Ergot of hye.
nutum by Dr. Stearns of New York, up to the present time, a
variety of conflicting opinions have been entertained respecting
its value as an obstetrical agent. Some authors of the highest
repute have declared its utter inutility and incompetence to ex-
cite uterine action, no matter how eligible the circumstances, or
how carefully the dose has been apportioned. Another class,
of equally high character, is found to attribute the most rapid
and energetic effects to its employment; so much so, as to lead
to its denouncement as too violent an agent for obstetrical pur-
poses, appearing to be injurious to the child at all times; its
impression being destructively transmitted from the mother to
the infant; in some instances even involving both in the same
sacrifice. A third and numerous class of high authorities is re-
corded as maintaining an opinion equally at variance with the
truth as the two preceding, viz. that the ergot may be always
given with advantage, the safety of the mother or of the child
being never endangered. It would be tedious and misplaced to
quote the authorities above alluded to on the present occasion $
and moreover it is unnecessary to do so, inasmuch as they will
be found in Mr. Wright’s elaborate and valuable prize essay on
Ergot of Rye in the fifty-third volume of the Edinburgh Medi-
eal and Surgical Journal.
Viewing this discrepancy of opinion among authors of ac-
knowledged celebrity, it becomes an object, not only of theore-
tical, but of practical interest, to endeavour to search out the
cause or causes which have been instrumental in producing such
an effect.
When we find such names as Chaussier, La Chapelle, De-
sormeaux, Gardien, and Capuron in the list of those who main-
tain the inertness of the secale cornutum, if we had not practical
experience to the contrary, we would be inclined to bow to such
high authority, and agree with the latter, that “it is a drug
which it is requisite speedily to expunge from the list of the
Materia Medica.” But when we have witnessed the efficacy of
the medicine in numerous instances, and find its character sub-
 Dr. Beatty on Krgot of Rye. 203
stantiated by the united experience of its many successful em-
ployers, we are disposed to look for some reason for its failure
in the hands of the practitioners above mentioned. Two causes
of such a failure may be suggested : first, the administration of
the drug in inadequate doses; second, the inferior quality of
that which was employed, It is not improbable that the French
authors, whose names have been just mentioned, were disposed
to use the ergot with great caution, owing to the circumstance
of the drug being at that time considered in France and Switzer-
land as a highly noxious substance, and capable of producing
fatal effects in those to whom it was administered. This may
have led them to employ it in quantities too small to produce the
desired effect upon the uterine fibres. But it is more likely that
the second cause just alluded to may have led to the failure, for
it is owing to investigations conducted more recently that we
have become aware of the perishable nature of the medicine,
and the readiness with which its peculiar virtues are destroyed.
Ignorance of this fact may have led to the administration of the
ergot in an inert condition, owing to its having been deteriorated
by keeping. There is scarcely any medicine that spoils more
quickly, and requires more care in its preservation, than the
one under consideration; and even in the present day, with all
the knowledge of its properties which we possess, I have reason
to know that it is at times employed in a state in which it is ut-
terly devoid of its peculiar properties, and completely inert as
an obstetrical agent.
Some time ago I was in attendance on a lady at a short dis-
tance from this city, in whose case I wished to administer the
ergot. Having recently used the dose, which I habitually carry
about me, I sent a messenger to a very respectable apothecary
living in the adjoining suburb, to whom I wrote a note, request-
ing that ifhe had any good and fresh ergot he would send me
some, and if not that he would send on the messenger to my
own house for it. Ina short time the man returned with a pa-
per from the apothecary, on opening which I found a black,
204 Dr. Beatty on Ergot of Rye.
damp mass, more like wet turf-mould than any thing else. if |
had used this in ignorance of its being spoiled, of course dis-
appointment would have been the consequence, and my faith in
the power of the drug would have been shaken.
The second objection, viz. that the ergot is at all times de-
structive to the life of the child, has probably arisen from the
employment of the medicine at improper times. Thus recourse
has been frequently had to its aid in cases of difficult labour
arising from mechanical opposition to the exit of the child. In
such a case the destruction of the infant is almost sure to follow,
for the delay which necessarily occurs between the adminis-
tration of the dose and the expulsion of the head is almost cer-
tain to produce fatal results.
In a former communication* I have stated that I consider a
delay of two hours after the ergot has been taken, as sufficient
to cause the death of the child. I will revert to this subject in
a subsequent page, at present I will only observe, that persons
who employed the drug under circumstances like these must
have been led to form the opinion that it was highly dangerous
to the life of the infant.
The third class of authors above alluded to have formed far
too sweeping an opinion of the merits of this medicine, when
they state that it may be always given with advantage; the
safety of the mother or of the child being never endangered.
This is a kind ofpraise most likely to do mischief, and damage
the reputation of a valuable remedy, by inducing others to em-
ploy it under circumstances in which it is quite inadmissible.
From a very extensive use of the ergot I am quite prepared
to maintain that none of the three opinions is correct, but that
the truth lies between them. The medicine, when fresh, and
carefully preserved, is in fact one of great energy, and influences
not only the mother but also the infant. It requires to be used
with great discretion, for while it will in one case effect the de-

* Dublin Medical Journal, vol. xxi. p. 301.

 Dr. Beatty on Ergot of Rye. 205
livery of a living child, it will in another destroy the life of the
child before birth, or operate so injuriously upon it as to cause
its death shortly after it is born; or produce a peculiar effect on
its nervous system which I have observed, and will presently de-
scribe, but which I do not find described in any work that I
have perused.
The difference of effect upon the infant depends upon the
length of time that intervenes between the administration of the
dose to the mother and the conclusion of the labour. If this
takes place quickly no mischief is done to the child; if it be
alive when the medicine is taken, it will be born so; but if a
delay of even two hours should occur, the probability is the
child will be still-born. It is, I believe, generally imagined
(and I entertained the opinion myself until lately) that the death
of the child is owing to the kind of action excited in the uterus
by the ergot, differing from the natural labour pain in this, that
after the contraction of the uterus has been excited, no com-
plete relaxation of its fibres takes place; there is an occasional
increase in the strength of the effort, but it never relaxes so long
as the influence of the ergot continues. It is, as it were, one
continued pain, at times greater, but never entirely ceasing.
The effect of this continued contraction of the fibres of the
uterus upon the great blood-vessels which traverse its walls to
reach the surface of the placenta, must be to intercept the circu-
lation to a certain degree. Now although this cause contributes,
no doubt, in some cases to produce unfavourable effects upon
the child, f am disposed to think that it is not the only cause of
fatal mischief in all, but that in some there is a noxious influ-
ence exerted on the nervous system of the infant, producing re-
sults of different degrees of intensity, and that these effects vary
from the death of the infant, to certain spasmodic affections of
the muscular system after birth. A few cases from my note
book will serve to illustrate the position I have here taken up.
I will first read some in which the medicine was given with ad-
vantage to the mother and safety to the child.
 a
Go
ea

206 Dr. Beatty on Ergot of Rye.

~ Case I.—Mrs. C., fifth pregnancy. Her former labours bad

been natural and easy, occupying on the first occasion fifteen
hours, on the second, nine hours, on the third, six hours, and
on the fourth, five hours. On this occasion the pains were from
the beginning weak, and slow in returning, and after the head
had come down to rest on the perineum they became more
faint, and appeared insufficient to expel it. The soft parts were
well relaxed, and a little more energy in the uterine action was
all that seemed requisite to insure a speedy delivery. Nineteen
hours had elapsed since the labour commenced, and finding the
pains diminishing, rather than increasing in strength, I gave my
patient half a drachm of the ergot, and in ten minutes after she
had swallowed the dose, a strong pain came on, which com-
pleted the delivery of a live child.
Case If.—Mrs. T., of a pale, delicate habit, and lax fibre,
was thirteen hours in labour of her first child. The head was
easily passed through the brim and into the cavity of the pelvis,
although the pains had not been strong during any part of the
process, When the head distended the perineum, the pains
subsided in strength and frequency, and although no mechanical
obstacle to delivery existed in the soft parts, the labour was ar-
rested by a deficiency of energy in the expelling power. The
ergot was given in the same dose as in the former case, and a
living child was born in fifteen minutes after its administration.
Case I1L.—Hon. Mrs. A. This lady was confined two
years previously of her first child, at which time her labour was
only ten hours in duration, but she had very profuse heemorrhage
after the birth of the child. On this occasion labour began at
six o’clock, p. M., by discharge of liquor amnii, soon followed by
pains. I saw her at eight, ep. m., when the pains were trifling,
but recurred with regularity every quarter of an hour. They
increased until ten o’clock, at which time the os uteri was nearly
dilated and soft. Some haemorrhage now appeared, which con-
tinued (although at no time profuse) through the remainder of
labour. At eleven o’clock about one-third of the bead had
 Dr, Beatty on Ergot of Rye. 207
passed through the brim of the pelvis, but the strength of the
pains diminished so as to have no effect in its advancement.
The patient now complained of a constant pain in the back
without any remission, but with an occasional increase in seve-
rity. She soon began to experience great exhaustion and sink-
ing; complained of want of air, and cried out to have the doors
and windows of the room opened. The pulse continued natural
and steady. Some-cordials were administered, which had the
effect of restoring her. In this state she remained until one
o'clock, a. m., when finding no return oftrue uterine action, the
os uteri and external parts being perfectly relaxed, I gave half a
drachm of ergot; this was followed in the space of a quarter of
an hour by one good pain, I now repeated the dose, which
quickly produced energetic action of the uterus. ‘Three pains
expelled the child, alive, just twenty minutes after the first dose
had been given. ‘The placenta was found lying in the vagina,
from whence it was readily removed, without the loss of an
ounce of blood. The cord in this case was only fourteen inches
long.
Case [V.—This lady, Mrs. K., was pregnant of her fourth
child; all her previous labours had been natural and easy.. On
this occasion the pains were unusually few and feeble, and she
was thirty-four hours in slow labour before I was called to her.
The membranes had ruptured early, and continued to drain
away. I found her walking about her chamber without any
pain. On making an examination I perceived the os uteri di-
lated, and the head nearly resting on the perineum, The pains
were now suspended for five hours, at the end of which time [ —
gave her the usual dose of secale cornutum. In five minu
after she had taken the medicine the pains returned, at first
feebly, but gradually increasing in strength; the child was ex-
pelled alive in half an hour.
Case V.—Mrs, M. This lady was very near dying from
uterine hemorrhage after her first confinement, which took place
in the country. This caused her to come to town, and place
208 Dr. Beatty on Ergot of Rye.
herself under my care on the present occasion. Labour pains
set in at four o’clock, a. m., and continued with regularity until
seven o'clock, when they diminished a good deal in strength.
A slight draining of blood now appeared, which having rather
increased at eight o’clock, made me uneasy about the delivery
of the patient, who was of a very thin and feeble frame, and
weak constitution. I prepared the ergot in the usual way, by
infusing a drachm of the powder in four ounces of boiling wa-
ter, and adding some sugar. Of this I now gave her the half,
which soon restored the uterine contractions, and in half an
hour the head was born. I then gave the remaining portion of
the medicine before the shoulders were expelled. The uterus
contracted firmly, excluding the child alive, and leaving the pla-
centa in the vagina, from whence it was removed without any
further loss of blood.
Case VI.—Mrs. A.; fifth pregnancy. Her former labours
had been easy and natural, and sometimes very rapid. This
was the case at her last confinement, on which occasion the
child was born before I could reach her house. At the present
time the labour was very slow, and protracted. The soft parts
were well relaxed, and the head was quite moveable in the
pelvis. The only obstacle to delivery seemed to be an inert and
sluggish uterus. To rouse the dormant powers of this organ
the ergot was given in two doses, at an interval of twenty mi-
nutes between them. Labour pains were excited in a short
time after the last portion had been swallowed, and a living
girl was born in one hour from the administration of the first
dose.
Here we find that the duration of labour after the adminis-
tration of the medicine varied from a quarter of an hour to two
hours, and that in all the child was born without any unpleasant
effects.
I will now read a few cases in which a longer period than
two hours elapsed after the dose was given, and in which the
peculiar effects to which I wish to direct the attention of the
 Dr. Beatty on Ergot of Rye. 209

Society were observed. These effects are certain spasmodic

conditions of the muscles of the whole body, alternating with
relaxation or palsy, and accompanied by evidences of derange-
ment of the functions of the cerebro-spinal system. It will be
perceived that there is in these cases a difference in the intensity
of the affection, in some appearing slighter than in others, but
the kind of affection will be recognized in all. In an interesting
paper by Dr. Catlett* he notices the tendency of ergot to pro-
duce hydrocephalus in the early stage of infantile life, and
having detailed five cases in which the death of the infant from
this disease took place at different intervals after delivery, he
says: “It will be seen, that of the above there are none con-
nected with a first delivery, or any in which the child was sub-
jected to any lengthened or forcible impaction. Is there any
warrant from this fact to infer that the ergot had here exerted
any specific influence upon the foetal constitution, as alluded to
by Dr. F. H. Ramsbotham, independent of the extra-mechanical
pressure induced by its action? It becomes indeed a very inte-
resting question, if it be admitted that ergot has an agency in
the cerebral disturbance thus set up in the infant economy, to
determine in what manner it is effected: whether, as above
hinted, it be a purely mechanical effect, or occurring through
the medium of direct absorption into the fceetal system.”
It appears to me that the cases I am about to relate will go
a great way towards the solution of this question, by the evi-
dence they afford ofa direct poisonous effect produced on the
infant before delivery.
Case VII.—Mrs. N., was eighteen hours in labour of her
first child. The pains were weak and ineffective, and at the end
of sixteen hours they seemed to diminish in strength and fre-
quency. ‘The os uteri was well dilated, and the child’s head
nearly rested on the perineum, which was pliable and cool. A
dose of ergot was given, and was followed by a second in twenty

* Edin. Med. Surg. Jour., vol, lvii. p, 83,

VOL, Xxv. NO. 74, bh
210 Dr. Beatty on Ergot of Rye.

minutes, the first not having produced any uterine action. From
this period the pains became more active, but at no time were
they violent, and at the expiration of two hours from the admi-
nistration of the medicine the child was expelled to all appear-
ance dead. The surface of the whole body, as well as the face, |
was ofa deep blue colour, resembling the appearance presented
by a child in whom the foramen ovale is open. All the muscles
were ina state of rigid contraction; so much so, that the limbs
remained straight, and could be with difficulty bent. The fin-
gers were straight, with the exception of the last phalanges,
these were bent, and crooked downwards, being firmly fixed in
that position. No effort was made at inspiration. The cord
was now divided, and blood was allowed to flow from the cut
extremity, which it did slowly, A warm bath was provided,
and pulmonary insufflation was employed, and at the end of fully
half an hour my exertions to restore animation were successful.
The child breathed, but the rigidity of the muscles continued
for a long time after it showed signs of life, and when the tonic
spasm relaxed it was only for a short period, and was quickly
succeeded by general convulsions. This condition of alternate
convulsion and relaxation continued without intermission for
three days. During this time leeches were applied to the tem-
ples, and the head was extensively blistered. ‘The spine was
also blistered from the occiput to the middle of the back, and
the usual antispasmodic medicines were given by the mouth and
rectum. By degrees the intensity of the convulsion appeared to
subside, and the interval of relaxation became longer, the stra-
bismus, which had been very great, now disappeared, and the
child finally recovered.
Case VIII.—Mrs. P. This was a case of placenta presen-
tation, to which I was called by Mr. Murphy of Rathgar. The
haemorrhage had ceased when I saw the lady, but I found her
very much exhausted, complaining of noise in her ears, with a
small, thready pulse at 120, On examination I found the os
uteri dilated to the size of a half-crown piece, with an edge of
 Dr. Beatty on Ergot of Rye. 211
the placenta encroaching on its area towards the left side. There
was no pain at this time, although there had been some in the
course of the morning. The examination reproduced hemor-
rhage; I immediately plugged the vagina, and gave her halfa
drachm of ergot, which was repeated in a quarter of an hour.
Pains soon came on, weak at first, but regular; they increased
so much in an hour after the medicine had been given, that I
removed the plug, and found, as I expected, the os uteri more
dilated, and the membranes tense, and protruding at each pain.
I now ruptured the membranes, and from that moment all hee-
morrhage ceased. A warm cordial draught of wine and water
was administered to the patient. The pains increased in power,
and at the expiration of two hours and a half from the time the
ergot was given, a girl, apparently still-born, was delivered.
This child presented precisely the same appearances as those
described in the last case, but it required a perseverance of two
hours’ duration before it could be considered safe to relinquish
our attention toit. At length it was quite restored, the spas-
modic state of the muscles relaxed, and no convulsions fol-
lowed.
Case PX.—Lady N. This was the third time I was called
to attend this lady; her two former labours had been natural,
On this occasion, after labour had been well established for
four hours, the pains ceased entirely, and did not return until
alter waiting eight hours, during which time stimulating injec-
tions and frictions to the belly, &c. were employed. Finding
there was no sign of the return of uterine action, I gave a
drachm of the ergot in divided doses. The uterus was soon
thrown into action, and in three hours the child was born, blue
and stiff, and insensible. After great exertions respiration was
established, but the child had severe convulsions, which lasted
for forty-eight hours after its birth. These subsided, but left
the child in a state resembling paralysis, with occasionally a
convulsive motion of the muscles of the face and limbs, and
fixed strabismus. No treatment seemed to have any effect upon
 212 Dr. Beatty on Ergot of Rye.

- this condition. Twenty days after its birth the following report
was taken: “ This child has remained in a state of insensibility
up to the present time; the strabismus has lately disappeared,
but it seldom opens its eyes. The limbs are apparently power-
less. It makes no effort to suck, but it swallows breast-milk
with difficulty when put into its mouth, The difficulty is in-
creasing. The bowels act naturally.” In this state the child
lingered on until the twenty-fifth day, when it died.
Case X.—Mrs. M. This lady was in labour of her third
child. Her previous labours had been very slow. I saw her
after she had been ten hours ill on the present occasion. ‘The
waters bad been discharged, the os uteri was quite dilated, but
the head had not entered the pelvis. No pain having occurred
for an hour after my arrival, I gave her the ergot as usual. Its
operation was very tardy, it did however excite the uterus to
act, and in two hours anda half after its administration the
child was born livid, rigid, and dead. No resuscitation could
be effected in this child.
Case XI.—Mrs. K. This lady’s labour began at midnight,
by rupture of the membranes, without pain. It was her eighth
pregnancy. On my arrival I found the os uteri dilated to the
size of a shilling, and the head presenting. Matters remained
in this state for nine hours, when a sudden and copious heemor-
rhage took place, and flowed with great rapidity. I immediately
gave the ergot, and plugged the vagina. Pains did not come
on for near an hour, and then were weak, but continuous. ‘The
child was born in three hours after the medicine was given. It
was dead, livid, and rigid; the hands were firmly clenched.
No success attended our efforts at resuscitation.
Case XII.—Some time ago I was called in consultation
with Sir Philip Crampton to see a child, then three years old,
and labouring under a very remarkable spasmodic disease.
When the child was carried into the room by its mother it ap-
peared as if every muscular fibre in its body was in a state of
paralysis, The limbs all hung loose and powerless; the head
 Dr. Beatty on Ergot of Rye. 213
fell about by its own gravity, unsupported by the muscles of the
neck. The countenance was idiotic. While we looked at the
child, this state of utter flaccidity was slowly changed into one of
spasm of every muscle of the body. The limbs were contracted
into the most grotesque forms, the back was forcibly bent back-
wards, and the head was extended and flexed, and rotated, and
all these motions were performed slowly and in succession.
After this paroxysm of muscular action the whole child relapsed
into its former state of flaccidity and helplessness, and this scene
was repeated several times while it remained in the room. We
were told that this condition had continued since its birth. I
was so much struck by the resemblance this condition bore to
that in which I had seen the children above described, that I
inquired from the lady what was the nature of her labour when
this child was born, and I learned that it had been long and
tedious, and that she had got ergot of rye to quicken the pains,
The child was still-born, great difficulty was experienced in re-
suscitating it, and it had never been free from the alternate
spasm and palsy since its birth.

In the cases just recorded, the condition of the infants was

very unlike that of still-born children delivered under ordinary
circumstances, and when no ergot had been administered to the
mother. The distinguishing characteristics are, the general
lividity of the surface, the universal rigidity of the muscular
system, producing the stiffened limbs and clenched hands in
those infants in whom life was extinguished; and the remark-
able kind of alternating spasm and palsy which supervened in
those that were resuscitated. ‘The nearest approach to this
state in new-born children, and that which most resembles it is,
the condition in which children are born dead, with symptoms
of congestion of the cerebral vessels, in whom, it is true, we find
the countenance suffused and livid, but the peculiar affection of
the muscular and nervous systems is wanting, Children pre-
senting this appearance of congestion are usually born after
214 Dr. Beatty on Ergot of Rye.
difficult labour; but in the instances above detailed this was
not the case, some of them were tedious, but none of them
difficult.
That the foetus in utero is capable of being influenced by
the circulating fluids of the mother, is proved by the well-
known fact, of the communication of syphylis, small-pox, &c. to
the unborn child; and that substances taken into the stomach
of the mother can affect the infant, is shown by the experiments
of Majendie,* who found in the foetus of animals the odour of
camphor, and the colour of madder, with which he had fed the
mothers. It is still further established by the case reported by
M. D’Outrepont,f of a foetus poisoned by opium taken by the
mother.
Admitting this point to be established, it remains to be seen
whether the effects described above, and imputed to the direct
agency of the ergot of rye, bear any resemblance to the effects
produced by the introduction of this drug into the circulation.
Upon this point we have very satisfactory information in the
elaborate essay of Mr. Wright, already alluded to. Before
proceeding to recount the results of his experiments, he takes
notice of some of the epidemics of spasmodic ergotism, caused
by eating bread made of rye containing a large portion of ergot,
which visited different parts of the Continent during the last cen-
tury. This disease almost devastated Freybourg, and overran
many of the Cantons of Lusatia, Saxony, and Sweden. Accord-
ing to Videlius, the patients were attacked with spasms and con-
vulsions, accompanied with violent pains, which were said to
equal those of luxation, and to be similar in their type. In
some instances the patients became lethargic, and when reco-
vering from such state gave respectively signs of stupidity, in-
toxication, and extreme lassitude, after which the fit subsided
fora time. But there generally remained vertigo, tinnitus au-

* Velpeau de l’art des accoucemens, p. 196.

+ Revue Medicale, t. iv. p. 121.
 Dr. Beatty on Ergot ofRye. 215
rium, nebule oculorum, rigidity of the members, and excessive
feebleness.
In 1722 Silesia, in 1723 the environs of Berlin, and in 1736
Wirtemburg, in Bohemia, sustained the disastrous effects of
ergotism. ‘The disease commenced with a disagreeable sensa-
tion of tingling or itching in the feet; a violent cardialgia then
came on, and the disease ascended to the hands and the head.
The pains ina short time subsided, the head became heavy,
and vertigo prevailed, the eyes appearing to have a thick mist
before them. ‘The fingers and hands were so spasmodically
contracted that no force could straighten them, and the pain
was described as equalling that of luxation. Some of the pa-
tients became totally blind, and others had double vision. The
memory also failed, the conversation was wild and unintelligible,
and the movements staggering and awkward. Some became
maniacal, some melancholic, and others comatose. ‘The disease
was usually accompanied with opisthotonos. Of 500 patients,
300 infants perished, considering as such all under five years of
age
Burghard gives an account ofa convulsive epidemic which
raged in the Canton of Silesia. The patients were the subjects
of excessive spasms, which convulsed the extremities, and the
head, eyes, and lips in particular, attended with an aberration
of reason which no medicine could restore. Those who died
showed, previously to dissolution, a sort of paralysis, which de-
generated into apoplexy. Such as were fortunate enough to re-
cover laboured for some time under excessive debility, particu-
larly of the joints, stiffness, and even immobility of the limbs,
enfeebled intellect, &c.
This short abstract shows the convulsive character of the
disease induced by the use of ergot as a matter of food, and
points out the brain and spinal marrow as the organs principally
under its influence,
Let us now inquire into the effects of this drug when intro-
duced directly into the circulation ; and here I may remark that
216 Busbeatty on Ergot of Rye.

the foetus in utero, with respect to the introduction of noxious

matters into its system, is circumstanced similarly to animals on
whom we experiment by injecting fluids into their veins, for if
the poisonous material does reach the foetus, it’can only do so
by the route of the umbilical vein.
Exp. 1.—Mr. Wright injected a strong infusion of ergot
into the jugular vein of a dog, who cried and struggled vio-
lently on receiving it, the urine flowing in a full stream, the pu-
pil dilating immediately, the pulsations of the heart being too
rapid to be counted. In four minutes its action was much di-
minished in force and frequency, and general muscular flaccidity
prevailed, with slight quivering of the whole frame. In another
minute the heart beat with singular rapidity and force, during
which complete opisthotonos came on. After the lapse of ano-
ther minute and a half the dog cried in a plaintive tone, the
heart beat slowly and laboriously, the breathing was remarkably
slow and profound, and under these circumstances the animal
died, in exactly nine minutes from the period of injection.
Exp. 2.—Another dog was treated in a similar way, but
when only half the quantity was injected excessive spasmodic
action ensued, with dilatation of the pupil and discharge of
feces. In three quarters of a minute the convulsions had ceased,
and there were only to be observed the most perfect helplessness
and flaccidity of the limbs, with a quick and feeble pulse. This
state continued through the further space of halfa minute, when
very slight tremor of the muscles of the hind and fore legs suc-
ceeded, accompanied with a drawing down of the lower jaw and
perfect emprosthotonos, The motion of the heart was now very
slow and intermittent. The emprosthotonos, with an occasional
convulsive sigh, continued until four minutes and a half from the
commencement, when all signs of life were gone.
Several other experiments were made by Mr. Wright, with
different quantities of the infusion, and all produced results dit-
fering in intensity, but similar in kind.
The question now arises, does the blood of the mother be-
 Dr. Beatty on Hrgot of Rye. 217
came impregnated with the noxious properties of the ergot?
This point has been also settled by Mr. Wright, who has proved
that the oil of ergot (upon which the peculiar action of the drug
seems to depend) is present in the blood of animals who have
taken the medicine by the mouth. He detected the oil in the
blood of a dog to whom he had given the powdered ergot ; and
he gives an account of the method pursued, which it is not ne-
cessary to mention here, but he has established the fact by his
investigations, and we are thus enabled to comprehend how the
influence of the drug can be extended from the mother to the
unborn child.
It might appear strange at first sight, and difficult to under-
stand, how a medicine taken in the usual medicinal doses, and
with apparent impunity, by the mother, shall nevertheless act
injuriously on the feetus in utero. But the difficulty is, in a
great degree, removed, when we consider, first, that the system
of the mother is very generally acted on by the ergot, though
not to any injurious extent; and secondly, the great suscepti-
bility of infants to the action of narcotics. ‘That the maternal
system is more or less influenced by the ordinary doses of the
ergot, is shown by the remarkable depression in the pulse,
which so constantly follows the administration of the drug; the
rate of the pulse often falling twenty beats in the minute; and
in some instances dangerous comatose symptoms have ensued.
This, coupled with the fact above alluded to, that infants are
peculiarly liable to be dangerously affected by very minute
doses of narcotic medicines, enables us to comprehend how the
foetus may be injured bya poisonous matter circulating with the
blood of the mother.
It is plain that the longer the time that elapses after the me-
dicine has been taken into the stomach of the mother, the more
certainly will its noxious principles be absorbed and mixed with
her blood, the more certainly also will these principles be trans-
mitted to the foetus by the constantly arriving current of blood
VOL. XXV. NO. (4. oF
218 Dr. Beatty on Ergot of Rye.
through the umbilical vein, and the more likely will the foetus
be to suffer from their effects.
From these observations I think we are justified in coming
to the conclusion, that the administration of ergot of rye toa
woman in labour is attended with danger to the child, when-
ever a time sufficient for the absorption and transmission of its
noxious properties elapses before the child is born; and from
the cases above stated I am inclined to place two hours as the
limit of safety, and to consider a prolongation of labour beyond
that period as perilous to the infant.
It would appear that the degree of effect produced differs
with the time that elapses between the exhibition of the dose
and the birth of the child. In some we find spasm and lividity,
with a capability of being perfectly restored to life; in others
resuscitation was followed by convulsions terminating in idiotey,
with alternate spasm and palsy. In others the convulsions were
followed by death at a remote period; and in others the life of
the child was completely extinguished before birth.
Two practical deductions may be drawn from these obser-
vations,—first, that the ergot should never be given in any case
where there isa likelihood of the labour lasting more than two
hours after its administration, except when it may be employed
to secure the life of the mother, as in the cases of placenta pre-
sentation and accidental hemorrhage above quoted—(Cases
VIII. and XI.) ; and secondly, that if we find delivery is delayed
to two hours, we should resort to artificial assistance to save the
life of the child.
 Dr. ¥. Battersby on Scirrhus of the Pancreas. 219

Art. VII.—Two Cases of Scirrhus of the Pancreas, with

Observations on the Diagnosis of Affections of that Gland.
By Francis Barrerssy, A.B., M. B., T. C. D.; Fellow
of the Royal College of Surgeons in Ireland; one of the
Medical Attendants of the Dublin Institution for the Dis-
eases of Children, and of the Sick Poor Institution; and for-
merly Demonstrator of Anatomy in the School of Medicine,
Park-street.
[Read before the Surgical Society of Ireland, March 30, 1844.]
Tue complete disregard of the pancreas by the ancient fathers
of medicine is strongly contrasted with the rather exaggerated
importance attributed to it by the writers of the sixteenth cen-
tury, who evidently, as Dr. Abercrombie remarks, did not found
their opinions on any very accurate observations. Highmore
considered it the seat and source of apoplexy, palsy, and hys-
teria ; while Schenckius, Fernelius, and Riolanus extended
its
influence to almost all the diseases of the human frame.*
At the present time, of all the organs in the body there is,
perhaps, not one whose diseases are so little attended to, or
thought of, as those of the pancreas, and this arises, partly, from
the symptoms during life connected with its affections being so
obscure and ambiguous as to be generally overlooked or mis-
interpreted ; and, partly, because, as Lawrence remarks,+ “ mor-
bid changes in it of any kind are extremely rare.” It becomes
therefore a duty to record every instance of the latter tending to
throw light on its pathology, for the history of which Aber-
crombie says,t “facts are wanting ;” and it is with this view I
beg permission to exhibit to the Surgical Society the morbid
parts concerned in the following case, which, in some respects,
will be found not undeserving of attention.
On September 3, 1843, I was requested to visit Mrs. M5

* Edinburgh Med. and Surg. Journal, vol. xliy. p- 86; and

vol. xxi. p. 243.
t Medico-Chirurg. Transactions, vol. xvi.
t On Diseases of the Stomach and Abdominal Viscera.
220 +Dr. F. Battersby on Scirrhus of the Pancreas.
lady, aged between 55 and 60 years. She had been remarkable
for her embonpoint, and had always enjoyed good health until two
years previously, when she became subject to severe pains in the
back, which affected also the shoulders and arms, and were sup-
posed to be rheumatic. After the lapse of a year there was dis-
covered in the epigastric region a deep-seated pulsating tumour,
about the size and shape of an orange, having aregular diastolic
enlargement synchronous with the pulse, and a well-marked bruit
de soufflet. Her disease was in consequence considered to be
aneurism of the aorta, by (I have permission to state) Mr. John
Hamilton, Surgeon to the Richmond Hospital, who did not till
after a most careful examination arrive at this conclusion, war-
ranted by the foregoing facts, which I have given in his own
words. She also suffered from fluid eructations, and an obscure,
deep-seated pain.
In the course of a month or two this tumour subsided, and
the pulsation ceased. A new set of symptoms then arose: the
uneasiness extended over the abdomen, and the stools were
of
passed with pain and forcing, which after awhile became
of
such severity as to resemble, as she said herself, the pangs
labour.
I found her extremely emaciated. She looked like a skele-
con-
ton. Her complexion was of a dingy, leaden hue, and the
red very
junctiva of the eyes was slightly jaundiced. She suffe
the
much from constant pain and uneasiness in the lower part of
par-
abdomen, which was somewhat prominent and tympanitic,
ticularly in the region of the caecum.
There was a marked fullness of the epigastric region, in
which was to be felt a deep-seated, solid, and fixed induration,
having a flattened surface and a defined outline inferiorly, which
ran transversely between the cartilages of the ribs. It was with-
out pulsation, but a bruit de soufilet was audible on the appli-
cation of the stethoscope over it in the course of the aorta.
There was a continued unpleasant sensation in the epigastrium
and right hypochondrium, increased by pressure on the swelling,
 Dr. F. Battersby on Scirrhus of the Pancreas. 221

which seemed to be totally unconnected with the stomach or liver.

Constipation invariably aggravated her suffering, and the bowels
were seldom moved without the use of lavements (of which she
could not receive more than a pint at a time) and aperients;
and the passage of the stools was attended with violent straining
and intense distress, which drew from her screams, loud and
piercing. The stools generally consisted of watery, ropy mu-
cus, deficient in bile; when at all solid the faeces were not
thicker than a small sized finger. Her body, whether in bed
or out of it, was always in an incurvated posture, bent forwards.
She was in a constant state of anxiety and restlessness, never en-
joying sound repose for any length of time continuously. Her
appetite, hitherto good, was now nearly gone. She used nothing
but fluid nourishment in small quantities, since having had, a
week or two before, an attack of dysphagia, which had been re-
moved by the application of an opiate plaster over the pit of the
stomach, and she still continued to wear a portion of it, of the
size of a crown-piece, over the top of the sternum, believing
that it kept off any return of the complaint. Even fluids she
disliked taking, as their passage, she said, always made her
worse. Atno time had she been subject to vomiting, but there
were occasional eructations of a clear watery fluid, not exceed-
ing a table-spoonful at a time, which she described as being
bitter. Her mouth seemed always full of saliva; the tongue
was pale and clean; there was no thirst. Pulse 70, intermit-
ting, and variable in strength. The legs and thighs were highly
anasarcous.
She died on the 2nd October, little alteration having taken
place in the symptoms, except an increase of the dropsy, and
that, towards the conclusion, she did not suffer much unless
when the bowels were being moved. Opiates and mild laxa-
tives were the only remedies which procured relief. Mercury
was not given in any shape. The ptyalism and eructations per-
sisted throughout. When questioned about her complaint she
222 Dr. I’, Battersby on Scirrhus of the Pancreas.
used often to lay her hand over the epigastrium, and declare
that there was the source of all.
Thirty-six hours after death I examined the body, assisted
by Mr. Brady of Newtown Mountkennedy.
Emaciation extreme; anasarca of both upper and lower ex-
tremities; fluctuation in lower part of abdomen. The hard
prominence of the epigastrium was very distinct, all tympanitis
having disappeared.
The cavity of the abdomen contained about a quart of clear
straw-coloured serum. ‘The rectum in its entire length was
flaccid, and empty. The rest of the large intestine was very
much contracted, containing a thick, tenacious, pale mucus; the
mucous membrane was healthy, but vascular. The sigmoid
flexure of the colon, for the distance of three or four inches
the sub-
from the sacro-iliac symphysis, was particularly narrowed,
mucous tissue being thickened, dense, and of a pearly white
colour; the muscular tissue was also hypertrophied, and of a
bluish hue. This part of the colon was firmly bound down in
its position by a hardening of its mesentery, which presented a
great thickness where it divides to enclose the intestine, and it
had in that part a dense, firm, and knotted feel, with small no-
dules of hard, yellow, adipose material projecting under its
surface. The same degree of alteration was remarkable as far up
as the transverse colon inclusive, and the subperitoneal cellular
tissue of the left side, generally, was indurated and contracted;
even the spleen and kidney were thus affected, the latter was
smaller than the one of the right side, and firmer; its cortical
substance was atrophied, and its pelvis was very vascular.
The gastro-hepatic omentum was very dense, hard, and
much thickened, especially that part of it in front of the foramen
of Winslow, and the contained vessels and ducts were intimately
cemented together. ‘The same thickening and hardening had
invaded the cellular tissue surrounding the cardiac orifice of
the stomach, which forcibly resisted the introduction of even
the little finger. ‘The stomach was small, and its mucous mem-
 Dr. F. Battersby on Scirrhus of the Pancreas. 223
brane dark-coloured, but otherwise presented nothing remark-
able, except that it was connected with the left extremity of the
pancreas, which was universally hard and enlarged, and had
lost every trace of its natural structure. Near the centre of this
gland, and at its lower edge, existed a thin, translucent, horny
cyst, which was slightly prominent, about the size ofa walnut,
and lay directly over the aorta. Its base was surrounded by a
hard, cartilaginous, scirrhous formation, which in part projected
into it. The rest of the gland was composed of a less solid,
but unyielding, heavy substance, apparently made up of dense,
closely interwoven, membranous bands.
The pancreatic duct was pervious for about an inch, only,
from the duodenum. The ductus choledochus and hepatic
ducts were not interrupted in any part of their course. ‘The in-
ferior transverse portion of the duodenum was closely adherent
to the morbid pancreas, and, by being, as it were, drawn to-
wards it, was so contracted as scarcely to admit the index finger.
The mesenteric vessels and nerves were also involved in the
scirrhous mass, which was so closely united to the subjacent
parts, that it was necessary to remove them along with it from
the surface of the spine underneath. ‘The aorta was diseased in
its entire course through the abdomen, ‘There were atheroma-
tous and ossific deposits under the lining membrane, which in
some points was eroded.
The liver was rather small, of a dark grey colour, and
dense, owing apparently to a thickening of its cellular tissue.
The gall-bladder contained a small quantity of light yellow-
coloured bile, and its coats were much thickened.
The thoracic viscera were healthy ; there were old pleuritic
adhesions. The heart was small and firm.
In this case the pancreas, which was much more degenerated
than any other part, was evidently the point of origin of a
scirrhous disorder, which by secondarily affecting the other
parts, thus gave rise successively to the symptoms of contraction
of the colon and of the cardiac orifice of the stomach. Neither
of these canals was so much reduced in diameter as to present
224 Dr. F. Battersby on Scirrhus of the Pancreas.
to the passage of the food, or feeces, any great obstacle, which
was increased in both instances by spasm, no doubt the cause of
the temporary dysphagia, as during its continuance (it lasted for
a week) the patient was nourished by enemata of broth, as she
could not swallow even liquids. She was then under the care of
my friend, Doctor M‘Clelland. When I saw this lady the na-
ture of the disease and the parts affected were pretty evident,
although, independent of the induration in the epigastrium and
emaciation, the usual symptoms of scirrhus of the pancreas,
such as vomiting, jaundice, and epigastric pain, were either ab-
sent, or were so very insignificant, as to be obscured by the more
urgent symptoms arising from contraction of the large intes-
tines. Complications of this kind it is, in the diseases of the
pancreas, which render their diagnosis a matter of so great
difficulty,—a difficulty elegantly and forcibly expressed by a
French author in reference to the symptoms of inflammation of
the gland. He says: “Ses cris de douleur s’il en a de propres,
sont étouffés par ceux bien plus energiques de l’estomac, du
foie, des intestins ou du péritoine toujours souffrans en méme
temps et bien plus vivement que lui.”* The ambiguous nature
of any pain peculiar to affections of the pancreas is commonly
admitted, and many think, with the author just quoted, that the
only certain guide in such cases is the detection of the enlarged
or indurated gland, which, in general, is possible only in an ad-
vanced stage, after great emaciation has ensued. This sign,
however, in the case I have related, so far from affording assis-
tance towards forming a diagnosis, was itself the very source of
error.
The enlarged+ pancreas has been observed to be the seat of
Se laa ee cadeae
* Nouveaux Elémens de Pathologie Médico-Chir. Par Roche et Sanson, t. i.
p- 613.
+ “Cum ad hoc stadium pervenerit morbus, plerumque tactus ope percipi
solet tumor, magis minusve mobilis, durus, ad magnitudinem pugni accedens vel
etiam eam excedens, supra umbilicum positus, mox ad epigastrium, mox ad alteru-
trum hypochondrium tendens si tangas sepe dolorificus interdum pulsans.”’—
J. Frank, de Morbis Pancreatis, &c., p. 368.
 Dr. F. Battersby on Scirrhus of the Pancreas. 225

pulsations, but, being without any of the other characteristics of

aneurism, except, perhaps, a bruit de soufflet, it is readily distin-
guishable from the latter. Dr. Fletcher lately brought before the
Birmingham Pathological Society a specimen of scirrhus of the
pancreas, the head of which was very much enlarged, and enclosed
the duodenum, so as to form astricture of that intestine, just be-
yond the pylorus. The parts had been removed from the body of
a woman, aged 52, who was extremely emaciated, and whose coun-
tenance indicated organic disease. She complained of great thirst;
the stomach rejected all aliment, and the bowels were costive.
Her sufferings, at times, were extreme, and. the pain was seated in
the region of the stomach, towards its pyloric extremity, and
was increased by pressure. The whole surface of the abdomen
was tender ; there was hardness, and increased space of dulness
in the epigastrium, and, on applying the hand, a very distinct
pulsation was perceptible, simulating an aneurism, each impulse
being attended by a distinct bruit de soufllet, while she lay in
the recumbent posture, but which ceased on her being placed in
the semi-erect, in which position the pulsation in the epigastrium
very much diminished. There was no bruit de soufflet audible
on applying the stethoscope over any part of the spine.* A case
related by Sandwith} is peculiar as regards the situation of the
pulsation. An unmarried woman, aged 67, complained of conti-
nued pain, in the epigastric region, which extended to the right
hypochondrium ; deep pressure increased the pain, and there was
a remarkable pulsation below the cartilages of the false ribs on
the left side. She was a good deal emaciated, and without fever.
Bowels costive; appetite bad; no sickness or vomiting. ‘The pain
sometimes was most intense, and on these occasions she exhibited
signs of distraction. Her body was agitated in the most violent
manner; she tore the bedclothes, and said she could tear the
flesh from her bones, The pancreas was found to have the

* Provincial Medical Journal, Jan. 20, 1844.

+ Edinburgh Medical and Surgical Journal, vol. xvi. p. 381.
VOL, XXV. NOv 74. 26
226 Dr. F. Battersby on Scirrhus of the Pancreas.
usual marks of scirrhus, and the splenic artery was imbedded
in scirrhous matter.
Andral mistook a case for aneurism of the aorta. It is
headed “ Cancer du Pancreas simulant un Anevrisme de |’Aorte
abdominale.” A woman, aged 54 years, who had been three
months ailing, was admitted into La Pitié. There were into-
lerable pains in the dorsal region, radiating to the left side of
the thorax; they continued sometimes for hours, sometimes en-
tire days, affected the whole of the abdomen, and were lost in
the region of the spleen. She compared these pains to the blows
ofa hammer, sometimes to the darting ofa dagger through the
back ; they were worse at night. Her tongue was coated, yellow-
ish ; there was complete loss of appetite; her face was pale and
expressive of suffering. Nothing could be discovered on examina-
tion of the hypochondria by the hand. An attack of diarrhoea, with
low fever, carried her off. The liver was sound; between this organ
and the diaphragm was a cancerous tumour the size of an egg.
The intestinal mass having been separated, an enormous tumour
was immediately observed in the position of the pancreas, formed
of encephaloid, scirrhous, and tuberculous matter, It was the
pancreas which had undergone this transformation, only a few
fibres of it could be distinguished in the middle of this mass,
which compressed the abdominal aorta, and the nervous plexus
spread over this vessel, which accounts for the acute pains the
patient suffered during life.
Andral asks: “ Was it possible in the present state of our
knowledge to determine the seat of this disease, and to arrest its
progress? We do not think so,” he answers, ‘* our experience
only served to lead us into error.” “ En nous rappelant des
faits analogues, en considérant cette douleur perforante, ces
coups de marteau regus dans le dos, nous etions trés portés a
croire a l’existence d’une anevrisme de l’aorte abdominale.’*
These cases show how closely scirrhus of the pancreas may

* Lancette Frangaise, t.v. No, 16.

 Dr. F. Battersby on Scirrhus of the Pancreas. 227
simulate the symptoms of abdominal aneurism.* In that of An-
dral, the severity, and nature of the pain so similar to that ob-
served in certain cases of aneurism of the aorta, sufficed to lead
astray one of the most learned and experienced physicians of the
age. In mine, the error was inevitable, where all the physical
signs of aneurism seemed to be present. ‘There was not only a
rounded, yielding tumour in the course of the aorta, but with
pulsation and bruit de soufilet, and an apparent systole and
diastole, due, no doubt, to the early development of the cyst,
which, probably, in the progress of the disease, had its fluid con-
tents lessened by the encroachment of the scirrhus, while, the
close union of the latter to the spine having removed the im-
pulse of the aorta, towards the conclusion no other symptom
remained but the bruit de soufflet, which was not likely to mis-
lead.
Excessive pain is not a constant symptom of scirrhous pan-
creas, it is generally of an obtuse kind, deep-seated, often re-
sembling lumbago ; sometimes there is none whatever, and, on
account of the great emaciation, the patient has been supposed to
be phthisical, “J’ai vu,” says Laénnec, “ plusieurs fois, avec
mes confréres, MM. Recamier et Richerand, une jeune dame qui
semblait phthisique, et qui fit avancée dans la maladie.—J’af-
firmai constamment que les poumons me paraissaient sains, et
effectivement ils furent trouvés tels a ’ouverture de son corps—
la maladie etait due 4 un squirrhe du pancreas accompagné
d’un simple catarrh.”t A mistake of this kind is not to be ex-
pected at the present time, now that we have all profited by Laén-
nec’s discoveries; but the fact is interesting, as bearing on the
point in question, and as it shows how easily, without the know-
ledge derived from auscultation, names high in the Profession
were formerly liable to be led astray.
Had jaundice or obstinate vomiting existed in these cases

* For another disease simulating, by its pain, that of aneurism of the aorta,
see my paper ‘‘on Exostosis of the Spine,” in the 24th volume of this Journal.
¢ Traité d’Auscultation, t. i. p. 693.
228 Dr. F. Battersby on Scirrhus of the Pancreas.
the nature of the disorder would have been less obscure. These
symptoms are frequent attendants on scirrhus, as well as other
affections of the pancreas, and arise, the first, from obstruction
or obliteration of the common or biliary ducts, by the pressure
of the morbid growth, then seated in the head of the gland,
which, in the same way, is often found to narrow so much the
pylorus, or duodenum, that these have been found scarcely large
enough to admit a common sized catheter, as in the two cases
related by Sewall.* It is, however, remarkable, that vomiting
is not always consequent upon great narrowing of the parts.
Michaelis saw a case in which there had been no vomiting,
although the duodenum and pylorus were compressed to such a
degree as scarcely to admit the introduction of a goose-quill ;
and Dr. Greene has given a case where there was no vomiting
until a fortnight before death, although “ there was great con-
traction of the pylorus, which was hard, thick, and firm. The
ascending, and transverse colon, and head of the pancreas were
bound down into a cancerous mass, with which the duodenum,
also, was connected. The cystic and hepatic ducts were both
obstructed by the cancerous growth, and were much dilated
above the strictured part. The patient was intensely jaun-
diced.”+ When the stomach rejects its contents, soon after they
have been received, the vomiting may be supposed to be due to
its irritation, by the hard or enlarged pancreas; the food re-
mains much longer if the pylorus be compressed, and when the
obstruction is beyond the entrance of the ductus communis into
the duodenum, it may be suspected when the food remains two
or three hours and the rejected matters are more or less tinged
with bile.
Enormous dilatation of the stomach, and of the gall-bladder
and ducts, are additional effects of this compression, whence
have arisen some singular mistakes. A man presented himself
rear TY

* Medical and Physical Journal, vol. xxxi.

+ Dublin Medical Journal, vol. xxv. p. 172.
 Dr. F. Battersby on Scirrhus of the Pancreas. 229

to M. A. Petit with a tumour, in the epigastrium, having the

form, the volume, and all the exterior characters of a hernia; it
had come on after violent efforts. It was soft, compressible,
easily reducible, and was attended by hiccup and vomiting.
Petit thought he recognized a strangulated hernia of the stomach
or colon. In the presence of all his colleagues he operated, and
found the stomach in “ the centre of the tumour unenclosed in a
hernial sac.” The engorged pancreas had pushed it forward,
and kept it pressed against the abdominal walls; it underwent
thus a sort of strangulation, which occasioned all the deceptive
appearances of a hernia. It was closely adherent to the pan-
creas,*
The gall-bladder has, also, been mistaken for ventral hernia,
as in an instance given in the Reports of the Pathological So-
ciety. A female, 86 years of age, had, four months before death,
the symptoms of hepatic disease, and a tumour appearedalittle
above the umbilicus: it was soft and compressible, could be
made to alter its position, and received a slight impulse from
coughing. Mr. R. W. Smith exhibited the morbid parts. ‘The
liver was of a dark green colour, with a number of white, hard
tubercles on its surface. Tumours, of a similar character, existed
in the pancreas towards its right extremity, and the substance of
the gland was remarkably indurated. The termination of the
pancreatic and common biliary ducts was compressed almost to
obliteration ; the pancreatic duct, throughout the substance of
the gland, was dilated so as to admit of the introduction of the
forefinger. The ductus choledochus, and hepatic ducts in the
substance of the liver, were also greatly enlarged: the latter
formed cavities capable in some places of admitting the passage
of two fingers. The gallbladder, distended to a very great de-
gree, passed down, below the umbilicus, towards the right iliac
fossa. A tumour, of scirrhous hardness, and about the size ofa
pullet’s egg, lay behind the pancreas, but not connected with its

* Discours sur les maladies observées a |’Hotel Dieu a Lyons.

230 Dr. F. Battersby on Scirrhus of the Pancreas.
glandular structure, having the hepatic artery passing through
its centre. The skin and internal organs were deeply jaun-
diced.* M. Mondiére,t in stating that the ductus choledochus
is sometimes enormously dilated, refers to one instance, only, in
which, he says, it had attained a diameter of two inches. He
seems not to have been aware of the very extraordinary example
of this, given by the late Dr. Todd, which is unnoticed even in
the comprehensive and recent workt of Joseph Frank, on Dis-
eases of the Pancreas and Liver.
Dr. Todd was requested to examine a girl aged 14 years.
Her skin was orange coloured, and she was greatly emaciated;
her lower extremities were anasarcous, She seemed to suffer
much pain, frequently screamed aloud, yet was almost insensible
to external objects. There was a tumour observable in the ab-
domen, which on examination was found distended with fluid,
and the epigastric and right hypochondriac regions were par-
ticularly so. A distinct tense swelling occupied those regions,
and could be traced extending below the umbilicus. At one
point, somewhat more prominent than the rest, a little below the
ensiform cartilage, and to the right of the linea alba, a fluctua-
tion was very evident. This point was sensible. Under the
impression that there was an abscess of the liver, an opening
was made, and two quarts of viscid, green bile got exit. After
death the liver was found healthy, and the hepatic and common
ducts were enormously distended, containing a quart of bile.
They extended from the porta of the liver to the os sacrum,
lying behind the duodenum, pancreas, and root of the mesen-
tery, and stretching in a transverse direction, so as to cover the
anterior surface of the right kidney and a greater part of the
left. The smaller hepatic ducts were so much enlarged as to

* Dublin Journal of Medical Science, vol. xvil. p. 382.

+ Archives Genérales de Medecine, t. xii.
$ Praxeos Medica Universa Pracepta. Monographie de morbis systematis
hepatici et Pancreatis. Auctore Josepho Frank. Leipsia, 1843.
 Dr. F. Battersby on Scirrhus of the Pancreas. 231
admit one of the fingers without difficulty. A valvular convo-
lution in the cystic duct prevented the dilatation of the gall-
bladder. The extremity of the common duct in the duodenum
could not be discovered. The pancreas was scirrhous, and that
portion of the gland, with which the ductus choledochus is con-
nected, together with the surrounding cellular substance, was
converted into a hard, solid mass, closely adhering to the duo-
denum, and the lower part of the enlarged biliary duct which
seemed completely obliterated.*
Cruveilhier gives an instance of scirrhous degeneration of
the head of the pancreas, compressing the termination of the
ductus communis, which, as well as the gallbladder, was
very much enlarged, and the anterior surface of the pancreas
was raised by a watery tumour, of considerable size, containing
a transparent serous fluid. It formed an elongated pouch lying
transversely, and was recognized as the dilated pancreatic duct,
from the circumstance of its inner surface being marked by
transverse wrinkles and the small openings of the branches of
the duct. The absence of these indications was sufficient to
remove any supposition of the cyst, in the case I have given,
being one of this description, even if its connexion with the
scirrhus, which was obvious, could have left room for doubt.
To compression of the vena porta and cava is likewise to be
ascribed the common occurrence of ascites, and anasarca, in or-
ganic affections and inflammatory enlargements of the pancreas.
In the case of the latter, given by Dr. Crampton,t in which
there was “a circumscribed hard enlargement in the epigas-
trium, nearly circular, with a defined margin, and very tender
on pressure, the abdomen being very much distended, with
evident fluctuation, and the legs cedematous,” the symptoms
supervened in four days from the commencement of the attack.

* Dublin Hospital Reports, vol. i. p. 325.

+ Anatomie Pathologique, t. i. p. 286.
¢ Transactions of Association of Physicians in Ireland, vol. ii, p. 137.
932 Dr. F. Battersby on Scirrhus of the Pancreas.
the
Dr. Crampton recognized the case as one of inflammation of
pancreas, and, in reference to the dropsy, says, that “ inflam-
mation of the serous membranes was probably an attendant.”
This is controverted by M. Mondiére, who remarks, that “ acute
rarely, if
pain would, then, have existed, that partial peritonitis
would
ever, produces ascites, and that, having been present, it
|
not have disappeared so readily as it did.” This opinion,
g
may add, derives much support from the fact of the legs havin
been cedematous, and from the subsidence of the dropsical
pan-
symptoms part passu with that of the enlargement of the
of
creas, and is supported by a case, mentioned by Portal,*
aneurism of the aorta caused by the pressure of an hypertrophied
pancreas, and furthermore, by the analogous occurrence of
dropsy in the advanced stage of mesenteric disease.
I have already alluded to the emaciation attendant on scir-
rhus of the pancreas, in reference to which Abercrombie says fi
“‘ There is much reason to believe that diseases of the pancreas
have a most important influence upon the functions of digestion
and assimilation, and that this is one origin of the remarkable
affection that has been called anemia.” Pemberton remarks,
that « the body (in scirrhus of the pancreas) is often reduced to
the utmost state of emaciation,§ and the integuments of the ab-
domen appear to rest upon the spine ; this appearance, there-
fore, of the abdomen, when it occurs, might distinguish diseased
pancreas from scirrhous liver, or enlarged spleen; in which
cases the patient before death has, almost always, a considerable
enlargement of the belly. In the same way, also, this will dis-
tinguish it from affections of the mesenteric glands, for here too,
before death, the abdomen becomes enlarged. Diseases of the
kidneys produce little emaciation.”
BM ee gi ee ee eee
* Traité d’Apoplexie, p. 390.
+ Edinburgh Medical and Surgical Journal, vol. xxi.
t On the Abdominal Viscera, p. 66.
§ « C’est aux individus atteints d’affections organiques du pancreas qu’on
peut appliquer a bon droit cette expression figurée, la peau est collée sur les 08.
Dict. des Dict. de Médécine.
 Dr. F, Battersby on Scirrhus of the Pancreas. 233
Having now referred to most of the symptoms* usually as-
cribed to diseases of the pancreas, I must beg to trespass a
little farther upon the attention of the Society, while offering a
few remarks upon one I observed in the case I have brought for-
ward, and I am the more desirous of doing so, because, though
it has been noticed frequently by our continental brethren, this
symptom has not been even mentioned (so far as I am aware)
by any writer in our language. Iallude to the ptyalism.
According to M. Mondiére:+ ‘the physician who suspects
an affection of the pancreas, should above all things pay at-
tention to the state of the salivary glands and their secretion.
Foureroy had already observed, that in ¢ obstructions’ of the
pancreas the salivary glands separated more saliva than natural.
Sometimes, so far from the secretion of saliva being augmented,
it is, on the contrary, diminished.” All this is referred, by M.
Maria Gelcen, to the effect of sympathy, the absence or pre-
sence of ptyalism depending on the nature of the affection of
the pancreas. ‘There exists,” he says,t “a great sympathy
between the salivary glands and the pancreas, on account,
doubtless, of the similitude of their structure and functions, and
the knowledge of this sympathy, he adds, can explain to us why
there ensues a considerable ptyalism in consequence of lesions
of the pancreas, and why the salivary secretion is considerably
diminished in its engorgements or obstructions.” Certain in-
stances of metastasis of inflammation are attributed to this
sympathy; thus Andral found the pancreas injected in an in-
dividual who had a very much enlarged parotid; and Mondiére

* In the case of scirrhous pancreas by Abernethy (Lancet, vol. xvii. p. 66), the
patient ‘‘ was constantly stooping forwards; towards the latter part of his life he
lay in bed propped up with pillows :” just as occurred in the case I witnessed.
This position is generally assumed, as it relieves the epigastric pain, and was re-
markable in both of Mr. Sewal’s cases. In the first of Dr. Crampton’s cases, that
of chronic enlargement, it is worth remembering, that, on the contrary, the patient
could not stoop, from the pain of the tumour in the epigastrium.
* Archives Générales de Medicine, t. xii. p, 153.
+ Journal Complémentaire, t, xi. p. 10.
VOL, XXV. NO. 74, 2H
234 Dr. F. Battersby on Scirrhus of the Pancreas.
cites the case of a person with a great enlargement of one
parotid, which, having rapidly disappeared, was replaced by an
affection of the pancreas; inflammation of the testis succeeded
to this, and finally a blister settled the inflammation in the
parotid which suppurated.
Vascular congestion of the pancreas, as of the liver, may
be indicated by its tumefaction and diminished secretion,
or by a copious flow of the latter. Both of these occurrences
took place in the case recorded by Dr. Percival,* the tumour
formed by the pancreas, in the epigastrium, having been re-
moved by a spontaneous diarrhoea.
The high authority of Dr. Copland lends weight to the
opinion which attributes to augmented pancreatic secretion, a
certain form of diarrhoea (the D. pituitosa of Sauvages) and that in
connexion with the salivary glands. He says: “in some forms
of this, occurring during difficult dentition, or after the use of
mercurials, or upon the suppression of ptyalism, the stools have
consisted ofa thin, ropy mucus, of a translucent hue, and have
seemed to be augmented pancreatic secretion.” This form of
diarrhoea, when mercurial, is styled by Dietrich, “ ptyalismus
pancreaticus mercurialis,” because the mineral affects the ab-
dominal rather than the buccal salivary glands.§ Pereira, re-
garding it, says: “ there is fullness of the left hypochondrium;
burning pain and tenderness of the region of the pancreas ; and
the evacuations are frothy, whitish, tough, and often greenish,
at least in the commencement, from intermixed bile.” “ ‘These

* Trans. King and Queen’s College of Physicians in Ireland, vol. ii. p. 129.
} Dictionary of Practical Medicine, vol.i. p. 524.
+ Ephem. A. C. N. t. vill. obs. vii. p. 25.
§ Mr. Colles has omitted to notice this affection, but has described the more
common dysenteric symptoms produced by the mercury, ‘“ taking effect on the
alimentary canal instead of the salivary system.” ‘‘ From the third to the seventh
day of the administration of mercury, the patient is liable to attacks of griping,
frequent desire to go to stool, and tenesmus ; and these efforts are only attended
with slight evacuations, chiefly of mucus tinged with blood.” —Colles on Venereal,
p. 44.
 Dr. I. Battersby on Scirrhus of the Pancreas. 235
symptoms” he continues “ may fairly be referred to an affection
of the pancreas analogous to that of the salivary glands.”*
In the Dict. des Sci. Méd. it is said, that “when inflam-
mation of the pancreas is sympathetic of that of the salivary
glands, there is observed occasionally a sort of ‘balancement’
between the secretion of the pancreas and that of these latter;
thus, when the salivation is very abundant, the local symptoms of
the inflammation of pancreas diminish, and constipation ensues;
when, on the contrary, the salivation as well as the irritation of
the salivary glands diminish, an abundant diarrhoea and symp-
toms of an affection of the pancreas follow.” A case given by
Schmackpfeffert illustrates this. A girl, 29 years of age, con-
tracted syphilis in becoming pregnant. After delivery she was
placed on corrosive sublimate; having used it for some time
the symptoms disappeared, but she was salivated to the amount
of four pints per diem. This secretion having diminished, a
diarrhoea set in, which augmented in proportion to the diminu-
tion of the former. She became feverish; had great thirst; loss
of appetite; nausea; with distended belly. She complained
especially of anxiety in epigastric region, with heat, and ofdeep,
obtuse pain, fixed in that position and extending towards the
right hypochondrium. These symptoms were augmented when
the stomach was full. After an improvement of five days’ dura-
tion she became worse, and had bilious vomiting. She felt
continually above the umbilicus a deep pain, which hindered
her lying on the back or left side, and was augmented by full
inspiration. Diarrhoea returned to such a degree that she had
thirty liquid stools in the twenty-four hours, and the stools,
which had been yellow or watery, resembled saliva. Then
supervened swelling of the parotids, which were hot and painful,
and the stools became suppressed. She died with symptoms of
an affection of the head and chest. The pancreas was found
red and tumified, particularly at its right extremity; it appeared
* Materia Medica and Therapeutics. 2nd Ed. p. 708.
+ Art, Pancreas.
¢ Observationes de quibusdam pancreatis morbis. Halle. 1817.
236 Dr. F. Battersby on Scirrhus of the Pancreas.
also abnormally consistent, and blood issued in many points
from it when incised. Its excreting canal was much dilated.
The parotids were inflamed, and there were adhesions ofthe left
lung, with some effusion.
An analogous case is given by Professor Harless.* A student
submitted himself to mercurial treatment for the removal of
some symptoms which he imputed to an old syphilis. For months
he took regularly half a scruple of calomel daily, when, to re-
move pediculi pubis, he used frictions of mercurial ointment.
After the third friction his mouth became sore, and a violent
salivation was established, and the stools, before natural,
became suppressed. Professor Harless then saw him and found
no other symptom of disease but the salivation, with the excep-
tion of tension of the epigastrium. By the use of quinine
and opium the salivation diminished; at the same time the
tension of the epigastrium increased, the patient complained of
a sensation of disagreeable heat in this part, and, after having
examined it with care, the Professor soon discovered a slight
tumefaction. The constipation persisted, and repeated lave-
ments succeeded in removing some hardened feces only. ‘The
salivation, however, which had been much diminished, re-
appeared with more violence, and immediately the epigastric
symptoms were relieved, the salivary glands becoming simulta-
neously tumefied, hard, and painful. The salivation was again
abated without the pancreas appearing to suffer, and finally, on
the tenth day this and the epigastric pain returned simultaneously
and remained till the fourteenth day, when the patient fell into
a copious sweat, which continued three days and removed all
the symptoms. Mondiére says: ‘comparing this case with
Schmackpfeffer’s it is worth remarking the suppression of the
feecal matters as soon as the salivation was established, the re-
ciprocal influence of the pancreas on the salivary glands, and of
these upon the former; finally, the prompt disappearance of every
ee

+ Uber die Krankheiten des Pancreas, u. s. w. in Abhandlungen der phy-

sicalisch Med. Societat. zu Erlangen,
 Dr. F. Battersby on Scirrhus of the Pancreas. 237
symptom of disease of these secreting organs by the establish-
ment ofa copious sweat.” Dr. Crampton’s case, already men-
tioned, confirms this view ofa reciprocal influence existing be-
tween the pancreas and salivary glands, as the inflammation of
the former seemed to be due to the patient, with his mouth sore
from mercury, having exposed himself to cold after a warm bath.
We have already seen that diarrhoea, alternating with sali-
vation, is a consequence of inflammatory derangements of the
pancreas; in scirrhus of the gland, on the contrary, con-
tinued constipation* is almost invariably present, and, accord-
ing to the authority already quoted, is attended by salivation,
‘“‘ which (as it is stated) coming on at a more or less advanced
stage of the disease, is a symptom almost constant.”+
This “ balancement” of the secretion of the buccal and ab-
dominal salivary glands is further illustrated by what occurs
during pregnancy, in which salivation accompanied by consti-
pation is very frequent. In suppression of the lochia§ and in
hysteria,|| salivation has been observed, but according to Dr.
Dewees, “the sympathy between the salivary glands and the
impregnated uterus is, perhaps, as remarkable as any that takes
place,” and Mondiéreseems to consider pregnancy as an occasional
predisposing cause of inflammation of the pancreas. If the in-
creased action in, and determination of the fluids to, the salivary
* Alvi obstructio pertinacissima evadit. J. Frank. Op. Cit. p, 870.
t Arch. Génér, t. xil. p. 138.
+ ‘Ina very moderate degreeit (salivation) may be considered as a very general
attendant upon gestation, as almost all women at such times have more than an
ordinary quantity of saliva secreted; it is very distressing and enfeebling when
excessive, and is, almost always, accompanied with acidity of stomach and con-
stipation of the bowels. It has, almost always, an unpleasant taste, though not
offensive in smell. It keeps the stomach in a constant state of irritation, and not
unfrequently provokes vomiting, especially if the saliva be tenacious,’’ Dewees on
Diseases of Females, p. 214. This was probably the nature of fluid eructations in
the case I have given ; the patient was not in the habit of spitting out the supera-
bundaunt saliva.
¢{ Rees on Disorders of the Stomach.
§ Sydenham, Whytt, Cheyne, and others; see Laycock on Nervous Diseases of
Women, p. 266.
238 Dr. F. Battersby on Scirrhus of the Pancreas.
elands be transferred from these to the pancreas it can be readily
allowed, that inflammation of the latter is as possible as the
more fortunate occurrence ofan increase of its secretion. Cham-
bon de Montaux* makes no doubt of this being the source of
the glairy, or watery fluids vomited by pregnant women. “ On
examining,” he says, “the nature of the humours which some
pregnant women vomit, it is seen that they are mostly com-
posed of a liquid, thin and analogous to the saliva; it appears
that in these cases the pancreas furnishes an abundant portion
of this fluid, which ascends like the bile into the cavity of the
stomach, from which itis expelled by this viscus irritated by it.”
He has so little doubt on the point, that he argues from it the
probability of salivation in pregnancy; he continues: “therefore,
the salivary glands being allowed by physiologists and phy
sicians to have a similar use and structure to those of the pane
creas, it is not to be wondered at if they furnish an abundant
saliva.” The diarrhoea without fever, of pregnancy, in which
the stools contain “a great quantity of serosity,” and to which
he gives the name of “diarrheé nerveuse,”+ may have its origin
likewise in augmented pancreatic secretion.
The same kind of sympathy between the testes and pancreas
seems to be indicated by a case already alluded to, and on this
subject Portal remarks, that “there are diseases of the testicle
which affect the lumbar region, and give rise to suppuration of
the pancreas or its neighbourhood.”{ The sympathy between
the testes and parotids is fully manifested by the phenomena of
metastasis of inflammation, from the latter to the former, in
cynanche parotidea, and “ experience has proved that this local
determination is a favourable omen, for its non-occurrence as
well as its expulsion has been frequently succeeded by inflam-
mation of some other organ, generally the brain or its mem-
branes, and even death has been the unfortunate issue.Ӥ The

* Maladies de Ja Grossesse, t. i. p. 87, ‘* Du crachement frequent.”

{ Op. Cit. p. 181. § Anatomie Medicale, t. v. p. 353.
t Cycl. Pract. Med.—Art. Parotitis.
 Dr. F. Battersby on Sczrrhus of the Pancreas. 239
suppression of the ptyalism of pregnancy has been also followed
by fatal consequences from alike cause. ‘‘ Baudelocque knew a
young married lady who had an abundant salivation during her
first pregnancy. M. Bouvart and he were for a long time soli-
cited by her family to stop it, but they obstinately refused. At
her second pregnancy the salivation reappeared. Bouvart had
died, and they called another physician and another accoucheur,
who arrested the salivation, and the next day the lady was seized
with apoplexy.”*
in the fatal cases of inflammation of the pancreas related by
Schmackpfeffer and Lawrence, can we not recognize a similar
translation of the morbid action to the brain and its membranes,
and an additional proof of the identity of the pathological re-
lations of the pancreas and the other salivary glands? In
Schmack pfeffer’s case the suppression of an extremely copious
diarrhoea, derived apparently from pancreatic secretion, was
coincident with a return of the tumefaction of the parotids and the
fatal symptoms. In the one recorded by Mr. Lawrencet (though
unfortunately the condition of the bowels, towards the conclusion,
is not mentioned), yet, during the greater part of its continuance
they were relaxed, the patient suffering much from thirst, and
from pain, which was occasionally very severe, and referred ex-
actly to the situation of the pancreas. She felt, besides, ex-
hausted, and her skin was completely bleached. The lady’s
illness commenced when she was five or six months advanced in
her first pregnancy, and was attended with the foregoing symp-
toms of pancreatic disease, and she died five weeks after deli-
very, without any symptom of an affection of the head having
manifested itself, unless as such be considered an irritability of
the stomach, which came on five days before death, during
which period nothing but rennet-whey was retained on the sto-
mach. On dissection the internal parts of the body were ex-
tremely pale, and almost bloodless, with the exception of the
erent es
et

* Imbert, quoted by Doctor Churchill, ‘on Diseases of Pregnancy,” &c. p. 76.

+ Med. Chir, Trans. vol. xvi.
240 =Dr. I’. Battersby on Scirrhus of the Pancreas.
spleen and pancreas. This gland was throughout of a deep,
dull red colour, firm to the feel externally, and when divided the
lobules felt firm and crisp. The cellular texture round the
pancreas and duodenum, the omenta, the root of the mesentery,
the mesocolon and appendices epiploice of the arch of the colon,
were loaded with serous effusion. The surface of the dura
mater, covering the cerebral hemispheres, was lined, in the
neighbourhood of the falx, with a very thin, soft, and almost
mucilaginous layer of a light red tint. It could be scraped off
with the handle of the knife, leaving the membrane of its natu-
ral appearance. There was sliglit serous infiltration of the pia
mater. The blood-vessels of the brain were moderately full.
From all that I have stated, the close relations and intimate
sympathy existing between the abdominal and buccal salivary
glands can scarcely be questioned, and that the value of these
facts, applied to the diagnosis of diseases of the pancreas, is not
altogether problematical, I think, is proved by the following
case, kindly communicated to me by Mr. Robert L. Mac Don-
nell, which of itself does away with the reproach of a recent
writer,* who seems not to have known of the two cases recog-
nized by Drs. Percival and Crampton, when he says, that ‘ dans
Petat actuel de la science on peut quelquefois soupgonner une
affection du pancreas, mais on ne la reconnait jamais.”
Thomas Meighan, a labourer, zt. 24, was admitted into the |
Meath Hospital, Sept. 30, 1841, under the care of Dr. Graves.
He stated that for four years he had been subject to severe pain
in the stomach, which came on, at first, only once a fortnight,
but then after each meal, and sometimes in the middle of the
night. He was pale and emaciated; his skin sallow, features
pinched; and he had much the appearance of a man labouring
under organic disease. The pain alluded to was seated in the
epigastrium, and came on generally after meals, and was re-
lieved by vomiting. The abdomen was by no means prominent,
no tumour could be felt, and pressure did not cause pain. His
en

* Dictionnaire des Dictionnaires..—Art. Pancreas.

 Dr. F. Battersby on Scirrhus of the Pancreas. 241
tongue was remarkably clean and moist. Pulse 72, soft and
regular. Respiration natural. He had constant constipation.
On the 2nd of October he had an unusually severe paroxysm of
pain, followed by vomiting of nearly a basin full of dark fluid,
_ covered with a thick scum of the same colour; this matter was
inodorous, and its discharge was succeeded by a complete sub-
sidence of the pain. He had had one such attack before ad-
mission. Meighan now passed under the care of Dr. Stokes.
On the 6th of October he had a second attack of severe pain,
followed also by vomiting of a fluid, resembling the mash for
horses composed of bran and water. This also was without
smell, On the 20th of October it was observed that the abdo-
men was more distended and prominent than before, and fiuc-
tuation was easily detected when he was placed erect. There
was no change in the other symptoms. The constipation re-
quired the constant use ofa combination of castor oil and croton
oil. On the 21st he had another attack of vomiting of brown
fluid, and again, once more before death. The ascites increased,
and his legs became cedematous, and the pain more severe, and
more frequent; he emaciated, and the excessive constipation
continued. ‘The abdomen, however, remained without pain on
pressure, and he never had the least headach or thirst. A week
before death he was seized with severe diarrhoea, which resisted
all treatment, and carried off the ascites and cedema of legs, and
left the belly soft and flaccid again, without, however, allowing
any tumour to be felt.
The thoracic viscera were quite healthy. The stomach and
intestines were exceedingly large and distended. The muscular
tunic of the stomach was hypertrophied, and its pyloric extre-
mity had formed so intimate an adhesion to the liver that it was
necessary to remove both together. The pylorus was not con-
tracted. On that part of the left extremity which lies in appo-
sition with the liver there was a well-marked depression, about
two inches in its long diameter, and one inch across, with edges
thick, hard, and elevated. On making an incision into this the
VOL. XXV. NO, 74, a1
24:2 Dr. F’. Battersby on Scirrhus of the Pancreas.

knife passed through an exceedingly dense cartilaginous sub-

stance, which was confounded with the structure of the pancreas.
The liver was healthy, also the duodenum and jejunum, but the
rest of the intestinal tract was covered with small patches of
closely adhering lymph, as if dashed upon it, the intervening
mucous membrane being very vascular. The submucous coat
was thickened, and nearly of cartilaginous appearance. No
hypertrophy of the muscular coat.
Mr. Mac Donnell has added: ‘The cleanness and great
moisture of the tongue and mouth generally, were very striking,
and attracted the attention of three German physicians,* at the
time attending Dr. Graves’ Clinique, and from this circumstance,
principally, they were led to pronounce the person to labour un-
der disease of the pancreas. As this was the first time Mr.
Mac Donnell’s attention was directed to the subject he was in-
clined to doubt the accuracy of the diagnosis, and though ‘the
post mortem examination showed that the disease was not con-
fined to the pancreas, yet that gland was sufficiently engaged to
confirm the accuracy of their opinion, founded on the extreme
moisture, and the pale and macerated appearance ofthe tongue.”
The barmy nature of the fluid vomited in this case I have
frequently observed in connexion with ulcers of the stomach,
whence it was here evidently derived, seeing that the pancreas,
from its degeneration, was incapable of secreting it; but the
common occurrence of pyrosis, with rejection of limpid fluid
alternating with diarrhoea, in chronic alterations of the pancreas,
may, I think, throw light on many cases of the former not gene-
rally supposed to be derived from that gland. Andral’s authority
seems to bein support of this. After enumerating+ the ordinary
symptoms of pyrosis, such as constipation, salivation, curvature
of the body forwards to relieve the pain, with rejection of fluid,
having frequently the appearance of saliva, and always with the

* Drs. Krieger, Norman, and Gunther, from Berlin,

+ Cours de Pathologie interne, t, il. p. 175.
 Dr. F. Battersby on Scirrhus of the Pancreas. 243
property of being bitter and stimulating, he concludes: “all
these are symptoms of inflammation and of different chronic al-
terations of the pancreas.” Dr. Kerr* admits, that ‘* we are in-
deed without any evidence that the fluid is actually secreted by
the stomach, and it has been surmised, from the resemblance
between the natural secretion of the pancreas and the ejected
fluid, that it may be derived from this source.” The difficulty
with him is the improbability of the pancreatic fluid passing
into the stomach, which may, it appears to me, occur just as
readily as the passage of the bile upwards by an inverted action
of the duodenum.
Majendie, also Leuret and Lassaigne, found the pancreatic
fluid alkaline in their experiments; and in those of Tiedemann
and Gmelin the fluid which first flowed was acid, while the lat-
ter portions were alkaline. Miller considers it acid while
fresh, from which it is rendered probable that the fluid of
pyrosis, when tasteless as well as when acid, may be vitiated
pancreatic secretion, which may, even in its natural condition,
have different reactions according to circumstances, in like man-
ner as the saliva, ‘“ which becomes alkaline when food is taken,
though it is acid at other times.” But the saliva undergoes an
increase of acidity occasionally; thus Prout found a case in
which “ acid seemed to be formed not only in the stomach but
salivary glands, the breath of the patient smelt strongly of vine-
gar ;°; and Guersent says, he thinks “ this is generally the case
in individuals who have the teeth destroyed by the effect of
acids, it being more probable that they become worn away by
the constant action of the saliva than by the matters vomited,
which can have only a passing effect.Ӥ In proof of this he
says that he has relieved some cases of acidity by having absor-
bent substances kept in the mouth after these introduced into the
stomach were without avail. In the same way the pancreatic
fluid may become of increased acidity, and this is very likely to

* Cyclopedia of Medicine.— Art. Pyrosis.

+t Mitscherlich. Miller. { Monro on the Gullet, p. 412. saab

§ Dict. des Sciences Médicales.—Art,. Absorbans,

244 Dr. F. Battersby on Scirrhus of the Pancreas.
occur when the fluid is superabundant, it being an observation
that secretions altered in quantity are generally changed in their
quality also. Even the mild secretion from the lachrymal
gland becomes so irritating and acrid in scrofulous ophthalmia,
and in inflammation of the lachrymal gland,* as to excoriate the
edges of the lids and the cheeks.
Nor should the excessive quantity of the fluid occasionally
rejected in pyrosis raise a difficulty in tracing its source to the
pancreas, when we consider the amazing extent to which the
flow of saliva sometimes proceeds, and that the pancreas is three
times larger than all the salivary glands together. Dewees
has observed the salivary glands during pregnancy to secrete
from one to three quarts of saliva in the course of the day. In
a case by Mr. Gorham,f the patient spat out as much as four
quarts in the same period, and never less than two quarts; and
in a case ofscirrhous pancreas, mentioned by Rahn,§ it amounted
to more than ten pints per diem. In fact Mr. Abernethy used
to remark, that the pancreas is not so liable to disease as other
parts, from the facility with which it secretes, and this will ac-
count for “ its having never been observed to be the seat of in-
flammation by either Baillie, Meckel, or Andral.” ||
Whether these deductions with regard to the occasional
origin of pyrosis be well founded or not, it may be not altogether
useless to have drawn attention to the subject. No doubt, I
think, can remain as to the relative action of, and sympathy be-
tween, the abdominal and buccal salivary glands, which I have
endeavoured to explain, and if, by bearing this in mind, assis-
tance be afforded for a more accurate diagnosis of diseases of
the pancreas, some good must be attained when all other symp-
toms are confessedly so obscure and ambiguous.

* Dr. Todd ‘ on Inflammation of the, Lachrymal Gland.’”—Dublin Hospital

Reports, vol. iii.
+ Blumenbach’s Physiology, by Elliotson, fifth edition, p. 88.
+ London Medical Gazette, June 30, 1838.
§ Diagnosis Scirrhorum Pancreatis. Goétting. 1796.
| Lawrence, Med. Chir. Transactions, vol. xvi.
 Dr. H. Kennedy on Climacteric Disease. 245

Art. [X.—Observations on Climacteric Disease, with Cases.

By Henry Kennepy, M.B.T.C. D.,L.R.C.8.1.; one of
the Medical Officers of St. Thomas’s Dispensary.

To the late Sir H. Halford the Profession in this country stands

indebted for the first distinct account of climacteric disease.
The Paper alluded to was published in the year 1813, and
after a good deal of searching I have been unable to find any
farther notice of the subject. True, indeed, the Dictionaries and
Cyclopaedias of Medicine speak of the disease, but in a very
brief, and to my mind, unsatisfactory way; nothing, in fact, has
been added to the original paper, while in some of them the
matter of this valuable and elegantly written communication is
not even given in full.* Sir Henry Halford himself attributes
the slight notice which has been taken of this disease to the fact,
that being often joined with some organic lesion, it hence has
been overlooked. This, no doubt, is one reason, though it strikes
me another may be given, arising out of the idea, which I be-
lieve to be a very general one, namely, that climacteric disease
is only met with in advanced life. ‘This idea, which pervades
the entire of the Paper alluded to above, will, I think, be found
to be erroneous, 4 least I may state with certainty that an
affection which agrees in every respect with climacteric disease,
is by no means unfrequently met with in individuals between
twenty and thirty years of age. ‘To direct attention to this
point, which I believe to be one of some importance to recog-
nize, as well as to enter into some more of detail on the subject
generally than has hitherto been done by any one, is my object
in the following remarks.
From the time of Galen to the present period it has been
nearly universally believed, that certain epochs of human life

* It may be right here to except Mason Good’s account of the disease; but
even it is avowedly based on the Paper alluded to above. It is, however, worthy
of perusal.
246 Dr. H. Kennedy on Climacteric Disease.

are very liable to be accompanied by disease of a certain cha-

racter. A good deal of trouble has been taken to ascertain at
what exact periods of life such a disease shows itself, and par-
ticular years, such as the forty-second and sixty-third, have been
determined on: the latter of these periods has indeed been
called the grand climacteric, as being the time above all others
when the disease is apt to declare itself. In the cases of climac-
teric disease which have come under my own notice, I have not
been able to confirm any of these points, nor indeed is it likely
that such will ever take place. The different constitution of
every individual, both bodily and mental, his pursuits, his ha-
bits as to eating, drinking, and clothing, and probably above
all as to the exercise taken in reference to these, must, I should
think, cause an endless variety in the periods at which the sys-
tem gives way, and climacteric disease establishes itself. Be
these things, however, determined as they may, it is enough for
my present purpose to know that such an affection as climacteric
disease really exists, for this point has been questioned: it is
easily settled, however, by referring to any half dozen of grown
up individuals, when it will be found that one at least of these
has had the disease. Were I to speak from my own experience,
I should say that the persons who pass through life without
having laboured under it, once, if not twice, are the exceptions
to the general rule.
Of the causes of this disease very little is known. In very
many cases it is not possible to trace it to any, while in a few it
seems to be brought into existence by such causes as the follow-
ing:—a slight cold, the influenza, any sudden shock to the
system, as for instance a trifling fall, anxiety of mind brought
on by a man’s business going astray, or, what is very common
indeed, some disappointment, or ‘‘ hope deferred,” in relation
to the more tender feelings of the heart—a debauch of any
kind. Of these a common cold is the most constant, a point
which Sir H. Halford has especially noticed. It is self-evident
however that such causes are not enough in themselves to pro-
 Dr. H. Kennedy on Climacteric Disease. 247
duce the disease: they can only act by setting in motion aseries
of symptoms, for the production of which the system has been,
as it were, previously preparing itself; in fact they are imme-
diate, as contra-distinguished from predisposing causes: but it
must be again repeated that in numerous instances the disease
comes on without any assignable cause. While speaking of
causes it must not be lost sight of that actual disease may usher
in the attack, and continue through its progress. This part of
the subject will be alluded to farther on.
Climacteric disease in general commences in a very gradual
way. From three to six weeks may pass over, the individual
not feeling quite well, and yet not making any distinct complaint.
I have known it happen too, though it is not common, that the
patient was observed by his friends to be looking ill for a con-
siderable time before he made any complaints whatever. In
the great majority of cases, however, the remarkable change the
countenance undergoes is not observed till a later period of the
disorder. Pains of one form or other are among the most com-
mon symptoms ushering in the attack: these may be ofa dart-
ing and transient character, passing through the entire frame, or
they may be more fixed and confined to a certain part. In the
former case they are set down as rheumatic or gouty pains, ac-
cording to the habits, or, it may be, the wishes of the individual ;
while in the latter nothing remarkable is to be observed about
them, except that in general they are in a very marked degree
periodic. Another very common symptom complained of in the
earlier stages of the disorder is weakness, which is referred in
general to the knees, the patient expressing himself in the usual
way, by saying that these parts feel as weak as water. It is not
alone when the patient is walking about that this weakness is
complained of; on the contrary, they suffer from it while lying
on a sofa, and I have seen it complained of to such a degree
that it was described as amounting to absolute pain. It is also
worthy of remark, in connexion with this sense of weakness, that
it does not seem to be increased by any exercise the individual
248 Dr. H. Kennedy on Climacteric Disease.

may take. In one instance, which will be given in detail, this

symptom recurred for several days, and at a particular time of
each day, before any other symptom showed itself, the individual
during this period wondering what could be the cause of such
weakness. |
It has been already stated that the disease under notice
generally commences in a gradual way. To this, however, there
are some remarkable exceptions, and this is an important point
to keep in mind, I have kuown the disease commence with
what may be called acute symptoms. Thus a common bilious
attack has been followed at once by the usual symptoms, and
well-marked climacteric disease has been established within four-
teen days. A case of this sort will be detailed. A common
cold, or influenza, have been already mentioned as ushering in
the attack. But probably the most important of this class of
cases is where the disease commences with head symptoms of so
acute a character as to throw the medical man entirely off his
guard. Under such circumstances a wrong view Is very apt to
be taken of the case, and erroneous treatment adopted in con-
sequence. This will be alluded to again.
After the pains, which have been before spoken of, have
existed some time, other symptoms make their appearance, in
quicker succession too than the commencement of the disease
would lead one to expect. ‘The appetite begins to fail; this
soon increases to a total loss of it; and finally, should the attack
be a well marked one, an utter aversion for all sorts of food
succeeds. With this there is of course loss of flesh, and strength
both of mind and body, and above ail the sleep at this period
goes astray. In a disease which is marked by such a variety of
symptoms there is no more constant one than this loss of sleep;
one exception only has come under my notice where it did not
exist. |
Such are what may be called the general symptoms of cli-
macteric disease, which has been described by Sir H. Halford
as consisting in a loss of flesh, in a very marked change in the
 Dr. H. Kennedy on Climacteric Disease. 249
expression of the patient, and in a quickened circulation. The
two first of these would appear to be all but constant: the latter
however is by no means so. _ I have seen cases where from first
to last the pulse was not raised in the slightest. As regards the
expression it has been deservedly noticed, for it is a truly re-
markable one: it is not merely that the individual looks ill, but
all at once, as it were, several years are added to his life, and he
gets the credit of being much older than he really is.
It must not however be supposed that the three symptoms
just alluded to constitute climacteric disease. Far from it. I
have never seen a case where others were not superadded, and
for these latter it is that medical relief is commonly sought.
The symptoms spoken of, varied though they be, may, for the
sake of description, be referred to the head, chest, or abdomen.
What it is which makes the disease take one of these directions
in preference to another, we are of course in complete ignorance
of: such is however the fact. When the head is the part
affected, pain in it is the most common complaint: it may affect
either the entire head, or it may be confined to the front or the
back. It is very little amenable to treatment, while it is marked
by the most extraordinary periodicity. In some instances it is
not so much pain as weight which is complained of, and which
is sure to be aggravated by any movement, as by shaking the
head. In others again it is a sense of reeling or dizziness, or of the
blood flowing to the head with unusual force, giving rise to the
most distressing throbbing : each and all these feelings are almost
invariably periodic. It is most important to bear in mind too
what was before alluded to, that all these symptoms may be in
a still more aggravated form, and may be accompanied by a
sense of numbness, or even paralysis, of one side of the body.
This is not a state of complete paralysis, for as far as I have yet
seen, it is recovered from entirely. It is the form of paralysis
which in my own experience is most usually met at a period of
life at which this disease is not common, I mean between twenty
VOL, XXV. NO. 74, 2K
250 Dr. H. Kennedy on Climacteric Disease.
and forty years of age, and it is very readily indeed mistaken for
other and more serious forms of the disease.
When the patient has complained of the chest the following
symptoms have come under my notice :—severe pains in the
shoulder joints, not to be distinguished from rheumatism; very
distressing pains of a burning character referred to one or both
clavicles, sometimes to the soft parts in the neighbourhood. At
other times again these sensations have been complained of in
one or more of the dorsal vertebree. The most common chest
symptoms, however, are most probably fits of dyspnoea: these
may occur in the day-time, when they are in general slight, but
they are certain to recur towards evening, or during the night,
and, in the cases I have seen, with great violence. For the
time being, in truth, the individual labours under well-marked
paroxysms of asthma. With those fits the patient may be ha-
rassed with palpitation of the heart, which, however, may exist
by itself, and when it does it gives rise to as distressing symp-
toms as any connected with climacteric disease. It may be ob-
served, in passing, that the more localized any of these symp-
toms are, the more severely the organ affected seems to suffer.
With the symptoms already detailed cough may also exist,
which may at times be traced to bronchitis, or again may be of
a spasmodic character, when no cause can be made out for its
existence.
The digestive system suffers very constantly in climacteric
disease, possibly more so than any other: some indeed have at-
tributed the affection to derangement of the abdominal organs,
but, I believe, erroneously. The tongue in general shows more
or less of fur, while a bad taste in the mouth, particularly in the
morning, is often complained of. The state of the appetite has
been before alluded to, amounting in the worst cases to an ac-
tual disgust for all solid food; in such, thirst is a common
symptom, particularly at night. Even in cases when food is
taken, it seems never to be enjoyed, nor to nourish the patient
as under other circumstances. Besides a distaste for food, dys-
 Dr. H. Kennedy on Climacteric Discase. 251
pepsia in several forms may be met with: pain at any
period
after eating is very common; I have seen some cases where
there existed the most violent attacks of gastrodynia,
at least
the symptoms were such as to lead me to supp
ose that the pain
was owing to some irritation in the stomach.*
In others again
it seemed to be seated lower down in the alimenta
ry canal, the
pain then coming on at a particular time of the nigh
t. In place
of pain it is at times a sudden secretion of air
which distresses
the patient, and this may go on to a degree whic
h no one can
have any idea of who has not witnessed it. Like ever
y other
symptom in the disease it is periodic. A tendency to
constipa-
tion of the bowels almost always exists, and this takes
place
whether head, chest, or abdominal symptoms predominate: the
discharges are usually dark and unhealthy. Sir Henry Half
ord,
when speaking of the renal secretion, says that it is not
dimi-
nished, From this opinion I must with every respect differ; at
least I know that patients themselves have told me that their
urine was not passed in the usual quantity. One thing is cer-
tain about it, that in many instances a deposition of the lithates
is going on during the entire progress of the disease: this fact
would go to prove, though to a certain extent only, that the
more fluid parts of the urine were not in the usual quantity.
When speaking of the symptoms which the patient may
complain of in or about the chest, pains in one or more of the
dorsal vertebree have been mentioned: similar pains are much
more constantly met with however in the lumbar region, at
times referred to the spinal column itself, and again to either
side, or it may be to any of the nerves arising from this neigh-
bourhood. I have known sciatica in the most violent form to
accompany climacteric disease, and in one instance, attended
by
the late Dr. Ephraim M‘Dowell and myself, paroxysms of
pain
of the most exquisite kind were referred to the right sper
matic
i
* In two instances this organ was in so irritable
a state as on several oecasions
during the progress of the disease to induce vomiting,
from causes which, under
other circumstances, would not have done so.
252 Dr. H. Kennedy on Climacteric Disease.

cord. The lumbar pains alluded to are often accompanied by

a sense of beating in the part, while at times an actual jumping
of some portion of the muscular structure takes place. Cases
too will be met with where, in place of pain, the patient com-
plains ofa sense of tingling or numbness; in fact any morbid
nervous sensation may exist. While alluding to nervous feel-
ings it may be observed, that burning in the palms of the hands
and soles of the feet is a very constant attendant of the disease.
Anasarca of the lower limbs is another which will be met with
pretty frequently: it is more common when climacteric disease
comes on in advanced life, but I have seen it in a young person.
It may go on from the slightest degree of puffing about the
ankles or in front of the tibia, to the most considerable swelling
of both limbs.
With any combination of the symptoms which have been
detailed, it is scarcely necessary to observe that the mind must
closely sympathize. I have never met an instance in which it
ex-
was not more or less powerfully affected. In the severest
amples of the disease the individual becomes totally unfit for
his usual avocations: his thoughts are gloomy and desponding
in the extreme, and nothing will persuade him but that his lat-
ter end is fast approaching. The state of mind is in truth very
peculiar, and such as no one who has ever seen the disease
could by possibility overlook. At times this is shown by great
irritability of temper, and persons naturally of the most gentle
dispositions become quite the reverse.
Such is a brief sketch of the more prominent symptoms
which the disease under consideration presents, varied of course
ina thousand ways in each individual case. I have before stated
that in the majority of instances the patient refers his sufferings
to one of the three great cavities of the body: exceptions to this
rule will however be seen: thus I have met examples where
the head and chest were affected alternately in the one patient,
and again the stomach and heart: under these circumstances
the disease is not so well marked as when only one set of organs
 Dr. H. Kennedy on Climacteric Disease. 253

is attacked. Sir H. Halford states, that though he has met the

disease in females, still its severer and better marked forms oc-
cur in men. While this is admitted, it should at the same time
be observed, that within my own observation climacteric disease
is fully as frequent among the former as thelatter. I think too,
that as a general rule, men suffer more during the progress of
the disease from derangement of the digestive system and brain,
while on the contrary females suffer more from symptoms refer-
rible to the lungs or heart.
The duration of this affection is always very considerable: I
have never known it occupy less time than between four and
five months; while, on the other hand, I have seen individuals
who were not quite well at the end of two years. Were Iasked
the average period that it takes to run its course, I should say
about nine months. This point is one worth bearing in mind,
for otherwise the patient is very apt indeed to lose confidence in
his medical adviser, who may not have given him notice of the
length of time his sufferings may last.
On the diagnosis it will be unnecessary to dwell long. As
long as the disease is, as it were, developing itself, doubts may
exist as to its nature, and these may last from a month to six
weeks. The pains which have been already described as so
constantly present in the earlier stages of the complaint, may be,
and indeed I know they have proved very embarrassing to the
medical man in making his diagnosis; and until other symp-
toms declare themselves it may be impossible to decide. The
signs upon which most reliance may be placed are the loss of
rest, of appetite, of flesh, and above all, the altered expression
of the countenance, one and all of these too coming on and
continuing without any apparent cause. To enter at any length
into this part of my subject would here be out of place: it will
suffice to revert again to two points, which have been already
glanced at: one is the great importance of not mistaking certain
cases of climacteric disease for actual organic disease: this, I
must again repeat, is particularly apt to occur in reference to the
254 Dr. H. Kennedy on Climacteric Disease.

brain. One case will be given in corroboration of what is stated,

that is where treatment was adopted which the circumstances by
no means justified, and where, when a directly opposite treat-
mant was had recourse to, the patient got well. In some cases
too, where the heart is the suffering organ, the symptoms are so
very like those of organic disease, that an erroneous diagnosis
is very likely to be made. The second point alluded to is the
necessity of ascertaining, as far as we possibly can, that no or-
ganic disease of even the slightest kind exists: I do not mean
by this such an amount of real disease as might of itself cause
the symptoms of the climacteric affection; for this may occur,
though of course it would be easily recognized; but merely such
an amount of disease as may serve to usher in the affection more
immediately under consideration. When this happens, the one
affection is very apt to aggravate and keep up the other, and
vice versa; and hence the necessity for a correct diagnosis in
this point of view. Of the diseases which in a very mild form
may act in this way, and which have come under my own notice,
I may mention bronchitis as the most common, then pneumonia,
and lastly pleuritis.*
A few words will suffice on the prognosis of this affection.
In the majority of instances the disease may be expected to ter-
minate favourably; more so, I should say, than what Sir Henry
Halford’s remarks would lead one to expect. It is truly asto-
nishing from what a state the patients, who labour under this
affection, will recover. Over and over again persons are given
up as hopeless cases of disease, and yet they ultimately come
through, and live for years afterwards. It must not, however, be
inferred from this, that the affection is therefore atrifling one.
Far from it. Climacteric disease proves fatal often enough in
advanced life, as to force on us the necessity of ever giving a
guarded prognosis. Even in early life it may be fatal; one

* One instance of enlargement of the liver has also come before me, where the
disease appeared to arise from it,
 Dr. H. Kennedy on Climacteric Disease. 255
most important case of this sort came under my own observation,
and will be given in detail.
As to the ultimate and perfect recovery of the patients, Sir
H. Halford seems to think that they very seldom shake off en-
tirely the effects of the attack. This, I confess, does not agree
with the results of the cases which have come under my own
observation ; I mean of course the majority. Possibly the cause
of the difference may arise from the fact that one party includes
cases of the disease which occurred in early life, and where of
course the chances of shaking off the disease entirely are much
greater than in advanced age. I think it right, however, to ob-
serve, that patients between fifty and sixty years of age, after
having passed through the disease, have expressed themselves
as feeling quite well, and have appeared to their friends and
others to be so.
On the treatment it will be only possible to make some re-
marks ofa general character, such as it would appear to be im-
portant to keep in mind in the management of every case.
What then is, or rather appears to be (for it is all conjecture),
the nature of the climacteric disease? A decay for the time
being of the several functions constituting life, but more par-
ticularly of those of the nervous system. To any one studying a
case of the disease it appears as if the system had gottired, and
could not carry on its various functions with its wonted energy.
That the nervous system is profoundly engaged would appear to
be evident: the periodic nature of almost all the symptoms,
together with the fact that in the great majority of cases these
symptoms are functional, not organic, would seem to confirm
this idea. Whether it be true or not, however, certain it is that
the treatment best adapted to the disease is consonant with it.
In other words stimulants, as a general rule, afford the most
relief, of course suited to the demands of each individual case.
In considering the treatment, the duration of the attack,
which has been before alluded to, must not be forgotton, It
may be stated, once for all, that it is not possible to shorten the
256. Dr. H. Kennedy on Climacteric Disease.
disease: its symptoms may be alleviated, or on the other hand,
there is nothing easier than to aggravate them; but to put a
stop to them entirely is, I believe, impossible. Hence the great
importance of not using any treatment which has this object in
view; in truth our treatment should, for a certain period at
least, be what is called expectant: but when this period has
passed over, then remedial measures may be employed, and
with every prospect of success. While it has been just stated
that the symptoms may be alleviated, it is right to observe that
I mean only for the time being, for in fact they offer a degree
of obstinacy for which every one should be prepared, and this
occurs whether they be referrible to the head, chest, or abdo-
men. It is, if I recollect right, Dr. Stokes who has stated the
important rule, that if we meet a set of symptoms, as for in-
stance those indicative of heart or lung disease, and that these
persist in defiance of all ordinary treatment, we may be led to
conclude that organic disease exists. Now climacteric disease
offers a remarkable exception to this rule: for here we will see
a series of symptoms persisting, in spite of all treatment, not
only week after week, but month after month, and yet the indi-
vidual gets quite rid of them at last.
Another point of consequence in the management of these
cases, though to some it may appear trifling, is to instil confi-
dence into the mind of the patient. He must be told at all ha-
zards that he will certainly recover, and I know no more impor-
tant part of the treatment than for the medical adviser, as far as
in him lies, to “ minister to the mind diseased.” If he do not
attend to this point he may well indeed “ throw his physic to
the dogs.” The mind, as has been already mentioned, is in a
very peculiar state : for the time it dwells on every subject con-
nected with the individual; it renders those selfish who were
never so before; it exaggerates and depresses by turns; and
what is most important to remember in connexion with it is this,
that it, as well as all the other sources of suffering, are to an
extraordinary degree influenced by the weather. It is, I be-
 Dr. H. Kennedy on Climacteric Disease. 250
lieve, now generally admitted, that even in health we are af-
fected more or less by the changes of the weather: in climacteric
disease this sensibility is increased tenfold, the individual be-
coming actually a living barometer.
As to any specific line of treatment for this disease, I know
ofnone. Any symptoms must be met as they arise; it is pos-
sible to alleviate many of them, such as where pain exists; but
the important rule to keep in mind is, not to do too much.
This is particularly to be observed as regards any treatment of
a lowering character, which many of the symptoms that arise
appear to call for. In advising the not doing too much, I by no
means wish to imply that any deception is to be carried on.
Far from it. All I mean to say is, that we are not to treat the
disease as we would any ordinary one, nor the patient as if he
were in his usual circumstances.
Of the medicines from which the most benefit has arisen in
my own hands I may mention quinine and other tonics, the gum
resins, acetate of lead, anodynes, and purgatives. One and all
of these will in turn be found useful, more particularly quinine.
It must be observed, however, that in the ordering of medicine
for this disease, the ingenuity of the medical man will be taxed
to the very utmost: the medicines, in fact, now cause symptoms
which under ordinary circumstances they would not do: hence
he is obliged to be very particular in his combinations, and will
have to alter them again and again before they will be found to
agree. Purgatives, which are peculiarly useful, afford a good
example of what is meant. Thus, for instance, any one might
order six or eight grains of cathartic extract and two of blue
pill to be taken at bed-time: when he comes to inquire the
next day, however, he learns to his surprise that the patient has
passed a miserable night; that he has had a great deal of pain,
and it may be sickness of stomach, and very possibly the medi-
cine has not acted at all on the bowels. Hence arises the ne-
cessity for combining, as a matter of course, such medicines as
will be most apt to sit easy on the stomach, as the expression is,
VOL. XXV. NO. 74, aL
298 Dr. H. Kennedy on Climacteric Disease.
and. it is really very curious to observe what a slight alteration
will answer the purpose: thus a grain or two of an anodyne ex-
tract, a gum resin, or even a tonic in general answers remark-
ably well. Sir Henry Halford recommends in these cases the
compound decoction of aloes, and I believe it seldom disagrees.
Together with the means just indicated, a change of air and
scene is ever desirable: the proper period for advising these is
however most important. I have on different occasions known
individuals sent to the Continent and elsewhere, and return
again, no change for the better having taken place, and often
very little obliged to their medical adviser. At least one-half
of the period usually occupied by the disease should be allowed
to elapse, that is, about five months, before any change of this
sort is thought of: it will then come on with good effect, and
tend powerfully to restore health.
In those instances where some appetite still remains, the
diet should ever be plain in quality, and moderate in quantity ;
any, the slightest, indiscretion is sure to aggravate the sufferings
of the patient, and this, I have observed, is more apt to take
place at the end of forty-eight rather than twenty-four hours.
In many instances animal food causes so much pain during di-
gestion that it has to be given up for the time: of course other
and milder food must be used. Other points in the manage-
ment of these cases might still he alluded to, but I believe the
great and leading ones have been stated, and to enter further into
this part of my subject would prolong the Paper to an uncalled
for length. Before concluding, I shall detail a few cases illus-
trative of the several points already glanced at.
Case I.—A gentleman in his 27th year, without any appa-
rent cause, began to suffer from extraordinary weakness of his
knees: it came on and went off at a particular period of the
day, and lasted, without any other symptom whatever, for a fort-
night. He then began to complain of pains, which were de-
scribed as ofa burning character, and which affected the soft
parts about one and sometimes both clavicles. These were at
 Dr. i. Kennedy on Climacteric Disease. 259
first slight, and only felt in the day-time: by and by, however,
they became more severe and more constant, and ultimately the
nights of the patient were rendered absolutely miserable by
these pains, which entirely prevented him from lying on either
side. With these symptoms there was impaired appetite, with
very considerable loss of flesh, a marked change in the expres-
sion of the countenance, occasionally a sense of burning in the
palms of the hands, and always a tendency to constipation.
There was no fur on the tongue at any period of this case, nor
was the pulse raised in the slightest, provided the patient kept
at rest; but a very slight exertion, or a very small quantity of
any stimulant, was enough at any time to raise it considerably.
The mind was gloomy and despondent in the extreme. In this
state the patient continued for nearly seven months, during
which time a variety of treatment was tried, and among the rest
country air; but all without avail. At this period the several
symptoms gradually began to abate, apparently under the use
of full doses of quinine, and finally the patient recovered com-
pletely at the end of about ten months, and has remained well
ever since, six years having elapsed since the attack.
This case presents a well-marked example of the disease
under consideration. Its mode of commencement, as well as
the anomalous pains, are both worthy of notice. At one period
it was supposed the patient was about to get phthisis: subse-
quent events, however, did not verify this conjecture. The case
was remarkable too for there not being an entire loss of appetite,
such as marks many of these cases.
Case I1.—W.K., a gentleman in his 24th year, was ob-
served to be looking ill for a month, without making any com-
plaint whatever. He had been, while an infant, very hard to
rear, but up to the period of the present attack no sickness of
any moment had occurred. After the month had elapsed he
began to complain of some pain in the lumbar region of the
spine. It was intermittent in its character, and at first very
slight, so much so as to be scarcely complained of; in the course
260 Dr. H. Kennedy on Climacteric Disease.
of three weeks, however, it had increased so much as to become
a distinct cause of distress, and, finally, the patient’s rest was re-
gularly broken by the pain coming on at a particular hour of
the night. It is to be observed that it was not fixed on any one
spot: the treatment adopted drove it, as it were, from place to
place: at times it was referred to the spine, high up between
the shoulders, and again as low down asthe sacrum. With this
symptom the bowels had become constipated, the urine was
somewhat diminished in quantity, and constantly deposited the
lithates, while the patient had lost a good deal of flesh. He
was still, however, going about, and his appetite, though im-
paired, was not otherwise deficient. His mind had become de-
pressed, and to an extraordinary degree anxious about himself.
At the end of about two months and a half the treatment used
seemed to be benefiting him for several days, and under the
highest advice he was sent to the country. He remained there
five weeks, during which time—so far from improving—he ra-
pidly lost ground; and when he returned to town it was at once
evident that his life was in the most imminent danger. He was
now very much emaciated; the pulse could scarcely be felt at
the wrist; the appetite was entirely gone ; and he was obliged
from weakness to be constantly reclining. He did not, how-
ever, suffer from pain any where. From this period till his
death, which took place about a month later, he presented but
too well-marked an example of an entire break up in the sys-
tem,—a complete wreck both of mind and body. Subsultus of
the entire body made its appearance during this last month,
and also, though a later symptom, an apthous sore throat.
Within a week of his death too, what might be called a typhoid
state came on, and at times the mind wandered a good deal.
The entire duration of this case was about five months and a
half. It was not in my power to obtain a post-mortem exami-
nation, which I much regret.
The leading features of this important case I have given in
 Dr. H. Kennedy on Climacteric Disease. 261
full. It is the only instance which has come under my notice,
and which proved fatal in early life. Its gradual commence-
ment in what at first appeared to be of no moment, and its pro-
gress, step by step, from bad to worse, or nearly so, are all
worth noting. The apparent amendment which took place pre-
vious to the patient going to the country was owing to full doses
of quinine. It will be observed that during the entire of the
case no particular organ seemed to suffer. There was no com-
plaint of the head, nor was there any cough, nor could the ste-
thescope detect any sign of disease; and though the digestive
system was deranged, it was more as if it had ceased to perform
its functions, than that any sign of disease whatever existed.
This is not either my individual opinion, for during the last
month the patient was seen by Sir Philip Crampton and Sir
Henry Marsh, and neither of these eminent persons could, on
the closest examination, detect any sign of organic disease.
Case III.—A person about 49 or 50 years of age, got what
he called a bilious attack, and which he had often laboured un-
der before: for this he was ordered some medicine, and after
four days he was all but well. While in this state he happened
to dine with the Lord Mayor (for it was in the times of the old
Corporation), where I should suppose he indulged rather freely.
Certain it is that the following day, when I saw him, the attack
seemed to have been renewed, but it did not yield now as it had
done in the first instance; on the contrary, as the first brush of
illness appeared to decline somewhat, other symptoms made
their appearance. Of these the most prominent and distressing
were attacks of violent pain referred to the region of the sto-
mach, but which I believe to have been situated in the colon.
These attacks came on at uncertain intervals, and at the end of
a fortnight they seemed rather to have declined of themselves
than to have yielded to the treatment adopted. In the mean
time the patient had lost flesh out of all proportion with the du-
ration of his illness; his sleep had gone astray, and his appetite
262 Dr. H. Kennedy on Climacteric Disease.
was completely at a stand.* The tongue remained furred, but
there was no excitement whatever of the pulse, which had now
become very weak and languid. He remained in this state be-
tween three and four months, during which period he was sub-
ject at times to paroxysms of the most violent coughing, in one
of which he threw up a good deal of blood. He finally reco-
vered completely, deriving great advantage from change of air
and stimulants, and at the present moment is quite well.
Climacteric disease established itself more rapidly in this
case than any other which has come under my notice. It is of
course highly probable that it would have come onalittle later
without any apparent cause, but certainly the cause stated above
seemed to act at once as the starting point. ‘The case was one
of considerable interest, for two medical gentlemen who saw the
case could not be persuaded but that organic disease must have
existed. The result of the case showed, I think, that this im-
pression was erroneous. The mind of the patient, which I
should have alluded to before, was, during the existence of the
attack, ina truly pitiable state. He was naturally of an anxious
turn, and what between his own bodily sufferings and the
anxiety about his business, his mind was brought to a state of
gloom and despondency which I really can find no words to ex-
press adequately.
Casr 1V.—A lady, of about 30 years of age, and unmarried,
began to complain of general weakness of the frame. It was
soon accompanied by impaired digestion and periodic head-
aches of a very severe character while they lasted: at times
these were accompanied by a sense of giddiness, to such a de-
gree that the patient was in danger of falling. After having
lasted about six weeks these head symptoms subsided, but only
to be followed by others referrible to the chest. She now began
to suffer from violent fits of dyspnoea, coming on always during

* The expression of his countenance too changed so much, that actually some
of his friends were unable to recognize him.
 Dr. H. Kennedy on Climacteric Disease. 263
the night, and most frequently at a particular hour: she had
also, at very uncertain intervals however, attacks of palpitation
of the heart, which were most distressing to her. The fits of
dyspnoea were so urgent, when at the worst, that she was obliged
to leave her bed, and have the windows of the bed-room thrown
up, literally gasping for air. These symptoms were slightly re-
lieved by treatment, yet they persisted for rather more than four
months, when a sea-voyage, together with medicine, of which
the gum resins formed a large part, seemed to restore her
health; but it was a much longer period before she could be
said to be completely recovered. It may be well to observe,
that this patient was naturally any thing but of an hysteric tem-
perament, nor was the menstrual function at any period of her
illness deranged. ‘The peculiar expression which her counte-
nance assumed has not yet left her, though four years have now
elapsed.
‘This was a well-marked example of climacteric disease, as it
is usually met with in the female. It will be observed that the
symptoms were not of that persistent kind which is seen in
men: neither did the mind seem to suffer as much as in them;
nor yet did the attack, at least in its severity, last at all so long
as it commonly does with them.
Case V.—A gentleman, upwards of 40 years of age, of a
highly intelligent and refined mind, had been annoyed for a pe-
riod of two months with flying pains through different parts of
his body, but more particularly affecting one or other portion of
the spine. During this period he was observed to fall away in
flesh, though his appetite was not impaired. It was now that
something went wrong with his business, and he was imme-
diately seized with head symptoms of a very serious character.
Fits of giddiness and violent headach came on, which were fol-
lowed by paralysis of one half of the body, together with great
thickness and difficulty of speaking. ‘To those symptoms were
added the others which I have so often had occasion to repeat :
the sleep was broken without any apparent cause, there was
264 Dr. H. Kennedy on Climacteric Disease.
marked derangement of the digestive system, with constipation
of the bowels; and the mind not only became desponding in
ihe extreme, but it was also perfectly childish, the patient on
several occasions becoming actually hysterical. The treatment
adopted was such as would benefit the more ordinary forms of
paralysis, but here it seemed perfectly useless, and after having
been persevered in for more than four months it was given up,
the patient having got tired of trying what appeared to do so
little good. He was now advised to give up all local treatment,
and in place ofit to go to the country, and try a course of tonics
with stimulants. This line of treatment seemed at first only to
aggravate the symptoms, particularly the use of the stimulants,
the patient being naturally of a highly nervous temperament.
In a short time, however, the system got accustomed to their
effects, and then all the more serious symptoms, including the
paralysis, began to decline, and at the end of about fourteen
months this patient was restored to all his powers, both bodily
and mental.
This was a very well-marked example of one of the varieties
under which climacteric disease shows itself. In a preceding
part of this Paper I have alluded to the importance of distin-
euishing this affection from the more ordinary forms of brain
disease, and also the great liability which exists of adopting
treatment directly-the reverse of what is right. I believe, in
fact, that the symptoms depend on a deficiency of the nervous
energy, and not upon those of either congestion or inflammation.
Hence the treatment ought to be some modification of the
stimulant. The paralysis which existed in this instance was
not complete, and indeed this is one of the most important dis-
tinctions between the two cases. ‘Two other instances, which
were precisely similar, as far as regards the paralysis, have
come under my notice, but I do not think it necessary to detail
them here.
The five preceding cases appear to be sufficient to give a
general idea of the forms under which climacteric disease usu-
 Dr. H. Kennedy on Climacteric Disease. 265
ally presents itself. I could detail a number of other instances,
more particularly where the stomach seemed to suffer the most,
but the length to which this paper has already run must, for the
present at least, forbid it. I would just observe, however, that
while the great leading features of the affection seem to be the
same in all, there is, as far as I have seen, an endless variety in
the minute symptoms of each individual case.
It may be well, in conclusion, to throw into a series of pro-
positions all that is at present known on this subject.
1. That there exists such an affection as climacteric decay or
disease.
2. That this point is proved by the peculiar nature of the
symptoms, by the usual progress of the disease, by the complete
recovery of the patients, but, above all, by the fact, that the dis-
ease is by no means uncommon in early life.
3. That of the remote causes of the disease nothing is
known; but that its immediate causes may be, and often are,
the following :—a slight cold, a fall, a bilious attack, anxiety of
mind from any cause, a debauch. That it often comes on with-
out any assignable cause.
4. That climacteric disease usually begins in a very slow
and insidious way, but that it may commence much more ra-
pidly, under which circumstances it is very likely indeed to be
mistaken for organic disease.
9. That it may prove fatal in early, but still more frequently
in advanced life.
6, That it commonly occupies a period of nine months.
7. That it would seem to be as frequently met with in wo-
men as men, but that it is seen better marked in the latter.
8. That the greater number of those attacked recover com-
pletely, but that, under some circumstances, the effects of this
disease are never after entirely shaken off.
9. That during the first half of its progress the symptoms
present an unusual obstinacy to treatment; but that during the
latter half medical treatment may be of essential benefit.
VOL. XXvV, NO. 74, 2M
266 Dr. Law on Aneurism of the Aorta.

10. That the best treatment seems to consist in giving conf-

dence to the patient, in a change ofscene and air, and in combi-
nations of medicines, of which stimulants, tonics, anodynes, and
purgatives form the principal part.

Art. X.—Cases of Aneurism of the Aorta. By Rosert Law,

M.B., A.M., M.R.LA., Professor of the Institutes of Me-
dicine in the School of Physic in Ireland; Physician in
Ordinary to Sir Patrick Dun’s Hospital, &c. &c.
[The pathological specimens of the following cases were exhibited at the Patho-
logical Society.]

Since the publication of my Observations on the Diagnosis

of Aneurism of the Aorta in a former number of this Journal,
two cases of this disease have come under my observation, which,
from their exhibiting in a very striking manner the peculiar cha-
racter of pain, to which I have already directed attention, and
from other interesting features which marked them, | deem a
suitable sequel to these observations. In both cases the same
obscurity attended the diagnosis in the early stage of the dis-
ease, and in neither was it recognized still the subjects came
into hospital. One had been treated (asi < of such cases have
been) as rheumatism, and with the usuaf measure of success,
viz. a short and passing relief, from stimulating applications to
the seat of the pain. ‘The other had been for a short time in
hospital, but was soon discharged without any relief. From
the account he gave we suspect the story of his pain was not
credited, and that he was treated as a malingerer, but to which
he had but little pretension.
Case 1L—True Aneurism of the ascending, and Arch of the
Aorta; false Aneurism of the descending Aorta bursting
into the Cavity of the Pleura.
Garrett Walsh, aged 62, slater; a large, brawny, athletic
man; admitted into hospital November 29, 1842. He says
 Dr. Law on Aneurism of the Aorta. 267
that, although he drank freely, and often had occasion to use
mercury for syphilis, he enjoyed good health till a year ago,
when he fell from a height of about eight feet, and struck his
breast against the end of a ladder. When asked what was the
precise point struck, he refers to a point about two inches above
the left mamma, and nearer to the sternum. He was not obliged
to give up work till within the last three weeks; still he has
been for some time suffering pain in the chest, especially in the
evening.
The following are the signs exhibited on admission: marked
venous congestion of the neck and of both arms, especially the
left; percussion yields a dull sound at the upper part of the
sternum, and extending to the right side; posteriorly the left
side seems to be a shade duller than the right. When the hand
is applied to the second intercostal space over the anterior left,
it discovers an obscure pulsation, which becomes very plain to
the stethoscope placed here, Both in this position, and corres-
ponding to the dull sound at the top of the sternum, there is a
distinct impulse, with two sounds like the sounds of the heart,
but becoming weaker according as the stethoscope is moved
nearer to the cardiac region. The respiration seems to be a
shade weaker in the left than in the right side. The heart is
quite regular in its action, beating very quietly. Pulse equal
at each wrist. Voice hoarse, also his occasional cough. No
stridor in the natural respiration, buta full inspiration produces
it. Deglutition of solids alone difficult: he refers the obstruc-
tion to the lower part of the sternum, He complains of a sharp,
lancinating pain darting though his chest, from the sixth rib on
the left side to the base of the scapula. He has had no
paroxysms of dyspnoea, but is sometimes roused at night by
severe fits of coughing. He is much distressed by flatulency;
bowels very torpid.
Diagnosis.—Aneurism of ascending arch of aorta.
R. Pil. Foetid. Composit, gr. xii.
Muriat. Morphie. gr. i. M.
Ft. pil quatuor. Sumat unam 6ta quaque bora.
268 Dr. Law on Aneurism of the Aorta.
December 5. He states that he felt something give way
in his chest, with a distinct sound, during the night. There ae
at present, a distinct, heaving, internal motion corresponding to
the left subclavicular and supra-scapular regions. From this
period, for several months, there was but little variation either
in the physical signs or constitutional symptoms. All the variety
consisted in the pulsation becoming more distinct and his
complaining more of pain, which he generally referred to the
supra-spinatus fossa, but which he accounted for by a blow
which he had received there from a constable’s staff. Although
the intensest pain was felt here, there was scarcely a point of
the left side where he did not feel it more or less, and at his
own request he had the side generally covered with blisters.
The difference in the respiration in the two sides became more
marked, although as yet there was not a very decided difference
in the results of percussion. The impulse, too, both posteriorly
and anteriorly, was accompanied with a double sound. We could
not account for all the phenomena on the supposition of a single
aneurism, we, therefore, expressed our conviction of there being
more than one. The difficulty we had about the impulse felt
posteriorly, was, the fact of its being attended with a double
sound, which our previous experience had only found to attend
aneurisms of the portion of the aorta on which the pericardium
was reflected; aud as there was no conceivable direction that an
aneurism of the arch could take, and produce the phenomena
we had to account for, we inferred the existence ofa second.
Our treatment consisted in the occasional exhibition of pur-
gative pills composed of calomel, aloes, and assafcetida; and
in the habitual use of pills of muriate of morphia and assa-
foetida, which relieved both the pain and the flatulency, which
distressed him very much. His appetite was good; and he got
a liberal allowance of animal food and porter.
He continued in hospital till July, when he found himself
so much easier, and the weather being fine, he thought he would
try how he would get on at home. He continued out of
 Dr. Law on Aneurism of the Aorta. 269
hospital till September, when he returned, but not on account
of any unfavourable change in his symptoms, but to procure the
comforts and medical treatment, that he could not have at home.
Our report on September 10 was: ‘he says his breathing is
much improved. The left side of the chest, at its superior part,
is much more prominent than the right. Both infra and supra-
clavicular spaces filled up. And here is a very distinct pul-
sation with a double sound. The superficial veins of the left
side of the neck and chest, and of the left arm, are greatly en-
larged, while the fore-arm and hand are ofa deep livid hue.
He has a sense of numbness in both hands, especially in the left.
Pulse weak, but regular, and equal in both wrists. He is sub-
ject to sudden weaknesses, and to a disposition to syncope. There
is scarcely any respiratory murmur to be heard in the left sub-
clavicular region, as far down as the third rib. Percussion
yields a somewhat duller sound in the posterior left than in the
right side; the respiration here also is more feeble than in the
right. Double pulsation heard all through both sides posteriorly,
especially in the left. He has no cough. Voice hoarse. Has no
paroxysms of dyspnoea. He complains of pain in different
parts of the chest, but refers it most frequently either to below
the mamma, or to the supra-scapular region, where he received
the blow. He retains his old predilection for blisters, and is
never satisfied unless when he has on one at least. The heart’s
action is quite regular. He continues to derive much benefit
from his two kinds of pills; purgative, and those composed of
morphia and assafcetida. After stopping six weeks in hospital,
he again went out, feeling himself pretty well. However, before
he left, we observed that the pulsation in the left subclavicular
region was more marked with its distinct double sound; per-
cussion also yielded a duller sound in the posterior left; where
the double pulsation was also very palpable. The respiration
here, too, was much more feeble than in the opposite side. Its
intensity was much increased by a full inspiration, so that we
270 Dr. Law on Aneurism of the Aorta.
constantly observed that we never missed the respiration pos-
teriorly, however feeble it was, in contrast with its entire ab-
sence anteriorly in the subclavicular space. The plain inference
from this was, that the lung was always interposed between the
tumour and posterior side of the chest, while it seemed to be
displaced altogether anteriorly. He had entirely lost all difficulty
in swallowing. He was never without a deep, hoarse voice. He
re-entered the hospital, October 27, loudly complaining of op-
pression of his breathing and of beating of his heart. He re-
ferred his chief distress to the epigastrium and cardiac region.
The physical signs had altered considerably; there was a much
more palpable fullness in the left subclavicular region, with a
very strong double pulsation, which caused a heaving motion of
this part of the chest. The sound here was very dull; and there
was not a trace of respiratory murmur. The sound posteriorly
along the base of the left scapula was dull, and the double pul-
sation was heard though a feeble respiratory murmur, with sono-
rous and sibilant rales. The congestion, almost amounting to a
varicose condition of the veins of the left side of neck, chest, and
of left hand and arm, had quite disappeared. The night after his
admission he experienced the sensation of something giving
way in his left side, when he immediately felt as if he was
dying; his pulse failed; his extremities became cold; his
lips were quite blanched ; and he was bathed in cold clammy
perspiration. Cardiac mixture (composed of camphor mixture,
carbonate of ammonia, and Hofman’s anodyne), and heat applied
to the feet, revived him. At our visit next morning, we found
him in a very low, depressed state; the pulse at the wrist
very feeble; his tongue very much loaded; the pulsation in
the subclavicular region very weak in comparison with what it
had been. We dreaded the effects of any motion in examining
him, as we had no doubt of some serious internal mischief
having taken place, and were equally certain that this mischief
consisted in an internal hemorrhage. His sputa were tinged
with blood,
 Dr. Law on Aneurism of the Aorta. 271
October 31. He is still very low and weak. Pulse stronger,
and fuller in the left than in the right wrist. The subcla-
vicular pulsation still comparatively feeble. Heart’s action quite
regular.
November 4. Complains much of oppression of his breath-
ing. He says, he has quite lost the sharp pain that he used
to have, but feels in its stead a dull aching sensation all through
the left side.
9th. Pulsation under left clavicle much diminished. He
feels himself almost quite relieved of the weakness and de-
pression under which he has laboured for several days. What-
ever oppression he feels he refers to the top of the sternum.
Sonorous and sibilant rales heard through anterior left.
20th. Breathing very much oppressed. Dulness on per-
cussion through almost the entire anterior left side to its base.
Heart’s action normal, but heard at the right side; very slight
pulsation under left clavicle. Universal dulness through all
posterior left, especially in inferior half. Distinct double pul-
sation along the posterior margin of the scapula, heard through
a feeble respiratory murmur mixed with bronchial rales.
Adhibeantur hirudines sex summo sterno.

2lst. His breathing is much relieved, still he can only lie on

his back with any ease.
24th. The pulsation under the clavicle much stronger than
it has been for some time. Dulness on percussion of the upper
part of sternum and left subclavicular region. No trace of
respiratory murmur jn this situation. To one hand placed on
front of the left side, and another posteriorly along the base of
the scapula, there is conveyed a distinct heaving sensation. The
antero-posterior diameter of the chest in this position is much
increased. He says he is quite free from pain. He continues
to take his pills of morphia and assafoetida, with the addition
of a grain of ipecacuanha to each.
28th. Pulsation very strong under the left clavicle, par-
ticularly towards the shoulder. It communicates a_ visible
272 Dr. Law on Aneurism of the Aorta.
motion to the entire side. Complete dulness of all the posterior
left side to its base. Has had return of what he calls the sharp
nipping pain, which he refers chiefly to the left mamma, and to
behind the point of the shoulder, towards the spine. He has
much difficulty in expectorating. In the course of the night he
discharged from the mouth at once, about a pint of florid frothy
blood, and in the effort to get up more, which could be dis-
tinctly heard gurgling in his throat, his face became quite livid,
he fell back and expired.
Examination of the Body twelve Hours after Death.—On
carefully dividing the cartilages of the ribs on the left side,
some fluid blood, or rather bloody serum, escaped from the
pleural cavity. ‘The sternum being removed, this cavity was
seen to be divided into two distinct compartments; one very
large, occupying the two inferior thirds, and filled with serum,
deeply tinged with blood, with large, loose, coagula of blood
init. There were at least three pints of this bloody fluid. The
internal surface of this cavity was coated with lymph, deeply
stained with blood, and which could be detached in shreds.
We proceeded to examine the aorta, by separating it from the
spine, just where it leaves the thorax to enter the abdomen,
and about four inches above this we came upon a large tumour,
lying upon the left side of the bodies of the vertebrae, and ex-
tending up aconsiderable way. It required great force to de-
tach it from its posterior attachment, and the hand, passed be-
hind it for this purpose, came into immediate contact with the
rough, eroded vertebrae. The tumour extended into the left
side, and had contracted a firm adhesion posteriorly with the
second and third ribs, near their articulation with the spine, and
had caused an erosion of these ribs. We now directed our at-
tention to the heart, which occupied its normal position, and
exhibited its natural dimensions. The aorta, however, imme-
diately from its origin at the heart to the termination of the
arch, was dilated to nearly three times its natural size, and was
converted into a complete osseous tube. This change of struc-
 Dr. Law on Aneurism of the Aorta. 273
ture extended into the branches proceeding from the arch. —
There was a uniform dilatation of its circumference, which
reached near to where the left subclavian artery was given off.
On opening the aorta, in its posterior wall, just where its de-
scending portion begins, there was to be seen a circular opening,
with smooth, rounded edges, nearly as large asa half-crown piece,
which led into a large cavity extending up into the top of the
left side of the thorax, and also downwards, and occupied by
the tumour, which we before remarked, and which consisted of
large masses of lamellated fibrine. The lining of this cavity
was a rough, scabrous, irregular membrane, differing very little
in appearance from the diseased internal coat of the artery, and
with which the fibrine was connected ; some masses were at-
tached to it, as it were, by pedicles. The dilated aorta had
pushed aside and downwards, the apex of the lung, while the
organ appeared to be spread upon the tumour. Jt was reduced
to a thin plate of pulmonary tissue, interposed between thetumour,
and the side and posterior wall of the chest. From alittle above
its base there was a cellular, adhesive band connecting the
pleura pulmonalis and costalis, and which divided the side of
the chest into the two compartments to which we have already
adverted. This adhesion formed the floor of the upper cavity,
and on it rested a large mass of fibrine, enveloped externally by
the lung; while it was the roof of the inferior cavity. We could
not discover any rent by which the upper and lower compart-
ments communicated; but we did find one which admitted a
probe from the upper cavity, through its rough, scabrous lining
into the lung. The left bronchus was filled with blood. The
left side of the bodies of the six upper dorsal vertebree were ex-
tensively eroded; their cartilages much less so. The internal
coat of the aorta, from where we commenced our examination,
viz. where it leaves the thorax, to its origin, was the seat of ex-
tensive atheromatous and osseous degenerescence. This con-
dition was most marked in the ascending portion, which formed
the true aneurism, and in the descending portion, from whose
VOL. Xxv. No. 74, - 2N
 a

274 Dr. Law on Aneurism of the Aorta.

7

side the false aneurism arose. The trachea was but slightly
pressed upon, and this pressure seemed to arise from its being
engaged between the dilated arch of the aorta and the highest
portion of the aneurismal tumour, which was attached to the
sides of the vertebrae, There was no apparent pressure on the
cesophagus.
This most interesting case presented many features well
worthy of consideration. It afforded us an instance of the co-
existence of true aneurism, involving all the coats of the artery,
and one from rupture of the internal and middle coats, and be-
ginning so immediately at the point where the dilatation of the
artery ceased, that there existed an almost uninterrupted con-
tinuity between them. ‘This relation of the two aneurisms con-
tributed to render the diagnosis somewhat more difficult. The
dull sound at the top of the sternum, with the double pulsation,
added to the venous congestion of the neck, thorax, and left up-
per extremity, satisfied us of an aneurism of the ascending aorta.
But when the pulsation became distinct posteriorly, and was
also double, it was this that perplexed us. For we could not
conceive it possible that an aneurism only engaging the accend-
ing and archof the aorta, could take such a direction as it must
needs do to present the phenomena that we had to account for.
Still when we attributed this posterior pulsation to a second
aneurism engaging a different portion of the artery (which the
explanation of the phenomena required), we did so in despite of
our experience of the invariable singleness of the pulsation, when-
ever aneurism arose from any other part of the artery than that
upon which the pericardium was reflected, as was noticed, we
believe, first by Dr. Hope. ‘The double aneurism accounted
sufficiently for the posterior double pulsation. The relation of
the true aneurism to the trachea is interesting, as exercising very
slight pressure upon it, and therefore not producing the ordi-
nary stridulous breathing so common when the aneurism en-
gages the ascending aorta; which we attribute to the second
aneurism attracting to itself the force of the circulation, and
 Dr. Law on Aneurism of the Aorta. 275
thus relieving the dilated portion. We would also observe, in
confirmation of this, that the hoarse, raucous voice, and stridu-
lous breathing, were more marked at an early stage of the dis-
ease than afterwards ; and the congested condition of the veins,
which constituted so striking a feature at first, and which served
as one of the principal diagnostic marks, latterly entirely dis-
appeared; both which phenomena must, of course, have been
due to a change in the true aneurism, by which its pressure on
the parts became less. While the trachea was relieved, the
lung suffered, from being compressed between the side of the
chest and the pulsating tumour; and it was found, that accord-
ing as the pulsation became more distinct, the respiration be-
came more feeble. The interposed lung always, to a certain
extent, rendered percussion uncertain as regarded the tumour.
One of the most remarkable circumstances of the case is
the long interval that elapsed between the attack, which, from
the nature of its symptoms, must have been a rupture of the
aneurism and a consequent hemorrhage, and the fatal termina-
tion. The large cavity, filled with bloody serum and coagula,
exactly resembled a circumscribed pleuritis; and had it not
been for the unequivocal signs of hemorrhage that he exhibited
a month previously, and those followed by an increasing oppres-
sion of his breathing, we should have regarded it as a case of
circumscribed hemorrhagic pleurisy. We suspect the hemor-
rhage into the pleural cavity was very gradual; and we would
account for the lymph that coated it in the same way as in
ecchymoses lymph forms round the effused blood. That death
should follow immediately on the last rupture of the aneurismal
sac, isno matter of wonder, when we consider that it took place
into the lung.
The appearance exhibited by the artery in this case was
such as would naturally lead to the disease. We can easily
imagine that this arteritis was produced by the different acci-
dents he met with, operating on a constitution deteriorated
by intemperance. We would remark, that the two accidents to
276 Dr. Law on Aneurism of the Aorta.
which be referred his ailments, viz. the stroke of the ladder
against the chest, and the blow of the constable’s staff on the
shoulder, corresponded as nearly as possible with the internal
position of the two aneurisms. We have so often met with this
disease attributed to accident, that we believe it to be a frequent
cause of it, The absence of any abnormal sound in either aneu- —
rism is in exact conformity with our experience of aneurism of ;
the thoracic, as contradistinguished from that of the abdominal
aorta.
We have not much to say on the subject of the treatment.
The medical treatment was very simple, as the indications were
very few; still we doubt if there be any case in which such
agonizing torture admits of greater alleviation. We cannot speak
too highly of the combination of morphia and assafoetida in re-
lieving the pain and the flatulency, so constant and so distressing
inthis disease. The comfort and ease of the patient were also very
dependent on attention to his bowels, which always responded
to the purgative pill, composed of calomel, aloes, and assafoetida.
With regard to diet, we found that he was always worse when we
attempted to restrict him; we therefore gave a liberal allow-
ance of meat and porter. We believe experience has now fully
established the superiority of this dietetic management of aneu- :

rism over even a modification of Valsalva’s method, and not

alone upon the grounds that such a method conduces to an im-
perfect sanguification and to the formation of blood deficient in
fibrine, and therefore little disposed to coagulate, and so lessen-
ing the prospect of a radical cure, which, however problematical,
should ever be regarded as possible; but also because that it
‘nduces a nervous state of the system, which affecting the heart, —
hurries its action, and may thus cause injurious effects. We —
have already observed how the disease itself requires no ad-
ventitious aid to produce this nervous irritability, as we have
seen the strongest man exhibiting as marked hysteria as we ever
witnessed in the most delicate females. |
 Dr. Law on Aneurism of the Aorta. 277

Case IL.—Aneurism of the Abdominal Aorta opening into the

left Pleura, and compressing the left Lung and Heart.
Robert Harris, aged 35, of a thin, spare habit, labourer,
s that
was admitted into hospital February 20, 1843. He state
with
three years ago, while ploughing, he was suddenly seized
.
pain across his loins, which has quite disabled him ever since
He describes the pain as darting down to his hips and left
groin, and into the left testicle. He has tried many remedies
.
for it, but which never afforded him more than temporary relief
It was always taken for and treated as rheumatism. It comes on
with tolerable regularity every evening about nine o'clock, and
continues for several hours. Besides this intermitting acute
pain, he suffers from a constant, dull, aching pain. The de-
scription he gave of his pain led us to suspect an aneurism, and
on applying the stethoscope to the epigastrium, a distinct, soft,
musical souffle was heard mid-way between the ensiform carti-
lage and the umbilicus. Pulse 84. Heart’s action regular.
His appetite is bad. Bowels very torpid. He suffers much
from flatulency.
The repetition of our examination next day not only es-
tablished the presence of the souffle, but also discovered a dis-
tinct pulsation between the last rib and the ilium. He was or-
dered the following pills:
R, Pil. Foetid. C. gr. xi.
Muriat. Morphie, gr. i. M.
Fiant pilule quatuor; una Atis horis sumenda.

Report.—March 7. He is at this moment suffering agonizing

torture from pain darting down the back and left thigh. Coun-
is
tenance bespeaks the greatest distress. The epigastric bruit
much stronger, while the pulsation between the last rib and the
ilium is more feeble. Pulse 74, small and contracted.
Habeat Extract. Opii aquos. gr. i. 2da quaque hora.
y
Sth. Pulse 84, soft and weak. He suffered intense agon
from nine o’clock last night till five this morning. Epigastric
278 Dr. Law on Aneurism of the Aorta.
pulsation strictly confined to median line, neither to the left
nor right, nor above nor below a space which the circumference
of the stethoscope covered. The posterior pulsation between
the last rib and ilium very distinct. Countenance very anxious.
Bowels very confined.
Adhibeatur lumbis Vesicat. Muriat. Morphie, gr. ii. sparsum.
Enema purgans. Four ounces of Mutton; six ounces of Wine.

9th. Had no return of pain last night. Epigastric pulsation

weaker. Countenance much more composed.
10th. Pulse 90, small and irregular. Was seized with dis-
tressing pain early this morning, which he describes as a hot,
burning sensation passing down the left thigh. Stomach irri-
table and sour.
R Mist. Amygdal. 3vii.
Liquoris Potassz.
Opii Sedativ.
Aitheris Sulphuric. :
Spirit. Ammon. Aromatic. sing. 3i.
Syrupi Aurantii, 3ss. M.
Sumat cochl. ii. ampla 3tiis horis.
Arrow Root seasoned with Brandy.

For several days the pain has been relieved by camomile

stupes applied to the back, and opium taken very largely.
17th. He suffered great agony last night, which he referred
chiefly to below last rib and ilium, but far back towards the
spine. As long as he remains quiet he is comparatively free
from pain, but whenever he attempts to change his position the
motion immediately causes suffering.
Our reports for several days presented but little variety,
telling merely the same story of great suffering, from the con-
stant aching and the intermitting short pain, described as a hot,
burning sensation, principally proceeding down in the direction
of the left thigh and groin. Opium, largely administered, af-
forded but little relief, and never produced even the slightest
 Dr. Law on Aneurism of the Aorta. 279

tendency to narcotism. The epigastric bruit altered but little in

its character, and the pulsation posteriorly became stronger.
27th. We now, for the first time, missed the bruit in the
epigastric region, while the pulsation between the last rib and
ilium has increased much in intensity, communicating a strong
impulse to the side. Heart’s action stronger, and, ifI may use
the expression, more irritable. Pulse 84. Complains of tender-
ness when the left side of abdomen is pressed. He has suffered
what he calls severe “shots” of pain through the left thigh,
groin, and into the left testicle, although he has taken eight
grains of opium within the twenty-four hours.*
Enema e Decocti Amyli, 3ii. et Tinct. Opi, 31.

* We content ourselves too often with merely calculating the number of the
pulse, without examining the heart itself, an examination which discovers to us
what could not be learned from the pulse. What we have designated an irritable
action of the heart consists in a very short contraction of the ventricle, and is best
expressed by the French word vif. Such is the constant character of the heart’s ac-
tion in the class of diseases which, from the disturbance they produce in the vital
functions, have been termed diseases of constitutional irritation, such as phlebitis,
inoculation with an animal poison, &c. In such cases but a single short sound
can be heard, and, as has been observed, it very closely resembles the action of
the foetal heart. This character of the heart’s action may consist with a pulse not
more frequent than natural, but it is in general accompanied by a rapidity of
pulse not met with in any other disease, with the single exception of hemorrhage.
In some of these cases we have counted the pulse at the wrist at 200 in the mi-
nute. We have never met with even an approximation to this frequency of pulse
in uncomplicated fever, and then we have met with it even before we have had
other evidence of hemorrhage, we have always suspected this was coming,—a
suspicion which has always been confirmed by a discharge of blood from the
intestines. We have not much difficulty in understanding why the diseases of
constitutional irritation and hemorrhage should agree in producing this rapid
pulse; for, in fact, hemorrhage causes the same derangement of the nervous sys-
tem that those diseases do. We can discover in this rapid action of the heart
after hemorrhage an effort of the vis medicatrix nature, endeavouring to make
amends for the small quantity of blood sent forward at each pulsation by sending
it often. And we have sometimes seen persons who largely employed depletion to
subdue inflammation, mistake the rapid pulse which they had caused by such
depletion for the effect of the inflammation not yet extinguished, and deplete
280 Dr. Law on Aneurism of the Aorta.
28th. Bruit returned to the former position in the epigas-
trium.,
30th. At five o’clock this morning, when getting out of bed,
he was seized with a sudden feeling of faintness, followed by a
general agitation of the entire body. He felt a sensation as if
there were some oppressive load of which he vainly tried to re-
lieve himself.
10 oclock, a.m. His countenance bespeaks the deepest
anguish. He complains of severe pain in the left side of the
abdomen, which is full and hard, and dull on percussion.
There is no bruit de soufflet in the epigastrium, nor heaving of
the side as formerly. Heart’s action quick (vif) and irritable.
Pulse weak and dicrotous. Stomach irritable. The slightest
pressure, even to touch the left side of the abdomen, down to
the thigh, causes great pain. There is no dyspneea.
Fomentatio Anthemidis abdomini. Extract. Opii, aquos. gr. i.
omni hora. Soda Water and Brandy.
9 o'clock, p.m. There is no pulse to be felt at the wrist.
3lst. He has hada tolerably tranquil night. Pulse has re-
turned to the wrist, dicrotous as yesterday. The only sound
heard in the epigastrium is the weak action of the heart. There
is no longer any pulsation in the left side. The heart beats
with a single stroke and slight pulsation. Face deadly pale,
and bespeaking great distress. Great suffering from the slightest
touch of the left side of the abdomen, whose dulness on percus-
sion contrasts strongly with the tympanitic clearness of the right
side. Although he took nine grains of the watery extract of

further, and so of course add fuel to the flame. This tendency of large depletory
measures to produce derangement of the nervous system, renders the employment
of opium in the treatment of acute diseases a nice point of practice in the ma-
nagement of such diseases. We have seen a nascent pleuritis not unfrequently
strangled by a single venesection and a full opiate. The degree to which the
nervous system mixes itself up with the circulation in the phenomena of inflam-
mation, explains the advantage of such practice.
 Dr. Law on Aneurism of the Aorta. 281
opium, and a drachm of laudanum in an enema, he had not the
least disposition to narcotism.
Repetatur fomentatio, et Opii granum omni hora.
April 1. Pulse 108, stronger. An indistinct bruit de soufilet
is now heard in the epigastrium. The pulsation hitherto exist-
ing between the last rib and the ilium, in rather an anterior po-
sition, now became much more posterior, and nearer to the
vertebree.. He has taken nine grains of opium since yesterday,
without any tendency to narcotism.
2nd. Bruit de soufflet is now distinct in the epigastrium,
but much more diffused than formerly, extending over to the
left hypochondrium. A pulsating tumour is now. distinctly seen
and felt in the left lumbar region. The heart’s action is accom-
panied with impulse and bruit de soufilet. Pulse 108, small
and sharp. ace very much drawn, and of a yellowish, lemon
colour. Eyes sunk and glassy. Thirst urgent. He has no
longer any feeling of tenderness when the abdomen is pressed.
There is a remarkable fulness of the left side of the abdomen,
extending from between the last rib and the ilium forwards and
downwards towards the pubis, and which is peculiarly dull on
percussion. He has had no return of the sharp, lancinating pain
for five days, although he has taken twelve grains of opium since
last visit, without any sign of narcotism. He asks now for some
chicken, which I have ordered for him. Three hours after this,
while ‘sitting up eating his chicken, and expressing his convic-
tion that he wonld recover, he fell back and expired.
Lamination of the Body fifteen Hours after Death.—On
removing the sternum a clot of blood “was seen to cover almost —
the entire anterior surface of the pericardium, and to be conti-
nued from this upon the greater part of the external surface of
the left lung. It was a continuous coagulum of about three
lines in depth that seemed to be spread upon these organs, and
compressed the lung. This blood had got into the thorax from
the abdomen; for, corresponding to the base of the lung, the
VOL. XXV, NO, (4. : 20
282 Dr. Law on Aneurism of the Aorta.
diaphragm was pushed up so as to form a conical projection
into the chest; and at the apex of the projection there was a
small circular opening through which the blood appeared to be
oozing.
In order to facilitate our ulterior examination, we removed
the smaller intestines and as much ofthe large as we could con-
veniently. We then found a large, loose coagulum of blood,
occupying the left iliac fossa, extending from the anterior supe-
rior spine of the ilium to the pubis. This was shining through
the peritoneum, There wasalso a considerable effusion of blood
‘nto the cellular membrane, connecting the peritoneum with the
anterior wall of the abdomen, as well as into that behind the
bladder. We now directed our attention to the aorta, and
found in its course a tumour, bound down to the spine by the
crura of the diaphragm. This tumour did not rise much above
the level of the vertebree. On slitting up the anterior wall of
the artery, just opposite the cceliac axis of vessels, we discovered
in its posterior wall a circular opening with smooth edges, about
the size of a half-crown piece. This opening led to the tumour,
which lay in a cavity hollowed out of the vertebrae. It was a
mass of lamellated fibrine, and appeared to be equal in its ver-
tical and transverse diameters, being about four inches in length
and breadth. ‘Posteriorly it lay upon the bare eroded bones.
The cavity in which the tumour lay occupied the bodies of the
two last dorsal and the two first lumbar vertebrae, while aé each
side it was formed of cellular membrane, which was whole and
entire at the right side, but appeared to have given way at the
left. A large, dark coagulum of blood effused into the cellular
membrane, behind the peritoneum, filled up all the space at the
left of the spine, from the diaphragm down to the attachment of
the psoas muscle. This coagulum formed a perfect mould of
the parts. It completely enveloped the kidney; and infiltrated
into the substance of the psoas muscle of, made it, by its full,
swollen appearance, contrast strongly with the muscle of the
opposite side. It also was infiltrated into the cellular tissue,
 Dr. Law on Aneurism of the Aorta. 283

which, in the absence of the peritoneum, connects the posterior

surface of the descending colon with the anterior surface of the
kidney. It was the superior part of this coagulum that pushed
up the diaphragm, and supplied the blood that was effused on
the lung and heart. In this clot could be seen the nerves pro-
ceeding from the spine, as well as cellular filaments traversing
it in various directions, and which appeared to hold the mass
together, Its firmness was not uniform, being much greater
more externally than nearer to the spine. The heart was per-
fectly healthy. Its left ventricular cavity alone was smaller than
usual, but this was due, no doubt, to the hemorrhage before
death; for it admitted of being enlarged by very little force.
There was no disease of the aorta through any part of its course.
This case suggests many interesting considerations. It con-
firms the importance that we attached to the peculiar double pain
that we have already noticed as so constant in certain aneurisms
of the aorta. It was its existence that led us to look for aneu-
rism, and to suspect that the case was not, as it had been re-
garded, one of rheumatism.
Since our observations on Aortic Aneurism have been pub-
lished, some very interesting cases of exostosis of the spine have
been published by Dr. Francis Battersby; in one of which he
states that the nature of the pain coincided exactly with that
which we have described as pathognomonic of aortic aneurism
arising from the posterior part of the artery. Dr. Battersby’s
single case that exhibited this coincidence of pain, does not de-
tract much from the value that we have attached to this symptom,
from the rarity of such cases, compared with aneurism of the
aorta causing disease of the spine, and from the absence of other
ground for suspecting aneurism—especially the bruit de soufflet,
which we have found to be constant in aneurism of the abdominal
aorta. It is only when it becomes a question between aneurism
of the thoracic aorta and exostosis of the spine, that we might
be embarrassed, where we have the usual bruit de soufilet as con-
stantly absent, as we have it present in aortic aneurism. Dr.
284 Dr. Law on Aneurism of the Aorta.

Battersby’s case, added to one which I have recently met witlr,

which proceeded from the front of the abdominal artery, and in
which the occasional intermittent pain was present, and where
there was no affection of the bone, answers a question which I
proposed in my recent observations, viz. upon the lesion of what
structure or tissue does this twofold pain depend? I expressed
my opinion, that while the occasional lancinating pain was due
to the affection of the spinal nerves, the continued aching, boring
pain, was caused by the affection of the bone: the correctness of
which opinion these two cases seem to prove.
Another point of interest in this case is the succession of
hemorrhages that seem to have taken place at more or less dis-
tant intervals, and which were marked by distinct symptoms
during life, and appeared after death in the different degrees of
firmness of the different coagula. ‘The most recent unques-
tionably was that effused on the lung and heart; the next seemed
to be that which extended from the ilium to the pubis, and which
appeared to be continued from the most external part of that
which ranged along the spine, while the internal part of this was
the least consistent, and was probably of the same date as that
which penetrated into the thorax. Of course the tumour, com-
posed of lamellated fibrine, and which lay on the spine, consti-
tuted the original disease. Iam inclined to believe that at the
time that he presented himself first at the hospital, the original
aneurism had given way, and that the pulsating tumour, which
soon after his admission exhibited itself between the last rib
and the ilium, was the result of it. This pulsation gradually in-
creased, till symptoms occurred plainly indicating a heemor-
rhage. Now the flattened tumour, extending from the anterior
superior spine across to the pubis, presented itself. From this
time the pulsation changed its position, becoming much more
posterior and nearer the spine, till his sudden death: and the
looser condition of the part of the coagulum next the spine, con-
tinuous with the effusion into the thorax, coincided exactly with
this altered direction of the pulsation. The death in this case
 Dr. Law on 4neurism of the Aorta. 285
would seem to be the mixed result of hemorrhage, and of the
compression of the important organs upon which it was exercised.
The abdominal organs bear pressure better than those of the
thorax, and therefore furnish fewer symptoms towards the de-
tection of the disease.
We have only a single observation to make relative to the
treatment :—that there is scarcely any limit to the extent to
which we may exhibit opiates without their producing narco-
tism. The only other case in which we exhibited anything lke
the same amount of this remedy, without its producing, not to
say narcotism, but any effect whatever, was the case ofa ner-
vous female, who laboured under hysterical mania. She took a
drachm of Bentley’s sedative in the course of an hour, without its
producing any effect.

The preceding cases, added to those which we have already

adduced, warrant us in drawing the following inferences:
When aneurism arises from the posterior part of the aorta
we generally want the evidence of a palpable tumour to indicate
the disease.
When the tumour is resisted in its development by unyield-
ing structures (as is the case when it arises from the posterior
part of the aorta), it produces in these structures changes giving
rise to peculiar symptoms, especially to a peculiar character of
pain, which, if not exclusively confined to this disease, exists so
much more frequently in it than in any other, as to be enough at
all times to awaken a suspicion of aneurism. However obscure
all other symptoms of aneurism of the aorta, apart the existence
of a palpable tumour, may be, still it rarely happens that there
are not some, which, added to the existence of the particular
pain, may not suffice to make up what this latter may want of an
exclusive pathognomonic sign of the disease.
If this pain be connected with the lower dorsal and lumbar
vertebrae, and depend upon abdominal aneurism, there will be,
286 Dr. Law on Aneurism of the Aorta.
according to our constant experience, a bruit de soufilet in the
course of the artery.
If the pain be connected with the upper or thoracic dorsal
vertebree, and be owing to aneurism, it seldom occurs that there
is not some difficulty in deglutition, or some obstruction in the
respiratory apparatus, either affecting the trachea, and so weak-
ening the respiration in both lungs, or exercised upon either one
bronchus or upon one lung, and so producing a difference in the
relative form of the respiration in the two lungs. In the absence
of the bruit de soufflet (which we have almost always found ab-
sent in thoracic aneurism, except where the valves of the aorta
were involved in the disease), some one of these symptoms will
generally be present to confirm the value of the pains.
The character of the pain consists in a constant, aching,
boring sensation, and a sharp, lancinating pain.
To relieve the agonizing pain of aneurism, there is scarcelya
limit to the amount to which we may exhibit opium, without
producing narcotism.
In the treatment of aneurism, low diet should be avoided, as
lessening the prospect of a radical cure of the disease, and as
increasing a nervous irritability,—the constant accompaniment
ofit.
The interval between the fatal termination and the bursting
of an aneurism is various, and is much influenced by the impor-
tance of the organs which the hemorrhage may affect. If it
burst into the pericardium, and compress the heart, such interval
will, of course, be shorter than if it compress a less vital organ.
If there have been an adhesion between the laminz of the peri-
cardium the effusion will be more gradual, and therefore the
interval will be longer than if no such adhesion existed, as we
have proved by experience. ‘The suddenness of the fatal termi-
nation would seem to be in proportion to the extent and sudden-
ness of the hemorrhage, and the importance of the organ or
organs, whose function may be mechanically interfered with by
the effused blood.
 Dr. Sealy on a peculiar nervous Affection, &c. 287

Art. XI.— Observations on a peculiar nervous Affection in-

cidental to Travellers in Sicily and Southern Italy. By
J. Hunecerrorp Szaty, Esa, M.D.,A.B., late Resident
Physician at Florence, Messina, &c.
Tue peculiar disease which I am about to describe I had fre-
quent opportunities of witnessing during my residence in Sicily
and Southern Italy.
It is characterized by an excessive irritability, attended with
extraordinary mental and muscular activity, and seldom attacks
the new comer, but more frequently those who have been resi-
dent between two and three years, and not yet acclimatized, and
just beginning to suffer from nostalgia. In it, a consciousness
of disease exists, which is incapable of being expressed, and the
mind is disturbed by visions, which the sufferer is almost
ashamed to avow; the imagination is morbidly awakened, yet
the mind of the patient is still under the control of judgment,
yet with scarce a capability of obeying its dictates.
Having suffered much from it myself, and witnessed it in all
its stages in others, varying, indeed, from the sublime of fearful,
asI saw it in the case of an English clergyman at Messina, to
the ridiculous of absurd nervous fancies, in those not previously
subject to such hallucinations, I consider myself peculiarly quali-
fied to offer a few remarks on it, which I hope may prove ser-
viceable to travellers in the countries of which I shall treat.
That it is a disease of climate | am well convinced, and that
all are more or less liable to it in visiting those countries, my
experience has assured me. ‘The modifications of it are, how-
ever, great, and the grades various, from slight excitability to
serious and formidable disease, affecting the mind and body ; it
consequently behoves every traveller to be particularly cautious
of his diet and general health, and to observe carefully his im-
pressions and sensations, to guard against this insidious and
formidable enemy, and, by attacking it at the commencement,
overcome it effectually.
288 Dr. Sealy on a peculiar nervous Affection
To the travellers in Rome, Naples, and Sicily these obser-
vations will peculiarly apply.
That it has not hitherto been sufficiently noticed and de-
scribed, my acquaintance with the literature referring to Italy
and Sicily assures me. In fact, little or no notice is taken of it
by any of the writers on climate with which I am acquainted,
such as Clarke, Johnson, &c.
It seems a hyper-elimination of the nervous principle, a
peculiar elastic evaporation, ifI may so express it, of a spiritual
consciousness and capability, aroused by electrical agency or in-
visible atmospheric influence.
The imaginative and the sanguineo-nervous temperaments
are peculiarly liable to it, and suffer much during the prevalence
of the Scirocco wind, particularly at Rome and Palermo, and
at Naples and Sicily, when the atmosphere is charged with elec-
tricity, or when thunder is brewing, as the vulgar phrase is, and
particularly during earthquakes in Sicily.
That all should experience excitement in that elastic atmos-
phere is little to be wondered at. It forms a considerable part
of the charm of travel and climate; it is, however, when that
excitement becomes excessive and permanent that it requires
consideration and control. No one, I believe, has ever crossed
the Alps without finding in himself a sense of elasticity on the
Italian side different from the more cloudy atmosphere of the
Swiss mountains ; and how much more is that experienced on
first landing in Naples or Sicily, supposing that the traveller has
come by sea. He must be indeed a dull clod of unimpassioned
clay who would not feel excited beside the tombs of ‘Tasso or
of Virgil, or seated on the rock of Scz//a contemplating Sicily.
In fact, the impression of vigour is so great, as a plain, un-
imaginative London gentleman expressed himself to me, as
we strolled in the Marina, at Messina, together, that he felt
as if “ he wished to knock down every one he met,” and although
a man of a sobered time of life, and, I have reason to believe,
quiet habits in England, he became so excited to mirth, as to
 incidental to Travellers in Sicily and Southern Italy. 289
be almost unbearable, and this without the smallest assistance
from internal stimulants. The extraordinary rarity of the at-
mosphere contributes much to this, the force with which impres-
sions are conveyed to the senses; in fact, in Sicily the air is so
attenuated and transparent that distance seems almost annihilated,
and sounds come on the ear with appalling force; the perpetual
ringing of their church bells, and the firing of their gioco di
fuoco on fete days, is enough to startle the best strung nerves;
and the perpetual roaring of their criers about the fish-stalls is
truly horrifying. The noises both at Naples and Messina, where
the slightest sound is audible, from the tenuity of the atmos-
phere, is appalling; and yet, curious to say, the natives do not
appear to mind it, although they all seem much alive to nervous
impressions, which the restlessness of their motions indicates:
you never see a Neapolitan or a Sicilian at perfect rest, he is
always either twisting his cane or shaking his leg, or contorting
himself in some way or other, but absolute rest seems incom-
patible with his existence. This same excitability the English
traveller feels more or less, according to the character of his
nervous system.
Some portions of Italy, however, possess this influence much
more than others. The difference between Rome and Naples,
in that respect, is very striking, and the locality it is, doubtless,
which so influences the appearance and habits ofthe inhabitants.
_ The difference between the two cities may be thus summed up,
as regards the stranger. At Rome you are pleased, at Naples
you are amused ; the hypochondriac is rendered worse at Rome,
at Naples he is debarred from gloomy thoughts by the multi-
titude of animated objects around him: the Toledo at Naples is
a perpetual Roman Carnival. At Rome you derive your grati-
fication from inanimate objects, and from your own reflections.
At Naples you have no time to reflect, your mind is amused and
engaged by others; it isa varied and amusing panorama; the
gait of the Roman differs from that of the Neapolitan, it is
VOL, XXv, NO. 74, 2 P
290 Dr. Sealy y on a peculiar nervous Affection

more slow and solemn. The Corso at Rome and the ‘Toledo
at Naples, may be compared to St. James and the Strand in
London.
While resident in Florence several cases of this nervous af-
fection presented themselves to me, affording curious, and some
of them most amusing traits; but the severest form I ever wit-
nessed of it was in Messina in Sicily, which I shall here relate,
omitting merely the name, as the exceeding peculiarity of the
mental symptoms of the patient, a talented and most respected
clergyman, may render it painful to him to have revived those
recollections of the awful times in which I attended him, should
this ever meet his eye. |
Having arrived at Messina, by steam packet, from Naples,
and aware that there was no resident English physician in the
island, I was shortly after my arrival waited on by a gentleman,
saying, that their resident clergyman was dangerously ill, and
requested my immediate attendance, that they had written to
Malta for one, the English merchants of the town being in the
greatest state of alarm about him, and that they had been most
anxiously expecting the arrival of some ship containing one ;
that the town was quite in a ferment about him, the Church of
England Service having been suspended for some weeks, Inas
short a time as possible I made my call. I found the gentleman
in bed, his countenance was haggard and wretched, his eyes
glaring out of his head, and deeply suffused and bilious; his
skin was dry and parched, and almost verging on the icteroid
tint; his tongue was dry, and red at the edges, and covered
with a brown fur in the centre and back portion; his pulse was
small and quick ; and his general expression denoted the deepest
misery and suffering, although his mind was perfectly clear.
On inquiry, I found he had been ill three weeks, during which
time he was under the care of a Sicilian physician, and was gra-
dually getting worse. On inquiring what medicine he had taken,
he said very little, and that not of a purgative character, althougl
 incidental to Traveilers in Sicily and Southern Italy. 291
he was aware that he wanted it, as his bowels had not been
moved for some days. He attributed the attack to an incau-
tious exposure to the sun, that his Sicilian doctor had declared
his complaint to be March fever, and was treating him accord-
ingly with large doses of quinine, which he did not fancy agreed
with him. He was certainly not getting better, and was very
glad [had arrived, as he thought an English physician would
see his case in a different point of view from an ignorant Sici-
lian, and he hoped would be able to do him some good. On
further inquiry I found that the only other medicine, beside the
quinine, he had taken was infusion of taraxacum, that panacea
for all Sicilian maladies.
In a short time I met my Sicilian confrere in consultation,
and asked him his view of the case; he said it was a simple case
of March fever, and would quickly subside under the continued
use of quinine and taraxacum, that he had never known them
fail. I begged to differ from him, and said it struck me that
with such a tongue, and such a gorged state of the chylo-poietic
viscera, accompanied with such high nervous excitement, quinine
was inadmissible, and suggested the use ofa smart dose of blue
pill, and compound colocynth pill, to excite the biliary secre-
tion. ‘The latter formula he had never heard of; the blue pill
he had heard of, but did not believe that there was any in the
island, unless [ had some, if so, he had no objection to try it. I
fortunately had, having been supplied at Naples by my friend,
' Mr. Jessop, resident English apothecary at that city, with all
medicines necessary in general practice in Sicily; and on men-
tioning the subject to the gentleman, he was delighted at the
idea, and said it was, he was sure, the very thing he wanted, that
he was poisoned by the Sicilian drugs, which did him no good.
I accordingly administered to him a smart dose of each, to the
Sicilian’s great horror, who thought six grains of each a dose
sufficient to killa buffalo. I ordered, at the same time, leeches
to his head, which was hot and throbbing, mustard sinapisms
to his feet, the pills to be followed up by a bitter saline mixture
292 Dr. Sealy on a peculiar nervous Affection
d in
to full purging, and the most perfect quiet to be preserve
matter
the palace where he resided ; this 1s, however, a difficult
in the Ma-
to obtain at Messina, although his residence was not
,
rina, for between the braying of donkeys and crowing of cocks
of
beside the ringing of bells and roaring of provision venders
d
every description, from the exquisite pesche spada, or swor
up-
fish, to the humble lettuce, Messina is one long continued
roar, deafening, maddening, confusing.
On seeing my patient within twelve hours, I found a con-
pro-
siderable improvement; the medicine had acted copiously,
r
ducing several highly bilious stools, attended with such foeto
re it,
that the gentleman assured me that he could scarcely endu
to
that it literally made him ashamed, the effluvia appearing
nce
poison the atmosphere of the whole palace. His countena
a
was much improved, and his skin had assumed something of
,
more healthy aspect; his mind was also much more composed
and his nervous system quieted ; there was no longer that fearful
twitching of the muscles, nor consciousness of mental horrors.
The case was now clear to me. Mr, was naturally ofa
highly excitable and nervo-sanguineous temperament, a bene-
ficed clergyman in England, and educated at Oxford, where he —
had taken a high degree, led away by the enthusiasm of a highly
gifted and ardent imagination, he deserted his snug rectory to .
tread the fields of classical romance and historic renown. On

his return from Greece he was induced, by the solicitations of !

the British merchants at Messina, a numerous and wealthy body,
to establish himself there, more with the Christian hope of
founding an English episcopacy in the island, where one had —
never before existed, than with any expectation of pecuniary re- —
ward; and for many months before my arrival in the island he —
en
npr

laboured hard in his vocation, admired and loved by a respec- —

table congregation; nor did I ever, indeed, see in any part of ‘
the world a more sincere and deep sympathy exhibited, than —
was expressed for his miserable situation,—for most miserable ;
it was when I first saw him, and that of his amiable and dise—
 incidental to Travellers in Sicily and Southern Italy. 293
tracted lady, whose hands were one moment raised in prayer, at
another clasped in silent agony at beholding her beloved hus-
band in such a situation—insanity struggling with reason.
My limits in this Paper will not allow me fully to detail the
entire case of Mr. During my six weeks’ attendance on
him, much curious details of the progress and character of his
malady were imparted to me, as he progressed to recovery, for
such did take place in my hands, affording me the sincerest gra-
tification of any act of my professional life, and most sincerely
did I then, and ever shall, thank God for having been the
means of saving the life of this accomplished and truly Christian
clergyman, by my accidental arrival in the island.
During the progress ofhis disease, his mental hallucinations
were extraordinary, almost amounting to what the French mes-
merisers denominate clairvoyance, and his visions frightful; his
pervading wish, as he expressed it to me, was to tear every thing
near him, to shout, to sing, and curse; he fancied he saw his
limbs leaving his body, and occupying, disintegrated, separate
portions of the large apartment where he lay; he was convinced
of the unreality of the vision, and of its being the result of a
diseased imagination, yet so palpable was the delusive vision
that he could scarcely correct the delusion by the utmost effort
of reason, or disbelieve the apparently so palpable evidence of
his senses.
The bodily disease, separated from the mental hallucination,
evidently had its origin in the biliary and chylo-poietic viscera;
the turgescence of the hepatic viscus, and engorgement of the
prima via, as well as the nature ofthe alvine discharge, indicated
this; the relief also afforded by the evacuation of the most foul
contents, and the subsidence of the nervous and phantasmagoric
hallucinations subsequent to it, fully establish it.
The case was, however, a protracted and critical one, re-
quiring an immensity of care and medicine, to the astonishment
and horror of my Sicilian fellow-labourer, who gave me up the
case altogether, and retired in disgust at my disregard of the
2O4 Dr. Sealy on a peculiar nervous Affection
virtues of the Zion-toothed taraxacum, shrugging his shoulders at
the “ dura ilia” of the British. |
This case is interesting from the well-marked character of
the symptoms, and exceeding severity of the disease; it was, in
fact, the disease in its severest type, and attended with its most
appalling symptoms, almost, in appearance, at one time resem-
bling delirium tremens, and affording all the symptoms of that
fearful malady. The minor modifications of the disease, met
elsewhere, were not attended with such severe constitutional
symptoms, and, in fact, in many cases where severe and distress-
ing mental hallucinations existed, were unaccompanied by mor-
bid appearances. In fact in many the tongue was clean, although
generally white and flabby, retaining the impressions of the
teeth for a long time after the mouth was opened, as in hysteria.
A Mr. H., who called on me in Florence, had some of the most
curious hallucinations it is possible to conceive; his great dread
was to meet the human eye; he had also an extraordinary in-
clination for grinning and contorting his countenance, and an
utter dread of taking medicine, fearing, as he said, the impos-
sibility of cleansing himself after it. He-said it came on at
Rome, where he had spent a winter. He was an accomplished
and highly educated gentleman, and was fearfully alive to the
horrors of his nervous afiliction.
A poor woman, whom [ also attended at Florence, had an
almost uncontrollable desire to murder her children, of whom,
she admitted, she was doatingly fond; it came on her gradually,
she said, having been five years in Florence, and that she had
not felt it until the two last years. She was, when Ifirst saw
her, a picture of suffering and misery. She was seated in her
own apartment, on a high wooden chair, with her legs drawn
tight into the back rung, and her back bolt upright, not resting
against the back of the chair, but seeming almost as if in em-
prostotanic spasm; she was trembling violently, and her face
and hands bathed with cold perspiration. Her mind was clear,
although labouring under a sensation of some impending horror
 incidental to Travellers in Sicily and Southern Italy. 295
or apprehension, for which she could not account, and had not
the slightest reason. Her habits had been always temperate,
and her circumstances comfortable; her husband being a re-
spectable English groom.
In all these cases, and several others I have met, [ could
always trace the disease to some engorgement of the chylo-poietic
viscera, and, in fact, I always considered the disease as a modi-
fication of hypochondriasis, aggravated by peculiar circum-
stances, the nervous system being over-exerted by atmospheric
influence, while the biliary and digestive was deranged at the
same time.
The treatment I have generally found to succeed best is
a modification of mercurial and vegetable purgatives, with a
modified anodyne and stimulating system of treatment. Under
this plan I have generally found my patients recover, or at least
obtain relief. Some miserable cases of self-destruction and in-
sanity have, however, come under my notice, which I may detail
in my next, with notice of the Medical Institutions of Tuscany
and the Papal States,

Arr. XII.—On the dark abdominal Line, and the Formation

of an umbilical Areola, as Signs of Delivery ; ina Letter
to the Editor of the Dublin Medical Journal. By W. ¥.
Monrtcomery, M. D., Professor of Midwifery in the King
and Queen’s College of Physicians in Ireland.

Sir,—My attention was, within the last few days, called by a

well-informed pupil, at present attending my lectures, to a very
useful Paper, by Dr. Rose Cormack, in the London and Edin-
burgh Medical Journal for last February, on the dark line ocea-
sionally observable on the abdomen of pregnant and puerperal
women, extending from the pubes to the umbilicus, and, some-
times, thence to the ensiform cartilage, ‘“ showing that it often
depends on other causes than recent delivery ;’ in which, after
2
296 Dr. Montgomery on the dark abdominal Line and
asserting that Mr. Turner was the first who directed attention to
this mark, he adds: “ In Dr. Montgomery’s work on the Signs
and Symptoms of Pregnancy, there is possibly obscure allusion
made to it, when this author says: ‘In some cases there is also
to be seen, extending between these two points, a brown line, of
about a quarter of an inch in breadth, especially in women of
dark hair and strongly coloured skin.’ It does not, however,
clearly appear from the context, that Mr. Turner was anticipated
by this distinguished author.” And again, at page 130, in a
review of Dr. Campbell’s recent work, my notice of this subject
is spoken of as an “ obscure allusion, if allusion at all, it can be
called.”
In Mr. Turner’s Paper, which was published in August, 1842,
in the same Journal, he distinctly claims priority to all others, in
formally noticing this peculiar mark as among the signs of de-
livery; to which claim, Iam quite ready to believe that he con-
scientiously thought himself entitled; but, I must add, that the
claim was incautiously made, because he might, with very little
trouble, have satisfied himself, by a reference to my work on the
Signs of Pregnancy and Delivery, to which he has referred in
the course of his Paper, thatIhad distinctly noticed the matter,
five years before.
Now, Sir, whether my notice of this peculiar sign was so
obscure, as to render it doubtful whether I referred to it at all
or not, as implied in the above statements, I must leave to you and
others to determine, when I shall have laid before you the pas-
sages in which it is mentioned. I will only say, that if they are
to be considered only as obscure, or equivocal allusions, I shall
be more than ever at a loss to know what would be considered
as distinct.
At page 296 of my work, above referred to, after describing
the broken streaks, pearl-coloured lines, and other marks found
on the abdomen after delivery, I have said: ‘“‘ These marks are
sometimes accompanied by a brown line, extending from the
 Lormation of an umbilical Arcola, as Signs of Delivery. 297
_ pubes to the umbilicus, which will be noticed more particularly
presently.” |
At page 304, after again noticing these broken lines on the
surface of the abdomen, it is added: “In some cases there as,
also, to be seen extending between these two points a brown
line of about a quarter of an inch in breadth, especially in wo-
men of dark hair and strongly coloured skin,”
And again, at p. 307, this mark is, a third time, mentioned
in these words: “ The brown line sometimes found extending
from the pubes to the umbilicus is only of occasional occur-
rence, &c.” |
Now, Sir, I should think, that after the perusal of these pas-
sages, few, who attach the ordinary meaning to the term “ con-
text,” will be found to adopt the opinion of Dr. Cormack, that
“it does not clearly appear from the context” that Mr. Turner
was anticipated by me, in the description of this dark abdominal
line, as an occasional, but not constant sign, observable in puer-
peral women.
With regard to my claim to priority in the description of this
peculiar appearance, all I will venture to say is, that as far as
my reading and research have enabled me to ascertain, it was
not enumerated among the signs of delivery by any author, pre-
vious to the publication of my notice of it in my work, in June,
1837. No mention of it, as among the signs of delivery, is to be
found in Beck’s Medical Jurisprudence, up to that date; nor
did it appear in that very comprehensive work until the edition
of 1842, when, after describing the linee albicantes, it is noticed,
for the first time, in these words: “ Along with these, Dr. Mont-
gomery (pp. 304, 307) has sometimes noticed a brown line, of
about a quarter of an inch in breadth. extending from the um-
bilicus to the pubes, especially in women of dark hair and
strongly coloured skin.”* Which quotation, occurring in a
work so universally known and read, as Beck’s is, could hardly

* See Sixth Edition, 1842, p. 171, Note,

VOL: SXV. No. 74. 2Q
298 Dr. Montgomery on the dark abdominal Line and
have been expected to escape the attention of any one writing
expressly on this subject in the two subsequent years. |
In conclusion, I beg to observe, that I have in a few instances
observed accompanying the dark abdominal line, another ap-
pearance ofa similar kind, not hitherto described by any one, as
far as 1 am aware. It consists in a dark-coloured circle, or
areola, surrounding the umbilicus, extending in breadth about
a quarter ofan inch all round that part, and in general, but not
always, varying in depth of tint according to the colour of the
hair, eyes, and skin of the woman. Unlike the mammary areola,
there is no turgescence or elevation of it above the surface of
the surrounding skin, neither are there any prominent follicles
upon its disk, One specimen of this I saw within the last few
days, in a lady with very dark hair and eyes, who had just given
birth to a child, which, there was every reason to believe, had
been dead nearly a month. The abdominal line was faintly
marked, as was also the circle around the umbilicus, and the
mammary areola looked faded. The first time I observed this
appearance was in 1840, and it was its extreme depth of colour
which arrested my attention, while in the act of adjusting a
binder on the patient. It is of much less frequent occurrence
than the dark abdominal line, but I have never as yet seen it,
except in the puerperal woman. Whether it is ever produced
under circumstances unconnected with pregnancy, remains, as far
as I know, to be determined by more extended observation.

The following are the conclusions, in reference to this dark

line, to which my observations have led me:
1. It is generally, but not always, present in puerperal wo-
men, and in women advanced in pregnancy.
2. It is occasionally visible at early periods of gestation. I
saw it faintly, but quite perceptibly marked in a lady with very
dark hair and eyes, who had just miscarried in the second
month. Consequently
 Formation of an umbilical Areola, as Signs of Delivery. 299
3. When it is visible, it is no proof of the woman having
been delivered at an advanced period of gestation, or of a viable
child, as supposed by Mr. Turner. 3
4. It is occasionally observable in states altogether uncon-
nected with gestation. In one case, I saw it distinctly marked in
a girl of about ten years of age, who was affected with mesen-
teric disease; and in another instance, I found it well developed
ina ce labouring under ovarian tumours and enlarged liver.
- Its depth of colour is, in general, proportioned to the
sivas of the hair, eyes, and skin; but to this, there are many
exceptions.
6. It is, in general, more strongly coloured, and more dis-
tinctly defined, a day or two after delivery, than before or during
labour.
7. Its shade and depth of colour are apt to vary at different
times, in the same case, without any obvious or intelligible
cause.
8. IT have not seen the umbilical areola except at the time
of mature delivery ; but I take for granted, as a matter of course,
that it may, like the dark line, be observed during gestation.
“T remain, Sir, your’s very truly,
W. F. Montcomery.
Molesworth-street,
3rd April, 1844.
 BIBLIOGRAPHIC NOTICES.

An Anatomical Description of the Human Gravid Uterus and

its Contents. By the late Wittiam Hunter, M. D., &c. &e.
Second Edition. Edited by Epwarp Riesy, M.D., &c. &c.
London, 1843, pp. 75. Plates.

Tue generally irksome task of criticism assumes quite another

aspect, and becomes a gratifying occupation, when, with can-
dour and sincerity, we can offer the author, in recompense for
his exertions and labours, the well-deserved meed of eulogy
and approbation; and in such a pleasing position we now find
ourselves placed.
Dr. Rigby is already well known to the Profession in these
countries, not only as the son of one whose name is familiar
wherever British midwifery is known, but on his own account
also, as an accomplished physician, and successful practitioner,
in the great metropolis, and as the author of more than one va-
luable treatise on subjects connected with obstetric medicine;
and on the present occasion he has rendered a most acceptable
service to his brethren, by undertaking to place before them a
new edition of a work celebrated all over the world, but be-
coming latterly so scarce that it was only procurable with great
difficulty; and besides, although highly valuable, was neces-
sarily deficient in all those numerous facts and opinions with
which more modern investigation and discovery has so largely
and usefully enriched the anatomical and physiological depart-
ments of midwifery.
Originality does not appear to have been Dr. Rigby’s aim in
re-editing this work, nor, indeed, could it well have been; but
he has well supplied, from a variety of sources, referred to in his
notes, such information as was required to bring the considera-
tion of the matters treated of up to the level of our present
knowledge, and added many judicious and accurate remarks
thereon.
At p. 40 e¢ seq. the editor has given a full and satisfactory
analysis of the more modern opinions on the structure of the
 Dr. Hunter on the Human Gravid Uterus. 301

placenta and its mode of union to the uterus, to which he has

added a theory of his own, for which we must refer the reader
to the work itself.
We perceive, with satisfaction, in his notes on the decidua,
that Dr. Rigby refers, and most justly, the discovery of the de-
cidual cotyledons to Dr. Montgomery of this city, and we per-
fectly agree with him in thinking !
‘That no one can read Dr. Montgomery’s description of them,
after that quoted from Dr. Sharpey, and examine the diagrams of
Plate V., particularly fig. 4, without coming to the conclusion, that
the decidual cotyledons of Dr. Montgomery are identical with the
uterine glands of Dr. Sharpey.”—p, 52.
And we must add, that we think it would have been, in Dr.
Sharpey, more in unison with the liberal spirit of scientific in-
quiry, towards one who had anticipated him, had he more fully
and candidly acknowledged the previous discovery of Dr. Mont-
gomery than he has done in the very slight and equivocal allu-
sion to it, in his Paper on the subject.
On the whole, we have, in this volume, a most desirable ad-
dition to our works of reference. Its size is far more convenient
than that of the original edition of 1794, edited by Dr. Baillie.
As to the “ getting up,” nothing could be more elegant; and of
the Plates we cannot speak too highly,—they are at once taste-
fully designed and beautifully executed; while the price is so
moderate, as to place the work quite within the reach of the
student, as well as of the senior members of the Profession, of
whom, we venture to predict, few will be without a copy of this
valuable treatise.
We cannot, however, agree with our author in his doubts
(pp. 20, 21) of the reality of the nerves of the uterus discovered
by Dr. Robert Lee, and so beautifully represented in his Plates.
Having inspected Dr. Lee’s dissections, we are prepared to state
our opinion to be in unison with that of Mr. Lawrence, Mr.
Stanley, and Sir B. Brodie, as expressed in their letters on this
subject, viz. that Dr. Lee has succeeded in displaying ganglia
and nerves, of which he has given correct representations.—
Vide Medical Gazette for January 19, p. 523. And we think
it but justly due to Dr. Lee to say that he has, in this instance,
made one of the most brilliant additions to modern discovery
connected with the organization of the uterus,
302 Bibliographic Netices.

Anatomical Manipulation ; or the Methods of pursuing prac-

tical Investigations in Comparative Anatomy and Phy-
siology. Also, an Introduction to the Use of the Micro-
scope, &c. By Atrrep TuLk, M.R.C.S., M.E.S., and
Arruur Henerey, A.L.S., M.Mic.8. London, 1844.

In the study of human, as well as of comparative anatomy, the

accuracy of our observations, and the justness of the inferences
deduced from them, must, in a great measure, depend upon the
manner-in which the various complex structures, which enter
into the composition of animal bodies, are displayed and pre-
pared for examination.
To the student, therefore, it is of the highest importance to
acquire a practical knowledge of the contrivances to be adopted,
the instruments to be used, and the general means to be em-
ployed in his researches. ;
Although several very excellent works on these subjects
have been published in this country, yet, owing to the present
advanced state of the sciences of Comparative and Structural
Anatomy, and especially to the recent application of improved
microscopes to the investigation of these subjects, the “ In-
structors” referred to are but little available as useful guides to
the anatomist.
In order to supply this deficiency, the work before us has
been produced,—a work which we feel assured will afford va-
luable assistance to every one entering upon the studies of com-
parative anatomy and physiology.
The authors inform us that they have taken as their model
the treatise of M. Straus-Durckheim, entitled “ Traité Pratique
et Theorique d’Anatomie Comparative,” following his plan more
or less closely in the First and Third Parts, condensing and trans-
lating his matter, and making such additions and alterations as -
they considered needful; while the whole of the Second Part
has been written anew.
The First Part treats, in a very comprehensive manner, of
the mechanical arrangements required in the dissection of ani-
mals; leaving it to the student to select those portions which
may be best adapted to his means, and the particular direction
of his investigations. Under the head of Mechanical Arrange-
ments are included dissecting rooms and tables, workshops,
troughs, skeleton frames and boxes, tools, &c.; an excellent
description is also given of the various instruments invented for
injecting vascular tissues, the different kinds of injections used
by anatomists, and the substances employed in preparing and
 Tulk and Henfrey’s 4natomical Manipulation. 303
preserving animal structures. This section of the work contains
much useful information, and is illustrated by a number of well
executed wood-cuts.
The microscope forms the subject of the Second Part, which
commences with a brief summary of the optical principles on
which these instruments are constructed. The laws of refraction,
and the effects of different forms of lenses upon rays of light
passing through them, are well explained; and the action of
simple magnifiers, their imperfections, and the means by which
spherical aberration and chromatic dispersion are corrected, are
described in a clear and intelligible manner. The different im-
provements in simple microscopes are next detailed, by the
adoption of which the aperture can be increased, so as to give
penetration without losing distinctness or definition.
The author then proceeds to the consideration of the com-
pound microscope, and the relative advantages of various eye-
pieces and object glasses. A second chapter is devoted to the
mechanical construction of microscopes, the best methods of
illumination, and the modes of using the camera-lucida, pola-
rizing apparatus, micrometers, and other accessory instruments.
For the dissection, preparation, and preservation of minute ob-
jects, and the general manipulation of simple and compound
microscopes, many valuable directions are given to the student,
and the descriptions are, in most instances, accompanied by ac-
curate diagrams, which very much enhance the excellence of
the work.
The Third Part, by Mr. Alfred Tulk, contains directions
for dissecting and preparing the various systems of organs in
the different classes of animals. In his introductory remarks
the author gives the following good advice to students:
‘« Next in importance to the dissection of an animal, it is indis-
pensable for the student of comparative anatomy to acquire the art of
describing with accuracy, perspicuity, and distinctness, the various
objects which his scalpel has disclosed; a faculty, indeed, by no
means attainable at first, and which can be gained only by practice
and a strict observance of the meaning of the terms used in scientific
language. It is almost needless to insist upon drawing, as most
useful in aiding our actual researches, and the pen. Lastly, in pre-
paring to investigate any point in comparative anatomy and phy-
siology, if with a view towards publishing the results of his labours,
the observer should never neglect to make himself acquainted with all
that has already been done (if any) upon the subject, both by the old
and recent authors of this country and the continent. In this way
much useless pains, and subsequent disappointment as regards origi-
nality, will be frequently avoided.”
304 Bibliographic Notices.
The best course to be pursued in dissecting animals, when
circumstances admit of it, is to proceed from without inwards,
and to study carefully each part in succession as it presents it-
self: in accordance with this plan, the author has arranged his
ample and judicious directions, treating separately of each sys-
tem in the vertebrata, articulata, mollusca, and radiata. We
cannot follow him in detail through this important, because
practical, portion of his subject, but we can assure our readers
that the matter and manner of this section are fully equal to the
preceding parts of the work. To every student of comparative
anatomy and physiology we strongly recommend this treatise, as
an instructive companion and useful guide to the study of these
sciences.

Traité de Toxicologie. Par M. Orrita. Quatrieme Edition;

revue, corrigée, et augmentée. Paris, 1843. Two vols.
A Manual of Medical Jurisprudence. By Atrrep 8. Taytor,
Lecturer on Medical Jurisprudence and Chemistry in Guy’s
Hospital. London: John Churchill. 1844. pp. 679.
Principles of Forensic Medicine. By Wit1am A. Guy, M.B.
Cantab. ; Professor of Forensic Medicine, King’s College,
London. London: Renshaw. 1843. Parts I. and II.

Or the many distinguished ornaments of the French School of

Medicine, none have laboured more indefatigably—more suc-
cessfully, than M. Orfila. For some years past valuable mono-
graphs on various of the most important subjects of public
medicine, have emanated in rapid succession from his pen, most
of which are distinguished by his accustomed accuracy and re-
search. During the above period his celebrated treatise on
Legal Medicine has passed through three editions, its author
being at the same time charged with the important functions of
Professor of Medical Chemistry, and Dean of the Faculty of
Medicine.
His treatise on Toxicology, the first edition of which ap-
peared about twenty years since, has justly gained for him
(what in the language of his compatriots is termed) an Muropean
reputation. The important accessions which the science has ac-
quired by the recent labours of this distinguished public phy-
sician, entitle him to the gratitude of all who duly estimate the
importance of forensic medicine. And here, were the occasion
a suitable one, we should feel tempted to inquire how it has
happened, that although few are disposed formally to deny that
 Orfila,.—Taylor.—Guy. 305
a knowledge of public medicine is indispensable to the well-
informed practitioner, yet practically, in our medical circles, its
facts and principles fall upon the ear of the majority as idle
tales.
It would doubtless be not uninteresting to trace the origin
of that misconception and apathy, which in these countries have
assigned a position of mere tolerance to a department of know-
ledge of confessed public utility, one which has occupied some
of the most trenchant intellects, and has largely engaged the
attention of such men as Paré, Louis, Haller, Hunter, and
Foderé.
In very truth, the conventional language even of many en-
gaged in medical instruction, assigns to forensic medicine a po-
sition amongst the “ minor courses,” placing it lower than natural
history in the scale of practical utility, and consequently, as at
present circumstanced, it drags on a disputed scholastic existence.
The root of all this is to be found in various circumstances, of
which some of the most prominent are, ignorance of the basis
on which a knowledge of the science reposes; the irremunera-
tive nature of public medical services; and the intrinsic difficulty
of the subject itself, as compared with other departments of me-
dical science. We have no intention, however, of entering, ex
cathedrd, into the consideration of these topics, or of discussing
the most feasible methods of effectuating a more rational state
of opinion and feeling, in regard to the subject. We shall con-
tent ourselves with adducing in evidence of the condition of
things just noticed, the fact (a singular one doubtless), that the
College of Surgeons of England, we believe not five years since,
formally repudiated forensic medicine, which had a:short time
previously found favour in its sight; it now declares it, by the
mouth and act of its council, a superfluous branch of medical ac-
quirement,
Such a procedirre on the part of a body, which ostensibly
represents the Profession in England, and which should be the
guardian and motive instrument of medical education in that
country, is calculated to awaken surprise, and merits the severest
reprehension. The progress of medical science in Ireland and
Scotland, as on the Continent, has led to the incorporation of
- legal medicine with the ordinary branches of study, as indis-
pensable to the aspirant for public favour; the incredible an-
nouncement, on the contrary, of the London College, almost
tempts us to inquire whether the position of the English practi-
tioner is of such a nature as to confer upon him an exemption
from contributing his quota to the public safety. If indifference
to the study of forensic medicine exist amongst ourselves, it Is
VOL. XXV. NO. 74, 2R
306 Bibliographic Notices.
surely not surprising, that it should prevail in at least an equal
degree amongst the various grades of the legal Profession, to
whom, notwithstanding, an acquaintance with its leading topics
is frequently indispensable. ‘This is even more strikingly apparent
amongst the higher functionaries, whose peculiar office it is, or
should be, to secure the development of such scientific facts and
principles as are required in evidence in our courts of judicature.
These persons, however, for the most part, exhibit a lamentable
want of acquaintance with judicial medicine, and fall frequently
moreover into the error so prejudicial to the interests ofjustice,
of considering that an extensive acquaintance with medicine in
its curative relations, constitutes the medical witness a suitable
guide to a jury in the decision of medico-legal questions. ‘Thus,
it suffices, in the eyes of such persons, that an individual should
be an expert anatomist, to constitute him a proper referee in a
question of strangulation; whilst the evidence of an eminent
practitioner, albeit such an one may be wholly uninstructed in
medico-forensic inquiries, outweighs that of individuals who have
wisely considered it necessary to be instructed in both departments,
and have taken the proper and only satisfactory mode of becoming
so, namely, that of studying the public, as they would any other
special department of their Profession. ‘I’o so monstrous an extent
has this practice hitherto prevailed amongst our judges, that in
any case of unusual occurrence, an instructed witness Is placed in
danger of being considered ignorant, should his opinion have
the misfortune to contravene that of some practitioner of repute.
Tt would be well if those engaged in the practice. of such
departments of law as bring them in contact with medical evi-
dence, would take the trouble to compare and ascertain the dis-
parity of the facts of curative and judiciary medicine; they would
then become aware of the propriety of the question which Dr.
Smith has proposed to be put iz limine to every medical witness,
‘¢ Whether he has studied Medical Jurisprudence ?* ,
Nothing, in our judgment, tends more powerfully to lead to
a correct estimate of the real scope and value of forensic medi-
cine, and also to prove that despite of the dicta of colleges, a
more wholesome tone of opinion has already commenced, than
the treatises and monographs on medico-legal subjects, which
have of late years emanated from the British Press.
To our continental neighbours in Germany and France must
be conceded the credit of having initiated the collection of facts
and principles in public medicine. To the stimulus thus given
there has been a response in the works of Male, Smith, and Pa-
ris, which, in spite ofall their imperfections, have done much to

* In the conventional sense of the term.

 Orfila.—'Taylor.—Guy. 307
awaken the interest of medical men to this important depart-
ment of their duties. |
The great frequency of charges of poisoning, the critical and
strictly medical character of the inquiries to which they give
rise, and the momentous consequences which from the nature of
the crime they necessarily involve, have led to a greater advance
in the toxicological, than in the other branches of medico-legal
science. It would not be difficult to show, that from the nature
and connexions of the latter, such must necessarily be the case,
but these considerations must give place to a brief exposition
of the works named at the commencement of the foregoing re-
marks,
There does not appear to be any material alteration in the
arrangement of the subjects comprised in the present edition of
Professor Orfila’s treatise. The main feature in which it dif-
fers from that which preceded it, is to be found in the copious-
ness and novelty of the details into which he enters in the con-
sideration of individual poisons.
M. Orfila adheres to the classification adopted in the third
impression of his work, namely, one based on the physiolo-
gical action and vital manifestations of the various substances;
the inconvenience and imperfection of which are evident from the
fact, that under varying circumstances of quantity, state of ag-
gregation of the poison, &c., on the one hand, and peculiar con-
ditions of the stomach and system, and certain more obscure
influences on the other, the action of our commonest poisons
is subject to singular variations. Thus with the exception of
certain local powerfully corrosive poisons, and a few narcotics, a
large number of deleterious agents might be indifferently,
and with equal propriety, ranged in the class either of irri-
tants, or narcotico-acrids. In the present state, however, of our
knowledge of the action of poisons, probably no better one
can be proposed. ‘The last of Orfila’s divisions, the septic poi-
sons, is of doubtful propriety.
Having disposed of some generalities relative to the methods
to be employed in studying the agency of any special substance,
and added some new observations on the imbibition of liquids in
the living and dead body, our author enters on the considera-
tion of the class of irritants, which occupies the greater part of
the first and the commencement of the second volume.
Most important alterations have been made in the chapters
on the mineral and oxalic acids, which may be said to have
been re-written. In the section on sulphuric acid will be found
some elaborate investigations relative to the detection of that
substance considered in the free state, a satisfactory mode of
effecting which has been till lately a desideratum in judiciary
308 Bibliographic Notices.
injuries. The Professor seems, however, on this as well as other
topics, to be unacquainted with, or at least passes over in si-
lence, the researches of his German and English cotempora-
ries.
The chapter on Arsenical poisons 1s replete with most im-
portant details, embodying the author’s more recent researches
on the absorption, and especially the detection of arsenic in the
blood, and in organs remote from the seat of its primary appli-
cation; researches which have gained him great celebrity, and
attracted universal attention. .
In the present edition the observations on the physiological
action of arsenic have been in some respects, and, we think,
disadvantageously, curtailed; this is perhaps more than com-
pensated for by the elaborate mode in which the subject of
the detection of the poison is treated. In handling this im-
portant topic, M. Orfila has not omitted the ndispensable pre-
caution of discussing the various heresies and errors with
which this subject has been encumbered by numerous assail-
ants, whose pertinacity, as is often the case, appears to have
been only commensurate with their ignorance of the matter
under discussion. Amongst many others, the professor has
dealt summary justice to the speculative objections of M. Ras-
pail, whose fertile imagination, aided by his scientific acquire- _
ments, would have sufficed to nonplus a less practised oppo-
nent. The methods proposed by the author for the detection
of the poison in a state of complex admixture (haud impertti
loquimur), are in some respects unsatisfactory. ‘The carbo-
nization by nitric acid is undoubtedly one, which if used as
a preliminary to the employment of Marsh’s method, 1s
only likely to succeed in M. Orfila’s hands. The method of
carbonization by sulphuric acid is much simpler, and more ef-
fectual, and, under certain modifications, is not subject to the
objection which applies with considerable force to the mode
which our author seems to prefer to all others—that of deflagra- —
tion with nitrate of potass. The latter mode is undoubtedly most
effectual to the complete destruction of the organic matter;
but open to the serious objection of dissipating in some cases
even a considerable amount of the arsenic. The recent method
of precipitating metallic arsenic as devised by Reinsch, is con-
sidered in an appendix, and reported on not very favourably, a
result which we are disposed to attribute in part to the natural
unwillingness of the professor to abandon methods which have
led to such brilliant results in bis own hands,- We are, how-
ever, satisfied by repeated experience, that the method of
Reinsch, under proper management, is adequate to the detec-
tion of arsenic in proportion fully as minute as that to which
 Orfila.—Taylor.—Guy. 309
Marsh’s proceeding is responsive, provided that in the case of
the blood, liver, &c., one or more preliminary carbonizations
by sulphuric acid are employed. |
The consideration of the irritant poisons is followed by a
new chapter on the chemico-forensic relations of compound
poisoning, a subject to the practical investigation of which
several instances of late occurrence have directed the attention
of medical jurists. The narcotics and narcotico-acrids are dis-
cussed with the same care and accuracy evinced in other parts
of the work.
Without wishing in the least to detract from the intrinsic
merits of Professor Orfila’s performance, and while fully acknow-
ledging its many excellencies, we cannot state that the volumes
before us, practically important as they are, and exhibiting as
they do.so vast an amount of labour, can be considered as em-
bodying the present state of medico-legal science in reference to
poisoning. Many important discussions of frequent occurrence
in courts of justice, are either but slightly touched upon, or
wholly omitted ; e. g. the quantity of the various substances re-
quired to destroy life, the smallest quantity which has been
known to cause death in the previously healthy human subject;
the largest quantity from the effects of which individuals have
escaped with life; the period within which the various poisons
usually prove fatal, &c. The chapter on poisoning in the ab-
stract sense, without reference to any particular substance, and
the medico-moral relations of poisoning, are dismissed with
comparatively slight notice ; and this is the more to be regretted,
not only from the vast experience of the author, but also from
the fact, that such considerations frequently present themselves
forcibly to the attention of the forensic physician. ‘The work of
Professor Orfila is not free from the same fault, which pervades
those of the majority of his countrymen, and in which respect no
obvious sign of amendment is discernible, except in the produc-
tions of Rayer and a few others, namely, a neglect of, or want
of acquaintance with, the labours of his brethren in other coun-
tries, especially in Germany and Great. Britain, from which
sources his work might have derived most important accessions,
The above-mentioned deficiencies in the recent edition of
Professor Orfila’s Treatise, the forensic physician will find in a
considerable degree compensated for, bya production which has
recently appeared from the pen of Mr. ‘Taylor, Lecturer on
Forensic Medicine in Guy’s Hospital, London, entitled, “ A
Manual of Medical Jurisprudence.” Were we to judge from
the title, taken in conjunction with past experience of the various
mutilated compilations which have appeared in the guise of
310
Oa
Bibliographic Notices.
Manuals, we should not be inclined to presage great things con-
cerning it. ‘The reader, however, will meet with an agreeable
disappointment when he finds the modest “ Manual” an elabo-
rate and valuable treatise on forensic medicine, the work of one
practically acquainted with his subject, possessing an ample ex-
perience, and evincing a discriminating judgment in the selec-
tion of all that is most important in the labours of his cotempo-
raries. We must confess, however, in limine, our regret that
Mr. Taylor should have so far deferred to established custom
as to retain the term ‘‘ medical jurisprudence ;” we say this, not-
withstanding the sanction of high authority, which our author
might plead in support of his retention ofthe title; but as we
are impelled (possibly from mere obstinacy) to enter the an-
cients’ protest, “ nullius addictus jurare in verba magistri.”
We appeal to the fact that jurisprudence being the knowledge
of law, medical jurisprudence (and in this sense the French
writers properly accept it) is the science or knowledge of those
legal matters which relate to medicine; as, for example, to the
liabilities, privileges, and immunities of medical persons, the
enactments relative to medical corporations and education, and
finally, the legal provisions regarding those subjects which in-
volve medical evidence in courts of justice, as injuries to the
person, or incompetency of mind, &c., the character of which
enactments no doubt materially influence the nature and ex-
tent of the inquiries of forensic medicine, but are yet essen-
tially distinct. It is, therefore, evident, that while every in-
structed writer on forensic medicine must present to his readers
an intercurrent exposition of medical jurisprudence, the great
body of his work must be constituted by those medical facts
and principles which are suited to the exigencies of the prac-
titioner appearing in the forum. Were we even to concede
the title “ Medical Jurisprudence,” still that department of
knowledge, in its conventional acceptation, embraces within
its precincts the extensive subject of medical police, or pub-
lic health, on which the great majority of writers in these
countries (professedly) on medical jurisprudence, are nearly
or altogether silent. Practically, the chief objection to the
designation lies in its tendency to misguide the student, by lead-
ing him to the belief that his studies in this department are
to be largely of a legal character, an idea to which the very su-
perfluous proceeding of delegating in part to the barrister the
conduct of a course of forensic medicine, has afforded a coloura-
ble pretext.
Having indulged, however, our critical longings for the ex-
tinction of the ¢zt/e, we find the conrents of the manual com-
 Orfila.— Taylor.—Gnuy. 311

pelling us to a very different mode of feeling. Mr. Taylor is

obliged, partly by the nature of the subject (notwithstanding
the systematic treatises of the German school), to act the eclec-
tic, and hence the various topics are arranged rather in the order
of their importance, than in relation to their supposed mutual
connexion, which, even when effectuated in treatises, however it
may assist the memory, will be found sadly disjointed in the
coroner’s court or crown solicitor’s office, where the subtle
arrangements of pains-taking medico-legal authors are uncere-
moniously deprived at once of their beauty and their value.
Mr. Taylor occupies about one-third of his work with the
practical consideration of the subject of poisoning, which topic
he handles with much accuracy and ability.
Our author has wisely abstained from those curious disqui-
sitions on the history of poisoning, in which so many medico-
legal writers delight to indulge, and which, apart from their
interest to the imagination, serve only to occupy the place of more
important matter. This practice has been carried into many
departments of the science; surely, however, it can beoflittle
practical moment to the forensic physician whether the hemlock,
at the hands of which Socrates met his fate, was the Conium or
some other deleterious herb, or to possess an accurate acquaint-
ance with the relative frequency of infanticide in the various
countries from Kamschatcha to Peru.
Mr. Taylor, in opening the consideration of the subject of
poisoning, has addressed himself to the practical questions con-
nected with the definition of a poison. We may here remark,
that in charges of poisoning, as in questions relative to insanity,
counsel not unfrequently endeavour to involve the medical wit-
ness by requiring definitions, in which the latter are sometimes
exercised to their no small discomfiture. The questions dis-
cussed by our author hold relation to the statutable provisions
regarding this crime, as modified by 1 Vict. c. 85, s. 2. . The
following observations embody his judgment on the matter:
‘¢ The fact that a poison has been commonly regarded as a sub-
stance which produces serious effects when taken in small quantity,
has induced many who have adopted this arbitrary view to assert, that
certain substances which have actually caused death are not poisons;
and this doctrine has been apparently strengthened by the fact, that
were not some such distinction adopted, it would be difficult to sepa-
rate the class of poisons from substances which are reputed inert. In
answer to this view, it is perhaps sufficient to show, that there is no
good reason for assuming this as the distinguishing character of a
poison; for it is impossible, even among substances universally ad-
mitted to be poisonous, to make any division according to the effects
312 Bibliographic Notices.
produced by the quantity taken. In relation to the quantity required:
to operate fatally, the difference is not so great between cream of tar-
tar and oxalic acid, as between oxalic acid and strychnia. If we con-
sider nitre and cream of tartar to be poisons, there seems to be no
good reason for excluding common salt (the chloride of sodium). Me-
dical practitioners would scarcely be prepared to admit this last-men-
tioned substance into the class of poisons; but it is to be observed that
in a very large dose, it is capable of acting as a powerful irritant, and
of inflaming the mucous membrane of the alimentary canal to the
same extent as much smaller doses of other well-known irritants. An
instance of common salt having caused death occurred in the north of
England in the year 1839. A young lady swallowed, it is supposed,
about halfa pound of this substance, for the purpose of destroying
worms. It was considered to be a harmless substance, according to
the common notion ; but in the course of about two hours, some alarm-
ing symptoms made their appearance, and medical assistance was sent
for. She was found to be in a state of general paralysis; and
although the stomach-pump and other antidotal means were speedily
employed, she died in the course of a few hours. After death there
were found the post-mortem changes generally indicative of the effects
of a violent irritant on the alimentary passages.
<< This case is deserving of attention, not merely from its novelty, but
from the evidence which it furnishes of the fallacy of the popular doc-
trine, that what is taken so freely in small quantities, without mischief,
may be taken, with equal impunity, in large doses. Ina toxicological
point of view, we do not see how the effects of salt, in this case, are to
be distinguished from the action of the sulphate or acetate of copper;
nor how, if we agree to call the latter substances poisons, we can con-
sistently refuse this appellation to the former. It may appear to be a
violation of common language, to call the chloride of sodium a poison,
but assuredly it would be a greater inconsistency, to refuse to consi-
der‘it as such, merely because it requires to be exhibited in a larger
dose than some other irritants,””"—p. 2.
‘“‘ In Medical Jurisprudence, therefore, we must look to the effects
produced by particular substances on the system, and their adequacy
to cause death under symptoms of poisoning, rather than to the mere
quantities in which they may have been taken.
‘¢ These remarks on the looseness of the common definition of the
term poison have been suggested by the fact, that medical men
have been severely pressed in cross-examination on trials for certain
criminal offences, to state what is strictly a poison, and what is not. We
shall see hereafter that in charges of attempted poisoning, or ef criminal
abortion by the administration of drugs, it is not an indifferent matter
for a witness to be able to say what substances are noxious and what
are inert; or to show, how some bodies, commonly reputed inert, may,
under certain conditions, act deleteriously on the system.
‘¢ There is another point of view in which this question may re-
quire to be considered, namely, What is to be understood by a deadly
 Orfila.—Taylor.—Guy. 313
poison? In most indictments for poisoning, it is customary to de-
scribe every poison as deadly, a form of expression decidedly bad,
and calculated to give rise to legal objections. The substance admi-
nistered might with equal propriety be described as poisonous, or of a
destructive nature; but those who draw up indictments are but little
informed on such matters, and they can never speak of a poison with-
out describing it as deadly.”—pp. 3, 4.
‘* It appears to me that the term deadly can be used with respect
to those poisons only which may prove speedily fatal in small doses,
such as strychnia, morphia, prussic acid, and arsenic, and that it could
not with any sort of propriety be applied to such substances as the
sulphate of copper. The error essentially lies in the legal wording
of the indictment, with which, of course, a medical witness is not
concerned. If an objection of this kind is to be held valid, and a
question of criminal poisoning to be dismissed on so trivial a point, it
is reasonable to expect that greater care should be used in drawing up
indictments, as also that medical terms should not be employed by
non-medical persons without proper supervision. Otherwise, it is ob-
vious that the ends of justice must be defeated. Differences of opinion
among educated medical witnesses are not likely to exist where slight
previous reflection has been bestowed upon the subject.”—pp. 4, 5.
“In legal medicine, it is difficult to give such a definition of a
poison as shall be entirely free from objection. Perhaps the most
comprehensive definition which can be suggested is this: ‘A poison
is a substance, which, when taken internally, is capable of destroying
life without acting mechanically on the system.’
“¢ Under this definition, it might be objected that the whole class
of medicines, and numerous substances of an inert nature, would be
included. Thus it is well known, that there are many cases on re-
cord, in which cold water, swallowed in large quantity, and in an ex-
cited state of the system, has led to the destruction of life, either ra-
pidly by shock, or slowly by inducing gastritis. Any cold liquid,
such as iced water, beer, or ice itself, may have an equally fatal effect.
The action of water or cold liquids, under these circumstances, cannot
be said to be mechanical ; it appears to be due to the shock suddenly
induced on the nervous system through the lining membrane of the
Stomach, and yet it would be inconsistent to class these inert liquids
among poisons.
‘“‘ In all cases of this description, it appears to me, that we are
justified in drawing the following distinction between poisonous and
non-poisonous substances. If the deleterious effect does not depend
upon the natureof the substance taken, but upon the state of the sys-
tem at the time at which it is swallowed, the substance cannot be re-
garded as a poison. All poisonous substances are per se deleterious,
the state of the system, setting aside for the present the peculiar
effects of idiosyncracy and habit, has very little influence on their ope-
ration. ‘The symptoms may be suspended for a time or slightly mo-
dified in their progress, but sooner or later the poison will affect the
VOL. XXV. NO. 74, 258
ol4 Bibliographic Notices.
healthy and diseased, the old and the young, with a uniformity in its |
effects, not to be easily mistaken. A distinction of this kind cannot,
however, be drawn except by a professional man, who has given at-
tention to the subject of toxicology, and, therefore, it is no matter of
surprise that poisoning should have been in more than one instance
erroneously imputed, in cases where death has followed the drinking
of cold liquids.
‘¢ In thus giving the medical definition of a poison, it is necessary
to observe, that the law never regards the manner in which the sub-
stance administered acts. If it be capable of injuring the health of
an individual, it is of little consequence so far as the responsibility of
a prisoner is concerned, whether its action on the body be of a me-
chanical or chemical nature. Thus a substance which simply acts
mechanically on the stomach, may, if wilfully administered with in-
tent to injure, involve a person in a criminal charge, as much as if he
had administered arsenic, or any of the ordinary poisons. It is then
necessary that we should consider what the law means by the act of
poisoning. If the substance criminally administered destroy life,
whatever may be its nature or mode of operation, the accused is tried
on a charge of murder, or manslaughter, and the whole duty of the
medical witness consists in showing that the substance taken was the
certain cause of death.”—pp. 5, 6.
Again, in adverting to the term in the statute, “ destructive
thing,” he has interwoven with the text many most important
cases and inquiries relative to mechanical irritants, as pounded
glass, pins, &c.
In the chapter on the Physiological Action of Poisons, the
student will find the most recent information. ‘The conclusions
of the author on this subject are as follows:
‘¢ 1, That the remote influence of poisons is sometimes conveyed
through the medium of the blood. 2. That it may be conveyed by
contact with the sentient extremities of nerves, probably of the gan-
glionic system. 3. That some poisons may act in both ways at diffe-
rent times.”—p. 19.
Our author very properly rejects the fantastic and unsup-
ported speculations of Liebig, as to the intimate nature of the
remote action of poisons.
Those who are called-on to conduct the medical investigation
of a charge of poisoning, or to perform a post-mortem inspec-
tion in such cases, will do well to study carefully the instructions
given in the fourth chapter, the majority of which, though highly
important, are commonly neglected by practitioners; they tend
strongly to correct the prevailing practice of merely opening the
stomach or the head, as suspicion may happen to point in the
direction of narcotic or irritant poisoning. By such ‘mode of

ye
xaq
vd
ehh
 Orfila.—Taylor.—Guy. 315
proceeding the real cause of death very commonly escapes no-
tice; thus we were lately consulted ina case in which the atten-
tion of the inspector was exclusively directed to the stomach,
the contents of which were submitted to analysis, the cause of
death being probably connected with the head.
Our space will not permit us to dwell on the chapter on
General Poisoning, which we shall only heartily recommend to
the consideration of the medical jurist. The illustrative cases
have a special value, as they are derived from the various cir-
cuits and other sources not usually available, and hence convey
to the practitioner a much more instructive view of the actual
nature of the inquiries to which he must hereafter devote his
attention.
Mr. Taylor has conferred a marked benefit on the forensic
physician in the consideration ofa variety of questions constantly
arising on trials, as to the minimum dose of various poisons, and
other inquiries, to which we have alluded in speaking of Pro-
fessor Orfila’s recent work, and to which medico-legal writers.
have hitherto devoted but little attention. |
In the chapter on Arsenic, various novel and valuable obser-
vations of this kind will be found. The author, in treating of
the antidotes to this poison, seems unfavourably disposed towards
the hydrated sesquioxyde of iron, and adduces, in support of
his views, certain experiments of his own, which tend to confirm
those of previous observers. To such, however, we must deci-
dedly object; as the factitious mixtures employed in such trials
ean never represent the natural secretions of the stomach ; and
although we may concede,with Mr. Taylor, that pulverent arsenic
and hydrated sesquioxyde of iron mutually react in but a slight
degree, yet it is evident that the principal mischief is effected
by the absorbed arsenic, and as solution is an essential prelimi-
nary to absorption, the experiments made on the reputed anti-
dote with solutions of arsenic are not wholly irrelevant. We
would also state, that within the sphere of our own observation,
instances have occurred strongly inclining us to a favourable
opinion of the antidotal powers of the oxide, which, of course,
should not be employed to the exclusion of the mechanical me-
thods of expulsion, and which also, for reasons now well under-
stood, should be administered in considerable quantity, and its
use persisted in as long as there is reason to believe that the
prime vie retain any of the poison.
‘The forensic chemistry of poisons is amply, indeed minutely,
discussed, of which the disquisitions relative to arsenic afford
an excellent example. Several of the lately proposed methods
of verifying arsenical sublimates which have “ encumbered”
science “ with their aid,” have been justly left unnoticed; in
 7

316 Bibliographic Notices.

reality, without adding anything valuable, they tend only to
exhaust the memory and disgust the student. In treating of
the various substances employed as poisons, Mr. ‘Taylor has
thought proper to superadd instructions for their quantitative
analysis. ‘This latter is frequently required where questions
arise concerning the amount of poison administered in suspected
articles, with reference to its adequacy to the production of
dangerous or fatal results, or even (as occurred ina recent case),
to determine the intent of the accused. Quantitative analysis
may be useful also, not only in imputed poisoning, but also in
regard to a query constantly and ignorantly propounded by bar-
risters, coroners, &c.,—whether the quantity found in the
stomach was sufficient to have caused death?
Our author has dealt with the mercurial poisons in an able
and instructive manner. He has not neglected a topic which
has recently come before the public, and which is of much mo-
ment to practitioners—the distinction between mercurial saliva-
tion and cancrum oris, which are sometimes confounded, and
which, apart from the history of the case, are not always
easily distinguishable. In discussing the suitable antidotes
to the soluble mercurial preparations, Mr. ‘Taylor does not pro-
nounce positively as to the constitution of the compound formed
by the agency of a solution of albumen upon that of the bi-
chloride, which, as our readers are aware, was formerly consi-
dered, on the authority of Orfila, as a compound of calomel and
albumen. This theory, which has been recently abandoned by
the Professor, has given place to one equally erroneous—that it
is a direct combination of the corrosive sublimate and albumen.
The latter view is based on the solubility of the precipitate in chlo-
ride of sodium and the extraction of a soluble salt of mercury from
the compound so produced, by the agency of sulphuric ether.
We find, however, that peroxide of mercury, acted on by chlo- —
ride of sodium, gives rise to the double chloride of sodium and
mercury, which (and not sublimate) is extracted by ether.
Were any additional facts necessary to establish the opinion
so well substantiated by Rose,* namely, that the compound —
under consideration consists of albumen, united with peroxide
of mercury, the following observations which we have made on
the matter seem conclusive :
1. The compound may be formed directly by the union of
albumen and the hydrated peroxide of mercury.t
2. It may be procured by precipitating with albumen a so-
lution of pure pernitrate of mercury as nearly neutral as possible.
* Poggendorf Annalen, B, 28, St. 1., 135.
+ The solution of albumen (holding suspended the oxide in small quantity),
being freely and continuously agitated.
 Orfila.—Taylor.— Guy. 317
No explanation appears to have been hitherto offered of the
different effects produced by sublimate on the mouth and mu-
cous membrane of the stomach; the slate-grey tint sometimes
observed in the latter case, indicating that the compound formed
contains metallic mercury, probably mixed with albuminate of
the peroxide, as occurs when a solution of albumen is added to
proto-nitrate of mercury. |
Practitioners, in employing albumen as an antidote to subli-
mate, should be aware, that it may be given in too great quan-
tity, as the compound formed is soluble in an excess of albumen,
and, we doubt not, is the deleterious combination which enters
the blood, and produces the remote influence of the poison. So
long as the vomited matters contain a white opaque material
admixed, the antidote should not be withheld ; when the e7ecta,
on the contrary, become transparent, the further employment of
the remedy is generally useless, and may be injurious.
The observations of Orfila on this antidote deserve men-
tion :
‘< T] résulte de ces expériences et de beaucoup d’autres analogues,
1° que le précipité d’albumine et de sublime corrosif peut étre pris
sans danger 4forte dose ; 2° qu’ilest vénéneux lorsqu’il est dissous dans
VYalbumine, mais qu’il l’est beaucoup moins que le sublimé corrosif;
3° que lorsqu’on administre du sublime corrosif mélé avec une quan-
tité de blanc d’ceuf plus considérable que celle qu'il faudrait pour
, animaux périssent, sion a empéché le vomisse-
obtenir le precipitéles
ment, ce qui dépend de la dissolution du précipité d’albumine et de
sublimé dans l’exces d’albumine: toutefois, l’action de ce mélange est
beaucoup moins énergique que celle du sublime, puisque les animaux
tardent beaucoup plus a périr, et qu’aprés la mort on trouve a peine
ou on ne découvre point des traces d’inflammation dans le canal di-
gestif (voy. expér. 20°, p. 541); 4° que les chiens qui ont avalé 60
ou 75 centigrammes de sublimé, et auxquels on a laissé la faculté de
vomir, périssent rarement lorsqu’on leur fait prendre abondamment du
blanc d’ceuf délayé dans l’eau, ce qui dépend de la propriété qu’a
Valbumine de se combiner avec le sublimé qu'elle trouve dans |’esto-
mac, et de fayoriser le vomissement: en effet, le poison est rejeté a
mesure qu’il se combine, et l’on a par conséquent peu a redouter |’ac-
tion de la portion du précipité qui pourrait étre dissous par l’exces
d’albumine; 5° que tous les animaux qui ne prennent pas une assez
grande quantité de blanc d’ceuf meurent au bout de trois ou quatre
heures, lors méme qu’ils n’ont avalé que 60 centigrammes de sublime,
ce qui est d’accord avec ce que j’ai établi ailleurs, savoir que le sub-
limé corrosif, mélé avec une quantité moyenne d’albumine, donne un
liquide dans lequel il y a encore du sublimé, et qui doit par consé-
quent agir comme poison; 6° enfin, que de toutes les substances pro-
posées jusqu’é ce jour comme antidote du sublimé corrosif, l’albumine,
employée en quantité convenable, est la plus utile, quoiqu’elle ne neu-
318 Bibliographic Notices.
tralise pas compiétement les propriétés vénéneuses de ce poison, parce
qu’elle peut étre prise impunement, qu’elle forme avec le poison un
corps nullement délétére lorsqu’il n’est pas dissous, enfin parce qu'elle
est & la portée de tout le monde,et que son application peut étre faite
immédiatement apres ingestion du poison.”—pp. 543, 544.
Recent observations have shown that the yolk of egg is an
equally, if not more, efficacious counter-poison.
The multiplied medico-legal questions relative to wounds
next occupy Mr. Taylor’s attention, the importance of which
subject with that of the preceding, is evident from the fact, that
in one year in the United Kingdom, there were no less than
1213 trials, involving questions of murder and manslaughter by
wounding or poison. We feel it incumbent on us to state the
discussions relative to wounding are conducted witha complete-
ness, skill, and judgment, reflecting the highest credit on the
author, who evinces in every department a sound practical
knowledge of the subject. ‘This chapter will be found of sig-
nal utility to the practitioner in the performance of his forensic
duties, connected as they are with the solution of the following
problems and considerations, each of which our author accu-
rately investigates.
‘‘ What is a wound? Is.the wound dangerous to life, or did it
produce ‘ grievous bodily harm?’ Whether the wound was inflicted
before or after death? By what means was the wound inflicted? If
by a weapon, what kind of weapon? How or by whom was the wound
inflicted? Circumstantial evidence ? Was the wound the direct cause
of death? Death may follow a wound but not be caused by it; was
the wound the indirect cause of death ? For how long a time has the
wound been inflicted? How long did the deceased survive ? Acts in-
dicative of volition and locomotion in persons mortally wounded; on
wounds as they affect different parts of the body; fractures and
dislocations ; gun-shot wounds; on burns and scalds; burns from
corrosive liquids.”——pp. xii. xii.
The inquiries connected with secondary causes of death in
wounding are fully entered upon. Such investigations are of
moment, not only to the continental medical jurist, but also in
these countries; because, although the law looks to the intent,
rather than the resadt, yet a discretionary power is vested in
the hands of our judges, in awarding the amount of punish-
ment.
In the present work will be found a detailed account of the
mode of identifying blood-stains, an inquiry of frequent occur-
rence, and which occupied attention in a very important trial
for murder, by wounding, which has just terminated in this city.
 Orfila.—Taylor.—Guy. 319

The chapter on Infanticide has been constructed with very

considerable care, and evinces correct and deliberate judgment.
The author has cut away the foundation on which reposed
much of the sentimentality observable in the writings of Wm.
Hunter, and other English authors on this subject, and which
had its origin in a Draconic enactment of the period of James
the First, rendering live birth and wilful destruction of offspring
synonymous—a statute which, although long since abrogated,
one might conceive, from the repeated objections of counsel on
the score of the hydrostatic test, to be still in force. Notwith-
standing the pains bestowed on this chapter, it is evident, from
what has occurred on the different circuits within the last few
years, that owing to the severity of our legal enactments, ac-
quittals will probably continue to be obtained in spite of
clear evidence of criminality; legal precedents requiring proof
of conditions altogether transcending the skill of the most ac-
complished forensic physician. )
The discussions connected with death from the various
forms of obstructed respiration, are treated of in a practical and
able manner. In adverting to the question of strangulation,
our author, we perceive, has not omitted to notice the important
ease of The Queen v. Byrne, which was tried a couple of years
since in this city, on which he remarks:
‘‘ The state of the countenance alone, will scarcely warrant the
expression of an opinion; for there are many kinds of deathin which
the features may become livid and distorted from causes totally un-
connected with the application of external violence to the throat.
Let not a witness, then, lend himself as an instrument in the hands of
a counsel for the condemnation of a person against whom nothing but
a strong suspicion from circumstances may be raised, and where me-
dical evidence is unable to throw any light upon the probability of
death having resulted from strangulation. See the trial of Mrs.
Byrne, for murder, Dublin Commission Court, Aug. 1842. This trial
is full of interest to the medical jurist. Some post mortem changes
appear to have been mistaken for marks of strangulation.”
To which we would add that, probably, there has not for
along period occurred an instance more strikingly illustra-
tive of the Jamentable effects of popular prejudice, and non-
acquaintance with forensic medicine, more especially observable
on the case of certain legal functionaries, who, having to de-
velope and place in order before a jury the facts of an investi-
gation on which a life depended, should feel it their duty to be
instructed on such topics.
The chapters on Rape and Insanity contain much useful
information; we should be glad to see them enlarged in the
next edition of the work, which might also include a chapter on
320 Bibliographic Notices.

the signs of death, not in reference to medico-political pre-

cautions, but as presenting matters incidentally useful in various
questions of violent dissolution, infanticide, &c. Nor should we
object to a section on pseudo-morbid appearances, and their
diagnosis, a subject, we may observe, by no means as precisely
understood, or as much attended to, as the modern exclusive
zeal for morbid anatomy would lead us to believe, and one
moreover, of grave moment in public practice. The sections on
abortive and retarded births contain, ina condensed form, much
novel and useful matter.
In undertaking the task of presenting to the medical man a
practical guide in the performance of his public duties, Mr.
Taylor has acquitted himself with no ordinary ability and suc-
cess. He has evidently not sought the construction of a treatise
embodying all the known facts of the science; thus wisely
avoiding a mode of proceeding, the adoption of which has
loaded most modern works in this department, with incongruous
details, but has rather brought his extended experience to bear
on the practically important and every-day discussions of the
forum. The author manifests an accurate acquaintance with
the present state of medico-legal science, and has availed him-
self of the most important recent accessions of the German and
French schools. A circumstance, however, which we consider
of much importance, and which exhibits at once the industry
of the author and his devotion to the science, is to be found in
the numerous illustrations of the various topics of juridical
medicine, which appear for the first time in the present pro-
duction. Thus the practitioner may learn what is unquestion-
ably of the highest moment, not only the facts required of him,
but also their varying combinations, from the latter of which
new departments of inquiry constantly arise.
The publisher has co-operated with the author, and has
performed his part efficiently. ‘The volume, which is well got
up, contains, for its size and price, a very unusual amount of
matter.
The intrinsic merits of Mr. Taylor’s labours must speedily
place his work in a distinguished position, as a guide and
indispensable companion to the practitioner, in the exercise of
his public functions. _
Of Dr. Guy’s work, two parts only have appeared, and
consequently we are not as yet in a position to estimate accu-
rately the value of his labours: those already before us, without
professing to add much original matter, are plainly constructed
with care, and evidence an orderly and perspicacious mind. The
article on Insanity is valuable and elaborate, more especially
that part of it which regards the criminal responsibility of the

a‘io
 Dr. Lee on the Theory and Practice of Midwifery. 321
insane. The discussions, also, relative to infanticide,develope
the latest information, and incorporate the author’s recent re-
searches relative to the statical evidence of live birth. The
writer has observed a lucid order in the. discussion of the
various topics already published. In reference to works on
public medicine in general, we would remark, that while we
should be far from depreciating the importance of that quality,
and its uses to the student, we are yet free to confess, that in
practice the advantages of systematizing will speedily be found:
overrated, especially if (as we conceive has happened in the
case of many modern writers) it implicate the substitution of
the ideal for the real. In truth, their productions not uncom-
monly realize the conception embodied in one of our English
classics,—that of a consultation relative to the occurrence of
death per plethoram, after removal ofa limb, a result which,
it was argued, must necessarily take place; experience, how-
ever, controverting the preconceived notions of the physicians,
the latter, not a whit disconcerted, stoutly averred that the
consequence alluded to ought to have occurred.

Lectures on the Theory and Practice of Midwifery, delivered

in the Theatre of St. George’s Hospital. By Robert Lez,
M. Doi. RoBi
Any publication from the pen of Dr. Lee is deserving of the
careful attention of the Profession, inasmuch as his productions
are marked by care, accuracy, and minute observations; and
although we do not always agree with his conclusions, it is with
diftidence and caution we dissent from him.
Some time ago we noticed in this Journal his work on
Clinical Midwifery, and expressed a regret, that along with the
cases he had not given more detailed conclusions, In the pre-
sent volume, however, Dr. Lee has supplied that deficiency,
and it shall be our endeavour to lay them before our readers.
In order to do this, however, we must pass over the anatomy
and physiology of the organs of generation—not that the chap-
ters do not deserve a careful analysis, but because our limits do
not admit of both, at least at present—and we think it better
rather to complete the subject of operative midwifery, than to
touch upon many others.
We pass then, at once, to Lecture 28, upon the Forceps.
Lecture 27 is occupied with the history of its invention, but
contains nothing new. Dr, Lee opens the Lecture with an
allusion to the great variety of modifications which the instru-
ment has undergone, and after stating that he prefers ‘* Cham-
VOL. XXY. NO, 7/4. 2T
322 Bibliographic Notices.
berlen’s forceps, with the lock and wooden handles of Smellie—
in fact Denman’s short forceps, covered with leather,” he pro-
ceeds:
‘‘ But in truth I attach comparatively little importance to the
shape and dimensions of the forceps you use; I think it nearly a
matter of indifference whether it has a pivot lock, or Smellie’s lock,
and whether the handles consist of wood or metal, provided the case
will justify the use of the forceps, where it is had recourse to, and
you know the principles which ought invariably to guide you in its
employment.’
It is quite possible, however, to have a very bad pair of
forceps, and although the hand that is to use them is of the
highest importance, yet a little attention to the curves of the
blades, and to the temper and finish of the instrument, is of
great consequence also. ‘The greatest curvature should be near
the point of the blade, and so managed, that when applied, and
in action, the widest part of the instrument shall be that part
of it which embraces the widest part of the head of the child.
Dr. Lee properly observes that the forceps is not calculated
for labour when the cervix uteri, or soft parts, are swollen and
inflamed, or undilatable, nor where there is considerable me-
chanical obstruction to the transit of the child. But
‘It is chiefly in cases of protracted and difficult labour, from
feeble and irregular, or partial uterine action, from passions of the
mind, original or accidental debility in the mother, and other consti-
tutional causes, which impair the energy of the brain, and nervous
system of the uterus, that the forceps are used with advantage, and
where, if any disproportion exists between the foetus and pelvis, it
is only in a slight degree. The forceps is not applied because there
is a great deficiency of space in the pelvis, a great want of due pro-
portion between the head and the pelvis, but because there is a want
of power in the uterus to propel the child through it, the want of
which power we endeavour to supply with the forceps. This is the
only legitimate ground on which we can proceed in the application
of the forceps, whether it be exhaustion, convulsion, haemorrhage,
or whatever the circumstances may be which renders immediate
delivery necessary to preserve the life of the mother and child. Itis
not for our own convenience, to spare ourselves the anxiety and
fatigue of a protracted attendance upon any case of labour, to acquire
skill and dexterity in the use of the forceps, that the instrument is
to be applied, nor because it is in our power to do so, but because
of certain local and constitutional symptoms appearing in the parent,
or because the child is in danger from long-continued pressure, that
we have recourse to artificial delivery. The gradual cessation of
labour pains, and the descent of the head being arrested, are un-
questionably the best indications we can have for the propriety of the
 Dr. Lee on the Theory and Practice of Midwifery. 323
interference of art. If the uterine contractions cease, and the head,
swollen and compressed, becomes arrested and impacted in the pelvis,
and there is exhaustion, fever, and disturbance of the brain, and we
believe that the head of the child will not be expelled by the natural
efforts, it is our duty to endeavour without delay to extract it with
the forceps. To apply the instrument when it is known with abso-
lute certainty that the child is dead, would betray, to use the mildest
expression, the highest degree of insensibility and folly.”—p. 301.
With a little modification we agree with this quotation; but
if the head be “ impacted in the pelvis,” we should not certainly
consider it exactly a case for the forceps, nor do we quite think
it the “highest degree of insensibility and folly” to extract a
putrid head with the forceps, when, as we know by experience,
we thereby avoid a much more tedious operation with the
crotchet. 1
Dr. Lee agrees with the practitioners of this city in object-
ing to the use of the long forceps, on account of the danger to
the mother : and in his reprobation of applying this, or any other
instrument clandestinely, we heartily agree with him.
' The instructions for the mode of applying the forceps are
clear, minute, and judicious, but as they do not differ from
those given in the standard authors, we do not think it necessary
to quote them.
The next operation we shall notice is Craniotomy :
‘‘ When the child is dead, where a great disproportion exists be-
tween the head and the pelvis from any cause, and the os uteri is im-
perfectly dilated, and the parts swollen and rigid, and an ear cannot
be felt, and circumstances occur demanding immediate delivery, re-
course must be had to the perforator and not to the forceps. It is in
difficult labour from distortion of the pelvis that we are most frequently
compelled to open and extract the head; and where this exists in a
high degree, and the brim is so contracted that the head cannot enter
it, the operation ofcraniotomy often requires the employment of strong
extracting force for several hours, and fatal contustion and laceration
of the uterus, bladder, and vagina can only be prevented by the
greatest caution and dexterity, and a perfect knowledge of the struc-
ture of all the parts, It unfortunately happens that in some cases,
before the operation is performed, the soft parts have already been in-
jured by the long-continued pressure they have sustained; the same
thing happens here which takes place in strangulated hernia when
the operation has been delayed too long, and sloughing follows. In
cases of slight disproportion between the head and pelvis, or when
there is none, but delivery becomes necessary in consequence of con-
vulsions, hemorrhage, or exhaustion, the operation is attended with
little dithculty and danger; much less than the application of the for-
ceps.”—p.313,
324 Bibliographic Notices.

This is rather too loose an assertion ; that there is little diffi-

culty when there is no disproportion, may be quite true, but
when the necessity for craniotomy arises from exhaustion, even
r.
though there be no difficulty, there is often very great dange
In many such cases which have come under our notice, the pa-
su-
tient has died in consequence of the shock of the operation,
peradded to a prolonged labour. In these cases of extreme
distortion, “ requiring the employment of strong extracting
t, as
force for several hours,” to the imminent risk of the patien
Dr. Lee justly observes, we have derived most effectual aid from
a pair of long slight forceps (not what are called craniotomy
forceps, for which we have as great an aversion as Dr. Lee), by
away
which the bones of the head can be broken off and taken
until only the base of the cranium remains. ‘This
piecemeal,
ssor
instrument was recommended and used by the late Profe
it.
Hamilton, though Dr. Lee does not seem acquainted with
The following observations upon these cases are of great practi-
cal value.
‘‘ Great care must be taken in perforating the head in cases of
sharp
extreme distortion, that the os uteri be not wounded with the
edges of the instrument. To obviate this, if the outlet be not so much
fore and
contracted as to prevent the hand from being introduced, the
up
middle fingers of the left hand, or all the fingers, should be passed
head, and the
within the os uteri, to the most depending part of the
while the
opening made in the same manner as already described,
of
orifice is protected by the fingers expanded. The undilated state
the uterus adds greatly to the difficulty.
ly
‘(In extracting the head with the crotchet, it not unfrequent
, and re-
happens that the bones of the cranium are all torn to pieces
pelvis.
moved before the base of the skull has entered the brim of the
It is impossible, under such circumstances, to fix the point of the
crotchet in the foramen magnum, as some recommend; and the best
mode of proceeding is to pass the fingers of the left hand over the
head as far as possible, and to slide up the crotchet between the fin-
gers and the outside of the head, and fix its point in one of the orbits;
about the angies of the lower jaw, or wherever a secure hold can be
In this manner, as recommended by Smellie, | have some-
obtained.
I had
times succeeded in extracting the head in a short time, where
begun to despair of ever doing so by fixing the crotchet in the inner
317.
surface of the base of the cranium, or by any other means.”—p.
The section on “induction of premature labour” is much too
its
short to be of use to junior practitioners. Dr. Lee agrees in
pelvis ,
morality, safety, and utility, not ouly in cases of distorted
but in some of the dangerous diseases of pregnancy, and remarks:
to this
‘© In cases of slighter distortion recourse should not be had
labour s that a child
operation, until it has been proved by one or more

in

i>
 Dr. Lee on the Theory and Practice of Midwifery. 325

at the full period could not pass without lessening the head. Labour
should not be brought on until the seven and a half month of gestation,
or alittle later, where it is known that the pelvis is very little con-
tracted. In cases of very great distortion of the pelvis, the induction
of premature labour at an early period, even of the first pregnancy (as
has already been stated before the sixth month) is likewise known to
be a safe operation, and to render craniotomy and the Cesarian sec-
tion wholly unnecessary. The only effectual method of bringing on
premature labour is to puncture the foetal membranes, and discharge
the liquor amnii. I have repeatedly detached the membranes with a
catheter, from the lower part of the uterus, but labour has not fol-
lowed. Ihave strong objections to the exhibition of ergot for the
purpose of inducing premature labour, without taking the uncertainty
of its effects into account.”
Whilst agreeing with Dr. Lee as to the most effectual means
of exciting uterine action, our experience rather confirms that of
Dr. F. Ramsbotham, as to the value of the ergot of rye. Dr.
Lee then adds:
_ T have successfully employed the probe-pointed catheter, with a
stiletto, in many cases, to puncture the membranes, when I could not
do so with instruments less curved, and having sharp points. When
you are about to induce premature labour, pass up the forefinger of
the right hand to the os uteri, and when you have ascertained its pre-
cise situation, slide up along this finger the fore and middle fingers of ©
the left hand to the posterior lip, then withdraw the forefinger of the
other hand and take the handle of the instrument with it, and pass up
the point into the groove formed betwixt the fingers of the left hand,
to the os uteri, and gently press it forward along the cervix into the
cavity of the uterus, about an inch and a half or two inches, when the
membrane will generally be felt offering a slight degree of resistance.
The stiletto should then be pressed forward with the thumb, and a se-
cond puncture made through the membrane before withdrawing the
instrument. The blunt point of the catheter enables us to pass it into
the uterus with safety, when the os uteri is so high up that the finger
cannot even reach the anterior lip.” —p. 319.
We have thus laid shortly before our readers the opinions
of Dr. Lee upon the principal obstetric operations, and we have
done so especially in reference to the notice we gave ofhis little
work on Clinical Medicine, and not because of the superiority
of this part of his lectures. ‘There are many other subjects of
great interest upon which he has entered more fully, and with
equal or greater ability, and at a future period we hope to lay
them also before our friends. Meantime, it hardly needs our
recommendation to insure an extensive sale for this volume.
Dr. Lee’s reputation stands among the highest, nor will it be
 326 Bibliographic Notices.
lessened by the present publication, and we take our leave of
him for the present, with respect for his zeal, industry, and talent.

Natural History, Pathology, and Treatment of the Epidemic

Fever at present prevailing in Edinburgh, and other
Towns. By Joun Rose Cormack, M. D., &c., &c., &e.
Ir is well known that occasionally, during the prevalence of
our ordinary typhus or typhoid fevers, there occur isolated
cases of what have been termed sporadic yellow fever, such as
occurred in Paris in the end of summer, 1822, and have been
met, we should suppose, by most physicians engaged in exten-
sive fever practice in this country once or more in the course ~
of their lives.
But it rarely happens that such cases become the epidemic
disease of the season. Such, however, was the case, to a certain
extent, in Dublin, in 1826-7, and in the large towns in Scot-
land during the past year. Of the former, we have a descrip-
tion ina very able lecture in Dr. Graves’s Clinical Medicine,
in which he draws an analogy between the Dublin epidemic,
and the yellow fever of warm climates, showing that the patho-
logy of both is the same, that they differ but in degree. The
Scotch epidemic has excited the interest of medical men in
that country, and called forth a number of essays from Drs.
Alison, Henderson, Smith, &c. &c., and the volume now before
us, from Dr. Cormack, whose opportunities of observation seem
to have been ample, and to have been diligently made use of
for the purpose of this treatise. He himself informs us, during
the whole time of his connexion witb the new Fever Hospital,
he has daily devoted a large portion of time to observing and
recording the features of the prevailing Epidemic, both when
interfered with by medicines, and when allowed to run its
~ natural course.
We have already, in the last Number of this Journal, an-
nounced the publication of this interesting work, and in pur-
suance of the promise then made, we proceed to give a brief
analysis of its contents. Dr. Cormack arranges his observations
under the heads of—I. Ordinary, or moderately congestive
form of the disease. 2. Highly congestive form. 3. Patho-
logy of the disease. 4. Sequelz of the disease. 5. Treatment
of the disease. 6. Statistics of the cases,
The following is his description of the ordinary form of the
disease:
‘‘ In ordinary cases the countenance of the patient has a peculiar
appearance, which we may designate bronzed, for want of a better
 Dr. Cormack on Epidemic Fever. 327
term. Though no words can accurately convey what is thus meant
to be described, the appearance itself is very characteristic, and has
never failed to arrest and interest the medical visitors to the hospital
to whom it has been pointed out.
‘‘ The symptoms of invasion are in all cases remarkably similar,
both as to their nature and order of occurrence.
‘* The patient is first seized with coldness, rigors, head-ach, pain
in the back, and more or less prostration of strength; but the latter
symptom, it must be remarked, is often not at all urgent, many walking a
long distance from the country to the hospital, especially during the
first days of the disease, and a still greater number of the destitute
town patients lounge about in the streets after their seizure, and
come in to us on their legs,
‘* After a period varying from less than half an hour to several
hours, the cold fit terminates, when the severity of the head-ach
greatly increases, and a dry, burning heat comes over the whole body,
accompanied by much thirst and general uneasiness.
‘““ The hot stage is succeeded by a sweat, usually very profuse,
continuing for a number of hours, and seldom attended or followed
by any relief to the head-ach, or other pains.
‘* Sometimes, though rarely, there is no sweating for two or three
days after the seizure. Occasionally also there is no well-marked
hot stage between the cold and sweating fits; and, at least in a few
cases, the sweat breaks out on the face and upper part of the body,
while the patient is yet in his initiatory rigors.
** It is proper to remark, that during the whole course of the
disorder, the perspiration has a characteristic disagreeable smell, and
is decidedly acid, as is proved by its reddening litmus paper, and that
sometimes with intensity. During the three stages of the initiatory
paroxysm the pulse is rapid, being sometimes as high as 150°, sel-
dom below 90°, and commonly ranging between 90° and 120°. Du-
ring the rigors I have in several cases found it wiry and tremulous;
in the hot stage, it is often hard, and not very easily compressed; at
the sweating period it becomes fuller and softer, and does not exhibit
that deficiency in strength shown after and during the perspiration
of a more advanced period of the fever.
‘“* For the first forty-eight hours the tongue commonly continues
moist, exhibiting at the same time a white, or brownish-yellow fur,
excepting at the point, where there is usually a clear space, extending
over a space often (as in typhus abdominalis) shaped like a triangle,
the extremity of the tongue forming the base. Afterwards the tongue
becomes dry, and longitudinally streaked on the centre with brown,
in which state it continues till the approach or arrival of the crisis at
from the third to the ninth, but in the majority of cases on the fifth
day.
‘‘ During the first four days some of the patients have occasional
short rigors; but most commonly they are in a state of dry, ardent
fever, with occasional sweatings. These sweatings occur, or at all
events commence, in most cases between 2 and 9 a. M.; but to this
328 Bibliographic Notices.
rule there are many exceptions. In a considerable proportion even
of the ordinary and mild cases, nausea and vomiting usher in and
attend the sufferings of the first days. Pain at the scrobiculus cordis
generally accompanies these symptoms; not unfrequently itis present
without them. A symptom which uniformly occurs during the first
four days, is severe muscular and articular pain. General uneasiness
or pain in the abdomen (but particularly above the pubes, and over
the liver and spleen when pressure is made on these regions) are CF
very commonly, but by no means uniformly met with. =
‘‘ So long as the patients suffer much from the symptoms now ee
described they sleep badly, and frequently not at all, unless opiates o
are administered. The severe pains in the joints and muscles are
often sufficient to account for the bad nights complained of, but even
with those who do not suffer much from this cause, sleeplessness is a
distressing symptom up to the crisis.
A remission on the third day is very common. It occurred in
all the cases which I have had an opportunity of attentively observing, —
from the invasion onwards. _
‘¢ On or about the fifth day, there is an evident manifestation of
the violence of the disorder being expended, and this change for the
better is often very sudden and complete. One day we hear the
atient moaning and groaning in pain, and on the next he is at ease
and cheerful, his only complaints being of hunger and weakness.
This state is generally ushered in by a copious sweat, or by epistaxis
or diarrhoea. The sweating was by far the most critical evacuation
till the beginning of Octeber, when diarrhoea and dysentery, formerly
rare occurrences, became common, and at the present time (Oct. 30)
they are as usual as sweating. After this change the pulse, tongue,
and skin are quite natural, and the facial bronzing often becomes
less striking. For several days, or till about the fourteenth or
fifteenth day of the disease, there is a period of intermission during
which a great deal of lost strength is regained, and a steady im-
provement goes on in all respects.
‘¢ On or about the fourteenth or fifteenth day from the beginning aS
teas
of the disease the patient relapses; or, in other words, has a paroxysm s
of fever similar to that which began his first attack. The relapse —
takes place late or early, just according to the date of the first conva-
lescence, as will be clearly seen from all the cases to be detailed. lc =
sometimes happens that the onset and progress of the second attack
is attended by severer and at other times by milder symptoms than i
those of the first. In the relapse the abortions most commonly take :
place. In it also the muscular and articular pains are very often Gey
most severe. Cases which in the first attack were strictly mild and 5|
ordinary, have in the second become signalized by jaundice, delirium,
diarrhoea, dysentery, and other grave symptoms, Such occurrences aie

are, however, not common. *

«© A large number of patients have a second and generally mild:
relapse on or about the twenty-first day. As these relapses take place
often after dismissal from the hospital, it was some time before I dis-
covered the frequency of third attacks.
 Dr, Cormack on Epidemie Fever. 329
‘‘ In those who are young and of good constitution the conyales-
cence is rapid and complete. In the old and debilitated it is other-
wise ; but I have never seen any one, old or young, die of the ordinary
form of the fever.
‘* ‘The above is a succinct account of the course of the disease in its
most common form.
‘* Some cases are subjoined which, I beg the reader to remark, are
given not so much as illustrations of the treatment, as of the natural
history of the fever.”
Passing over these, which, we may remark, appear to be re-
ported with much care and accuracy, we come to the author’s
description of the highly congestive form of the disease: +
** Although many of the cases issuing in death, or characterized
by extreme severity, present symptoms very different from those
hitherto detailed, there can be no doubt that the disease is essentially
the same, the difference being only one of degree, as will be more
especially unfolded hereafter. Both forms are undoubtedly the result
of the same morbid poison.
‘* One of the most common symptoms in the highly congestive
form of the disease is yellowness of the conjunctiva and of the whole
surface of the body. It generally appears between the third and
seventh day, and is always most intense on the face, neck, chest,
abdomen, and thighs. The hue of the neck and chest is the most
vivid ; then comes, of equal or nearly equal brightness, the abdomen :
then, somewhat fainter, the thighs; then, considerably paler still, the
legs, arms, and forearms; the hands and feet get their colour later,
always to a much less extent, and sometimes not at all, The yellow-
ness occasionally appears during the relapse, and not in the first
attack. I have seen it present in both. Associated with the yellow-
ness there are generally depression, more or less delirium, dusky and
often porter-coloured urine, black, melzena-like stools, and hamor-
thages from some of the mucous membranes. In the worst of the
cases, black, coffee-ground-like matter is ejected from the stomach and
passed per anum. In some cases the black vomit occurs without the
yellowness; and, on the other hand, at the autopsy of yellow patients
who have had no black vomit, this matter has been found in the
stomach and other parts of the alimentary’ canal.
‘‘ Enlarged liver and spleen and tender-and tympanitic abdomen
are less constant, but still very usual symptoms in cases characterized
by yellowness or extreme congestion. Difficult micturition has been
complained of by several of my yellow and purple patients. A deep
persistent colour of the face appearing before or immediately after
the invasion of the disease is a certain prognostic of danger, and is
seldom absent in those destined to be yellow. Since I first made this
observation it has received, among others, two notable verifications in
the cases of my assistant, Doctor Hende, and Mary Wallace, one of
the nurses. Doctor Hende, I pointed out to my other assistant, Mr,
VOL. XxV. No. 74, . 2U
330 Bibliographic Notices.
Reid, as deeply purple, at noon, when we were engaged with the visit :
at 3 P. M. he was in the initial paroxysm of the fever. Mr. Reid and
I remarked Mary Wallace becoming first bronzed, and at last purple,
before she was laid up, and in consequence advised her to take the
chlorinated solution, which she did not do. Both became yellow, and
both narrowly escaped with their lives.
‘‘ With the exception of the purple countenance, the symptoms
which usher in the congestive form of the disease differ little from
those attending the disorder in its milder degree. As has already
been remarked, there is some considerable difference in the cases as
to the time at which the yellowness appears.
‘¢ Generally in the severe cases there is merely a remission about
the seventh day, but no intermission; and even in those who died a
few days later, a slight amendment was noticed about the usually cri-
tical period.
‘Tn my dissections of the purple and yellow cases I have uni-—
formly found bile in the gall bladder, a pervious state of all the bile
ducts, and bile in theduodenum. Excessive capillary congestion was
exuded blood was found
always met with; and in the severe cases
between the muscular and mucous coats of the intestines.”

This last passage naturally leads us to the question, what is

the origin of the yellow tinge of the skin in these cases, and in
yellow fever? and passing by for a time the author’s remarks on
the pathology of the disease, we shall notice his views of this
part of the subject as well as those of other writers : ;
Several explanations have been offered; as that of Tho-
massini, that hepatatis, sometimes recognizable by dissection,
sometimes not so, is in all cases present. ‘That of Broussais,
that violent irritation of the duodenum is propagated to the
secreting organ. Doctor Graves’s opinion that spasm of the
ducts is the cause: and, lastly, the opinion favoured by our
author, that the cause is in the blood, and probably is connected
with the non-elimination of bile from that fluid.
The first and second explanations may be answered in the
language of Dr. Graves.
First, as to an internal hepatitis, that
‘© As no such inflammation to our knowledge has been detected in
those cases of yellow fever which present an apparently healthy state
ana-
of the liver, and as the most accurate descriptions of the morbid
tomy of yellow fever with which we are acquainted report a healthy
state of the liver in a majority of cases, we must, for the present at
least, consider the jaundice of yellow fever as independent of hepatitis.”
Then as to duodenitis, the same writer observes :
‘Tf the irritation or inflammation of the duodenum was propa-
gated to the liver, we must expect to find that organ inflamed.”
 Dr. Cormack on Epidemic Fever. 33|
Dr. Graves thus states his own opinion (18th lecture):
‘‘ Tt is well known to pathologists, since the time of Broussais,
that jaundice is as frequently produced by duodenitis as hepatitis, if
not more so: but I do not think that theexplanation he gives is appli-
cable to our cases. He concludes that when the mucous surface of
the duodenum is thrown into a state of excitement, we may have a
consequent affection of the liver, for the duodenum bears the same
relation to the liver as the mouth does to the parotid gland; and we
know that an irritation of the orifice of the ducts leading from this
and the other salivary glands is immediately followed by an increased
flow of their secretions. But our dissections have shown that the
small intestines were affected not only by inflammation, but were acted
upon by violent spasms, producing invaginations of different portions
of the canal; and there can be no doubt that the ducts (possessing
Such considerable vital contractility), participated in these spasms,
and thus prevented the flow of bile into the duodenum as effectually
as if they were tied bya ligature, or their canals obstructed by calculi ;
and this explanation obtained great support from the fact, that the
jaundice came on suddenly in most of the cases, and was always
preceded or accompanied by violent and convulsive contractions of
the abdominal muscles and intestines.”
Dr. Cormack thus expresses his opinion that the yellow
tinge is one of the effects of the introduction ofa morbid poison.
into the blood. |
‘<The yellowness of the skin in yellow fever has been ascribed to
general ecchymoses, and possibly in some instances it may originate in
this cause ; for Andral has shown that it is this which produces the
saffron colour of the skin, in what is improperly called the jaundice
of new-born children, I have noticed that in my cases the yellowness
was always most intense when the blood had been drawn to the sur-
face by blisters, sinapisms, or other means. However, if this expla-
nation be adopted in regard to yellow fever, it can only apply to those
eases in which the yellowness is partial, or limited to particular parts
of the body. Moreno, Gilkreest, and others have seen the sheets
stained yellow with the perspiration, and this we could hardly expect
were it merely ecchymoses which discoloured the skin. Moreover
(as in the present epidemic) the fluid in the cavities, and the urine,
have often a yellow tinge, and John Hunter states that the latter
stains linen rags yellow, like that of a person in the jaundice. For-
dyce attributes the yellow skin to a redundant secretion of sebaceous
matter. Saunders believed that it depended rather upon a particular
state of the lymph in the cellular substance of the parts, than upon
the absorption of bile into the circulating mass, The most rational
explanation seems to be that it is the result either of an absorption of
bile, or of its non-elimination from the blood. There may be instances
in which the former is the cause; but when we remember the disor-
dered state of the secretions, and the diseased condition of the blood,
332 , Bibliographic Notices.
it seems more natural to conclude that the bile has either not been se-
creted, or secreted in very small quantity.
‘¢ The bite of a particular kind of viper possesses the remarkable
property of causing the skin to become deep yellow, and that some-
times within the space of an hour. ‘To produce this effect, however,
the poison must be in a concentrated form, and actually introduced
into the circulation. The primary effect both of the poison of yellow
fever and of the viper, seems to be upon the blood, and in both in-
stances there is a partial or complete suppression of the secretions.
As intimately connected with this subject, it may be mentioned that
yellowness of the skin, yellow sweats, and yellow urine, have ensued arI
i
i
a
a
l
aaN
from eating certain kinds of poisonous fungi and fishes; and it may
also be stated that there is a remarkable resemblance in the effects
produced by the poison of animal and vegetable putrid matter, and
the poisonous principle of certain fishes and fungi. ‘Thomas states re
te
itd
(ana
EN
RA a

that from the effect of the fish poison he has seen the whole body be-
come yellow, and the urine and sweat assume the same hue, the latter
civing a deep yellow tinge to linen. He observed these symptoms in oo

several cases, and particularly in himself, from eating the pirea ma-
rina, a poisonous rock fish. The resemblance between the post mor-
etl
i
lnp
nl
Ro
LFe

tem examination in cases of poisoning from fungi, to those detailed as a

e

characteristic of yellow fever may be seen by consulting Christison rea

on poisons.”
Our predilections for a humoral pathology would induce us
to lean to this explanation, rather than to any of the foregoing;
it is supported by a very striking case of sudden supervention of
E
oh
n,i

jaundice in typhus in which on dissection the liver and ducts

were found healthy, and the heart and vena cava enormously
distended with fluid frothy blood (page 90), as well as by obser-
vations instituted by Dr. Cormack and others, which prove the
blood to be in an altered and dissolved condition during, and
even prior to the disease under consideration.
«¢ There seems good reason to believe that a number ofindividuals
who do not actually succumb under the influence of the epidemic, are
nevertheless affected by it in a marked and characteristic manner, such
as by slight chills and sweatings, some beadach and vomiting, with
prostration of strength. All of these symptoms in a mild form may
occur combined, or some of them only may be present. In one in- aa
ea
ae
stance in which the whole of the group of symptoms occurred, along
with the bronzing of the countenance, they entirely disappeared within
twenty-four hours, an emetic having been given thiee hours after their
invasion. . . . . Probably change of air, either alone, or conjoined
with the use of certain remedies, such as Labaracque’s chlorinated sack
ncaa
ted
G
J
solution of soda, might in a considerable number of cases have proved
sufficient to ward off, or perhaps, more correctly speaking, to arrest
the disease in dimine. ‘This belief is principally grounded upon the See

te
y
ie

ats
Fl ase
 Dr. Cormack on Epidemic Fever. a0
fact that for some days before there exists any other evidence of the
presence of the disease, the countenance assumes a peculiar premoni-
tory hue, indicating, | apprehend, a dissolved state of the blood, and
a want of tone in the capillary vessels. When the vital fluid is still
more dissolved in the subsequent stages of the disorder, we also find
an increased inability to circulate in the capillaries, from the enlarged
calibre, or relaxed state of these vessels, disabling the organs ofsecre-
tion from performing their functions, from congestion, as is frequently
manifested by the scanty urine and yellow skin, which latter symp-
tom, as the cases detailed sufficiently prove, does not arise from any
obstruction in the biliary ducts, but depends upon the bile not being
separated from, or being reabsorbed by the blood. Another class of
symptoms produced by this capillary congestion, is haemorrhage from
the mucous membranes, with occasional black vomit. That the blood
really is in a dissolved state was made manifest to us, first, by the
imperfect coagulation which it underwent when drawn from the veins
of the patients, a homogeneous and spongy mass being formed in
place of a firm fibrinous clot, with a supernatant serosity ; second, by
the ecchymoses which was uniformly observed to surround flea-bites, or
other slight injuries of the skin; therd, the frequent occurrence of
purpurous spots ; fourth, the hemorrhage; and fifth, the discoveries
made by the microscope.
‘¢ Professor Allan Thompson had the goodness to lend me his
able assistance in examining the blood of a number of my patients,
by means of the microscope. A few drops were taken from the
thumbs on the same day (Oct. 24th), of about a dozen persons, some
of them in the pyrexial, and others in the apyrexial stave of the dis-
order; and it was found that in all of them there were an unusual
number of pus globules, and in some cases, in addition to this, all the
globules were found serrated and notched. One gentleman present
on this occasion was observed to have his blood exactly in the same
state as the fever patients, and within two days he was seized and
went through two mild attacks, or to use conversational phraseology,
the fever and the relapse. The blood of some other healthy persons
was also examined at the same time; it exhibited nothing unnatural
and none of these latter individuals have taken the fever, although
more than a month has now elapsed since the observation was made.”
These observations are highly interesting, and accord with
those of several writers on the yellow fever in America. Our
readers are no doubt familiar with the reference to these con-
tained in Dr, Tweedie’s article on fever, in the Cyclopedia of
Practical Medicine. Dr, Potter, whom he there quotes, states
that it was remarkable
‘¢ In all cases in which it was deemed expedient to bleed, the
blood wore the same general appearances. After a separation the
serum assumed a yellow shade, often a deep orange, and a portion of
the red globules was invariably precipitated.”
304 Bibliographic Notices,

He also found the same condition prior to the attack in the

blood of those who resided in the malarious district, while in
the blood of those who lived in a healthy district no such ap-
pearances were to be met ; and he further states, that of the six
apparently healthy persons whose blood gave such indications,
four were seized with fever during the epidemic, the other two
escaped any formal attack, but complained occasionally of head-
ach, nausea, and other indications of disease.
Would not this orange hue of the serum explain the appear-
ance of the skin and-secreted fluids, without the necessity of
supposing actual jaundice (though this is no doubt mostly pre-
sent) in these cases? and does it not countenance the seemingly
fanciful hypothesis of Saunders, that the colour of the skin de-
pends rather upon a particular state of the lymph in the cellular
substance of the parts, than upon the absorption of bile into the
circulating mass?
To return to Dr. Cormack.
‘‘ The present epidemic,” he considers, ‘‘ possesses positive and ne-
gative characters strikingly distinguishing it from the fever which
generally prevails in Edinburgh, viz. :
‘©1, The sudden and violent invasion of the disease.
‘© 2, The bronzing, hardening, and purpling of the countenance
before seizure. This was one of the most remarkable peculiarities
of the prevailing epidemic.”
By one it seems it was compared to the Walcheren epidemic,
By another to the aspect of the inhabitants of the marshy dis-
tricts of Italy, and it appeared to our author to bear a resem-
blance to the descriptions of Andouard and Blanc, of the change
of colour of the countenance before it assumed the yellow cast
in patients affected with yellow fever in warm climates.
“© 3, The almost uniform occurrence of one or more relapses.”
So great is the tendency to this, that the author says most
confidently, unless anti-periodic remedies are employed, one or
more relapses will occur with hardly a single exception. He
does not offer any explanation of this peculiarity. It may be
remarked, that in some parts of this country the prevailing fever
of the past year has shown a similar tendency ina greater degree
than we ever remember, but of course in nothing like the same
proportion as the above. It is a remark of Dr. Cheyne, that in
Ireland short fevers especially are prone to relapse.
“A, An unusual number of cases exhibiting yellow skin, black
vomit, and hemorrhage.
 Dr. Cormack on Epidemic Fever. 335
“5. The short duration of the pyrexial state, and its mode of
termination.”
In these particulars, as well as the preceding, Dr. Cormack
shows that the epidemic resembled the Irish one of 1826, while
it bears an equal resemblance to yellow fever, a term, he contends,
which should be banished from the nomenclature, inasmuch as
yellow skin, and black vomit, black stools and urine, and heemor-
rhage are consequences ofcongestion liable to occur in fevers of
all types and countries.
“6, Severe muscular and articular pains in the disease, and
during convalescence.”
These the author thinks may possibly depend on the pre-
sence of urea in the blood.
“<7, The rosy, elliptical eruption resembling measles is absent
in almost every case in the present epidemic.”
This, the author truly observes, is one of the most remarkable
distinctions between the symptoms of this epidemic, and that
which has been common in Edinburgh for a number of years
past. He starts the inquiry, suggested by its occasional pre-
sence, whether the two fevers, though apparently so different,
are not the results of modifications of the same morbid poison?
As the question of the speciality of T'yphus will come under our
notice shortly, when examining another work now upon our ta-
ble, we shall not dwell upon it at present. Dr. Cormack does
not, we conceive, throw much light upon it, indeed he states
that his own opinions are not settled, having been modified by
recent experience, and he says:
‘‘ Tf some think that on this point there has been exhibited an un-
due reluctance to enter fully upon an important pathological inquiry,
I beg to remind them that data are yet wanting to entitle us to discuss
it fairly and with profit. This may be attempted in asubsequent pub-
lication at the close of the epidemic.”
We hope so, and shall expect to receive much information
upon a most interesting question, from so candid and _pains-
taking an inquirer as the author.
“« Severe vomiting is much more common, as are likewise gas-
tric, gastro-hepatic, gastro-splenic, and gastro-enteric symptoms.
‘In the mild cases the matters vomited are generally the injesta,
tinged with green of various degrees of intensity.
‘‘ In the most malignant of the yellow cases there is sometimes a
fine inky sediment in the vomit, at other times the grounds are gru-
336 Bibliographic Notices.

mous, in consistence like the thick part of hare soup, and varying in
colour from dark brown to black.
‘‘ The grumous matter of the black vomit, in its various forms, is
unquestionably blood extravasated from the capillaries of the stomach,
and chemically altered by the action of the acids of the stomach
upon it.”
The acute pain which patients often complain of when pres-
sure is made over the stomach and duodenum seems, Dr. Cor-
mack thinks, to depend, in the majority of cases, upon flatulence
alone. Atall events, when accompanied by gaseous distention,
which it generally is, he has found far more advantage from tur-
pentine enemata, carminatives, and fomentations, than from
leeches. A valuable remark.
Fulness of the liver has been noticed during life in some
cases, but not so frequently as the same affection of the spleen,
a
a
ile

which becomes so much congested and enlarged, and gives so SAN

much pain on pressure, as to simulate splenitis. ‘The enormous

e
*)a;

congestion, however, of this organ has, according to Dr. Cor-

mack, as little to do with inflammation as any of the other con-
gestions met with in the fever.
On the origin of the epidemic Dr. Cormack does not throw
any light; he states, that “ facts are not wanting to give colour
to the belief that the disease has been imported into this coun-
try.” What these are he does not state. He considers the
disease is contagious:
‘¢ Of this we have sufficient evidence in the fact, that almost all
the clerks and others exposed to the contagion have been seized.
Dr. Hende and his successor, Mr. Reid, in the new Fever Hospital; cpa
Sag
see
spa
ahr
ai
she
pal
‘
picts
is
ge
‘ii
Me
i.

Dr. Bennet, my successor there; Mr. Cameron, and his successor Mr.
Balfour, in the adjoining Fever house, as well as most of the resident
and clinical clerks in the Royal Infirmary, have gone through severe
attacks during the past summer and autumn. Hardly any of the
nurses, laundry women, and others coming in contact with the pa-
tients, or their clothes, have escaped,” &c.
It does not seem to spread by contagion out of doors, at
least not in the 2ew town, where isolated cases of great severity
have occurred, but have not propagated the disease. Probably,
as Dr. Cormack seems to think, its power in this repect 1s not
strong, requiring the aid of the consortus @grotorum for its
diffusion. In other words it might perhaps be termed by ob-
stinate opponents of the doctrine of infection, a factitiows con-
tagion created by accumulation of sick persons, and not origin-
ally belonging to the disease.
The structural lesions caused by the fever are shown by a
 Dr. Cormack on Epidemic Fever. oot

summary of all the dissections made by Dr. Cormack. The

following seem to have been the usual appearances:
Bile ducts pervious; inspissated bile in the gall bladder;
black matter similar to that vomited contained in the stomach;
mucous membrane of stomach and intestines dark coloured from
congestion, and with occasional patches of submucous exudation
or extravasation of blood. Liver sometimes yellow, and re-
resembling the condition described by Louis,—sometimes dark
and tinged with blood. Spleen generally soft, sometimes enor-
mously distended, weighing, in one instance, two pounds. ‘Fre-
quently, general internal congestion and yellowness of tissues.
‘¢ Enough has been seen,” says the author, “ to indicate at least
’

the nature of the lesions to be expected in similar cases, viz. 1. abun-

dance, or even an excess of bile, and a pervious state of the biliary
ducts; and 2, more or Jess congestion of organs, with, frequently,
extravasation of blood in various situations. These appearances are
either identical with, or analogous to, what the majority of observers
have noticed and described as being those which are found in persons
dying of yellow fever. It may be interesting to refer to a few of
them.”
Want of space forbids our extracting these,
The chapter on the sequel of the disease consists chiefly of
extracts from Dr. M‘Kenzie’s Paper in the Medical Gazette for
24th November, on the peculiar form of Ophthalmitis affecting
Convalescents; and remarkable from its resemblance to that
which occurred in persons recovering from the Dublin Epidemic
of 1826, described by Doctor Jacob in the fifth volume of the
Transactions of the Association of Physicians.
The remarks on treatment are highly judicious and impor-
tant, and merit the study of all who may be called upon to treat
this disease. He thus states the principles upon which his prac-
tice was founded:
‘* At an early period of my experience I became convinced that
there were three states most apt, either separately or conjointly, to
cause death, and which, therefore, ought to be anxiously looked for,
and, if possible, promptly corrected. They are:
‘“‘ Ist. Congestion of the mucous membrane of the stomach and
intestines, terminating in effusion of blood and subsequent destruc-
tion of large portions of this tissue.
“2nd. Congestion of one or more of the abdominal viscera,
particularly of the liver and kidneys, disabling them from the
performance of their seeretive function, thereby causing bodies to
circulate with the blood which ought to be separated from it, and
which bodies we know to act as poisons when not so eliminated
from, or when directly introduced into the circulation.
VOL. XXV. NO. 74. 2x
338 Bibliographic Notices.
“3rd. Debility and sinking.
‘Ath. It will also be necessary to speak of the measures to be
adopted to prevent or modify relapses.
‘© The best means by which to prevent these evils are the cautious
but steady use of purgatives, the determination of blood to the surface
and extremities, and in some cases its abstraction. When the kid-
neys are not performing their functions, a small bleeding from the
lumbar region by cupping, or even a dry cupping in those in whom
depletion would be hazardous, proves of signal benefit. Of course
when there is debility and a risk of sinking, cordials and stimulants
must be administered; and if, along with this, which is no uncommon
case, there be nausea or vomiting, they must be combined with
sedatives.
‘‘ It has seemed proper to make these general statements before
speaking separately of the various therapeutic agents, which will now
be done.
‘¢ Abstraction of Blood.—This powerful method of interference,
for good or for evil, most naturally claims our attention, as to it have
been ascribed numerous and great advantages. Several medical friends
who have visited the hospital have urged me to practise it both gene-
rally and topically, from the success which they imagined had at-
tended it in many cases. I have been told, for instance, and that
very confidently, that patients bled in an early stage of the fever sel-
dom relapsed or became yellow, and rarely suffered, except to a very
small extent, from muscular and articular pains. Though I certainly
did not expect toreap these advantages from the abstraction of blood,
yet observing that the fever was attended in its commencement by
much arterial excitement and congestion, it appeared to me both rea-
sonable and justifiable to make some experiments upon the effects of
venesection in suitable cases. In most, if not in all the instances, the
headach was either relieved or entirely removed for a short time, and
the hard and frequent pulse was rendered softer and slower. These
beneficial changes were often not effects though sequences of the
bleeding, as was satisfactorily proved by the very same changes fre-
quently occuring as suddenly and unequivocally in patients in the same
wards, and affected in the same way, who were subjected to no treat-
ment whatever.”
He thus states his preference of general to local bleeding:
‘It is supposed by some that leeching is less objectionable than
general bleeding, but I think the contrary of this supposition is often
the truth. In opening a vein and allowing the blood to flow when
the patient is sitting up, we have in the effect produced at the time,
an accurate index by which to regulate the quantity to be taken ; and
then it is almost always easy to arrest at pleasure the flow of blood
from the brachial vein, With leeches it is different, and especially in
the present epidemic, where the tendency to hemorrhage, and the
difficulty of arresting it, are so great, that I have several times seen
alarming depression caused by the oozing from one or two leech bites,
 Dr. Cormack on Epidemic Fever. 339
between the time when they had been removed in the afternoon of
one day and the noon visit of the next. The special objection to
leeching is the danger of causing the loss of an uncertain quantity of
blood.
‘«In several cases of pulmonary inflammation of various forms and
degrees, I have seen all the symptoms disappear under the use of anti-
mony and morphia combined, or the liberal use of the morphia and
ipecacuan lozenges. These remedies, when used along with fomenta-
tions, sinapisms or blisters, are safe, and generally efficient substi-
tutes for local bleeding, in thoracic complications. As the result of
my experience then in this matter, I would say that the cerebral,
pulmonary, and abdominal complications in which it is proper to
abstract blood are extremely rare, and that in very many such in-
stances it is a most hazardous practice. ‘The statements which have
been already made sufficiently justify this opinion, so far as the cere-
bral and pulmonary symptoms are concerned, and, with regard to the
abdominal affection, this will be equally easy.
‘* In some of the most severe and threatening cases of abdominal
pain and extreme tenderness on pressure, the patients have been well
brought through simply by the diligent use of copious warm poultices
and fomentations: enlarged and tender spleens have often done well
with this simple treatment. Ido not mean to say that it would be
proper in all such cases to abstain from abstracting blood; but am
anxious to point out how exceedingly valuable these remedies are,
and how much safer it is in weak persons to rely on them, than to
take away any blood. Francis Rose (vide page 60), when far spent
in strength, was seized with acute symptoms of enteritis and diar-
rhea. A little morphia was added to the whiskey which he was
taking, to sustain his feeble and fluttering pulse, and his abdomen
was most assiduously fomented, Contrary to all expectation, the
symptoms abated, and recovery ensued. Depletion in any form
would, I think, have killed him.”
The internal use of diaphoretics he disapproves of, but he
recommends the use of external heat and moisture.
‘¢ Although of opinion that all diaphoretic and sudorific drugs are
of little advantage, and that violent sudorific doses are injurious,
Iam yet of opinion that I have very often seen the best possible
results from other means employed for the purpose of diaphoresis
and sweating, such as the wet blanket, the partial warm bath, and
tepid sponging. The general warm bath is apt to produce exhaustion.
I had three young patients affected with ardent fever, and dry,
hacking cough, closely wrapped up in a blanket wrung out of hot
water; above this were placed several dry blankets. ‘They sweated
most copiously from ten to fourteen hours, and were then removed to
a dry bed, where they all sweated again so freely, as to require to
have their linens changed. They emerged from this sudorific regimen
} perfectly free from fever, cough, and pains, but excessively weak
and languid.”
340 Bibliographic Notices.
He also speaks highly of cold sponging in severe head-ach,
and of the aspersion of the arms and chest with cold water in
eases of irritability and restlessness.
Purgatives form, in the author’s estimate, a most important
part of the treatment :
‘‘The great aim in administering these medicines in this and
other fevers, should be, to clear out the bowels fully, and, if possible,
daily, at the same time carefully avoiding such substances and doses
as might cause gastro-intestinal irritation, or debility from catharsis.”
Compound powder of jalap, compound colocynth pill, with
blue pill and calomel combined, in cases of irritable stomach,
with a quarter or half a grain of opium, the black draught,
aloes and assafcetida, and castor oil, were those mostly used.
Croton oil he considers a very suitable purgative in this disease.
His experience is unfavourable to the use of mercury, which
he has latterly never used.
‘‘ The cases have gone on at least as well as formerly, during the
pyrexial stage, and convalescence has been more rapid from there
being no retardation of it from sore mouth.” ‘* As the biliary secre-
tion is excessive, and not diminished in the yellow patients, it seems
absurd to give a medicine which unquestionably acts as a direct stimu-
lus on the liver.”
To relieve the muscular and arthritic pains, colchicum
was given without any good effect. The hydriodate of potass
appeared to be useful, especially during convalescence; an
observation which, our experience leads us to say, might be ex-
tended to other fevers.,
Different tonics were given with good effect, more especially
quinine, and the saccharine carbonate of iron.
The work concludes with a statistical table of cases.
The length of our extracts sufficiently shews the sense we
entertain of the importance of this work. It is a modest and
brief, as well as a faithful and learned account of the epidemic.
We cordially recommend it to our readers, and again express
our opinion that it deserves to be placed beside Cheyne and
Barker’s Report, in the library of every medical practitioner.

Minor Surgery; or, Hints on the Every-day Duties of the

Surgeon. By H. H. Smirn, M. D. Illustrated by En-
gravings. Philadelphia.
pub-
Tus is a very useful little work, and we know no book
lished in England which gives such minute and satisfactory
descriptions of the uses and modes of application of bandages,
 Dr. Smith’s Minor Surgery. 341
straps, splints, &c., each description being illustrated by a good,
though rather coarse wood-cut. There are a series of these
illustrations, which exhibit the use of the handkerchief in various
diseases of the head, body, and extremities, in a variety of in-
genious ways, many of which were not known to us before,
and their adoption we think will be likely to be found useful.
‘* The handkerchief, or square linen, may,” he says, ‘‘ replace
all the bandages that we have before treated of, and in its dimensions,
as well as in the tissue composing it, must be regulated by the size
of the part to which it is to be applied, or the circumstances of the
moment. It is, therefore, a matter of indifference whether it be of
silk, cotton, or linen; and if too short to go round a part at the time
of its application, may be easily lengthened by attaching to its extremi-
ties two pieces of tape or ribbon. From this original piece we may
form various other shapes suited to circumstances, viz., the triangle,
the long square, the cravat, and the cord, made by twisting the
cravat on itself.
The following is his account of Baynton’s plan, and will
convey a specimen of the style of the work :
‘“‘ As the treatment of ulcers by the use of adhesive strips is of
considerable importance, a detailed account of Baynton’s plan is here
given.
‘¢ Several strips of adhesive plaster, the manner of preparing
which has been already described, of about two inches in breadth, and
sufficiently long to pass round the limb and leave an end of about four
or five inches; several longitudinal compresses made of soft calico,
and a calico roller about three inches in breadth, and varying from
four to six yards in length, according to the size of the limb, are first
prepared. Then one of these strips is to be applied to the sound side
of the limb, opposite the inferior part of the ulcer, so that the lower
edge may be placed about an inch below the lower edge of the sore,
and the ends drawn over the lower part of the ulcer, with as much
gradual extension as the patient can conveniently bear; the other
strips are then applied in the same manner, each above and in contact
with the other, until the whole surface of the sore and of the limb is
covered from one inch below to two or three inches above the affected
art.
‘“‘ The whole of the leg, if it is the part affected, should then be
covered equally with the longitudinal compresses, and the roller ap-
plied round the limb, from the toes to the knee, with as much firmness
as the patient can support without complaint. One or two spiral turns
of the roller should be first passed round the ankle-joint, then as many
round the foot as will cover and support every part of it, except the
toes, and the same continued up the limb as far as the knee; the
roller should be carried from the ankle upwards in reverses, as many
of them being made as the parts require, in order that each turn may
342 ' Bibliographie Notices.
lie flatly on the limb, Should the parts be much inflamed, or the
suppuration be very abundant, the applications are to be wetted fre-
quently with cold spring water. The patient may take exercise if he
pleases, as this will be found to alleviate the pain and tend to accele-
rate the cure. The bandage ought to be daily applied soon after rising
in the morning, when the parts are most free from tumefaction; and
the force with which the ends of the plasters are drawn over the limb
gradually increased as the parts return to their natural state of ease
and sensibility. When the cure is thus far accomplished, the roller
should be applied with as much tightness as the patient will bear,
more particularly if the limb be in that enlarged or compressible state
denominated scorbutic, or if the edges of the wound be thickened.
«© We may remark, that this bandage is liable to produce excoria-
tions of the limb, but these are never serious except when they occur
over the tendo-Achillis. To prevent them or accelerate their disap-
pearance, Mr. Baynton recommends the application of a small shred
of soft leather under the adhesive plaster: or a bit of sheet lead may
be used in place of the shred of leather, as it answers better.
‘¢ During the years 1830 and 1831, several of the most eminent
surgeons of Paris submitted Baynton’s method of compression to a
series of experiments, which, as the result will show, were highly
favourable to it. Velpeau found the average time of cure ten, fifteen,
or twenty days, for ulcers of three, four, or five inches in circum-
ference. Ph. Boyer, who perhaps pushed the experiments further
than any one else, found the average period of treatment calculated
upon a large number of cases, to be twenty-six days; and this result
isso much the more striking, as Duchatelet was noticing at the same
period the average length of time required by the older methods,
which he found in six hundred and ninety cases to be fifty-two days
and a half, giving a difference of more than half in favour of Baynton’s
plan. In the course of these experiments some modifications were
introduced ; as, for instance, that by Velpeau and Ph. Boyer, of the
substitution of good diachylon plaster for the mixture of Baynton.
So, with respect to the breadth of the plasters, the above surgeons
found them more advantageous when only an inch or an inch and
quarter broad. In the course of the experiments, Roux and Ph.
Boyer found that the inflammatory state of the ulcer did not counter-
indicate the employment of compression, which often arrested even
its secondary effects. Marjolin, however, recommended the reducing
of the inflammation before proceeding to compression. Velpeau and
Roux extended the compressive treatment to contused wounds with
disorganization of the skin, which were getting into an atonic state,
andalso, to every species of wounds with or without loss of substance, .
when the cicatrization was slow, or otherwise checked by a general
vice of the constitution, attending, however,
in the latter case to inter-
nal remedial agents calculated to benefit the system. Ph. Boyer
endeavoured to cure syphilitic and scorbutic ulcers by compressive
strips alone, but without success; while, by exerting this species of,
 Dr. Smith’s Minor Surgery. 343
compression, and employing, at the same time, the ordinary internal
remedies, the cure was remarkably hastened.
‘‘ Ph. Boyer’s observations all tend to Support the opinion of
Baynton himself, that, when the leg is properly bandaged, walking,
at least moderately, tends to facilitate the cure, and renders it more
complete. With regard to the periods of renewing the bandage, Vel-
peau found it quite sufficient to change it every three, four, or five
days, according to the degree of irritation. Boyer never dressed them
oftener than once in forty-eight hours. Valbrune considered it
necessary to renew the bandage oftener, if the cessation of swelling
caused it to become relaxed, but agrees with Velpeau and Boyer in
thinking that the less often the bandage is disturbed the better.”
 SCIENTIFIC INTELLIGENCE.

the
Case of extensive cancerous Ulceration of the Leg, in which
Limb was removed after the Glands in the Groin had become en-
larged, without a Return of the Disease.—Secondary Hemorrhage
on the tenth Day after Operation, by John Stuart Vesey, M. D.,
Surgeon to the Magherafelt Poor-House, &c. &C. |
[For the Dublin Journal of Medical Science.|
William Ray, aged 64, a large and powerfully built man, consulted
me on the 2Ist of August, 1842, labouring under the following symp-
toms: the front and sides of the right leg were covered by an ulceration,
with a border of dark purple and immoveable skin which reached, above,
below,
to within a hand’s breadth of the tuberosity of the tibia, and,
covers the anterior part of the ankle joint. The ulcer itself presented
the following characters: it was nearly four inches long, and two and
a-half broad; its edges were very hard and elevated ; inverted at some
and
parts, everted at others: the surface presented alternate elevations
depressions, with here and there isolated formations of large unhealthy
granulations, from each of which a dot of thick white matter could be
pressed. The discharge from the diseased surface was thin and brown,
profuse in quantity and possessed of the peculiar odour that charac-
terizes cancerous ulceration. He had had from the commencement
of his ailment, a burning and stinging pain in the sore, extending to
sed
the foot; but within the last three weeks this symptom had increa
to such a degree as to render him miserable, and deprive him totally
of sleep. The disease was of four years’ duration, and during that time
he had consulted many practitioners, and tried numerous applications,
without any success. Several surgeons, one of them of high emi-
nence, had told him the disease was cancer. On the thigh of the ©
same side, within two inches of Poupart’s ligament, its long diameter
a
parallel to the course of the vessels, there was a swelling larger than
hen egg, which a minute examination proved to be formed by the
junction of three irregular glandular tumours. Its base could be
grasped by the hand, but it admited of slight motion in all directions.
It was firm to the feel, but this firmness was by no means deserving of the
name of ‘stony hardness.” It gave him no pain, and the skin over it
was not discoloured. It was of twelve months’ standing, and began, he
says, as a small, moveable, painless kernel. In the left breast (close
to the nipple) there was a firm tumour as large as a marble, and, like
It
that in the groin, unattended by pain or cutaneous discoloration.
made its first appearance three months before.
On the back of the metacarpal bone of the right thumb, there was
 Screntific Intelligence. 345

an unhealthy sore, about an inch in length, with elevated edges and

a border of dark-coloured skin. It was of five weeks’ duration; at-
tended with a scanty discharge, and a constant burning pain, worse
at night; but never increased by the sharp and sudden stings that
characterize the ulcer on theleg. He had no cough, nor any irre-
gularity of respiration; no tumour or uneasiness in the abdomen.
Pulse natural.
The man himself was desirous to have the limb taken off, but there
was some hesitation on my part before I decided on this step. I was
so situated that I could not have the advantage of a surgical consul-
tation; but on examining, again and again, the enlarged glands in
the upper third of the thigh, I came to the conclusion, from their
mobility and freedom from pain, that they had become enlarged from
mere irritation, and had not yet assumed the cancerous action. I saw
nothing to forbid an operation on the tumour in the breast, although
the ulceration on the thumb was unhealthy, yet it had less the ap-
pearance of well marked cancer than ofa common sore in a worn
down habit. In fine, I thought all his symptoms would be apt to yield
to treatment if once the constitution could be, as it were, removed
from under the influence of an irritating and extensive disease. Ac-
cordingly, on the 2d of September, 1842, I removed the limb below
the tuberosity of the tibia and head of the fibula. The superficial
vessels bled considerably ; the tourniquet could not be effectually ap-
plied, owing to the extent of enlarged glands in the upper third of the
thigh, and my assistant failed in making adequate pressure on the
artery between Poupart’s ligament and the glandular mass. I expe-
rienced the usual difficulty and delay in securing the tibial vessels,
oWing to their great retraction; and, from this cause, as well as the
others adverted to already, the arterial hemorrhage was unusually
great. An alarming syncope was the consequence, to rouse him from
which a liberal supply of wine internally, and cold water dashed
forcibly in his face, were necessary. When placed in bed he acted
like a madman, shouting loudly, and tossing about, with every other
evidences of strong nervous excitement. A draught, containing
tincture of opium was administered. In half an hour no further bleed-
ing having occurred, the stump was dressed with adhesive plaister
and a bandage.
> Ordered wine and chicken broth.
On the third day the angles of the wound for about an inch in ex-
tent, had united, the centre was open. Up to this, and for the two
following days, he laboured under high nervous excitement, with great
pallor of the face, weak and rapid pulse, oppressed and hurried respi-
ration, though nothing abnormal could be detected by the stethos-
cope.
From 6th to 12th September, the stump had made no progress
in healing; on the contrary the centre of it looked very unfavourable,
and was covered by an ash coloured coating: its starting causes him
much annoyance. Continue wine and soup, and let him have pills
of camphor and hyosciamus,
VOL, XXV. NO. 74. 2¥
346 Scientific Intelligence.
At9 o’clock p. m. September 12th (tenth day after operation),
secondary hemorrhage took place, and before I could reach his house
he lost at least twenty ounces of arterial blood. I found him sitting up
in his bed, calmly and collectedly expecting the worst. Upon remov-
ing the clotted tow which his friends had largely used to the bleeding
surface, I found that the hemorrhage had ceased, accordingly I did
not interfere with the adhesive plaister, but ordered the stump to be
exposed to the air, and to be kept wet with spirits and water.
September 16th. No return of the bleeding. The surface of the
wound had taken ona much more favourable aspect, and healthy gra-
nulations had made their appearance. He was still much annoyed by
starting, and fancied the amputated limb was still remaining in its
place. The skin over the sharp end of the tibia was slightly swollen
and red. Dry lint was placed in the cavity, and subsequently lint
steeped in Tinct. Myrrhe.
October 2Ist. The last ligature was removed this day; some force
necessary to do so, as it was held firmly by the granulations; wound
not larger than a sixpence and healthy.
December 10th. Wound healed; general health very good. The
mass of enlarged glands in the upper part of the thigh had quite dis-
appeared, the tumour in the breast had disappeared, and the ulcer on
the hand had healed.
March 20th, 1844. It is now eighteen months since the opera-
tion. The man has grown fat, and says he has not for many years
enjoyed such excellent health as he does at present. The stump is
quite sound and serviceable.

Remarks on Sibbens, by D. Wills, Esq., Surgeon, Cumnock,

Ayrshire.—It is no part of my present purpose to enter into any histo-
trical account of sibbens. Those who may feel curiosity on that sub-
ject, | refer to an essay of great ability and research, in the April
Number of the Edinburgh Journal of Medical Science, for 1826, by Dr.
Hibbert, where he attempts to prove that the sibbens of Scotland and
the West Indian yaws are identical, and under the joint term of fram-
boesia ranks them as a disease of the remotest antiquity. He also at-
tempts to establish, and seemingly with greater success, that the mor-
bus Gallicus, or French pox of the fifteenth century, was not lues
venerea, but framboesia; and not only do all the descriptions of the
disease, which at that period struck a general panic over Europe,
support his opinion, but the various modes by which it was commu-
nicated are those assigned at the present day, not to lues, but to fram-
boesia. Asa remarkable confirmation of his opinion, the first alarm
began from the years 1483 to 1493, yet none of the medical writers
of that period (and they seem to have been many and minute in their
descriptions), make the slightest allusion to bubo until 1533, a period
of 50 years! Suppose the complaint to have been lues, the lechery
of the age must have been great to present such a formidable phalanx
of disease, as to induce the parliament of Paris, in the year 1496, to
 Scientific Intelligence. 347
prohibit all those affected from conversing with the rest of the world,
under pain of death; and James 1V. of Scotland, in the following
year, to banish them to the island of Inch, or to have them burnt on
the ‘‘ cheike with the marking irne, that they may be kennit in time
to cum.” Dr. Adams also, in his valuable work on morbid poisons,
gives sibbens a seniority to syphilis in Europe, and thinks them en-
titled to rank as distinct diseases.
Mr. Hill of Dumfries again, in the year 1769, maintained that
the sibbens of Dumfriesshire and Galloway were nothing but a mild
form of the veneréal, and about the same time Dr. Freer supported
alike opinion in an inaugural dissertation, where he throws out a
fanciful theory regarding the possibility of lues being, like itch, the
product of certain specific animalcule. Between these he supposes
a flirtation to have arisen, and the result to have been a cross mon-
erel breed of sibbenitic animalcula. Dr. Mason Good has rather sup-
posed sibbens to be a cross production between lues and yaws. ‘ Sib-
bens,”’ says this author, ‘‘ is a variety of lues rendered hybrid by
passing through a constitution already contaminated with yaws.”
When Dr. Gilchrist first called the attention of the Profession to
sibbens, by an essay in the Edinburgh Collection of Medical Essays
and Observations, the disease would seem to have retained more the
character of the French pox of the fifteenth century, and of the West
Indian yaws, than it does at the present day. This change is, no
doubt, mainly to be attributed to the improved habits of the lower
orders. But[ must hasten to my more immediate object, namely, to
point out the striking similarity, if not identity, that subsists between
this disease, and that form of the venereal, called by some authors the
Jungoid venereal ulcer.
Mr. Henry James Johnson, in the April Number of the Medico-
Chirurgical Review, for 1834, in giving an account of this fungoid
venereal sore, under the name of venereal condyloma, has presented
so minute and faithful a description of sibbens, as it at present exists
in this part of Scotland, as almost to make me doubt if that gentleman
had not his model from Ayrshire, with this difference, that what he
calls a secondary symptom is our primary. ‘This is easily accounted
for. Mr. Johnson has been in the habit of seeing the disease in the
form it assumes when got by coition; we again commonly meet with
it as caught by contact of the lips, or through the medium of tobacco
pipes, &c. Sibbens, however, are frequently communicated by coi-
tion; and then the disease has all the characters of venereal condy-
loma.
In order that those more conversant with venereal condyloma may
have an opportunity of judging how far these two affections corres-
pond, I will now attempt to give a description of sibbens, as they at
present appear in Ayrshire, Galloway, and Dumfriesshire, drawn
from personal observation alone.
Sibbens do not originate in the form of a pustule, as most writers
on the subject would have it, but in that of a tubercle or condyloma.
This error, however, is the more excusable, from the fact, that when
348 Scientific Intelligence.
the condyloma begins to ulcerate, the delicate cuticle may often be
seen vesicated, or raised, and partly lying loose, round the circumfe-
rence of the tubercle. ;
I have not been able to divide sibbens into the simple and ulcerated
forms. The tubercles do not rise simultaneously. bat in succession,
and may be seen, both in a simple and ulcerated state, in the same
subject. No doubt, in good constitutions, and those of very cleanly
habits, the tendency to ulcerate is less than in those who are the re-
verse; but I look on the distinction as chiefly one ofstage. They ulce-
rate much earlier on-some parts than others. On the tonsils and
palate, where they usually make their first appearan ce, they ulcerate
early, but can rarely be seen distinctly. In their other haunts, the
tongue, cheeks, angles of the mouth, anus, groins, and genital or-
eans; though often clustered, they seldom fully coalesce, and have
less tendency to ulcerate.
A sibben condyloma may vary in size from that of a silver penny
to that of a sixpence—is either circular or oblong, and raised above
the surface, from the thickness of a sixpence to that of a penny
piece, is often as high above the surrounding skin, while in its sim-
ple form, as it ever is after, showing the impropriety of the term fun-
gating ulcer. It varies in appearance, as in site, In its simple or
ulcerated state, when situate on the dorsum and back part of the
tongue, it has the appearance of a common wart, and is but little al-
tered in colour from the parts around ; about the angles of the mouth
and round the anus, that ofa wart also, and whiter than the surround- —
ing parts. The resemblance to a wart would be stronger, could we
suppose that excresence as having a little more vitality, anda reddish
tint. In the groins and arm-pits (very rare) it is deep red and glossy, £
and it is here, after the delicate cuticle has peeled off, that they
chiefly assume somewhat the look of a raspberry in miniature, from
whence the disease takes its name. The condylomata, in what | am — i.
inclined to consider their more advanced or ulcerated stage, when si- .
tuated on the dorsum of the tongue, are surrounded with little glossy -
red areole, from the natural coating around them being removed, and
when studded over with them, give that organ an oddly mottled look,
and it may be that a deep fissure runs down its centre, or the whole
coating may have peeled off, giving the sound parts the glossy beef- —
steak appearance. At the commissures of the lips, and round the
anus, it would be difficult to say when, or if, strictly speaking, they
can ever be said to ulcerate, their appearance remaining but little
changed throughout. Indeed, they may be said to ulcerate only on
the tonsils, tongue, and inside of the labia pudendi, and merely to ~
vesicate elsewhere. In front of the scrotum, or on the pubes, the
ulcerated tubercle assumes the form of a crust or scab. When met
with on the scalp there is a crust also; and no doubt, were they to ap- =
pear over the body generally, and thereby be exposed to evaporation, . a
this would be their usual form. Their appearance on the female ~ :
parts of generation is so accurately described by Mr, Johnson, that i=
 Scientific Intelligence. 349

would only be copying that gentleman’s words in attempting a de-

scription; but | may take this opportunity of stating that sibbens
caught by coition are not always accompanied with gonorrhoea, and
are oftener without than with that discharge, particularly in males.
Sibbens, at the end of a month from their commencement (and
we are but rarely consulted so early) are, in ordinary cases, confined to
one or both tonsils,; these are seemingly ina state of superficial ulce-
ration, and covered with a sort of thin, whitish slough. To these who
wish to become acquainted with the disease, I would say, mark this
so-called slough or hazy-whitish appearance: it attends the disease
throughout, and by it alone the experienced eye can at once make a
sure diagnosis, In all other sore throats, where a slough is formed,
or lymph thrown out, the white has a dense appearance, and well-
defined border; but here itis thinner, and blended or shaded off,
till lost in the surrounding inflammation. The termination, again,
of the inflamation, in the two cases, is reversed: in sibbens it termi-
nates up on the palate, in an abrupt edge; whereas, in common sore
throats, it is in general insensibly lost. With this state of the tonsils,
there is invariably enlargement of some of the glands under the lower
jaw, and these two symptoms constitute the disease for the first four,
five, or six weeks, the patient merely complaining of slight soreness,
when in the act of swallowing any thing hard. Soon after this
period, the condylomata make their appearance on other parts of
the mouth, and by the end of six or eight weeks begin to rise up
round the anus.
Between the second and third month the disease is at maturity,
and presents the following characters:
When the parts about the glottis have become implicated, the
patient is hoarse—this he may or may not be. We look into his
throat—the tonsils and edge of the loose palate have a granular ap-
pearance, and are as if thinly whitewashed. The palate and uvula
have a thickened and contracted look—do not rise and fall with their
usual freedom, and up from them there is a blush of inflammation,
ascending even as far as the roof of the mouth, there terminating in
a well-defined border, At or immediately within each commissure
of the lips is a cluster of flat, warty excrescences; a few similar ones,
it may be, exist on the back part of the tongue, or round its edge, or
inside the cheeks; and invariably, at this stage, a bunch of them is
found round the anus, attended with a red blush, extending an inch
up on the nates.
Such are the symptoms that attend an ordinary case of this dis-
ease; but cases do occasionally occur ofa more virulent character
ai the outset, which give rise to all the pain and difficulty in deglu-
tition experienced in ordinary sore throat. We also occasionally
meet with a rash resembling measles or roseola, which, from its early
appearance, cannot be ranked properly as a secondary symptom.
The disease sometimes, though rarely, attacks the toes also.
I am aware, that even in the ordinary form of sibbens, that is in
those cases where the virus has been introduced into the system by
B50 Screntific Intelligence.

the mouth, the condylomata often appear on the perinzeum, groins,

and genital organs by simple extension, but in all cases where they
are first met with on these parts, the disease has been caught by
coition. When caught by coition, the inguinal glands become early
affected; but have no tendency to suppurate here or any where else.
The tonsils in this form seldom become affected in less than six
weeks, and sometimes never during the whole course of the disease,
Without giving a detailed account of the symptoms, I will merely
eive a short history ofa single case of the very worst kind, which,
with its branching, will include all the phases of the affection I have
ever seen,
A respectable farmer’s son came to me with symptoms of clap,
such as running, redness of the lips of the urethra, &c., but with
little or no scalding in voiding urine. He soon after got slight go-
norrhceal ophthalmia and sibbens. Shortly after him a servant lad
from the same quarter applied; he had yaws, as the disease is com-
monly called on the tonsils, gonorrhoea without scalding, condylomata
on the scrotum, and a sore at the orifice of the urethra having the
‘

look of chancre, which, on healing, produced stricture, and obliged

him occasionally to use a bougie for a long period afterwards. I had
made inquiry of this lad, and was not surprized at a dirty female
servant from the same house handing me a note from her mistress, ee
aaee
ea
ae
|e

requesting me to examine the bearer, as she had become so loathsome

that the other maids had refused to sleep with her. And little won-
der; from beyond the anus to above the pubes, and for three or four ag
heees

inches down the thighs, she was scalded and studded over with these
ulcerated condylomata. Between her toes were what had the look
of deep white sloughs, but were in reality only a sort of watery
growths as distinctly seen where they emerged from between the
toes. This woman married, and had her first child about two years
after I had attended her. ‘The child, some time after ita birth, began
to whine and cry incessantly, became hoarse, the mouth and fauces
got fiery red, as did the inside of the alz nasi, and out from them Pe
emerged a kind of eczema that gradually extended itself over the
face, head, and body, where it met with its fellow that had emerged
from the anus, and ultimately completed the child’s destruction.
Her second child narrowly escaped the same fate. This woman at
first denied ever having had any sore about her from the time I had at-
tended her, but at last admitted her having had two or three dozls, .

and showed me a sore between the right mamma and arm pit, about
the size of a shilling, of a circular shape, with livid and undermined
edges. This is almost the only sibbenitic ulcerI ever met with.
I might have suspected this case as having been mixed up with the
true venereal, but for the fact of having repeatedly met with cases ia
a
F
NN
S
i
a
a
l
similar in all its branching, only milder in degree, and wanting the
ulcer. Moreover, such a thing as lues among our moorland commu-
nity is exceedingly rare.
The secondary symptoms of sibbens, with the one exception al-
ready mentioned, are, so far as my observation goes, wholly confined
«t
a
ee
ef
e
4a

cil
“44
Oe
+s
7.
ine
a>
 Scientific Intelligence. J
Qo

to the skin, and are ofa trifling kind. The pityriasis-like stains are
the most common. These appear on any part of the body, the breasts
and arms, being the most easily accessible parts, have been to me the
mostcommon. They vary in size; their colour may be red, reddish
brown, yellow, or slightly leaden; they are at times slightly scaly.
Small patches of psoriasis are also occasionally met with; indeed, I
think the former sometimes runs into the latter by becoming slightly
elevated, reddish, and desquamating. In a very few instances only,
and not for many years, have ] seen any thing like ecthyma, and
can only recollect that some of the crusts were broad as a sixpence,
and very few in number, a proof that the disease is becoming milder
in its character. We often hear of the constitution being contami-
nated by the disease as evinced by destruction of the palate, bones of
the nose, sibbenitic ulcers, &c.; and I know a few individuals here
with permanently impaired voices who are said to have had sibbens
in their youth; but if such cases ever do occur from the disease
itself, they must now be rare indeed, since after practising in a dis-
trict of country where yaws are very common, and treating many
hundreds of cases, extending over a series of twenty-seven years,
I have met with nothing beyond what is already mentioned.
In regard to the period of incubation, or the length of time that
may intervene between exposure and the first symptoms of the dis-
ease, I have never been able to arrive at any satisfactory conclusion.
The first symptoms are in themselves so trifling as often to be over-
looked, and early application is never made; nor can patients often
tell when or how they became contaminated. It is said by some
writers to be from seven to ten weeks; and the fact of one after
another in a family being often attacked for months after the most
rigid precautions had been put in force, favours this long period.
In an unfortunate case, where, in attempting to reduce simply en-
larged tonsils, the disease (I had reason to believe) was communicated
by the quill containing the caustic, the complaint was perceptible
within the fortnight. But allowing there had been no taint previous
to the application of the caustic, the case is not exactly in point, being
one of inoculation.
It is said that sibbens, like the yaws of the West Indies, undergo
a natural cure, after running a course of from six to twelve months.
When they might undergo a natural cure I cannot tell; but of this I
feel certain, that they have a strong tendency to run a course in de-
fiance of treatment. A case from three to six months’ standing, is
easily cured in a fortnight, and in all probability permanently so;
not so a case of so many weeks. Wecure them, ’tis true, but two
to one the case is again in our hands in six weeks, and this it may be
again and again.
This is so true, that we never can warrant a house permanently
clean in less than a year, and sometimes not for a much longer period.
Some may say we repel the disease by injudicious topical treatment,
and thus keep it, pent up, as it were, in the system, for a longer
392 Scientific Intelligence.

period than would otherwise be required for it to runa natural course;

but I have seen a case in no way interfered with by treatment re-
maining at the end of two years in all its primitive perfection and
simplicity. On the other hand, it might be said, we do not continue
treatment long enough ; but then how does it happen to be successful
in the one case, and not in the other ?
This strong tendency in the virus, when once introduced into the
system, to run a course, coupled with the fact that I have never met
with sibbens twice in the same subject, has impressed me with the
belief, that, like West Indian yaws, a first attack affords indemnity
from a second. Those writers on the disease who have had the best
opportunity of judging seem silent on this point, and the vulgar opi-
nion, prevalent until lately, is lost, that one attack lasts a man’s
life-time. ; |
‘ Sibbens,” says Dr. Hibbert, ‘¢ are the engendered product of
rank uncleanliness; but they are only fed and fostered by unwhole-
some food and filth: this is all. The disease is propagated by con-
tagion, and contact too of no commen kind, being no more caught by
sleeping in the same bed, than is the venereal. This may not have
been the case at an earlier period, when the tubercles would seem to
have spread over the body generally. At the present day, we act
under the belief, that the poison can only take effect where applied to
a delicate membrane, such as that which lines the lips, mouth, and
genital organs, or to an abraded surface. Its application may be
either direct, or indirect through the medium of tobacco pipes, glasses,
spoons, &c. The most common mode by which the disease is com-
municated is direct, by contact with the lips in billing and cooing;
next in point of frequency, is smoking from the same pipe; it is also,
as has been stated, occasionally caught by coition.
‘¢ Whether sibbens, the venereal, and the yaws of the West Indies
originally sprung from a common stock, forms an interesting subject
for inquiry. It is perfectly plain, however, that each, now, at least,
is equally, nay, better entitled to rank as a distinct disease than
variola, varicella, and the other minor pox. Sibbens are distinguished
from the venereal, by the greater number of their sores, by their
elevated character, and by the ulceration in the former being much
more superficial than in the latter. The first rarely contaminates the
constitution, the last often. Between sibbens and the venereal con-
dyloma there does not appear any difference; and I will be much ;
astonished indeed, if, on farther inquiry, the latter is not found to be
often communicated by the mouth. Whether sibbens may have
wandered from our mountains to the cities, or venereal condyloma from
towns to us, it is not for me to decide.
Sibbens, and the yaws of the West Indies, retain some very
important characters in common, such as the whitish ulceration of
the tonsils, the fungoid character of the sores, a first attack probably
giving immunity from a second, and their appearing to run a some-
what similar course in point of time. Yet in some respects they
 Scientific Intelligence. 3353
differ: sibbens, from first to last a trifling disease, are never ushered
in by any constitutional symptoms, never induce a cachectic state of
constitution, and the sores are confined to the neighbourhood of the
mouth and great outlets. Regarding West Indian yaws, the reverse
of all this is true.
However wrong Dr. Hibbert may be in regard to sibbens being
the offspring of uncleanliness alone, I cannot do better than copy his
means of prevention: ‘‘ The importance of cleanliness,” says he,
*‘ admits of a ready explanation ; the poison upon which this affection
depends is more or less deleterious, according to the various degrees
of concentration which it undergoes; yet even in its most concen-
trated state its action is so gradual and so slow, that if common acts
of ablution were daily practised, long before it could have time to act,
it would stand every chance of being either rendered comparatively
inert, or evenof being totally removed from the surface of the body.”
In another place he says: ‘‘ Let but the judicious treatment of patients
afflicted with sibbens be accompanied with the daily immersion of
such as are exposed to the contagion in any river, and the sibbens in
a whole parish will be eradicated in a twelvemonth.” I have been in
the habit of advising all who are exposed, to a thorough washing with
soap and water of the whole body, two or three times a week. As an
instance of the effects that may be assigned to preventive measures,
the disease had been from 1825 to 1835 gradually on the increase,
when about the latter period the alarm became so great as to give rise
to a general distrust in all intercourse, and the consequence was a
marked decline in the complaint. It was a curious fact, that during
the ten years’ reign of sibbens, itch was in complete abeyance; and
scarcely a case was to be met with, till about 1836 and 1837, when it
took the lead with more than its usual virulence.
If cleanliness is of importance as a preventive measure, it is no
less so as a means of cure. In country practice, we in such cases
substitute a thorough washing for the bath. Mercury has a specific
effect in sibbens, and is in general at once resorted to. The general
health being in no way affected, the patients are often allowed to fol-
low their usual ont-door employments, and take a blue pill night and
morning, till the gums are slightly sore ; in short, a gentle course of
mercury continued for four or five weeks; while, at the same time,
and in all stages of the disease, we freely apply a rod ofcaustic to the
sores in the mouth, as often as circumstances will allow,—deliberately
running it into all the folds around the tonsils. When a whole fa-
mily are affected, and live at a distance, they are instructed how to
apply the caustic every second day to each other, with a brush and
strong solution. The condylomata about the anus and genital organs
disappear with great rapidity under the local application of the ungt.
hydr. fort., and attention to cleanliness. This disease is so com-
pletely under the control of mercury, thatit rarely resists its influence
beyond two or three weeks, even without any local application; but
so strong is its tendency to run a course, that patients will sometimes
VOL. XXV. NO. 74. 22
354 Scientific Intelligence.

return on our hands again and again, even after full salivation. This
is particularly the case with the better classes who make earlier appli-
cation. It isno uncommon occurrence for patients to return on the
following year, and the very same month at which the disease first
made its appearance the year previously, with little painful sores on
the edge of the tongue: one, in particular, on the very tip. These I
attributed to the mercury, and contact of the teeth, till I found them
capable of propagating the disease. These, in some constitutions,
may appear at the end of two years. Such require caustic only for
their cure. When the submaxillary glands have returned to their
natural state, and every symptom of the complaint has been gone for
three or four months, the patient generally may consider himself
pretty secure.
Infants who have caught them after birth, and children, get ra-
pidly and often permanently well by a single grain of calomel daily
for two or three weeks.
I have only given the hydriodate of potass a sutlicient trial to
prove its effects, as far inferior to mercury, and also the tincture of
iodine to the sores, as less effectual than the lunar caustic.
Fer the secondary symptoms, they are now so rarely of the cha-
racter that indicates a tainted constitution, that under attention to
cleanliness alone they gradually disappear.— London and Edinburgh
Monthly Journal.

On Cerebral Auscultation, by S.S. Whitney, M. D., of Newton,

Mass.—It is true, ‘* that there are no physical signs applicable to the
brain, such as are dependent on a cause similar to that of the act of
inspiration and expiration of the lungs, or perhaps of the systole and
diastole of the heart, while in their healthy state; for the brain, in its
normal condition, can of itself develope no physical phenomena. The
thing is incompatible with a physiological state of the organ.
There are, however, certain conditions of the brain, in which a .

new order of things has been discovered to take place; and the very 5&
a
fact that it is known and can be shown to exist only in certain de-
rangements of that organ, while in its physiological condition, signs
which are purely negative in their character are developed, proves the
former to be, not only a physical sign, but one which is most surely
pathognomonic of some derangement of the organ itself.
Such then, being the case, can it be shown that the organs within Ohte ee
=SA

the cavity of the cranium are ‘so disposed” as to render the art of
auscultation or percussion in any way available, and that these phy-
sical signs are applicable to the brain? The very thought ought to vera

commend itself to the consideration of every true lover of science.

Heretofore, and even at the present moment, the diagnosis ofdis-
eases of the brain rests solely upon the plausibility of physiological
and pathological induction. But inductive signs are known to vary,
and to vary exceedingly in organs of the most simple structure, front
the force of the slightest variation of circumstance. How infinitely
 Scientific Intelligence. 355
more complex and variable then, must they be when dependent upon
the mere breath of circumstance, over an organ of such exceedingly
complex structural organization, as that of the brain! Yet in regard
to this organ, although we may never, perhaps, attain to that degree
of precision, I might say physical certainty, which has been attained,
in regard to diseases of the organs of the thorax, may we not rationally
anticipate, that, with what industry and perseverance can accomplish,
and with what may be accomplished by a newer and more rational
method of investigating its diseases, our knowledge may become as
certain, and our diagnosis of the diseases of the brain, in a degree,
may be made with as much precision, as that of the heart and
lungs!
In auscultating the heads of healthy children, four very different
and perfectly distinct bruzts are heard passing through the brain.
They are evidently the sounds which are produced by the act of res-
piration and deglutition, by the impulse of the heart and the voice.
The one which first attracts the attention, is that which is pro-
duced “* by the impinging of the air against the walls of the nasal
cavities during the act of respiration.” It commences and terminates
with the respiratory act, and in this respect, is peculiar and easily re-
cognized. This sound has been denominated “ the cephalic sound
of respiration.”
‘* The second sound which strikes the ear, is one whose impulse
Seems to be transmitted from a distance. It is evidently that of the
heart, and is a soft mellow sound, resembling that produced by softly
palpipating the cheeks when distended with air.” This sound is syn-
chronous with the action of the heart, and varies in frequency and in-
tensity, as the contractors of that organ vary in rapidity and power.
This has been called the ‘‘ cephalic sound of the heart.” The sharp,
piercing, and vibratory sound, which accompany the act of crying or
speaking, and which can be so distinctly heard over every portion of
the skull, has been termed the “ cephalic sound of the voice.” It
varies somewhat in its tone at different parts of the bead, being the
least shrill and piercing at the unclosed fontanelle. The other sound
which attracts attention, and the only remaining one of the normal
sounds of the head, attends the act of deglutition. It is a dull, mas-
sive, liquid sound, and so peculiar, that when once recognized, it
never can be mistaken for any other bruit. This is the “cephalic
sound of deglutition.”
Such are the bruits, which are heard in the heads of infants be-
fore the closure of the fontanelle. As age advances, and the density
of the brain and cranium increases, these sounds become somewhat
modified. The change which some of them undergo in the numerous
lesions of the encephalon is, however, exceedingly slight; still, others
are so manifestly changed in their character, as to become symptoms
of cerebral disease.
Besides a modification of the ‘‘ cephalic sound of the heart,” under
the influence of certain diseases of the cranium, to a consideration of
which this paper is more particularly devoted, I shall have occasion,
306 Scientific Intelligence.
hereafter, to speak ofan equally striking modification of the “ cephalic
sound of the voice,” which is found to accompany, and which I think
is characteristic of a particular affection of the brain. It resembles,
as nearly as the nature of the organs could admit, the sound which is
known to accompany the effusion of fluid between the two pleurze of
the lungs, and is never heard, except in those diseases of the brain
which are attended with a similar effusion between the membranes
by which this organ is enveloped. It is, indeed, no more nor less
than a simple egophony of the brain; and as such, I doubt not, but
that hereafter it will be found a valuable acquisition to the category of
signs, which belong to this obscure and difficult class of lesions.
During nearly five years, in which the observations herein detailed
have been made, I have noticed the ‘‘ cephalic bellows-sound,” or
some modification of it, in no less than eighé different and perfectly
distinct lesions of the brain. In some of these, it has been a well-
marked, constant, and invariable symptom; in others, it has been less
so, while in all it has been sufficiently striking to render it a valuable
and independent physical sign.
The different diseases in which this symptom has been present
and characteristic, are thus arranged:
1. In simple congestion or irritation.
2. In acute inflammation of the brain, with or without effusion.
3. In chronic bydrocephalus.
4. In acute or local compression of the brain.
5. In induration, or scirrhus transformation of the substance of
the cerebellum.
6. In ossification of the arteries of the brain.
7. In aneurism of the basilar artery.
8. In aneurism, and certain bydrocephaloid diseases.
[The author here gives four cases illustrative of the light thrown
on the diagnosis by auscultation.|
I shall now speak, in the second place, of the cephalic-bellows, as
connected with an acute inflammation of the brain.
Within the time that these observations have been made, I have
noticed this phenomenon in nineteen different and distinct cases of
acute inflammation of the brain. It was present in all of them as a
prominent and unequivocal symptom; and as such, its progress and
development were carefully noted, from the commencement to the
termination of the disease in each case. [Three cases are here de-
tailed at length.|
Beside the bellows-sound already described, my attention was, for —
the first time, attracted to the presence of a peculiar, and to me novel
sound, connected with the passage of the voice through the brain
and skull. It has a much sharper and shriller tone than that of the
natural voice, and seems to strike upon the ear, as though the shrill
notes of the clarion were echoing through the vault of the cranium
below. It has, moreover, another character which renders it alto-
gether so untque, that when once heard, it cannot easily, the second —
time, escape recognition ; I mean a trembling-brazen-vibratory sound,
 Scientific Inteliigence. 357
which in imagination, resembles nothing so much as the noise pro-
duced by singing, crying, or speaking through the teeth of a comb,
previously covered with a bit of silk, parchment, or paper. In two or
three instances, since recording this case, I have noticed that this
sound corresponded almost exactly with the trembling, bleating sound
which is so characteristic of the egophony of the lungs. And, in-
deed, so nearly does this sound resemble in every essential particular
that of egophony, and so nearly also do the pathological conditions,
necessary to the development of these phenomena, resemble each
other, that I know of no appellation, by which this can be better de-
signated from that, than by applying to it the term ‘ encephalic
or cerebral egophony.’ But to resume the history of this case, it
will be sufficient to state, that the bed/ows-sound still remained a con-
stant and important symptom, so long as the powers of life were well
sustained, and failed only when they had become so much enfeebled,
as to render existence, every moment, an improbability. The ego-
phonic sound of the voice, on the contrary, was equally present and
distinct from the time of its first appearance, up to the moment when
the last groan told that life had indeed departed from the body.
I have noticed the cephalic bellows-sound in actual aud local
compression of the brain.
This physical phenomenon of the encephalon has been observed
also in induration, or scirrhous transformation of the substance of
the cerebellum.
I have observed, in the sixth place, the cephalic bellows-sound,
as a symptom of ossification of the arteries of the brain.
In the seventh place, the cephalic bellows-sound has been observed
accompanying an aneurism of the basilar artery.—A bridged from a
long paper in the American Journal of Medical Sciences for October,
1843, and London and Edinburgh Journal.

Dr. Marshall Hall on the Mechanism of Vomiting, in a Letter

to Dr. Anderson.—\4, Manchester-square, 15th Jan. 1844.—
Dear Sir,—I beg to thank you for your kind and polite present of a
copy of your interesting paper on the Mechanism of Vomiting, which
Ireceived this morning. There are three paragraphs in it, on which I
beg to make a few remarks, which you will probably do me the favour
to communicate to the excellent Journal in which your own appeared.
The first of these occurs page 8: ‘“‘ The opinion that the muscu-
lar fibres of the diaphragm are actively engaged in vomiting, seems
to be supported by two cases related by Boisseau, in which that
muscle was torn by violent vomitive efforts. It would, I apprehend,
be difficult to explain this occurrence by a reference to Dr. Hall’s
theory; for the mere fact of the diaphragm’s suffering compression
in common with the viscera of the chest and belly, many of which
possess weaker powers of resistance, would not account for its lace-
ration.”
My view of this event is, that it occurs in the final, actual, full,
and violent expiration which uniformly takes place at the close of
358 Scientific Inteliigence.
the act of vomiting. The larynx is opened, the air in the thorax es-
capes; the contraction of the abdominal muscles proceeds, and all the
force of that contraction is applied to the diaphragm, and carried up-
wards to the uttermost. It is the same force, the same violent expi-
ration, which so beneficially empties the bronchial tubes of the redun-
dant mucus in certain cases of bronchitis, in which emetics are pre-
scribed.
The second paragraph to which | have alluded, occurs at page 9:
“ Violent efforts of vomiting were immediately induced, causing the
expulsion of a considerable quantity of milk ; and, at the same mo-
ment—that is, during the effort by which the milk was discharged,
—the diaphragm became tense and rigid, and descended towards
the abdomen.” And: ‘on introducing two fingers into the opening
which 1 had now made into the abdomen, | felt the diaphragm to be
strongly contracted during each effort of vomiting.” That the dia-
phragm ‘ descended,” and became ‘ tense and rigid,” during the act
of vomiting may be admitted; but that it ‘‘ strongly contracted,” is, I
think, more than the mere contact of the fingers could teach us. The
account is not, it appears, limited to a detail of the fact, but involves a
statement of the mode or rationale of that fact. My view of the case
is this: atthe commencement of each act of vomiting, which is an act
of the muscles of expiration, the contraction of the intercostal muscles
carries the diaphragm forcibly dowwards, part of the parietes of the
abdomen yielding somewhat to this forcible pressure. At this moment
it may be found to have ‘ descended,” and to be ‘‘ tense and rigid.” |
I have only to add, that if the diphragm does contract during the
act of vomiting, it musé, in exactly an equal degree, counteract that
process, which is one of expiration, whilst the diaphragm is an organ
of inspiration. Such contraction is not usual in nature's opera-
tions. 7
The last paragraph on which I beg to remark occurs at page 11.
It relates to the fact of the ingurgitation of air into the stomach during
the state of nausea which precedes the act of vomiting. You observe :
‘‘ Dr. Hall does not allow the diaphragm any share in the produc-
tion of thts phenomenon.” Had I indeed made this assertion, I
should certainly have committed a grave error. But you have only
partly quoted my statement, of which I must here adduce the re-
mainder. Itis this: ‘‘It is not improbable, too, that in some in-
stances of vomiting, in which the action of the abdominal muscles was
subtracted, a similar effort of inspiration has drawn substances from
the stomach into the cesophagus, which has eventually expelled them
by an inverted action.” It is of these two actions that I have said,
‘Neither of these phenomena could result from any action of the dia-
phragm ;” and not of the ingurgitation of air into the oesophagus
during the state of nausea, which is, as | imagine, effected by an act
of inspiration, in which the diaphragm really does take a part.
I should have been elad if you had noticed the subject of vomiting
from the oesophagus, and discussed that of vomiting from the stomach,
when this organ exists (in the case of hernia), within the cavity of
 Scientific fitelligence. 359

the thorax at greater length; for the cases of what may be desig
nated hyper-diaphragmatic vomiting appear to me greatly to eluci-
date this singular act of ejection in general. J am, dear Sir, your’s
very truly, MarsHaAtu Hatt.
To Davip Anperson, M.D., &e.
London and Edinburgh Medical Journal.
On Dislocations of the Astragalus, with the lower ends of the
Tibia and Fibula inwards, illustrated by Cases, by Henry Hancock,
Esq., Surgeon to the Charing-Cross Hospital.—The object of this
paper is to direct attention to an injury of comparatively rare occur-
rence—dislocation of the astragalus from the os calcis and scaphoides,
the ankle-joint remaining entire. The writer, after alluding to nume-
rous authors who considered that such an accident could not occur,
gives an account of the only four cases he has met with in the works
of various writers, viz., two in the last edition of Sir A. Cooper’s work
on Dislocations and Fractures, edited by Mr. B. Cooper; one related
hy Professor Harrison in the Dublin Journal, vol. xv., designated
‘‘ Displacement of the Foot outwards, with Fracture of the Fibula;”
and a fourth described by Dupuytren in the Lecons Orales, vol. i. p.
225, as ‘“‘a fracture of the fibula with dislocation of the foot in-
wards.” Both these latter titles the author considers erroneous; for
it is very doubtful whether, in reality, the astragalus with the lower
ends of the tibia and fibula are not the parts displaced ; and even if
this be not the case, it is only a portion and not the whole of the foot
which is dislocated,
The following cases are related by the author.
John Middleditch, a strong, healthy man, et. 24, was admitted
into the Charing-Cross Hospital, under the author’s care, on the Sth
of December, 1840, with an injury to the right ankle, having fallen
from the top of one of the vats in a brewery. Four days afterwards,
when the swelling was reduced, it was found that the fibula was frac-
tured about three inches above the ankle; the axis of the tibia, in-
stead of falling on the centre of the foot, was thrown inwards and
slightly forwards, giving the leo the appearance of being twisted in
that direction. The position and direction of the foot were not mate-
rially altered, further than by its projecting considerably on its outer
side and the toes turning slightly outwards, but its dorsum looked
upwards as in the natural condition. Upon carrying the finger along
the outer edge from the heel forwards, the anterior extremities of the
os calcis, where it unites with the cuboid bone, could befeltdistinctly,
whilst above there was a considerable cavity instead of the prominence
formed by the astragalus and external malleolus. By pressing the
finger along the dorsum of the foot, a depression could also be distin-
guished behind the posterior margin of the scaphoid bone. On the
inner side of the foot was a prominence corresponding to the internal
malleolus, of which the inferior margin could be distinctly defined;
and anteriorly and inferiorly, another projection, more prominent,
evidently caused by the head of the astragalus, over which the skin
 oy
——

360 Scientific Intelligence.

was tense, thin, and vesieated. The distance between the internal
malleolus and prominence of the os calcis was somewhat greater than
in the sound foot, and that between the lower end of the inner mal-
leolus and the sole of the foot diminished above an inch. The ankle-
joint was still capable of flexion and extension, and there was very
considerable motion in the centre of the foot, corresponding to the
calcaneo-cuboidal articulation, forming as it were a double joint. It
was concluded that the astragalus had been forced from without in-
wards, off the upper articulating surfaces of the os calcis, carrying
with it the lower ends of the tibia and fibula, most probably resting
upon the lesser process of the os calcis. The various steps by which
reduction was eflected are next described.
The integuments over the point of pressure sloughed and separated
on the third day after the reduction, leaving the anterior part of the
astragalus exposed in its proper position ; and this was succeeded by
considerable discharge for several days, in the course of which, the
internal calcaneo-scaphoid ligament sloughed and came away; the as-
tragalus being now no longer restrained in that direction, gradually
twisted round upon the calcis, until at length a large portion of its
head protruded through the opening in the integuments: this pre-
vented the wound from closing, and, as the bone could not be kept in
its proper position, but had Jost its articular cartilage, and was pass-
ing into a state of necrosis, he subsequently, with a small saw, re-
moved its head to the extent of about three quarters of an inch; after
which the wound gradually healed, the parts became consolidated,
and the man left the hospital cured in July, just seven months after
the accident.
Ten months subsequently the following report was made :—He
walks as well as he did before the accident, without stick, or artificial
support of any kind. The leg is larger than the opposite one, and
there is some thickening around the ankle; but the motion of the
joint is good, and the direction of the foot and the situation of the
nalleoli natural: he is able to do his work, which at times is very
heavy, as well as ever he did, his leg being entirely free from pain,
The particulars of the last case are taken from the surgical notes
of the late Mr. Howship, and relate to a preparation in the possession
of the Royal College of Surgeons. It appears, from the position of
the bones, that the same accident had occurred as that described in
the former case; but that the dislocation had not been reduced. The
author enters into a detailed account of the bones. He then con-
cludes his paper with some observations on the treatment to be pur-
sued in these accidents, giving the opinions of various writers on dis-
location of the astragalus.
Mr. Lloyd made some general observations on the subject of the
paper, and particularly combated the propriety of amputation, save in
extremely rare and desperate circumstances. In the vast majority of
instances of dislocation of the astragalus, amputation, as it was not
required, so was it altogether inadmissible. In former days, indeed,
the operation was even commonly had recourse to; it was one of the
 Scientific Intelligence. 361

old canons of surgery that it should be so; and he quoted the case of
a late governor of Newgate, whose leg he had himself, when a young
man, dissected, after it had been removed by a couple of old surgeons,
where he found the injury so trifling, that he plainly saw the step
which had been taken as altogether unnecessary.
Mr. Hancock, who seemed to have mistaken the tendency of Mr.
Lioyd’s remarks, adopted them as justifying the amputation which he
had advocated. Mr. Lloyd explained, and Mr. Hancock was some-
what tart in his reply to the surgeon of St. Bartholomew’s.
Mr. Quain directed Mr. Hancock’s attention to the true bearing
of Mr. Lloyd’s remarks, who had, in fact, quoted the amputation
which had been performed on the Newgate governor as an instance
of antiquated surgery, a practice which certainly would not generally
be imitated in the present day.
Mr. Davies related an anecdote of Mr. Abernethy, whose surgery
was always largely tempered with humanity, and who never took up
the knife without regret: —A London merchant had suffered a dislo-
cation of the astragalus at some considerable distance from London,
where, we presume, Mr. Davies was at that time settled in practice.
Mr. Davies recognized the nature of the injury, and aware of the de-
licate point of surgery he bad to deal with, he recommended a con-
Sultation. Mr. Abernethy was selected by the patient, and he arrived
at Mr. Davies’s house about two o’clock in the morning, his whole
travelling baggage consisting of a shirt tied up in a pocket-hanker-
chief. Though he arrived at two o'clock, Mr. Davies, nevertheless,
found him up and walking in the garden when he put out bis own
head between five and six. On seeing the patient Mr. Abernethy
approved the temporizing measures that nad been pursued, totally
repudiated amputation, and took his leave. The patient made a good
recovery; and if he did not gain a leg that was as supple about the
ankle-joint as the other, he still had a limb which was a great im-
provement upon a wooden one, and that served him to stump about for
many a long year afterwards.— Medical Gazette, April 5, 1844.

Case of Obstruction in the Intestinal Canal, terminating

favourably on the ninth Day by spontaneous Vomiting and Evacua-
tion of the Intestine’s Contents, by Sir George Lefevre, M. D.—The
subject of the present case was a little girl of twelve years of age, of
a very delicate constitution, strongly marked scrofulous disposition,
and with very feeble digestive powers, so that she was unable at all
times to digest fruit or vegetables. She had been attacked by an
epidemic autumnal cholera, which prevailed amongst children in the
town where she was residing, and which yielded to the usual mode of
treatment. Soon after the termination of this, she was attacked bya
disease of an opposite nature, and became obstinately constipated,
whilst the stomach rejected every thing that was taken in. Purga-
tives had been employed in every shape, but without effect; leeches
bad been applied to the abdomen, which had been fomented freely.
VOL, XXV. NO. 74. 3A
362 Scientific Intelligence.
Such was the history of the case, which I received from the two
medical men in attendance previous to my seeing her. I saw her on
the 27th of August in the afternoon. She was much flushed in the
face, had an anxious countenance, a small, quick, compressible pulse,
a cold, moist surface, the extremities being colder than natural, She
suffered from distention of the abdomen, without complaining of much
pain, and she vomited continually a green, bilious-looking fluid. As
no inflammation was apparent, and as more depletion was not, under
the existing circumstances, indicated, soothing measures were em-
ployed. The vomiting was the most annoying symptom, from its
frequency rather than from any distress which it occasioned, for this
dark-green fluid was thrown up without much effort. A small blister
was applied to the pit of the stomach, and small doses of prussic acid
administered in almond-milk. This treatment seemed to check the
vomiting for many hours successively. She passed a tranquil night,
but no relief to the bowels had been obtained by stool, and the abdo-
men was much more swollen. Croton oil was given internally and in
clyster during the day, and as warm applications seemed to have no
effect, bladders filled with ice were applied all over the belly. The
patient was restless and uneasy, continually changing her place in
bed, but this arose from distention rather than from any acute pain,
About midnight of the 28th, she complained of twisting and severe
pain in the bowels, ofa colicky nature; there was also more pain
upon pressure than previously, and as opiates were administered with-
out benefit, I applied a dozen leeches to the abdomen with immediate
relief to the distressing symptoms, which subsided soon afterwards.
She got some sleep, and was free from pain when awake. Iwas
obliged to return to London, and did not see her again till the after-
noon of the following day. I learned from the physician in atten-
dance that she had passed the day on which Ileft her pretty well,
but that at midnight the same symptoms recurred as on the night
previous, and, notwithstanding her state of great exhaustion, he had
again applied leeches with benefit. He informed me that the vomit-
ing had returned, and that the matter brought up was evidently from
the ilium, and the seat of the stricture seemed to be about the caput
coecum.
There was no question, upon minute examination, that the matter
vomited up proceeded from the small bowels. The distention was
now very great, respiration was much impeded, and the little patient
suffered severely. A long elastic tube was introduced into the rectum,
and which was carried into the colon, into which water was forced by
a pumping syringe. The operation was productive of great distress
to the patient, and was ineffectual as to relief. The night was rest-
less, and the following day the little sufferer seemed much exhausted.
The face was colourless, the countenance anxious, the body covered
with a cold, clammy sweat, and she expressed herself as if about to
die. The bed-room having a southern aspect, and the weather being
sultry, I desired that she might be removed into acoolerroom. She
was carried in the arms to bed, and as she was much fatigued by the

ie
ete
vig
 Setentific Intelligence. 363
operation IT gave her a glass of Madeira wine, which she drank with
pleasure, but hardly had she swallowed it, when she made signs for
the basin, lifted herself up in bed, and threw up a dark green fluid to
the amount of three pints. She experienced immediate relief, and
breathed more freely, and the upper part of the body became more
loose and compressible. I gave her some more wine, which remained
-on her stomach; she had no more nausea. Constant friction was
maintained over the abdomen, and injections of vinegar and water
were repeated every hour. ‘The first was returned without being ace
companied by any solid matter, but had a foetid smell. The second
was accompanied by pieces of flocculent matter of a membraneous
appearance, and the fluid returned was horribly feetid, like putrid
water in which flesh had been macerated.
She was now enabled to compress the abdominal muscles, and
make an effort to go to stool, which the previous great distention pa-
ralysing the action of the muscles had prevented her from doing.
Much of this membraneous matter came away after each injection.
The smell was most offensive. About four hours after the sponta-
neous vomiting she asked to go to the chair, when the bowels gave
way, and a large quantity of solid excrement was voided. She passed
several more stools in the course of the evening, and then slept tran-
quilly. The following morning I gave her a dose of castor oil, which
produced its desired effect without creating nausea, andI left her con-
valescent. I learned subsequently from my colleagues that she had
a good deal of constitutional fever for four or five days. She re-
covered in a short time, and her digestive powers are now better than
previous to her illness. The obstruction was relieved only on the
ninth day of the disease.—Jbid.

Spina Bifida cured by operation.—Oct. 17, 1837. An infant,

daughterof Mr. Leac ofSkeneatele
h, s, eight months old, was operated on
byDr. Stevens this morning forspina bifida. The tumour was seated over
the upper part of the sacrum, about three and a-half inches broad from
side to side, nearly the same in a vertical direction, and rising about
two inches above the surrounding surface, indented along the middle
vertically by a thick irregular band of integument. ‘The covering of
the tumour was not healthy skin, but a peculiar thin membrane of a
reddish colour, traversed by numerous vessels like varicose capillary
veins. The healthy integument formed a hard edge at its line of
union with the covering of the tumour. The whole swelling was
somewhat pendulous, narrower at its base than about the middle, and
in size held about the same relation to the size of the infant, as it did
at the time of birth. It had been once punctured with a needle, when
the child was only a few weeks old. The wound, which had never
cicatrized fairly, is now covered with a sort of scab.
In the operation to-day it was punctured with an iris knife, and
about four ounces of clear serum, tinged with a few drops of blood,
issued from the puncture in the integuments. The child did not ap-
pear to suffer any inconvenience from the evacuation of serum, but
364 Scientific Intellugence. ——
te
bim
ot
; foal
be
oi
pena!
Jes.
wate

it produced a slight sinking at the anterior fontanelle. The child’s

general health is good. There did not appear to be any deficiency of
bone about the outer portion of the base of the tumour. The healthy
integument mounted a few lines above the base, before giving place
to the peculiar envelope above noticed.
October 20th. The tumour was again tapped on the right side.
Not more than an ounce of serum escaped.
October 21st. The tumour was again punctured in three places
along its lower edge on the verge of the sound skin. About four
ounces of serum escaped without any bad symptoms. The tumour is
now somewhat shrivelled, but the diminution does not appear equal to
the amount of fluid evacuated.
October 30th. The fluid continued to ooze slowly for nearly
twenty-four hours after the last punctures. Since that period, the
child has been drooping and fretful, with some febrile symptoms, per-
haps partly owing to her teeth, Recently, the sae of the tumour has
become inflamed; and within two days, the child has been observed
to keep her left lex drawn up, and to ery when it is disturbed. She
has taken little or no medicine, excepting a slight dose of magnes ia.
The tumour is kept wet with a spirit-lotion. The anterior fontanelle
is considerably depressed.
The tumour was not punctured afterwards. The febrile symptoms
and spasm of the muscles soon subsided ; and in a few days the little
patient returned with her parents to the country. At a second visit
to the city in the spring or summer following, the child was again pre-
sented to us for examination. The sac of water had disappeared, and
all that remained of it was a small bunch of indurated and corrugated
integument.
Two drawings of the disease are given, one taken before the ope-
ration, and the other two years after, at which time the child was
perfectly healthy.
I think it important to state, that the fluid in the sac was dis-
charged very slowly; at the rate of about three drops in a second,
while about one-third of it was left behind ; that slight pressure was
made upon the tumour after each evacuation, and as far as was prac-
ticable in a restless child, maintained there; and that strict injunc-
tions were given to keep the body in a horizontal position. Once,
when the head was suddenly elevated, soon after the tumour had been
evacuated, a tendency to syncope and spasm was manifested, which
disappeared as soon as the child’s head was depressed.
Remarks.—Considering the analogy between spina bifida and
hydrocele of the tunica vaginalis testis, and other serous sacs, we may
anticipate a thickening and induration of the sac, with a correspond-
ing degree of contraction in the former case, as well as in the latter.
The desideratum then is, to open the sac and draw off the fluid safely-
This leads to the inquiry— What are the dangers of the operation¢
The first danger is the producing of syncope and spasms, by the
too sudden removal! of the pressure of the fluid upon the serous cavities
in the ventricles and spinal marrow. The means of obviating this
danger are, drawing the water off slowly, leaving some in the sae
 Scientific Intelligence. 365
undischarged, keeping the patient in a horizontal position, and, if
necessary, making pressure upon the tumour and upon the head.
With these precautions and resources, this danger cannot be deemed
a formidable one.
The next danger of which I shall speak, is the occurrence of in-
flammation of the inner lining of the sac, extending peradventure to
the spine and cerebral cavities. There was a period of two or three
days of restlessness and feverishness in Mr. Leach’s child, which I
attributed to this cause, but which disappeared without any particular
treatment. Of course, no prudent surgeon would repeat the punc-
ture, until the effects of the previous operation had subsided. —
The next question of which I shall speak, is of an entirely diffe-
rent kind, and I infer the possibility of it only from analogy, reason-
ing from what occurs in some cases of paracentesis abdominis; that
is, an habitual increased secretion produced by repeatedly drawing off
the water. I should judge, that such a state of things was to be ob-
viated by increasing the degree of inflammation, and of course the
thickening and contraction of the sac, after each puncture, by pres-
sure sufficient for the purpose.
These considerations lead me to conclude, that the puncture of
spina bifida may be made with very little danger and a fair prospect
of success.—New York Journal of Medical Science.

Case of Ovarian Tumours—both the right and the left being

removed at the same Operation, by J. L. Atlee, M.D., of Lancaster,
Pa.—My pear Docror—A few days ago I was invited by my old
friend, Dr. Jno. L. Atlee, of this city, to accompany him on avisit
to the patient from whom he removed, seven weeks ago, two ovarian
tumours. As the operation of removing both diseased ovaria had
never been previously performed, I felt much interest in seeing the
case. We found the patient waiting to accompany her surgeon on a
morning drive, agreeably to previous arrangement; but the Doctor
was prevented doing so, in consequence of unforeseen professional
engagements. The lady, who is under thirty years of age, and has
never been married, had suffered from ascites for the last three years;
and for this disease she had been tapped four times, the ovarian tu-
mours having remained undetected until after the third paracentesis,
Convinced that these enlarged ovaria were the cause of the dropsy,
Dr. A. proposed their removal, to which the heroic patient consented.
An incision about nine inches in length, in the course of the linea
alba, and commencing at the pubes, was made into the abdominal
cavity. The left ovarian tumour was found attached merely by the
round ligament, which floated free in the abdomen; while the tumour
on the right side, adhering about two-thirds of its extent to the brim
of the pelvis and the omentum, required some careful dissection in
its removal. They were both removed without any copious hzemor-
thage, and this large wound, which was brought together by the
interrupted suture, is now, seven weeks after the operation, com-
pletely united, with the exception of the lower extremity, where the
366 | Scientific Intelligence.
ligatures upon the round ligaments still remain, As not an unfavour-
able symptom has thus far been presented, the patient may be safely
pronounced out of all danger incident to this terrible and unprece-
dented operation.
Although the removal of diseased ovaria had its advocates in the
last century, the operation (vide Good’s Study of Medicine) having
been actually done, and successfully too, in 1776, by L’Aumonier,
surgeon-in-chief of the hospital of Rouen; yet, in consequence of
its condemnation by such high authority as the names of De Haen
and Morgagni, it became so completely neglected, that when Dr.
McDowell, of Kentucky, reported three cases in which he had ope-
rated successfully, it. was discredited by the Medico-Chirurgical
Review; but this opinion was doubtless due in part to certain impro-
babilities connected with the details.
Professor N. Smith, of Yale College, reported, in 1822, in the
American Medical Recorder, an interesting case of the successful
extirpation of an ovarian tumour. In 1826, Dr. David L. Rodgers,
of New York, performed the same operation, and so successful was
the issue, that ‘‘in six weeks from the period of the operation, her
catamenia had returned, and her health entirely recovered.” This
operation has been done no less than five times by Dr. Clay, of Man-
chester, and each time, too, successfully. Dr. Reese, in his notes
to Cooper’s Surgical Dictionary, says, that in the London Medical
Gazette for 1829, three cases of extirpation by Carysman, are re-
ported by Dr. Hopfer, of Biberback.; and that of these, two proved
fatal, while the third was so successful, that the woman subsequently
bore children. In the Edinburgh Journal, for October, 1820, it is
related by M. Lizars, that he attempted to extirpate an ovarian
tumour; but no tumour was found, and the case proved fatal. ‘Two
cases of the operation have since been reported by the same distin-
guished surgeon, but the results are not known. Dr. Alban Gold-
smith, of New York, has also operated by extirpation thrice; the
first two having been successful, while the last proved fatal; but in
the third case he ascribes the unsuccessful issue solely to the circum-
stance, that he had trusted to an animal ligature, which, giving way
prematurely, caused the supervention of secondary hemorrhage
within the abdominal cavity. By Professor Mussey, of Cincinnati, a
successful case is reported, in which he opened the sac, and effected
adhesion between its walls.
As regards the extirpation of these tumours, the late Doctor
McDowell, of Kentucky, may be considered a sort of pioneer, having
done it oftener and more successfully than any other surgeon in the
world; besides he laid open the peritoneum to a great extent for ex-
tirpating other abdominal tumours. But Dr. Goldsmith relates a
curious case in which he was concerned with this pioneer-operator.
The patient, who had suffered, during a considerable period, from
ascites, had tapped herself no less than ninety times; and discovering
at length a tumour, which she supposed to be the cause of her dropsy,
she made application to Dr. McDowell for its extirpation. The event,
 Scientific Intelligence. 307
however, proved, much to the surprise of the two Surgeons, that the
tumour was merely a mass of the intestines conglomerated by adhe-
sions. The operation was abandoned, and the woman died ; but this
case, as wellas that of Lizars’, should certainly not be placed in the
category of unsuccessful operations for this disease.
In view of this liability to error in our diagnosis, this operation is
even now condemned by many. ‘I have known,” says Dr. Reese,
in his notes to Cooper, ‘‘ a number of these ‘ exploring operations,’ as
they are called, result disastrously, like Dr. McDowell’s case; for in
Several instances the operation has been abandoned, but the patient
has died on the table. To cut into the abdomen in an exploring ex-
pedition may well be regarded as of questionable morality, and is
‘most villanous surgery.’ ”
I have thus briefly summed up a history of the operations for dis-
eased ovaria, under the belief that these cases, combined, tend to es-
tablish a new principle in surgery, viz., the comparative safety of
making large openings into the cavity of the abdomen. Wounds of
the abdomen, involving lesions of the intestines or other abdominal
viscera, with the operations for strangulated hernia, have been the
only cases in which surgeons have interfered with the abdominal con.
tents; and the great fatality of these cases always inspires much ap-
prehension when the abdominal cavity is opened. The successful re-
sult, generally speaking, attending the extirpation of enlarged ovaria,
would seem, however, to show that operations within the abdomen are
by no means so fatal as the profession have been led to believe—an
opinion that is substantiated by the difhculty so frequently expe-
rienced in exciting inflammation in the tunica vaginalis testis, in the
operation for hydrocele. Besides, in the case before us, in which
both ovaria have been extirpated, for the Jirst time, we have additional
evidence of the comparative safety of this operation. Here, then, is
another of the triumphs of American surgery,—the introduction ofan
operation with much practical effect, which is regarded in Europe,
with few exceptions, as unsafe and impracticable.
The tumours weighed two pounds: one a pound and a quarter;
and the other, three-fourths ofa pound. But a further detail of the
case might be deemed improper, as a full account of the operation and
of the subsequent treatment, has been promised by Dr. Atlee for the
American Journal of the Medical Sciences. I am, respectfully,
your’s, &c.,
J. M. Foutz,
ToSamuet Forry, M. D.
New York Journal of Medical Science.
Liquor of Hydriodate of Arsenic and Mercury, in cutaneous
and uterine Affections, by Isaac E. Taylor, M.D., of New York.
This new chemical combination was first recommended to the pro-
fession by M. Donovan, in the Dublin Medical Journal. Having
prescribed this preparation in a number of cases during the previous
eighteen months, Dr. Taylor presents a detail of them in the April
368 | Scientific Intelligence.

number of the American Journal of the Medical Sciences. He is

decidedly of opinion that it produces a more marked effect than the
various remedies usually resorted to, in those intractable forms of dis-
ease, Lupus, Rupia, Psoriasis, Secondary Venereal, &c.
‘

Case 1.—Lupus exedens of the Nose.—Diretta Dridwhotten, t

aged 74, bornin Germany, and exceedingly fleshy. When first seen,
had blackish incrustations around the left ala, and on the septum
nasi, a portion of the ala having been removed by ulceration, and
causing by its contraction the nose to be drawn to one side. A string
of tubercles, the size of buck-shot, extended from the external can-
thus to the internal, and from the internal up the nose to the fore-
head. The lower eyelid was everted to its full extent, exposing the
conjunctiva palpebralis, and producing an unpleasant deformity to look
upon, Several of these tubercles were ulcerated, and had brown crusts
upon them. The disease commenced twenty years ago on the left
angle of the nose, which was accidentally struck by a whip, and shortly
ulcerated. This was after a time healed by a French physician, with
an external application ; it, however, broke out again, and has since
gradually progressed, till it has reached this extent. Her general
health good. Various remedies have been tried in her case, but with-
out mitigating it in the least. After the bowels were regulated, and
advice given as to her diet, she was placed upon the solution, five
drops three times a day, with a table-spoonful of water. She con-
tinued taking the ‘liquor’ till October, when it was applied locally to
the part, and after a short time it was perfectly healed, the dark and
black incrustations were entirely removed, and a clear shining surface
exposed, the unpleasant foetor and discharge ceased. The tubercles
around the lower eye-lid were reduced even with the skin, except a mala
ee
Lit»
eh
$7
tieE

very large one at the external canthus; the lid has recovered nearly
its natural position, and the conjunctiva saved from being exposed to
the action of the air. After a month it commenced its work again
on the nose, but was a second time arrested, and to this date has not
returned, but presents a surface healed through its whole extent in
the nose. The only tubercle at present remaining is the one at the oat
RO
ea
a¥aa
i%

external canthus of the eye that has a crust upon it. SN

PR
SO
aAIidTal
ahs
Passing over the remaining cases detailed by Dr. Taylor, we come aae a?
to his ‘“‘ Remarks,” in which he cautiously and justly observes : Fy.

aR
«¢ Whatever doubt may exist as tothe exact nature of these cases, %
the length of time some of them have been affected, and the benefit é
they have derived from the use of the remedy, must go far to urge
ca
)
its trial in the chronic affections of the skin.” | ae

In addition to the evidence here presented in favor ofthe ‘ daguor ag.

hydriodatis arsenici et hydrargyrv’ in certain chronic cutaneous “ ay

affections, we are enabled to lay before our readers the further ex- es
ae

perience of Dr. Taylor, as presented in the following communication :

@

“ New York, August 20, 1843.

«Mr. Eprror,—Since the article from which the preceding ex-
tracts have been taken was published in the April number of the
American Journal of Medical Sciences, several cases of Lupus, with
 Scientific Intelligence. 369
various other eruptive diseases, have come under my notice. The
total number oflupus cases (exedens and non-exedens) which have fallen
under my observation during the last fifteen months, has been twenty-
two ; eighteen in my own practice, and four in that of other gentle-
men. ‘The efficacy of the “liquor” has been more particularly ob-
served in lupus owing to its obstinacy in yielding to any constitu-
tional remedies, and the exceedingly important benefit accruing from
its use; yet of infinite and decided advantage in the more intractable
form of the other eruptive diseases. As respects lupus, I would here
remark, that there is a feature in its diagnosis which has escaped the
attention of all the authors on the subject, which is, its predilection
for the left side, whether of the exedens or non-exedens, or vorax
form ; whether occurring on the cheek, the arm, or the body, the
left side has almost invariably been effected, only two cases out of
the twenty-two exhibiting it on the right side. A second feature
worthy of note, so far as my experience has gone, is that females are
more especially subject to it, not one of the cases I have seen being
in a male ; the proportion being much greater than that of Royer’s,
nor has it obtained, agreeably to Royer, in scrofulous patients, or
those predisposed to scrofula; nor in conformity to the opinion of
Plumbe, that the cachectic system was always manifest in the cases
he saw; on the contrary, fully two-thirds the patients under my
charge were of healthy appearance and constitution, the secreting
functions being free, and the chylopoectic viscera not disturbed, and
in several cases it was observed in its incipient state in all its forms;
and as it is seldom that it comes under the eye of the pathologist, at
its commencement, it becomes difficult to determine whether it origi-
nates in unhealthy inflammation, or always with a tubercular eleva-
tion of the cutis; and, as various opinions prevail on this point, Iam
induced to join in the opinion of Biett, that tubercles are not the >
elementary lesions in every case of lupus, but that it is attended from
the commencement with simple erythema.
From the number of cases stated, it will be observed that what
was considered a rare disease, and of great rebellion, has become more
frequent, and not only can be ameliorated in its extensive ravages,
but frequently cured for a long time, as some of the cases have been
seen, and it had not returned in them. ‘This frequency might very
justly give rise to the question whether these were all cases of
lupus? or whether some of them were not tubercular syphilis, a dis-
ease they are more nearly allied to than any other, and which in some
Suspicious cases (where only the tubercles are evolved) it is exceed-
ingly difficult to determine; but the well-marked characters so fre-
quently noticed in the secondary disease, militate greatly against a
mistaken diagnosts.
Respecting the non-exedens form, the treatment with the Dono-
van’s liquor has proved of no benefit, nor has it answered when ap-
plied locally, nor has any ‘treatment, whether constitutional or local,
been of benefit, but when locally applied had a tendency to aggravate
it. In one case, much benefit was derived from acetic acid applied
VOL. XXV. NO. 74. 3B
370 Scientific Intelligence.
locally ; still, in others it failed. The smallness of the dose has not
been changed, but in one instance, when it was raised to ten drops.
Ptyalism has not been observed in any other cases but those reported,
when it has been continued for over six months, nor has any affection
of the bowels exhibited itself under its use ; and it affords me plea-
sure to add my further experience respecting its value in the eruptive
diseases in all their chronic forms, particularly in that of lupus, so
intractable, destructive, and formidable-—Isaac E. TayLtor.—New
York Journalof Medicine.

Muriate of Ammonia internally.—In the medical treatment of

pleurisy, and subacute inflammation of the lungs, and congestions of
the mucous membrane, I have availed myself very satisfactorily ofa
German remedy, which is almost universally employed in such cases,
viz. the muriate of ammonia.
In English practice it has generally been confined to external use,
whereas it is employed by the Germans in a great variety of internal
complaints. It usurps the place of the nitrate of potash in British
practice. Its employment is confined to sub-acute affections, con-
gestive states of the mucous membrane of the bronchia, and chronic
affections of the serous membrane: where the inflammation runs very
high, the nitrate of potash and soda are preferred. It has no very
decided action on the system, although it sometimes stimulates the
kidneys; but it is considered to be deobstruent, and to unload the
vessels gradually, so that convalescence is achieved without any criti-
cal evacuation. It relieves thirst, and the tongue gets unloaded under
its use. It has certainly a decided action on the mucous membrane
generally, and is useful in old coughs accompanied by gastric de-
rangement.
I was loath to employ it when J first commenced practice in St.
Petersburgh, but the good recommendation of my German colleagues
overcame my scruples, and during the last ten years of my sojourn
among them, I prescribed it most freely, and have reason to speak
most highly of it. I never failed to use it in the many cases which
that climate affords of such affections as are benefited by it.
Its combination with the tartrate of antimony, in a solution of ex-
tract of liquorice, is a valuable prescription. The following is the
form usually employed :
Bo Ammoniz Mur, 3j.; Ext. Glycyrrhiz. 3iij.; Antim. Tartar.
or, ij.; Aquee distil. Zviij. M.
A large table-spoonful of this mixture is administered every two
hours. The antimony forms no inconsiderable part in the operation.
When its nauseating effects have made sufficient impression upon the
disease, it may be withdrawn, and the muriate continued by itself.
In many cases the latter is only administered.
Stomach coughs are greatly benefited by it. Where the tongue
is loaded, it cleans rapidly under its use. A variety of affections of
the mucous membrane, sore throats, enlarged tonsils, relaxation of
the uvula, &c. feel its influence.—Sir G. Lefevre on thermal Com- s ;
fort.
 Scientific Intelligence. 371
Case of Bicephalous Monstrosity ; Removal of one of the Heads
by Ligature.—I was called, on the 3lst of October, for the especial
purpose of “cutting off a growth from the head of an infant” born
the day before. The mother, who had been confined about eighteen
hours, was seated at her spinning wheel; the infant was asleep in its
cradle. Examined particularly, the head was found small, the fore-
head flat and ape-like; the face and all other parts of the body natural.
Upon the occiput, and near the posterior fontanelle, there was a
large mass, rather larger than the head of the child, appended by
means of a pedicle an inch and a half in diameter. This mass ex-
hibited the several features of the face—a cleft for the eye, but with-
out any eye-ball; an elevation in the seat of the nose, and a fold in
the place of the mouth. It had no bony cranium, but was composed
of a thick sealp, covered with hair, and having a cartilaginous con-
sistence in some places. On the posterior aspect of this cephalic mole
there was a spherical mass of a bright red colour, within which dis-
tinct fluctuation was apparent. When this red mass was pressed,
the infant gave no indications of suffering, When the false head
was touched, it cried. When the pedicle was compressed, there were
no signs of pain, but symptoms corresponding to those of apoplexia
sanguinea were induced, viz. a stasis in the circulation of the part.
This led me to believe that the removal of the part with a ligature
might with propriety be attempted. I therefore laid open the soft
fluctuating part, by an incision two and ahalf inches long, and gave
vent to about five ounces of clear yellowish serum. On separating the
edges of the incision with a couple of blunt hooks, I obtained a dis-
tinct view into the interior of the supernumerary head: there I saw
two normally formed hemispheres, with sharply defined convolutions,
parted by a deep sulcus, within which lay a firm falciform process.
J now passed a well-waxed ligature or band around the pedicle,
aud drew the knot with moderate tightness. The infant gave no in-
dication of suffering; it remained perfectly quiet. The ligature was
drawn more firmly, upon which the respiration of the child became
quickened and forcible ; the pulse more frequent, harder, and smaller;
the pupils dilated ; and the blood-vessels of the head and face injected.
The external jugular vein even became apparent through the layer of
fat, of considerable thickness, which covered it. I thought it pru-
dent to take a little blood from this vessel. A third pull upon the band
completed the ligature, at which moment a stream of blood burst forth
from the puncture of the external jugular vein, and three ounces were
allowed to flow. The infant was put to the breast, which it took greedily,
The pseudo-cephalic mass was now of a deep livid colour; and a
few minutes after the operation was over, it had become quite cold.
Laid open longitudinally through the thick scalp, I came upon a re-
gular dura mater, which, besides the falciform process already men-
tioned, exhibited an imperfect tentorium cerebelli; beneath this a
small, dark red medullary mass presented itself, which, however, had
no simiiarity in point of structure with the cerebellum; it was with-
out the convolutions and sulci that were apparent on the cerebral lobes :
it had no hemispheres, no subdivisions, no crura, no vermiform pro-
 372 Scientific Intelligence.
cess. There was no trace of a medulla oblongata. On raising the
cerebral mass, I could, however, make out a kind of pons Varolii—a
sinooth medullary mass, by which the hemispheres of the brain were
connected. I perceived no other commissure. The crura cerebri,
as well as all the other parts at the base of the brain, were entirely
wanting, During the course of this examination the infant was
never interrupted in its business of sucking. The parts were covered
with a piece of linen dipped in spirits, and the child laid in its cradle.
I remained an hour in the house, only quitting it at the distance of
three hours after the operation, at which time the infant was tran-
quilly asleep, and breathing quietly: there seemed every prospect of
a happy issue to the case. On my returning next day, however, to
see my patient, the parents met me at the door, and informed me,~
with great satisfaction, that God had not persisted in punishing them
with the changeling oaf, for it had just died. Death followed 36
hours after the operation.
The parts were examined anew by Dr. Kersten and M. Loesch,
The conclusion was, that the case was one of true, though incom-
plete bicephalus. The encephalon of the normal head was perfect in
all its parts. There was no cerebral connexion between it and the
pseudo-cephale; but nervous cords and blood-vessels could be traced
into the latter, and processes of the dura mater extended into the con-
necting pedicle.—Dr. Buehring, in Casper’s Wochenschroft, No. 1,
1844, and Medical Gazette.

Onan Epidemic Pseudo-Syphilis, by M. Alies.—The district of

of R , near Luxeuil, contains a population of 700 inhabitants. In
1840 and 1841, symptoms very like those of syphilis appeared in about
80 individuals. The principal feature of the malady consisted in an
eruption of mucous tubercles in the neighbourhood of the anus and
genitals. Common report attributed the origin of the disease to one
of the inhabitants who was supposed to have had connexion with in-
fected women, who on his return to the village communicated the
disease to his family, whence it spread throughout the whole district.
M. Aliés does not pronounce on the true nature of the disease ; it is
beyond doubt, he says, its appearance and situation closely resembled
syphilis, and mercury rapidly cured it, whilst in those patients who
would not submit to this plan of treatment the disease lasted a long
time. Nevertheless, the order of appearance and succession of the
symptoms, their mode of transmission and termination induced him to
doubt its being of a syphilitic nature, together with the fact that a
great number of his patients denied having been exposed to any source
of infection, and in all there was a complete absence of secondary
symptoms.—Journal de Medicine de Lyon and Gazette Medicale.
| [We regret very much that we have only seen a short abstract of this
paper, but from what we have been enabled to lay before our readers,
they will perceive that there is evidently a close resemblance between
it, and the characters of ** Sibbens,” detailed in another part of this
Number.—Ep.}
 THE

DUBLIN JOURNAL
OF

MEDICAL SCIENCE,
JULY 1, 1844,

PART I.

ORIGINAL COMMUNICATIONS. -

Art. XIII.— Notes on Ovariotomy. By Firetwoop Cuvrcutt,

M.D. M.R.1.A.; Hon. Fellow of the Philadelphia Medical
Society ; Physician to the Western Lying-in Hospital and
Dispensary; and Lecturer on Midwifery, &c. at the Rich-
mond School of Medicine.
[Read before the Dublin Obstetrical Society.|

THERE are some diseases so generally fatal in their results, and

so little under the control of ordinary treatment, that a prac-
titioner may be fully justified in having recourse to extraordinary
expedients, even though attended with serious risk, provided
only that the risk from the operation be considerably less than
the mortality from the disease under ordinary remedies.
This remark I would apply to the operation for the extir-
pation of diseased ovary, which has recently attracted so much
attention in England; and as the subject is one of so much im-
portance, I make no apology for laying the matter somewhat
at length before this Society: for, on the one hand, we find the
VOL, XXV. NO. 75. 3.0
374 Dr. Churchill’s Notes on Ovariotomy.
disease almost unmanageable by the methods hitherto adopted,
and ending fatally sooner or later; and on the other, an ope-
ration of the severest kind, and averaging a high rate of mor-
tality, is proposed as a remedy. If experience shall exhibit a
fair and reasonable proportion of successful cases, then, although
severe, the operation will be justifiable; but if its fatality at all
equal that of the disease, it will clearly be altogether objec-
tionable.
But before we enter into the merits of the operation itself, it
may not be amiss to notice one or two points in the pathology
and history of the disease for which ovariotomy is proposed as a
remedy.
Dropsy of the ovary, though sufficiently distinctive as a name,
yet comprehends considerable differences of morbid structure;
for instance:
1. The enlarged ovary may consist of a single cyst, with
thin membranous parietes containing a serous fluid.
2. Instead of a single cyst there may be many, each separate
from the other, or two or more communicating together. ‘The
fluid may vary in quantity, quality, and consistence in each,
being in some limpid serum, in others green, yellow, or brown
glutinous matter; in others, of the appearance and consistence
of honey; and in others, hydatids.
3. In cases of multilocular dropsy of the ovary, we find
more or less of solid matter, sometimes chiefly at the root of the
tumour, in others forming a large portion of it.
4, Again, we find the ovaries enlarged considerably from
fibrous tumours. Dr. Baillie remarks, that “the ovarium is
much enlarged in size, and consists of a very solid substance
intersected by membranes, which run in various directions. It
resembles in its texture the tumours which grow from the outside
of the uterus, &c.”
5. Lastly, the ovaries may be the seat of malignant depo-
sitions, and though, as in the case of fibrous tumours, the en-
largement is not so great as in dropsy, yet it sometimes attains a
considerable size.
 Dr, Churchill’s Notes on Ovariotomy. Ste

Although we find these diseases attain to a great deve-

lopment without much complaint on the part of the patient, we
cannot therefore conclude that they cause no irritation in the
neighbouring tissues, for we very commonly find adhesions more
or less extensive between the tumour and abdominal perito-
neum, or effusion into the serous cavity.
The symptoms to which these enlargements of the ovaries
give rise are partly mechanical, partly sympathetic, and partly
constitutional, Pressure on the neighbouring organs will be in
proportion to the amount of the disease and its situation. Thus
the patient may suffer from dysuria, or even retention of urine,
from difficulty in evacuating the bowels, and from pain along the
sciatic nerves, whilst the tumour is in the pelvis, After it rises
above the brim, these symptomis are generally less marked, but
certain unpleasant consequences result from pressure upon the
intestines and stomach, and, when the enlargement is excessive,
from the pushing upward of the diaphragm.
It is not very uncommon for some of the signs of pregnancy
to be present, owing to the intimate sympathy of distant organs
with the ovaries.
For a considerable time—varying in different patients—there
are few constitutional symptoms, the suffering being chiefly local ;
but after some time, as the disease advances, a great change
takes place, in consequence of diseased action going on in the
ovary. Dr. Burns observes: “ In the course of the disease the
patient may have attacks of pain in the belly, with fever, indi-
cating inflammation of part of the tumour, which may terminate
in suppuration, and produce hectic fever: or the attack may be
more acute, causing vomiting, tenderness of the belly, and high
fever, proving fatal in a short time : or there may be severe pain,
lasting for a shorter period, with or without temporary exhaus-
tion, and these paroxysms may be frequently repeated. But in
many cases these acute symptoms are absent, and little distress
is felt until the tumour acquires a size so great as to obstruct res-
piration, and cause a painful sense of distention. By this time
376 Dr. Churchill’s Notes on Ovariotomy.

the constitution becomes broken, and dropsical effusions are

produced. Then the abdominal coverings are sometimes so
tender that they cannot bear pressure ; and the emaciated pa-
tient, worn out with restless nights, feverishness, and want of
appetite, pain, and dyspnoea, expires.”*
This disease may terminate in various ways. 1. In some
cases by resolution and absorption of the fluid ; this, however, is
extremely rare, even-in early dropsy, and, of course, infinitely
more so when the disease has made much progress. 2. In-
flammation may attack the covering of the sac, giving rise to
adhesions; and in some of these cases the contents of the sac
may be evacuated into the intestines or vagina with temporary
relief, and in a few cases ending in a perfect cure. 3, The tu-
mour may be attacked by inflammation, ending fatally; this is
not uncommon after tapping. 4.. The parietes of the ovary may
give way, evacuating its contents into the cavity of the perito-
neum : or more frequently the walls of some one of the cysts ina
multilocular dropsy give way under the general pressure, and
open into the abdomen. Peritonitis generally follows, often end-
ing fatally.
Thus in very few cases, indeed, is there hope of cure by ab-
sorption ; in others there may be spontaneous, though temporary,
relief afforded by the evacuation of the fluid through artificial
openings; but upon the whole there is little prospect before a
patient afflicted with this disease but long continued annoyance,
more or less suffering, and sooner or later broken health, a shat-
tered constitution, and death.
In an estimate of unusual modes of relief like the present, it
would be very desirable to ascertain not merely the ordinary re-
sults of the disease, but the period of time occupied in arriving
at them. But in the present instance this is impossible, as the
course of the disease is irregular: in some cases the termination
is comparatively early, in others the disease lasts many years.
idea ane AT ae

* Midwifery, p. 139.
 Dr, Churchill’s Notes on Ovariotomy. 377
We therefore lack one element for a complete calculation. The
general opinion is uniform as to the results, and the little benefit
to be obtained from medicine, except in early cases; so much
so, that when the tumour has attained a certain size, the only
relief anticipated is from surgical treatment.
So far then our object is clear, having ascertained, as nearly
as we can, the consequences of the disease when left to itself, or
under medical treatment alone; we shall next review shortly, the
different surgical methods which have been proposed, and then,
by a fair comparison, estimate the value of each.
It will have been noticed that in the preceding observations
I have said nothing upon fibrous growths, or malignant disease
of the ovaries, and for the obvious reason, that although such
have been extirpated, it is not for them that ovariotomy is pro-
posed, but for ovarian dropsy.
1. The ordinary surgica! operation for the relief of ovarian
dropsy is abdominal paracentesis, puncturing the tumour by a
trocar, and evacuating its contents. No doubt that by this ope-
ration the life of the patient is frequéntly prolonged, and pre-
sent relief from the over-distention is afforded, but by degrees
the sac refills, and all the former inconveniences recur, with no
hope of relief, except by a repetition of the operation. Thus,
for instance, Portal tapped one patient twenty-eight times;
Ford, another forty-nine times, drawing off altogether 2649
pints. Morand evacuated 427 pints in ten months; and Marti-
neau drew off 495 pints within a year; and from the same pa-
tient 6631 pints, by eighty operations, in twenty-five years.
But the necessity for a repetition of the operation is neither
the only nor the worst inconvenience attendant upon abdominal
paracentesis. The sudden evacuation of so large a quantity of
fluid may cause alarming or even fatal exhaustion; or if she re-
cover from this, the tumour itself, or the peritoneum, may be
attacked by inflammation, with its consequences,
Moreover, if the tumour be multilocular, and the cells do
not communicate, or if their contents be not fluid, the operation
378 Dr. Churchill’s Notes on Ovariotomy.
will fail altogether. The same result will obtain if the tumour
be fibrous or scirrhous: in the latter case, indeed, the fatal re-
sult will rather be accelerated.
Mr. Southam has furnished us, in his Essay, with a table,
which, so far as it goes, may enable us to form an estimate as to
this operation. He has taken ten cases from Dr. Bright, five
from Dr. Barlow, and added five of his own.

Duration of Life af- | No. of

Patient] Age. a ae ter first Operation | Times Cause of Death.
ried.| gle. :
of Paracentesis. tapped.

44 ;1 . - | 24 hours. 1 Inflammation.
Bie Moet Mod, fos 6. 1a OO 1 Do.
—H.|..|..{.. | Several days—10? | Do.
E. S. | 836 | 1 | .. | Few days—7 ? 1 | Do.
M. H.| 40 | ..|.. | 1 month. 1 Ulceration of sac, and
escape of contents in-
to abdomen.
450. 1. 2 VT do. 1 Exhaustion from exten-
sive scirrhous disease.
5. ote Po t Lak, 103 1 | Exhaustion.
ered 2 months. 2
E. W.| 26 | 1 4 do. 3 Exhaustion.
Sor; | S54 7 do., 1
M.M./ 53 | 1 val EO; 5 | Inflammation.
©. Hie) 420 | os pis du Sudo, 6 Exhaustion.
ae bad 8 do. 1 Do.
SHBie} 2Oriesi. 1 |9 do. - 4 Inflammation.
ea) coe. F 1 15.do. 6
A. M.| 34 | 1 ots ES a0: 2 | Inflammation.
— T.;} 33 | 1 -- | 4 years. 7 | Exhaustion from pres-
sure of tumour.
E. W.| 27 | .. | .. | 4 years 9 months, 14 | Inflammation after tap-
ping.
EB. SON. a TT years, 4 | Do.
M.N.| 35 | 1 os 185 do: 11 Do.

‘*Thus, fourteen died within nine months after the first

operation, four of whom survived it only a few days. Of the
remaining six, two died in eighteen months, and four lived for
periods varying from four to nearly nine years. It further ap-
pears that paracentesis does not prolong life, on an average, for
more than eighteen months and nineteen days, and that one in
five dies from the effects of the first operation.”*

* Mr. Southam’s Remarks, &c., Med. Gaz.

 Dr. Churchill’s Notes on Ovariotomy. 379
Of eleven cases of dropsy of the ovary admitted into Guy’s
Hospital, seven were tapped, three of which were unsuccess-
LT
2. From the unsatisfactory results of paracentesis, certain
modifications have been proposed ; thus it has been suggested,
that, after emptying the sac, some stimulating fluid might be
injected, as in hydrocele, for the purpose of exciting inflam-
mation which may end in obliteration of the sac. However,
after pointing out inflammation of the sac as one cause ofa fatal
termination, it will scarcely be necessary to do more than refer
to it as increasing the risks of tapping.
3. Dr. Blundell has proposed early tapping as a practice
‘“‘which may be thought of” in these cases, on the principle
that as in the smaller cysts, the accumulation is less rapid, the
patient would be spared suffering. He thinks that a puncture
might be made into the tumour whilst in the pelvis, or that an
incision being made through the abdominal parietes, the finger
might guide the trocar down to the tumour.
We are not aware of any cases thus treated, nor do we an-
ticipate that the results would be more favourable than from
tapping in the usual way.
4, An attempt at cure has been made by Ledran, Houston,
Voisin, and others, by making a free incision into the ovary,
evacuating its contents, and converting the opening into a fistu-
lous sore. Capuron states, that “this method is generally
adandoned, because it was remarked that it accelerated the
death of the patient ;’+ and Dr, Burns remarks that in no case
has he seen benefit from it.t
Dr. Blundell proposed a plan something like this, but in-
stead of an incision he suggests the removal of a part of the
cyst, “so as to enable it to evacuate its contents into the peri-
toneal sac.”8

* Guy’s Hosp. Rep. 1837-8. Tt Mal. des Femmes, p. 187.

t Midwifery, p. 142. § Diseases of Women, p. 118.
380 Dr. Churchill’s Notes on Ovariotomy.
5. Lastly, the extirpation of the diseased ovary has not only
been proposed but practised to a considerable extent. Asa
considerable number of cases are before us, it 1s not ne-
ceessary to occupy time in adducing at length the opinions of
different writers, further than to observe, that it is said to have
been first recommended by Vanderhaar, and afterwards by De-
laporte, Morand, and Logger. In more recent times it is advo-
by Blundell.
It is opposed by De Haen, Morgagni, Murat, Capuron, Ha-
milton, &c.
I may add Dr. Hamilton’s objections, that they may be
tested by the cases adduced; he says: “ 1. It is extemely difficult
to distinguish enlargement of the ovary in its early stages; and
it is still more difficult to foretell the progress of such enlarge-
ments; any operation might, therefore, be useless or unnecessary,
unless if there be no disease, and unnecessary if the disease be
in a stationary condition. 2. There is always a risk, in cases of
enlarged ovary, that there may be a complication of organic
disease or that morbid adhesions may have formed, connecting
the disease with other parts. 3. As no prudent practitioner
would think of operating unless the patient’s health suffered or
seemed to suffer from the disease, there must, in every such
case, be the hazard of some malignant affection existing, which
no operation could remedy.”*
After these preliminary remarks I shall very slightly enu-
merate the cases in which the operation has been performed,
including those where the ovary was removed, those in which,
the disease being ovarian, obstacles prevented the completion of
the operation, and those in which the operation was needlessly
performed, owing to an error of diagnosis. I shall then throw
these into the form of separate tables, so as to enable the Society
to form a correct judgment of the whole.
1. The ovary was first removed, I believe, by L’ Aumonier
ci ce a I ee ee ee

* Pract. Obs. Part I. p. 120.

nae
TY
 Dr. Churchill’s Notes on Ovariotomy. 381
of Rouen,* on certainly very slight grounds. The disease
appears to have been an abscess of the ovary (after delivery)
communicating with the uterus by means of the Fallopian tube.
M. L’Aumoniér opened the abdomen by an incision four inches
long, and removed the ovary. The patient recovered.
2. In 1809, Dr. M‘Dowal of Kentucky operated upon Mrs.
Crawford. The incision was nine inches long, a ligature was
tied round the Fallopian tube, the tumour opened and removed,
and the patient recovered. The tumour contained gelatinous
matter, and the sac weighed seven pounds and a half.
3. He repeated this operation some time afterwards upon a
Negro woman, but found the tumour so firmly adherent to the
bladder and uterus that he feared to remove it, and therefore
merely evacuated the jelly-like fluid and closed the wound.
The woman recovered.
4, In 1816 he performed the operation for the third time,
andon a Negro woman. The incision extended from two inches
above the umbilicus to within one inch of the pubis; the liga-
ture was applied around the Fallopian tube, and the tumour ex-
cised. It proved to be a scirrhous ovary. The woman rapidly
recovered.”’+
5&6. The American Editor of Good’s Study of Medicine
refers to two other successful cases by Dr. M‘Dowal, but I am
not able to give the particulars.+
7. Moreover in the New York Medical Journal, 1824, Mr.
Foltz speaks of a case by Dr. M‘Dowal, which proved fatal, and
the British and Foreign Review mentions a fatal case also, but
whether the same or different I do not know. At least it would
appear that Dr. M‘Dowal performed the operation six times,
Se a hh
* Edin. Med. Surg. Jour. Vol. xviii. p. 532.
+ Lizar’s Observations on the Extraction of diseased Ovaria, pp. 4, 5.
t ‘* Dr. M‘Dowal has recorded five cases in which this Operation was suc-
cessful. The ovarium has been extirpated also by Dr. D. L. Rogers of New York.
The patient recovered, but died with dysentery eighteen months after the Operation
,
Dr. Alban G, Smith has likewise performed the same operation, and with highly
beneficial results.”
— Note in Amer, Edit. of Good’s Study of Medicine, vol. ii. p. 590,
VOL, XV. NO. 75; oS
382 Dr. Churchill’s Notes on Ovariotomy.
8. Dr. N. Smith of Connecticut, operated upon Mrs. New-
bridge of Norwich, et. 33 years, July 5, 1821. The tumour
had been growing several years, having disappeared three times,
probably from bursting. The incision was three inches long,
and the fluid having been evacuated, the sac was separated
from its adhesions to the peritoneum and drawn through the
wound, a ligature was applied and the sac excised. It weighed
two or three ounces, ‘The patient recovered rapidly.
9, In 1823, Mr. Lizars of Edinburgh proposed the operation
for the relief of what he conceived to be ovarian disease. The
patient was et. 27, and had one child. The incision extended
from two inches below the ensiform cartilage to the pubes, but
no tumour could be found. The wound was closed, and the
patient recovered..
10. In 1825, he repeated this operation in the case of Janet
J., et. 36, unmarried. The tumour had formed no adhesions,
and after the ligature had been applied was easily removed.
Some hemorrhage occurred, but she recovered after some time,
11. In 1825, he operated in like manner upon Isabella C.,
et. 25. The tumour was adherent, but he succeeded in separa-
ting and removing it. It weighed seven pounds. ‘The patient
died in two or three days of gangrene of the peritoneum.
12. He operated a fourth time, upon Magdalen B., et. 34,
unmarried. ‘The tumour was found to be solid and supplied with
large vessels, and it was decided not to remove it. The wound
was closed, and the patient recovered.*
13, Dr. A. G. Smith of Danville, Kentucky, operated upon
a negress, et. 30, mother of several children. The incision ex-
tended from the umbilicus to within an inch of the pubis.
Having evacuated the fluid, he drew out the sac, tied its pedicle
and removed it. ‘The patient recovered.t
14. Dr. Quittenbaum has published a successful case of
extirpation in which the long incision was used.

* Lizar, ut supra, p. 9, et seq. + North Amer. Med. Jour, Jan, 1826.

$ Comment. de Ovarii Hypertrophia et Historia extirpationis Ovarii, &c., cum
success facta.

tt
a
 Dr. Churchill’s Notes on Ovariotomy. 383
15. In 1829, Mr. David Rogers of New York, having first
tapped his patient, made an incision from two inches below the
umbilicus to the pubes, and having carefully separated the ad-
hesions which the tumour had contracted to the peritoneum, he
drew out the sac, applied a ligature and removed it, The
solid part weighed three pounds and a half. The patient re-
covered.*
16. 1826, Dr. Granville opened the abdomen of a patient
to the extent of six inches, for the purpose of extirpating an
ovarian tumour, but finding it firmly adherent, he decided to
leave it, and closed the wound. The patient recovered.+
17. He has published a short account of another case, in
which he removed the diseased ovary, but the patient died three
days afterwards.t
18. Previous to 1828 Dr. Dieffenbach operated by the long
incision on a patient, zt. 40, but decided not to remove the
ovary on account of the supply of large vessels. The patient
recovered.§
19. Dr. Chrysmer performed the operation upon a woman,
eet. 47, mother of eight children. The incision extended from
the xyphoid cartilage to the pubis, and, after evacuating the fluid
in the abdominal cavity, the tumour was separated from its ad-
hesions to the stomach and peritoneum, a ligature applied, and
removed. It weighed seven pounds and one-third, consisted of
cartilaginous and lardaceous matter and green sanies. The pa-
tient died in thirty-six hours of gangrene of the intestines.
, 20. He operated in a similar manner upon apatient et. 38,
mother of five children. The adhesions were cut through, a
double ligature applied, and the tumour removed. It weighed
eight pounds, and consisted of cells filled with honey-like mat-
ter and green sanies. ‘The patient recovered.
21. His third operation was upon a patient labouring under
$$ eee
* American Medical Journal, vol. v. p. 549.
t London Medical and Physical Journal, vol. lvi. p- 141.
¢ Med. Gaz., Jan. 13, 1843, § Archiv. Gen. de Med., vol. xx. ps 92.
 i

384 Dr. Churchill’s Notes on Ovariotomy.

other diseases. There were but slight adhesions. The pedicle

was four inches thick, it was tied, and the tumour removed,
weighing six pounds anda half. The woman died in thirty-six
hours. The peritoneum and intestines were gangrenous; uterus
cartilaginous; right ovary enlarged; tubercles in the liver, &c.*
22. In 1826 Dr. Martini performed the operation upon an
unmarried woman, et. 24. The incision was nine inches long,
but the tumour was cartilaginous, and inseparably united to the
brim of the pelvis. Dr. Martini contented himself with re-
moving a sacculated portion from the superior part of the tumour,
and then closed the wound. The patient died in thirty-six
hours, apparently of hamorrhage.f
23. A case is mentioned in vol. xiv. of Froriep’s Notizen of
this operation, but without the name of the operator. The pa-
tient was 48 years old, and had been tapped five times in six
months. The tumour had a broad base, and was so firmly at-
tached to the os innominatum that it could not be removed.
The patient died on the sixth day afterwards.
24, Dr. Ritter operated upon a woman et. 31. He first
performed paracentesis abdominalis, and a fortnight afterwards
removed an enlarged ovary by the long incision. The patient
recovered slowly.
25, In 1834, Mr. King, of Saxmundham, operated upon
Soph. Puttock, at. 40, but after making an incision seven or
eight inches long, no tumour could be found. The patient re-
covered.
26. In 1836 he operated, by the short incision, upon Hannah
Cavell, zt. 37. The tumour, which consisted of a single cyst,
with a solid base, was punctured, and twenty-seven pints of
fluid evacuated. The sac was then drawn out, and excised be-
low the ligature. The patient recovered.§

* Archiv. Gen. de Med., vol. xx. p. 94.

+ Ibid. p. 96.
t Med. Jahrouch d. kk. Oester. Staates, vol. ii. p. 256, 1832.
§ Lancet, Jan. 21, 1837, p. 586.
 Dr. Churchill’s Wotes on Ovariotomy. 385

27. In 1833 Mr. Jeafferson, of Framlingham, operated up-

on Mrs. B. The incision was about one inch and a half long,
and after evacuating the fluid, the sac was drawn out, and,
after a ligature had been applied, removed. The patient re-
covered.*
28. In 1836, M. Dolhofft operated on M. Bock, xt. 23.
The fluid was first evacuated by an incision and puncture. The
incision being enlarged, more fluid escaped (fifteen pints in all)
and the sac was removed. Noadhesions. The patient died in
two days of peritonitis.
29. He also opened the abdomen in another case, but the
tumour was solid, and so fixed in the pelvis that he did not re-
move it. ‘The patient died in eight hours.
30. He opened the abdomen of a third patient, but found
notumour. ‘The patient recovered.
31. In November, 1836, Mr. West of Tonbridge operated
by the short incision (two inches) on Mrs. Harrison, and having
punctured the sac, and drawn off twenty pints of fluid, the sac
was easily drawn out and excised, after its pedicle had been tied.
There were no adhesions. The patient recovered.t
32. Mr. Gorham§ states, that Mr. West repeated the ope-
ration on Miss S. ‘Twenty-four pints of fluid were evacuated,
and the sac extracted. ‘The patient recovered.
33. And on A. M., et. 24. Her constitution was much
shattered previously, and she sank.
34. In another case Mr. West performed the operation; the
patient recovered, but was not cured of the disease, as she had
to be tapped afterwards,
35. Mr. Gorham also gives a case by Mr. Hargraves. The
patient was et. 40; adhesions had formed, and the cyst was
multilocular. The patient recovered, but was not cured.||

* ‘Trans. of Prov. Med. Association, vol. v. p. 245.

+ Rust’s Magazin, 1838, vol. li. p. 82.
¢ Lancet, Nov. 25, 1837, p. 307. $§ Ibid. Oct. 14, 1839, || Ibid.
386 Dr. Churchill’s Notes on Ovariotomy.
36. In 1840 Mr. B. Phillips operated by the short incision,
and the patient died.*
37. In 1841 Dr. Stilling performed the operation upon a
patient at, 22. The incision was six inches long. The patient
died of hemorrhage.T
We now come to Dr. Clay’s cases, which have excited so
much attention in England.
38. In Sept. 1842, Dr. Clay operated upon Mrs. Wheeler,
set. 46. The incision was twenty-seven inches long; the tumour,
partly solid, and partly fluid, weighed twenty-eight pounds, was
removed, and the patient recovered.
39. Oct. 7, 1842. Mrs. Berwick, et. 57. Incision four-
teen inches, Extensive adhesions. Tumour excised, weighed
twenty-four pounds, ‘The patient recovered.
40. Nov. 8, 1842, Mrs. Edge, zt. 39. Incision twenty-
eight inches. Very extensive adhesions. ‘Tumour removed,
weighed seventy-three pounds. Patient recovered.
Al. Oct. 26, 1847. Mrs. Dillon, et. 47. Incision sixteen
inches. ‘The tumour is described as ‘ anomalous,” and with
extensive adhesions. It was not removed. She died on the
seventh day, of inflammation.
42. Nov. 17, 1843. Mrs. Hardie, et, 45. Incision four-
teen inches. The tumour was a fleshy tubercle of the uterus,
and the entire, except the cervix uteri, was removed. The pa-
tient died immediately from hemorrhage.
43. Mrs. Lythgow, et. 40. Incision fourteen inches. Ova-
rian tumour, weighed twenty-six pounds; very extensive adhe-
sions. She died in thirty-six hours from hemorrhage.
44, Aug. 21,1843. Miss Hayne, et. 22. Incision four-
teen inches. ‘Tumour was adherent, and weighed twenty-six
pounds. She recovered.

* Medical Gazette, vol. i. 1840.

} Brit. and For. Rev. Extracted from Holscher’s Hanoversche Annalen,
Hft. 3, 1841.
 Dr. Churchill’s Notes on Ovariotomy. 387
45. Aug. 30, 1843. Mrs. Elliott, zt. 40. Incision fourteen
inches. No adhesions. She died thirty-six hours after exci-
sion, of inflammation.
46. Oct. 2, 1843. Miss Jackson, et. 43. Incision fourteen
inches. Extensive adhesions. Tumour removed, weighing
thirty-one pounds. She recovered.
47. Oct. 3, 1843. Mrs. Jones, xt. 59. Incision sixteen
inches. Very extensive adhesions. Tumour removed, weighing
fifty-four pounds. The patient died of exhaustion thirty-two
hours afterwards.
48. Oct. 4, 1843. Mrs. Brocklehurst, et. 45. Incision
fourteen inches. The tumour was an hydatid, weighing sixteen
pounds, and was excised. She recovered.
49, Oct. 9, 1843. Mrs. Tweedale, zt. 58. Incision eight
inches. This was a case of pelvic tumour, but of what nature I
am not aware. It was removed, and weighed twenty-four pounds,
Dr. Clay says the patient recovered from the operation, but died
on the tenth day.
50. Nov. 16, 1843. Mrs. Priest. Incision sixteen inches,
An ovarian tumour, having very extensive adhesions, and weigh-
ing twenty-six pounds, was removed. The patient recovered.*
51. Jan. 6, 1844. Patient, et.49. She had ten children.
Alter the abdomen was laid open by the long incision, the dis-
ease was found to be uterine. A ligature having been applied
around the cervix, the uterus and ovaries were removed without
hemorrhage. The patient died after three weeks.
52. In 1843 Mr, Morris performed the major operation suc-
cessfully.f
53. In 1842 Mr. Walne operated by the long incision upon
Mrs, I’., et. 58, mother of five children. The tumour was free
from adhesion, and after the application of the ligature, was re-

* I am indebted to the politeness of Dr, Clay for this corrected list of all
the operations he has performed. Only part of them have been published in the
Medical Times,
+ Manchester Courier.
388 Dr. Churchill’s Notes on Ovariotomy.

moved. It consisted of many cysts and solid basis. ‘The pa-

tient recovered.*
54, He operated again in 1843 upon Mrs. R., et. 57, after
applying a double ligature round the tumour, which weighed six-
teen pounds three quarters. The patient recovered.
55. In the same year he operated upon Miss A. K., et. 20.
The broad ligament constituted the pedicle, and a ligature
having been applied, it was divided. The tumour weighed
twenty-eight pounds. The patient recovered.
In none of these cases were there any adhesions between the
tumour and surrounding parts.
56. Oct. 11, 1843, he operated upon Mrs. P., eet. 54, and
after making an incision five inches long, he found such exten-
sive adhesions that he desisted, and closed the wound. ‘The
patient recovered.
57. In another case he removed a diseased ovarium with a
fatal result.t
58. In 1843 Mr. Southam operated upon Mrs, H. by the
long incision. The tumour, before the operation, was perfectly
moveable, and proved to be cystic sarcoma, weighing four pounds
twelve ounces. The ligature was applied, and the diseased
ovary removed. ‘The patient recovered.§
The account given by Mr. Southam is remarkably interest-
ing, and speaks well for the practical sagacity of that surgeon.
I have been much indebted to his extensive researches in the
collection of these cases.
59. In June, 1843, Dr. F’. Bird of London performed the
operation, The incision was three or four inches long. ‘The
sac was punctured, and then drawn out and excised, after the
application ofa ligature, The patient recovered.|| |
60. He has repeated the operation since with success, The
tumour consisted of cysts and solid matter, and weighed twenty-
seven pounds.{]
* Medical Gazette. 1 Ibid.
¢ Med. Gazette, Feb. 23,1844, p.686. § Med. Gazette. 1843.
~ |) Med. Gazette, Aug. 18, 1843. q lbid. Dec, 29, 1843, p. 409.
 Dr. Churchill’s Wotes on Ovariotomy. 389
61. In the last Medico-Chirurgical Review* isa case copied
from the New York Journal, in which the operation was
per-
formed by Dr. Atlee of Lancaster, U. S., in June, 1843.
The
patient had been tapped for ascites three times, and
only after
the third time was the tumour detected. The operation
consisted
in an incision nine inches long, which exposed two
ovarian tu-
mours, with adhesions, The latter were separated, the pedicles
tied, and both ovaria removed, The patient recovered
well.
62. In a recent Number of the Medical Gazette} is an
ac-
count of an operation, by Mr. Heath of Manchester, for the
re-
moval of supposed ovarian tumour, but upon making the
long
incision it was discovered that the tumour was uterine.
The
operator determined to remove the uterus, tumour and all.
The
patient died of hemorrhage in seventeen hours. ‘The
symp-
toms were those of a uterine, and not ovarian tumour, and
allowing that such a mistake might be made without blame,
it would have been far better not to have meddled with a disease
which seldom, if ever, compromises life, and hardly interferes
with comfort. |
The last Number of the British and Foreign Medical Re-
view notices some additional cases.
63. The first was by Mr. Lane, who tapped the patient ten
days before the operation, and extracted the ovary through an
incision, reaching from the umbilicus to the pubis, The patient
has so far recovered. |
64. Mr. Key also performed the operation in Guy’s Hos-
pital, July 29, 1843. Patient aged 19, unmarried, Incision
four inches at first, No adhesions. Incision enlarged up to
near ensiform cartilage. Pedicle small, Ligature applied, and
tumour removed, Tumour multilocular cysts, with large vessels,
Patient died Aug. 6, of peritonitis.§
65. Mr. Greenhow, of Newcastle, operated Sept. 3, 1843.
Patient aged 29, married. For four years she suffered from fre.
a
ssc

* Jan. 1844, p, 258. + Dee: 8,143,

t Jan. 1844, p, 237. § Guy’s Hos. Rep., Oct. 1843, p. 4738
VOL, XXV. NO. 75, 3 E
390 Dr. Churchill’s Notes on Ovariotomy.

quent uterine hemorrhage. Long incision. Several adhesions;

ligature applied, and tumour excised. Patient died on seventh
day, of peritonitis.*
66. Mr. B. Cooper operated. Patient aged 32, married,
but had no children, Long incision. Some adhesions. Double
ligature, and excision. Patient died of peritonitis the seventh
day,t in consequence apparently of a portion of omentum being
included in the ligature.
Taste I.—Cases of Extirpation of the Ovary.
No. and Operator. Age} Incision. Result. Character of Dis- | Adhesions.
Date. ease.

1 JT” Aumonier. - | 4 inches. Recovered. | Abscess of ovary.

2—1809| Dr. M‘Dowal. 29 %do. do. Gelatinous matter.
3—1816 do. -e | Long. do. Svirrhous ovary.
4 do. ° e e e e do.

5 do. 8 do.
6 do. oe tal remeansn ious Died.
7—1821| Dr. N. Smith. 33 | 3inches. | Recovered. | Cyst, fluid. Adhesions.
8—1825| Mr. Lizars 36 Long. de.
9—1825 do. 35 do. Died. ee Adherent.
10 Dr. A. G. Smith 30 do. Recovered. | Cyst, fluid.
i Dr. Quittenbaum, | .. | About 4 in. do.
12—1829| Mr. D. Rogers. -. | About 3in, do. Solid and fluid. Adhesions.
13 Dr. Granville. ee lgeeteete sao m are Died.
14 Dr. Chrysmer. 47 Long. do. Cart. and larda- Adherent.
ceous matter.
15 do. 38 do. Recovered. | Honey-like and do.
green sanies.
16 do. Erie T Oo: Died.
17 Dr. Ritter. 31 do. Recovered. | Cyst, fluid.
18—1836| Mr. King, 57 Short. do. do.
19—1833| Mr. Jeafferson. oe do. do. ao.
20 M. Dolhoff. 23 Long. Died. Cyst and fluid, Adhesions.
21—1836| Mr. West. An Short. Recovered. do.
22 0. be do. do. dO.
23 do. 24 do. Died. do,
24 do. ee do. Not cured. do.
25 Mr. Hargraves. 40 do. do. Multiloc. cysts. Adhesions.
26 Dr. Clay. 46 | 27 inches. | Recovered. | Cysts,sol. and fluid. do.
27 SSeS be 67 | 14 do. do. do. Ext. adh,
28 shes ae ete 39 | 28 do. do. do. do.
29 Serie 40 | 14 do. Died, do. do.
30 Ses) tehe* 22 | 14 do. Recovered. do. Adhesions.
31 aes 40 | 14 do. Died. do. None.
32 23 48 | 14 do, Recovered. do. Ext. adh.
33 to ees 59 | 16 do. Died, do. do.
34 Area cers 46 | 16 do. Recovered. do. do.
35—1840| Mr. B. Philips. e« | 2 inches. Died.
36—184)| Dr. Stilling. ee | 6do. do.
37—1842| Mr. Walne. 58 Long. Recovered. do. None.
38—1843 do. 57 do. do. do. do.
39 do. 21 do. Died.
40—1843 do. 20 do. Recovered. do. do,
41—1843| Mr. Morris. oe do. do.
42—1843| Mr. Southam. on do. do. Cystic sarcoma. do.
43—1843| Dr. F. Bird. «| 3or4in. do. Cyst and fluid. do.
44—1844 do. : do. do, Cysts and solid do.
matter.
45 Mr. Atlee, - | 9 inches. do. siaache <oldne Adhesions,
46 Mr. Lane. Long. do Cysts fluid. None.
47 Mr. Key. 19 do. Died, do. do.
48 Mr. Greenhow. 29 do. do ice PS ee do.
49 Mr. B. Cooper. 32 do. do

* Med. Trans., Jan. 20, 1844, p. 240, + Ibid. p. 241.

 Dr. Churchill’s Notes on Ovariotomy. 391

Taste 1—Cases of ovarian Disease in which the Operation

could not be completed.

Date. Operator. Cause of Failure. Result. Incision.

|50 Dr. M‘Dowal. | Adhesions to blad- | Recovered.| Long.

| der and uterus.
51 Mr. Lizars. Solid and very vas- do. do.
cular tumour.
52—1826 | Dr. Granville. | Firm adhesions. do. 6 inches.
53 Dr. Dieffenbach.} Vascularity. do. Long.
54— 1826 | Dr. Martini. Solid and fixed tu- Died. do.
mour.
55 Anonymous. Fixed tumour. do.
56 M. Dolhoff. do. do. About 6 in.
57 Dr, Clay. Exten. adhesions. do. Long.
58 Mr. Walne. do. Recovered. | 5 inches.

Taste I1.—Cases in which the Operation failed from an Er-

ror in Diagnosis.

Date. Operator. Result, Disease.

59—1823 Mr. Lizars. Recovered. No tumour found.

60—1834 Mr. King. do. do.
61 M. Dolhoff. do. do.
62 Dr. Clay. Died. Uterine tumour.
63 do. Recovered. Hydatid.
64 do. Died. Pelvic tumour.
65 do. do. Uterine tumour.
66 Mr. Heath. do. do.

Let us now attempt a little closer analysis of these cases. It

will be remembered that the question at present is not whether
each operation was justifiable or suitable, but merely as to the
results of the operation under given circumstances.
1. The entire number of cases—whether dropsy, or scirrhus
of the ovary, uterine disease, or simulated tumours—amount to
sixty-six: of these forty-two recovered, and twenty-four died, or
about 1 in 23,
Of the forty-nine cases (Table I.) in which the ovary was
extirpated, sixteen died, or 1 in 3/5. Of the nine cases (Table
392 Dr. Churchill’s Notes on Ovariotomy.
II.) in which the operation could not be completed, four died,
or 1 in 21; and of the eight cases (‘Table III.), where the ope-
ration was unnecessary, four died, or 1 in 2.
2. It is not quite so easy to give the comparative mortality
of the long and short incision, because the definition of each is
scarcely settled. Taking the length of the wound as our cuide,
without reference to the tapping of the tumour before extraction,
we will include all cases under the term “ minor operation,”
where the incision did not exceed four inches; and under the
term “ major operation,” where it exceeded that.
Of the true ovarian cases in Table I. there are fourteen cases
of the short operation, of these thirteen recovered, and two died ;
and thirty-four cases of the long operation, of whom twenty-one
recovered, and thirteen died, or 1 in 2,8. In the second and
third Table there are fifteen cases of the long operation, of whom
seven died, or 1 in24. Of the forty-nine cases of the long ope-
ration twenty died, or 1 in23. At the same time it must be
observed that in the cases of the short operation there are much
less irritation and injury owing to the absence ofadhesions; and
in some cases the short operation would have been perfectly use-
less, so that if any attempt were to be made, it must be by the
long incision, with all its risks. ‘The comparison therefore is
not quite fair.
3. Age does not appear to have had much influence upon
recovery or death, for the ages mentioned in six of the fatal
ovarian cases were 23, 25, 40, 40, 47, and 59; whilst those of
the successful ones range between 20 and 60.
The same may be said, as far as the information extends, of
the married or single condition of the patients.
4. At first sight one would expect a considerable variation
in the result of cases in which there were adhesions from those
in which there were none, because of the violence necessary;
and this seems to be confirmed by the cases of Chrysmer and
others, where the patients died of gangrene of the peritoneum;
yet of seventeen cases in which the adhesions were found, and in
some very extensive, eleven recovered, and six died. This,
 Dr. Churchill’s Votes on Ovariotomy. 393

however, shews the great disadvantage of adhesions, and there

are certain cases, one of which we have just seen, in which these
were so extensive that removal of the tumour would have been
impossible,
5. Certain of the operations (Chrysmer, Clay, &c.) were
performed upon women labouring under other organic diseases,
or suffering from great constitutional exhaustion, and these cases
proved fatal.
6. The operation was several times frustrated by the exces-
sive vascularity of the tumour, or its firm attachment to the pel-
vis, and though several of them (four out of eight) recovered,
yet these are additional reasons for serious investigation.
7. It is further shown by Table III. that the operation was
performed when no tumour at all existed—when the tumour was
uterine, or growing from the pelvis, or an hydatid. At first
sight it might be supposed that such errors of diagnosis were the
result of carelessness, and that the first could scarcely occur.
And yet Mr, Lizars is a surgeon of no mean experience; and
M. Dolhoff had his patient in hospital under his observation
for a year or so. Very lately I was consulted for a supposed
ovarian tumour, and upon examination there was a distinctly
shaped abdominal tumefaction, which had all the feel of a
uterine or ovarian tumour, and yet upon calling off the pa-
tient’s attention, and setting the abdominal muscles into action,
it entirely vanished.
It may be worth while now to looka little closer at the diag-
nosis of these tumours.
1, The abdominal muscles appear to acquire the power of
involuntarily assuming the form and appearance, and of commu-
nicating the sensation of a tumour. In some cases it seems as
though the result of the form given to them by a former preg-
nancy. Against this deception we can in a great measure guard
ourselves, by prolonging our abdominal manipulation, and call-
ing the muscles into action by leading the patient to converse.
Percussion will also aid us in coming to a right conclusion, and
394 Dr. Churchill’s Notes on Ovariotomy.
if we make an examination per vaginam and per rectum, there
will be but little doubt remaining. And I would observe that
an examination per rectum is most valuable in all cases of real
or supposed ovarian disease.
2. In the majority of cases the continuity of the tumour,
ascertained by the perception with a finger on the os uteri of a
shock impressed upon the abdomen, is nearly decisive of a tu-
mour being uterine, and the very feeble or absent impression of
such shock, of its being ovarian. The exceptions are mainly
those cases where adhesions have taken place, uniting the pelvic
viscera closely together. Dr. Simpson of Edinburgh has re-
cently proposed the use of a bougie for this purpose. It is to
be introduced into the uterus, and then, he states, that by turn-
ing it one way, and pressing the tumour the other, it is quite
possible to establish a distinction between the uterus and ovary
in cases of ovarian disease. Or it might be possible that the di-
rection taken by the bougie would establish the same fact.
Again, a careful examination per rectum and per vaginam
will very often, even where the tumour is adherent, prove that
there are two tumours, and their different density, or the com-
parative vividness of shocks communicated from the abdominal
tumour, may justify the inference that one is the uterus and the
other the ovary.
Lastly, the history of the disease may throw some light upon
its nature. Uterine tumours are generally of slower growth, of
smaller size, more dense to the touch, seldom attacked by in-
flammation, and rarely painful; and although none of these cir-
cumstances are conclusive alone, they may be very decisive in
conjunction with other signs.
3. It may not be very difficult to come to a conclusion as to
the existence of adhesions, though far from easy to estimate
their extent. The mobility of the tumour, if it do not fill the
entire abdomen, will generally decide the question; but when
the disease attains an enormous volume, we can do little more
than form a conjecture. There is a sort of rolling feel when a
 Dr. Churchill’s Notes on Ovariotomy. 395
tolerably free ovarian tumour is moved, and a crepitus when ad-
hesion has occurred, which is not easily mistaken; and a change
of posture may afford additional information.
4. It is, of course, almost impossible to estimate the vascu-
larity ofan abdominal tumour. Occasionally we may distinguish
with the finger the pulsation of an artery, and more than once
I have ascertained the fact with the stethoscope. A careful
examination should always be made with this instrument.
These hints may show at least the obscurity of the means of
diagnosis, and perhaps aidalittle in dispelling some of that ob-
scurity. At all events it is certain that difficulty and doubt
exist, or such mistakes would not have happened in the hands of
careful men; and as these errors may be repeated, I would ear-
nestly advise that when, on opening the abdomen, the tumour is
found to be uterine, no attempt be made to remove it. The
patient has a far better chance of recovery if the disease be un-
touched, and it is unlikely that any evil consequences will result
from the tumour itself. It isa sad reproach that a patient should
die, not of the operation, but in consequence of attempting that
which was not originally contemplated,
Conclusions.—Fven after the details I have given, it is
very difficult to come toa definite and perfectly satisfactory con-
clusion, because, 1. we have not sufliciently accurate data to es-
timate the progress of the disease unaided by surgery. 2. The
table quoted from Mr. Southam is clearly too limited to afford
a fair average of the results of tapping, and it is not easy to ob-
tain sufficient facts to enlarge it. 3. The cases in which ova-
riotomy has been performed are of sucha mixed character, that
it is impossible to select with fairness those cases in which the
operation was demanded for the relief of urgent suffering, and
suitable to the nature of the disease, without the appearance of
partiality. And 4, from the obscurity of the diagnosis, it is too
much, perhaps, to expect that our practice in future will be free
from those drawbacks on the operation.
But bearing in mind these difficulties, and making allowance
396 Dr. Churchill’s Notes on Ovariotomy.
for those drawbacks, I think we may conclude that there are
cases in which the operation would be justifiable; and on. these
grounds,—we find the general opinion is against the curability
of the disease by medical means ;—that after a time the pa-
tient will die from local disease or accident, or constitutional
disturbance, and that meantime she suffers more or less incon-
venience ;—that tapping in almost all cases affords but temporary
relief ;—and that, as far as the limited statistics we have adduced
are admissible as evidence, it is attended with great danger:
;e. 1 in 5 died of the first operation, and of twenty patients,
fourteen (more than two-thirds) died within nine months ofthe
first tapping; whilst of the entire number of those who under-
went the operation of ovariotomy, about one-half have abso-
lutely recovered so far.
We may add, that of those who died, some were in an un-
favourable condition for any great operation, and many had no
other hope of relief.
not
2. If we reject those cases in which the operation could
those
be completed—those in which it was unnecessary, and
d
when the patient laboured under organic disease, or a debilitate
and broken constitution, the mortality is twelve in forty-two, or
1 in 31. Even making allowance for the difficulty of diag-
nosis, it does appear to us that in future sufiicient judgment
may be exercised to reduce the proportion to something near
this.
3. Again, if the operation were confined to cases of unilocu-
lar cysts without adhesions, or even to cases requiring the major
operation where no adhesions exist, the results, according to our
statistics, would be more favourable. At present it would seem
desirable, if possible, to limit the operation to these cases.
4. Let it be observed, that so far we have canvassed the
merits of the operation on the recorded results, not on the pro-
priety or impropriety of it in any or all of the cases related ; but
it would be impossible to shut our eyes to the fact, that it has
been sometimes performed without a due regard to the condition
 Dr. Churchill’s Votes on Ovariotomy. 397
of the patient—to the necessity of an operation at all—or to the
one in question being exactly adapted for the purpose.
To justify the operation in an individual case, the patient
should be so far inconvenienced by the disease as to require
surgical relief of some kind; and yet, on the other hand, she
ought not to be in a condition which would prohibit other great
surgical operations. In such cases the alternative is tapping or
extirpation, and our judgment should be formed upon a careful
estimate of the results of each,
Again, it is clear that no operation of this magnitude should
be attempted when there is coincident organic disease ofa se-
rious character in other organs; nor have we sufficient evidence
to justify an extension of the operation to other diseases than
those of the ovaries.
5. As to the mode of operating, it appears to me, that it is
better to commence with the small incision, and, if necessary,
afterwards enlarge it. The great advantage of this plan appears
to be, that after making the incision (in some sort an exploratory
one), if the sac, after being emptied, can be drawn out, we es-
cape with the slighter risk; if there be obstacles, owing to solid
matter, it can be enlarged without difficulty; and if these ob-
stacles be such as to deter us from completing the operation,
we can recede with much less danger to the patient; and thisI
think of vast importance, considering the present uncertainty of
our diagnosis,
I have thus endeavoured to lay before the Society such in-
formation as I have been able to obtain concerning this impor-
tant operation, without appearing as its advocate or its opponent.
beyond what the statistical results will justify. These results
are, I think, neither so favourable as some of its friends have
represented, nor so discouraging as its opponents have asserted.

VOL. XXv. NO. 75. 3K

398 Dr. Porter on the radical Cure of Hydrocele.

Art. XIV.— Observations on the radical Cure of Hydrocele.

By Wittiam Henry Porter, M.D., one of the Surgeons
of the Meath Hospital and County of Dublin Infirmary;
and Professor of the Theory and Practice of Surgery in the
Royal College of Surgeons in Ireland.
Ir may be almost universally observed, that where a number of
methods are proposed by which to attain any given object in
surgery, or a variety of operations performed for the cure of any
one disease, either that disease presents itself under such diffe-
rent conditions and circumstances, as almost to resolve it into
separate species, or else the curative measures are inadequate
and imperfect. Thus it is with the disease under consideration:
few have had a greater variety of operations performed for its
relief or cure—few seem to have attracted a greater share of
professional attention, and there are few on which general opl-
nion is more divided with respect to a safe and effectual mode
of treatment than hydrocele of the tunica vaginalis. Yet is it
in general a simple disease, its pathology well understood, and
the rationale of its cure easy of comprehension ; the difficulty of
the treatment not consisting so much in the removal of the dis-
ease, as in doing so without the infliction of much suffering, and
without a risk of failure or relapse. Again, the nature of the
affection and the situation it occupies are calculated to impart to
it a considerable degree of interest: the pardonable apprehen-
sion experienced by. every person at the existence of any de-
rangement in this important locality, particularly of one, the
nature of which he may not understand, together with the actual
inconvenience such tumour may occasion, will render any patient
anxious as to the result, as well as most desirous of relief. Such
relief, to a partial extent, can always be afforded by puncturing
the tumour, or, as it 1s termed, by the palliative mode of treat-
ment; but it is but too well known by experience that the part
enlarges again with a greater or less degree of rapidity, the in-
convenience is renewed if not increased, until, wearied and ha-
 Dr. Porter on the radical Cure of Hydrocele. 399
rassed by a constantly recurring annoyance, the patient at length
becomes dissatisfied, and insists that something may be done to
free him from it for ever. In the humbler walks of life, and
amongst persons obliged to earn a livelihood by active exertion,
there are other and better reasons for seeking a radical cure, an
object for the accomplishment of which numerous operations
have been (as I have said) devised, each in its own time advo-
cated and extolled, but each, nevertheless, either so unsuccessful,
or attended by such countervailing disadvantages, that many
surgeons, whose opinions are entitled to the highest respect,
would willingly dissuade their patients from the attempt, and
advise them to rest contented with the occasional relief afforded
by the palliative method. Still, for the reasons I have men-
tioned, the radical cure of hydrocele may not, and perhaps ought
not, to be abandoned, and therefore it becomes an important
subject of inquiry if by any means, either the adoption of anew
operation, or a modification of one of the old, an equal degree
of success can be obtained with less suffering or danger to the
patient.
I am not now disposed to enter upon an analysis of the dif-
ferent operations by incision, excision, seton, caustic, and injec-
tion, or of the various circumstances that might possibly render
one of these preferable to another; neither shall I discuss the
various conditions of the parts that might justly cause any at-
tempt at a radical cure to be regarded as injudicious or inad-
visable. Such considerations, however essential to a general
understanding of the subject, would be out of place here, where
I am about to refer to one operation alone. I wish, then, to be
understood as speaking of cases in which there exists no posi-
tive objection to the radical treatment—in which the testicle is
sound—the tunica vaginalis unaltered—the patient’s general
health unimpaired—and the circumstances generally favourable
to the attempt, and as wishing to point attention to an operation
which I believe to be simple, easy of performance, unattended
400 Dr. Porter on the radical Cure of Hydrocele.
by many of the disadvantages incident to others, and equally
effectual in accomplishing the desired result.
The predilection of the Profession at present seems greatly
to incline to the operation by injection, and considered only with
reference to a cure, it is sufficiently successful, so that we might
rest on it without seeking farther improvement, if it was not that
in its performance, and the subsequent progress ofthe case, it is
occasionally open to some objections. In the hands of careless,
ignorant, or inexperienced practitioners, the cellular tissue of
the scrotum may be injected with the fluid instead of the tunica
vaginalis, and a distressing and dangerous inflammation may
thence ensue; nor is it unfair to argue against an operation from
an error in its performation, when the object is to substitute
another that is not liable to any similar casualty. But even
when performed in the most judicious manner it may be, and
too frequently is, followed by unpleasant consequences, such as
inflammation and suppuration of the sac, the formation of
sinuses, protracted discharges, and the different forms of consti-
tutional derangement that will be likely to attend such local
affections. Itis true I have not seen these symptoms actually
lead to a fatal termination, although such cases have been fami-
liarly spoken of, and in bad and broken and irritable constitu-
tions, the occurrence would be far from impossible; but I have
seen inflammation and fever reach such a height as to occasion
no inconsiderable alarm both to patient and practitioner. It
was the observation of some such cases that first gave me a dis-
taste for the practice in which I had been educated, and induced
me to abandon the operation which I had frequently performed
myself. An operation, I conceive, may be very objectionable
without being actually fatal, and if any one is lable, even occa-
sionally, to be followed by a painful, tedious, and wearisome
confinement, it ought to form a good reason for hesitating to
adopt it, and for seeking some other that may promise a greater
immunity from similar inconvenience or suffering.
With reference to clinical surgery, this operation is open to
 Dr. Porter on the radical Cure of Hydrocele. 401
the objection of not being based on any fixed principle, and
consequently being more or less empirical. Surgeons are not
agreed as to the exact material that ought to constitute the in-
jection, or even as to the requisite degrees of its strength or
temperature: every one has his own particular favourite opinion
in these respects, and in any two hospitals scarcely will a pupil
be able to meet with two cases treated in a precisely similar
manner. ‘Thus I have seen one practitioner use a fluid of so
high temperature as to be unpleasant to the hand, whilst another
has preferred cold water. The contents of the hydrocele itself—
solutions of different salts in various degrees of strength and
concentration—wine diluted with water in different proportions
—brandy and water in like manner—and solutions of iodine,
have been all employed, the latter of which at present seems to
be highly extolled, and all have been followed by a cure,
although, doubtless, in some instances a heavy penalty has been
exacted for it. Again, surgeons are as little prepared to say
what the effect may be, or to explain the pathology of the cure,
supposing it to have been accomplished. In many cases there
can be no doubt that the cavity is obliterated by the universal
adhesion of the tunica vaginalis scroti to that of the testis, our
pathological museums furnishing abundant evidence of this fact.
In other instances these adhesions are partial and in spots, and
then the cure is generally incomplete. Again, we know that
the cavity sometimes suppurates, giving rise to painful and pro-
tracted discharges, and frequently to the formation of sinuous
ulcerations; the cure, under such circumstances, being always
dearly purchased. Perhaps the most favourable termination is
where the cavity remains still free, and without any attachment
at all, as if merely some alteration had been wrought in the dis-
eased function of the membrane, but then there is a liability to
relapse at a future period, for I have seen a hydrocele produced
by a blow in a tunica vaginalis, that had been to all appearance
successfully treated by injection two years previously. But it
may be said that a minute examination of each case might easily
402 Dr. Porter on the radical Cure of Hydrocele.
explain many of these discrepancies, both as to symptom and
result, and doubtless it is not difficult to conceive that a very
irritating form of injection, or a great susceptibility of inflam-
mation in the patient should lead to consequences that would not
be expected under more favourable circumstances. Yet this is
not the point. What is complained of is, that after an expe-
rience of so many years, and in the present advanced state of
surgical science, it has not been satisfactorily determined what
is the least objectionable form of injection; and again, that
with any form hitherto employed there is no certainty of a defi-
nite result: each may fail altogether, or, on the other hand, may
lead to results that would be infinitely more disastrous.
I have operated frequently for the cure of hydrocele by in-
jection, and, I suppose, with as much success as others have ex-
perienced, but I never could consider it a safe or satisfactory
operation, or propose it to a patient with the same confidence
which I have felt in other cases. I have known it to be almost
abandoned in the private practice of some eminent surgeons,
who never advised it, and performed it, when obliged so to do,
with evident reluctance. Even authors who have advocated it
most strongly admit such a number of exceptions to the general
rule, as to show that they could not have viewed it otherwise
than in a dubious light. Thus Dupuytren, who says that the
operation by injection is one of the best, the most prompt and
most simple for the cure of hydrocele, yet enumerates a vast
number of complications that would render it improper, and
then states that when there exists the least doubt, the least un-
certainty on the nature of the disease, some other ought to be
selected. In such he generally recommends the operation by
incision. Boyer, who says that it is the only operation at pre-
sent performed in France, in England, and in the south of Ger-
many, acknowledges that it is so often unsuccessful as to have
furnished its opponents ground for their strongest objections.
In the edition of Sabatier, edited by Dupuytren, I find it laid
down, that of all the methods hitherto devised for the radical
 Dr. Porter on the radical Cure of Hydrocele. 403
cure of hydrocele, that by injections is the only one now in ge-
neral use, yet the two objections of its going too far, or not far
enough, are fairly and petioly stated. ‘* Mes journaux me ra-
pellent plusieurs cas ou il n’a cu aucun succes,” is the acknow-
ledgment of one of these facts, and the other is put with sufficient
strength in the following sentence: “II en survient quelquefois
de beaucoup plus graves, et qui dependent de l’inflammation
excessive du testicule et de ses enveloppes: je n’ai pas vu quil
en soit resulté rien de tres facheux, mais les malades ont beau-
coup souffert, et ils ont été extrémement long temps a guérir.”
Under these circumstances I was induced to make trial of other
operations, and, after the experience of several years, have
adopted that one which I am about to describe, which, if not
altogether free from the objection of a possible relapse, or return
of the disease, is not so liable to be followed by the severe and
violent inflammations that render the operation by injection so
perilous.
This operation is partly that by incision, the only difference
being, that instead ofdividing the tunica vaginalis in the entire
extent of the tumour, my incision extends only from an inch to
an inch and half in length: and partly that by the tent, an ope-
ration first proposed (it is said) by Franco, but revived and re-
commended by the celebrated Larrey. Having first punctured
the tumour in order to examine the state of the parts, and satisfy
myself that it is a case in which an attempt to cure the disease
radically may be safely made, or at least in which such attempt
would be justifiable, I allow the sac to fill again. When the
disease has reappeared, and the tunica vaginalis is as much dis-
tended as it previously had been, I perform the operation thus:
Having that part of the scrotum in which I intend to operate
shaved, I make the incision of the length above mentioned,
down to the'tunica vaginalis, and examine carefully whether any
vessel has been wounded that could possibly furnish a consider-
able quantity of blood. I then pass a bistoury into the tunica
vaginalis at one extremity of the incision, out at the other, and
404 Dr. Porter on the radical Cure of Hydrocele.
divide it by a rapid withdrawal of the instrument. Having
completed the incision, a tent of rolled lint, moistened with oil,
and secured with a ligature, so as to be easily withdrawn, is in-
troduced. The operation is then completed. The patient may
be placed in bed. On the succeeding day I generally bleed
from the arm to the extent of ten, twelve, or fourteen ounces;
and particularly if the scrotum is red, and shows a tendency to
inflammation. Latterly I have adopted this practice as a pre-
ventive in all cases with apparently the most satisfactory results.
The tent is left to become loose, and drop out of itself, which
usually takes place on the third or fourth day, and need not be
replaced; but it is desirable to break up any adhesions that
may be formed between the lips of the wound, and to introduce
the finger occasionally into the cavity of the tunica vaginalis
until the sixth, after which it may be treated with light super-
ficial dressing, and the cure is generally perfect in about three
weeks.
I have now practised this operation for fifteen years, and,
comparing it with others, have not much reason to feel dis-
satisfied. At first I was in the habit of plunging the bistoury at
once into the tumour, and completing the incision to the requisite
extent, by making it cut its way outwards rapidly and at once.
This gave an appearance of great simplicity to the operation,
but in some instances caused the fluid to become extensively in-
filtrated in the cellular tissue, which looks unseemly, although
really of no consequence, as it is absorbed in a few hours: but
the following circumstance induced me to abandon that, and
adopt my present mode of proceeding. In July, 1837, I ope-
rated on a gentleman above 60 years of age, and in doing so
opened a tolerably-sized vessel in the scrotum, and dressed the
patient without being aware of the circumstance; the contrac-
tion of the parts, and the introduction of the tent, probably pre-
venting the flow of blood: hemorrhage took place, however,
into the sac, and on visiting him in a few hours I found the tu-
mour as large as it had been before the operation, of a dark, red
 Dr. Porter on the radical Cure of Hydrocele. 405
colour, very painful, and with a coagulum protruding through
the wound. I was obliged to incise the tumour through its en-
tire extent, turn out the clots, and secure both ends of the vessel
by ligature: and although the case eventually terminated in a
perfect radical cure, yet the patient had to undergo a severe at-
tack of inflammation, profuse suppuration, and a confinement so
protracted, that it was two months before he was able to walk
abroad. Thisis the only casualty of the kind I ever experienced,
and a recurrence of it is, I think, sufficiently provided against
by the precaution of cutting carefully through the teguments
before the tunica vaginalis is opened. I now perform this ope-
ration with the greatest confidence, and without more prepara-
tion than may be necessary to ascertain whether the parts are in
a condition to warrant any interference at all, and think I have
so treated cases in which the injection would scarcely have
proved successful. There is a patient of mine now pursuing the
laborious occupation of a porter, on whom the operation was
performed six years since; it was a case of double hydrocele, of
immense size, the scrotum being so distended that the penis was
obliterated, and appeared like a navel in the middle of the
upper portion of the tumour: one of the cysts contained a dark
coloured fluid like port wine, evidently produced by an admix-
ture of blood, the result of some recent blow or accident. In
this case both the hydroceles were operated on at the same
time, yet the patient progressed without a bad symptom, and
was so far recovered as to be able to leave the hospital in less
than four weeks. The disease has never returned since.
I have also operated on a double hydrocele complicated with
hernia—a practice which I would by no means recommend, but
which may be mentioned, as exhibiting the comparative mild-
ness of the effects of this mode of treatment.
In any deviation from the beaten track I am aware that the
innovator is apt to magnify the importance of his own opinions,
and perhaps he may do so without any intention to deceive,
attributing to them advantages which they may not possess in
VOL. Xxv. NO. 75. 3G
406 Dr. Porter on the radical Cure of Hydrocele.
any eyes but his own. For this reason I wish to advance my
own with as much moderation as possible. I claim no disco-
very—it would be difficult indeed to establish such claim in the
treatment of hydrocele—but merely the revival, with some mo-
dification, of a very ancient mode of practice; and the value I
am disposed to attach to it may be comprised in a few words.
The operation I advocate is scarcely more painful than the
ordinary puncture by a trochar, and, if carefully performed, is
free from the possible occurrence of any untoward accident: it
is decidedly more exempt than that by injection from the in-
flammation and suppuration of the cavity, with all its unpleasant
consequences—indeed the quantum of inflammation is generally
rather below what is desirable than otherwise; and the cure is
perfected much more rapidly than by any other radical mode of
treatment whatever. Here, however, I rest all claim to supe-
riority, for the recovery is sometimes incomplete, and the dis-
ease returns, but if it does so, and after some time the patient
finds his expectations falsified, and his suffering and confinement
endured in vain, it is no more than what may and often—very
often—has happened under the more favoured treatment by in-
jection. The point then would be, to ascertain in which case
there might be a greater probability of relapse, and this | am
unable to determine, neither do I think the opinion ofthe advo-
cate of a particular operation would meet with or deserve that
implicit reliance should be placed upon it. It must be tested
by every practitioner for himself; but of the positive advantages
I have detailed there cannot be the smallest doubt. During
this past winterI have performed the operation on two patients,
and directed the attention of a large class of students to them.
They both recovered within the short space of three weeks, to
all appearance perfectly and radically cured, and have remained
so, for I have seen them frequently since: it would, however,
be premature to calculate on the impossibility of a relapse,
although there is no reason to apprehend such a result, or to
fear for these men more than for numbers of others, who, ope-
 Dr. Bullen on Polypoid Growths of the Uterus. . 407
rated on at different periods during the last fifteen years, are
many of them still living proofs of the radical efficacy of this
operation.

Art. XV.—On Polypoid Growths of the Uterus. By D. B.

Butten, M. D., one of the Surgeons of the Cork North In-
firmary.
[ Read at the Cork Medical Society.]

THE cases of polypoid disease of the womb whichI wish to bring

under the consideration of the Society are, Ist. The simple or
true fibrous polypus; 2nd. The cystic polypus; 3rd. The ma-
lignant, granular, or tubercular polypus, sometimes called the
cauliflower polypus. The uterus may also be the seat of various
deposits and morbid growths, the more frequent of which is the
fleshy or fibrous tumour. These fleshy tumours occupy differ-
ent situations in relation to the component parts of the substance
of the uterus. They may be developed either immediately un-
der the peritoneal coat, or in the muscular substance of the womb
itself, or directly between the proper tissue of the uterus and the
internal mucous membrane. This is the description of uterine
tumour which sometimes degenerates into a cartilaginous sub-
stance, and becomes the seat of osseous or calcareous formation,
and has been described by old writers under the name of womb-
stones. These fleshy tumours are not very vascular, and do not
entail much danger to the patient, except when pregnancy super-
venes, or the uterus becomes the seat of inflammation.
The term polypus of the uterus is used to designate tumours,
which grow from the inner surface of the uterus, or ofits os or
cervix, and are attached by a neck or pedicle, less in diameter
than the body of the tumour itself. ‘They originate under the
mucous membrane, which still covers them, and expands with
their growth, It is difficult, nay almost impossible, to detect
a polypus of the fundus of the uterus in its earlier stages, until
it enlarges and distends the uterus to a degree that often excites
408 Dr. Bullen on Polypoid Growths of the Uterus.
a suspicion of pregnancy ; it causes scarcely a perceptible change
in the appearances of the organs of generation. Ata very early
period, however, it frequently occasions profuse hemorrhage.
This discharge of blood would appear to proceed from the con-
gested state of the vessels of the mucous membrane covering the
tumour, which become gorged and varicose from impeded cir-
culation, produced by mechanical pressure, and is brought on
by any circumstance that causes a determination of blood to the
uterus. The bleeding that accompanies polypus is generally
checked and controlled for a time, by the same agents that are
found effectuain l arresting other kinds of active hemorrhage
from the uterus. As the irritation produced by the growth of
the tumour gives rise to an inflammatory state of the lining
membrane of the vagina, the mucous secretion of the passages
is increased, causing leucorrheea, which sometimes becomes very
purulent and offensive. Sooner or later this discharge becomes
coloured by a constant sanguineous oozing from the polypus. it
the patient still continues to menstruate, severe hemorrhagic
discharges are observed to occur at the menstrual periods. The
time of life at which polypi develope in the uterus is extremely
various; they sometimes grow even during pregnancy, and have
been found in"women.who were never married.
Eliza Hickey, aged 50 years, was admitted into the North
Infirmary on the 5th of April. She has had seven children, the
youngest seven years since; catamenia never ceased; about ten
months began to have heavy losses, most severe at the menstrual
period. A week before Christmas she was attacked with violent
hemorrhage, accompanied by bearing down and forcing; after
much straining a large tumour came down into the vagina, and
protruded from the vulva. Up to this time, except from loss
of blood, she had not suffered much uneasiness, nor felt much
pain. A midwife, supposing it to be a prolapsus of the uterus,
replaced the tumour in the vagina. Since the protrusion of the
tumour, the losses have been incessant, with occasional retention
of urine, and whenever she makes a continued effort to bear
 Dr. Bullen on Polypoid Growths of the Uterus. 409

down it protrudes at the vulva. The appearance of this poly-

pus is similar, in many respects, to a prolapsed or inverted
uterus, and a mistake in the diagnosis could easily be made
upon a casual inspection. The tumour is of great size, and oc-
cupies the whole space of the vagina. ‘The mucous membrane
which covers it is extremely vascular, and several large veins
tinged with blood can be distinctly seen ramifying through it.
Upon the surface are irregularities with a marked indentation,
that has quite the appearance of the os tincee. When the poly-
pus is replaced in the vagina, the tumour is felt in the hypogas-
trium, above the pubis, of the size and shape of the womb in the
sixth month of pregnancy. When the tumour is forced down
beyond the vulva, the abdominal swelling disappears, and on
passing up the finger as high as it can reach, the base is found
broadly attached to the fundus, which it drags down in its de-
scent, and inverts the uterus. In cases of this description the
uterine bougie or sound, proposed by Professor Simpson, may
prove a very useful instrument, especially where the tumour,
growing from a broad base, projects from the os uteri, and the
other symptoms may leave a doubt whether the tumour was a
true polypus, or the fundus of the womb chronically inverted.
If the bougie passes along the tumour into the uterine cavity to
its usual depth, the disease is not inversion of the uterus. In
making this exploration, however, the uterus should be replaced
in situ, and the fundus felt through the hypogastric walls, for
if, as in Eliza Hickey’s case, the polypus drags down and in-
verts the uterus, the sound will be prevented from entering
into the uterine cavity.*
Having brought the tumour as far beyond the vulva as could
be done without using much force, a ligature was applied to the
base, taking care not to include any portion of the uterine walls;

* Since the above paper was read before the Society, a very able article upon
uterine polypus, by Dr. Ashwell, has been published in the Guy’s Hospital Reports,
in which are some observations of a similar purport to those I have made.
410 Dr. Bullen on Polypoid Growths of the Uterus.
upon tightening it, the substance of the neck of the polypus gave
way a little under the pressure, and there was a rush of blood,
Applying the ligature did not cause much pain. ‘The tumour
was then replaced in the vagina. 10 o’clock that night, com-
plains of sharp pain in the womb, with much general uneasiness;
great irritation of the bladder, and frequent inclination to pass
water, which comes away in small quantities; great pain in loins
and sacrum. The tumour can be felt above the pelvis, inclining
to the left side, but there is no distention of the belly, nor is the
pain increased on pressure; no vomiting; pulse 76; the dis-
charge from the vagina is very abundant, consisting of muco-
purulent fluid deeply coloured with blood; ordered fomentations
to the abdomen, and to take a grain of the watery extract of
opium every four hours.
April 7th, forty-eight hours after the operation, complains
of great pain in the back and lower part of the pelvis ; cannot
force down the tumour ; and the abdomen is swelled and tender
to the touch; the discharge from the vagina is exceedingly of-
fensive ; pulse very small and quick; tongue fouland dry; the
expression of the countenance anxious and sunken, ‘The symp-
toms manifestly indicate the accession of irritative fever, pre-
ceding mischief within the abdominal cavity, so that it becomes
necessary to remove the tumour from the uterus without delay.
I applied Levret’s midwifery forceps, which locks with a screw,
to the tumour, and by using torsion with a considerable degree
of force, succeeded in detaching and extracting a globular
fibrous polypus larger than a child’s head ; it weighed nearly
two pounds. An immense quantity of foetid, muco-purulent
fluid, which had been pent up in the cavity of the uterus, escaped
upon the extraction of the tumour, and she passed a great quan-
tity of urine. There was some hemorrhage, which was checked
by injecting a solution of alum into the uterus, The ligature
remained attached to the neck of.the polypus, but did not ap-
pear to give her any uneasiness.
April 10. The ligature has come away, and she feels quite
 Dr. Bullen on Polypoid Growths of the Uterus. 4)1
easy and comfortable ; scarcely any discharge from the vagina ;
all feelings of uneasiness in the abdomen have disappeared.
Passes urine freely, and without irritation. ‘Countenance pale,
evidently from anemia, and pulse very small. Ordered the
sulphate of quinine and full diet.
Incised wounds, of even a trivial extent, within the passages
lined by mucous membrane, are very apt to give rise to trouble-
some hemorrhage. It is therefore the safer course to avoid, if
possible, the use of the knife in removing morbid growths from
the uterus and within the vagina. A ligature can always be ap-
plied without difficulty or danger, and after compression shall
have induced a certain degree of adhesive inflammation in the
surrounding parts, so as to diminish the chance of hemorrhage,
the separation of the tumour can be effected with perfect safety
by torsion or excision. Ifthe polypus, after being tied, is al-
lowed to remain within the uterus until it becomes putrid, the
constitutional disturbance arising from the absorption of putrid
matter may give rise to fever of a typhoid type, and to purulent
depositions in the appendages of the uterus. About four years
since I removed a very large fibrous polypus from a woman of
the name of Julia Kearney. It was attached to the fundus of
the womb, This woman never had children, and the passage
was very rigid and irritable, so that there was great difficulty in
reaching the neck of the tumour. A strong ligature was applied
by means of Gooch’s double canula. The polypus did not se-
parate for nine days. Although tightening the ligature was not
felt, yet after a few days the uterus became exceedingly painful,
the abdomen tender and swelled, and the vagina so very irri-
table, that it was impossible to make any attempts at manipula-
tion. About the sixth day the constitutional fever was of a
typhoid type, which continued for some days after the polypus
came away, and seriously threatened the life of the patient.
If the large polypus in Eliza Hickey’s case had been allowed
to remain until it had become a putrid mass, obstructing the
discharge of the muco-purulent fluids from the cavity of the
412 Dr, Bullen on Polypoid Growths of the Uterus.
uterus, the ovarian tubes would soon have been gorged with pus,
and dangerous febrile symptoms would have ensued. In the
last number of the Provincial Journal a case is detailed by Dr.
P. Murphy, in which he applied a ligature to an uterine polypus
in a lady of 43 years of age, and otherwise healthy. ‘The
tumour had not been brought away even on the twelfth day,
though from the time of the operation the discharge had been
peculiarly offensive. Pain in the epigastrium came on, which
continued to increase, with vomiting, and the patient died.
Upon dissection the abdomen was found much distended, adhe-
sion of the peritoneum slight and general, but recent. Left
ovary converted into numerous thin transparent cysts, containing
a straw-coloured fluid. Right ovary could not be traced, but
in its site, and close to the uterus, was an abscess, which had
given way, and on being fully opened its wall was found gan-
grenous. ‘The polypus lay loose in the vagina. Here we have
the patient going on well for a few days, when rigor sets in,
followed by vomiting, sweats, pain and swelling of the abdomen,
foetid discharge from the vagina, pulse small, frequent, and she
dies, with manifest indications of low, diffusive inflammation of
the peritoneum, pus in the fallopian tube, suppuration com-
mencing in the ovary, sloughing of the substance of the uterus,
and all the appearance of uterine phlebitis. This train of symp-
toms does not seem to have arisen from acute inflammation
originating in that portion of the uterus to which the polypus
had been attached, and the ligature directly applied, and ex-
tending from thence along the membranes of the neighbouring
parts. They appear more to have been produced by the pre-
sence of an offensive source of irritation within the uterus, and
the poisonous influence of the absorption of putrid matter.
There are strong grounds for assuming that earlier abstraction
of the tumour would have prevented such a formidable train of
consequences.
The investing membrane of an uterine polypus is sometimes
the seat of inflammation, and if the patient has not previously
 Dr. Bullen on Polypoid Growths of the Uterus. 413
applied for medical aid the difficulty of making a correct
diagnosis is increased by this cause. On making an examination,
the surface of the tumour is found coated with coagulable lymph,
and adhesions are formed between the polypus and the internal
surface of the dilated uterus and of such portions of the vagina
as may be in contact with it. This circumstance gives the poly-
pus more decidedly the aspect of a prolapsed uterus, and may
easily be mistaken. If, in a case of this description, inflamma-
tion should be followed by sloughing, and the tumour separate
and be thrown off, a person may easily be led to imagine that it
was the uterus itself which had been detached and came away.
The cystic variety of uterine polypus more generally grows
from the cervix uteri, and seems to consist of a morbid byper-
trophy of the submucous or mucous membrane of the affected
part. About three months ago a young woman from Inniscarra
applied at the Infirmary with a cystic polypus, which protruded
at the vulva, and was attached by a narrow neck to the anterior
portion of the cervix uteri. The tumour consisted of a semi-
transparent, but very vascular, membranous sac, which appeared
filled with gelatinous fluid. It had a good deal the character of
being a dilatation of one or more of the Nabothian glands. Her
attention was first directed to this tumour immediately after the
birth of her first child, which took place three months pre-
viously, when it was supposed to be some portion of the placenta
which had not come away. [t caused no pain, and gave her
very little uneasiness, When it was proposed to her to come
into hospital and have it removed, she expressed a wish to post-
pone the operation until she had weaned the child she was |
suckling, She went home, and has not yet come back. When
she does I shall remove the polypus, by applying a very fine li-
gature. Now nothing could be easier than to snip off polypi
of this description with a scissors, but some cases in private
practice have come to my knowledge, in which profuse and un-
manageable hemorrhage ensued after this very trivial operation.
I have seen a wound in a mucous membrane, scarcely larger
VOL. XXV. NO. 79. 3H
414 Dr. Bullen on Polypoid Growths of the Uterus.
than a leech-bite, pour out a quantity of blood that was embar-
rassing. A single drop each second is a drachm a minute, and
nearly half a pound in the hour. Pressure is useless, for if you
plug the vagina the compress acts as a warm stupe, and increases
the flow of blood. Styptic washes are quite unavailing, and the
only means to be depended on is the actual cautery. The ne-
cessity, however, of using the actual cautery in cases of such
apparently trivial character, causes so much alarm in the minds
of the patient and her friends, especially in private practice, that
it had better be avoided.
The morbid anatomy of the cauliflower excrescence of the
uterus is still doubtful, as pathologists have not yet agreed whe-
ther to consider it as partaking of the nature of erectile tumour
or of vascular sarcoma. When this form of disease is recog-
nized in its earlier stages there can be no doubt that many of
the more characteristic symptoms of sarcomatous development
are absent, but as it advances it becomes the seat of malignant
tubercle and encephaloid deposit. The growth, even at the
time that it appears to be little more than an irregular vascular
vegetation within the os uteri, has the small granular character
well marked upon its surface; and ifa portion be broken down,
the vascular or cellular framework becomes perceptible, inter-
spersed with distinctly organized opaque bodies like tubercles,
scattered through which transparent hydatids can frequently be
seen. These developments present all the features of the ma-
lignant parasite, so admirably described by Mr. Carmichael.
The cauliflower polypus is not attended with much pain, <and
the tendency to active arterial hemorrhage constitutes one of
the most marked symptoms of the disease.
This form of uterine tumour appears to be hereditary in a
very remarkable degree, as it presents itself in several of the
female members of the same family. Three sisters in one family
of the highest respectability in this neighbourhood, died upon
successively reaching the age of 43 years, of this disease. ‘The
three were married; one had a numerous family, the other two
 Dr. Bullen on Polypoid Growths of the Uterus. 415

never had children. On the 4th of last February I was sent for
to see Mrs. M‘C, She was about 40 years of age, had had five
children, and been generally healthy. Three months before I
saw her, she had been confined of a healthy child. The labour
was natural, and not very severe, For some days after delivery
the lochial discharge was unusually abundant, and upon getting
out of bed at the end ofa week she was attacked by a sudden
and heavy flooding that made her swoon, ‘This circumstance
recurred eyery time she attempted to make any exertion. When
I saw her she was very pale, and evidently suffering under the
effects of continued losses of blood. She did not complain of
any pain whatsoever ; had not much leucorrheal discharge; but
between the accessions of hemorrhage some watery secretion
kept flowing away, which was quite inodorous. I ordered her
the superacetate of lead, with enemata of cold water and lauda-
num, and cold applications to the lower part of the pelvis and
the insides of the thighs. Under this treatment the hemorrhage
was arrested for a week. At the end of that time I was sent for
again, and found the hemorrhage had returned with great vio-
lence. I immediately examined the uterus, and on passing my
finger within the os, found it very much dilated, and plugged
up with an irregular, rugged tumour, growing from the internal
surface, and extending round the whole circumference within
the cervix. On dilating the vagina with the speculum, an irre-
gular shaped granular mass is seen projecting into the passage.
The colour of the tumour is a dull, sodden grey, interspersed
with patches of a pale red, and dotted over with distinct, whitish,
granular bodies, about the size of mustard seeds. The general
aspect of the polypoid growth does not exhibit that degree of
vascularity which may be expected in a morbid development,
which occasionally pours out blood in such great profusion.
The circular lip of the os uteri can be distinctly traced by the
finger, soft, lying over, and protruded before the polypoid ex-
crescence. The base of the tumour takes its rise about three-
fourths of an inch within it, and the texture of the edge of the
416 Dr. Bullen on Polypoid Growths of the Uterus.
cervix has not yet been disorganized by the extension of the dis-
ease. The patient does not complain of pain in the affected
parts, and bears pressure upon the hypogastrium. She allows
the speculum to be used, and the tumour to be handled, without
any expression of pain. Upon leaving the room after examining
her, I told her sister there could not be doubt of the nature of
the disease, and that I feared the complaint was of a malignant
nature, and there were unhappily serious grounds for appre-
hending it may terminate fatally. She at once expressed herself
quite prepared for the communication I had made; for just
seven years before my father had been called into consultation
upon their eldest sister, who was attacked in the same way, and
after examining the womb he gave his opinion in much the same
words I used, and in four months after she died. Palliatives
being the only measures here indicated, I directed the extract
of conium, with the use of cold water enemata, whenever there
should be a recurrence of the hemorrhage. Latterly the losses
of blood have not been either so frequent or violent, but [ con-
sider this change owing to the state of anemia subsequent upon
previous bleeding. The watery discharge has increased in
quantity, being ofa brown colour, and still inodorous. Her face
is deadly pale, with dropsical swelling beneath the eyes, and
the lower extremities are beginning to become cedematous.
This form of disease differs in a marked degree from carci-
noma of the womb. ‘The sensations of pain in cancer of the
uterus are most acute, hot, and lancinating. ‘The process of
ulceration goes on rapidly, and the neighbouring lymphatic
glands participate in the diseased action. The contiguous struc-
tures of the uterus and upper part of the vagina, the posterior
wall of the bladder and urethra, and the anterior wall of the
rectum, with their connecting cellular tissues, become blended
together in one mass of carcinomatous ulceration. ‘The surface
of the ulcer is exquisitely painful when touched. The leucor-
rheal discharge is foetid and sanious, and by its acridity causes
pruritus and excoriation of the passages and vulva. ‘he func-
 Dr. Bullen on Polypoid Growths of the Uterus. 417
tions of the bladder and rectum are greatly disturbed, and, if
the patient survives for any time, perforation of their coats takes
place, so that the vagina becomes a common cloaca for the dis-
charge of the urine and feces. In Mrs. M‘C.’s case, although
the disease is now very far advanced, there is no change of
structure in a very considerable extent of the cervix uteri. The
whole of the canal of the vagina is healthy, and the parts in
connexion with the bladder and rectum do not offer any altera-
tion of structure. It seems as if the morbid vegetation grew
from a defined and circumscribed root confined to a limited por-
tion of the uterus, and that the tendency to disorganization does
not extend along the circumjacent textures in a degree propor-
tionate with the increasing growth of the polypoid excrescence.
This particular characteristic of the cauliflower polypus was
strongly evinced in another case that I had under my care a
short time since.
Mrs. P., aged about 30 years, had been much reduced in
flesh and strength by repeated and severe miscarriages. The
last abortion took place in the sixth month of pregnancy, and
was attended by painful and protracted labour, which was fol-
lowed by unusually abundant losses. From the time of her de-
livery a sanguineous discharge never entirely ceased, and occa-
sionally there was a rush of pure blood. She did not complain
of pain in the region of the uterus, and bore pressure on the
lower part of the abdomen without inconvenience. T[inding the
uterine hemorrhage to continue, after a few days I examined the
womb, and found the polypoid vegetation already grown to a
considerable size. Its base was situated within the uterus, and
involved, at least, one-half of the circumference of the cervix.
The morbid growth already projected beyond the os uteri into
the vagina. By means of the double canula I was able to carry
a loop of silver nearly round the whole base of this polypoid
tumour, but upon attempting to tighten it, the wire easily cut its
way through the diseased mass, and detached a large portion
of it. Arterial blood poured out in large quantities, and though
418 Dr. Bullen on Polypoid Growths of the Uterus.
the bleeding was somewhat checked by injecting alum and water,
it did not cease until the patient had fainted. Nitrate of silver
was then freely applied to the parts from which the portion of
the tumour had been separated. ‘This operation appeared to
have checked the growth of the excrescence for some time, and
she went to the sea side for change of air. At the end of some
months I saw her again, and found the polypoid vegetation had
grown with fearful rapidity. It then nearly occupied the pelvic
cavity, filling up the vagina, and with a considerable portion
protruding from the vulva. In the left iliac fossa there was a
hard defined tumour, not very painful to the touch, but convey-
ing the impression that the morbid growth had developed in the
ovary and was expanding in the abdomen. The pressure of this
diseased mass upon the bladder and rectum made the evacuation
of the urine and feeces attended with the greatest difficulty.
With the increase in the size of this tumour the tendency to ar-
terial hemorrhage diminished, and the greatest uneasiness was
produced from its bulk, and the mechanical pressure upon the
important organs in its immediate vicinity. On passing the hand
along the sides of the tumour, I found the base could still be
felt clear and circumscribed, as at the time of my previous ex-
amination, The edge of the os uteri was yet defined and soft;
the walls of the vagina, and its connexions, did not present any
signs of carcinomatous disorganization, nor had the polypoid
growth formed any adhesions with them. Operation with a view
to remove the disease was not to be entertained, but the suffer-
ings from the pressure on the bladder and rectum became so
urgent, that I was obliged to make an effort to obtain even a
temporary mitigation. By means of the canula and wire I suc-
ceeded in bringing away a large basinful of the diseased mass.
The flow of blood was tremendous, and only ceased after con-
tinued syncope, when all arterial action appeared to have been
suspended. The surface ofthe substance which I removed was
rough and granular; its texture very friable, and easily rubbed
down between the fingers, showing a reticulated appearance
 Dr. Bullen on Polypoid Growths of the Uterus. 419
like sponge. Lobulated aggregations of small, whitish, opaque
bodies, manifestly tubercular, were thickly scattered throughout
its extent, interspersed with distinct cavities containing transpa-
rent hydatids. The size of the morbid growth was much re-
duced upon removal, showing that its great bulk was chiefly
owing to the quantity of blood which it had contained. In some
weeks the rapid regeneration of the tumour compelled the un-
fortunate patient to solicit again its removal, even at the risk of
sinking under the loss of blood. She bore up against the he-
morrhage at the operation, but the drainage of the system was
too much, and she sunk in a few days under the general symp-
toms of anemia and constitutional exhaustion. This lady was
an only daughter, and gave me to understand that her mother
and aunt had both died before the age of 40, under similar cir-
cumstances with herself.
It is a sad admission to make that this formidable disease,
selecting its victims amongst women in the prime of life, and
generally making its appearance at times connected more or less
with parturition, should be unmanageable by the curative agents
which science has yet placed within our reach, Attempts to
destroy cauliflower excrescence of the womb by the application
of the ligature and use of caustic are only temporary measures,
and there is much reason to fear that the irritation consequent
upon these means sometimes gives increased activity to the de-
velopment of the disease. If it was possible to recognize this
growth at a very early period, and to ascertain that the base
was confined to a defined part of the cervix, and did not involve
the texture of the body of the uterus, amputation of the cervix
uteri offers the only chance of removing the disease with ulti-
mate success. ‘These cases, however, at their commencement,
are most insidious, and on account of the absence of pain and
any leading symptom are completely masked under the appear-
ance of menorrhagia, or profuse lochial discharge. It is only
when the morbid growth has attamed a certain bulk, encom-
passing the greater part of the internal circle of the cervix,
420 Dr. Bullen on Polypoid Growths of the Uterus.
and filling up, and distending the cavity of the uterus itself,
that the real nature of the disease is recognized. In every
case I have yet seen the tumour grew from within the uterus,
and its aspect was widely different, and easily distinguishable
from the florid warty vegetations, which are often seen upon the
external lip of the cervix, accompanying obstinate leucorrhoea
and certain forms of syphilis, Partial excision of the neck of
the womb would be worse than useless, and amputation of the
whole cervix, to insure extirpation of all the diseased part, could
alone be entertained. In estimating the cogency of the reasons
which should influence us in determining amputation upon an
organ so inaccessible as the uterus, we should bear in mind the
unfortunate results of the majority of operations performed for
the removal of diseases really malignant. The tubercular cha-
racter of cauliflower polypi of the womb, together witb the
presence of hydatids in their structure, and the tendency to the
development of encephaloid deposit leaves little doubt of their
malignant nature, although they may run their course without
carcinomatous ulceration, and the other symptoms which distin-
geuish true cancer. There is no question of deeper interest at
present occupying the minds of professional men than to arrive
at some satisfactory principles for determining the diseases in
which operations are advisable. The proposition in medicine
has not yet been solved, whether diseases mild in their origin
become malignant in their maturity. Upon this point, however,
the more recent manifestations of opinion appear to assume, that
growths essentially malignant are malignant ab initio, or from
their first development in the system; and that when the pecu-
liar state of constitution occurs which suffers the malignant for-
mation to start into existence, there can be no security against a
renewed invasion of the disease. It must be confessed that the
honest exposition of the accumulative experience of modern
surgeons is diminishing the confidence hitherto reposed in the
knife for the removal of cancerous and malignant growths; and
strong proofs are daily being adduced that the average duration
 Dr. Bullen on Polypoid Growths of the Uterus. 421
of life is longer in those cases which are not subjected to opera-
tion. By the statistical Report read before the last Scientific
Congress of Italy by Dr. Regnoli, it appears that out of 250
persons on whom cancerous formations had been extirpated by
the knife, scarcely twenty had survived three years. The dis-
cussions at present going on in the Academie de Medicine of
Paris, show that the more extended researches in the pathologi-
cal anatomy of abnormal organic productions have materially
modified the current opinions which have heretofore prevailed
amongst the most eminent operative surgeons in France. Upon
this subject a most valuable light has been thrown by the statis-
tical statements of M. Leroy d’Etiolles, which shew the impor-
tance of calculations made of the relative duration of life between
numbers of persons affected by cancerous complaints who have
been operated on, and who have not undergone operation. My
own experience leads me to the conclusion that carcinomatous
developments, if left to themselves, may be eventually, but are
not immediately fatal, and that the extirpation of cancerous and
malignant growths does not prolong life. In tubercular polypus
of the womb I would not therefore, unless the case presented
itself under singularly favourable circumstances, advise a patient
to undergo excision of the cervix uteri. This question of accu-
rately determining the differential diagnoses in cases of cancerous
degeneration and fibrous formations, with regard to deciding
the propriety of operating and avoiding operations, is most im-
portant, not only in a scientific point of view, but as deeply in-
volving the comforts and feelings of a large class of patients and
their friends. Happily for society the time is rapidly passing
away when medical men could build a reputation of professional
eminence upon the mere practice of mechanical dexterity.
Other and higher qualifications are now required, and it is the
special province and first duty of associations formed for the ad-
vancement of medical science, to collect the individual expe-
rience of their members, and, by accumulating evidence, to lay
the groundwork for enabling the Profession to arrive at true and
VOL. XXV. NO, 75. rs
422 Mr. Wilde on the early History of aural Surgery, §¢.
practical judgments upon such subjects. In such inquiries spe-
culation only leads to error. Facts and the aggregate testimony
derived from the results obtained by the practice of medical
men scattered over great space and much time, giving, with
candour and fairness, the number of recoveries and deaths, can
alone furnish the elements for sound and satisfactory con-
clusions.
ye eee
(ug epi

Arr. XVL—Some Observations on the early History of aural

Surgery, and the nosological Arrangement of Diseases
of the Ear. By W. R. Witpe, M.R.1.A., Surgeon to St.
Mark’s Ophthalmic Hospital and Dispensary for Diseases of
the Eye and Ear.

In the present day, when literature in every Protean shape and

form has compassed the land, and knowledge may be truly said
to run to and fro throughout the earth ; and when the polyglott
cyclopzdia of the press has outstripped in the race all other
feats of human prowess of the nineteenth century, it might be
deemed unnecessary to follow the old school system of detailing
or
the early history of that particular branch of the healing art,
,
its elementary or collateral sciences, of which this essay treats
were it not that in an art but just emerging from the darkness,
jgnorance, empiricism, prejudice, and superstition, which is even
yet the condition of aural medicine and surgery, its history not
only becomes interesting, but practically instructive.
I might, with the generality of writers upon the history of
he
medicine, commence with the times of Hippocrates, for
makes several allusions to the affections of the organs of hearing,
not, however, as idiopathic forms of disease, but as symptomatic
it must
of other maladies of an acute and chronic nature; but
I
be borne in mind that at that period of medical science (and,
regret to add, that it has in a great part descended to the pre-
sent) the affections of the ear, whether functional or organic, were
ding
spoken of, lectured on, written of, and described, not accor
 Mr. Wilde on the carly History of aural Surgery, §c. 423
to the laws of pathology which regulate other diseases, but by
a single symptom, that of deafness. “If,” says Dr. Kramer,
“ by tumours behind the ears, to be dispersed by copious diar-
rhoea if they are not to prove fatal, we are to understand otitis
interna and its terminations, and carious destruction of the mas-
toid process, as a result of the otitis interna; and if, further, I
mention that the treatment of deafness (viz. as it occurs as a
functional disorder only of the ear, without any perceptible ex-
ternal alteration of the organ) merely consists of not washing
out the ear, but cleansing it with wool, dropping in oil, directing
the patient to walk out, rise early, drink white wine, abstain
from salads, and allowing him to eat bread, and such fish as in-
habit rocky shores, I shall have collected ad/ that is of most im-
portance to give an idea of acoustic medicine at that time.”
To Celsus, the successor of Hippocrates, we are indebted
for the first acknowledgment of the specific or independent
forms of aural disease—for having introduced the practice of
ocular inspection of the auditory canal—and for some general
rules for the treatment of the inflammatory affections of the or-
gans of hearing; but this advance in acoustic medicine, which
we owe to Celsus, is more than counterbalanced by his intro-
duction into practice of those stimulating nostrums which were
then, and have been since, applied to the membrana tympani
without discrimination and without mercy; and many of which
are made use of in the present day. Galen followed in the
track of his great predecessor, and although he advanced some-
what in symtomatology, and although he was evidently better
acquainted with the causes of the inflammatory diseases of
the ear, yet he and his disciples so increased the number of
remedial agents, which were applied to the external meatus,
that we find aural medicine and surgery, toward the end of the
fifteenth century, but a collection of hard names, and uncon-
nected symptoms, the fanciful theories based on causes the most
improbable, and a category of medical substances from the ani-
mal, mineral, and vegetable kingdoms, principally, however,
424 Mr, Wilde on the early History of aural Surgery, &c.
composed of hot spices and stimulating applications, of which I
may mention castor, ox-gall, garlic, frankincense, opium, nitre,
alum, iron filings boiled on vinegar, hellebore, myrrh, turpentine,
and many other such substances, each lauded by their respective
admirers, and extolled as panaceas for deafness in all its nume-
rous forms and modifications.
It would afford us neither literary interest nor practical
utility, commensurate with the task, to detail the notions con-
cerning the treatment and diseases of the ear, as they may be
found scattered throughout the writings of Aurelianus, Paul of
fAigina, Razes, Serapion, Hali Abbas, Mesue, and Dioscorides,
the works of the three latter of whom were translated into
Geelic by several distinguished Irish physicians from the be-
ginning of the fourteenth to the end of the sixteenth century.
At the conclusion of the fifteenth century the anatomy ofthe
ear received a new impulse, and was raised to its proper footing
by the investigations and discoveries of some of the most distin-
cuished anatomists and physicians of that age, and in compli-
ment to their labours it was, that the subsequent anatomists
gave those parts names which we retain to the present day, as,
the tube of Eustachius, the aquaduct of Fallopius, the liquor of
Cotunnius, and the fissure of Casserius; but although these dis-
tinguished men made the world better acquainted with the
anatomy of the organ of hearing, and thus removed one of the
greatest obstacles to the investigation of aural pathology, their
successors in medicine advanced but little in the investigation
and treatment of diseases of the ear.
The first special work upon the ear that I have been able to
discover is that of Heurnius Mercurialis, entitled, «‘ De ocu-
lorum et aurium affectibus Prelectiones,” 99 and the first edition
of which was published at Frankfort in 1584.
Mercurialis was chiefly a compilator from the works of the
Greeks, Romans, and Arabians, and as an original investigator
deserves no credit; but he collected all that was known and had
been written before his day on aural discase; the little he did
 Mr, Wilde on the early History of aural Surgery, &c, 425
add, was that of a few more nostrums, and therefore he may be
consulted with advantage by those of the fraternity who~s¢id/
adhere to the good old rule of applying such remedies as hot
onions in acute inflammations of the meatus or tympanum.
I must not omit to mention, as connected with aural patho-
logy, that it was in this, the sixteenth century, that the attention
of the philanthropist was first turned towards the lamentable
condition of the deaf and dumb. Prior to that period, during
those ages wont to be called enlightened, and in those countries
styled civilized, and even refined, among the Egyptians, Greeks,
Romans, and Hebrews, and even still in the Orient, the deaf
mute was, and is, but little removed from the brute, and is often
employed for the basest and most degrading offices, such as hu-
manity in the present day, at least in this country, shudders
at. Up to this period the deaf and dumb were not considered
susceptible of improvement or instruction of any kind, and their
very passions, unrestrained by any influence, human or divine,
were frequently made to minister to the cruelty or sensuality of
those around them.
How long this might have remained the stereotyped con-
dition of these unhappy, isolated children of Adam, but for the
fatherly affection of Joachim Pascha, the chaplain of Prince
James the Second, of Brandenburgh, about the year 1560, it is
difficult to say. This good and venerable man undertook, and suc-
ceeded in instructing his own mute daughter by means of a series
of pictures. After him a Spanish Benedictine monk at Sahagan,
in the kingdom of Leon, one Petro de Ponce, who died in 1584,
taught the two sons ofa Castilian nobleman and a young Arra-
gonise to read and write with elegance, not only the language
of their own country, but also the Latin tongue; and it is also
related by Ambrosio Morales, the historian of this distinguished
and indefatigable man, that they could understand by sight the
expressions of the lips; and likewise spoke as those do at pre-
sent who have been taught in a modern deaf and dumb institution,
Having elsewhere enlarged upon this subject, [ have made
426 Mr. Wilde on the early History of aural Surgery, &¢.
an
this digression merely for the purpose of fixing the date of
interesting inquiry in aural pathology.
The first book that treated of our subject in the seventeenth
century was a posthumous Latin work of Jos Heurnius, on the dis-
eases of the organs of hearing, published by his son, the cele-
he
brated Otho Heurnius, in 1602. Lincke, however, says that
was but a compiler.
Heretofore the treatment of aural diseases consisted, for the
most part, in medical agents and empirical nostrums ; but at the
beginning of that century (that is in 1646), the principles of sur-
gery were brought to bear upon this class of affections by the
master hand of Fabricius von Hilden. His observations on the
of
extraction of foreign bodies, on polypus, and other affections
the external auditory conduit, are well worthy of perusal ; and
to him is generally ascribed the invention of the first speculum
auris, as well as the first ear instruments on record. ‘This spe-
culum was formed on the principle of the common forceps-like
instrument now in general use.
This is the instrument, or one similarly constructed, which
tradition has handed down to the present day, as having been
used by Fabricius; but from the following passage in a still
older writer, Peter de la Cerlata, “ per inspectionem ad solem
trahendo aurem et ampliando cum speculo aut alio instrumento,”
Lam led to believe that means were employed before his time
for examining the external auditory passages. Instruments of
this kind, and for this purpose, having been once recognized and
employed by practitioners, have since been variously modified,
according to the ingenuity of the inventor ;—yet their first in-
troduction into practice decidedly formed an epoch in aural sur-
gery. Fabricius’s observations, and the description of his instru-
ments, will be found in his “ Opera Omnia” published in 1646.
After the days of this great surgeon, the next work of any
merit that appeared in connexion with aural medicine, was pub-
lished by a Genevese anatomist, Theophilus Bonet; his obser-
vations, as they are set forth in his great work, the “ Sepulere-
 Mr. Wilde on the carly History of aural Surgery, &c. 427
tum,” or “ Chirurgica Practica,” were chiefly confined to the
pathology of the ear from dissection ; but in a practical point of
view he advanced little beyond the limits attained by his pre-
decessors. A few years later, toward the conclusion of the
seventeenth century, aural surgery received a new impulse from
the talents and laborious investigations of the distinguished
French anatomist, Du Verney. Of late it has become the fashion
to decry the labours of this great man—in my humble judg-
ment unjustly—for he was far in advance of his time, and
although the pathological is not as voluminous, nor perhaps as
accurate as the anatomical part of his writings on the organ of
hearing, still he was a lucid painter, and a graphic describer of
disease. He was the first person who arranged the diseases of
the ear according to the anatomical structures affected, as, into
those of the outer ear and meatus, those of the middle ear or
tympanum, and those of the internal ear or labyrinth. From
the times of Eustachius to the period on which we are now en-
gaged, we have no work upon the anatomy of the organ of
hearing equal to that of Du Verney’s, and to this day it may be
consulted with advantage. We likewise are indebted to the
work of Du Verney far more than is generally acknowledged,
or perhaps writers are aware of, for having given the first im-
pulse to anything like a knowledge of aural anatomy and sur-
gery in England ; for his book, which was published inParis in
1683, was translated into English after his death, and published
in London in 1737, being thus, though a translation, the first
treatise in point of time upon aural medicine or surgery in our
language. This is now a work of very great scarcity, yet there
can, I think, be little doubt but that Mr. Saunders availed him-
self largely of the labours of Du Verney. Before we take leave
of this gentleman I may remark, that to him, and not to Lalle-
mand and Itard, as I lately stated, we are indebted for the pre-
judice that up to this day exists with regard to the treatment of
otorrheea. But the latter are the more blameable, as they,
from the age in which they lived, and the giant growth of medi-
428 Mr. Wilde on the early History of aural Surgery, S¢.
cal knowledge since his time, should have known better; but [
believe, like many modern practitioners, they chose rather to
transmit the prejudices of 150 years before, than take the trou-
ble of investigating for themselves.
Without entering minutely into the history of aural medicine
during the latter part of this, the seventeenth century, which
after all would consist in the enumeration of the Latin writings
of various continental. authors, more curious than instructive,
let us pass on to the penultimate century of our own period, and
I do this the more readily, for that in it aural medicine first
dawned in Great Britain, It is remarkable, that the discovery
which Eustachius made, of the tube which bears his name, had
no practical influence upon this branch of medicine; and that
for nearly two hundred years surgery made no effort at availing
itself of this improvement, for the purpose of remedying diseases
of the ear. In 1724, M.Guyot,a postmaster of Versailles, proposed
to the Parisian Academy of Sciences to inject the Kustachian tube,
by means of a catheter introduced through the mouth, for the
removal of obstructions in that canal, and also in the middle ear.
It seems, however, that the French academicians were not suf-
ficiently aware of this valuable discovery, or at least the valuable
proposal (for it is a question whether he ever performed it
himself),
In the latter part of the year 1741, an English army surgeon,
Archibald Cleland, published in the Philosophical Transactions
an account of “instruments proposed,” as he states, “ to remedy
some kinds of deafness, proceeding from obstructions in the ex-
ternal and internal auditory passages.” ‘The first of these con-
sisted “ofa convex glass, three inches in diameter, fixed ina
handle, into which is lodged some wax candle, which, when
lighted,” he says, “will dart the collected rays of light into the
bottom of the ear, or to the bottom of any cavity that can be
brought into a straight line.” Insignificant and incomplete as
this instrument of Cleland undoubtedly was, it is, nevertheless,
 Mr, Wilde on the early History of aural Surgery, &c. 429
deserving of our attention, inasmuch as to it may be traced the
subsequent inspector auris of Deleau, of Itard, Buchanan, and
Kramer. The principal object of Cleland’s inspector for throw-
ing a stream of artificial light into the meatus, was for the pur-
pose of discovering the presence of hardened cerumen, which he
removed by means of a jet of medicated steam introduced into
the external meatus, but * if,” says he, “ this has not the desired
effect, and the person still remains deaf, the following instru-
ments are made to open the Eustachian tube; if upon trial it
should be found to be obstructed, the passage is to be lubricated
by throwing a little warm water into it, by a syringe joined to a
flexible silver tube, which is introduced through the nose into
the oval opening of the duct, at the posterior opening ofthe
nares, towards the arch of the palate.” These Eustachian ca-
theters had affixed to them a sheep’s ureter, to the other end of
which was attached the syringe, “ whereby,” he says, “ warm
water may be injected; or they will admit to blow into the
Kustachian tube, and so force the air into the barrel of the ear,
and dilate the tube sufficiently for the discharge of the excre-
mentitious matter that may be lodged there.” He likewise used
probes, of the same size as the catheters, to explore the Eusta-
chian tube. Cleland was either unaware of, or disbelieyed, the
account given by Guyot, of his having introduced an instru-
ment into the Eustachian tube through the mouth, nineteen years
before, for in his essay in the Philosophical Transactions he
does not once allude to the circumstance. To him, however,
is undoubtedly due the merit of having first introduced a cathe-
ter into the Eustachian tube through the nose, the only certain
way, I believe, of performing such an operation.
Fourteen years afterwards, that is, in May, 1755, Mr. Jona-
than Wathan published a more detailed essay in the Philoso-
phical Transactions, on “a method proposed to restore the
hearing when injured from an obstruction of the tuba Eusta-
chiana.” This gentlemen, who seems to have been a good
practical anatomist, as well as a dexterous surgeon, had an op-
VOL, XXV, NO. 70. 3K
430 Mr. Wilde on the early History of aural Surgery, §c.
portunity of making a post mortem examination in a case of
deafness, wherein it was found that both oT tubes were
“stuffed quite full of congealed mucus.” If Cleland over-
looked, or was unacquainted with the proposed operation of the
Versailles postmaster, Wathan seems to have completely over-
looked the more recent and effectual discovery of Cleland, but
in allusion to the post mortem examination to which I have just
referred, he says, in the commencement of his very admirable
essay, “as all these concurring circumstances strengthen me in
my opinion, they likewise incited me to make trial of an opera-
tion that was sometime ago proposed to the Academy of Sciences
by M. Guyot, but the author having zever practised it, he
wanted the recommendation of facts to support and enforce it, it
was, therefore, rejected by them as impracticable.” And ina
note, he adds, that Guyot having proposed the introduction of
it through the mouth, which is quite impossible, “ Petit proposed,
and that learned and skilful anatomist, Mr. John Douglas, first
demonstrated the possibility of passing the probe through the
nose into the Eustachian tube, and to him I freely acknowledge
myself indebted for the hint.” The catheter used by Mr.
Wathan was not much larger than a common sized probe, and
was bent alittle at the end, very nearly in the same form as that
used by Kramer, the distinguished Prussian aurist; and with
this and a syringe, he injected and washed out the Eustachian
tube and middle ear. There can be no mistake about the mode
of Wathan’s proceeding, for he has given a very good represen-
tation of the operation in a plate attached to his Essay in the
Philosophical Transactions.
[have dwelt thus long upon the operation of the introduction
of instruments into the Eustachian tube, because it formed the
second, and perhaps one of the greatest epochs in the history of
our art; because the merit is due to our own countryman; and
because none of the English works upon aural surgery are sufli-
ciently explicit upon this point, and many ofthe continental ones
are altogether uninformed with regard to it. Dr. Kramer, in
 Mr. Wilde on the early History of aural Surgery, &c. 431.
his critical literary review, being still under the impression that
Guyot had introduced the catheter through the mouth.
The essays of Cleland and Wathan, imperfect as they were,
were decidedly the greatest addition to aural surgery made in
the eighteenth century, and had the discoveries and valuable
observations of these practical men been followed up in Eng-
land, it is probable we would now be far in advance of our
continental neighbours.
I have been long familiar with, and have frequently exhibited
to many of my medical friends and pupils, a peculiar form of deaf-
ness not depending upon apparent disease in the ear, or the acoustic
nerve, in which the membranum tympani has fallen in, towards the
inner wall of the middle ear,—has lost, in all probability, much
of its vibratory power, and, when examined under a strong light,
the handle of the malleus can be seen pressing out through it.
In this affection, which, I have reason to believe, is very often
mistaken for nervous deafness, we have what may be termed
short hearing, from an alteration in the vibratory membrane of
the ear, in like manner as we have short sightedness, or myopia,
from a peculiar alteration in the curve of the cornea or trans-
parent membrane of the eye. I find, however, upon carefully
perusing the paper of Cleland,* that he had some idea of the
effect which I have here described, being produced (as I have
frequently known it to be) by accident. ‘ There is,” he says,
* another kind of deafness, which proceeds from a violent clap
of thunder, noise of a cannon, or the like. Jn this case it is pro-
bable that the position of the membrana tympani is altered,
being forced inwards upon the small bones, and so becomes con-
cave outwardly. In this case no vibration of sound will be com-
municated to the drum until the membrane has recovered its
natural position.” With regard to Wathan’s paper, I would
strongly recommend its perusal, as the cases he describes are most
valuable in the diagnosis of obstruction of the Eustachian tube.
During the remaining half of the 18th century I have little to
nna

* See Phil. Trans, vol, xli. part li, p. 850.

432 Mr. Wilde on the early History of aural Surgery, Se.
record; the art does not appear to have advanced asingle step,
either in Britain or any other part of Europe. Books and essays
were written, no doubt, but their authors added little to the labours
of their predecessors. The great majority of these writings ema-
nated from the German press, as, for instance, those of Gniditsch,
Wildberg, Milloradovics, Kritter, and Lentin. Of the French
school may be mentioned Desmonceaux and Leschevin ; the wri-
tings of the latter will be found in the Memoirs of the Royal
Academy of Surgery of Paris for 1763. Having lately had oc-
casion to examine this dissertation, which was undoubtedly the
best of its day, I am bound to say that the lavish praise be-
stowed upon it by the French, and the severe criticisms of the
German writers, within the last few years, were alike unmerited.
Up to this period (the end of the eighteenth century) no
special work upon the diseases of the ear had appeared in Eng-
lish print, with the exception of the translation of Du Verney in
1737, to which I have already alluded. Two English works
have, it is true, been enumerated by foreign writers, but they
were not written upon the diseases, properly so called, but on the
congenital defects of the organs of hearing.
One of these, entitled, «‘ Philocophus, or the deaf and dumb
Man’s Friend,” emanated from Mr. Bulwer in 1648. It was
chiefly founded on the history of the Castilian nobleman, to
whom I have already alluded, as being one of the first mutes
taught to understand language from the motion of the lips. The
other work appeared in 1669, and was much to the same effect,
being “The Elements of Speech; an Essay of Inquiry into the
natural Production of Letters: with an Appendix, concerning
persons that are Deaf and Dumb,” by Mr. William D. Holser.
I have lately met with another work of this description,
written in the year 1783, entitled, “Vox Oculis Subjecta,—a
dissertation on the art of imparting speech to the natural deaf
and dumb.”
The members of the Medical Society of London, instituted in
1773,and composed ofthe physicians, surgeons, and apothecaries
 Mr. Wilde on the early History of aural Surgery, §c. 433
of that time, were not insensible to the low condition in which aural
medicine stood toward the end of the last century, and in their
valuable memoirs will be found some scattered notices upon the
diseases of the ear, from the pens of the president Dr. Sims, Mr.
Houghton, Dr. Zeucker a Prussian, and Dr. Roslet of Ostend.
Most of these papers contained post-mortem examinations of cases
of deafness, a practice that, I regret to say, has not been followed
up, and very much to the detriment of acoustic medicine. In
Mr. Sims’s essay he enters into a physiological discussion regard-
ing the nature of the Eustachian tube; the object of which was
to shew, that while we heard all external sounds by means of,
or through, the meatus externus, we were conscious of our own
voice only through the Eustachian tube. The practical part of
his paper is, however, exceedingly valuable, particularly with
respect to the pressing of air through the tube into the middle
ear, by closing the mouth and external nares, and then making
a forced expiration; but this had been already explained by
Cleland in 1741.
At the conclusion of the last, and about the beginning of this
century, aural surgery and medicine were still at a very low ebb,
particularly in Great Britain. ‘This want of real medical know-
ledge by the regular practitioner upon the subject of diseases of
the ear was, however, soon taken advantage of, not only by pro-
fessed quacks and nostrum-mongers, but by the electrical, gal-
vanic, and magnetic doctors of that day, who corresponded to
the homceopaths, hydropaths, and mesmerisers of the present.
At the period to which I allude each of these chemical agents,
as galvanism, magnetism, and electricity, together with the ce-
lebrated metallic tractors, were applied to the ears of persons
labouring under deafness, and numerous and wonderful were
the cures vaunted in the periodicals of the day, as having been
effected by these remedies ;—cures almost equalling those now
performed on the eye by prussic acid: while secret, but never
failing acoustic drops, stimulating embrocations, and the like
impostures, were pawned upon the public by all those who
had ingenuity and effrontery enough to make money in that
434 Mr. Wilde on the early Estory of aural Surgery, &c.
kind of way. And here let us for a moment digress from the
direct course of our subject, to answer a question that I have
often heard propounded—Why is it that the empyric and
the pretender, either licensed or unlicensed—for in those days
there are as many and as impudent quacks with, as without
diplomas—why is it, we are often asked, that the charlatan
frequently succeeds in practice better than the honest prac-
titioner? By the term success, we do not mean professional
success in his art, but pecuniary success in life, and esteem
among those with whom money “ makes the man.” Now
although we cannot always answer this query, nor would the
same explanation be applicable to every instance, we can, how-
ever, assert one fact, which, in a great measure, contributes to
the success of the quack, and it is this,—the hearty response
of his patients to the lesson picked up from the showman—
‘speak a good word to your friends outside.” Let any well
educated, honest practitioner, be called on to treat an urgent,
and alarmingly dangerous case, where insidious death stands at
the sick man’s door—let him bring all the powerful acquire-
ments of long years of patient study and observation of disease
—his anatomical and pathological knowledge—an eye practised
to disease, and a head stored with the sound, rational, scientific,
practical principles of his art—let him add to this the kindness
of a friend, nay, often the benevolence of a benefactor—let him
pass anxious days and sleepless nights watching each turn of
disease in his patient, and ministering to every of the many
wants that surround the bed of lingering sickness—let him do
all this, and finally (under Providence) restore the patient to
health and to his friends—stand, as we may say, between the
living and the dead, and beckon back the approaching king of
terrors, and give again to society a valuable life, and to his
family the only earthly means of support—what is his reward?
He is, generally at least, paid his fee, and the patient and his
family are generous enough to say they feel grateful for all his
kind attention ;—for we will not curtail it of whatever good
 Mr. Wilde on the early History of aural Surgery, &c. 435
feeling may be shewn on the occasion. But compare this with
a patient who imagines he is cured of an imaginary disease by a
water doctor, or an atom doctor, a mesmeriser, or a magnetiser,
is he not immediately converted into a partisan ?—does he not
become a missionary for the nostrum-monger ?—does he not go
about from house to house detailing the miracle of his cure,
the skill of the doctor, the horrors of the regular prac-
titioner, and the great benefit conferred upon mankind by
being converted into hydraulic machines ; or expressing his
surprise that people will go about their ordinary business
** clothed and in their right mind,” like the man from whom the
seven devils were cast out, instead of being wrapped in a wet
sheet; while others will wait upon you specially, to beg and en-
treat you will not convert your poor stomach into an apothecary’s
shop by taking all that terrible doctor’s stuff, instead of procuring
rest and ease to all your ills, by just such an anodyne as would
be formed by pouring one drop of laudanum into the Bos-
phorus, where it leaves the Euxine, and drinking a thimble-full
of the same water where it enters the Mediterranean! But not
content with this, these medical missionaries abuse all regular
practitioners, and often force (for humanity’s sake,as they say) the
charlatan upon the patient, who then trusts to his address for fu-
ture fame and profit. But to return to our text.
Several experiments had been tried by anatomists and phy-
siologists upon dogs and other animals, in order to discover
whether the function of hearing could be carried on with a per-
forate, or imperfect membranum tympani. These investigations
upon the lower animals being deemed inconclusive, Mr, Chesel-
den, the father of English surgery, proposed to experiment in
this matter upon the living human subject, and for this purpose
a condemned criminal was pardoned, on condition of submitting
to the operation! but a popular outcry prevented its being put
in force!! Some years afterwards, Sir Kverard Home, in his
article upon the muscularity of the membrana tympani, having
expressed his desire to know the result of perforation or de-
436 Mr. Wilde on the early History of aural Surgery, Se.
struction of this membrane, Mr., afterwards Sir Astley Cooper,
published a letter in the Philosophical Transactions for the year
1800, entitled, «Observations on the Effects which take place
from the Destruction of the Membrana Tympani of the Kar.”
Although this paper did not advance our practical knowledge
upon the subject, yet it called the attention of British surgeons
to the treatment of this important organ, and put an end toa
very generally received notion among the Profession, that hear-
ing would be totally lost on the opening of the membrana tym-
pani; notwithstanding that a couple of hundred years ago it was
believed by anatomists that an aperture existed in this structure,
as a normal condition during life.
In the following year (1801) Cooper published an essay in
the same work on the perforation of the membrana tympani, as
a means of removing a particular species of deafness, —that
caused by the obstruction of the Eustachian tube, and, accord-
ing to his ideas, a consequent want of vibration in the tym-
panal membrane. This paper commenced a new era, and opened
up a wide field in aural surgery. Like all discoveries in medi-
cine, however, it was at the time, and in other hands, too fre-
quently had recourse to, and often misapplied. The brilliancy
of this operation, and its instantaneous, nay, in some instances,
almost miraculous effects, urged men to employ it who were
totally ignorant of its application, as well as of the structures
and diseases of the organs of hearing generally; so that it soon
fell into disuse, and although recommended by this high autho-
rity, the superior instruments we now possess of diagnosing with
greater accuracy the condition of the middle ear, and its internal
faucial aperture, by means of the air-douche, and also owing to
the comparatively few cases of deafness solely depending on
closure or stricture of the Eustachian tube, has rendered its
performance much less frequently necessary than was at first
supposed. This may be termed the third epoch in our art.
A few months before Sir Astley’s death, I had a long con-
versation with him upon the subject, and to shew the interest
which he took in aural diseases to the very last, I may remark,
 Mr. Wilde on the early History of aural Surgery, &¢e. 437
that some little discussion having arisen regarding the subse-
quent condition of the perforation in the membrane, heat once sent
off to Bond-street for a linen-draper, on whom he had operated
some years before, in order to exhibit to me hisear, although, at
the same time, from the number of persons who were desirous
of consulting this great surgeon, there was scarcely room to sit
down in any of his waiting apartments. This trivial circum-
stance, however, as all who knew Sir Astley are aware, was cha-
racteristic of the zeal and enthusiasm of the man.
Himley, Itard, and Deleau, improved and modified the in-
struments and the operation of Cooper. We cannot, however,
conclude this notice of Sir Astley’s improvement, without quot-
ing the pertinent and judicious remarks with which he closes his
memoir—advice and remarks, I regret to add, that have been
but little attended to, and that are, therefore, as applicable to
the present time, as they were to the period at which they were
written, upwards of forty years ago.
‘JT hope others will be induced,” he says, in alluding to the
success of his operation, ‘* to second my feeble efforts, and to di-
rect their attention to a subject which appears to beofthe high-
est importance, and to have been too much neglected by medical
men; for a knowledge of the structure ofthe ear is by no means
general in the profession, and still less are its diseases under-
stood. A prejudice has prevailed that the ear is too delicate an
organ to be operated upon, or, as it is commonly expressed,
tampered with; and thousands have thus remained deaf for the
rest of their lives, who might have been restored to their hear-
ing had proper assistance been early applied.”
As the space allotted to an essay of this description is neces-
sarily limited, I find I must compress the history of our art, with
few exceptions, into the labours of British aurists. I have, in
the preceding pages, remarked upon the condition of aural sur-
gery about the commencement of this century, but at the same
time, Iam bound to say, that the well-marked inflammatory
diseases of parts of the auditory apparatus, such as the auricle,
VOL, XXV. NO. 75. 3 L
438 Mr. Wilde on the early History of aural Surgery, Se.
external tube, and membrana tympani, were generally treated,
by all well-educated surgeons, as in the present day, by strict
antiphlogistic means, such as the local abstraction of blood,
purging, and counter-irritation,—but here the judicious inter-
ference of art ceased.
First upon the list of British writers upon the acoustic ap-
paratus and its diseases, stands John Cunningham Saunders, the
distinguished oculist, and the founder of the London Infirmary
for curing Diseases of the Eye, on whose merits, as an original
observer, a sound practical surgeon, and acritical anatomist, I
need not, to the readers of this Journal, expatiate. His work
upon the anatomy and diseases of the human ear was first pub-
lished in 1806, and although, as I already alluded, he availed
himself of the labours of Du Verney, still to Saunders we are
indebted for our first special English work upon this subject,
and to him the various charlatans, that have ever ventured to
set forward their ideas in print, are indebted for the mine from
which they drew forth the material of their various and volumi-
nous publications. Saunders, as an aurist, has been unjustly
dealt with: he wrote, not only in accordance with, but beyond
the knowledge of, his time, and Kramer not only criticises his
work with too great severity, but denies it the place, which, ina
chronological point of view, it deserves. ‘This, however, is ac-
counted for by Kramer’s having quoted from, and perhaps he only
had access to, the third edition, published in 1829, just nineteen
years after Mr. Saunders’ death. The practical portion of the work
consisted of the diseases of the meatus externus, and those of the
tympanum, of the obstruction of the Eustachian tube, and of the
diseases of the internal part of the ear, to which are added cases
of incipient nervous deafness successfully treated. ‘The plates
of Mr. Saunders’ work are worthy of inspection, and were evi-
dently drawn from recent dissections.
For six or eight years we hear nothing of aural surgery in
Great Britain, and our space will not permit of our even enume-
rating the names of the different Continental writers for the first
 Mr. Wilde on the early History of aural Surgery, §c. 439
twenty years of the nineteenth century. The untimely death of
Saunders, and Cooper’s increasing, more extended, and more lu-
crative line of practice, seem to have cast a veil over this branch
of knowledge in these kingdoms. In the years 1813-15 and 17,
we find three special works on aural medicine; of the first of
these, “ A Treatise on the Hye, and on some of the Diseases of
the Ear,” by Mr. J. Kennedy, there is little even to criticise;
the second, “ Dissertatio de Aure humana et ejus Morbis,” was
an inaugural essay published by Mr. Ball at Edinburgh, like-
wise of little note; and the third was the first work of the since
far-famed John Harrison Curtis. Let us read its high sounding
title: “A Treatise on the Physiology and Diseases of the Ear,
containing a comparative View of its Structure, Functions, and
of its various Diseases, arranged according to the Anatomy of
the Organ, or as they affect the external, the intermediate, and
the internal Ear.” Let us draw from the writings of a foreigner,
who had never seen the redoubted London aurist, the opinion
that a man of honesty and practical experience formed of this
and his other subsequent works. ‘ Curtis,” says the writer,
‘‘ treats every discharge from the ear exclusively, and in a sum-
mary way, by means of astringents; obstructions of the Eustachian
tube, with emetics and perforation of the membrana tympani ;
whilst in spite of all the entreaties of Saissy he has never once
practised catheterism of the Eustachian tube on the living sub-
ject. He makes tinnitus the chief symptom of nervous deafness,
which he treats with purgatives, especially calomel, as long as
the strength of the patient holds out.” “In all doubtful cases the
chief attention is directed merely to ascertain whether the liquor
cotumnii be partially or totally deficient !! or, whether hardened
wax exist In the meatus.” ‘* In the otitis of children he sticks
opium into the affected ear, &c., so that throughout all his wri-
tings, nothing but the most crude empiricism is to be met with ;
and yet among his compatriots, as well as abroad, Curtis generally
possesses the reputation of being a distinguished aurist.” And
one of the first English medical periodicals of the day thus ex-
440 Mr. Wilde on the early History of aural Surgery, §€.
presses its admiration of the same person: “ Mr. Curtis, in his
treatise on the physiology and pathology of the ear, has appro-
priated the whole of Mr. Saunders’ essay. The exact words, indeed,
have, in some instances, been changed, but the plagiarism 1s too
manifest to escape even the most inattentive reader. To this pa-
raphrase of Mr. S.’s work, Mr, Curtis has added some things
from other authors, and some histories of cases treated by him-
self (of course all most successfully), and has thus concocted a
treatise, which, with singular effrontery, he has put forth as en-
tirely of his own composition, and as containing the results of
his own practice. This work has now, for a period of about
twenty years, been forced upon the attention of the public, by
the advertisement of successive editions ; and it is a melancholy
fact, that there should have been found editors of medical jour-
nals either so ignorant or so careless, as to lavish commendation
on such a production.” Almost in a similar category may be
classed the writings of Williams, surnamed the nostrum-monger,
and also those of Stephenson and Wright. The latter followed
something of the plan laid down by Curtis, of simply recomposing
the words of his first work ; for as to new ideas, there were none,
nor old ones to add them to. In order to form either a new
edition, or a new book, we find the changes rung to the follow-
ing tunes for about ten or eleven years: ‘An Essay on the hu-
man Ear, its anatomical Structure, and incidental Complaints,
1819 ;” «The Aurist, or medical Guide for the Deaf, 18255”
“Plain Advice for aid Classes of deaf Persons, the Deaf and the
Dumb, and those having Diseases of the Ear, 1826,”—verily this
must have been a popular book. “ On the Varieties of Deafness
and Diseases ofthe Ear, with proposed Methods ofrelieving them,
1829 ;” “ Observations on the Effects of Mercury on the Organs
of Hearing, and the improper Use of it in Cases of nervous Deaf-
ness, 1827.” To this was added, ‘‘ The present State of aural
Surgery,” together with three or four others, all by the re-
doubted Mr. William Wright. To these productions may be
added those of Webster, Thornton, and Fletcher; works simi-
 Mr. Wilde on the early History of aural Surgery, &c. 441
lar in substance and composition, although, perhaps, not so fla-
grant in plagiarism. There is one English work that we would
rescue from the criticism which has been already applied to its
predecessors. In 1823, Mr. Thomas Buchanan, an intelligent
surgeon of Hull, published an engraved representation of the
anatomy of the human ear, to which were added some surgical
remarks upon Eustachian catheterism, together with an acconnt
of the operation of puncturing the membrana tympani, and con-
cluding with a synoptical table of the diseases of the ear, Mr.
Buchanan no doubt put forward many fallacies in his work, par-
ticularly his ideas with regard to the physiological uses and dis-
eases of the external meatus, but in a literary point of view we
may remark, that he seems to have fallen into the snare almost
peculiar to English aurists, for within a couple of years he fol-
lowed up whatever success may have attended his first publica-
tion, by producing two other works, one the ‘Illustrations of,”
and the other, “ The Guide to, acoustic Surgery ;” and in 1828
appeared a fourth work, “ Physiological Illustrations of the Or-
gans of Hearing, more particularly of the Secretion of Cerumen,
and its Effects in rendering auditory Perception accurate and
acute.’ Buchanan, however, deserves our commendation and
commands our respect, as being the first English writer who,
since the days of Saunders and of Cooper, based his works upon
a knowledge of the principles of anatomy and surgery ;—and to
him we are indebted for the second, in point of time, improve-
ment in the inspector auris, by means of which, as I have already
explained elsewhere, artificial light was transmitted through the
meatus on the membrana tympani.
About this time (1820) some notices of aural diseases ap-
peared in the medical periodicals of this country, and foremost
among the writers of these stands Mr. Henry Earle, whose
short, but accurate and practical observations upon some dis-
eases of the external meatus, published in the London Medico-
Chirurgical Transactions, are well worthy of perusal ; and the
Lancet and Medical Gazette likewise contain some detached
442 Mr. Wilde on the early History of aural Surgery, $e.
notices, and the details and pathological appearances of several
cases of the diseases of the organs of hearing.
Within the last twelve years there have appeared three small
works upon the anatomy and physiology of the organ of hearing,
by Mr. Swann, Mr. David Todd, and Mr. Caswall. The first
of these little works, from the originality of its ideas, and the
speculative theory of its author, justly attracted attention in an
anatomico-physiological point of view, yet neither it nor the
other two with which it is associated should have been enume-
rated in an essay upon the history of aural surgery, but that to
each were affixed some observations upon the pathology gene-
rally, and the congenital defects in particular, of this particular
organ of sense. These observations, however, are as crude and
unpractical as they are speculative and unfounded. I may
merely mention one of these as a sample of the rest: Mr. Todd
proposes as a remedy for congenital deafness depending on de-
rangement of the structures in the tympanum, the introduction of
such acrid substances as ammonia, cantharides, and the mineral
acids, in order to produce such an inflammation as may rouse
into activity the dormant powers of the parts contained within
that cavity !
Here we leave English aural surgery for the present, that is
about the year 1830, and first let us visit our Gallic neighbours.
The splendid discoveries of Laennec with regard to the stetho-
scope, and the morbid or abnormal sounds produced by streams
of air passing through or over diseased structures, were notlong in
being laid hold of asa means of diagnosis by those of his coun-
trymen who had devoted their talents and energies to the inves-
tigation and treatment of diseases of the ear. loremost among
these stood Deleau, and next to him Itard; the works of the
former were the first to introduce into general practice in Europe
the introduction of various medicated vapours, as well as fluid
injections, into the middle ear, by means of catheterism of the
Eustachian tube, a practice since so successfully employed by
Dr. Kramer of Berlin. But it should not be forgotten that si-
 Mr. Wilde on the early History of aural Surgery, &c. 443
milar means were employed in England nearly a hundred years
ago by Cleland and Wathan. ‘The labours of Itard are princi-
pally worthy of support, from the clearness and perspicuity of
his views, and from his vast experience in treating the inflam-
matory diseases of the external and middle ears, yet his work is
by no means devoid of those prejudices and nonsensical super-
stitions which, even tothe present day, like the amulets of a
by-past age, still hang upon or surround the works of aural
surgeons,
We now pass over a long lapse of years, owing as much
to the brevity necessary in this paper, as to the paucity of writers
in that period, and turn again to Germany, where we find aural
surgery in the highest condition of any country in Europe. As
the space allotted to an article of this description is necessarily
limited,I must compress my observations within the limits of
two works, those of Lincke and Kramer. The former never
having been translated into the language of this country, few of
my readers can have had an opportunity of being acquainted
with its merits; [shall only say for it, that although it contains
but few original observations, and is, perhaps, rather prolix in
its literary analysis, yet it comprises all that was known upon the
subject of aural surgery at the time in which it was written, in
1840. Another industrious compiler is Doctor Schmalz of
Dresden, whose work on the Deaf and Dumb is one of the
very best in print. To Doctor Kramer of Berlin we are in-
indebted for the best treatise that has yet appeared upon this
intricate and hitherto neglected branch of the healing art. I
rejoice to say his work has been translated into English, and
although I differ from him in his classification, and also on
some pathological questions, still I am bound to say it is the
best work upon the subject which it professes to teach, which
has yet appeared in British print. Independent of the general
value and truthful observation of this work, it also put forward
some important discoveries in acoustic medicine. One of these
is that of the air-press, for the purpose of more accurately intro-
444 Mr, Wilde on the early History of aural Surgery, §e.
ducing atmospheric air through the Eustachian tube into the
middle ear, and also the introduction of certain gaseous sub-
stances, as, for instance, the vapour of ether into the middle ear
for the removal of one of the most incurable maladies—nervous
deafness. As a means of diagnosing the condition of the tube
and middle ear, it is, and ever will be, highly valuable, nay, in
many cases it is indispensable ; but I must confess, that although
I have used it very extensively for the last three years, I have not
had experience of the same beneficial results from the introduc-
tion of zetherous vapour, as the tuition, or the work of my friend
led me to expect; in fact the cases in which it is applicable are
comparatively very rare.
Kramer’s discoveries, and his most scientific work, seem to
have excited a new taste for aural surgery in Great Britain ; and
well educated surgeons and honest men have at last come for-
ward to rescue this branch of the healing art from the hands of
quacks and charlatans. The names of Mr. Pilcher, Mr. Wharton
Jones, Mr. Toynbee, and Mr. Williams, are now a sufficient
guarantee that the empiric and the nostrum-monger will soon be
driven from the field. And yet that many of those latter still
drive a thriving trade, may be learned from the puffs and praises
bestowed upon them in several of the literary periodicals of the
day. In one of these, which, from our own knowledge of the
honour and integrity of its editors, as well as its hitherto stern
and uncompromising stand against quackery ofevery description,
and its high reputation for honesty of purpose and substantial
literary merit, we really expected better things, it is not only as-
serted, but endeavoured to be proved, that by dropping “an
alkaloid” into the external meatus, or rubbing the surface of
the membrana tympani with it, persons born deaf and dumb
have been almost instantaneously cured! nay, not only is hear-
ing restored on the moment, but the miracle (for miracle it
certainly is, if true) extends to the organs of speech also, as in
one case, and that too given on the faith of a medical man,
and conveyed ina letter to the operator; he says, that “ after
 Mr. Wilde on the early History of aural Surgery, &c. 445
repeated examinations of many of the objects under your care,
previously to any thing being done, I satisfied myself that they
were both deafand dumb. I have witnessed the application of
your remedy to the ears, and bear testimony to them having in
my presence obtained the sense of hearing.” But—miracle upon
miracle—the faculty of speech to one who had never heard the
sweet sounds of a human voice, follows almost as matter of
course; for, adds the narrator, “‘ and by my own tuition, in a
few minutes afterwards acquired the power of speech!” Query
—was it broad Scotch they spoke?
It is always a matter of difficulty to argue on a medical or
legal subject with a non-professional person, for it is quite im-
possible (especially with respect to medicine) for a person un-
instructed in anatomy and physiology, medicine and surgery,
&e., to be convinced of his error, any more than it is for him to
form an opinion of the merits of a cure or the causes of a failure.
How few students, after two or even three years’ study in the
preparatory and elementary courses, would be capable of esti-
mating the value of any medical production put into their
hands, and yet ‘ in order to ascertain in what respects Doctor
Turnbull’s practice differed from that which is general in the
profession,” we are gravely informed by the editors of the
Edinburgh Journal, that they “ studied the most recent and
approved works on aural surgery.” Such discussions with non-
medical persons should be avoided as much as possible, they
tend to no good, and were it not our conviction that Mr.
Chambers, for whom we entertain the highest respect, has been
made the dupe of Dr. Turnbull, we would not have alluded to
the subject. Had the Editor known anything of the structure
of the parts he is attempting to describe, he would have been
better informed than to publish an account of an analogy be-
tween the ceruminous.glands in the external meatus, and the
mammary gland in the female; for in the article to which we
allude he says: ‘ Finding cured persons relapse in consequence
VOL. XXV. NO. 75. 3M
446 Mr. Wilde on the early Eistory of aural Surgery, &c.
of the defect of wax, Dr. Turnbull was prompted to use his in-
genuity in endeavouring to discover a means of sustaining that
secretion. He reflected that the application of the mouth of the
child to its mother’s breast, by removing the pressure of the at-
mosphere, causes the milk immediately to flow, and he conceived
that a similar result might follow with respect to the wax of the
ears, if he could by any means remove the pressure of the atmos-
phere from the external parts. For this purpose, he at first
used a syringe with an Indian rubber mouth exactly fitted to the
aperture of the ear.” Now the veriest tyro in medicine knows
that it does not depend on any atmospheric pressure, but 1s
owing to a morbid action in these follicles themselves that the
ear-wax is not secreted. In fact they are, if there be any ana-
logy at all in the case, in something of the same condition that
the flow of milk, and the mammary gland are in, in females not
giving suck. But as we fear we would not be understood, we
cannot stop to explain to this non-medical editor the difference
between the funtcions and processes of secretion and excretion.
Would any other but a non-medical person be absurd enough
to suppose that the application of an exhauster to the nipple
would produce a secretion of milk : or cause a flow ofmilk, unless
such had been already secreted in the lactiferous tubes? But yet
we read—< the plan was successful ;” and the reason assigned is,
because “ the blood-vessels resumed a free circulation, and the
flow of wax recommenced.”
Again, we learn that “ the clearing of the Eustachian tube,
for which no means formerly existed but the application of me-
dicine to the bowels, or the dangerous use ofa catheter, was
affected by Dr. Turnbull by the same simple means.” Well
may the friends and admirers of the Russell-square professor
employ the term dangerous, for the only record of any accident
or ill effect having arisen from the employment of this exceed-
ingly simple and harmless operation, occurred to Dr. Turnbull
himself, two of whose patients, in the year 1839, fell victims to
 Mr. Wilde on the early History of aural Surgery, &¢. 447
the operation of catheterism of the Eustachian tube, and on
both of whom coroner’s inquests were held. One of these, it
appeared in evidence, was, almost immediately after the opera-
tion, attacked with emphysema of the throat and inflammation
of the brain, of which he died in a week; and the other, a lad,
named Joseph Hall, aged 18, and in perfect health, “ fell back
in the chair apparently lifeless, and never spoke afterwards.’*
In the first of these cases it appears most likely that the emphy-
sema was caused by the instrument rupturing and tearing the
mucous membrane; and in the second, in all probability, the
death was caused by the shock or concussion given to the base
of the skull by the volume of compressed air,—for where the
mouth of the catheter was we know not, After this it seems the
Doctor changed his hand, and finding that it was rather a
“‘ dangerous” experiment to “ blow up” his patients, determined
to suck them as much as possible; and, in order to effect this,
Mr. Chambers informs us, that by means of an air-pump, in
connexion with a small glass tube, “ introduced into the mouth
of the patient,” and consequently behind and above the soft pa-
late! “and applied to the orifice of the Eustachian passage,
communication is opened between the previously rarified air in
the receiver and the orifice, from which a discharge of mucus is
soon made into the tube, which is then withdrawn.” 2
But we
cannot discuss further those matters with a person who speaks
of the “ vibrations of the tympanum!” With one word more
let us dismiss this subject of Dr. Turnbull and his review ;—a
word worthy of consideration to those Who may be induced by
the article, to which we allude, to submit their deaf mute friends
or relatives to useless pain and profitless experiment. It is this:—
Were the miraculous cures of the Saviour performed on cases or
diseases that art, either then or now, could have remedied ?—
could remedial agents, or man’s interference, have raised the

* Lancet, July 6, 1839, + See Chambers’ Journal, No. 519.

448 Mr. Wilde on the early History of aural Surgery, §¢.
dead—thrown instantaneously the vigour of youth, and the health
and strength of manhood, into the limbs of the cripple—given
power to the parylitic—steadiness to the palsied—and calmness to
the possessed ; or have cooled the fevered—given sight to the blind
—speech to the dumb, and hearing to the deaf ?__If, without the
special interference of Providence, these individuals could have
been cured, then, in my humble opinion, they were not mira-
racles; but if without the pale of art, or beyond the power of
human means, then were they miracles, and cannot now be per-
formed but by similar means. That, however, the age of mira-
cles is again at hand, Mr. Chambers appears to have some idea,
for, no doubt aware of the instantaneous restoration of speech
and hearing to the deaf mute being one of the miracles assigned
to Christ, he concludes by saying: “‘ Every thing but trodden
who
out of existence,’ is, in one word, the fate of the individual
has been the first merely human being to cause the deaf to
hear.” But why discuss a question arising out of an assertion
to
as to the possibility of perfectly and instantaneously restoring
speech and hearing the congenital deaf mute, which all sober-
minded men in the community, save and except the Doctor and
his reviewers, deny?
Let us, in conclusion, inquire what the legitimate aural
practitioner in the present day is, and how far his art extends
over the regions of disease. FFirst, a practitioner in aural sur-
gery, or, if it pleases the public to call him an Aurist, in our
day must, or at least ought to be, in the first instance, a well-
educated] surgeon and physician, instructed in anatomy, phy-
siology, chemistry, materia medica, and the other elementary
branches of the healing art, who applies the recognized prin-
ciples of medicine and surgery to the diseases and abnormal
conditions of the organs of hearing, in the same manner as the
modern ophthalmic surgeon does to the diseases of the eye.
With regard to the second proposition, of how far our art ex-
tends over the regions of disease—we daily hear and read, and
 Mr. Wilde on the early History of aural Surgery, §c. 449
it has been reiterated from mouth to mouth, and copied from
work to work, that the treatment of diseases of the ear is an
opprobrium to the healing art, and without the pale of human
knowledge. To this objection against our art it may fairly be
urged, that notwithstanding the injudicious treatment prescribed
by quacks and nostrum-mongers; and, as in many instances, we
know it is, the total abandonment ofall treatment by the general
practitioner, still were the statistics of all our diseases carefully
collected, it would be found that there were among them as
many curable cases of affections of the ear, as there are among
the severer maladies of the eye, or among diseases of the chest,
the brain, the liver, or any other organ, the treatment of which
falls to the lot of either the physician or surgeon. It must, how-
ever, be admitted, that up to a very recent period, this question of
—‘ what can you do for deafness ?” might have been asked with
great justice, because, from the circumstance of well-educated
medical men in this country either considering it beneath their
station or acquirements to treat so insignificant an organ spe-
cially, or not finding in the direct cultivation of aural surgery a
sufficient remuneration for their time and talents, this branch of
the healing art has remained in that state in which ophthalmic
surgery was half a century ago—in the hands of charlatans
and mountebanks. All this, added to the smaller share of
sympathy afforded to the deaf than the blind, and to the circum-
stance of impairment of hearing interfering less with man’s
means of subsistence, and also to the fact that it is much more
easy to pawn cures of deafness than cures of blindness upon the
general public; besides the greater difficulty of minutely exa-
mining, either during life or after death, the accurate condition
of, or the morbid changes which occur in the middle and inter-
nal ear, serve to account for why aural pathology and aural sur-
gery have not kept pace with the other rapid improvements in
medical science, and why so few works worth reading have been
as yet written on the subject. Above all, the well-instructed
450 Mr. Wilde on the early History of aural Surgery, &c.
aurist of our time possesses a knowledge and a power which is
not general among the Profession—of making an accurate diag-
nosis, which, when given with honesty, will frequently save the
patient much anxiety, loss of time and money, and often much
unnecessary suffering.
I offer the accompanying nosological arrangement of diseases
of the ear, defective as I know it is, more for the purpose of elicit-
ing inquiry, and asa basis for future investigations, than as pos-
sessing any great merit of its own.
To the difficulties attending all synoptical arrangements, we
have here to encounter additional ones, arising from the obscurity
of the parts affected, and the absence of definite pathological
knowledge with regard to many of the diseases of the organs
of hearing. And whether we attempt a classification, accord-
ing to the symptoms, as the means employed by Cullen and
Mason Good,—or whether it is based upon the pathology and
morbid anatomy of the tissues affected, as made use of by our
modern nosologists, the same difficulties beset us.
The first chart of aural diseases worth mentioning is that
arranged by Galen. It consists of five affections, viz.: otalgia,
baruckoia, kophotis, parakousis, and parakousmata ; but these
it is perfectly evident, were but symptoms, not diseases, and to
these he added, pain in the ear from cold, inflammation, and
“ex flatulento spiritu aut crassis et viscosis humoribus est ex
serosis et santosis humoribus.” |
The first attempt at an arranged nomenclature of aural dis-
eases in Great Britain was that by Buchanan in 1825, who, in
his ** Illustrations of acoustic Surgery,” endeavoured to classify
those affections according to the parts affected, but his diseases
are mere symptoms. It consists of three orders, twelve genera,
and thirty-three varieties ; that, however, this division is most im-
perfect, nay, in some respects positively absurd, may be learned by
an examinationof his fourth genus alone, styled, “ Impedimentum
Eivternum,” or obstruction of the external meatus, under which
 Mr. Wilde on the early History of aural Surgery, &c. 451
he enumerates four species, each resulting from causes totally
different, and quite unconnected with one another, viz.: ‘Jm-
pedimentum Extraneum, from extraneous substances; Jmpe-
dimentum Induratum, from indurated wax; Impedimentum
Polyposum, from polypi ; and Impedimentum Excrescens, from
excrescenices !”
Kramer seems to follow this classification in some respects,
in his division of the diseases of the external, middle, and in-
ternal ear; but this method had been long before attempted by
Du Verney. Kramer makes seven sections, viz.: diseases of
the auricle, of the external meatus, and of the membrana tym-
pani; inflammation of the mucous membrane, of the cellular tis-
sue, and periosteum of the middle ear; and two forms of ner-
vous deafness, the erethitic and the torpid. The inflammations,
which are those diseases on which his work principally treats, he
divides into those affecting the various tissues, as the cellular, the
mucous, and the fibrous; but there are many, and very formid-
able diseases too, on which he is perfectly silent.
Mr. Wharton Jones’s arrangement* is entirely an anatomical
one, consisting of two parts, viz.: the diseases of the accessory
organs of the apparatus of hearing,—and the diseases of the fun-
damental organ of hearing, ear-bulb, or labyrinth, with the mi-
nute sub-divisions of both these portions.
Mr. Williams does not attempt any classification whatever,
and Mr. Pilcher’s work is likewise defective in this respect; his
arrangement, if such it can be termed, being a simple enumera-
tion of aural affections, divided into, the abnormal conditions or
malformations; otitis, or acute inflammations ; chronic diseases
of the ear; and nervous diseases of the ear.
Lincke is by far the best modern classifier; he makes three
divisions—first, inflammations of the organs of hearing; second,
affections caused by solution of continuity; and third, affections

* See Article ‘Ear and Hearing, Diseases of,”’ in the Cyclopedia of Surgery,
part ix.
452 Mr. Wilde on the early History of aural Surgery, §¢-
caused by cohesion of parts; but he does not classify the dis-
eases of the sentient portion of the auditory apparatus, or ner-
vous deafness. We hope to see a third volume from this author
on these most obscure forms of disease.
I have retained the original terms in order to preserve a
tabular arrangement which I have here attempted. His first di-
vision contains two sections, the simple and the complicated, and
the former is again-subdivided according to the locality, as:
FIRST DIVISION.
Inflammations of the Organs of Hearing.
Sec. 1L—Stmple. Sec. I].— Complicated and specific. |
Outer Ear. “ Attritus Auricule. Otitis, Erysipelatosa.
Erythema Auriculee. 5 Catarrhalis.
Inflammatio Auricule Phleg- » Gonorrhoica.
monosa. » Rheumatica.
Pernio Auricule, a frigore. , Arthritica, s. Otagra.
Inflammatio Meatus Audi- »» Scrophulosa.
torii. 5» syphilitica.
Inflammatio Membrana Tym- »5 Morbillosa.
pani (Myringitis). », scarlatinosa.
Middle Ear. Otitis Universalis » Variolosa.
s. interna totalis. 5, Eczematica s. Crusta Lac-
Inflammatio Tube Eustachi- tea.
ane (Syringitis). »» . Herpetica.

SECOND DIVISION.
A ffections caused by Solutions of Continutty.
‘Contusio Auriculz.
Vulnera Auricule.
Fractura Auricule.
Vulnera Membrana Tympani.
Vulnera Totalis Auris.
Coloboma Auricule.
Foramina Membrane Tympani.
 NOSOLOGICAL TABLE OF THE DISEASES OF THE EAR.

|
MecuanicaL INJURY.
f { Incised. Circumscribed— Abscess.
Wounps anpD INJURIES, . Lacerated. a Acute, . ij |Diffuse.
Contused— Fractured. INFLAMMATION, lChronic.
With Granulations.
ALTERATION FROM PRESSURE,. . . +. - =s - Meitchne OPaAcITY
Sloughing. MEMBRANE OF TYMPA- CoLtapsE, witH sHORT HEARING.
NUM. Loss oF VIBRATION.
{ Phlegmonous. PERFORATION.
e | Erysepelatous. ULcERATION.
INFLAMMATION, ee.) C(eCSC«w SS s«*Furuncular. Morsip Deposits IN.
hone bitten.— Chilblain. Mem. Tym. wanting.
Specific—Gouty. ConGENITAL MALFORMATION, | covered byafalse Membeane.

Herpes. INJURIES OF.

AFFECTIONS OF THE SKIN, _ |Bes Acute.
DISEASES OF THE AURICLE Pemphigus. Catarrhal.
AND MASTOID PROCESS. HyprertTropny. INFLAMMATION, Rheumatic.
CANCER. Chronic.
he ay Encysted. With thickening of mucous Membrane.
, Specie
Sypuintitic ULCERATION. INFLAMMATION oF Masror1p CELLs.
Navus. Specific.
INFLAM. OF PERIOSTEUM. eae.
oF Mastorp GLAND. DISEASES OF THE OrorrHa@a INTERNA, . ~ With morbid growths.
Masrorp Procts.d goo ABSCESS ON Caries — Ear.
MIDDLE EAR
CaRIEs. AND CAVITY OF TYMPANUM.. = Meningitis or Cerebritis.
( Imperfect Development. EUSTACHIAN TUBE.
" M Auricle wanting. Polypus.
ONGENITAL MALFORMATION, . . . ; ° douhic. Fungus.
Morsip GrowTHs, . Osteosarcoma.
cleft.
Ossification of Fenestre.
Wouwnps AND INJURIES.
ForEIGN Bopliss IN. IncrEasED Mucous SECRETION IN.
Collapse. EXTRAVASATION OF BLoopD IN.
. « stricture. Loss or THE OssIcULA.
ALTERATION IN TUBE, |
Dilatation. ANCHYLOSIS OF OssICULA.
Ossicula wanting.
[ ConGENITAL MALFORMATION Fenestre wanting.
|Cirecumscribed.
; pee Pate Diffuse.
ae
Chronic. Catarrhal.
INFLAMMATION, Rheumatic. | INFLAMMATION, Syphilitic.
eet Chronic, with thickening of mucous Membrane.
Specific—Gonorrhceal.
Stricture.
Herpes. EUSTACHIAN TUBE. . Mucus.
OssTRUCTION—FROM Enlarged Tonsils.
Thickening of Cuticle.
AFFECTIONS OF THE SKIN, Morbid Growth ofCuticle. Thickened and relaxed Membrane.
Aphthous Ulcers. |DILATATION OF,
- Myrineitis. |Foreign Boptss IN.

OF THE EXTERNAL
orCatarrhal. Tube wanting.
Concentra Marrormarion, ¢3 ——
DISEASES Simple purulent. imperfect.
MEATUS. lis 7 - Polypus or fungous Growths. l
- «+ Granular Membrana Tympani. { Mecuanica InJury, Fracture of petrous portion of temporal bone.
OrorrH@A EXTERNA, =
Caries. |INFLAMMATION.
Perforate Membrana Tympani. ( Erethitic form.
External Fistula. Torpid form.
Nervous DEAFNESS,. . From cerebral Disease.

as Polypus. Mercury.
Morsipv GrowTHs, Bony Tumours. |Otalgia, from disease of acoustic Nerves.
| Funevs Ha&maropgs.

as=
|Acute. DISEASES OF THE INTERNAL EAR. OsTEOSARCOMA,
Cerumen, increase of. Chronic ; Cartes.
s or Ceruminous GLANDS
: deficiency of. Auditory Nerves atrophied or wanting.
aDraeee alteration of.
Concenirat ManrorMaTIoN < Labyrinth deficient, . wiel.

i
ULcErRaTION.
Polypous Excrescence in. Labyrinth filled with caseous Matter.
Closed by false Membrane.
ConcENITAL MALFORMATION, . ,. Meatus wanting.
Dear
With congenital Malformation.
contracted. DuMBNESS . . . 4 Without apparent Defect.
[ To follow p. 454.

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 Mr. Wilde on the early History of aural Surgery, §c. 453

THIRD DIVISION.
Affections caused by Cohesion of Parts.
« Dilatatio Meatus Auditorii.
Structura Meatus Auditori.
Compressio s. Thlipsis Meat. Aud.
Collapsus Meatus Auditorii.
Atresia s. Obliteratio Meat. Aud.
Dilatatio tube Eustachii.
Strictura tubs Eustachii.
Obturatio tubz Eustachii.
Collapsus tube Eustachii.
Obliteratio tube Eustachii.
Imperforatio tube Eustachii.
Sr ure Aneurisma et Varix Auriculee.
Cirsomyringa.”*
I am indebted to this enumeration of Lincke’s for the first ac-
count of some of the diseases I have introduced into the accom-
panying Nosological Table; yet, with few exceptions, they have
all passed under my own observation, and I have not admitted
any but upon my own personal knowledge, or on authority of
undoubted veracity. To enter minutely into the description of
this chart, or the position given to each disease in it, would be
trenching on a subject not intended to be included in this essay.
In fact it explains itself. ‘The nomenclature, as far as it was
possible, has been reduced to English, except in such terms as
“hypertrophy” and ‘‘ naevus,” &c. The term Myringitis is em-
ployed to signify inflammation of the external layer of the mem-
brana tympani, and is therefore placed among the affections of
the external meatus. The description of the rarer forms of aural
disease, as those now, for the first time, brought before the pro-
fessional public, I must reserve for another opportunity.
semen CS

* Handbuch der theoretischen und practischen Ohrenheilkunde,—von Dr. Carl

Gustav Lincke. Zueiter Band. Die Nosologie und Therapie der Ohrenkrankheiten.
Leipzig, 1840.
VOL. XXYV. NO. 79, 3.N
454 Mr. Wilde on the early History of aural Surgery, §c.
It may appear strange that tinnitus auriwm, or noise in the
ear, is not enumerated among the affections specified in this
classification ; but I have long since convinced myself that it 1s
but a symptom, and not a special disease; and so variable an
attendant is it, that like musce volitantes in the eye, which it
very much resembles, we cannot, as yet, accurately determine
what are the particular morbid states which is symptomatic of
it, or accompanies, The value of tinnitus aurium, as a means
of diagnosing diseases of the brain and diseases of the ear, as
well as the peculiarity of the sensations accompanying certain
morbid conditions of these organs, would form a very valuable
addition to our pathological knowledge.
 BIBLIOGRAPHIC NOTICES.

Remarks on the Use of Vivisection as a Means of scientific

Research ; ina Letter addressed to the Earl of Caernarvon,
President of the Society for preventing Cruelty to Animals.
By Ricuarp Jameson. 1844, Pamphlet.

Tuis is a very clever letter, defending the expediency of per-

forming experiments on living animals to elucidate physiology
and surgery, and to improve the manual dexterity of the surgical
operator. It was written in consequence of the Society for the
Prevention of Cruelty to Animals having passed a severe cen-
sure on those members of the Profession who had performed
experiments on live animals. We cannot wonder, where the
utility of the end is often so obscure, that the casual observer
should view with disgust and abhorrence the mutilations which
the practised physiological investigator performs, with such ap-
parent sang froid, on animals that have such claims on our
sympathies—as the faithful dog or the noble horse—when, even
to those who see clearly the end and aim of those slicings of the
brain, those prickings of the nerves, those incisions down to lungs,
heart, or intestines, the sight is repugnant, and the science of
medicine appears in a garb far from attractive, when it demands
the sacrifice of such hecatombs of poor, inoffensive brutes, by
means which would appear to the uninitiated wanton devices of
cruelty to increase the natural pain attending dissolution, by
wounds short of death, by tearings and breakings of limbs, by
starvation, or the exhibition of deleterious food, and by the ex-
cruciating tortures of poison. But most men of science will
allow that medicine has been materially benefited by experi-
ments on living animals, and that Cooper, Harvey, Haller, Hun-
ter, and others have arrived at important truths by such means,
unattainable by any other. But while we allow this, and fully
agree with Mr. Jameson, that bad as the means may seemingly
be, they are often fully justified by the aim to be attained, we
cannot but feel, that, in Paris especially, it has been overdone,
and that the return has not been commensurate with the outlay
456 Bibliographic Notices.
of animal suffering and animal life. And though the Society
for the Prevention of Cruelty to Animals have gone rather far,
as most enthusiasts do, yet as enthusiasm generally obtains some
portion of its object, so this Society will doubtless have some
effect in making the ignorant pause before they cut.
Mr. Jameson isa very hard hitter, and we think our readers
will not fail to be amused with the manner in which he handles
the Rev. Mr. Styles. With regard to the great exaggeration
of the number of experiments performed on living animals, he
says:
“Foremost in the list of exaggerators, I must place the Rev.
John Styles, D.D. He is the author of an Essay which gained a
prize of £100, as being the best out ofthirty-four papers sent into the
Committee of your Society, and may, therefore, fairly be regarded
as the chosen champion of its cause; I shall bestow as much space
as the limits of this letter will allow, in exposing some of his most
glaring misrepresentations. But few words are necessary to do this,
for the statements refute themselves by their very absurdity.
« He informs the public, ‘ that every surgeon’s apprentice thinks
himself entitled to find his way into the arcana of nature, by scalping
cats and rabbits to see where their brains lie. * The transactions,’
he adds, ‘ of the college of the medical craft in this sense would con-
yict them before a convocation of Ashantees.’ Very likely—and
why? Because the Ashantees, like Dr. Styles himself, are unable,
from ignorance of physiology, to appreciate the end for which vivi-
sections are employed. Supposing that the Ashantees would be
shocked at experiments on living animals, how much more horrible
would they think a surgical operation performed on one of them-
selves! What needless cruelty to wrench a fine firm tooth out of a
poor child’s jaw; or stab him in the arm with a poisoned weapon;
or make a gash in the thigh of a man who has only a little swelling
behind his knees; or, when a person has been stunned by a fall, what
wanton barbarity to cut his scalp and saw off a piece of his skull!
‘How could such cruel experiments answer any good end?’ would
be the wise remark of some Ashantee Doctor of Divinity.
“ Where Dr. Styles collected his information about the ‘sur-
geon’s apprentices’ I know not, but it looks exceedingly like a hoax
practised on his credulity by some waggish student, who thought to
satisfy the Doctor’s love of the marvellous, by telling him horrible
stories of ¢ what they did at the hospital.’ I will give one or two
proofs how excessive his credulity is. He gravely asserts, that
‘oxen are compelled to travel for many days without food, thei
hoofs worn off, and on bleeding stumps.” He might just as well
have said at once, ‘with their heads worn off.” The only instance
at all parallel to this of the hoofs, is to be found in the ¢ Surprising
Life and Adventures of Baron Munchausen.’ He had a famous
greyhound that ran till he wore his legs away, but was not useless
even then, for being a staunch dog, says the Baron, he made a capital
pointer.
 Mr. R. Jameson on the Use of Vivisection. 457
_ “ Again at page 128, we are told that ‘the hippopotamus or
river-horse, which, when overcharged with too great a quantity of
blood, strikes himself against the point of a sharp reed until he has
bled sufficiently, and then rolls into a particular kind of mud until
the bleeding is staunched, supplied the ancients with the original idea
of phlebotomy.’ An animal whose hide is proof against a bullet,
bleeding itself with the point of a reed!!
“ But not content with single absurdities of this kind, the Doctor
groups into one sentence a whole cluster of them. Speaking of the
small amount of pain inflicted by preedacious animals upon others, he
says: ‘they obey an instinct which destroys the life of their victims
at the least possible expense of pain. It is usually in the night-time
and in the hour of sleep that they sink under the fangs of their de-
stroyers; twenty strokes sent home in one instant to the sources of
life afford no time to reflect that they are about to lose it.’ If Dr.
Styles had studied the animal creation before writing about it, or if
he had kept his eyes employed as he walked in the fields, or even if
he had only sat by the fireside and watched his cat, he never would
have written such nonsense as this. Do hawks and kites kill sleep-
ing birds, or foxes sleeping rabbits, or swallows sleeping insects, or
do spiders subsist upon somnambulent flies? Had the Doctor’s cat
depended for her sustenance upon sleeping mice, who, while in that
state, are always in their holes, she would have fared but poorly.
And when she does catch a mouse, is its life destroyed ‘at the least
possible expense of pain ??
‘¢ But one of the Doctor’s greatest exaggerations, and one which
most appropriately belongs to this the first division of my subject,
relates to the number of animals experimented upon. Not only does
‘every surgeon’s apprentice’ think himself entitled to destroy them,
but ‘in this country many thousands of animals of all descriptions,
from the worn-out horses and asses regularly bought for the purpose,
to the most minute insect, are dissected alive.’ This is a very vague
way of talking: it is easy to say—‘ many thousands ;’ but I do not
believe that one thousand animals, large and small, are used for vivi-
section in the course of the year throughout Great Britain. But as
the Doctor is so fond of great numbers, I will just remind him that
King Solomon, his pattern of humanity, killed in one day twenty-two
thousand oxen, and as many sheep. These animals, it will be said,
were killed to the glory of God. And, I ask, do not the discoveries
of physiology advance his glory °”
Mr. Jameson gives a slight cut or two at Mr. Drummond,
whom, however, he lets off rather easily, as he also does Mr.
James Macauley, another essayist on cruelty to animals, This
last writer derives his chief strength from numerous quotations
from the Scriptures; and we shall see by the following quota-
tions how Mr. Jameson disposes of him and King David at the
same time:
‘““Tt is remarkable that among oD the numerous passages
oD
which Mr.
458 Bibliographic Notices.
Macauley cites from the writings of King David, there is not @ single
precept* which enjoins humanity to brutes! All the quotations from
the Psalms are descriptive either of God’s power over the animal
creation, or of the cruelty of men towards each other.
He demonstrates the incorrectness of the popular notion of
the sensibility of insects:
«© See a child catch a ‘ daddy-long-legs ;? the insect escapes by
leaving a leg or two in his pursuer’s grasp; and an instant after ob-
serve the mutilated animal feeding as quietly as if nothing had taken
place. The ichneumon fly deposits her eggs in the body ofa living
caterpillar : the young are hatched there, and the caterpillar conti-
nues to feed uninterruptedly while the intruders are actually devour-
ing its living tissues.”
« To ascend from insects to animals whose nervous system is more
completely developed—to birds and quadrupeds. Here, no doubt, as
they are subject to fewer casualties, and are furnished with more
perfect means of escape, we find an increased susceptibility of pain.
But how absurd to pretend, even in these creatures, that the pain
resulting from surgical operations is as great asin man! How tri-
fling comparatively is the mere physical pain of an amputation to that
eaused by the anticipation of it, or by the consideration of its re-
sults! Contrast the situation of an idiot who has lost a hand, with
that ofa surgeon or an artist similarly mutilated. Would Raffaelle
or Michael Angelo, or any other great painter, have grieved over the
mere severing of so many inches of bone and sinew; or would not
the feeling that from henceforth all his glorious conceptions—all the
visions of grandeur and beauty on which he had mused for years—
must fade away for want of the power to embody them, have caused
a pang infinitely more severe than any bodily torture? What would
have been the state of mind of John Hunter, brooding over a vast
system of physiology, and trusting to his industry and manual skill to
work out and prove all his theories, if compelled to lose his right
hand? The idiot and the brute no doubt suffer from wounds, or
from the various causes which may bring about their death, but, as
Dr. Styles observes (and for once he is right), ‘that fatal moment is
not embittered to them by any of the feelings which render itso
painful to most of the human race, regret for the past and solicitude
about futurity. They feel the pang of nature but not of mind.’ ”
Mr. Jameson then exposes the popular fallacy of most of the
writers of the Society, that wounds of the brain are painful,

* “ The practice of this monarch was notoriously the very reverse of humane.
When he conquered the Syrians, he ‘houghed all the chariot horses.’ (2 Sam. viii. 4.)
Nor was he less cruel to his human captives: ‘ Whosoever getteth up to the gut-
ter and smiteth the Jebusites, and the /ame and the blind, that are hated of David’s
soul, he shall be chief and captain.’ (2 Sam. v. 8.) ‘ And he brought out the people
that were in it (Rabbah) and cut them with saws, and with harrows of iron, and with
axes.’”? (1 Chron, xx. 3.)
 Mr, R. Jameson on the Use of Vivisection. 459
and mentions a case related by Sir C. Bell, where after a pistol
ball had passed through a man’s head, he could enter the fin-
gers deep into the anterior lobe, without the patient complain-
ing of anything but of the integument, But is not this integu-
ment always more or less extensively divided, particularly in
experiments on the cerebellum? The truth is, perhaps most of
the experiments on animals are necessarily attended with much
suffering to the poor brutes, those by poison especially so; we
look, therefore, on this ground of argument, adopted by Mr.
Jameson, as very weak ; it is much preferable to allow that much
pain and misery are inflicted in the great majority of cases, and
to rest their apology on the only true ground of defence, that
of the great benefits afforded by them to mankind.
Let us see how he treats another of the writers opposed to
Vivisections :
“A paper-war on the subject of vivisection has, I perceive, been
carried on for some time in the pages of the London Medical Gazette.
Among the most violent of the anti-vivisectors is a Dr. Hull, who
deals about his blows with the blind fury ofa raw recruit, rather
than the steady skill of an old soldier. He calls those who make physio-
logical experiments by some very hard names; they are ‘diabolical,’
‘savage,’ ‘infernal,’ ‘damnable ;’ and he quotes as a great authority
a Mr. Mac something, ‘a surgeon of operative and literary fame,
who has been long impressed with the inutility of vivisections.” Nei-
ther the fame of Dr. Hull, nor of his friend, has yet reached the city
where [ am now writing, and I must be excused for the present if I
prefer to either of these gentlemen’s opinions, those of Harvey, Hal-
ler, Hunter, Bell, Dupuytren, Cooper, Orfila, and Hope, who have
all declared (and proved) that vivisection was absolutely necessary to
enable them to attain the important objects of their research. Ano-
ther in the Medical Gazette recently quoted a number of the Idler
against vivisection, as if the opinion of Dr. Johnson could be of the
smallest weight on the subject of which he was utterly ignorant. The
following are some of the passages quoted :
“* Among the inferior professors of medical knowledge is a race
of wretches, whose lives are only varied by varieties of cruelty, whose
favourite amusement is to nail dogs to tables and open them alive;
to try how long life may be continued in various degrees of mutila-
tion, or with the excision or laceration of vital parts; to examine
whether burning irons are felt more acutely by the bone or tendon; |
and whether the more lasting agonies are produced by poison forced
into the mouth or injected by the veins’ . . . . ‘he that burned
an animal with irons yesterday, will be willing to amuse himself by
burning another to-morrow.’
‘“‘ Here we observe the common fallacy of unscientific writers on
the subject of vivisection—that those who practise it do so ‘for
amusement ! Of course any persons who could derive the slightest
gratification from inflicting pain, either on their fellow-men or on
460 Bibliographic Notices.

the lower animals, would be most justly stigmatized as ‘wretches :’

but where are such monsters of absurdity to be found amongst medi-
cal men? At the very time that Johnson, like a ¢ good hater’ as he
was, composed the 17th No. of the Idler, Haller (at least as good,
as conscientious, and as pious a man as Johnson himself, and cer-
tainly not one of ‘ the inferior professors of medical knowledge’) was
engaged in a series of experiments on living animals, perhaps the
most extensive that has been ever performed; aud was laying the
foundation of that system of patient investigation and impartial re-
search which has produced such important results, and has raised
medicine from rude guess-work to the rank of philosophy.
«JT revere the memory of Dr. Johnson, but I do not love his
his
faults; nor can all my admiration of his independent character,
ty, and honest warmt h of
noble self-reliance, his unflinching integri
heart, make me forget that he was of all bigots the most prejudiced,
of all controversialists the most obstinate and virulent.”
In favour of his favourite position, Mr. Jameson next goes
on to prove that some of the most extensive experimenters on
animals were men of undoubted piety, as Haller, Robert Boyle,
Rev. Stephen Hales, Dr. Durham, and the famous Boerhave,
“a firm believer in the revelations of Christianity,” and lastly
Dr. Hope.
«J wish as much as your Lordship or any member of your So-
ciety that there were no such thing as pain in the world; but we
must take the world as we find it, with its good and its evil, its pain
and its pleasure, its joy and its sorrow, endlessly mingled and alter-
nating. A golden age such as Dr. Styles describes, in which beasts
of prey and the weaker animals lived together in harmony, could no
more have had an actual existence than those ‘impenetrable scales’
with which his liberal imagination has encased the whale.
« We judge of God’s will by his works, What we see done we
conclude he willed to be done. Now if we contemplate his works
in Nature, we see a never-ending process of destruction and repro-
duction of life going on, the former frequently attended by pain.
Whether we regard the great destroyer man, incessantly taking
away the life of other creatures to support his own, or the beasts of
prey roaming the desert and the forest, or the countless tribes of
fishes devouring those weaker than themselves; or when, as the in-
sect tribes escape our search by their minuteness, we aid our sight
with the microscope, and see that the very film that floats.on the
stagnant pool is one scene of slaughter and devastation; whichever
way, in short, we turn our eyes, we must be convinced that the
amount of pain in the world is great beyond calculation.
«© What is it that reconciles us to all this but a conviction that
it is necessary? and that this seemingly wanton waste of life is, in
reality, a most wonderful provision for preserving organic matter with-
in the limits of the animal kingdom, and thereby economizing, as it
were, Nature’s strength and resources? This is well stated by Pre-
 Mr. R. Jameson on the Use of Vivisection. 461
fessor Owen in his recently published Lectures on Comparative Ana-
tomy, where he speaks of the important office which the infusoria
perform ‘in preventing the gradual diminution of the present amount
of organized matter upon the earth. For when this matter is dis-
solved or suspended in water, in that state of decay which immediate-
ly precedes its final decomposition into its elementary gases, and its
consequent return from the organic into the inorganic world, these
wakeful members of nature’s invisible police are every where ready
to arrest the fugitive organized particles, and turn them back into
the ascending stream of animal life. Having converted the dead
and decomposing particles into their own living tissues, they them-
selves become the food of larger Infusoria, as the Rotifera, and of
numerous other small animals, as fishes; and thus a pabulum, fit for
the nourishment of the highest organized beings, is brought back by
a short route from the extremity of the realms of organized mat-
ter”
The next argument Mr. Jameson expands upon is the de-
gree of necessity which exists for these vivisections, to acquire or
impart knowledge. ‘The first example is that of Hunter, who
performed numerous experiments on dogs before he ventured
to perform the operation for the popliteal aneurism, now gene-
rally used, viz., tying the vessel at a distance from the tumour.
Sir Astley Cooper also, before tying the aorta in man, operated
several times on dogs, he also ascertained by numerous expe-
riments on animals, the exact process of union in broken bones,
and the causes which principally retard it.
‘¢ IT have yet to notice another illustrious example of talent and
industry, who has employed vivisection to a greater extent than per-
haps any of his contemporaries: I mean Professor Orfila. The ob-
jects which he, and others who laboured in the same field, had in view
were these:
“‘ Ist. By carefully and repeatedly observing the effects of poisons
on living bodies, to ascertain with precision what organ or set of or-
gans were specially affected by certain substances:
“ QIndly. To determine what antidotes would best counteract
such poisons, and how these antidotes could be most efficiently admi-
nistered :
“ 3rdly. To apply the knowledge thus obtained to cases where
death might occur under suspicious circumstances; and to ascertain,
by post mortem examinations, and the use of chemical tests, whether
poison had been administered,and, if so, what the nature ofthe poison
had been: points of the utmost possible importancein a legalinquiry,
as involving the life of a fellow-creature who may have been falsely
accused of murder.
-* I bring forward experiments of this kind the more readily, as
they determine at once the question of the lawfulness of vivisection,
by proving that the end for which they were instituted was a great
and important good, and attainable by no other means. These ex-
VOL, REV: NO: (Ds 30
462 Bibliographic Notices,
periments were nearly all painful, many acutely so, and lingering in
their operation: if wantonly employed, therefore, for mere curiosity
or for amusement, they would have been frightfully cruel. But what
has been the result? I refer in answer, to the treatment of persons
poisoned, as it existed even at the commencement of the nineteenth
century, contrasted with that of the present day. With what happy
promptitude in one case is the stomach-pump applied, instead of time
being wasted, and the patient at last sacrificed by relying upon sup-
posed antidotes; and how certainly, in another case, does the physi-
cian employ the means which chemistry has furnished him to neutra-
lize the deadly drug! To experiments on animals carefully conducted
and repeated over and over again, and to nothing else, can we attri-
bute the happy change from the fruitless trifling of the old herbalist
to the energetic practice of the modern physician.
‘¢ In alate number of the ‘ Quarterly Review,’ the illustrious writer
whose experiments I have alluded to is mentioned in a note, as hav-
ing ‘sacrificed the lives of 10,000 animals in the course of his re-
searches into the actions of poisons,’ and he is accordingly classed with
what the Reviewer is pleased to call ‘the Frenchified, butcherly
school of anatomical experimenters.’ I should like to know how
many thousand lives have been sacrificed with no other object than
mere amusement, by those hard-riding gentlemen whose exploits the
Reviewer elsewhere takes such pains to celebrate. The man who
devotes years of study to learn how he may best alleviate the pain or
save the lives of his fellow-creatures, is called a‘butcher’ If he
had quitted his study for the field, had dressed himself like a moun-
tebank, and had ridden his horse to death, or had killed ten times
ten thousand hares and rabbits, the Reviewer would have seen nothing
wrong in his conduct, and instead of a ‘butcher,’ would have styled
him ‘a gallant sportsman,’
«© The whole question of the lawfulness of the experiments of Or-
fila and others, is well stated by Sir David Barry, who devoted much
time and labour to an inquiry into the actions of poisons on living
animals, with a view to improve the treatment of poisoned wounds.
‘ Others,’ he says, ‘talk of needless cruelty. If any useful knowledge
is to be obtained by an experiment, none of the means necessary to
arrive at that knowledge can be useless, and none else can be adopted
without defeating the purpose aimed at; therefore, in useful experi-
ments, there never is needless cruelty, or, in other words, unnecessary
pain inflicted.’ ” 3
The importance of vivisection in physiology is next insisted
on, and to the opinion that the performance of any experiment
once is sufficient, and that it will do others to have the results
stated to them, he objects:
«‘ Thousands of dead bodies have been dissected, and there are
anatomical works without end which contain the results of such dissec-
tions, and yet each student has to go through the same processes, to
impress things on his memory. So if there be any thing seen on
opening a living animal which is important to be seen and to be re-
 Mr. R. Jameson on the Use of Vivisection. 463
membered, each must use his own eyes, and not content himself, any
more than in questions of human anatomy, with the written reports
of others,”
After considering its importance to the surgeon previous to
performing a great operation, he next objects to indiscrimi-
nate or careless use, and makes the following powerful remarks :
“In a passage which Dr. Styles quotes from Dr. Millengen’s
Curiosities of Medical Experience, the author says that vivisection
should not be made ‘a public exhibition or a student’s pastime.’ This
remark is most just. Among the precautions to be observed by the
vivisector, none is more essential than the avoidance of display. When
an important eid is to be gained (as was the case in the experiments
I have previously noticed, by Orfila, Dupuytren, Sir A. Cooper, Bell,
and others), the means indispensable to that end do not constitute
cruelty. In employing these means the experimenter is justified by
stern necessity, and, if duly impressed with the importance of his re-
searches, can no more feel an inclination towards display than a con-
scientious surgeon would during a critical operation. |
‘¢ Those who consider all infliction of pain on the lower animals
unjustifiable, may charge me with carrying the principle of expediency
too far, To such I would reply, by asking on what ground but the
supposed necessity to an end is the punishment of death tolerated in
the present day? The feeling of revenge, which originally prompted
it, is out of the question in a civilized community. It is inflicted on
offenders to deter others: ‘On ne corrige pas,’ says Montaigne, ‘ce-
luy qu’on pend; on corrige les aultres par luy.” Whether the pro-
posed end be really attained is doubted by many enlightened persons:
no doubt can exist, however, that the means are shocking, infinitely
more so than any vivisection of brutes. In killing the latter mere
pain is the result ; take the most agonizing process by which a crea-
ture’s life can possibly be extinguished, still it is so much bodily suf-
fering: we destroy a creature without moral sense, and incapable
therefore of doing right or wrong; we prevent no virtue in this life,
we hasten no punishment in another. :
‘¢ How different is the case of a criminal! Who can sayifhis life
were spared that he would not repent? It is not likely, perhaps, but
itis possible. He may have been seduced by evil example, the strong-
est temptation may have assailed him, he may never have had (how
often is this the case!) the benefits of education, If that education
and moral training were begun even now, his whole nature might be
changed, he might yet become a good and happy man: by killing him
you prevent all his possible virtues, you make him dve wicked. And
if we take the more solemn view of the question ; if we believe that
his future fate through all eternity depends upon his life here, what a
responsibility do we take upon ourselves! By making a change of
life impossible, we seal his everlasting doom.”
The natural repugnance one feels to inflict pain on the lower
animals is not a fair argument against these experiments, be-
464 Bibliographic Notices.

cause we feel an equal repugnance to inflict pain on our fellow-

men, and yet we perform the most painful operations, the scoop-
ing out of an eye for instance, convinced that by so doing we
purchase for the sufferer future benefit, far, far beyond the tem-
porary pain. Mr. Jameson concludes by dilating on this pro-
position : !
« That while necessity alone compels us to take away the lives of
animals, our accusers are daily accessory to their wholesale destruc-
tion, for the mere gratification of luxury, or as an amusement to
while away the passing hour.”
This tw quoque sort of argument is not exactly to our taste,
and, as we have said before, we would prefer taking the thing
on its merits or its necessity, than setting up a sort of oblique
defence by accusing the accusers of doing as bad or worse. Mr.
Jameson, with great talent, animadverts on the painful kill-
ing of animals for food; the mutilation of them to improve
their flavour; bulls and rams gelded, sows splayed, cocks con-
verted into capons ; geese confined to one spot close toa fire,
and stuffed with food, until a disease of the liver takes place,
which converts that organ into fat for patés de Strasbourg 5
turkeys crammed by main force; lobsters boiled alive, &c. He
vigorously attacks the inconsistency of the members of the
Society boasting of having put down bull-baiting and vulgar
pastime, while nothing is attempted against the nearly equally
cruel, but royal amusement of stag hunting. ‘*Did the poor
bull’s suffering arise from the social position of his persecutors
Or do you suppose the stag feels less agony because his tormen-
tors are lords and gentlemen? Prince Albert’s hounds bite as
sharply as the butcher’s bull-dog.” We should be happy could
we find space to present our readers with Mr. Jameson’s illus-
‘trations of how badly the patrons of the Society for the Preven-
tion of Cruelty to Animals, exhibit by their conduct the feeling
which their position would promise. Beginning with the Queen
(the chief patron) who baits hares with beagles, he then brings
forward the Duke of Cambridge, “ who killed with his own gun
about sixty head of game ;” the Duke of Devonshire and the
Duke of Buccleugh killing grouse, pheasants, and hares in
abundance; Lord F. Egerton, another patron, who gave the
clerks and agents in his employment a day’s coursing, when
they killed twenty-two hares. But we have made quotations
enough to convey some idea of the talent and interest of this
letter, and we shall therefore conclude with Mr. Jameson’s final
observations :
«“ Before I bring my letter to a close, allow me once more dis-
tinctly to repeat my declaration, that in charging your patrons with
 Dr. Rigby on Dysmenorrhea. 465
the grossest inconsistency and injustice, I do not mean to accuse
them of wilful oppression and tyranny. I have no doubt that the
hunters and shooters of Windsor and Chatsworth think they are
simply advancing the cause of humanity in punishing the baiters of
Westminster and cock-fighters of Hillingdon. The persecutors do
not see the wrongfulness of their own pursuits, simply because it has
never been fairly pointed out to them. The sportsman shoots and
hunts because his father and his friends hunted and shot before him ;
the possibility of his amusements being cruel has never once occurred
to him. Just so it was in Great Britain a century ago with respect
to slavery. Englishmen had been accustomed to buy and sell Ne-
groes just as they did pigs or poultry; and yet those Englishmen
were not perhaps worse people than their grandsons. Whitefield
(a sincerely pious Christian, if ever there was one) bought Negroes
and worked them, and at his death bequeathed them to— that elect
Lady, that Mother in Israel, that mirror of true and undefiled reli-
gion, the Right Honourable Selina, Countess Dowager of Hunting-
don.’ In his will the Negroes stand just midway between his ‘lands’
and his ‘books and furniture’! But one by one, and little by little,
men began to see that the slave-trade was wrong: Sterne said some-
thing, and Granville Sharp, and Clarkson, and Wilberforce, said
more, and at last most Englishmen were ashamed of what they and
their fathers had done as a matter of course; and now every child
will tell you that slave-dealing is a sin. When the thing was pointed
out to the people they saw it, but not before: having once clearly
seen it they can never lose sight of it again.
*‘ Ifthe Society over which your lordship presides be really anxious
to act up to its title, let it throw aside all that reverence for rank
which at present checks its efforts or renders them ridiculous, If
cruelty is to be punished, let it be condemned for its own sake, not
because its effects are sometimes painful to the beholder who happens
to have weak nerves: and let it be punished alike in all. In the
mean time, let the Society make a better use of its funds than to
give away a hundred pounds for an ‘ Essay on the Animal Creation,’
by one who is ignorant of the commonest facts connected with it.
Above all, let it beware how it attempts, by well-meant, but igno-
rant interference, to check the progress of a science, whose noble
aim it is, by mitigating disease, to prolong the lives, increase the hap-
piness, and promote the social welfare of mankind.”

On Dysmenorrhea, and other uterine Affections, in Connexion

with deranged Assimilation. By Dr. Ricsy.

In the short work before us Dr. Rigby has taken a good deal
of pains to shew an intimate connexion existing between de-
ranged assimilation and dysmenorrhoea, with some.of its conse-
quences and complications, Influenced by his admission that
466 Bibliographic Notices.
the investigation of the affections, to which his observations re-
fer, is still far from being so perfect as he could wish it to be,
we shall rest satisfied with laying before our readers some of
the points on which he particularly dwells, and for further in-
formation refer them to the work itself. It is divided into two
parts, the first being confined to a brief consideration of assimi-
lation with its derangements, and the effect of these, as evidenced
by a vitiated condition of the blood, and faulty secretion, with
an altered state of the functions of the skin and mucous mem-
branes. Into the details of these consequences of mal-assimila-
tion we shall not follow him further than to state, that having
shewn
“ That a very intimate connexion exists between the assimilation
of the albuminous principle, and the function of the mucous mem-
branes, it will be equally manifest that a healthy or unhealthy con-
dition of the one will determine a corresponding character of function
in the other. The secretion from those membranes is of a more or
less modified albuminous character, and experience shews, as a gene-
ral rule, that in mal-assimilation of the albuminous principle, this
condition of the mucous secretion usually holds a pretty exact cor-
respondence with the quantum of lithic matters discharged by the
kidney.”
Dr. Rigby further dwells on the altered state and action of
the mucous membrane, as remarked in the rheumatic and gouty
diathesis, wherein their circulation, but more especially the
venous, becomes much congested, and the membrane assumes
a relaxed, swollen, and deeply injected, even purplish appear-
ance ; at times coming on suddenly, and manifesting the same
erratic character as gout in other parts. As an illustration of this
he refers to attacks of gouty asthma. The occurrence of heemor-
rhoids he also adduces as a further illustration of the disposition
to congestion of the mucous membrane in these habits, with also
the increased secretion of an albuminous transparent mucus,
‘‘ particularly distinct in the rectum, and seemingly closely ana-
logous to the albuminous discharge from the cervix uteri and
vagina, in certain uterine affections.”
The great tendency in gouty habits of the mucous membrane
(but especially of the rectum) to secrete gas, is another point of
importance, which will be found to bear out the analogy he
wishes to demonstrate as existing between such gouty affections
consequent on mal-assimilation and the uterine affections, of
which we come now to speak. These he, “in default of any
more appropriate term,” designates uterine rheumatic gout,
meaning thereby to imply
“«¢ A certain series of local phenomena or symptoms preceded or
attended by a corresponding state of the general system; they are
 Dr. Rigby on Dysmenorrhea. 467
chiefly of a congestive or inflammatory character, or at least in some
degree resembling the phenomena of inflammation, being attended with
local vascular excitement ofa more or less acute nature, with the
chief features of inflammation, viz., heat, swelling, redness, and pain $
or of a chronic form, with much venous engorgement, swelling, indu-
ration, and ultimately alteration of structure. The first form is more
sudden in its attacks and recessions, more erratic in its movements;
the latter more gradual, but fixing on the part with a firmer hold,
and relinquishing it with proportional difficulty. The acute form is
usually seen in connexion with dysmenorrhceal attacks, or with the
uterine excitement which is generally observed in such cases, at the
half-way time between the menstrual periods. The other is mostly
attended by chronic leucorrhoeal discharge, and chronic or subacute
inflammation of the cervix uteri, followed by induration and organic
disease. If not arrested by proper treatment, the acute sooner or
later passes into the chronic form, in which case they may be looked
upon as different stages of the same disease. The majority, however,
of these affections are of a chronic or subacute nature; whether so
originally, or from the circumstance that the change from the acute
to the chronic form frequently takes place at an early period of the
disease, is not very easy to determine.”
Dr. Rigby’s experience goes to prove, that these symptoms
are mostly met with in systems more or less predisposed from
long continued dyspeptic and other gastro-enteric derangements,
not unfrequently, when the acute form is present, ushered in by
an attack of rheumatic fever or gout; or, the general diathesis
being gouty, by exposure to cold during a menstrual period or
an early abortion, constituting “in fact an attack of dysmenor-
rhoea ina gouty habit.” These are the cases in which exuda-
tions are now and then met with, but not necessarily so. The
cause of this exudation Dr. Rigby declares his inability to state
with certainty, but inclines to the opinion of its inflammatory
origin.
“If there be any fact,” he says, ‘“‘ which seems to be common to
all the cases of dysmenorrhcea which have been attended with exuda-
tion, it is the co-existence of some local inflammatory action ofa neigh-
bouring organ. In some it has been the kidney, in others (and on
the whole more frequently) the ovary, which may easily be presumed
from its close connexion with the uterus, and from the generally re-
ceived opinion of its being essential to the function of menstruation.
In others the os and cervix of the uterus itself have been the seat of
inflammation.”
The chronic form of this so called uterine rheumatic gout
is for some time, our author states, preceded by increasing de-
rangement of the assimilating functions, causing, as already al-
luded to, vitiated circulation, unhealthy action of bowels, with
468 Bibliographic Notices.
lithic deposits in the urine, headach and much depression of
mind, with more or less atonic leucorrhcea. The disease, in
many instances, seems chiefly confined to the vagina and rec-
tum, and is, therefore, unattended with dysmenorrhcea. There
are at times symptoms evidencing a state of congestion of the
pelvic region (coming on and going off suddenly), as a sense of
fulness, weight, heat, and throbbing, with extreme sensibility,
so as to require the greatest caution in sitting down.
“On examination, the labra and nymphe are usually found
swollen and flabby, and copiously moistened with a thick, creamy,
albuminous discharge. Occasionally, however, they are hot and
turgid; the vagina is ina state of soft, flabby tumefaction, its parietes
in close contact with each other, and its calibre much diminished-by
the swelling. The mucous membrane is swollen, and shews evident
marks of venous congestion; it is every where thickly covered with
the above-mentioned white, or yellowish-white discharge, and not
unfrequently the canal is so exquisitely sensitive as to render the
introduction of the finger very painful, and sometimes even impos-
sible.”
But the most remarkable symptom is the frequent discharge
of flatus from the vagina, apparently the product of secretion
from the mucous membrane of this canal, or of the uterus itself.
This phenomenon, Dr. Rigby is of opinion, never occurs, except
in uterine affections of a rheumatic, gouty character, and, so far
from being rare, he believes that uterine derangement, in con-
nexion with this diathesis, seldom or never occurs without the
presence of this peculiar symptom; the reason of its not being
noticed, he attributes to delicacy on the part of the patient:
“It varies,” he says ‘much in its appearance; at times taking
place to a very considerable extent, being formed very rapidly, and
escaping on the slightest motion of the patient; at other times it
only occurs towards evening, or is expelled on making any violent
exertion; while in some instances, it is only observed at the men-
strual pericds.”
The considerable excess of urea, uniformly observed in those
cases he had constant and regular opportunities of examining,
tends, our Author thinks, still further to establish the identity
of these uterine affections with gout.
A hemorrhoidal diathesis is also met with in a large ma-
jority, with a state of the mucous membrane of the rectum
analogous to that of the vagina already alluded to, with in-
creased secretion of mucus, and at times, flatus.
These attacks of pelvic congestion, though at first transitory,
eventually become permanent, and the disease may go on until
“ symptoms threatening the commencement of scirrhus are but
too distinctly established.” The darting, lancinating pains so
 Dr. Rigby on Dysmenorrhea. 469
generally deemed characteristic of scirrhus, Dr. Rigby thinks
not correctly so considered. ‘ Darting pains, however,” -he
says, “cannot be pronounced to be peculiar to this disease,
even in its earliest stage of induration.” He thinks they are
merely neuralgic, and are called into action by the sudden
paroxysm of congestion taking place in a gouty condition of the
part, bearing a close analogy to the twinge of a gouty foot, and
to the darts of pain in tic doloureux, depending on gouty or
dyspeptic irritation. This is plausible, but seems alittle hobby-
horsical.
Thus has Dr. Rigby, following out the views of Dr. Prout,
and applying them to his own peculiar department of practice,
endeavoured to draw an analogy between these uterine affections
and gout, and so refer them toa mal-assimilation. We have
abstained from giving any opinion as we passed along, but
cannot conclude without stating, that we think the whole has
been much overdone, and not by any means satisfactorily borne
out by the seven cases he gives. We had expected to have
been furnished with some additional information as to the
treatment, resulting from the views of these affections taken by
the Author, but find ourselves doomed to disappointment. The
treatment, as laid down, contains nothing new, resolving itself
merely into the round of aperients, tonics, and alteratives, with
the usual modes of relieving local congestions. As to the
exhibition of guaicum and colchicum, Drs. Dewees and Locock
had already advised such. Dr. Rigby concludes with a tabular
view of the analysis of the urine, as taken in three cases, and a
few directions, by attending to which, he says, the practitioner
may be enabled to observe the more important phenomena
presented by the urine in these diseases, and turn such know-
ledge to profitable account. For these we refer the reader to
the work itself, fearing we have already occupied too large a
portion of his time,

VOL, XXV. NO. 75. 3 p

470 Bibliographic Notices.

On Paracentesis Thoracis, with Cases. By H. M. Hucuss,

M. D., and Epwarp Cock.*
On Paracentesis Thoracis as a curative Measure in Empy-
ema and inflammatory Hydrothorax. By Hamutton Rog,
M. D., Physician to the Westminster Hospital.t
Account of a Case of Empyema, which recovered after Punc-
tures of the Pleural Sac. By Tusoruttus Toomeson, M. D.,
Visiting Physician to the Hospital for Consumption, and
Diseases of the Chest. :
Empyema, and its Cure, Medical and Surgical: the Result
of original Observations. By Dr. Atsert Krauss, Phy-
sician to the Royal Lying-in Institution at Danzig. |
Clinical Lectures—Paracentesis Thoracis. By Proressor
SCHONLEIN. |]
In the April Number of Guy’s Hospital Reports for 1844, we
find a long Paper on Paracentesis Thoracis, by Dr. Hughes
and Mr. Cock; the former treats of the medical, and the latter
of the surgical part of the question. In Dr. Hughes’ lucu-
brations we find nothing that is not sufficiently well known
already to our readers: it is composed of a few trite remarks
that have appeared over and over again in various forms in
different lectures and treatises published on the subject, and
we were not a little surprised to find many of them introduced
as if the result of the author’s own observation, and advanced
in a manner not only calculated to mislead an inexperienced
reader into the belief, that previous to the appearance of
Dr. Hughes’ essay, the Profession was immersed in midnight
darkness on the subject, but also to lead him to suppose that
the writer had made some important discoveries, which would
soon remedy this excessive ignorance. Our space is too
limited to enable us to give many passages from the paper to
support these statements, but we confidently refer to the Essay
itself for confirmation of them. Is there any thing new, we
would ask, in the following summary of the indications calling
for the operation of paracentesis thoracis?
“¢ The indications, then, for paracentesis in empyema, or chronic
pleuritic effusion, appear to be, in the first instance, the presence of
a large quantity of fluid in the pleura, rapidly effused; in the second,
the distress of the patient, dependent on the great accumulation of
fluid; and in the third, the existence ofa considerable amount of
* Guy's Hospital Reports, Second Series, No. 111, April, 1844.
+ Lancet, May 4th, 1844. $ Ibid.
§ From a Review in ‘‘ The Londcu and Edinburgh Monhtly Journal,” June,
1844, || Lancet, for 1844.
 Paracentesis Thoracis.—Empyema. 471
effusion, together with such a state of constitution, or of general
health, or such other circumstances, as would render a prolonged.
purely medical tieatment injurious, or undesirable.”
In other parts of his paper Dr. Hughes introduces remarks
that, notwithstanding their new garb, we must claim as old
acquaintances; thus, at page 58, our author, speaking of the
diagnosis between a phthisical cavity and pneumothorax, very
confidently puts forward, as the result of his own observation,
the following points of difference :
“‘ The diagnosis, in a vast majority of cases, may, notwithstanding,
be effected with facility, and, in circumstances of difficulty, may be
assisted by the following considerations: In simple phthisis, the
tympanitic resonance and the metallic tinkling (not common in any
degree) are rarely so well marked as in pneumothorax; while suc-
cussion is so very unfrequent in the former, as never, with certainty,
to have been heard by myself, or by any one with whom I have com-
municated on the subject. Laennec is reported to have heard it on
one occasion. In pneumothorax the chest is generally enlarged ; in
simple phthisis it is almost always contracted, In the former affection
the patient usually lies on the affected side; in the latter, upon either
side, or upon the back indifferently. In pneumothorax the cavity is
commonly at the lower part of the chest ; in simple phthisis the chief
excavation is almost universally at the upper part.”
Seeing that all the important points of diagnosis in the above
passage had been for some years before the Profession im Dr.
Stokes’s work, we did expect that our author would have made
some sort ofallusion to the researches ofthe latter gentleman, par-
ticularly as he admits in various places having perused that excel-
lent treatise; if so, we cannot help wondering how the passage
should have escaped his notice. It alludes to the diagnosis
between a phthisical cavity and pneumothorax, and runs thus:
LARGE CAVITY WITHIN THE LUNG. PNEUMO-THORAX, FISTULA, EM-
PYEMA.
“1, Metallic phenomena much 1. Metallic phenomena intense.
less developed.
“2, Signs supervening gradually. |2. Phenomena suddenly deve-
loped.
«“ 3. Side not dilated. It may be 3. Side generally dilated.
contracted.
‘¢ 4, Sound on percussion dull, or 4, Percussion exactly indicating
with resonance of a cavity. the extent of air and liquid.
“5, No lateral displacement of 5. Lateral displacement consider-
the heart. able.
‘¢ 6, Cavernous rale large. 6. Cavernous rale absent.
“ 7, Sound of fluctuation absent 7. The reverse.
or indistinct.
“ & Pectoriloquismoftenpresent. | 8. Pectoriloquism absent.’*
* Diseases of the Chest, p. 408.
472 Bibliographic Notices.
On comparing these two extracts, it will be evident to our
readers that all the valuable diagnostic points have been insisted
on much more fully by Dr. Stokes than by our author, and we
cannot but think that he would have done his readers a greater
service by extracting the whole passage we have just quoted,
than by the introduction of portions of it. Dr. Hughes next al-
ludes to the diagnosis between empyema and phthisis, in which
we find nothing worth quoting; he is evidently quite ignorant
of the forms of empyema, to which Dr. Green and Dr. Robert
Mac Donnell have directed the attention of the Profession, other-
wise he could not have written that he has
«Known many cases, very many cases, in which empyema has
been mistaken for phthisis. But this has arisen, notfrom any real
difficulty in the diagnosis ofthe two complaints, and when the physical
signs have been consulted, but simply from their not having been ef-
Jficiently employed.”—page 61.
We beg to assure Dr. H. that there are cases which do pre-
sent very great difficulties, even where physical signs have been
“ efficiently employed,” and by physicians equally skilful as he
is, in availing themselves of the assistance of those signs. In sup-
port of his view Dr. H. gives the following case:
ly
«An intelligent practitioner, and avery fair auscultator, former
town in
a pupil of Guy’s Hospital, sent a patient from the country chest,
of the
which he resided, for my opinion as to the condition
l sympt oms of
as the individual had many, cr most of the genera
indication of
phthisis, though he was unable to detect any physical
stripped
the existence of that disease in the apex of either lung. I ta-
the patient; the complaint appeared evident at a glanc e; auscul
de-
tion and percussion completely confirmed the hasty conclusionsl atten-
rived from simple inspection. I sent him back to his medica the whole
dant, with a note requesting him to inspect and examin e
wrote
chest, but without stating my own opinion. He immediately
of empyema,
in reply that there could be no doubt of the presence
and
which would consistently explain the whole course of symptoms, dis-
usly
that the clear indications of that disease had not been previo had not
covered, simply because the probability of their existence
tigated.”—page
been contemplated, and therefore had not been inves
62.
an-
We leave our readers to form their own opinion of the
H.
telligence of this practitioner, but we cannot agree with Dr.rly a
that he was “a very fair auscultator,” although “ forme
to be-
pupil of Guy’s Hospital 5” nor can we bring ourselves wise
lieve that he knew anything at all about the science, other in
he would not have sent his patient “from the country townas to
on
which he resided” up to London, for Dr. H.’s “ opini ously
the condition of the chest,” without having himself previ
evi-
examined every part, particularly as he had failed to find
 Paracentesis Thoracis.—Empyema. 473
dence of phthisis at the apex of either lung. This simple case
of empyema, examined bya careless or ignorant practitioner, is
adduced to shew how easily the disease might be mistaken for
phthisis ! !
Dr. Hughes next discusses the diagnosis between empyema
and malignant disease of the lung or pleura, and adds, that
“ Neither Dr. Townsend nor Dr. Stokes enter upon the diagno-
sis between these two complaints; and though I have recently pe-
rused, for the third time, the valuable essay of the latter gentleman on
malignant diseases of the lung, in the twenty-first volume of the
Dublin Journal, I am unable to collect therefrom anything which in-
duces me to alter the tenor of the following observations in the sixth
volume of Guy’s Hospital Reports.
«© Tt must, however, be added, that the disease sometimes, as in
the second case herein related, very accurately resembles empyema5
that the history of the case, and the physical signs are on such occa-
sions insufficient for the purpose of distinguishing the two complaints5
and that the diagnosis, if at all practicable, must be deduced from
the general symptoms, the peculiar character of the expectoration, the
obstruction to the flow of blood, through the superficial veins of the
affected side, and the appearance of malignant tumours in other parts
of the body.’ ”—page 60.
Here, again, we find Dr. Hughes appropriating to himself
the discoveries of others, and we see with what self-compla-
cency he puts forward the ground of diagnosis between malig-
nant disease of the lung and empyema, coolly asserting that
“neither Dr. Townsend nor Dr. Stokes entered upon the diag-
nosis between these two complaints.” This last announcement,
we confess, took us completely aback, particularly as we had so
often perused the points of diagnosis in Dr, Stokes’s book, to
which Dr. H. alludes, and we now quote them that our readers
may compare what Dr. Stokes published in 1837, with that put
forward by Dr. Hughesin 1844. After describing an interesting
case of cancerous disease of the lung, Dr. S. points out the par-
ticulars in which it differed from ordinary phthisis and pneumo-
nia, and then goes on to detail the circumstances in which it
differed from empyema :
« Lastly,” he says, “it was at one time supposed that the case
was empyema, but with this the signs were also irreconcileable; the
side was contracted, the intercostal spaces unaffected, the vibration
of the voice was not extinguished; position made no difference in
the signs; the heart was in its natural situation, and the liver was
not displaced until a short time before death. The dulness and ab-
sence of respiration, if proceeding from empyema, would point out
the greatest possible effusion, yet the remaining phenomena were
inconsistent with this condition.”
« But other unusual circumstances existed, namely, the varicose
 474 Bibliographic Notices.
state of the subcutaneous veins, the dysphagia, the predominance of
adema on the right side, the apparent enlargement of the liver, and
the growth of these external tumours, which were, doubtless, of the
same nature as the internal lesion.”
Again, in his paper on “ Cancer of the Lung and Medias-
tinum,” in vol. xxi of this Journal (and which Dr. H. says he
has read three times over, without finding anything which could
enable him to distinguish between that disease and empyema),
we find Dr. Stokes speaking more explicitly on the point:
«That the following symptoms are important as indicative of this
disease: pain of a continued kind ; a varicose state of the veins of
the neck, thorax, and abdomen ; edema of one extremity; rapid
formation of external tumours of a cancerous character ; expectora-
tion similar in appearance to currant jelly 3 resistance of symp-
toms to ordinary treatment.
«That though none of the physical signs of this disease are, se-
parately considered, peculiar to it, yet that their combinations and
modes of succession are not seen in any other affection of the lung.”
These passages, from Dr. Stokes’s writings, show, beyond
doubt, that he had, long before the appearance of Dr. Hughes’s
essay, pointed out the grounds of diagnosis ; and we only wonder
how Dr. Hughes could, after the third perusal of Dr. Stokes’s
paper, assert that he had not entered upon the diagnosis between
the two diseases. In one part of his paper, Dr. H. states, that
‘“* there are few members of the Profession for whose opinions I
have a greater respect, and [ may perhaps add, from whose
writings I have derived more information than those of Dr.
Stokes,’ we have only to hope that, in future,he wil! acknowledge
with candour the source from which he derives that information.
These remarks have been suggested by an attentive peru-
sal of Dr. Hughes’s various essays, all of which are strongly
tainted with the same fault we have pointed out, viz., putting
forward, as his own, the discoveries of others, and which, we
trust, will be remedied in his future lucubrations.
Mr. Cock prefers opening the chest “ below the scapula,
between either the seventh and eighth, or eighth and ninth ribs,
and at a point distant from one to three inches from the angles
of the bones.” At page 70, he says:
‘¢T will make a few remarks on the size of the instrument which
I employ for paracentesis thoracis; for I consider this to be a mat-
ter of considerable importance as regards the facility of introduction,
and the diminished liability to injury, as well as the successful result
of the operation. The trochar and eanula which I have found best
adapted for general use is about one-twelfth of an inch in diameter,
and about two inches in length, exclusive of the handle. In some
cases, where there exists great oedema of the subcutaneous tissue, a
 Paracentesis Thoracis.—Empyema. 475
longer instrument might be required to penetrate the pleural cavity,
and I have in more than one instance found it necessary to pit the
skin by pressure with the finger, before the canula could be pushed
far enough to reach the fluid. I prefer a circular to an oval instru-
ment, as the former is more easily introduced and does less injury to
the intercostal muscles, whose fibres are perpendicular to the long
diameter of the oval canula. I am aware that I use a much smaller
instrument than is usually employed in paracentesis, but I think it
has many advantages; its introduction is easy, and attended with so
little friction, that the operator feels his way before him, and is im-
mediately conscious when he has entered the cavity of the chest. It
gives but very slight pain, as it does little more than separate, in-
stead of lacerating the tissue through which it passes; and it is cal-
culated to elude the nerves and vessels, whose immunity from injury
no skill or care of the operator may otherwise be enabled to secure
on every occasion. On its withdrawal, the opening which it has
made becomes immediately and permanently closed, thus at once
restoring the integrity of the cavity which has been entered. It is
adapted to all ages, from the infant to the adult, and can hardly fail
to find its way between the ribs, however narrow the intercostal
space may be from age or formation, and however nearly the bones
may have become approximated during the progress of the disease.”
Mr. Cock next alludes to the narrowing of the intercostal
spaces, which, he very correctly observes, is noticed in the ad-
vanced periods of empyema ; but he is wrong in attributing this
change to a mere mechanical approximation of the bones to
each other, as it has been shown at the Pathological Society of
Dublin, to be owing to an actual enlargement of the ribs. the
tendency of which is to destroy the intercostal space, and thus
bring the ribs into closer proximity. Mr, Cock, however, de-
serves credit for having observed the fact, though unaware of
its true explanation.
Another advantage claimed by Mr. Cock for his mode of
operating is,
‘“« That it ensures a slow and gradual evacuation of the fluid, and
enables us to avoid the admission of air, both of which are, in my
opinion, matters of great importance in the operation, more especially
where the effusion is of recent occurrence, and when we may, there-
fore, reasonably suppose that the lungs have not become permanently
collapsed by the pressure.”
He next discusses the point, whether or not admission of
air into the cavity of the pleura, during the operation, is attended
with danger; he is decidedly of opinion that it is, but as we
intend introducing the interesting debate on this subject, which
took place lately at the Medico-Chirurgical Society, we shall
pass over Mr, Cock’s excellent remarks, merely stating, that he
has observed on some occasions, after the operation of tapping
476 Bibliographic Notices.
for hydrothorax, that a change has taken place in the character
of the fluid which either had been left in the cavity or had be-
come subsequently secreted ; that when, after the lapse of a short
period, paracentesis has again been performed, the fluid had
lost the limpid transparency of pure serum, and become turbid
and doscoloured, approaching more in its characters to the fluid
of empyema.
Dr. Hughes and Mr. Cock next give a table of twenty cases
of empyema, in which the operation was performed, in some
with perfect success, in others with relief. Out of the twenty
cases there were six in which phthisis complicated the disease,
in two of which the patients were labouring under the affection ©
at the time of the operation, and it was only proposed as a pal-
liative measure; in the other four cases the disease ensued
after the operation, or, at least, was not detected at the time it
was performed.
There were seven cases of perfect recovery, in five of which
there was no other disease; in one there was secondary syphilis,
in the other a “tumour of the abdomen.” ‘There were also
three cases of partial recovery, one of which was compli-
cated with an old pneumonia, another with ascites, diarrhcea,
and phthisis, and the third was accompanied by enlarged liver*
and ascites.
From these facts it appears, that when the empyema is uncom-
plicated with structural disease of the lungs or other organs,
that the operation, so far from being dangerous, has, in the hands
of Mr. Cock, been extremely successful; and we have no doubt
whatever that this success is in a great measure due to the mode of
operation proposed, and the instruments employed by him, which
we have reason to know are those now generally adopted by
most of our Dublin surgeons, and with very remarkable success
as compared with the old mode of tapping the chest. We must
now conclude our notice of this very useful paper, and regret
that we felt it our duty to speak of Dr. Hughes’s portion of it,
as our sense of duty dictated.
We are unable to give our readers a more full account of
Dr. Hamilton Roe’s paper on Paracentesis Thoracis than is
contained in the Lancet for May 4th, 1844, from which we ex-
tract the following notice of it, and the discussion that followed
the reading of Dr. Roe’s and Dr. 'T. Thompson’s communica-
tions, from which our readers will ascertain the opinions of some
of the leading members of the Profession in London, with re-
spect to the operation:

* The case is given in detail in the essay; the empyema was situated in the
left pleura, and was evidently one of those cases to which Dr. Robert Mac Donnell
has directed the attention of the Profession, and to which we shall return farther on.
 Paracentesis Thoracis—Empyema. ATT
_ “ The author commenced his paper by alluding to the very gene-
rally-received opinion of the uselessness of paracentesis thoracis as a
curative measure in the treatment of pleuritic effusions, as founded
upon the supposed facts, that re-accumulation of fluid necessarily takes
place after its withdrawal by the operation; that the frequent repe-
tition of tapping subsequently demanded in those cases in which life
had been prolonged by it, was only sufficient for the alleviation of
certain urgent symptoms; and, lastly, that recorded experience is
completely opposed to the employment of the operation. His own
experience had induced the author to depart from these opinions, and
a careful examination of the cases recorded by various writers during
the period of thirty years, had supported him in the correctness of
the results at which he had arrived. Of thirty-nine cases recorded
in British medical journals, between the years 1812 and 1842 (a pe-
riod selected as that in which an acquaintance with auscultation had
rendered the diagnosis more accurate), in all of which paracentesis
had been had recourse to, he had found that eleven only died.
Twenty-four cases had occurred to himself, and the chief object of
the author was to prove, from the results he had obtained, that the
operation was as free from danger as any other performed upon the
human body; that most of the evil consequences supposed to attend
it are far more imaginary than real; that it is commonly successful
when employed at an early stage of either empyema or inflammatory
hydrothorax, and the common cause of failure is to be found in the
late period at which alone it is alone regarded as admissible.
“The author next proceeds to notice at length the objections of
certain writers to the treatment of empyema by operation, and op-
poses the opinion that the ultimate removal of pleuritic effusion must
depend upon the action of the absorbents, and observes, ‘that the
proper function of the absorbents is to carry off the ordinary healthy
secretion, but not a diseased one; that this power may be sufficient
to take up the quantity usually secreted, and yet wholly unequal to
take up many pints added to it ;’ and that it is, at least, very proba-
ble that the action of the absorbents becomes paralysed, partly by
over-distention of the membrane in which they are situated, and
partly by the general prostration of strength produced by the great
suffering and the disturbance which the other functions undergo from
the pressure upon vital organs. These views were supported by a
case of inflammatory hydrothorax, in which the withdrawal of a small
quantity of fluid from the chest was sufficient to lessen the mechani-
eal pressure upon the absorbent vessels, and thus to enable them to
reassume their healthy action, and by which the great bulk of the
fluid was subsequently removed.
«“ With reference to the supposed dangers of the operation, the
author had been unable to find one case on record in which mis-
chievous results had occurred ; in his own practice no precaution had
been employed to prevent the admission of air into the pleural cavity,
but no bad results had followed; and even in one case (the only ex-
ample of the kind) in which the air failed to be absorbed with the
rapidity commonly observed, it had been readily withdrawn by means
VOL, XX¥. Ne: 7D. 3 2
478 Bibliographic Notices.
of a syringe, the wound made in tapping the chest having been
healed; but, although the accidental admission of air at the time of
the operation was never productive of bad effects, yet its continued
entrance in those cases in which a fistulous opening had been made
into the pleura, had very commonly been followed by mischievous
results; the author, therefore, was strongly in favour of the complete
removal of the fluid, and the immediate closing of the aperture.
Although it was difficult to determine what length of time might,
without danger, be allowed, for the exhibition of internal remedies,
yet, from his own experience, the author was induced to believe that
in the general class of cases three weeks is the longest period that
can with safety be permitted to elapse before the withdrawal of the
fluid. In none of his own cases had complete restoration of the lung
resulted after it had been subjected to the pressure of pleuritic effu-
sion for six weeks. It was important to understand rightly the exact
state understood by the term ‘cured empyema,’ much of the diffe-
rence of opinion relative to the propriety of tapping the chest depend-
ing upon the varied manner in which such expression is employed.
Thus, in the posthumous essay of Dr. Hope, a long line of cases of
empyema are recorded, in which the continued action of mercury
was followed by ‘cure.’ In the essay in question, however, it is not
stated that in any one case the lung had been restored to its healthy
condition. By the early employment of paracentesis, those changes
in the pulmonary tissue by which its expansibility is destroyed are
n
prevented, and thus, not only is the removal of the pleuritic effusio
effected, but the lung also restored to the full performance of its
function.
« The author next describes, at length, the morbid changes pro-
duced in the pleura by the long continuance of purulent collections,
more particularly alluding to the manner in which the pleural sae
becomes ultimately obliterated in chronic cases of empyema, in which
the effusion has been very slowly removed, and at a later period. As
one of the secondary effects he had also observed, that tubercular
disease of the opposite lung not unfrequently occurs in old cases of
empyema. Amongst the several changes produced in the lung
during the existence of pleuritic effusion, the most important were
those by which it was rendered subsequently incapable of expansion.
In old cases of hydrothorax, the author had observed such effects
to result from condensation of the pulmonary tissue, which was often
so complete as to prevent even partial expansion by the artificial in-
troduction of air. In the cases in which purulent secretion had re-
sulted, it had been frequently found that the pleura had become
wholly altered in character; in some cases adherent to the parietes
of the chest, in others greatly thickened and contracted, and so bind-
ing down and compressing the lung as to render its restoration 1m-
possible.
«¢ Twenty-four cases had occurred to the author, which had been
treated by paracentesis thoracis; of these eighteen recovered, and
six died. Nine of them were cases of purulent effusion, of which
eight recovered, and one died, Thirteen were cases of inflammatory
 Paracentesis Thoracis— Empyema. 479
hydrothorax, of which nine recovered, and four died. One was a
case of hydrothorax dependent upon cardiac disease, in which relief
was afforded by the operation, and the remaining case was one of
pneumothorax, having a fatal termination.
“In conclusion, the author remarked on the comparative value of
certain physical signs, alluding to one of them, namely, the disten-
tion of the intercostals, as a differential sign, serving to mark the
character rather than the quantity of the contained fluid. He had
repeatedly found that retraction of the intercostals had existed with
a very large amount of pleuritic effusion; and, on the other hand,
that very distinct bulging of those spaces had been present with a
very small quantity of fluid. In the former class of cases the fluid
had been serous, in the latter purulent, and he was disposed to adopt
the opinion of Dr. Stokes, and of some of the older writers, who
believe that the projection of the intercostals depends upon the puru-
lent character of the effusion. The inability for patients affected
with pleuritic effusion to lie upon the healthy side had not been ob-
served to accord with the opinion commonly expressed in systematic
works, but that the contrary rule obtained in nearly one-half of the
cases. It was somewhat remarkable that the disease more commonly
existed on the left side of the chest, and of the twenty-four cases ad-
duced by the author the ratio had been as two and a half to one.”

“In the summer of 1843, Dr. Thompson visited, with Mr. Ro-
barts, of Great Coram-street, a little boy, between five and six years
of age, who had suffered for two months from febrile symptoms. On
examining the chest conclusive indications were observed of purulent
effusion in the right side, and the operation of paracentesis thoracis
was performed on the 27th of June. The puncture was made through
the fourth intercostal space, and fourteen ounces of pus were with-
drawn, various precautions being adopted to prevent, as much as pos-
sible, the access of air. On the 30th of June the operation was again
repeated, and about a pint of matter withdrawn. ‘The relief ob-
tained, although very considerable, proved only temporary; notwith-
standing the use of appropriate remedies the accumulation was re-
newed, and on the 10th of July the operation was performed for the
third time, twenty ounces of pus being removed. After the per-
formance of the fourth operation, on the 21st of July, when twenty-
two ounces of thick, but not foetid matter was removed, the boy
improved in strength, and the excess in girth of the right side of
the chest over the left was materially reduced. On July 28th the
puncture, which had been for some days perfectly healed, opened
spontaneously, and within twenty-four hours, gave exit to about four
ounces of pus. After three days the discharge ceased, but above the
seat of the two last punctures a swelling was formed about two inches
in length, at the posterior part of which an aperture, discharging mat-
ter, appeared. On the 16th of August both openings were dis-
charging; the anterior spontaneously, the posterior when pressed.
The local symptoms gradually becaine more favourable and the ge-
neral health improved, so that in September the bey was able to walk
480 Bibliographic Notices.
out. The right side of the chest contracted, and in the month of
November was an inch and a half less than the left. in circumference.
A: partial healing of the aperture being followed by some aggravation
of the symptoms, it was determined to attempt the gradual emptying
of the sac and approximation of its sides. ‘This object was success-
fully obtained by means of plugs made of sponge, firmly tied with
pack-thread, and saturated with wax; matter, which was to the last
inoffensive, was thus repeatedly removed from the cavity. The
opening healed about the end of January, and the boy has since re-
mained perfectly well.
‘© The author remarks that, although serous effusion into the
pleural sac is frequently removed with little assistance from medical
treatment, yet that, in cases of considerable purulent effusion, there
is little hope of relief without an operation, which, in most instances,
should be performed early, without losing time and hazarding strength
by the use of mercury and diuretics. He argues that puncture of
the thorax involves no circumstance of peculiar hazard, provided
suitable precautions be adopted. Amongst these precautions he
urges the expediency of repeating the operation, in preference to
removinga large quantity of pus at once, and especially insists on
the conclusive evidence which recorded cases afford, that the practice
of leaving a canula in the wound is highly detrimental, in consequence
of the increase of pleural inflammation and decomposition of the
enclosed matter, owing to the long-continued contact of atmospheric
air.
“ Dr. C. J. B. WiILLiaMs inquired the average age of the patients
operated on by Dr. Roe. The success of the operation depended
so much upon age, that he was desirous of information on that point.
« Dr. Rog replied that few of his patients were under twenty,
and that some of them were above thirty.
« Dr. WitLiaMs rose, and said he considered that it would be
scarcely right to discuss the paper before the Society without being
acquainted more fully with its contents, than the abstracts read by
the secretary had enabled him to be. He would observe, however,
that the result of Dr. Roe’s cases was to him altogether a matter of
surprise, as the success was far beyond any thing he had seen in his
own practice, or recorded in that of others. If this success were
confirmed by subsequent experience, the prospect would be most
encouraging. He should not discuss the contents of the paper fur-
ther, but should refer to several points in connexion with the opera-
tion of paracentesis; and first, as to the propriety of adopting mea-
sures for the exclusion of air from the pleural cavity during the
proceeding. Now, several years since, he had performed the opera-
tion in a number of cases, and the result had been invariably fatal.
This had been the case also with Dupuytren and many other surgeons,
and the consequence had been, that the operation had fallen into
disrepute, and opinion was uniformly against its employment. In alk
the cases alluded to, no attempt whatever was made to exclude the ex-
ternal air, and the canula was sometimes left in the wound. The evil
effects were evidently the result of the entrance of air into the chest.
 Paracentesis Thoracis—Empyema. 481
He concluded this from the following facts:—The immediate effect
of the operation in all the cases was a very decided relief to all the
symptoms; and in no case of pure uncomplicated empyema was the
fluid first drawn off in any way foetid; and in addition to the imme-
diate relief, the patients seemed as if they would do well. In three
or four days, however, symptoms of irritative fever came on; the
pulse became quicker; the patient was affected with night sweats;
became cachectic; and died. Now, it was invariably found that the
discharge from the wound, whether of pus or air, became more and
more foetid as these symptoms progressed; and, indeed, one condition
seemed to bear so complete a relation to the other, that he had no
doubt that the cause of both was the same, and that this was the
entrance of the air. He had observed this sympathy, particularly in
adults, the exceptions to it being in children, in whom, when the
discharge and air from the wound were feetid, the constitution did
not always appear to suffer in the same degree. It seemed, indeed,
that there was greater power in the child than in the adult, to resist
the noxious influence of decomposed pus. Fully impressed with the
truth of these remarks, in all subsequent operations he had adopted
measures for the exclusion of air, and in none of these did the fetid
condition of pus come on, nor did any irritative fever occur. He
would now inquire whether the operation was an expedient one?
and reply to that question by saying, that it was not so frequently
necessary as had been snpposed; and he thought that by-and-by,
most practitioners would agree with Dr. Stokes, that it ought not to
be resorted to except in cases in which there was pus in the chest.
It might be difficult in some cases to decide whether the effusion
were purulent or not previous to the exploration of the chest, or of
the performance of the operation; but generally, he thought, the
hectic fever, the frequent pulse, and other constitutional symptoms,
might decide the question. In such cases, then, when the symptoms
were aggravated, when the dyspnoea was urgent, and life itself
threatened, he should resort to the operation. When these urgent
symptoms, however, did not obtain, and there was reason to think
the fluid to be serous, he should be inclined to wait for the effect of
remedies. He spoke thus from experience, for within the last few
years he had seen many cases (in which, years before, he should have
advised an operation), where the oppression of breathing and consti-
tutional disturbance had given way under the use of tonics and slight
stimulants. He related the case of a lady, in whom there was effu-
sion into the pleura, accompanied by much constitutional debility.
Antiphlogistic remedies, with mercurials, were employed, without
benefit, and she seemed to be sinking from the affection. He was
ealled in. It was evident that the system required support; tonics
and slight stimulants were accordingly administered, and from that
moment the constitution began to rally, and she eventually got quite
well. We did not, he thought, sufficiently consider the fact, that
effusion often depended on the low state of the circulation, and that
as the strength increased, the effusion diminished. Two objects were
sought to be obtained in the operation of paracentesis, the removal
432 Bibliographic Notices.
of the liquid, and the prevention of the ingress of air into the chest ;
the air irritated and kept up the effusion, and, he believed, by pres-
sure, prevented the expansion of the lung. With the view of pre-
venting this accident, he had practised, and recommended the em-
ployment of pressure on the parietes of the chest, which pressure
should be continued as long as the liquid was allowed to flow. By
this means alone, it was easy to prevent the entrance of air into the
pleura; but other measures had also been employed to obtain the
same result. Thus, it had been recommended that the patient should
be placed in a bath during the performance of the operation, so that
if any thing did enter the cavity of the chest, it should be water. This
plan was said to have been successfully employed in Berlin. Another
plan was, the employment of an instrument with a valve, which, while
it prevented the entrance of air, allowed of the exit of fluid; but this
instrument was liable to be blocked up by the matter. Again, it had
been advised that the intestine of a rabbit, or small animal, should be
attached to the canula, that the intestine should be placed in water,
so that the air would be kept out, and the fluid allowed to ooze out.
This plan had the advantage of allowing the wound to be kept open
for along time, and of preventing the necessity of a second operation.
The case, however, by Dr. Theophilus Thompson, read that night,
proved the value of repeated operations over that of emptying the
chest at one operation.
« Dr. Mayo took occasion to comment on a mixture of calomel
with sulphate of quinine, as used by Dr. Thompson, which he con-
sidered to be questionable, as one of the compounds might interfere
with the other.
« Dr. CursHam made an inquiry respecting the diagnostic dif-
ferences in regard to increase of size in the chest, in cases of serous
and purulent effusion.
‘«¢ Dr. THzEopHILus THoMpsoN, in answer tothe last question, re-
plied, that he had repeatedly seen the bulging out of the chest, both
in cases of serous and purulent effusion, and that he did not consider
it a diagnostic mark between the two kinds of fluid. The frequency
with which serous effusion was removed by the agency of medicine
would make him careful of resorting to operative means for its eva-
cuation. He related the case of a gentleman in whom, after mercu-
rial and other antiphlogistic means had been resorted to, the effusion
had been got rid of by the decoction of winter green ; and the case of
a boy, in whom calomel appeared to do harm, but who was cured by
the employment of spirits of sweet nitre, with demulcent medicines.
The objections raised by Dr. Williams had reference rather to the
mismanagement than to the use of the operation. These objections,
however, shewed the importance of employing the precautions which
he had alluded to. He vindicated the combination of remedies
which he had employed in his own case, and remarked that the com-
bination of tonics with remedies like calomel was often beneficial.
«“ Mr. Bensamin Puitips spoke from the result of his own expe-
rience, which extended over sixteen or seventeen cases, two of which
only were purulent, the others being serous. He had seen, in several
 Paracentesis Thoracis—Empyema. 483
of the latter cases, the bulging out of the chest, and he, therefore,
did not consider this sign as at all conclusive evidence of the effusion
being purulent. It was desirable, if possible, to determine whether
the effused fluid were purulent or serous, for, if purulent, the entrance
of air might be injurious. When he had performed the operation
in cases of hydrothorax, he had frequently observed the air to com-
pletely expand the chest, which became as resonant as a drum; but
no evil results had followed, and the air had disappeared in a few
hours, but by what means he did not pretend to say. His experience
with respect to the operation was less favourable than that of Dr. Roe,
as in not one case in which he had operated had the patient lived for
six months afterwards. In all the cases, immediate relief followed
the operation; in many, the relief endured for weeks, but the fluid
again accumulated, and tapping was again required. In some cases,
in which, however, there was no evidence of inflammation of the
pleura, the fluid from the second tapping contained more albumen
than that from the first.
‘¢ Mr. HEwer was surprised at the result of Dr. Roe’s cases. He
had seen several instances of effusion into the pleura which had been
operated upon, and they had all died. The only case which had
recovered was one in which nature had effected an external opening
for the effused fluid. In cases of hydrothorax there was occasionally
such a coating of lymph over the lung, that it could not expand,
even though the fluid were entirely removed. In these cases, the
exploring needle would fail in detecting the real nature of the case.
He related an instance in which a man died of dyspnoea two days
after the operation of paracentesis. It was found that the lung was
coated with such a quantity of lymph, that it could not be inflated
until several incisions had been made into the false membrane.
«Dr. Kinaston observed, that Dr. Roe’s results could not be
regarded as opposed to those of others, as they related to cases dif-
ferently circumstanced. In those instances of pleuritic effusion, in.
which paracentesis thoracis had been hitherto performed, it had not
in general been resorted to until the constitution had been completely
worn out by the long continuance of the disease ; whereas the point
which Dr. Roe’s twenty-four cases tended to establish was, that
although hardly ever successful, when postponed to this late period,
it would succeed in the great majority of the cases in which it was
required, if performed at a period when the constitution was better
able to struggle with the disease, and bear up under the effects of
the operation.
« Mr. Luoyn briefly alluded to three cases in which the effusion,
though supposed to be in the pleura, was really external to that
membrane. The fluid was evacuated, and the patients did well for a
time, but afterwards died of other diseases. He believed that tap-
ping, either in empyema or hydrothorax, never permanently removed
the cause of the disease, and that the patients soon perished, either
of that or some other disease.
“ Mr. Arnott had seen the bulging out of the intercostal spaces
as frequently in cases of serous as purulent effusion into the chest.
His experience proved that in cases of serous effusion, the entrance
484 Bibliographic Notices.
and
of the air into the chest did no harm, as it was soon absorbed,
gave rise to no bad symptom. When the effusion was purulent, he
should not allow more than twelve or fourteen ounces of effused
fluid to escape at one time, and he should employ pressure over the
t
parietes of the chest, as recommended by Dr. Williams, to preven
the ingress of air; he thought, however, that when the quanti ty of
exceed that already mentioned, there could
fluid removed did not
be little fear of air getting into the pleural cavity. He vindicated
the combination of quinine with mercury, in practice, as often most
serviceable. !
« Dr. WEBSTER passed an eulogium on the paper of Dr. Roe,
which shewed the advantage of resorting to the operation of paracen-
tesis early.
«Dr. Hamitton Rog, in reply to the observations of the previous
speakers, observed, that the first objection urged against the employ-
ment of paracentesis, by Dr. Williams, was that of the admission of
air into the pleural sac. In the course of the paper he had distinctly
stated, that although the admission of air into the pleura, during the
operation, was neither injurious in itself, nor mischievous in its subse-
quent effects, yet that its continued entrance, as in the case of a fistu-
lous opening, had not unfrequently been productive of bad effects.
It had been one of the objects of his paper to demonstrate the ad-
vantages of operating in the manner practised in the cases he had
brought forward, namely, that of withdrawing at once the entire col-
lection of fluid, and immediately afterwards closing the aperture
made by the trocar. In cases in which a fistulous opening had been
made, either by retaining the canula in the wound, or otherwise per-
mitting the continued ingress of air, unsuccessful results had followed,
in the majority of cases to be attributed to the physical changes pro-
duced in the pleuritic secretion, by the contact of the air; in many
examples of hydrothorax, treated by making a fistulous opening, the
effused fluid, before serous, had become purulent, and a severe form
of disease was thus induced. A good illustration of this fact had been
referred to both by Dr. Theophilus Thompson and himself, in the
ease which had occurred to Dr. Stroud. The strongest evidence
against the old opinion quoted by Dr. Williams, was to be found in the
cases related in the paper, in every one of which air entered freely
during the time of the operation, yet did no unpleasant effects ensue.
He had frequently found the pleural sac immediately afterwards
filled with air, producing all the physical signs of pneumothorax, but
that a few hours had sufficed for its removal by absorption. He had
been surprised at the observation made by Dr. Williams, to the
effect that air, admitted into the pleural cavity, was capable of ex-
erting the same amount of pressure on the lung as the fluid previously
contained. Experience completely disproved the correctness of the
remark, and the observations that had just been made by Mr. Arnot
and Mr. B. Philips strictly coincided with the results obtained by
himself, that the air admitted during the operation had commonly
been removed within a few hours. With regard to the fatal termi-
nation of the cases that had occurred under the observation of Dr.
Williams, there could be little doubt that their unsuccessful issue
 Paracentesis Thoracis.— Empyema. 485
was not in any way dependent upon the mere admission of air into
the chest, but that the cause was to be sought for in the period at
which the operation had been had recourse to. It had long been
the opinion of authors that paracentesis could only be regarded as a
dernier ressort; and if the cases alluded to by Dr. Williams had
been treated in accordance with such views, it was not remarkable
that no recoveries should have taken place. In all cases in which
the operation had been long deferred, the lung had become so much
compressed and atrophied, and its investing pleura so thickened, con-
tracted, and bound down by morbid adhesions, that its future expan-
sion could not take place, and though the collection of fluid might be
removed, the lung would be wholly lost as an organ of respiration.
If, however, the practice he had advocated were adopted; if the
operation were had recourse to at the only period at which it was
really of value as a curative means; if it were employed to remove
a disease rather than to protract it, very different and far more grati-
fying results would ensue. Dr. Williams had also stated that the
majority of cases of hydrothorax were to be cured by tonics, and that,
therefore, the operation of paracentesis was unnecessary. He (Dr.
Roe) dissented not only from the assumed fact, but also from the
inference deduced. He did not deny that many patients got rid of
pleuritic effusions by the use of tonics, after depletory measures had
been too actively employed, and that such persons did recover with-
out the operation; but the fact was not less true, that a large num-
ber of patients died annually from hydrothorax, even after the
employment of all those remedies commonly relied upon as useful in
the treatment of this disease. In few, if any, of the twenty-four
cases had the operation been employed until other remedies had been
unavailingly had recourse to. In reply to the prophetic remark of
Dr. Williams, that the operation of paracentesis would cease to be
‘employed in the treatment of hydrothorax, he was fully convinced
that it was only required to regard the operation in its true character,
as a curative measure, to demonstrate the incorrectness of the opinions
which had served to surround this operation by unreal dangers, and
to shew, by the record of cases, that it could be almost an exception
unsuccessfully (when early) employed. He believed that it would then
meet with general adoption, and a very few cases would be met with
in which it would be found inadequate to the complete removal of
the disease. In the course of his paper, he had especially directed
attention to the greater value of paracentesis as a remedial measure,
inasmuch as, by its timely employment, not only was the effusion
itself removed, but it also relieved the lung from the pressure exer-
cised by the surrounding fluid, by which its proper structure was
ultimately destroyed, and its subsequent expansion prevented.
“ Dr. P. M. Stewart, in relation to the combination of calomel
with quinine, remarked that Dr. Mackenzie, of Glasgow, was in the
habit of employing this mixture in cases of scrofulous diseases of the
eye. The state of the constitution, in some cases of accumulation
in the pleura, might be such as to render the medicine in question a
very desirable and valuable one.
VOL. XXV, NO, 75. 3R
486 Bibliographic Notices. :
“‘ Mr. Stanley, had operated on five cases of fluid in the chest; of
these, three were collections of pus, two of serum. Three ended
favourably, two fatally. With reference to the point at which para-
centesis might be most properly and safely performed, it had been
asserted by high authorities that the puncture should not be made
lower than between the fourth and fifth ribs; and Laennec had re-
corded two cases in which the puncture was as low down only as
between the sixth and seventh ribs; in one of these the diaghragm
was wounded, and in the other the trocar passed into the kidney,
and the patient died from extravasation of blood into the abdomen.
Notwithstanding these results, however, he (Mr, Stanley) had, in
two of his cases, made the puncture between the eighth and ninth
ribs; the proceeding was successful, and no bad consequences fol-
lowed.”

We have not been able to procure the treatise of Dr. KrausE,*

and must content ourselves with quoting from a notice of it in
the London and Edinburgh Monthly Journal, and we are the
more anxious to do so, as our cotemporary has extracted from
the work strong confirmations of some views advanced by Dr.
Mac Donnell, published in the March Number of this Journal.
“ Under the anatomical department,” says the Reviewer, “he
gives some details regarding the nature of the effused fluid, which
he divides into three species, the purulent, sero-purulent, and san-
guineous. It is difficult, be says, to state with accuracy the numerical
proportions of these three varieties; but throwing together single
eases, collected by other authors, along with those observed by
himself, he finds the first to be of much the most frequent occurrence,
and also the least dangerous, whilst, on the other hand, the sero-
sanguineous exhibits the most unfavourable results; thus, in 162
cases the effusion was purulent in 100, and the cures were 50; sero-
purulent in 41, the cures being 18; and sero-sanguineous in 20,
with cures 2. In that part of the work devoted to the causes, we
have another table, shewing the relative proportion of its occurrence
on both sides of the chest, and also the relative proportion in both
sexes, and the periods of life, a summary of which we subjoin. Of
137 cases, 96 were men, 18 women, and 23 children. In both sexes
the disease occurred more frequently in the young. Of the 96 men,
ol had not attained the age of 30; of the 18 women, 10 were under
the same age. The greatest number of cures occurred in the young.
Of the 51 young men, 25 were cured, and of the 10 young women, 5.
But the most favourable result of all occurred among children ; of the
23 children, 16 were cured. Out of the 187 patients, 81 were
affected in the left side, and 56 in the right. Of the 54 cures, on
the other hand, 80 were in individuals affected in the left side, and
24 in those affected in the right.”

* Das Empyem und seine Heilung auf Medizinischen und Operativem wege
nach eigener Beobachtung dargestellt.—Von Dr. ALBERT KRAvsE, Danzig.
 Paracentesis Thoracis.—Empyema. 487
‘In the interesting Paper of Dr. Mac Donnell, which appeared
in our [London and Edinburgh Monthly Journal] last Number, it
will have been observed by many of our readers that the able author
states, that enlargement of the liver very often accompanies empyema,
not only when it is seated in the right side, but also when it occurs
in the left cavity of the chest. This effect he ascribes to a ‘con-
gestion or engorgement of the liver, analogous to what takes place in
cases of morbus cordis, and diseases of the lungs, attended with
imperfect aération of the blood.’ He also remarks, «that it has been
mentioned by many writers, in their accounts of the appearances
noticed at the autopsies in cases of empyema, though unaware of its
connexion with the subject.’ In the work before us Dr. Krause
remarks, that disease of the liver is but a rare attendant upon empy-
ema, as he has only witnessed it in two of the numerous cases he has
seen; in one it was prodigiously enlarged, and studded over with
tubercles; in the other case hydatids were found in the viscus, On
looking over Dr. Krause’s cases, however, we find, that though in
many he makes no mention of the state of the liver at all, merely
concluding with the general remark, that the abdominal organs were
healthy, yet in those inwhich he does notice its condition, we find
that out of 14.cases where the effusion was in the left side, in 4 it is
stated to have been congested, in 2 much congested, and in 3 large
and congested; of the remaining 5 it is stated to have been hard in
2 cases, large and hard in 1, and softenedin 1. In those in which
the effusion occurred in the right side, out of 6 cases, it was large
and congested in 2, much congested in 1, large but bloodless in J,
small in 1, and sound in 1.’
So that out of twenty cases of empyema (fourteen of the
left and six of the right side) the liver was congested in different
degrees in twelve cases.
From the fact of this congestion of the liver having been so
frequently observed after death, there can be no doubt that its
presence would have been detected in many of the successful cases,
had the attention of Dr. Krause been directed to the subject;
but as it is, they fully corroborate the statements advanced by Dr.
Mae Donnell, and “ this condition of the liver must now be
considered as constituting an additional feature in the diagnosis
and pathology of empyema.” Dr. Krause gives an interesting
case of encephaloid disease of the lung, which was mistaken for
empyema, which we shall lay before our readers in his own
words :
<< Nisten Nadolski, aged 40, of a slender make, was admitted into
hospital on the 27th February. Up to that time she had always en-
joyed good health; had never suffered from chest complaints; and
was seized with pneumonia of the right side, which ran its usual course,
At the end of four weeks the patient was, by her own urgent desire,
dismissed, and although she had still some difficulty of breathing, with
purulent sputa, and there was still dulness on percussion at the base of
the right side, and want of respiratory murmur. She continued to
&
488 Bibliographic Notices.
improve at home, the cough disappeared, and she gained strength.
At the end of four weeks, difficulty of breathing again occurred, the
expectoration returned, she became hoarse, and complained of pain
during respiration. She was again admitted on the 27th May.
There was now considerable emaciation, and pretty smart fever.
The respiration was hurried, and the right side a little enlarged.
A firm tumour was observed under the right arm-pit, but some-
what anterior, which rested on the ribs, had a natural colour,
and was very slightly painful. A vein about the size of a quill
spread over it, running down from the arm-pit: the patient had first
remarked it fourteen days previously. The glands in the axilla were
free from swelling; respiration was heard at the summit and base of
the lung, but was wholly absent at the middle portion; percussion
was dull over the whole right side, and normal only under the clavi-
cles ; the expectoration was considerable, of a dirty green, with a pe-
netrating odour. The state of the patient much the same for some
days; she lay continually on her back, and slept little during the
night. The tumour continued to increase in size, became livid, and
fluctuation was felt. It was opened by means of a bistoury. No pus,
however, appeared, but a bloody-coloured serum, and the incision was
immediately filled with a grumous, homogeneous mass. There was
considerable haemorrhage from the wound, but this was controlled by
cold applications; the strength continued to sink, and she died on the
6th of June.
«¢ When the skin was dissected off the tumour, an encepholoid
mass of the size of the fist was remarked ; it lay upon the third and
fourth ribs, and was in part covered by the pectoralis major and ser-
ratus magnus. It could not be separated from the ribs, as it pro-
truded through the intercostal spaces, and had its root within the
thorax. On the sternum being removed, a large mass was perceived,
filling almost the entire of the right side of the chest. After being
separated from its attachment to the parietes, it was removed; on an
incision being made into the lung, the middle portion of it was found
to be completely supplanted by an encephaloid mass, which had the
consistence as well as the appearance of brain, and was traversed here
and there by fascicule of vessels. The apex of the lung for about
the breadth of a hand was in good condition, but compressed. Seve-
ral small tumours, varying in size from a nut to that of a hen’s egg,
were situated in the lower lobes; some rested on the ribs, and on
removing them, the former were found to be deprived of their peri-
osteum, but not carious; the cellular texture of the bone was sound.
There were no traces of similar tumours in any of the other cavities.
The left lung was somewhat oedematous, but otherwise healthy, as
were also the heart andliver. The kidneys and the intestines shewed
nothing abnormal. The glands of the chest were removed along with
the tumour, and could not be found. ‘Those of the neck and oppo-
site side were quite unchanged.”
We regret we have not room to insert two cases of empyema,
in one of which the matter escaped through a hole in the dia-
phragm, and descended down to Poupart’s ligament, where it
we
 Paracentesis Thoracis.— Empyema. 489
presented the appearance of a psoas abscess, and was opened.
The boy, however, soon died, and then the true nature of the
disease was discovered.
In the second case the matter perforated the diaphragm,
and burst into the transverse portion of the colon by two aper-
tures, through which feeces passed upwards into the right pleural
cavity, which had been the seat of the disease.
‘«¢ When an operation becomes necessary, Dr. Krause is decidedly
of opinion, that an early period of the disease is not the best, but that
itis much more likely to prove beneficial after the tendency to inflam-
mation is somewhat diminished.”
These views are (as our readers may perceive) in direct va-
riance with those of Dr. Hamilton Roe, the success of whose
operations affords, in our mind, strong evidence of the soundness
of his opinions.
We shall conclude this notice with an extract from one of
the Clinical Lectures of Schonlein, published in the Lanceé for
April 28th, 1844.
“Tread a few days ago,” he says, ‘in the Austrian Medical
Annals (Oesterreichische Medicinische, Jahrbiicher, 1841, Januar.
Juli), Skoda’s report on the cases of empyema that were treated in
his ward for diseases of the chest, and must confess that the facts he
makes known, with characteristic openness and sincerity, for he fre-
quently performed the operation, do not tempt us to follow his ex-
ample. Almost two-thirds of the cases he treated ended unfortu-
nately, for the operation was very soon followed by symptoms of
returning pleurisy. Here, in this case, where we are menaced with
a complication of delirium tremens, the indications with regard to
the treatment are changed, but I confess that the matter is not quite
clear to me, and that I am not inclined to come to a precipitate de-
cision, for the following reasons ; first, because the apparition of deli-
rium tremens merely threatens as yet, and has not actually taken
place: secondly, because,if delirium tremens should really supervene,
the operation might havea still worse result, for we know that wounds
during the existence of this malady very easily assume a putrid charac-
ter, and that every operation has an inflammable reaction upon the brain.
* * * «Jn the account of Skoda and Schuh, which I have
cited, a form of effusion into the cavities of the pleura is mentioned,
which cannot be distinguished during life, at least as yet, but which,
when the operation has been undertaken, not only makes it ex-
tremely difficult, but inevitably leads to a fatal termination, and fur-
nishes another reason why I must declare myself an opponent to the
operation; this is the case where coagulable lymph swims in the
effused liquid. I, for the first time, saw such a case in Wiirzburg, in
an elderly man, on whom Textor, at my request, undertook the ope-
ration. After more than a hundred of these flocci had already been
evacuated, the flow of the liquid was suddenly stopped. Textor
examined the wound with the finger, and thought that it had pene-
490 Bibliographic Notices.
trated into the pericardium, on feeling a mass similar to the cor vel-
losum, but it was only a convolution of plastic flocci, which, on
being pushed back, allowed free egress to the liquid. In consequence
of the irritation produced by the remaining flocci on the pleura, vio-
lent inflammation was brought on, which terminated fataily. Skoda
and Schuh have also cited several similar cases, and undertaken
the operation when there was no urgent necessity from the vio-
lence of the symptoms; their termination was unfavourable, and
on dissection the cavity of the pleura was found filled with coagulable
lymph. As yet we have no means of distinguishing the quality of
effused liquid, in each individual case during life; it is only to be
found out by autopsy. We have, therefore, another reason for not
undertaking the operation precipitately. ‘But,’ it might be ob-
jected, ‘by stimulating the secretions the flocci which remain after
the more fluid part has been absorbed, will produce the same me-
chanical irritation as after paracentesis” To this I answer, that
experience, it is true, can prove nothing in this question, but that
analogy and induction furnish sufficient grounds for invalidating this
objection. After paracentesis the emptying of the sac is rapid, and
the coagula of albumen and fibrine come into immediate contact with
the surface of the pleura, after the evacuation of the water; but we
know that the more rapid contact of a surface with a foreign body is,
the more violent the reaction becomes, and again, that when it
takes place slowly, the reaction proportionally decreases, and some-
times even does not occur at all, or in other words, the irritation
gradually wears itself away; this is a universal pathological truth.
But we have still another answer to this objection, for in the same
way that coagula of blood (for instance, in apoplexy of the brain)
are gradually absorbed by the surrounding fluid, so. the absorption
of the coagula of albumen and fibrine can also gradually take place in
this case, and this is a further reason for preferring, to immediate
evacuation, the slower process of absorption, by stimulating the se-
cretions.”’
We have now laid before our readers an analysis of all that
has been written within the last few months on this interesting
subject. Dr. Hughes and Mr. Cock are strong advocates for
the performance of the operation, but do not confine it to any
particular stage of the disease. Dr. Williams and Schonlein
are opposed to it, but their objections appear only applicable
to the advanced stages of empyema. Dr. Hamilton Roe ope-
rates early in the disease, and with marked success ; and though
Skoda, of Vienna, has been cited as averse to paracentesis in
Eimpyema, we know that he advocates the operation in the
early stage of inflammatory hydrothorax, for we ourselves have
seen him perform it on a patient who had been admitted into
his wards only a few hours previous to the clinical visit, and
who had been but a couple of days ill. In this instance he
resorted to paracentesis immediately he had satisfied himself of
the existence of fluid in the chest; in this he was, perhaps, too
precipitate.
 SCIENTIFIC INTELLIGENCE.

PROCEEDINGS OF THE PATHOLOGICAL SOCIETY OF

DUBLIN.
SEssion 1842-1843,
First Meeting, 26th of November, 184
2.
Str Puitie Crampron in the Chair.
1. Pneumothorax.—Mr. O’ Ferrall
cate to the Society a case of pneumothorax said that he had to communi-
circumstances; (the recent parts con
, attended with some unusual
cerned in the affection were on
the table). The subject was a fema
le, zt.
into St. Vincent’s Hospital in the last stag 40, who had been admitted
e of phthisis, suffering ander
the tubercular diarrhoea, but with littl
e cough. She gradually sunk,
but two days before her death she was
obs
complained of the sensation of a stitch erved lying on her side and
in the left side, which was
found to be tympanitic to percussion;
when she sat up in bed, the
same clearness of sound was observed
posteriorly; there was no dis-
placement of the heart, no sign of pres
sure from within; there was
no metallic tinkling, but there was amp
only 48 hours after these Symptoms were horic resonance; she lived
examined after death; the left lung was observed. The body was
found to be small and com-
pressed; in its superior portion was an
opening into the cavity of
the pleura, anterior and superior to
a large tubercular cavity in
the lung, with which it communicated
, It was remarkable that
there was no pleuritis. The pleura was
unusually dry. The dis-
placement of the heart had probably bee
n prevented, partly by adhe-
sions of the lung and partly by the low, exh
aus
and the feeble respiratory action. The case ted state of the patient
then was remarkable, for
being one of pure pneumothorax or pneuma
tothorax, in which there
had been no escape of fluid into the pleural
sac, because the opening
into the tubercular cavity was near its upp
er part; for there having
been no pleuritic effasion, probably in con
seq
that the patient survived the accession. of uence of the short time
the pneumothorax; and
lastly for the absence of any displacement
of the heart; as there was
also the absence of metallic tinkling, it mig
ht be worthy of inquiry,
whether this symptom is not to be consid
ered as connected only with
pneumothorax when there is also effusion into
the pleura.
2. Encephaloid Disease of the Liver.—Docto
r Lees said he had
to lay before the Society a good example of ence
phaloid disease of the
liver, taken from the body of a female who had
died on the previous
492 Scientific Intelligence.
into which she had been ad-
day, in the Hospital of the South Union,
iation and debility, labour-
mitted on Monday week ina state of emac t 46 years of age, and
ing under pleuropneumonia. She was abou th up to three months
heal
described herself to have enjoyed good eived a tumour in the right
perc
previous, when she, for the first time,
of her admission into hospital ap-
hypochondrium, which at the time to habitual constipation;
peared very large. ‘This tumour she ascribed
had there been at any for-
there was neither ascites nor jaundice, nor after death, the liver was
ed
mer period. When the body was examin
ement was principally in the
found enormously enlarged; the enlarg
tuberculated. Dr. Lees
right lobe; the surface of both lobes was meeting, shewed that it
the
having made a section of the liver before
ence phal oid structure intermingled
was pervaded throughout by the
gall bladder was implicated
with the parenchyma of the organ. The
two large, very dark-coloured
in the same disease, and also contained
ng life there had been no
gall-stones. It was remarkable that duri
ased condition, except the
symptoms to indicate this extensively dise The right lung appeared
tumour, perceptible in the hydochondrium. of the same disease that
healthy, but in the left, there was a deposit
affected the liver. Montgomery said
3. Vesicular Polypus of Os Uteri.—Doctority of producing to
rtun
that he was indebted to Dr. Lees for the oppo
ing form of disease, which
the Society a specimen of a very interest
two former occasions.
had been the subject of his observations on
of the os uteri; the pre-
The disease was the small vesicular polypus
patient just alluded to by
sent specimen occurred ‘n the uterus of the the mode of growth of
that
Dr. Lees. Dr. Montgomery observed,
an enlargement of the mu-
this polypus was peculiar; it consisted in remarked that the poly-
ciferous glands near the os uteri. It has been another high up within
pus rarely exists alone, there being usually There is often
but the one.
the uterus, but in this case there was
kind, either by excision or
great difficulty in extirpating polypi of this
has found that they may
ligature; in such cases Dr. Montgomery
nt solutions introduced
frequently be destroyed by strong astringe directly to the morbid
ied
through a bent glass tube, so as to be appl
e this was successfully ef-
growth. He had met with one case wher
ly fallen a victim to ano-
fected, but in which the patient had ultimate
the present the patients
ther uterine disease ; both in that case and non-development of the
or
were unmarried, and there was atrophy
larg er than those of a child
ovaria, which in this instance were not
three years old.
into lateral Ventricle;
4. Cerebral Apoplexy; Extravasation
laid before the Society a
red Ramollissement.—Doctor Corrigan
cerebral apoplexy ; there
preparation of the parts concerned in a case of
right ventricle and pro-
was a very large clot of blood occupying the
ed, some slight serous
truding into the left. When the skull was open r the arachnoid, over
unde
and sanguineous effusion had been observed if anything rather
was
each hemisphere, the tissue of the brain itself
 Scientific Intelligence. 493
firmer than usual, and was studded with red points; on cutti
ng down
to the right ventricle the clot was found, which was so
large that it
protruded, as could be seen in the preparation, into the oppos
ite ventri-
cle. It had broken up part of the optic thalamus and corpus
striatum,
and even occupied the posterior cornu; there was no effusion
at
base of the brain. At alittle distance from the clot was a spot the
of red
ramollissement, It had been a question among pathologists whether
this condition is precedent to, or consequent on the extravasat
ion of
blood; Dr. Corrigan thought that this case, with some of those
recorded
by Abercrombie, would prove that it follows the extravasation.
subject in the ‘present case was a woman who had suddenly The
fallen
down, and was brought to the Whitworth Hospital on the
14th
November in a comatose state, very cold and with a pulse scarc of
ely
perceptible. On the next day she rallied a little, but was obser
ved to
be paralyzed at the left side; the paralysis was both of motio
n and
sensation, and this Andral has considered a decisive symptom
of blood
having been effused. This patient continued conscious for two
days
and then sunk. In this case the effusion had been very sudde
n, and
Dr. Corrigan thought that it might be useful to contrast it with
ano-
ther form of apoplexy, exemplified in a case that he had formerly
at-
teaded along with Dr. Stokes. The subject was a gentleman
who
one morning at breakfast time was observed to be incoherent in
his
speech, somewhat bewildered and confused in recollection. The
Same symptoms were again observed at a later period of the day, and
continued in the same manner for two or three subsequent days, when
paralysis of the upper extremity occurred. In this case two distinct
effusions of blood were found, and the brain was in the state
of white
ramollissement, which was probably indicated by the disturbance of
the intellectual functions which preceded the effusion and paralysis.
5. Aneurism of the Abdominal Aorta.—Dr. Hutton said he
had to communicate a case of aneurism of the abdominal aorta. The
subject, Patrick Lynch, was zt. 50, who was admitted into the
Richmond Hospital on 21st April in the present year. Two months
previous to his admission, he was seen by Mr. Monahan, who found
him pale and emaciated, complaining of pain in the loins, and in the
left testicle, passing down into the thigh: there was a slight fulness
in the loins; the pulse in the femoral artery was not diminished.
When the stethoscope was applied posteriorly to the spine, a single
soufflet was audible. From this examination Mr. Monahan diagnosed
aneurism of the aorta; another gentleman, two days afterwards, con-
sidered the case to be one of lumbar abscess, having omitted to
examine with the stethoscope. Ina month after Mr. Monahan had
made his examination, a pulsating tumour became apparent in the
loins, which in the course of another month had attained an immense
size, reaching from the crest of the ileum up to the inferior margin
of the scapula; much of the enlargement was sudden, and attended
with a sense of faintness. At this period the soufflet had become
less audible, the pulse in the left femoral was diminished, the bowels
VOL. XXV. NO. 75. 3s
494 Scientific Intelligence.

were constipated, there was little or no suffering from neuraleic pains,

and there were no cramps in the lower extremity. After he was
admitted into Hospital, diarrhoea set in, and he sunk rapidly. It ap-
renal
peared that before his admission, he had been treated for
he
disease, had been cupped. on the loins, &c., and he stated when
of the
came into hospital that he believed his complaint was disease
kidney. In ten days after his admission he died in a state of syn-
No
cope, and had been jaundiced for two or three days previously.
deformity of the spine had been noticed during life, but when the
on
body was examined after death, curvature in more than one directi
of the parts, illus-
was ascertained. [Dr. Hutton exhibited a cast
of the
trating the relations of the tumour, which occupied the region
psoas muscle, and shewing the situation of the orifice in the aorta
spine
adjacent to the bodies of the vertebree. He also produced the
had
itself, attached to the pelvis, prepared by maceration.] The spine
nearly reache d the
been eroded by the aneurism, and the blood had
ges
canal; the bodies of the vertebrae and the inter-vertebral cartila
had presse d on the
were in several places absorbed. The tumour
empty ;
lobulus spigelii, and on the ascending vena-cava, which was
the right cavities of the heart were also empty.
6. Porrigo, or Tinea Capitis.—Dr. Corrigan said he wished to
or
direct the attention of the Society to some drawings of porrigo,
tion, and to illustr ate
tinea capitis, which he had there for their inspec
to
his observations on the disease. The true porrigo he considered
be a very rare disease, and incurable by any means as yet ascer-
three
tained. In the course of eight years he had met with but
classes;
cases of it, all of which were in the lowest and most destitute
he had never seen it in private practice. Severa l diseas es had
fre-
been confounded under the name porrigo, and hence quacks
they
quently got the credit of curing the incurable disease, when
affecti ons
had in fact only met with some of those more manageable
which were confounded with the genuine porrigo. The diseases
;
liable to be confounded with it were these :—impetigo of the scalp ar
eczema impetiginodes, and porrigo decalvens, which is not a pustul
r and
disease at all. The true porrigo is accompanied by a languo
imbecility which approaches to idiotcy: when, by poulti ces, deter-
e
gents, or other means, the scalp has been cleaned, and a red surfac
of distinct,
produced, the disease always reappears on it in the form
white, solid pustules, round and depressed in the centre; these had
been found to consist of phosphate of lime and albumen. He had
who had in vain
seen acase of the genuine disease in an adult,
travelled to every hospital almost in England and Ireland, with the hope
of being cured. The appearance of the disease in his case was well
expressed in one of the drawings. In fact, all the medical attendant
e clean,
can do in the treatment of this disease is, to keep the surfac
mental faculti es,
but the eruption is sure to return, and to affect the
as he had already observed.
 Scientific Intelligence. 49 or

Second Meeting, 3rd of December, 1842.

Dr. MontGomery in the Chair.
1. Cancer gelatineuse of the Abdominal Viscera.—Dropsy.—
Dr. Bigger said he had to lay before the Society a recent specimen
of a disease which is not often met with. It had been described by
Cruveilhier, and is the Cancer gelatineuse of the French Pathologists,
In the present case it pervaded all the abdominal viscera. The sub-
ject was a female who had first come under his notice about four years
ago. For several months she was affected with almost incessant vo-
miting; there was anorexia, thirst, want of sleep, and in short every
symptom indicative of prominent organic disease, with the exception
of pain, which was absent. At the end of a year the malady had in-
creased very much; she had become unable to swallow solid food, and
could with difficulty swallow liquids—in fact oesophageal vomiting
came on whenever the bulk of more than halfa teacup full of any sort
of food was taken in. Subsequently to her having been under his
care, she had been under that of his friend Mr. Nunn for two years,
Early in the second year of the disease dropsy made its appearance,
to relieve which diuretics, mercurial and other remedies were used,
but without success. Towards the last period of life the inanition had
become extreme: both ingesta and egesta were very small in quantity,
and the egesta from the bowels were frequently intermixed with trans-
parent hydatids. The patient continued to sink, and a fortnight
ago expired. Her friends would not allow any of the cavities to
be opened except the abdomen, and the examination was very
hurried. There was much fluid in the abdomen; all the viscera
were covered with small gelatinous hydatiform bodies, which existed
even in the omentum and mesentery. The stomach was very small—
there was a considerable thickening about the cardiac orifice—the tis-
sues of the stomach were altered in character—the muscular coat was
diaphanous, and had lost all the characters of muscle—the cesophagus
was concerned in the disease, which was ascertained by passing the
finger up into it during the dissection.
2. Pericardites.—Dr. Corrigan said the case he had to commu-
nicate was one of pericarditis, which he considered to be a good ex-
ample of the pathology of the disease. The subject was a boy, et. 18,
who was admitted on the 3rd of November into the Hardwicke Fever
Hospital. The expression of his countenance was remarkable, and
led to the suspicion that pericarditis existed; there was that slight
contraction of the brow which often accompanies the disease. There
was slight cedema of the integuments in front of the region of the
heart, an appearance for which different causes are assigned, some
attributing it to a serous effusion under the skin. ‘To the left side of
the sternum the integuments were swollen and smooth, and the entire
of that space was dull on percussion. On the 18th of November, the
respiration was hurried and rapid—the pericardium had suddenly be-
come distended. After this he was for some time relieved by the
496 Scientific Intelligence.
treatment adopted, but on the 29th he was jaundiced; his pulse was
extremely rapid and feeble; he continued to get worse, and died yes-
terday. For afew days previous, a bruit de soufilet was audible.
[Dr. Corrigan exhibited a cast of the upper part of the body after
the thorax was opened, the sternum and cartilages of the ribs being
removed, showing the thoracic viscera iz situ. The parts themselves
were also on the table]. When the thorax was opened, the pericar-
dium was observed to be enormously distended, reaching upwards as
far as the first rib. The heart itself was coated with a pulpy lymph,
which on some parts might be compared to the appearance which
would be presented by.oil or viscid matter interposed between two
opposite smooth surfaces, which were afterwards drawn asunder. Dr.
C. having cut into the left ventricle, shewed that there was a slight
thickening of the edge of the valves. There had been in this case a
very loud bruit de frappement, which was most remarkable when the
patient lay on his back: when he sat up or leaned forward it was
diminished, and sometimes altogether disappeared. These circum-
stances are important, as they distinguish this sound from the bruit
de soufilet, with which it is liable to be confounded. There was no
souffiet until the latest period of the disease, shortly before death.
3. Sub-arachnoid Meningitis of Cruveilhier.—Mr. O’Ferrall
laid before the Society the recent specimens and accurately coloured
drawing, illustrating a case which he said exemplified very well the
obscurity which involves the diagnosis of affections of the brain. The
subject was a female admitted into St. Vincent’s Hospital, suffering
under an abdominal abscess that occurred after parturition, presenting
the symptoms usual in such cases. A very large fluctuating tumour
appeared in the lower half of the abdomen; this, after some time,
pointed in the right labium, which at last gave way, and the contents
were evacuated. The tumour disappeared; the patient appeared to
be convalescent, and did well for several days. After eight or ten
days from the closure of the opening, she was observed to be remark-
ably dull, but did not complain of any pain; however at night she
complained of headach, screamed suddenly, and fell out of the bed.
She was raised in a comatose state, in which, with little variation of
symptoms, she remained for forty hours, during which deglutition was
very difficult, and the discharges were involuntary. Death occurred on
thesecond day after the attack: the case was evidently one of coma and
collapse, without any previous state of excitement. When the cra-
nium was opened, the arachnoid appeared healthy, there was no opa-
city, no deposition, but underneath the serous covering, and in some
places between the convolutions, there was a semi-liquid deposit,
which varied in appearance from white to yellowish ; there was none
at the base nor at the lateral parts of the brain. In the ventricles were
four or five drachms of fluid. The substance of the brain was firm.
Mr. O’F. considered it an interesting question for discussion, whether
this was a case of meningitis, or of deposit consequent on the abdo-
minal abscess? Most authors agree in describing such a case as one
 Scientiic Intelligence. 497
of meningitis, yet Marshall Hall warns us against inferring the exis-
tence of inflammation from the circumstance of a deposit being found
under the arachnoid, even if the deposition contain lymph; because,
as he relates, he has found this in cases of anzemia and of delirium
tremens. It is very dificult (Mr. O’Ferrall observed) to determine
what symptoms are pathognomonic of meningitis. Lallemand considers
them those of excitement, while, on the contrary, Cruveilhier describes
them to be torpor, coma (with the absence of pain), delirium, or con-
vulsions. Andral states that there are none of those symptoms that
may not be either absent or present in meningitis, and that the stage
of excitement may be so transient as to escape observation, or in other
cases that it maybe protracted so long before the occurrence of coma,
that it will appear to constitute the whole character of the affection.
This, however, is but an attempt to reconcile together opposite opi-
nions—the difficulties still remain. According to Dr. Bright’s opi-
nion, this was a case of meningitis, and some period of excitement
must have occurred. Mr. O’Ferrall concluded byobserving, that the
case was very interesting, both on account of the short time the dis-
ease had existed, and the difficulty of deciding whether it was menin-
gitis, or an affection connected with a previous purulent deposit.
4. Tuberculated Liver.—Dr. Molian said the specimens he had
to present to the notice of the Society, were taken from the body ofa
female 80 years of age, who had been twenty years a patient in the
Richmond Lunatic Asylum. Three weeks before her death she be-
came jaundiced, but there was no pain, no vomiting, no febrile dis-
turbance. The liver presented a remarkable state of disease, its sub-
stance being pervaded by innumerable cancerous tubercles, some of
which were softened. The gall bladder was filled with gall-stones. A
very large gall-stone was found intheduct. In this case during life there
was no suffering correspondent to the extent of the diseased condition
discovered after death: this is a circumstance often observed in luna-
tics. In this patient’s case, there was only some diminution ofthe usual
appetite for food, and an increased degree of emaciation in addition to
the icteric symptoms. In the head there was no appearance of dis-
ease, with the exception of a slight opacity of the arachnoid mem-
brane.
5. Abscess behind the Pharynz ; entrance of Air into the veins.
Mr. R. W. Smith said the preparation which he then exhibited to the
Society was from a female, at. 60, who was admitted on Tuesday last
into the Richmond Hospital. The history of her case was this: on
the previous Saturday in the act of deglutition, a bone had stuck in
the pharynx where it remained fixed for about three hours. Up to
the last moment of life she was unable to swallow solids. On admis-
sion into hospital she complained of pain in the throat (not in the la-
rynx); she was watchful and did not sleep. At the right side of her
neck a tumour was observable, it was variable in size and evidently
contained both air and liquid. On Friday the pharynx was minutely
examined, and a tumour was observed projecting into its lower portion,
A98 Scientific Intelligence.
The tumour was punctured with a trocar and some air escaped from
the wound; in a few minutes afterwards she fell back and expired;
the veins of the neck were distended with air.
When the body was examined after death, a large abscess was
found situated behind the pharynx and cesophagus, extending into the
posterior mediastinum. It bad burst by numerous small openings
into the cesophagus, and had also infiltrated with purulent matter all
the loose reticular tissue between that canal and the vertebral column.
Mr. Smith considered that in this case the fatal disease had originated
in the injury done by the foreign body to the mucous lining of the
pharynx, from which the abscess rapidly resulted. The veins had
been eroded and opened by ulceration. He would deduce from this
case and from the previous observations of Doctor Fleming the neces-
sity of a careful examination of every abscess occurring behind the
pharynx, and also that they should be punctured ina very early stage.
In the present case the death was caused by the entrance of air into
the veins, a mode of termination that had not been observed before
in similar cases.—(Museum, Richmond Hospital.)

Third Meeting, 10th of December, 1842.

Dr. MontrGoMERY IN THE CHAIR.
1. Dislocation of the Thumb.—Mr. R. W. Smith said, the pre-
paration which formed the subject of his communication to the
Society, was one of great interest to the surgeon. It was a case of
dislocation of the thumb, which had been sent to him by Surgeon
Brabazon, of Downpatrick. Every surgeon was aware of the extreme
difficulty of reducing dislocations of the thumb. The most frequent
occurrence of that kind is the dislocation in which the first phalanx is
luxated on the dorsum of the metacarpal bone. In the present case,
the second phalanx was luxated on the dorsum of the first. The
accident had happened to a man holding a horse by a long rein; the
horse started off suddenly, and the man was thrown to the ground,
with which his hand came into contact in such a manner, that a com-
pound luxation of the thumb was produced. [Mr. Smith exhibited a
drawing of the appearance it presented.] The head of the first pha-
lanx was forced through the integuments. The flexor tendon was
forcibly displaced, and lay between the first and second phalanges.
It was evident that reduction would have been very difficult, if not
impossible. Mr. Brabazon was apprehensive of tetanus ensuing;
he therefore preferred amputation, which he performed by cutting
through the first phalanx with a bone forceps.
Mr. Smith then produced a cast, and drawing of the dislocation
of the first phalanx of the thumb on the metacarpal bone, usually
described as Hey’s luxation. It would be seen that there was a
prominence towards the palm; the first phalanx was ata right angle
with the metacarpal bone, or nearly so. This was the more common
species of dislocation of the thumb, and is very difficult to reduce
 Scientific Intelligence. 499
In the case represented by the cast, a surgeon had proposed an ope-
ration which, from the patient’s description, Mr. Smith supposed to
shave been to cut down on, and remove the head of the bone; this
the patient refused to submit to, and the luxation remained unre-
duced.
As to the immediate cause of the difficulty of reduction, there
were various opinions. Hey conceived it to be the wedge-like shape
of the metacarpal bone, but this Mr. Smith considered could not be
the cause, because there was equal difficulty of reducing the luxation,
the reverse of Hey’s, where the metacarpal bone is luxated on the
dorsum of the phalanx, and where, consequently, the shape of the bone
could not offer the same obstacle; of this, which is an exceedingly
rare accident, there is a case recorded by Velpeau, where he failed
in effecting reduction, and where Roux was equally unsuccessful.
Mr. Smith approved of the explanation given by Mr. Adams in the
Cyclopzedia of Anatomy, that it is not owing to any mechanical ob-
stacle, but to the violent vital contraction of the numerous small
muscles of the thumb. Another alleged cause was, that sufficient
extending force could not be applied, but this is evidently incorrect,
for cases have occurred, where in the attempt to reduce, extending
force had been applied, and continued to such a degree, that the
second joint had been completely torn away from the limb.—( Museum,
Richmond Hospital.)
2. Aneurism of the Arteria innominata—Mr. Hutton pre-
sented a preparation and illustrative drawing ofa case of aneurism
of the innominata, in which the distal operation had been tried. The
subject of the case was aman named Fleming, aged 47, who had
been in good health up to March 1841, when he was attacked by
pain in the right shoulder and clavicle, and which gradually affected
also the neck, ear, and side of the head. This pain, which at first
occurred only at intervals, after some time become constant. In
June a cough came on which was dry and recurred in fits. After
this had continued for several days he began to expectorate. These
symptoms were succeeded by difhculty of swallowing, and severe
neuralgic pains. In November his loss of health and strength had
become remarkable, and there was then perceptible a small pulsating
tumour under the cleidomastoid muscle. He was admitted into the
Meath Hospital, and was there subjected to Valsalva’s method of
treatment, but with very little benefit. In April, 1842, he presented
himself at the Richmond Hospital; the tumour was then situated
close to the sterno-clavicular articulation, a little to the outside of the
sternal attachment of the sterno-cleidomastoid muscle; there was no
soufflet; the right radial artery felt as if its canal was somewhat
diminished, and the pulse was somewhat less in it than at the oppo-
site wrist; there was bronchial cough and dithculty of breathing; it
was observed that the dysphagia became less as the tumour had risen
above the sternum. After his admission into the hospital the pulse
at the wrist became gradually smaller, the tumour continued to in-
500 Scientific Intelligence.

crease in size, and passed across the middle line of the neck; its
longer diameter, which was two inches, lay across the neck, while
the diameter from above downwards was but an inch and a half. The
patient was quite aware of the fatal tendency of the complaint, and
also of the uncertainty of averting it by operation, yet he readily
consented that the operation should be performed. On the 27th of
June the operation was accordingly performed, by tying the right
carotid opposite to the cricoid cartilage ; he became very faint when
the ligature was applied, but after this faintness there set in a strong
reaction; the pulse, at the time of the operation, was from 50 to 70.
On the next day it had risen to 110, but the tumour, which had col-
lapsed when the artery was tied, did not resume its former dimen-
sions. On the second day after the operation, the tumour appeared still
diminished in bulk, and the pulsation in it was less. The fever was
gradually subsiding, and the patient getting better in every respect,
when he was attacked by bronchitis; for several days after this had
been subdued the progress of the case appeared favourable, the dith-
culty of breathing became less, and the tumour was becoming smaller.
However, on the 22nd day after the operation, there was hemorrhage
from the wound to the extent of about six ounces; the hemorrhage
was controlled by pressure. In five days after this hemorrhage
again appeared, but to the amount of not more than two ounces; a
steel collar was then applied, with a pad, in the manner suggested by
Surgeon Peile. Oa the thirtieth day after the operation, the ligature
was found loose, and there was considerable discharge from the wound,
to an extent far disproportioned to the surface of the sore. On the
thirty-sixth day he had an attack of diarrhoea, which was at that time
epidemic; unfavourable symptoms gradually supervened. On the
thirty-eight day he had rigors and convulsive motions resembling
epilepsy; on the following morning a thick, dark-coloured fluid was
discharged from the wound, but without jet. On the forty-first day
the rigors recurred. On the forty-second, the tumour was evidently
increased in size, and the sputa more bloody; from this time the
tumour gradually enlarged, and the pulsations in it became more
frequent. On the sixty-fifth day there was a sudden enlargement
of the tumour, accompanied by syncope. On the seventy-sixth day
he died. When the body was examined it was found that there had
been no attempt at union in the artery, it had ulcerated through at
the situation of the ligature; above this point there was atheroma-
tous deposition in the vessel; the aneurismal tumour contained puru-
lent matter and grumous blood; the coats of the innominata were
thickened; the tumour projected into the trachea, and had there
been perforated with a very small opening, through which the blood
had passed into the trachea and lungs; the lungs were slightly em-
physematous; the aorta was not dilated, but there was atheromatous
deposit between its coats; the left vertebral artery came off from the
arch of the aorta; the left subclavian was healthy ; on the right side
the carotid was filled by a large conical coagulum of about an inch in
extent. In the right subclavian was a coagulum evidently older than
 Scientific Intelligence. 501
that in the carotid; it extended from the origin of the
vessel to where
the vertebral is given off, but it was pervious into
the sac of the
aneurism; the right subclavian was diseased in the great
est part of
its course. The wound made in the operation had becom
e afistulous
Opening, and the aneurismal tumour had, by its enlar
gement, nearly
rcached the external orifice.—( Museum, Richmond Hospi
tal.)
3. Intestine protruded throughout abdominal Parietes durin
a Paroxysm of Hooping-Cough.—Mr. Adams presented the g
speci-
men, and also a cast, taken by Mr. Smith, from the parts
2m situ.
The case was a very unusual one, being a protrusion of
the intestines
(to an extent of about six feet of the tube) which had occur
ed to a
child ten years of age, in consequence of a violent paroxysm
of hoop-
ing-cough; it was not, however, a simple case of hoopi
ng-cough,
the child, who was very delicate, greatly emaciated, and neglected
by its parents, having also laboured under Pott’s curvature of
the spine,
and an intra-inguinal hernia, in front of which was a chron
ic abscess
with a fistulous aperture. The case was first seen by Mr.
Duignan,
the resident pupil at the Richmond Hospital. He found
the child at
the abode of the parents, who were poor people ; it had been
vomit-
ing, and was then lying on its back, with the legs drawn
up towards
the body: there were all the Symptoms of peritoneal infla
mmation
present, and when the bed clothes were removed, it was discovered
that there was a protrusion of the intestines in the right groin.
The
account given was, that the child on the previous night had
screamed
suddenly after a violent paroxysm of the cough; immediatel
y on
which the mother observed the intestines protruded, but instea
d of
sending for assistance, covered them with a weight of bed-cl
othes.
Mr. Duignan desired the child to be sent into hospital,
but this the
mother pertinaciously refused. The protruded portion of intestine
was at this time in a state of inflammation, very tender, and coate
d
externally by a dirty ash-coloured lymph. While an attempt
was
made at reduction, more of the intestine was protruded. About
noon
the case was seen by Drs. Adams, Power, and Macdonnell; there
was then about a foot in length of the intestine protruded, and
the
lymph thrown out on it was, as well as the intestine itself,
of a dark
livid colour; reduction was impracticable. At eight in the eveni
ng
the case was evidently hopeless; the child was cold, nearly insensible,
However, Mr. Adams and Dr. Hutton determined to make an
at-
tempt at reduction, although they could not prevail on the mothe
r
to send the child into the hospital. The case was obviously one from
which no surgeon could expect to derive any credit, there being’ peri-
toneal inflammation in addition to the protrusion of the intestine, and
every possible unfavourable circumstance being combined in the pre-
vious condition of the child’s health, and
the obstinacy of the friends
against its being sent into the hospital.Mr. Adams and Dr. Hutton
considered that the case might be viewed as one of wounded parietes
of the abdomen, with protruded intestine and stricture at the intern
al
opening, which ought to be divided; a director was introduced
and a
short incision made, when the child suddenly screamed and struggled
VOL, XXV. NO. 74. 3 T
502 Scientific Intelligence.
further with the
violently, and it was thought better to proceed no
an incision should
operation. It might be supposed by some, that
the reduction pro-
have been made to lay bare the ring, and then
done no good
ceeded with secundum artem, but this would have
ed. The case fur-
unless the stricture at the internal ring was divid
hooping-cough,
nished an example of the effect of the violence of the
aided by peculiar coincident circumstances. Mr. Adams remarked,
of protruded
that a similar resistance and struggle against reduction
intestine is sometimes exhibited by adults, for instance, in persons
surgical anatomy
wounded in the abdomen during inebriation. The
r's direction
of the present case shewed the propriety of Sir A. Coope ed hernia;
stran gulat
to cut upwards in dividing the stricture about a
ded the iliac
in this case an incision downwards would have woun
stric. Should
artery, while one inwards would have divided the epiga
lay open the whole
a similar case ever again occur to him, he would
seum, Rich-
course of the canal and dilate the internal opening. —(Mu
mond Hospital.)
and Engorge-
A. Pleuropneumonia; Subarachnoid Effusion, O’Ferrall
n.— Mr.
ment of the Brain, subsequent to eatensive Bur to the Society an
said that at the last meeting he had communicated
on an enormous ab-
instance of a cerebral affection, supervening
dominal abscess. The specimens he had now to lay before them
had been consequent
belonged to a case in which a cerebral affection
e burn. It had been
to a severe external injury, a very extensiv
either within the twenty-
observed of such cases, that death may occur
the period of collapse),
four hours immediately after the injury (being
perhaps not till after the
or it may happen in the second period; or
nt case was a girl nine
eighth or tenth day. The subject of the prese
s Hospital on the
years of age. She was brought into St. Vincent’ was severely in-
She
sixth day after she had met with the accident.
g all more or less burned,
jured, the arms, chest, neck, face, &c., bein
by Dupuytren, from
and exhibiting every variety of burn described
was in a state of extreme.
mere vesication to the deepest eschars. She She lived but a
powers.
excitement, with depression of the vital On ex-
during the night.
short time after her admission, and died left lung;
amining the body, there was found extensive pneumonia ofthe
h recently thrown out on
the pleuree were also inflamed, and had lymp
solidified, and there was a general
them. Some portions of lung were
cranium there was a great
condition of engorgement. Within the
of the brain, so great that it
turgidity of the vessels on the surface
the vessels might be com-
was perceptible through the membranes;
was a minute ramiform vas-
pared to leeches in appearance. There
lutions, and numerous red
cularity over the surface of the convo
substance of the brain.
points were observable on the section of the
were many interesting in-
There was subarachnoid effusion. There the brain. Did
tion of
quiries connected with the subject of this affec injury to the surface,
te
it arisefrom a sympathy with the more remo ? It
as some of the phenomena during life might lead us to believe
be the result of these secon-
was certain, however, that death might
 Scientific Intelligence. 503
dary lesions. As to the treatment of such cases, there was great
diticulty in determining on it; the state of collapse, or general de-
pression of the vital powers, renders depletion unadvisable, and in
the period of excitement, there are often circumstances which still
forbid it.

Fourth Meeting, 17th of December, 1842,

Mr. O’Ferraut, M.R.I. A., in the Chair.
1. Perforating Ulcer of the Stomach—Adhesion of Stomach
éo the Liver.—Mr. Hamilton observed, that pathologists are ac-
quainted with three species of ulcers of the stomach. The first are
small, of irregular figure, appear like abrasions, and are found in the
middle of the stomach. The second, or aphthous, are usually very
numerous; they are minute, and of a circular form, with well-defined
edges, looking as ifa bit of mucous membrane had, in each instance,
been cut out. The third sort, which is more common than either of
the others, is the simple chronic ulcer. The patient from whom the
present specimens were taken, was a female, et. 28, who had suf-
fered gastrodynia during the last four or five years. The pain was
increased after eating, and was often accompanied by vomiting of the
ingesta along with a fluid matter, which sometimes was acid, some-
times acrid, or salt. Her colour was a pale straw, and she was
emaciated. She had occasional intervals of ease, which, on one oc-
casion, when she was pregnant, lasted during the entire period of
gestation. In last May she had a violent attack, which was followed
by hematemesis ; there was also pain of a severe kind in the region
of the liver, and at the tip of the right shoulder, so that the medical
attendant who was at that time called in, considering it to be a case
of hepatatis, prescribed venesection, and the use of mercury. After
this she got much worse. About a week before her death, Mr. Ha-
milton saw her; in five or six days after this, he was again sent for
suddenly. He was informed that she had drank some porter, and
was eating an apple, when she was seized with sudden and very
severe pain at the epigastrium, which extended over the abdomen.
Mr. Hamilton found her screaming with pain; the abdomen was
hard, the muscles strongly contracted, and there was no tympanitic
sound on percussion. She complained also of pain in both her
shoulders, particularly in the right, where it was very severe. No
remedy that was tried gave any relief. In the evening she had
become stupified by the use of opium, but there was still no relief;
the pulse was very rapid. Mr. H. concluded, from all the symptoms,
that it was a case of perforating ulcer of the stomach, and escape of
its contents into the cavity of the abdomen. The pain after some
hours appeared to be principally in the hypogastric region, and the
desire to pass water became very urgent, yet none was discharged;
the catheter was introduced, and the urine drawn off, but in very
smal] quantity, the bladder having been by no means distended. On
the following morning she was evidently moribund, and the abdomen
504 Scientific Intelligence.
had become remarkably tympanitic. She died in twenty-four hours
from the commencement of the attack. After death the body was
examined; it was extremely emaciated, but the abdomen was enor-
mously swollen and tympanitic. On laying it open, a brownish
fluid, in which were scattered some small portions of apple, was found
in the peritoneal cavity ; a little lymph had been effused on the in-
testines, but generally they were transparent and healthy looking.
The spleen and the liver were pale; on rising up the left lobe of the
liver, a circular opening was discovered in the parietes of the stomach ;
it was situated in the lesser curvature, near the cardiac orifice; about
the opening lymph had been effused, by which an adhesion was
formed to the liver. In the centre of the opening lay a fragment of
the core of an apple; the opening from the interior aspect appeared
of an oblong form, the longest axis being from above downwards,
and the greatest extent of the perforation being in the mucous mem-
brane. The stomach generally was pale.
2, Bilocular Bladder.—Mr. Porter presented a specimen of a
bilocular bladder. The history of the case was this. On the 27th
of November he was applied to by a man suffering great distress from
retention of urine; this person had been sent in from the country,
and stated that on the preceding day, as he was unable to pass water,
a surgeon had introduced a catheter, and drew off a small quantity of
urine, which appeared quite healthy; at night the same surgeon was
again applied to, and attempted to introduce the instrument, but then
found that he could not pass it into the bladder; some blood came
away on making this attempt. Mr. Porter having attempted to pass
a small sized catheter, found that he could not reach the bladder; he
then sent the man to the Meath Hospital, and there succeeded in
passing one of a larger size with which he drew offa quantity of
healthy urine; ever since that occasion the urine had changed in its
appearanee; it'was putrid and mixed with bloody and purulent mat-
ter; the man gradually sunk and died. The parts were carefully
examined after death, when it was ascertained that there was no
false passage, in fact nothing abnormal, until the bladder itself was
reached, which appeared to be double, consisting of two chambers of
different magnitudes, communicating by a small aperture just large
enough to admit a quill; the ureters and urethra opened into the
lesser chamber, which was in a very diseased state, its lining mem-
brane was corrugated and very thick, and covered over with sabulous
deposit; the larger chamber had the structure of the bladder;. the
ureters were dilated and contained healthy urine; the prostate was
slightly enlarged. It was evident from the specimen, that the cathe-
ter could only have emptied the smaller cavity, and the constant pre-
sence of the urine contained in the other, must, have caused great
irritation.
3. Chronic Hydrocephalus.—Mr. Adams presented a prepara-
tion and drawings of a case of chronic hydrocephalus, He observed
that there was a similar case at that time in the Richmond Hospital,
 Scientific Intelligence. 505

and that there had been some discussion as to the propriety of at-
tempting to relieve by paracentesis of the cranium. It would be
recollected that three forms of hydrocephalus were recognized, be-
sides which many more were described by French authors, and there
was also the encysted, described by his friend Dr. Houston. The
preparation belonged to a case of both external and internal hydro-
cephalus co-existing in the same individual, the external hydroce-
phalus was at the right side, the internal at the left; the fluid con-
tained in the sac of the arachnoid compressed the hemisphere towards
the mesial line. The drawing was produced for the purpose of ex-
hibiting the peculiar appearance of the eyes, the cornea being almost
completely concealed by the lower eyelid. In this case the heat of
the head externally was remarkable, and the superficial veins were
distended. As to the success of the proposed operation of paracen-
tesis, Mr. Adams said he had no hopes, unless in the case of the
hydrocephalus externus, in case it could be diagnosed, which, in the
present state of our knowledge, he feared was impracticable.—(Mu-
seum, Richmond School of Medicine.)
4. Acute Inflammation of the Knee and Shoulder Jownts suc-
ceeding to Small-Pox.—Mr. R. W. Smith brought before the So-
ciety the case of a child four years of age, who had been under the
care of Dr, Hatton in the Richmond Hospital. This child had been
attacked by small-pox, which proceeded through its regular course,
but in ten days afterwards the child became affected by severe pain
and swelling of the knee joint. In two days after this it was admitted
into hospital; there was then considerable swelling about the joint,
which appeared to be distended with fluid; the epiphysis was evi-
dently separated from the shaft of the femur; the pulse at the wrist
was very rapid, the countenance anxious, and there was great pros-
tration of strength. An incision was made over the inner condyle
by which a quantity of purulent matter was discharged from beneath
the periosteum. In two days afterwards the shoulder joint became
similarly affected, and rapidly filled; the pain became very severe;
the child was constantly screaming; diarrhoea came on, then coma,
and finally death on the eleventh day of the disease. When the
parts were examined after death, there was found acute inflammation
of the synovial membranes and of the periosteum in the neighbour-
hood of the joints; all the surrounding tissues were more or less en-
gaged in the inflammation; the epiphyses had completely separated.
In one of the knee joints the cartilages had a cribriform appearance;
this, Mr. Smith observed, he had often met with in cases where the
bone had been acutely inflamed. There was extensive destruction of
the humerus; the periosteum was inflamed over half the length of
the shaft, and there was new bone thrown out in some spots. The
glenoid cavity of the scapula was covered with recent lymph, but the
cartilages remained sound. There was no purulent deposition in the
internal organs.—Jdzd.
506 Scientific Intelligence.
Fifth Meeting, 31st of December, 1842.
Mr. O’FERRALL, in the Chair.
1. Eccentric Hypertrophy of the left Ventricle—Aneurism of
the ascending Aorta.—Dr. Bigger said the specimens which he had
to lay before the society at that meeting were taken from the body
of an athletic man, who had formerly been a soldier, but who had
been invalided about nine years ago, ever since which time he had
been affected with violent palpitations. He had been under the care
of numerous physicians and surgeons during that period, and had un-
dergone every variety of treatment, but without benefit. He had
been frequently salivated, had been bled very often, and had been
blistered until the skin was no longer capable of vesication. On
Christmas Day he was admitted into the Adelaide Hospital, at which
time he had been seventeen nights without sleep. His countenance
was very pallid, but he still retained a considerable degree of mus-
cularity, he was incapable of taking any solid food, and complained
of pain in the epigastrium. He was suffering intense dyspnoea, and
was obliged to be supported in a nearly upright position. The heart
was pulsating strongly and extensively; there was a strong impulse
perceptible over a great part of the surface of the chest; both sounds
of the heart were audible; the pulse at the wrist was from 95 to 100;
superiorly in the chest there was fremissement; the apex of the
heart could not be distinguished ; the posterior part of the thorax on
left side sounded dull, and the crepitus of pneumonia was audible in
the lung; anteriorly on the same side, the respiratory sounds were
drowned in those of the heart, as if that organ completely filled the
whole of the anterior part of the thorax on the left side. On the
right side of the chest there were audible, along with the respiratory
murmur, subcrepitant and bronchial rales intermingled. The first
sound of the heart was not abnormal, the second was shorter, and
was accompanied in its latter part with a loud bruit de soufflet. The
diagnosis in this case was that there existed dilatation with enlarge-
ment of the cavity. There was clicquement along with the second
sound (and Dr. Bigger had observed in several cases which had come
under his notice, that the second sound is synchronous with the pas-
sage of the blood through the aortic valves). The patient died during
the week. When the body was opened, it was found that the heart
filled up the space indicated by the dulness, and the violent pulsation
during life. The heart completely filled the pericardium. The left
ventricle was of enormous size. The aortic valves were capable of
closing, but there were some bodies which to the touch felt like wire,
enclosed in their tissue. The aorta between the heart and the middle
of the arch was suddenly enlarged into a cavity of cartilaginous and
of osseous structure. This enlargement terminated suddenly by a
narrowing at the very middle of the arch, and this was probably the
cause of the soufflet concurrent with the second sound of the heart.
The descending aorta was of small calibre in proportion to the size of
the individual. The right side of the heart was dilated and filled
 Scientific Intelligence. 507
with fibrine. In the enlargement of the aorta just described, there
was a clot, with all the characteristics of that found in aneurisms,
passing through all the gradations of consistence, from firm fibrine in
contact with the parietes of the dilatation, to grumous blood towards
the axis of the artery. This aneurism would probably have burst,
had the man’s life been protracted. The left lung contained a fine
example of pulmonary apoplexy, whose situation could be detected by
the touch before the lung was cut into. The stomach was vascular,
and its mucous membrane was softened. The patient had vomited
near a quart of blood and mucus on the night before his death.
2. Multilocular Aneurism at the Base of the Brain.—Mr. R.
W. Smith said, the specimens he then produced to the Society were
from the body of a man, zt. 54, who was admitted in March, 1842,
into the Richmond Lunatic Asylum, under the care of Dr. Mollan,
He had been insane during three years previous. In hospital, his in-
sanity was characterized by great excitability, and disposition to com-
plain, with occasional paroxysms of violent excitement. Six months
before his death, he was attacked by spasmodic fits, in which the hands
were strongly clenched; they were sometimes of an epileptic cha-
racter. His hearing became gradually impaired, but there was no
paralysis. On the 12th of December, 1842, he was found ina state
of complete prostration, with respiration very slow, but not stertorous;
was delirious, but could reply to questions, although not readily ;
pulse natural. He died on the 14th, but without having been affected
by either coma, stertor, or convulsions. When the skull was opened,
there was found considerable turgescence of the vessels of the mem-
branes; the brain itself was of small size, and soft. At the base of
the brain, towards the left side, was discovered an aneurismal tumour,
about the size of a small apple; it occupied the floor of the third
ventricle; the tuber cinereum had been destroyed, as well as the
origin of the optic, and of the olfactory nerve of that side: the optic
nerve of the opposite side was flattened and softened. The aneu-
rism was multilocular; the posterior artery of the cerebrum was
traced into the sac; it had, perhaps, originated in a branch of the
basilar artery.
The middle artery of the cerebrum opened into the aneurism; a
similar circumstance had been described by Serres, who had recorded
two cases of aneurism within the cranium, one of the basilar artery,
the other of the communicating artery. There was also a case by
Cruveilhier, and Mr. Smith himself on a former occasion had commu-
nicated another case to the Pathological Society. The symptoms
during life in such cases are very obscure, and it is as yet impossible
to diagnose what may be the compressing force within the skull,
whose existence is indicated by the symptoms. It is remarkable that
in all the cases yet observed, there has been deafness, a symptom
unexplained by the pathological phenomena. ‘These tumours are,
however, of slow growth, and all contain laminated coagula; their
structure shews that they are true aneurisms, and they produce death,
508 Scientific Intelligence.

either by rupture and extravasation, or by disorganization of the cere-

bral substance by their pressure.
3. Phlegmasia Dolens; Interlobular Pneumonia; Purulent
Cysts in the Ventricles of the Heart.—Dr. Stokes presented the
recent specimens taken from the body ofa male patient who had died
of phlebitis, in whose case there were several points of interest, to
which, in connexion with the specimens, he begged leave to direct
the attention of the Society. . It was an instance of chronic phlebitis,
and was complicated with other morbid phenomena. The subject of the
case had been for two months under his observation in the Meath Hospi-
tal, and during that time there was no intermission of the symptoms.
The history of the case was this: the subject. was of Italian parentage,
and had been a Temperance Society man for some time, bat had broken
his pledge, and become addicted to drinking. When he was admitted
into the Meath Hospital, he presented many of the appearances of
delirium tremens, and gastric irritation, with a certain degree of
fever. Mr. Parr, the intelligent apothecary of the hospital, who
examined this patient very carefully, detected the existence of pneu-
monia in. the right lung. The pulse was very rapid, ranging, while
he was in the hospital, from 130 to 150; it was but once during
that. period observed to be so low as 120; this remarkable quick-
ness of the pulse continued up to the time of death. The other
important phenomena of the case were these: there was, during
the entire period, disease of the inferior portion of the right lung,
progressing slowly, and. obstinately resisting treatment, a circum-
stance which agrees well with the characters of specific irritation;
there was a persistent crepitus audible in the lung, which varied so
as to be at some times much smaller than at others; at the root of
the lung there was bronchial respiration; there were all the symp-
toms of dry pleurisy. That there was also phlebitis was indicated
by the condition of the left leg, which had the appearance: of a limb
that had been some time affected with phlegmasia dolens. This
patient died at last completely exhausted and broken down, appeared
quite anemic, and had all the symptoms ‘that might be expected to
occur in a case of purulent poisoning of the blood. The principal
results of the examination after death, were exhibited in the speci-
mens then on the table, which Dr. Stokes proceeded to describe.
The abdominal vena cava, and the veins of the lower extremities,
were carefully examined. In the cava was found a coagulum adhe-
rent to the lining membrane of the vein, which, when the coagulum
had been detached, was observed to be in that situation slightly red
and villous; this redness was quite decided; the surface of the
coagulum was rough. In the femoral vein were similar clots, and in
the thigh the artery, vein, and nerve were all agglutinated together;
the canal of the saphena vein was obliterated, and felt hard, like a
cord; this obliteration extended as far as the vein was traced, but
was most remarkable in the lowest branches. ‘These appearances
were in the left limb. As to the heart, the right ventricle contained
 Scientific Intelligence. 509
a number of small white tumours between the carneze column ; these
tumours are the same as those which Mr. O’Ferrall has met with, and
designated purulent cysts of the heart. There were some dark-
coloured coagula and creamy matter in this ventricle, but its lining
membrane presented none of the anatomical characters of inflamma-
tion. In the left ventricle were similar deposits of purulent matter,
contained in cysts; their contents were ofa creamy consistence. There
were three large cysts in this ventricle; they adhered very slightly
to the parietes of the heart. The inferior lobe of the right lung was
solidified; a section of it, made when it was recent, exhibited a
marbled surface, resembling red granite. In every pact of the lung
that was cut into, there was an analogous matter, to that found in the
heart, and sometimes granular points. There was a general phlebitic
inflammation of the lung, but no abscess had been formed within it;
there were similar deposits in the upper portion of that lung, and
also in the lung of the opposite side, with some intervening portions
of healthy tissue, agreeing with the interlobular pneumonia of Andral
and Cruveilhier, a name which is objectionable, as conveying an im-
proper idea of the nature of the disease. It is very remarkable
that there was no purulent deposition in the liver, spleen, kidney,
joints, or muscles. This case, observed Dr. Stokes, was one of those
of phlegmasia dolens which are most dangerous. Of that disease, all
the cases that occurred might be arranged in two classes; in one,
the first obvious symptom is the rapid swelling of the affected limb ;
in the other, which is by far more serious, there are severe consti-
tutional symptoms long before the leg becomes tumified. Cruveilhier
had observed, and Dr. Stokes’s experience enabled him to confirm the
observation, that the most dangerous cases are those which arise
from a poisoning of the blood; when the disease is localised, there
is a chance that the patient may recover. It was worth while to con-
sider whether the condition of the lung which he had. just pointed
out, depended on a mechanical deposition, or was the result of a
specific irritation of the lung. He thought it more probable that the
latter was the case, which would be most analogous to what occurs
in other specific inflammations. He would add, that as to the diag-
nosis of such cases, perhaps it would be made from observing the
obstinacy against remedial means—at least, all those we are at pre-
sent possessed of. He was not, however, without hopes that a specific
remedy might yet be discovered.—( Museum, Richmond Hospital.)
4. Erysipelatous Inflammation, extending to mucous Mem-
brane and Air Passages, subsequent to a Wound on the Head.—
Mr. R. W. Smith said he wished to present a specimen taken from
the body of a middle-aged man, of intemperate habits, who on last
Tuesday evening had received a wound on the head, but how inflicted
was not known. It was a large flap wound of the scalp. The man
was in the first instance brought to an apothecary, then to a barber,
then to a police station, and finally to the Richmond Hospital, where
VOL. XXV. NO. 75. 3.U
510 Scientific Intelligence.
he should have been brought at first. On the following day erysi-
pelas came on, and delirium, with other bad symptoms, and he died
on Thursday, within forty-eight hours from the receipt of the injury.
The fever in this case was typhoid in its character, and very rapid
in its progress, the tongue swollen, dry, and brown, and the wound
on the head sloughing. On opening the head, there was observed
an increased degree of vascularity in the brain. In the fauces and
bronchiz the mucous membrane was highly vascular; this redness
is still visible in the trachea. The lungs were congested, and easily
broke down under the finger. The liver presented an example of
cirrhosis, and there was ascites. The rapidity with which this case
ran on to its fatal termination wasremarkable. Mr. Smith believed
that the erysipelas had extended from the cutaneous surface to the
mucous by the mouth and mares; there was as yet no sub-mucous
infiltration.
5. Neerosis ofa Rib.—Mr. R. W. Smith said, he had also to
present a specimen which had been transmitted to him by his friend,
Mr. Brabazon, Surgeon of the Infirmary at Downpatrick. The speci-
men was a portion of the sixth rib in a state of necrosis, which
Mr. Brabazon had extracted from a boy who was sinking under
hectic when brought into the Infirmary; an aperture had been formed
which led down to the afflicted part, and through which matter was
discharged. The cough, and other hectic symptoms rapidly dis-
appeared, and the patient was recovered ina short time after the
operation.

Sizth Meeting, 7th of January, 1843.

Dr. O’BerRNeE in the Chair.
1. Softening of the Brazn.—Dr. J. F. Duncan exhibited the
recent parts in this case. The subject from which they were taken
was a female, aged about twenty-four years, who had been an inmate
of the North Union Workhouse for the last two years and a half.
She had an apoplectic attack in Manchester, where she was employed
in a factory; was afterwards a patient in Jervis-street Hospital,
where she remained six months, until, her case appearing to be a
hopeless one, she was sent into the workhouse. When she came in
there, she was completely helpless, was unable even to feed herself,
had lost the use of her limbs, and had aphonia. An issue was opened
on the vertex, and other remedial means adopted, after which she for
some time got better, but soon relapsed, and lost the use of the left
side. On Wednesday fortnight she had an epileptic fit, and another
on last Wednesday. During the whole progress of the case there
had been no complaint of pain. In the examination after death, the
skull was observed to be very thick, the arachnoid was in some spots
opaque, and slightly thickened; the substance of the brain in the
upper part of both hemispheres was very firm, but when the base of
 Scientific Intelligence. 511
the brain was examined, part of the anterior and middle lobes on the
right side was found to be in a state of ramollissement. There was
some effusion into the ventricles.
2. Ovarian Tumours containing Teeth and Hair.—Dr. Houston
exhibited to the Society a specimen of ovarian disease, which he re-
ceived from his friend, Dr. Irwin, of Castleblaney, and of which the
progress and final issue were, perhaps, unique. The tumour was as
large as an orange. It consisted chiefly of hair, bone, and teeth, and
had been extracted from the anus. The patient was a countrywoman,
named Dawson, et. about 50, and the mother of seven living chil-
dren. For nine years she had been subject to continued lumbar and
rectal pains, with alternations of constipation and diarrhoea. For the
last two years she had suffered from constant uneasiness, and drain-
ing of blood and mucus from the rectum: and in order to allow the
bowel to be emptied, she had been obliged, on every occasion of going
to stool, to introduce her finger and push aside some resisting body
which obstructed the passage. In this state she applied to Dr. Irwin,
about eight months ago. After making a careful examination, Dr. ~
Irwin judiciously determined on an attempt at extracting this foreign
substance, whatever it might be. He succeeded in pulling a certain
amount of it through the external opening; but then found it stopped
by a fold of the mucous membrane, which embraced it tightly round
the centre, where the mass appeared narrowed byacircular contrac-
tion. He then divided the mucous membrane with a scalpel at this
part, and was pleased at finding the entire come away unbroken. The
mucous membrane was vascular and relaxed; some bleeding occurred
from the wound of the knife; but it was arrested by plugging the rec-
tum. It was through the lateral and posterior wall of the rectum that
the tumour made its way into that bowel. The woman quickly reco-
vered, and remains (eight months) quite well in health, and free from
any disease or inconvenience in the rectum. Such, Dr. Houston
said, was the account given to him of this singular case by Dr. Irwin;
and it now remained for him to describe the tumour, and to offer a
few observations on the reasons which would, he thought, justify him
in regarding it as ovarian.
The tumour, when first examined, was about the size of a large
orange, narrowed about the centre. It was heavy and dense, and
emitted a fzecal odour. One end, the larger, presented an appear-
ance like dried clay, matted together with hairs. The other, some-
what smaller, was equally dense; the latter was covered with a firm,
gristly substance, like that of the gums, and presented on one side the
enamelled crowns of several teeth. The two pieces were so firmly
joined together, as to constitute one solid mass. On being macerated
for several weeks, the exact nature of the tumour became more mani-
fest. The smaller end [Dr. H. here exhibited the specimen] was
found to consist of a perfect organized bone, a sort of misshapen
lower jaw, with eleven teeth growing out of it, in sockets, and not in
a continuous row, bnt irregularly jumbled together in one place, as
close as they could lie. There were two incisors and one canine
tooth ; the rest were bicuspid and early molars. The teeth were all
512 Sctentific Intelligence.
tolerably perfect, some being a little bent, and others short. The
enamelled crowns were sharp and well-defined. The larger piece, of
which the mass was composed, was of a totally different nature. Ac-
cording to an analysis made by Dr. Aldridge, it consisted of a mass of
hairs matted together by ammoniacal magnesian phosphate, biliary
matter, and vegetable detritus. It adhered very firmly to the osseous
piece, especially to the projecting extremities of the teeth, some of
which were broken off with it in attempting a separation of the two
portions. This end of the tamour was obviously the more recent
production, and, according to Dr. Houston’s opinion, must have been
formed in the rectum by the slow accumulation of the fecal, excre-
mentitious deposits, arrested by the hairs and teeth of the primary tu-
mour, which, in being eliminated from the body, had been brought
into contact with, and had produced ulceration in the tunics of the
rectum. The operation of Dr. Irwin was, in this case, therefore, only
the completion of the last stage of the tedious, but sanatory and well-
directed efforts of nature to the same end. Dr. Houston remarked,
that as the woman, the subject of this tumour, still survives the dis-
charge of it, there must remain some doubt as to its source. He
thought, however, that its origin had been in the ovarium, and gave
a lengthened exposition of the nature, causes, and most common seat
of such tumours, with a view of proving, from precedent and analogy,
that such was the fact.
3. Acute Inflammation of the Pia Mater, with Inflammation
of the Cerebrum.—Mr. Adams said, I beg leave to lay before the
Society the case of a young lady, aged 23 years, who had laboured
under acute inflammation of the brain and its membranes, for eleven
days. The case terminated fatally, and its well marked symptoms,
melancholy to relate, were, from the beginning to the close, never
combatted by any mode of treatment which science should have
dictated, or even common sense suggested. During the first
four days of this illness, her family did not conceive any medical
advice necessary, and on the fifth day of it she was placed under
the medical care of an eminent professor of homceopathic medicine,
who continued to attend her daily, and daily to pronounce a fa-
vourable prognosis as to the probable issue of the case, until
four o’clock on Monday, the tenth day of her illness, when she be-
came affected with violent convulsions. On Tuesday, the 2nd of
January, the lth and last day of her illness, I was desired to visit
her. I found her comatose, and in articulo mortis; her death took
place a few hours after my visit. I obtained leave to make a post-
mortem examination of the brain; the result I beg leave now to lay
before this meeting, and as but three days only have elapsed since
the examination, the brain and pia mater still preserve nearly the same
anatomical characters of inflammation they then presented; the So-
ciety can bear testimony to these appearances, and to the faithfulness
of these drawings, executed by Mr. Conolly, of the inflamed brain.
No one who looks upon this specimen J hold in my hand, can doubt
that most acute inflammation of the brain and its membranes must
have in this case existed, and when we hear the clinical history of
 Scientific Intelligence. 513
this case, we shall feel reason to be surprised at the apathy of the
family of the youug lady the subject of it, who could look on patiently
and permit such acute symptoms as I have to relate to continue,
without their having recourse to other advice, or seeing that these
Symptoms were combatted by some more energetic measures than
those they saw adopted in this melancholy instance. The following
particulars of the progress and treatment of this case I very carefully
collected on the spot, partly from the family, and partly from a very
experienced and intelligent nurse, who for the last five days had
never left the patient’s bedside.
I learned that on the 24th December, 1842, that is, on this day
fortnight, the young lady first complained of being unwell and chilly;
on this day she had driven to Dublin with her sisters, and on her
return home in the evening, took a shivering. On the 25th (Christ-
mas Day)she was still complaining; remained in her room, not being
able to join the family circle this day at dinner. On Tuesday the
27th, she was considered better, and was down stairs in the drawing
room, but became very unwell, fainted, and was carried up stairs
to bed nearly insensible. On this day she mentioned to her sisters
that she saw objects double. None of these symptoms alarmed the
family, or induced them to procure any advice, until Wednesday, the
28th of December, when they called in to visit the young lady an
eminent professor of homeeopathy, who had been occasionally in at-
tendance on the family. He took charge of the case, and from day
to day, that is, from Wednesday until the following Monday, pro-
nounced that the case was one of fever, and going on favourably.
On this day, however, she had a violent convulsion. The testimony
of the nurse was, that she had not seen the young lady until Friday
night at ten o’clock, the 30th of December, 1842. On her arrival
she found her very restless, and she passed a very disturbed night.
<¢ She would fall into a doze and awake frightened, and would shrink
back in the bed as if she saw something she would avoid: she did
not complain of pain now, but her forehead felt very hot, her tongue
was white and coated, her pulse used to ‘come and go’ ”—was ir-
regular—‘‘ her head seemed heavy to ber; when she was raised up
in bed, her head fell on her shoulder.’”’ She was delirious throughout
the night. What she said was rather amusing, and would make
herself as well as those about her laugh. Upon asking the nurse to
particularize what she thought her mind was occupied with, as far as
she could judge from her words; she replied: ‘‘ She seemed to be
occupied (mentally) in her Sunday school, teaching children, whom
she would call by name; she would ask for her dress and her boots,
to go out, and inquire why the car was not brought round, but there
was much variety in her delirious thoughts; she would begin with a
religious hymn, and before it was concluded, she ‘ gambolled’ off
from this to something quite different.” On Saturday night she was
more disturbed and restless; she would get up in bed and cough,
say she saw something shining, and objects of a vast variety of
hues and colours; all the time her head would fall on her shoulder,
 514 Scientific Intelligence.
if it was not supported ; she said she saw her sister double. When
the basin stand, which stood alone in the corner of the room,
was shewn to her, she said she saw distinctly two basin stands.”
On Sunday night the nurse thought the young lady exceedingly ill;
she passed the night in the most restless manner, and had not what
she could call one hour’s sleep; she informed the family, and after-
wards the Doctor, who, notwithstanding, this morning (namely, the
3rd January, 1844), stated the young lady was better that day, and
_ was going on favourably ; however, at four o’clock, P. M., the young
lady was seized witha violent convulsion, which lasted for one hour.
After this she fell into a snoring sleep, and subsequently, up to the
time I saw her, never exhibited any signs of intelligence, if she ex-
cepted, that when a tea-spoonfull of fluid was placed in her mouth,
she swallowed it. The nurse thought she could not see; she lay in
a tranquil but comatose state all Tuesday, up to the time of my visit.
As to treatment, I learned from the nurse that the Doctor would take
a small white powder, like one grain of calomel, and would mix this
in twenty desert-spoonfuls of water; he desired the nurse to shake
this very well, and give a desert-spoonful every hour. He would
change the medicine now and then; but to her it all appeared the
same, and she could not observe any effect from any medicine she
took; she was not bled in any form, had not been blistered, her hair
was left untouched, and no cold lotion was applied until she was in-
sensible. After the convulsion on Monday, the nurse had been with
her from this day until her death, at half-past eleven on Tuesday
night, and the bowels had not been affected until just before her
death ; the secretion of urine was natural, as to quantity and quality;
the bladder was evacuated naturally twice in the twenty-four hours,
she herself giving notice to the nurse, until the convulsions occurred.
The case was said to be one of typhus fever. The Doctor allowed at first
a few grapes, but afterwards forbid even these ; she wished for chicken
broth, whey, and, subsequently, on Monday, for dry toast, none of
these allowed. Such was the history of the case and treatment I
learned on my first visit. I stated to the friends my conviction, that
a few hours would close the scene with respect to this young lady ;
that my impression was, that the case had been one of acute inflam-
mation of the brain and its membranes, and that all medicine would,
at that period, of course, prove unavailing; that they were quite in an
unnecessary state of alarm relative to typhus fever, and the spread of
infection, which, in this case, did not exist. I requested that I should
be informed when her death took place, and that a post mortem exami-
nation of the brain and its membranes, in this case, should be per-
mitted. At eleven o’clock on Tuesday evening, the 4th, she died,
and on Thursday, 5th January, 1843, I was informed that if “‘ J had
any curiosity” to examine the body, I might do so. I said that I did
feel an interest in the matter, and, accompanied by my friend, Doctor
Mayne, I examined the head. The body was remarkably well-formed,
was not much reduced in flesh; the skin of a natural colour, except
on the back, from gravitation of blood ; no specks or spots on the skin.
 Scientific Intelligence. O15
The calvarium removed, the dura mater presented a remarkably con-
gested appearance; when this was cut all round, the pia mater exhi-
hited a greater degree of redness than either Dr. Mayne or I had seen
fora long time; the sulci, between the convolutions, were occupied by
greatly distended veins ; the brain was firm and large; there was no
arachnoid inflammation, but the traces of inflammation of the pia
mater were most intense; the scarlet colour, from the minute injec-
tion of the vessels of the pia mater, was not confined to the surface of
the brain; but the portions of this membrane, which sink between the
convolutions, was equally red, and quite as brilliant in its colour, as that
on the surface; much bloody serum was found in the lateral ventricles
and spinal canal; the choroid plexus very much swelled and inflamed.
We next inverted the brain, and removed it, that we might examine
carefully the optic nerves and the basis of the brain, as from many of
the symptoms, particularly the ‘‘ double vision,” we judged we should
here find evidences of very acute inflammation. The arachnoid (which,
in the natural state, about the commissure of the optic nerves, is re-
markably transparent and distinct, and easily detached from the nerves
of this region)—the arachnoid was identified with the pia mater and
with the neurilema of the optic nerves. The notes taken, while
Drs. Mayne, Power, and I were examining it, were as follows :—
great vascularity of the pia mater, covering the under surface of both
hemispheres; minute vessels so congested, as to give the appearance
of scarlet cloth nearly ; this appearance not merely limited to the sur-
face, but the same vascularity can be traced into the pia mater,
lining all the sulci, and when the membranes are removed, the orey
substance of the brain presents everywhere a striking pinkish hue.
The superior and inferior intersulcal veins are distended everywhere
with black blood. The pia mater, from the pons forwards, where it
invests the mammillary eminences, tuber cinereum, and optic commis-
sure, is greatly congested, and so identified with the arachnoid that
the two membranes cannot be separated from each other. On pulling
off the membranes,{the tuber cinereum seems soft, pulpy, and has ac-
quired a pinkish hue, instead of the pale grey colour which is natural
to it. The same remark as to colour and consistence applies to the
optic tract, commissure, and nerve; and, in addition, all these latter
structures appear larger than usual, and the outlines of pinkish ves-
sels can be seen traversing the medullary substance. The tubercula
quadrigemina are remarkably congested and pulpy.—( Museum, Rich-
mond Hospital.)
4, Tubercular Infiltration of the Lung.—Mr. Hamilton pro-
duced the specimens in this case, and mentioned that the subject
from which they were taken was a boy seven years of age, of scrofu-
lous appearance, with swelled glands in the neck. About five months
ago, he had remittent fever, and after that scarlatina, but his conva-
lescence was not complete. He had cough, became emaciated, had
night sweats, and other symptoms of hectic. Mr. Hamilton, on
seeing him, was struck by the remarkable disparity which appeared
between the two sides of the thorax, the right appearing to be much
516 Scientific Intelligence.

larger, and the ribs not moved up and down in respiration, as those
of the opposite side were. By measurement he ascertained that the
right side was the larger, exceeding the left by an inch; the two
inferior thirds of the thorax on the right side sounded dull to per-
cussion, but respiration was still audible. In the left side the respi-
ration was puerile, and accompanied by a sonorous rale. Posteriorly,
the stethoscope detected cegophony. The sounds of the heart were
normal. The diagnosis formed from this examination was, that there
was effusion into the pleura, and solidification of the lung on the
affected side. Ina few days afterwards the boy died, and the fol-
lowing appearances were observed in the examination after death.
In the right pleura, there was found about half a pint of fluid, and
the lung of that side appeared a uniform greyish white mass, in fact,
a perfect specimen of tubercular infiltration; there were numerous
adhesions to the pleura costalis, and inferiorly to the diaphragm; the
convex surface of the liver adhered firmly to the diaphragm. The
left lung was studded with miliary tubercles. The pericardium ad-
hered closely to the heart, and the surface of the heart itself was
covered with tubercles. Tubercles were also found in the liver, in
the spleen, in the small intestines, and in the omentum; the kidneys
were the only viscera in which they were not detected. The bron-
chial and cesophageal glands were filled with a caseous matter.
5. Foreign Body accidentally lodged in Larynz.—Mr. R. W.
Smith exhibited the larynx of a child, six years of age, whose death
was occasioned by a nail which it had in its month, and had acci-
dentally swallowed; the nail, which was one of the common brass
nails used by upholsterers in covering chairs, did not pass into the
cesophagus, but got into the larynx, where it became fixed, and oc-
casioned suffocation. The child in this condition was brought to the
Meath-street Dispensary, where Surgeon Richey used every means
for its relief, but in vain. It was at this time completely asphyxiated.
Mr. Richey opened the trachea; a gush of air came from the lungs
through the incision, but no inspiration followed, although inflation
of the lungs was resorted to. The nail was found in the situation in
which the Society would observe it in the specimen before them,
lying in the larynx, with its point upwards in the sinus of the ven-
tricle of the larynx, and its head downwards below the glottis. Mr.
Smith observed that we should not be deterred by the result of this
case from attempting to restore animation in cases of asphyxia from
similar causes ; some cases were recorded, in which, after tracheotomy
or laryngotomy, the lungs had been successfully inflated, even when
no air had gushed from the wound.
6. Double Pneumonia.—Epileptic Convulsions.—Meningitis ?—
Mr. O’Ferrall said that he had on several former occasions directed
the attention of the Society to the difficulty of making an accurate
diagnosis of some obscure affections of the brain. His present com-
munication related to the same subject. A child three years of age
was brought under his notice; it was suffering from double pneu-
monia, but on the sixth day convulsions set in, which were preceded
 Scientific Intelligence. 517
by an increased degree of lividity, and by slight delirium. The con-
vulsions resembled epilepsy, and death ensued in fourteen hours after
their appearance, but there was no comatose state after them. When
the body was examined after death, the usual lesions consequent on
inflammation of both lungs were found. Of the appearances within
the cranium there was avery accurate delineation in the drawing
that he then produced. The brain itself was not unusually soft;
there was no subarachnoid effusion, but there was an extreme degree
of hyperemia; the sinuses were filled with black blood, and there
was great vascularity in the sulci. There was no fluid in the ven-
tricles, nor at the base of brain. The question then arose for the
consideration of the Pathological Society,—could this be looked on as
meningitis ? if this was decided affirmatively, the case might be con-
_ Sidered to correspond with the meningitis which Andral has described
as fatal in the stage of excitement; but should such appearances as
those observed in the present case be considered decisive evidence
that meningitis had existed? The opinions of pathologists were
various; some would assert that the black blood circulating in the
system, on account of the state of the lungs, was the cause of the
convulsions, and that there had been no meningitis, but only such a
state of the brain and of its membranes, as would accompany epilepsy
from any cause.

Seventh Meeting, January 14th, 1843.

Srr Henry Marsu, Bart., M.D., in the Chair.
1. Acute Necrosis of the Tibia.—Doctor Hutton presented the re-
cent specimens. The subject was a child nine years of age, who on
the 24th of last November was suddenly affected with excruciating
pain in the upper part of the tibia. On the third day from this, it
was brought to the Richmond Hospital, at which time there was
great pain in the part, swelling, tension, and a slight blush ; the knee
joint was alsoswollen, As it was evident that there was effusion, not
only into the joint, but under the periosteum, an opening was made
by incision on the anterior aspect of the tibia, and some fluid evacu-
ated, which was followed by some mitigation of the symptoms; but
in the course of the two or three following days an abscess formed,
contiguous to the knee-joint, but not communicating with it. This
was opened and its contents discharged without at all affecting the
swollen appearance of the joint. Subsequently the child exhibited an
extreme degree ofirritability, attended by thirst, anorexia, and febrile
symptoms. During three or four weeks a number of abscesses were
formed in succession about the knee-joint, but of these only one at the
innér condyle communicated with the synovial cavity ; the epiphysis
had separated from the shaft of the bone. Splints were then applied,
and with apparent benefit. In this way matters went on until the
7th of this month, when the child fell into a state of coma, and it died
VOL. XXV: NO. 79, os
518 Scientific Intelligence.
with all the symptoms of hydrocephalus. On opening the skull it
was observed that there was considerable subarachnoid effusion, and
several spots of opacity on the arachnoid itself. When the affected
limb was examined, it was found to have been the seat of acute ne-
crosis. There was an opening into the synovial capsule. ‘The upper
part of the tibia was extensively necrosed, and its cancellated struc-
ture diseased. The sequestrum of the tibia had the appearance of the
original bone, but was not of the same thickness, and immediately
under (or within) it was a granular membrane, attached to an inner
cylinder of bone, which, as well as the lower part of the shaft of the
tibia, had still retained its vitality. This membrane, Dr. Hutton ob-
served, can be traced along the whole line of the diseased portion.
The first appearance of the specimen might mislead an observer as to
the seat of the disease, but a very careful examination had convinced
Dr. Hutton that it was the external part of the bone which had been
destroyed, while the periosteum, and the medullary membrane, with
the interior of the bone attached to it, had been preserved. At first
sight it looked as if a thin sequestrum had been interposed between
the inner and outer surfaces of the bone; the smooth surfaces of the
sequestrum externally shewed that it was the outer part of the tibia
that had been necrosed. Doctor Hutton having alluded to the opi-
nions of several authors on this affection of bone, observed what he
had himself remarked, that in young subjects, inflammation of the pe-
riosteum is very frequently accompanied by separation of the epiphyses,
and this in several limbs. Cases illustrative of this combination had
been already presented to the Society in former Sessions by Mr. R.
W.Smith. The present case was remarkable for the rapidity of its
course, the epiphysis having been completely necrosed in six weeks
from the commencement of the disease, and also for the subsequent
inflammation of, and effusion within the serous membrane of the brain.
—(Museum, Richmond Hospital.)
2. Scrofulous Tubercles in the Cerebellum.—Mr. R. W. Smith
presented a coloured drawing of the brain of a child nine years
of age, admitted into the Richmond Hospital in last May, having
been ill for the previous seven months. In September, 1842, it was
remarked that this child had become greatly inclined to remain in
the recumbent posture; during five months before its admission
to the hospital it had suffered severe pain in the forehead, which
was exacerbated at night; it screamed frequently, and the head
required to be supported. At the time of its admission the look
was vacant, the pupils were dilated like those of an amaurotic
patient; they were insensible to light; the hearing remained un-
impaired; there was inability to either walk or stand up; of sight
all that remained was the power of distinguishing light from com-
plete darkness; the abdomen was tympanitic, and there were fre-
quent vomitings; there were no convulsions, and gradually this pa-
tient passed into a semicomatose condition, from which, on the 14th
of June, there appeared a favourable change ; the child became able to
stand up and to walk about ; the pain in the head ceased ; the stomach
 Scientific Intelligence. 519
no longer rejected_its contents, and the pavient became lively and in-
telligent. After this favourable state had continued ten days, the
unfavourable symptoms again returned. On the 24th of June there
was incessant vomiting, and on the 26th death took place, unaccompa-
nied by convulsions. During the last two days there was paralysis of
motion, but not of sensation. The results of the examination of the
body after death were these : there was effusion of blood into the ven-
tricles of the brain ; the brain itself was very large; the foramen com-
mune anterius was dilated. In each lobe of the cerebellum was one
scrofulous tubercle as large as a nut. The bones of the head were
very thin and diaphanous. Scrofulous tubercles were thickly depo-
sited in the mesentery. The tubercles found in the cerebellum were of
a greenish yellow colour, of a firm consistence, and had a laminated
structure like that ofa calculus. These tubercles are observed generally
to have this arrangement. In one of Cruveilhier’s plates there is a igure
exactly resembling the present specimen. These tubercles often exist
ef a very large size without producing any obvious symptom during
life, but frequently there is present some one remarkable symptom, such
as strabismus or vomiting; the vomiting is often treated as proceeding
from some disease of the stomach. The alteration in the condition
of the general health, and its sudden variations, such as were ob-
served in the present case, are known to occur also in many cases of
spinal affections, in which also tubercles are not unfrequently met
with in the cerebellum. It is extremely difficult, if not impossible, to
diagnose these obscure complaints; the symptoms are not modified
by either the size or the structure of the tubercles, unless when they
irritate or disorganize the cerebral tissue.—(Museum, Richmond
Hospital.)
3. Scirrhus of the Lung.—Dr. Stokes presented a specimen of
cancer of the lung, for which he observed that he was indebted to
Mr. Shannon, Surgeon of the South Union. The subject from which
the specimen was taken was an old man, who fora long time had suf-
fered from a cancerous ulcer on the face. Although the lung was affected
by cancerous disease, there was not, during life, any decided symp-
tom of any pulmonary lesion, unless that Mr. Shannon found that the
right side of the chest was rather dull on percussion. Still, although
the disease might be suspected, there was no pathognomic symptom
of its existence. The present specimen was one of great interest ; there
had, on former occasions, been presented to the Society examples of en-
cephaloid deposition, but no specimen of that organ affected by true
scirrhus had as yet been laid before it, nor had Dr. Stokes himself ever
met with such acase before the present. In this specimen the upper
part of the lung was very hard, difficult to cut, and the act of cutting
it produced a grating sound ; it was, in fact, of an almost stony hard-
ness. There was a well-marked line of distinction between this indu-
rated portion and the rest of the lung, which was infiltrated with a
gelatinous matter of a greyish colour. This gelatinous deposition ap-
pears to be the earliest stage of the cancerous disease; to this sucs
‘520 Scientific Intelligence.
eeeds the condition of induration, and then that of ulceration, a
state not yet arrived at in this instance. In most cases where the
deposition of cancerous matter in the lungs is extensive, the pleu-
ral cavities are obliterated, a circumstance which proves that irri-
tation is associated with this deposit of heterologous matter. The
absence of such symptoms as pain is also usual, and has been al-
ready remarked on former occasions in this Society. There were
some spots of ossific deposit within the coats of the aorta, near the
origin of the innominata.’ In the descending aorta there was inci-
pient ulceration. The cancerous ulcer on the face had been ori-
ginally indurated, and. there were cancerous warts on the surface
which, in progress of time, might have become cancerous sores. As
to the diagnosis of these cases he would remark, that they might
be considered as forming three species. In the first, the external
cancer precedes the internal; those are the easiest to diagnose, for
in them any evidence of organic change in internal parts may be taken
as evidence of their being affected by cancer. The second species
is that in which some internal organ is affected before the cancer has
exhibited itself externally ; and a third species is that in which only
the internal organs are affected, and the cancer does not engage any
part of the external surface. Of both these the diagnosis may be
very obscure.—(Museum, Richmond Hospital.)

Eighth Meeting, January 21st, 1843.

Mr. Avams in the Chair.
L. Polypus of the Uterus.—Dr. Montgomery presented to the
Society a specimen of polypus of the uterus, remarkable for its size,
and attended by some unusual circumstances. The operation by
which it had been removed was performed by Dr. Cusack, to whom
he was indebted for the specimen. The patient had suffered from
uterine disturbance during the last five years, and her complaint had
been pronounced to be inversion of the uterus. On her coming to
town, and consulting Dr. Cusack, the true nature of the complaint
was recognized; the pelvis was completely filled by a tumour as large
as the child’s head at birth; the diagnosis was difficult, but as the
tumour was larger than the inverted uterus would be, and as the pa-
tient had never borne a child, Dr. Cusack decided it to be a uterine
polypus, and that its immediate removal was necessary. It was de-
termined that it should be removed by ligature, and the application of
this was very difficult. It was applied by Dr. Cusack, and in four or
five days afterwards it was tightened by Dr. Montgomery. On the
fifth day the pedicle had been nearly cut through by the ligature, and
as it was very desirable to avoid the chance of the polypus putrefying
in situ, the pedicle was then broken by twisting the tumour round.
The tumour having been thus detached from its connexion, the diffi-
culty remained, of how it was to be removed from the pelvis; it was
found that it could not be extracted entire, even with instruments.
Denman had advised that in such a case the tumour should be allowed
 Scientific Intelligence. 521
to remain until it softened down, but in the present case Drs. Cusack
and Montgomery disapproved of such a course, lest, in consequence
of the pressure on the soft parts, the vagina should slough, and an
opening be made into the rectum. It was therefore resolved on to
introduce hooks into the polypus, and excise large pieces of it; its
bulk being in this manner reduced, it was drawn out. The further
progress of the case presented nothing unusual; the recovery was
complete.
The pedicle by which the polypus was attached to the uterus was
very short, but its diameter exceeded an inch.
2. Cirrhosis of the Liver.—Ascites.—Mr. O’Ferrall said he had
to lay before the Society a specimen of mammillated liver, and also
the brain taken from the same subject, a patient fifty years of age,
who was nearly ‘moribund when brought to St. Vincent’s hospital.
He had ascites and general dropsy, but no symptom of any cerebral
affection. On the night after his admission he became comatose very
suddenly, and without any premonitory symptom. Mr. O’Ferrall re-
ferred to some former instances of this condition which had come
under his notice, and observed that, notwithstanding the hopelessness
of the case, he considered it a duty to endeavour to restore the patient
to astate of consciousness. The condition itself was one of great in-
terest and deserving of attentive investigation; the symptoms of the
patient in this state of coma were these: pulse at the wrist very ra-
pid, and perhaps it might be described as compressible; in the tem-
poral artery the pulse was bounding; the pupils were contracted; the
respiration slow. He determined that arteriotomy should be performed.
When from ten to twelve ounces of blood had been withdrawn the
pulse improved, and then became weak. The head was now shaved,
blisters applied to the scalp, and other appropriate means resorted to,
with the result that the patient was restored to consciousness. In
two or three days afterwards the coma returned, but very slowly, and
in this state the patient sunk gradually and died. The brain was
the first object of attention in the examination after death; it was
very vascular, and was in a very slight degree softer than the brain
of intemperate persons is usually found, which are generally firm.
There was no effusion within the cranium; the ventricles were
dry. The pia mater was very vascular, especially in the sulci be-
tween the convolutions. There was no other morbid appearance
in the contents of the cranium. In the abdomen, besides the effu-
sion into the peritoneum, it was observed that the liver was in the
condition which Laennec designated cirrhosis, and which, he supposed,
consisted in a deposition of foreign matter within the structure of the
liver. This is the mammillated liver of some other pathologists ; the
small brown tubercles of Baillie. Cruveilhier considered this to con-
sist in an hypertrophy of the yellow tissue of the acini. Hope re-
ferred it to an interstitial foreign deposit, along with hypertrophy of
the acini, but this opinion appears to be ill founded. It would be ob-
served in the present specimen, that the section showed an uneven
surface, though less so than the exterior of the liver, On the surface
522 Scientific Intelligence.
of the section are numerous projections; these projections are soft and
pulpy, but the general substance of the liver and its cellular matter
are firmer. When the pressure of the cellular structure is taken off,
these softer portions protrude, and a biliary fluid exudes from a cen-
tral point in each; this proves that the acini are hypertrophied, and
the cellular structure indurated. Mr. O’F. having pointed out these
appearances in the specimen, remarked that the disease was not in-
frequent, and that its intimate morbid structure was not sufficiently
determined. In the body from which the specimen was taken, the
lungs were found in a state of congestion, but during life there had
been no symptom of the lungs being affected. The heart was very
small, its texture soft and flaccid, and its parietes thin. On the con-
trary, in many cases of cirrhosis the heart had been soft and very
large. In the present case the action of the heart was feeble, and this
was explained by the condition of the organ.
4, Contraction of left Auriculo-ventricular Opening.— Dr.
Bigger said, the specimen he had to present belonged to a case which
offered many points of interest regarding the diseases of the heart,
and its sounds, and which might, on that account, be considered valu-
able enough to justify him in laying them before the Society. The
subject of the case was a young female, who, when she first came
under his notice in August, 1840, was eighteen years of age. She
complained at that time of frequent palpitations, and difficulty of
breathing; her countenance was anxious, and there was a remarkable
blueness and lividity of the lips. The pulse at the wrist was 160.
When the stethoscope was applied over the region of the heart, both
sounds of the heart could be distinguished, and between them there
was a bruit; there was frottement audible over a considerable portion
of the side of the thorax. She was treated for pericarditis, and re-
covered, but in a month these symptoms again recurred, but were
less violent than on the first occasion; she was again relieved by
treatment. She had after this many similar attacks, complicated with
erysipelas of the face, and occurring at the menstrual periods. She
suffered from amenorrhoea. It was observed, that however treatment
relieved her other symptoms, the bruit still continued, except when
she was perfectly quiet. On the 4th of February, 1841, she again
came under Dr. Bigger’s notice. She had been previously in the
Meath Hospital for erysipelas of the face; she had now erysipelas
affecting the entire of the head. On the Sth the pulse at the wrist
was 70; there was a bruit de cuir; the face was still swollen, but
the heart symptoms were relieved: after this leeches were applied
to the epigastrium, and digitalis exhibited internally; the pulse at
the wrist was synchronous with that of the heart; there was a slight
fremissement, and the impulse of the heart was indistinct. By the
12th the erysipelas had disappeared, and she was in every respect
better. On the Ist December, 1842, there was a bruit de scie dis-
tinctly audible, the pulse at the wrist was 120, the face was ana-
sarcous, the dyspnoea was considerable; the nose was of a purplish
colour; there was crepitus in the left lung, and other indications of
 Sczentific Intelligence. 523
pneumonia. On the 14th she died. After death the body was ex-
amined; the right lung was solidified throughout, except a small
layer next the surface, which was emphysematous, and through it
were dispersed many spots of pulmonary apoplexy. In the apices of
both lungs there was calcareous concretion, and the pleura was
puckered over them, In the upper lobe of the left lung there was
some purulent infiltration; the lower lobe was in a very peculiar
condition, it was tough, very elastic, and in appearance resembled an
emphysematous lung; there had been an exudation of organised
lymph into its tissue. The heart was not very large, the auricles
appeared to constitute the greater portion of it; they were very
muscular, and distended with blood. The left ventricle was not much
hypertrophied ; the left auriculo-ventricular opening was funnel-
shaped ; the mitral valves were united together, leaving scarcely room
for a goose quill to be passed through; the left auricle was hyper-
trophied. The aorta and its valves were normal. It was remarkable
that in this case, the soufflet which was audible between the first and
second sounds of the heart, was as well marked as in cases where the
aortic valves are diseased. ‘The result of Dr. Bigger’s experience of
cases of this nature was, that when the aortic valves were diseased,
the soufflet accompanies the second sound ; but that it is heard between
the two sounds when the auriculo-ventricular opening is in a state
of contraction.

Ninth Meeting, January, 28, 1843.

Mr. O’Ferrazt in the Chair.
1. Fracture of the Neck of the Humerus, with Dislocation of
the Head of the Bone into the Axilla.—Mr. Robert W. Smith ex-
hibited to the Society an example of an injury of rather rare occur-
rence, viz. : luxation of the head of the humerus, with fracture of its
cervix ; the former was dislocated downwards into the axilla, and the
latter broken obliquely, about two inches below the head of the bone :
the fragments had united with considerable overlapping and conse-
quent deformity, and a new socket had been formed for the head of
the bone, beneath the coracoid process, upon the subscapular surface
of the scapula. Mr. Smith observed, that although the treatment of
this injury was attended with great difficulties, the diagnosis was not
generally so, as in simple luxation the arm is lengthened, but in this
injury, when there exists any displacement of the fragments (which
is almost always the case), the limb is shortened; it is further dis-
tinguished from the simple dislocation, by the head of the bone re-
maining motionless when the shaft of the bone is rotated, the elbow
also can in general be brought close to the side. Mr. Smith observed
that it was an injury almost necessarily followed by permanent defor-
mity; the luxated head of the bone could not be reduced, for no extend-
ing force could be made to act upon it in consequence of the exis-
tence of the fracture of the cervix, and were the attempts to be made
after the fracture had become sufficiently firmly united to admit of
524 Scientific Intelligence.
extension being applied to the limb, it would most probably fail, in
consequence of the adhesions formed around the dislocated head of
the bone; it was, therefore, a matter of the greatest importance not
to overlook the true nature of the injury at the time of its occur-
rence, that the patient might be made aware that the limb would be
permanently deformed, and its motion, to a certain extent, impaired.
Sir Astley Cooper, in the description which he has given of this in-
jury in Guy’s Hospital Reports, remarks, that it is usually the cause
of blame being unjustly thrown upon the surgeon in attendance.
2. Cirrhosis of the Liver.—Mr. R. W. Smith said he wished also
to present to the Society, a specimen of cirrhosis of the liver, on
which he desired to make some observations. This disease of the
liver was of frequent occurrence, many specimens of it had been com-
municated to the Society, and the pathology of it might be considered
as now well understood. The opinions of Laennec as to its nature
were not supported, nor were those of Cruveilhier completely ad-
mitted. It isnow considered to consist in a peculiar contraction of
the cellular tissue pervading the liver, the capsule of Glisson as it has
been named, Mr, Smith regretted that he was unable {at the last
meeting to remain to hear Mr. O’Ferrall’s communication, who had
anticipated (as he had since been informed), almost all that he could
have said on the subject. There remained, however, some points of
had
consideration, to which he would ask the Society to attend. He
observed, that in all the cases which he had seen, the left lobe was
always the part most affected, that appeared in the greatest degree
atrophied in this disease. Why this should be the case, is as yet
unknown. The tubercular lobulated appearance depended, as he had
already observed, on the contraction and condensation of the cellular
tissue, which was so characteristic of this disease; it would be ob-
served that each of these lobules was only connected to the bulk of
the organ by the vessels entering at its base. It would be recollected
that Mr. Adams bad communicated a specimen in which the lobulus
Spigelii was retained in connexion by the vessels only. In the pre-
sent specimen there were similar appearances, and it resembled
closely Cruveilhier’s plate illustrative of the isolation of the granules
of the liver. Each lobule was easily divisible, and its divisions sub-
divisible into smaller, so that the whole might be unravelled into a
racemiform structure, like that of the kidneys in the phocidee and
some other tribes. It had been observed that malignant diseases of
the liver are not accompanied by dropsy, as this always is, because it
interrupts the circulation. The cirrhosed liver does not admit of
being freely injected. It was also to be remarked, that it is always
accompanied by enlargement of the spleen, which, in many of these
cases, becomes larger than the liver. Mr. Smith conceived these
phenomena might throw light on the nature of the functions of
the spleen. Miiller had indeed given it as his opinion that the
theory of the connexion between the spleen and liver was fallacious,
but Mr. Smith thought that in this instance Magendie’s opinion was
to be preferred. He thought it extremely probable that the spleen
 Scientific Intelligence. 525.
was a reservoir for blood. He had found in two cases where the
spleen was greatly diminished in size and indurated, being almost
cartilaginous, that the liver was enlarged in size, congested enor-
mously, and universally hyperemic. In Dobson’s and Magendie’s
experiments on living animals, blood had been injected into the veins
after the abdomen was laid open, and it was observed that the spleen
then became enlarged. On the other hand it was diminished in bulk
by copious bleedings, All these circumstances tend to prove that
the function of the spleen is connected with that of the liver, and
with the process of sanguification (Museum, Richmond Hospital.)
3. Lungs emphysematous, with Tubercles scattered through
them; Apex of Heart formed by right Ventricle; Nutmeg Li-
ver.—Mr. O’Ferrall said the specimens which he then presented
to the Society, belonged to a case which shewed how very dif-
cult it sometimes is to form a correct diagnosis of phthisis, and
which also exemplified several important points in pathology. The
case was one of acute or rather subacute phthisis, combined with an
emphysematous condition of the greater portion of the lungs, a com-
plication exceedingly rare, and causing great difficulty in making the
diagnosis, The subject was a young man of about twenty-eight
years of age, who was brought into St. Vincent’s Hospital, labouring
under extreme difficulty of breathing; his countenance was livid and
expressive of great anxiety, and the nares widely dilated; when he
was stripped there was observed strong action of all the muscles ac-
cessory to respiration ; the jugular veins were distended; the action
of the heart could be felt under the sternum; under the right clavicle
there was a slight degree of dulness, and through the lungs there
were bronchial rales mixed with mucous and sibilant. Mr. O’Ferrall
thought that there was a slight flattening of the thorax under the
clavicle ; the patient was in no way emaciated, but had rather a mus-
cular appearance. The diagnosis formed was that the lungs were
emphysematous, and the heart displaced. On the morning succeed-
ing this examination he had hemoptysis and increased dyspnoea.
He died in ten days after his admission, but for the two or three days
immediately previous to his death there was but a trace of bluod in
the sputa. When the thorax was laid open, it was found that both
lungs were emphysematous, except a portion of the apex of the right
lung; there were tubercles scattered through both lungs, but in
greatest quantity in the left, yet the right lung was more solidified;
there was a less amount of tubercle in the apex of the right lung
than in the other parts. In the bases of both lungs were small
cavities containing pus; in one of these there was a clot of blood. The
heart was large, and its apex was formed by the right ventricle ; the
disease of the mitral valves, described by Mr. Adams, is usually ac-
companied by this condition. The large size and muscularity of this
heart were remarkable. The liver was in the state called the nutmeg
liver, and was a good specimen of the first stage of the hepatic venous
congestion described by Mr. Kerin.
VOL. XXV. NO. 75. Y
526 Scientific Intelligence.
4. Inflammation of the Base of the Brain; Ramollissement,
and Change of Figure of left Optic Nerve.—Dr. J. F. Duncan pre-
sented the brain ofa woman who had been long an inmate of the
North Union Workhouse. Previously to her admission, she had
often suffered from intense headach, with which she was also several
times attacked in the workhouse, and was two or three times in the
hospital. On the 6th of December, 1842, she was again admitted
into the workhouse hospital for the same affection, but there was no
other indication of any disease of the brain. A chronic abscess, situ-
ated externally near the neck, had suppurated, and was opened. She
appeared relieved, and left the hospital. On the 18th of January,
1843, she was again complaining, and on examination it was ob-
served that there was a slight ptosis of the left eyelid; the counte-
nance exhibited a stupid vacant stare ; there was no febrile symptom;
memory and consciousness were still perfect, but the sight was evi-
dently failing. She had a sensation of sparks, and bright objects of
different magnitudes floating before the eyes. She was very irri-
table, and had excessive vomiting. On the 19th the left pupil was
dilated, the left angle of the mouth was drawn inwards, and the
tongue drawn to the left side. On the 20th she was raving, with
incessant, loud, incoherent discourse, and had frequent severe rigors.
On the 22nd, there was, in addition to the previous symptoms, very
quick and irregular pulse; before this, it had never exceeded 80 in
the minute. On the 26th she got up out of bed three or four times
without assistance, although there was slight paralysis of the left
side. After returning to bed the last time, she fell into a comatose
state, and died suddenly. When the skull was opened, it was found
that there had been recent intense inflammation at the base of the
brain: there was false membrane on the lower surface of the brain,
extending from the commissure of the optic nerves to the cerebellum;
both the optic nerves had been inflamed, the left was softened and
flattened. A quantity of lymph, of a greenish colour, had been
effused at the base of the brain. Dr. Duncan conceived that these
appearances served to explain the symptoms of the case, as to failure
of vision. The treatment adopted, he would observe, consisted in
the application of counter-irritants, together with the internal use of
calomel and active purgatives. The bowels were obstinately consti-
pated all through the case, and of five blisters which were succes-
sively applied, the three last had failed to produce vesication.
5. Observations on Dr. Bigger’s Communication at the last
Meeting.—Dr. W. Stokes said, that with the consent of the Council
of the Society, he would now proceed to submit to the consideration
of the Meeting some observations in reference to a specimen which
had been produced at the last Meeting, by Dr. Bigger. It was one
of the advantages of that Society, that when an observer loses sight
of a patient, he may afterwards learn the progress and final results of
the case, from communications made to that Society by other mem-
bers, It would be recollected that Dr. Bigger’s specimen produced
 Scientific Intelligence. . 527
at their last meeting, was one of diseased mitral valves, without the
heart being hypertrophied, but with contraction of the right auriculo-
ventricular opening. The case was one of great interest and value,
not only to the pathologist, but to the practical physician, on account
of the extreme difficulty of making a correct diagnosis of phenomena
which, it should be borne in mind, may be present etther with or
without the existence of organic disease. The female who formed
the subject of Dr. Bigger’s communication, had been for some time
in the Meath Hospital under the care of Dr. Stokes, who, after atten-
tively investigating the symptoms, concluded on suspending his diag-
nosis; this he remarked at the time to Mr. Murney, one of the
clinical clerks, who had taken very accurate notes of the case. To
illustrate still further the difficulty of forming a diagnosis in cases of
this kind, he would mention the case ofa female, twenty years of
age, full and well formed, whose catamenia were scanty, but regular
in their periods, and the causes affecting which were not ascertained.
She was liable to violent palpitations after exercise, and was obliged
in consequence always to walk slowly. She was by no means hys-
terical, on the contrary she was remarkably strong-minded and in-
tellectual; her lips were livid, and she had a tendency to swelling of
the feet ; what was, however, most curious in the case, was a loud
musical murmur heard along with the second sound of the heart;
the second sound itself was normal; the heart was not enlarged, and
there was a similar sound audible in all the large arteries which could
be examined; none could tell how long these symptoms had existed.
This difficulty of diagnosis was felt even by Dr. Chambers, of London,
with whose reputation they were all acquainted. He had received
from that eminent physician a long letter, extending to eight pages
closely written, relative to the case ofa female patient of his, who
was at first thought to be chlorotic, and of which, as it exemplified
what he had been remarking, he would read some extracts to the
Meeting. Having read out several portions of Dr. Chambers’ letter,
Dr. Stokes proceeded to observe: that it was in practice always diffi-
cult, in the case of young females, to determine whether these
derangements of the heart’s action are functional or structural;
fortunately in the greater number of the cases which present this
difficulty, the diagnosis is not essentially necessary. In some young
females, a bruit is heard along with the first sound, but without any
enlargement of the heart; this is more frequently observed in anemic
individuals, than in the hysterical, or chlorotic. Of the merely
functional murmur there are many variations, but these do not depend
on any alteration in the force of the heart’s action; but when the
murmur is from organic causes, the variations which occur are found
to be dependent on alterations in the force of the action of the heart.
In most cases the bruit accompanies the first sound, the second sound
is pormal, and the musical bruit is also audible in the arteries; when
these symptoms occur in a young female, we may diagnose that they
are functional, or nervous, to use a common expression. The general
 528 Scientific Intelligence.
result of Dr. Chambers’ cases was in favour of this, and the most
successful treatment had been the long continued use of the iodide of
iron. In Dr. Bigger’s case this triple combination did not exist;
there was no arterial murmur. The question remained to be eluci-
dated, whether did this murmur in the arterial trunks arise from
some spasm of the solids, or from some peculiar affection of the fluids?
The same cause most probably produces murmurs in the arteries, as
well as in the heart. It should be kept in mind that the second
sound being normal, indicates that the valves are in the normal
State.

Tenth Meeting, 4th February, 1843.

Dr. Law in the Chair.
1. Ileus; Portron of small Intestine passing through an
Opening in the Mesentery.—Mr. Hamilton said the specimen he
then presented to the Society, was one illustrative of the pathology
of ileus. On last Wednesday he had been sent for to see a patient
in Townsend-street, and on his arrival, found a man of about twenty
years of age, suffering under an aggravated form of ileus. It had com-
menced about eight days previously, with pain in the abdomen,
constipation, and vomiting ; it did not at all yield to remedies. The
patient was vomiting every minute a yellowish matter, which was not
feecal; the abdomen was swelled, but not tympanitic, the tongue
was streaked, the pulse 118, and weak. He died on the tenth day
from the commencement of the illness, during the entire of which
period there was no dejection from the bowels. It was remarkable
that during the last two days there was no pain in the belly, no
tenderness on pressure, and on the day of his death the pulse had
fallen to 96. Dr. Abercrombie has observed a similar absence of
pain and quietness of the pulse in some of his cases. After death
an examination of the body was made. The ileum and jejunum
appeared distended, and in some parts were of six times the natural
calibre, forming pouches, which contained feces; these intestines
were of a deep port wine colour. The stomach was healthy; the
large intestines appeared smaller than was natural. In the lower
part of the right side of the abdominal cavity was discovered the seat
of the disease; there was there an aperture in the mesentery, through
which a portion of the small intestines protruded; the intestine at
_ that point was greatly contracted, and had all the characters of stric-
ture; it was flattened, but was still pervious. Above the stricture
was the distended vascular part of the canal, while below the intes-
tines appeared healthy. The case was one of very rare occurrence.
2. Injury of the Head ; Death of the Bone; Softening of left
Hemisphere; two Abscesses in the Substance of the right.—Dr.
Hutton presented the recent specimens, exhibiting great extent of
disease in the brain, which had been but little indicated by symptoms
 Scientific Intelligence. 529
during life. The subject had been admitted into the Richmond
Hospital, under Dr. Mac Donnell, on the 19th of December, 1842.
He was a bricklayer, who was at work on an arch of brick, which
had suddenly given way beneath him. In his fall with the ruins,
he
received a flap wound of the scalp; the occipito-frontalis and the
periosteum were torn down, and formed a flap hanging over the right
eye; the man was but little stunned, and after a short time he very
foolishly cut away the flap. There were no very urgent symptoms
when he was admitted into the hospital, and the shock to the system
appeared to have been but slight. He went on well for some days,
the sloughs were separating, and there were no Symptoms of the
brain having been injured; granulations formed from the margin of
the wound; gradually the case began to assume an unfavourable
aspect; there was no matter lodged under the scalp, but the wound
began to look unhealthy, and more of the bone was laid bare. On
the 15th of January he complained of pain in the interior of the
head, and especially towards the occiput; his mind gradually became
clouded, and in the course of a few days he had become quite stupid.
There was no paralysis except of the sphincters; the faces and urine
were discharged involuntarily; the respiration was diaphragmatic.
The stupidity increased to such a degree that he no longer replied
to questions, though he could still speak distinctly; there was no
strabismus until the last three or four days; the pulse was rarely
above 90 at any period of the case; the body became greatly emaci-
ated, and the skin was harsh and dry towards the conclusion of the
case; he died on the 29th of January. The appearances observed
in the examination after death were these: the scalp was detached
from the right half of the frontal bone; the surface of the bone
itself was yellow and cribriform ; the coronal suture was separated,
and the processes of indentation had been absorbed; the death of the
bone had passed beyond the suture, both externally and internally;
the dura mater presented the appearance usual in necrosis of both
tables; it was rough, and had lymph deposited on it; there was
subarachnoid effusion; the pia mater was injected, the substance of
the left hemisphere was softened. At the base of the brain there
was purulent lymph effused, particularly at the pons varolii, the
medulla oblongata, and the optic nerves. When an incision was
made into the right hemisphere, parallel to the longitudinal fissure, an
abscess was discovered, situated immediately under or in the cortical
substance ; there was another abscess of a larger size contained in a
sac, which communicated with the right ventricle; this sac was full
ofa tenacious matter, which had also passed into all the ventricles ;
their serous lining was inflamed, and layers of lymph could be raised
from the serous surface; there were cysts in the choroid plexus,
which had become vascular, and were covered with lymph: the
thalami of the optic nerves, the corpus striatum, and the anterior
lobes of the brain had also undergone a degree of ramollissement.
It was remarkable that in this case there had been no convulsions,
530 Scientific Intelligence.
and no paralysis except of the sphincters, and slight spasmodic con-
traction of the biceps.
3. Malignant Ulceration of the lesser Curvature of the Sto-
mach; Farre’s Tubercle of the Liver; Chronic Arachnitis.—Mr.
O’ Ferrall presented a specimen of malignant disease of the stomach,
of Farre’s tubercle of the liver, and of chronic arachnitis, all taken from
the same subject. The liver in this case was unusually soft; along
the lesser curvature of the stomach there was a track ofulceration
where the mucous membrane had been destroyed, and the malignant
deposition had taken place. In this case there had been black vomit-
ing and singultus before death. The brain of the same subject exhi-
bited the characters of chronic arachnitis. The subject from whom
these specimens were taken was a man seventy-seven years of age,
and was a person of very acute intellect; he related, when detailing
his case, that when he was about seven years of age his head had
been accidentally injured by being crushed between a mangle and
the wall of the apartment; that he easily recovered, but that after-
wards during boyhood and youth he was very excitable, and that
up to his fiftieth year he had frequent paroxysms of excitement, for
which he had often been cupped and had taken medicines, but from
the age of fifty to his death at seventy-seven he had no symptom
whatever of any affection of the encephalon. In the examination
made after death when the dura mater was raised, the arachnoid was
observed to be opaque; the characters of chronic arachnitis were ob-
servable ; in some parts there were adhesions of the opposite surfaces
of the arachnoid. This state was the same with that which Andral
would designate subarachnoid thickening and opacity, but Mr.
not
O’ Ferrall considered it as attributable to the arachnoid itself, and
to any subjacent tissue. The arachnoid passing from one lobe of the
cerebellum to another was opaque and thickened. The structure of
the arachnoid is probably cellular, otherwise it would be difficult to
understand how it could be nourished ; its exterior surface is evidently
the
cellular and flocculent, and it is impossible to separate this from
on
serous surface or layer. The present specimen shews the conditi
of parts which remains after chronic arachnitis, and the history of the
by treatment, and the
case shews the curability of that inflammation
capability which the membrane possesses of undergoing extensive mor-
bid lesions without any obvious derangement of function.
4. Hypertrophy with Dilatation of the left Ventricle; Mitral
Valves thickened.—Doctor Law presented a specimen of hypertrophy
with dilatation of the left ventricle, and disease of both the mitral and
aortic valves. The subject, a woman aged twenty-five, was admitted
into Sir Patrick Dun’s Hospital for an affection of the chest, consi-
dered at first to be bronchitis, or bronchitis combined with phthisis.
She had been twenty months nursing, had cough and night sweats;
after she was some days in the hospital attention was drawn to the
condition of the circulating organs; there was a double bruit audible
behind the sternum, extended pulsation propagated into the arteries,
 Scientific Intelligence. 531
dulness to percussion in the precordial region; the bruit could be
also heard below the mammez; the pulse was jarring and the pulsation
in the arteries visible. The question was, did these symptoms depend
on organic, or on functional disease? the diagnosis was of organic dis-
ease which was amply confirmed by the examination after death. It
would be observed that the left ventricle was elongated in both its axes;
the mitral valves were greatly thickened, so as to interfere with their
functions. Dr. Law observed that what Dr. Stokes had mentioned
at the last meeting as to the distinction between functional and orga-
nic disease of the heart, and the means of diagnosis, coincided with his
own observations. He had observed that where the affection is merely
functional, the bruit is confined to the first sound; and that disease
of the mitral valves is not liable to be confounded with a functional
affection, while disease of the aortic valves may; the diagnosis de-
pends on the bruit heard with the first sound. Inthe chlorotic and
anemic cases in which this occurs without any valvular disease,
there is only a single bruit; but when the valves are diseased, the
bruit is double. In some cases the second sound of the valves is not
heard, in consequence of the patency not being permanent, and in
these cases the dilatation is also less. There is, however, less chance
of injury from confounding these affections, than from mistake in
other cases. He might allude to a case of a female of very pallid
appearance that had come under his notice; the bruit de diable was
audible in the vessels of the neck, and the treatment with chalybeate
remedies was very successful. Dr, Corrigan had related a case of a
medical man who had been greatly injured by depletion, but who by
change of air and other appropriate means, was enabled to survive
for fourteen years. In that case the valves were much in the same
state as in the present specimen. He would conclude with observing,
that in chlorosis the blood is imperfect in its constitution; that in
anemia it is deficient in quantity, which is less than is requisite for
the due support of the body and the various secretions in a state of
health; and that in cases where the valves are diseased the blood
regurgitates into the ventricle. In all these cases there is a deficient
supply of blood, and hence a somewhat similar treatment is applicable
to all.
5. Cancerous Deposition in the cervical Vertebre.—Dr. Bigger
said it might be recollected, that on the 12th of February in the last
year, he had laid before the Society a scirrhous breast, with two
axillary glands, that had been removed by operation from a pa-
tient in the Adelaide Hospital by his colleague, Dr. Marks. He
had now to present the spine of the same subject, whose case he
would relate in explanation of the specimens. Mrs. M., aged forty-
seven, married seventeen years, had borne six children, of whom four
are still living; had nursed two of them, had suffered disease of the
breast during six years previous to her admission into the hospital,
where the amputation was performed, after which she left the hos-
pital on the 8th of March, 1842. Up to the 20th of July she
532 Scientific Intelligence.
appeared to be doing well, and had suffered no annoyance except
from the cicatrices of the wounds made in the operation. The cata-
menia were regular, there was no hereditary predisposition to malig-
nant disease, and strong hopes were entertained that the disease
would not reappear. About this time she complained of a slight
disposition to cough and dyspnoea, but there was no effusion into the
thorax. In November she complained of pains like rheumatism in the
lower extremities, then about the shoulders; their chief seat was re-
ferred to the back of the neck; tinglings in the fingers and symptoms
of paralysis succeeded; sensation was diminished; the arms became
affected with clonic spasms. The head next became affected, and for
some days before death it could not be raised; the slightest motion ren-
dered the pain in the neck intolerable. There was obstinate constipa-
ation and tympanitis of the abdomen. A seton was introduced in
the back of the neck at the third cervical vertebra, and opiates and
other remedies used as occasion required, but the disease was not to
be subdued. She died in a fit into which she fell on the 18th of
January. The body was examined after death; the spinal column
was observed to be changed in figure; the atlas and second ver-
tebree were sound; the bodies of the three next vertebre were
changed into a scirrhous structure; the third occupied a very small
space, the cancellated structure was softened, the cancelli had dis-
appeared; the fourth vertebra was softened; the cancelli broken
down, but it was not injured in its longitudinal axis; the fifth
vertebra was shortened. On raising the spinal cord out of the
canal, it was found to have been compressed. Outside the spine,
immediately under the muscles, was a large mass of cancerous mat-
ter, intermixed with bony particles.

Foreign Body in the Air-passages.—Doctor Houston commu-

nicated the following case to a late meeting of the Surgical Society of
Ireland :—Dolly Kelly, a healthy country girl, cet. 16, recommended
by Dr. Nicholson, of Rathdrum, was admitted into the City of Dublin
Hospital, March 15, 1841. About a month before admission, while
holding a piece of stick in her mouth, she laughed suddenly at some
observation made by a companion, when the stick passed backwards,
and she was seized instantly with a severe fit of coughing, which lasted
for upwards of an hour. She thought she had swallowed it, and had
a feeling as if it was sticking in the upper part of the throat. Pressure
there caused pain. She soon became alittle hoarse, and had repeated
fits of coughing, which were brought on especially by stooping or
turning her body much to one side. For a week, symptoms continued
much in this state, but she told no one of what had happened, expect-
ing to cough up the foreign body. At the expiration of this time the
sensation of pain had ceased to be felt high up, and was now com-
plained of as existing at the upper part of the sternum, leading her
to think that the body had passed further downwards. Now, too, for
 Scientific Intelligence. 533
the first time her expectoration was streaked with blood. Her voice,
during the second week, became quite inaudible from hoarseness.
By a liniment and some medicines, the hoarseness was removed. A
probang and an emetic satisfied her medical attendants that the foreign
body was not located either in the pharynx or oesophagus.
When questioned regarding the piece of wood, she described it as
having been about an inch lone, very hard and black, about the thick-
ness of a straw, and with a head flattened sideways. She could give no
further account of it than that she had found it on the floor, and not
knowing either its name or its use, never having seen the like before,
she put it into her mouth as a safe and ready place of keeping, until
she could make inquiry about it; and while thus held in her mouth,
the accident, as above described, happened.
Symptoms on Admission into Hospital.—Voice feeble and hoarse,
very hoarse on attempting to speak loud, but clear and silvery when
speaking low; cough frequent, and sometimes attended with pain, as
if from a pin sticking in the throat. This pain is produced also by
suddenly turning the head to one side or stooping; but there is no
_ pain on pressure anywhere in the neck. She gets fits of coughing in
bed, at night, much more distressing than those which come on in
the daytime, and accompanied with a croup in inspiration. Tracheal.
rales, rough, sibilous, and mucous, and the slightest effort produces
much aggravation of intensity in these sounds; the chest clear on
percussion, and equally so on both sides; the respiratory murmur
scarcely audible from loudness of tracheal sounds; however, when
the breathing is easy, both mucous and sonorous rales are audible on
both sides, and without an appreciable difference in degree in one side
as compared with the other. Stooping, conversing, or anything that
hurries the respiration, brings on paroxysms of croupy cough, during
which respiration is suspended, the face flushed, the eyes suffused
with tears, and the veins of the neck distended. Suffocation then
appears imminent; and yet all this distress is at once relieved by
swallowing a sup of any liquid—the mode of relief she always flies to
in such emergency.
The girl is healthy in every other respect, and has never had hys-
terical or other nervous symptoms.
Her story is so clear and circumstantial that there can be no doubt
of its candour and veracity.
May 19th, I performed the operation of tracheotomy, regarding
which it is unnecessary for me here to state further, than that having
arrived at, and laid bare the trachea, I lifted up the forepart of that
tube by means ofa tenaculum stuck into it, and cut out a square piece,
of the breadth of two rings, with a pair of strong scissors. The act
did not occupy a minute of time.
A violent struggle in respiration attended on this proceeding, and
on the instant of its completion, a gush of frothy mucus, tinged with
blood, was expectorated with force from the wound and at the mouth,
but no stick presented itself in either direction. After two or three
_ fits of coughing of this kind, the breathing became more than usually
VOL. xxv. No. 75. /
534 Scientific Intelligence.
calm and free; so much so, indeed, that the patient felt assured that
the offending body had been got rid of in some way. A flexible me-
tallic sound was introduced into the wound, and pushed thence up-
wards through the rima glottidis, and downwards, as far as it would
go, towards the lungs, and turned and moved in different ways, so as,
if possible, to detect by the touch the piece of wood; but nothing of
the kind could anywhere be felt. In the course of the evening a
similar examination was again made with a gum-elastic bougie, but
with no better result. There was still some cough, but the fits were
neither so prolonged nor so severe. It was a subject of remark by
all present, that in the introduction of these sounding instruments,
there was a complete absence of excitement when they were pushed
forwards through the larynx, whereas violent paroxysms of coughing
were produced by every attempt at pushing them in the opposite di-
rection, and this to such a degree, that had the discovery of the fo-
reign body in the bronchial tubes rendered justifiable or necessary the
introduction of a forceps for its extraction, the attempt must, from
this circumstance, have failed. The wound was then simply protected
by a piece of lint laid loosely on it.
20th. A good deal of irritative cough;little fever; no dyspnoea.
2lst. Slept well; tracheal rales still present, but less marked;
some mucous expectoration; but no feeling whatever of the presence
of the foreign body.
22nd. Wound suppurating and still open.
28th. Little cough; orifice of wound closing; all the expectora-
tion comes through the mouth. |
30th. Feels quite relieved of all the symptoms; wound nearly
closed.
July 4th (15th day). All the symptoms revived, and even worse
than they had been since admission into hospital, the consequence of
exposure to cold while sitting to a late hour in the garden, yesterday
evening. The symptoms, now, are more like those of laryngitis than
of inflammation of the trachea, so much so, that some of the medical
gentlemen in consultation feel disposed to regard the affection as one
which now is, and, from the first, had been one of laryngitis, simply.
Acting on this presumption, and to give the girl the chance of
being bettered by a course of treatment applicable to laryngitis, she
had leeches applied to the throat, and was mercurialised, and blis-
tered.
12th. All well again; the voice clear, but the breathing and
cough raucous.
15th. Again, during a fit of laughter, the patient was on the in-
stant attacked with a paroxysm of coughing, which lasted for about
half an hour, and during which the expectoration was pretty abundant,
and streaked with blood. |
24th. No bad effects remaining from the attack of yesterday;
wound quite healed.
August 2nd. Has recovered her voice, is free from cough, pain,
or abnormal rales of any kind, and feels nearly as well as she was be-
 Scientific Intelligence. 535,
fore the accident. Being myself about to leave home for a short time,
FQ and seeing no present object to be gained by detaining the
\\) girl in hospital, I permitted her to return to the country,
m, acquainting my friend Dr. Nicholson, at the same time, of
i i” all the circumstances of the case, and requesting of him to
inform me of the issue of it. The result has been, the trans-
mission to me, by him, of the piece of wood, of which the
annexed woodcut isan exact fac simile, and which the poor
girl threw up during a fit of coughing, in which she was
nearly suffocated, in about three weeks after her return to
ij the country. Itis the peg ofa child’s fiddle, perfect and
} unbroken, and corresponding accurately to the form of the
aon stick, as described by the girl when giving an account of the
accident which had happened to her.
After the expectoration of the offending body, all pectoral distress
ceased, and the girl regained her wonted health and strength.
Observations.—The diagnosis in this case, although embarrassed
by the want of accurate information regarding the size and form of
the piece of wood, was nevertheless sufficiently obvious to justify the
attempt at relief by operation. ,
The healthy condition of the girl ; her assurance of having, as she
thought, swallowed a piece of stick, of which she gave a very accurate
description ; the fits of coughing and dyspnoea which supervened on
the instant of the accident; the tinging of the sputa with blood; the
hoarseness; the presence of mucous and sibilous rales in the trachea;
the obtuse pain opposite the cartilage of the second rib; the stings of
pain felt in certain movements of the neck and back; and the per-
sisteney of these distressing symptoms, ever since their first aggres-
sion, together with the assurances derived from pressure and the use
of the probang and emetics, that the foreign body was not located in
the pharynx or cesophagus—all left little room for doubt that it had
passed from the mouth into the windpipe, carried by the air, inspired
with suddenness and force, during the fit of laughter to which she
had traced her sufferings.
It was the history and general symptoms of the case that led to
such a conclusion, rather than the signs furnished by auscultation and
percussion, which latter, it will be observed, were only those indica-
tive of thickening, with morbid secretions and occasional spasm of
some part of the lining membrane of the tube—viz., mucous rales,
with stridulous, croupy breathing. The most detailed and patient
examination could not detect any difference in the amount or cha-
racter of the vesicular murmur in one lung, as compared with that in
the other.

Cases of Poisoning by Ginanthe Crocata, by P. Bossey, Esq.—

Twenty-one convicts were employed, on the 4th February, 1843, at
the mortar-mill situated on the banks of a canal in the Royal Arsenal
at Woolwich. At 11 o’clock in the forenoon eight or ten of them
went round the building to an adjacent pond of water, in order to
536. Scientific Intelligence.
wash their spades and boots. One man (Chamberlaine) strayed
away from the rest, and found this plant growing near the brink of
the canal, the leaves and roots of which he mistook for celery. He
dug up some, washed, tasted, and conveyed it to his companions.
Several of the men returned to the spot, assisted him to obtain more
of the roots, ate them freely, and distributed portions among their
fellow-workmen who remained within the building.
At twenty minutes past eleven, under the direction of the keeper,
they were all about to fall into ranks for the purpose of returning on
board-ship:to dinner (most of them still eating and putting roots into
their pockets), when one (Wilkinson) without any apparent warning,
fell down in strong convulsions. The struggling was soon over; he
became better, but retained a wild expression in the countenance,
which was pale, and in a short time he had another fit. Whilst they
laid him upon a shutter, a second individual fell (Knight), and be-
fore they reached the yard adjoining the hulk, a third (Wilson), and
a fourth (Salt) had also fallen, and were convulsed.
I arrived to give assistance about a quarter before twelve o’clock.
Nine stout young men were at this time convulsed and insensible.
The three worst, Wilkinson, Knight, and Wilson, were lying in a
shed; Chamberlaine, Gundle, and Jeffs, had just fallen in the yard;
and Williams, Jones, and Salt, were struggling on the deck of the
vessel,
It was manifest that Wilkinson was dying. His bloated livid face,
‘the sanguineous foam about the mouth and nostrils, the stertorous
snort and convulsive breathing, and the extreme prostration and in-
sensibility, plainly indicated that every remedial measure would be
useless. Nothing was done but to raise the head and shoulders, and
he died in five minutes.
Knight had been strongly and repeatedly convulsed, and ap-
peared to be fast hastening into the same apoplectic condition. He
was insensible, speechless, the pupils dilated, the face swollen and livid,
the breathing laboured, and the limbs convulsed. To make him
swallow was impossible; the rigid jaws were therefore forced asun-
der, and, by means of the stomach-pump, warm water was abundantly
introduced and withdrawn from the stomach. Some leaves were ex-
tracted with the fluids, but the instrument was worked with the
greatest difficulty, owing to the severity of the convulsions. He died
in a quarter of an hour. ‘
Wilson had assisted to carry the two former: when near the yard
he was observed to look pale, and soon fell convulsed. He struggled
so violently that several strong men could scarcely hold him. | After
the fit he was restless; consciousness partly returned ; he answered
“yes” when his name was loudly called, and swallowed an emetic
solution of sulphate of copper. No vomiting was induced, the con-
vulsions were renewed; the stomach-pump was passed, but extracted
only fluids. A collapse threatening immediate dissolution followed;
his strength was gone, face pale, pupils dilated, breathing convulsive,
and he appeared dying. After some time the stomach-pump was
again employed, and small portions of the root, with a few leaves,
 Scientific Intelligence. 537
withdrawn. Convulsions returned, with strong struggling, and about
half-past twelve o’clock, ina fit, he suddenly died.
Emetics of salt and mustard, with warm water, were administered
to those who had fallen in the yard, under which they vomited freely,
and discharged a large quantity of imperfectly masticated root, and
were thereby greatly relieved. The convulsions ceased, sensation
and reason were restored, but there remained giddiness, pallor of the
face, dilated pupils, coldness of the extremities, much weakness, se-
vere rigors, and’a slow feeble pulse. Further vomiting was pro-
moted, and more of the root discharged. Friction and warmth were
applied to the extremities, whilst ammonia and rum, with thin gruel
and other drinks, were administered internally, till reaction was more
fully established.
Emetic doses of the sulphates of zine and copper, and also mus-
tard and water, were given without effect to the patients lying on
the deck of the vessel, They were also bled very largely, both from
the arms and jugular veins. The introduction into, and removal of
warm water from the stomach, by the pump, brought away small
portions of the noxious roots. Cold affusion upon the head, perse-
veringly used, lessened the struggling, and produced some exhaus-
tion. In three cases (Salt, Williams, and Burgess), the subsequent
fits became less violent; they passed into a state of maniacal delirium,
with much jactitation of the limbs, and, after some hours, were re-
moved into the hospital. But in one more patient (Jones), all these
remedies were ineffectual; he died convulsed at a quarter before
one o'clock. As a last effort, the trachea was carefully opened by
an incision, and artificial respiration kept up, but life was quite ex-
tinct.-
Several of the men who had eaten the root, seeing the others
suffer, took the salt-water emetic with success, and had no symptoms
of being poisoned; others felt giddiness and faintness in a slight
degree, and at 6, p. M., there were, upon examination, eleven who
required watching, and were, therefore, sent into hospital... ... 4
One young man, Joseph Salt, etat. 17, was bled largely the
first day, but during his subsequent illness, the extremely irritable
condition of the nervous system, and the severe bronchitis, prohibited
active depletion.
The post-mortem inspection shewed that many important organs
were very seriously injured.
The trachea and bronchi were injected, and the smaller bronchi
filled with mucus. The left pleura was lined with lymph, and its
cavity filled with serous effusion. The stomach and intestines were
pink on their external surface, the intestines glued together by adhe-
sive matter ; and there was much peritoneal effusion, with flakes of
adhesive lymph. The mucous membrane of the stomach and bowels
was softened, thickened, and everywhere coated with an abundance
of mucus. On washing this off, the membrane was much injected.
There vessels of the brain were more injected than usual, and there
was slight serous effusion beneath the arachnoid... ........
538 Scientific Intelligence.
[We have no room for the cases and post-mortem examinations,
which are given at length
]. |
From what has been related, it appears that the effects which
the cenanthe produced in these cases were a violent irritation of the
mucous membrane of the cesophagus and stomach, more particularly
of the follicular structures, and a state of severe and universal spasm
of the muscular tissues; it also induced insensibility, coma, delirium,
extreme congestions of internal organs, and, in those cases imme-
diately fatal, it occasioned permanent fluidity of the blood.
The first indication of treatment was, doubtless, to evacuate the
stomach; but, as its sensibility was destroyed, and the poison was
taken in the solid form, this could not readily be accomplished. Large
and immediate depletion seemed to be essentially useful, by removing
the imminent danger of extravasation from over-distention of the
vessels; the cold affusion was also beneficial in rousing the patient,
so as to make him sensible to the emetics, and so were purgatives
during the after-treatment.
Called thus in a moment to so many urgent cases of poisoning,
it became needful to use such remedies as were at hand; but, upon
reflection, it seems to me proper, in similar circumstances, to rely
chiefly on emetics given early, on large blood-letting immediately
employed, and the cold affusion.
Although the attempt to re-establish respiration by tracheotomy
failed in the case selected for it, in consequence, probably, of the
great effusion of blood afterwards found on both hemispheres of the
brain, yet it is worthy ofa future trial in single cases, where it can
be more conveniently practised.
Considering the great activity of this poison, that it is capable,
as we have seen, of extinguishing the life of a strong young man, in
full health, in one hows, and that many other fatal cases are recorded,
itis rather singular that the nature of the active principle of the
eenanthe is not yet well known, or the plant applied to medicinal
use.—Medical Gazette.
 INDEX
TO THE TWENTY-FIFTH VOLUME.

A.
Page
ALDRIDGE, Dr. John, onthe chyle,... 1-4... th tab) does OT,
Remarks on his paper on urinary diseases,
by Dr. Go_pine ae *. ‘guise at aeeeOd
Abscess perforating bladder . , Lange ina to asrtieh
Ammonia, muriate of;,internally oi. . ee we oe BEB
Anatomical manipulation. (Notice )isrelt hie a sth tones oop pede
Ameutismofthe abgominalaprtay cosicer isn + ‘set sos olnckengd OO
arterla IMnpMiMaldens sclerosis od, dew oA OGL
ascending aorta . . iia] kts nie eae aG
multilocular, at base of the Choe ‘niles &vincheotee OOF
Aorta, aneurism of, compressing the venacava - . . . . 167
Aorta, aneurism of, bursting into the pericardium . . 170, 179
_thoracic aneurism of, without murmur . iiiews UZ
cases of aneurism of the, by RoBrert Law,M. Tis d 200
Apoplexy, cerebral, without Dee ae. ay pions inte
cerebral. |; . ,. ‘ AO a WT AaSS
Arachnitis, chronic . . eet 030
Areola, formation of an umbilical, hats, as a,2 sign of ee
by Dr. MonrGomery . . 295
Arsenic and mercury, hydriodate ofain econ anal wieeaie
affections . . es al. os Ses e eee
Ascites consequent on eae ete grea, ae
PUStONG AS OIOCALONS Gl og eo et 8 es ey gg
Csculiony cCereDiak: «= >» . . « » * «) t uy nee Boe

B.
BaTTersBy, Francis, A. B., on scirrhus of the pancreas . . 219
Beatty, Tuomas Epwarp, M.D., contributions to erory
y 9 201
Biro, Dr. Gotpine, remarks on Dr. Aldridge’ paper on
urinary diseases . . - 2. + « nodt x d mien
540 INDEX.
Page.
Bladder, perforated by acne aes i secant ewe
communicating with uterus by uleeration gen Bielhe aes
ruptured in the female 2° 2 6 e+ se nes 176
bilocular .. ae <6 e e ee ae
Brain, engorgement of, froma buen 2 -xidineck.< da. eeoOe
softening of the . ses ee Ste ee ee
inflammatimn of tie MadpreR Wid A: Fic. ap. RO
Bright’s disease in kidney . . ng 66
Buen, Dr. D. B., on polypoid growths of the Sones aT
Cr FE.
Cancer. of the cervix tet . 0 cent oodles care ete oe alee
of the leg, &. . . , bing? queens Val a ae leeiia
of the abdomina l viscera . - Are bare ae
Cerebrum and pia mater, acute inflamma tion OF egacaceip g e e
Cancerous deposition in the mesentery and intestines . . » 172
deposition in the cervical vertebre . . . . . + o8l
Carcinoma of the maxillary glands and mamma . . . + - 179
Caries. ofthe vertebre . .. sia
Catalogue descriptive of the Park- street Awatamical and Pa-
| thological Museum, by John Houston, M. D. na ) 156
Census of Ireland for 1841, (Notice.) 29308 142
CuurcuHi.t, FLeEtwo op, M.D., on oxarieton y. we , SANS TLS
Chyle, on the, by Dr. Aldridge yorig pass
Climacteric disease, observations of, by Henry Kenwzpy,
M. B. eo jays: i cea ee
Convulsions, epileptic ote Se Ou
Coxze morbus, exfoliation of tHe head of the fouleie MN... died
luxation of the head of the femur in . . . 174,179
Cryptogamic. vegetations on the mucous coat of the stomach
after death.. >. 1aiisal INO Cij@ 20: Miers, 1988IEs SC 1S
* D.
Douerty, Ricuarp, M. D., on impending dissolution and
nervous affections ilivamfents) «0% 4 OU? PU aa

E.
Empyema, on the diagnosis of, by Ropert L. Mac DonneELt,
Esq. “.<". 5 eae rt seine eye 1
paracentesis in. (Notices. ) Cas 470
Entropium and triachiasis, observations on, by ‘W.R. Wi.bE,
I, A. :
Erysipelas, extending to mucous 3 membranes andair-passages . 9809

F.
Females, on the diseases of, by Dr. Churehill. (JVotice.). . 157
Fever, epidemic, of Edinburgh, natural ear &c., of, by Dr.
Cormack. (Notice.) . . » “ST58Ps26
Foreign body in the air-passages, by De Fonte?! , YAN, 532
 INDEX. 541
Page.
b SG:
Gastritis, acute i 174
Glottidis, obstruction of ‘the rima 160
rima, closed by warty vegetations 160
#
H.

Hemorrhage from an artery epee! into a tubercular cavity in

thelung. ... @ 168
Heart, enlargement ofthe . : 164
contraction of the left auriculo- ventricular opening . 022
apex of, formed by the right ventricle . 525
Hernia, from hooping cough . : 50l
Hemisphere, softening of the left, from iinjury of the head. 928
Humerus, fracture of the neck of, with dislocation into the axilla 523
Hydrocele, on the radical cure of, by Witi1am Henry Por-
PER, Me Darien) (: 399
Hydrocephalus, chronic . 504
ie *e
Tleus; portion of a small intestine passing eee an opens
in the mesentery . 928
Inflammation, diffuse, &c. by GERALD Osprey, M. B. 133
Intestinal canal, obstructions in eer e tes 361
Intussusceptio |
J.
Joints, knee and shoulder, acute inflammation of. . 505
Jurisprudence, medical, by Alfred S. Taylor. (Notice). 304
K.
Kewnepy, Henry, M.B., on clingggenc disease
¢ 245
Kidney, Bright’s disease in 166
Lis
Laryngitis, chronic a: 160
Larynx, warty deposition . .« 168
foreign body in . 516
Law, Roserr, M. D., cases a aneurism ad the dete, by y 266
Liver, fatty degeneration of. 165
Farre’s tubercle of 165
encephaloid, disease of 491
tuberculated 497
cirrhosis of. 521, 524
Farre’s Ricecla of 530
Lung, scirrhus of the. 519
tubercular infiltration of 515
Lungs, emphysematous . pas 525
VOL. XXV. NO, 75. 4A
 542 INDEX.
Page.
M. #

Mac Donne Lt, Rosert, Esa. on the diagnosis of empyema . 1

Medicine, forensic, by William A. Guy, M. B. (Notice).. . 304
Meningitis, subarachnoid . . tee
Midwifery, contributions to, by THOMAS E. BEATTY, M. 1D: =. -20t
lectures on, by Robert — M.D. (Notice).. . 321
Monster, bicephalous. fog eals
Montcomery’ s, WILLIAM 2 M. DD. address delivered before
the Dublin Obstetrical Society, by . 180
WituiaM F., M. D., on the dark abdominal
line and formation of an umbilical areola,
as Signs of delivery’. 7.95 uxiuscu:murte <giee
N.
Neckasie OF tne Te Ce ee ge Ge ee
the tibia... iv ican aoe,
Nerve, optic, ramollissement, and change offigure df 5.1925 BG
Nervous affections in infants, by Ricuarp DouERTY, M.D.. 44
peculiar to travellers in ee &e, ee Hun- ;
gerford Sealy, M.D. . ; 287

©;
Obstetrical Society, address to, by Witt1am I’. MonTGOMERY,
RG Ase (aes 180
(Esophagus, stricture the
of cardiac extremity oft fount . 173
* Osprey, GERALD, A. M., on diffuse inflammat ion occurring in
the exanthemata, Re: : PORTE: OP ASSES: BPE ahs eee
Osteosarcoma, benign, of the ail SPR S PY gf tele O80 R
Ovaria, scirrhus of . TS
Ovarian tumours, removal of both the right ‘and left, ‘at the
same operation os Vase Ose
Ovariotomy, notes on , byF. Churchill, M. D.gaerib 2 v i eee

P,
Pancreas, scirrhus of ; = 7S
two cases of corns of, by PRancis BATTERSBY,
A.B. M.D... . Re ns e e e hea
Parace ntesis thoracis. (Notes) Mh SAE RL
Pericarditis . . SE etee ae oe awe
YO NPS es ss hae y
Peritoneum, Shraiaee aepoution
Pharynx, abscess behind the. . ees, | 3 pate
*
Philosophy, natural, by Capes Bird, M. D. (Notice) » e eS
Phlegmasia dolens. . . FES), Seay te
he Ser le oF els te me n ®) eS. Te SUE 165
Phthisis AC Ee Spe he
Pleuropneumonia . Ay a meats c- 1e.g , ae
ioe BOO
Pneumonia in a child ae leven “worth
 INDEX. 543
ae
Pneumothorax . . -.* e 491
Pneumonia, interlobulat™ : = 508
double > : Sieg Oe +630 Fea G
Porrigo, or tinea capitis. . = Ss 494
PorTER, WM , Huey, M. D., on the radical cure of hydrocele 399
Poisoning by cenanthe crocata, cases of, psFs ayaa est - 35
Prostate, enlarged and inflamed . . . wel
Pylorus, scirrhts oi the pipet i Pr Ae *

R.
Rye, ergot of, its influence on the foetus in utero. . . .
S. ? |
pcmrhus of the osdpnagus. "af a. te te are 173
pamcreds and OWOTIa™ sy. t se soe e se e el ee
Ghoti: calor «sate roe oe ve ae Com e eee
the polorus ... . x Sp suede
SEALY, HunceErrorp, Esq., M. D. , on nervous 4 affectiongy c
dental to Relea, in Sicily,&e.
& . ca — 287
Sibbens, remarks on 346
Spina bifida cured by operation acs 363 —
Steatomatous deposition in arteries at the base of theae: 170
Stokes’, Dr., observations on Dr. Bigger’s communication at
‘the Pathological Society® «-. i. nbs 5, Gp be seme
Stomach, perforating ulcer of . . --. O02
malignant ulcerations of the lesser curvatureof 1 5 ae
Surgery minor, by H. H. Smith, M.D. (Notice.) . . 340
aural, &c. early history of, by W. R. Wiipg, M.R. ;A. 4228
Syphilis, pseudo, on an epidemic . . 3722
a
Thumb, dislocation of the . . dae Be mie ee
Toxicologie, Traite de, by M.OFfila. (Notice.)' 0-4 one eee
Tubercles in the cerebellum, scrotulolis. . + + * . & ~ -ole
Tumour, encephaloid thoracic ._. We oa en
ovarian, containing teeth, hair, hea: Va ah eee
Priachiasie, Observations 6. 49.0 = . . of sae bok 298
UY,
Vaccine vesicle attacked by diffuse inflammation . . . «= . 1838
Valves, mitral, thickeningofthe . .«.'... . +." 4 . 364
thickened. Ase kage 3) Acie alee ae
Ventricle, hypertrophy of the left . Me Gmanc SMe. 45 oD age
Ventricles of the heart, purulent cystsin . Ve sic nee
left, hypertrophy, with dilatation of . i> sh et on
Vertebre, lumbar, erosion of the bodies of. . .. . . . 163
caries of . . zac gp cae sel pel ea
cervical, cancerous deposition iTt Saeea \a) xe ) alecnceaeeen
*
*

*
 544 INDEX.
Page.
Vivisection, remar Le~* 2. . . 455
Uterus, vesicular p us oom 492
Umbilical areola.
Vomiting, on the mechanism of =. oe “ae
Urinary diseases, communication one . Pamels oc it 2p OS
as softened and relaxed. ‘ ae = ed we erode he
communicating with the bladder by ulceration. . . 1738
“ human, gravid, William Hunter, M. D., edited by
Edward Rigby, M.D. (Notice) . . 300
on polypoid growths of the, by D. B. Bullen, M.D. 407

wv
* Nosology of the Ear,.. . .-
4
ILDE, Mr., on the early history of aural mee and the
; 445 coe
observations on entropium and trichiasis, by. _ ee. a

we-

END OF VOLUME XXV¥.

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