Sample movement for lateral curvature to the right-expanding contracted (left) side, unbending spine, and pressure on projecting (right) shoulder. Is caused by unequal action of the spinal muscles, generally (but not always) accompanied by muscular weakness. Sound sense and experience prove that supporters, by preventing muscular action, increase the weakness and aggravate the disorder; while gymnastics, acting on all muscles alike, can, at most, only benefit the general health, but cannot correct relative disproportions of muscular strength. A CURE would consist in such regulated action of the muscles as, in accordance with the anatomy of the body and peculiarity of the deformity, would expand the contracted muscles on the shrunken side, and contract the expanded muscles on the projecting side, and, by introducing a series of muscular actions opposite that which produced the deformity, would thus reestablish a uniform and harmonious action of antagonist muscles, when the deformity would disappear. (See cuts.)

Sample movement for paralysis,-concentrating the will on the extensors of the leg, while the rest of the body is at rest.

3. ANGULAR CURVATURE OF THE SPINE (Pott's disease) consists of actual disease of the bodies of the vertebræ, with loss of substance at the point of disease. The weakened spine needs support, but the muscles should not be confined.

Is pro luced by a suspension of the nervous stimulus to the muscles by some cause affecting the nervous centres. The shock may have passed off, or the clot in the brain may have become absorbed, and the paralysis may still, wholly or in part, remain, because it requires a special effort to re-establish the connexion of brain and muscles. In ordinary exercise, the unaffected muscles perform the most of the action, while the paralyzed ones perform the least.

This process should be reversed, and the paralyzed muscles made to act while the unaffected parts are at rest. The nerves must be re-educated to perform their functions, by sustained, gentle, well-directed, and repeated efforts of the will on the affected muscles, till the latent power is developed to be an efficient one.

Spinal assistant" for angular curvature (Pott's disease), provided with hinges (f. f. f. f, G, G), which allow the spinal muscles to act.

An original instrument (see cut) is used, so constructed with several hinges which bend backward but not forward, that while the spine is supported and the diseased surfaces relieved from pressure, the muscles of the back are encouraged to act (instead of being prevented, as in all other instruments), and thus the muscles themselves are made the efficient part of the instrument acting over the curvature to reduce it. There is no confinement; it is very adjustable; the pressure is increased and diminished at pleasure, and it is worn with the greatest comfort. The importance of thus developing the spinal muscle, contiguous to the diseased point, cannot be overestimated, as results show.

4. THE TREATMENT

(which is based on the Swedish system of Ling). is purely scientific and physiological, and though it is not claimed to be applicable to every case, in many it is very clearly indicated; as, in dyspepsia and constipation, by acting on the stomach and bowels, to give tone to the digestive organs; in consumption. by expanding the chest, distributing the circulation, and increasing the aerating process; in diseases incident to women, by giving general vigor to the muscles, especially of the back, hips, and abdomen, relieving the downward tendency of the organs, and increasing the peripheric circulation, to relieve uterine and other internal congestions.

AND IN ALL CASES the treatment is done, not by the patient's unaided efforts, but by trained assistants, nicely adapting each movement to the strength and need of each patient, precisely as prescribed by the physician to secure the des red local or general results. There is nothing like "rubbing," "gymnasti s," or calisthenics" about it, patients are never fatigued, but from the first are very fond of it.

The co-operatin of the family physician, as is mostly the case in this city, is always desired when practicable. Cases likely to be benefited are solicited through the profession.

Original Lectures.

LECTURES ON THE PHYSIOLOGY OF THE CRANIAL NERVES.

DELIVERED IN THE COLLEGE OF PHYSICIANS AND SURGEONS.

BY

JOHN C. DALTON, JR., M.D.,

PROFESSOR OF PHYSIOLOGY AND MICROSCOPIC ANATOMY.

LECTURE III.

TO-DAY, gentlemen, we begin the examination of the seventh pair, or the facial. The facial nerve was considered by the older anatomists as belonging to the same pair with the auditory, for the reason that they both emerge from the substance of the brain very near each other, that they take the same course, and leave the cranial cavity by the same foramen, viz. the meatus auditorius internus. This foramen is situated on the posterior surface of the petrous portion of the temporal bone. The two nerves run side by side from within outward, and enter the same foramen together. Thus far they are associated as a single pair. But they have also certain characters which distinguish them from each other. From the difference in their consistency alone the facial has been called the portio dura, and the auditory the portio mollis. Then again, the distribution of the two nerves is different. The facial, instead of terminating, like the auditory, in the petrous portion of the temporal bone, enters a canal of its own, the aqueduct of Fallopius, and thence follows a zigzag course until it emerges upon the side of the face, by the stylo-mastoid foramen.

There are several curious points in the anatomy of this nerve, as it passes through the aqueduct of Fallopius. In one of the specimens which I have here, the irregular, zigzag course of the facial is very well shown. It first runs from behind forward and from within outward, then makes a very sharp elbow-like turn, and takes a course from within outward and before backward, then turning from above downward it finally reaches the situation of the stylo-mastoid foramen, and thus emerges from the interior of the cranium upon the side of the face. Such is the history of the facial nerve during its course through the substance of the petrous portion of the temporal bone. Then, having emerged from the foramen which I have mentioned, it runs first from above downward and from behind forward, and penetrates the substance of the parotid gland, where it breaks up into several different bundles, cr branches. The arrangement of these branches, and their separation from each other, and at the same time their mutual connexion, present an appearance which is known as the pes anserina, or the goose's foot. This appearance you will see in the preparation which I now show. You observe the emergence of the nerve at the stylo-mastoid foramen, its passage from behind forward, and its separation here into four principal divisions. The first is a division consisting of fibres which run from below upward, and are distributed to the muscles of the external ear; the second is a bundle passing from behind forward, and upward, to be distributed to the orbicularis oculi muscle. The third passes from behind forward, and is distributed to the superficial muscles about the anterior and middle part of the face. The fourth runs from behind forward and downward, to be distributed to the muscles of the lower part of the face. Here then you find that the facial nerve, so far as regards its distribution, is evidently to be considered a muscular nerve. Unlike the first and second divisions of the fifth pair, which we examined yesterday, this nerve sends its filaments to the muscles of the face, and the muscles only; and unlike the third division of the fifth pair, which was partly distributed to the deeper-seated muscles and to the teeth, this nerve supplies the superficial muscles, AM. MED. TIMES, VOL. II., No. 7.

those, viz. which close and dilate the orifices of the face. So much, then, for the anatomy of this nerve.

Let us see what can be ascertained with regard to the physiological character of these filaments. You will remember the method which has been adopted in every instance as yet to demonstrate the properties of any nerve. When we expose a nerve, in a living or recently killed animal, and irritate it, we excite either a painful sensation or a convulsive movement in the parts to which it is distributed. When we divide the nerve, we see what nervous properties are destroyed by that procedure. It has been found, with reference to the facial nerve, that if it be irritated in any part of its course, one effect is invariable; convulsive movements produced in the superficial muscles of the face. I have very frequently noticed, in operating upon this nerve, that when separate branches of it are irritated particular muscles will be thrown into convulsive action;-the muscles about the eye, about the ear, about the nose, and about the lips.

The facial nerve may be readily divided in the dog, cat, rabbit, and several other animals. All that is necessary to do, to divide it in the cat, is to make an incision from above downward and from behind forward, immediately behind the external ear, then reach the posterior edge of the parotid gland, lift this up, and continue the dissection underneath it, until at last you find the situation at which the branches of the nerve are passing forward. These branches can be followed backward to the stylo-mastoid foramen, and all the filaments divided at that point. In this cat, this operation was done a few hours ago. Now, the consequence of this division is a loss of power over the superficial muscles of the face. These muscles are the orbicularis oculi, dilators and constrictors of the nares, buccinator, orbicularis oris, and the levators and depressors of the lips. We can ascertain the existence or loss of muscular power in these parts by irritating the integument in various ways. For you will recollect that, so far, we have not found any sensibility in the facial nerve, but only the stimulus to motion. Now, in regard to the external ear, in the case of the human subject, the movements of that organ are very insignificant, and its muscles consequently are so slightly developed, that it is with some difficulty that they can be distinguished in an ordinary dissection of the parts. But in many of the lower animals, the movements of the external ear are exceedingly vigorous, varied, and extensive, and consequently the result of a division of the nervous filaments which supply these muscles is equally important. The cat is an animal particularly well adapted to illustrate this point, as its ear is exceedingly sensitive to any impressions made upon the integument. All we have to do is to irritate the posterior surface of the ear, and you perceive a violent twitching taking place, which in its promptness and certainty is similar to the act of coughing in the human subject, when the mucous membrane of the glottis is irritated. I will irritate the ear of this animal on the right side, and you will perceive a twitch at the slightest touch, yet if I irritate the ear upon the left side, where the facial nerve has been divided, we produce no effect whatever upon the movements of the organ.

Now, by this very simple operation we prove two things; in the first place, that the power of motion over the external ear is lost, and at the same time, in a way that I shall explain in a moment, that there is nevertheless no loss of sensibility. This, you will observe, is a very important point. When we divide a nerve going to a particular region, we wish to ascertain if motion is destroyed, and if so, whether sensibility is destroyed at the same time; or, if sensibility is destroyed, whether the power of motion remains. Now, how are you to determine this? In this way. You observe, if I touch the right ear, upon which side no operation has been done, the movement which takes place in consequence, is a movement of the ear, but not of the head. The animal keeps his head quiet, and satisfies himself by twitching the ear to avoid the pain. If sensibility were destroyed upon the left side, and I irritated

the ear upon that side, the animal would not show any indication of feeling. The truth is, that the sensibility of the skin remains; and although there is no convulsive twitching of the ear, we nevertheless see that the animal still feels, because he endeavors to withdraw from the irritation by moving the whole head. Here, then, we have

found that after division of the facial nerve the muscles of the external ear are paralysed, and the integument still retains its sensibility. This is because the integument of the external ear is supplied by the great auricular nerve, which is a branch of the cervical plexus.

Let us next see what effect has been produced upon the eye by the division of this nerve. The eye is opened, as we found the other day, by the action of the levator palpebræ superioris. This muscle is supplied by the oculo-motorius, and consequently if that nerve be left entire the animal has still the power of opening the eye. But the eye is closed by the orbicularis oculi, and that muscle is supplied by one of the branches of the facial nerve; the power of closing the eye, then, is gone. In this cat the sensibility of the cornea and the movements of the right side are unimpaired. If, however, I touch the cornea upon the left side, where the facial nerve has been divided, there is no closure of the lids. There is, however, a certain movement which you will notice, viz. a retraction of the eye within the orbit by the action of the straight muscles of the eyeball, which shows that sensibility of the cornea still remains. At the same time that the eye is drawn back, you observe that the third eyelid, or nictitating membrane, is partly thrown across the cornea by the pressure of the eyeball at its base. The only other point which is visible in the cat is, that the orbicularis oris is incapable of complete contraction on the injured side of the mouth. On the uninjured side, the angle of the mouth is completely closed, while on the left side it hangs partially open.

Now, the effect produced in this animal by a division of the facial nerve is different from that which we saw yesterday, in consequence of a division of the fifth pair. Here is the cat upon which I operated yesterday, by dividing the fifth pair at the Casserian ganglion. You will see that the right eyeball is still very prominent, as it was immediately after the operation. You will notice that the pupil upon the right side is very much contracted. Upon the left side the eye is perfect, and retains its ordinary appearance. I show you this animal again to-day for the purpose of calling your attention to the difference in the effects of the division of the fifth and facial nerves. When I touch the anterior surface of the cornea in the animal in whom the fifth pair nerve has been divided, the eye does not close, but it is not because she cannot close it, but because she feels no desire to do so. In the other animal where the facial nerve is divided, it is easy to see that motion has been lost while sensibility remains; so in the other it is easy to prove that sensibility is lost while motion remains. If I make a sudden movement towards both eyes, you perceive that there is immediate closure of both; this, however, does not prove that there is no sensibility in the cornea of the injured side, but simply shows the sympathy which exists between the muscles of the two sides. If I cover up the sound eye, no such move

ment is communicated.

In the cases, therefore, in which the facial nerves are divided, we find that the result of this operation is a paralysis of the superficial muscles of the face. We find that the facial is the great motor nerve of the face, presiding over the movements of expression, as the third division of the fifth pair presides over the movements of mastication.

There is still another point to be investigated. Does the facial nerve contain any sensitive filaments? Direct examination has shown that this is not the case. For if the facial nerve be irritated during its passage through the petrous portion of the temporal bone, in the living animal, as observed by Longet and other observers, no painful sensation is felt. But that is not the case if we irritate the nerve after its emergence from the stylo-mastoid foramen, when we find that the animal suffers evident pain. Now

how are we to explain this? A series of very ingenious experiments has determined the cause of this peculiarity in the functions of this nerve. Longet and others have found that the trunk and branches upon the exterior owe the sensibility which they undoubtedly possess, not to filaments of the facial nerve, but to those which it derives from the fifth pair. This has been proved in the following way :-I have stated that if the facial nerve be divided during its passage through the long canal, the result is a loss of power in the superficial muscles of the face; but it has not been found that the face loses any of its ordinary sensibility. The skin retains its natural properties in that respect; so that while we have destroyed motion we have not affected the sensibility, and consequently the power of sensation cannot belong to the fibres of the facial nerve. It is found, however, if the fibres of the facial be left untouched, and the fifth pair be entirely divided in-the interior of the cranium, not only is all sensibility of the integument and nucous membrane of the face destroyed, as we saw yesterday, but the sensibility of these very filaments and branches of the facial nerve is lost. This inosculation of the fifth pair with the facial is exceedingly important in a pathological point of view. I spoke the other day of the painful aflection of the face, called tic douloureux, a neuralgic affection of the branches of the fifth pair. Now it is a tolerably common occurrence in this affection for the patient to insist upon it that the pain runs along the track of the facial nerve; and this occurrence is so common that it was an operation recognised among surgeons, to divide the seventh pair, for the cure of tic douloureux. Now this operation, whenever done, was always productive of injury. The tie douloureur, however, was never cured by this operation, because the sensitive fibres which were affected, still retained their connection with the brain; and worse still, there was added to the trouble, a paralysis of the muscles of that side of the face.

Another point of considerable interest, in connexion with the physiology of the facial nerve, relates to the variations of its distribution in different species of animals, and the corresponding effects resulting from its injury or division. Now I take occasion here to illustrate the anatomy and distribution of this nerve upon the heads of the lower animals. I do it because it is necessary, in order to gain any complete and proper idea of the course and distribution of these nerves, to have the dissection fresh, which is almost impossible, and certainly very difficult, to get upon the human subject. Ard, in point of fact, for our purpose, dissections of the lower animals are equally good, since the general structure of parts in all vertebrate animals is the same, and the nervous distribution the same. In all the higher animals, the fifth pair divides into three branches, so that for our purposes of study they answer as well as if we had the human head. There are, however, certain peculiarities connected with the physiology and distribution of portions of the nerve which are connected, not with a difference in the plan of arrangement in different animals, but with the different degrees of development of various parts. For example, I have already mentioned that in the human subject the movements of the ear are insignificant; consequently, the muscles of that part are not well developed, neither is the nerve which supplies them very large, for an obvious reason. Therefore, if we divide the facial nerve, or have it destroyed by disease, in the human subject, the paralysis of the muscles of the ear is of no consequence. The patient never moved the ear before, and never requires to do so afterwards. This is not the case, however, with some of the lower animals, in which the movements of the ear are very extensive. It is not the case with the cat, with the rabbit, or with the horse. If you watch these animals, you will see how necessary are the movements of the external ear in enabling them to appreciate the intensity and direction of faint and distant sounds. So that although the facial nerve has no direct influence on the sense of hearing, yet indirectly it is very important as assisting in the accomplishment of the function. There is another very remarkable instance, in the horse,

of the indirect influence of the facial nerve upon the act of respiration. The horse is, in some respects, different from other animals, that is to say, he breathes through his nostrils only. We are in the habit of breathing through the nostrils to some extent, but we also can perform respiration through the mouth. This is the case with most of the lower animals; they generally, in ordinary respiration, cause the air to pass through their nostrils merely, but when hard pushed, they can breathe through the mouth also. In the horse, however, this is different. In him the larynx and opening of the glottis are in direct relation with the posterior nares; the larynx is so high up that there is no connexion between the opening of the glottis and the pharynx, and all passage of air through the mouth is cut off by the position of the velum pendulum palati. The horse, then, is able to breathe only through his nostrils. If you will watch the animal, even when in moderate motion, you will see the nostrils dilating very energetically, at each inspiration. Now if the facial nerves on both sides be divided, the nostrils consequently cannot expand, and we have a very different kind of respiration; the walls of the nostrils fall together, the animal cannot draw the air freely into his lungs, and the consequence is, death by suffocation.

The effect of injury of the facial nerve upon the human subject upon one side, which often happens in consequence of disease, is what we know as facial paralysis. The paralysis of the superficial muscles produces an alteration in the expression of the face. So far as regards the eye, you will notice of course at once, that the eff ct of the paralysis of the facial is entirely different from paralysis of the oculomotorius. In paralysis of the oculo-motorius the eye cannot be opened, in paralysis of the facial it cannot be closed. In consequence of facial paralysis, the lower eyelid falls down, all the muscles upon the affected side are relaxed, while the muscles upon the sound side are in their full vigor; consequently the features are drawn over to the sound side, and the whole face is twisted in an exceedingly unnatural manner. You will find, on examining a patient affected with this disease, that in consequence of the paralysis of the orbicularis oris muscle, the angle of the mouth on the affected side remains open and hangs downward. This produces great inconvenience in eating and drinking, but more particularly in the reception of fluids. It is found that fluids cannot be retained upon the affected side, but dribble away through the open angle of the mouth, so that whenever the patient attempts to drink, he is obliged to use the hand in order to close the mouth. Another difficulty is in mastication. The muscles of mastication move very well, but there is a peculiar difficulty which results; after a certain amount of food is masticated, it accumulates between the teeth and the cheek. For the buccinator muscle, which is one of the superficial muscles of the face animated by the facial nerve, being paralysed, does not prevent the food from crowding its way into the situation that I have referred to. These are the most marked and important consequences which result in the human subject from paralysis of the facial nerve.

There is one other very remarkable fact, however, which has attracted the attention of physiologists of late years, and which is so important that I will speak of it during the few moments which remain to us. It has been noticed in certain instances that paralysis of the facial nerve was not only productive of a loss of power in the muscles of the corresponding side of the face, but it was accompanied by a peculiar deficiency in the power of taste, in the corresponding side of the tongue. It has been found that patients suffering from facial paralysis upon the right side, are not absolutely incapable of tasting, but the sense of taste is very much blunted. This we can ascertain by holding a small sponge between the blades of a forceps, and moistening it with a solution of some sweet, bitter, or sour substance, and then placing it upon the superior surface of the tongue. It is thus found that while the sense of taste in the anterior part of the tongue remains perfect on the uninjured side, it is considerably blunted on the side where the facial nerve

has been divided. Now a great deal of difficulty has been experienced in explaining this curious fact. There is, I believe, however, no doubt at present, that it depends upon some influence communicated to the tongue from the facial nerve by the chorda tympani. For you remember that the mucous membrane of the anterior two-thirds of the tongue is supplied exclusively by the lingual branch of the fifth pair; and that the only communication between this branch and the facial nerve is established by the chorda tympani. The chorda tympani is a very slender filament, which leaves the facial nerve, during its course through the aqueduct of Fallopius, crosses the membrana tympani, passes from behind forward, and emerges from the petrous bone, by a distinct foramen. It then continues its course obliquely forward and downward, and joins the lingual branch of the fifth pair. I have prepared a dissection, showing the course of the chorda tympani in this head of the sheep. In the preparation you will see this nerve as an exceedingly slender filament, passing in a curved direction through the petrous portion of the temporal bone, and joining the lingual branch of the fifth pair, in front and below. What is the particular influence exerted upon the sense of taste by division of the facial nerve, we are unable to say. The chorda tympani is evidently motor in its character. Whether its paralysis acts upon the mucous membrane of the tongue, by affecting certain organic muscular fibres in its substance, or by some modification of the vascularity of the part, it is impossible to determine. The fact, however, is undoubted. Now this circumstance, taken in connexion with the anatomical relations of the chorda tympani, may be sometimes of great service in enabling us to make a differential diagnosis in cases of facial paralysis. For if we have an instance in which there is a loss of power in the superficial muscles of the face, we know that the disease of the nerve may exist in any part of its course. The nerve may be inflamed, pressed upon by a tumor, or destroyed by softening, either exteriorly to the stylo-mastoid foramen, or within the bones of the cranium. Now if we find, accompanying the facial paralysis, a want or diminution of the sense of taste, in the corresponding parts of the tongue, then we know that the origin of the disease must be deep-seated. For as the chorda tympani leaves the facial nerve in the aqueduct of Fallopius, any injury below this point will not affect the sense of taste. Hence, when this sense is impaired, the injury to the facial must be either in the aqueduct of Fallopius, or, what is perhaps equally probable, in the interior of the cranium itself.

Original Communications.

DIFFICULT OBSTETRICAL CASES,
BY GEORGE T. ELLIOT, JR., M.D.,

PHYSICIAN TO BELLEVUE HOSPITAL AND THE LYING-IN ASYLUM, CONSULTING
PHYSICIAN TO THE NURSERY AND CHILD'S HOSPITAL.

CASE I-Retention of Menses by an Imperforate Hymen -Operation-Death-Interesting Autopsy-Also a number of Illustrative Cases.-(Reported by P. C. BARKER, M.D., House Physician.)

"Alice æt. 17, born in Connecticut, of delicate organization, was admitted to Bellevue Hospital, June 23d, 1860. She never enjoyed good health from her infancy. In July, 1859, she experienced her first menstrual effort, which was not attended by any discharge. The molimen has regularly appeared since, the flow never. The mother, and even physicians, to whom she applied at various times, attributed the absence of discharge to the general condition of the girl, and administered iron and emmenagogues of various kinds. These only served to increase her sufferings. After a time the periods were marked by bearing-down pains like those of labor, which progressively increased in severity, and awakened more and more constitutional excitement.

On Thursday, the 21st of June, the last effort began. She suffered more pain in the back, and the bearing-down pains were more than usually severe, keeping her awake all night. She passed water with some difficulty, and obtained a movement from her bowels. On Friday a physician was called, who prescribed something to quiet her sufferings and left. Short relief followed. Another sleepless night, no water passed. Saturday morning.--Two physicians called, who ordered salts and senna, and advised that she should be sent to the hospital. She was admitted in the evening (23d), having neither had a movement from her bowels nor passed a drop of water for forty-eight hours.

Symptoms on Admission.-Very restless, anxious, tossing and moaning with pain. Pulse 112, tongue slightly coated. Palpation discloses an abdominal tumor, hard and tense on pressure, and perfectly dull on percussion. Catheter introduced with little trouble, and fifty-three ounces of bloody urine drawn, after which the tumor could no longer be felt. She immediately fell asleep, and on awaking in half an hour had a very free discharge from the bowels.

The external organs of generation were not deformed, but the vagina was perfectly occluded by an imperforate hymen, rendering the introduction of the finest probe impossible. The finger in the rectum discovered that the vagina was so completely distended that no fluctuation could be detected. The accumulation seemed to fill the pelvic cavity. 12 P.M.-Sleeping quietly. 24th, 9 P.M.Some pain in abdomen, relieved by catheterization. Thirtythree ounces of urine drawn off, which contained both pus and blood.

Dr. George T. Elliot sent for, who decided on operating after a careful examination; and in anticipation of the great danger to the patient, determined to make a very small incision, and allow the accumulation to drain away gradually. Choosing a pair of sharp-pointed scissors (by the advice of Dr. Gouley), he began to cut in the direction of the course of the vagina. The membrane was nearly half an inch in thickness. About four ounces of a tarry-looking fluid were allowed to trickle through a very small opening, when the patient was replaced in bed, and ordered Magendie's solution four drops, and oiled silk to abdomen. The administration of chloroform having produced hysterical symptoms, it was discontinued before the operation was commenced. 6 P.M.-Pulse 140; sol. morph. sulph. (Magendie) gtt. vij. 9 P.M.-Pulse 130; sol. morph. sulph. (Magendie) gtt. iv.

25th, 8 A.M.-A large quantity of menstrual fluid has drained away during the night; bladder had subsequently partially relieved itself; 3 vj. of urine drawn by catheter; pulse 120; feels better; has passed a comfortable night; still has a little pain; sol. morph. gtt. iv. 12 M.-Pulse 112; sleeps most of the time; vagina dilated by bougie. 6 P.M.-Pulse 120; gtt. iv. 11 P.M.--Pulse 120; gtt. v.

26th, 8 A.M.-Pulse 120; has slept most of the night; 3 xv. of urine drawn with catheter; discharge still continues. 3 P.M.-Injected warm water into vagina, to dilute the discharge, which still pours out. Nearly a quart in all must have escaped. Some pain; sol. morph. gtt. iv.; larger bougie introduced. 6 P.M.-Pulse 124; gtt. vj.; catheter regularly passed.

27th, 8 A.M.—Pain in abdomen, with nausea; some tympanitis; gtt. vj.; appetite, which has been very good, now failing. 12 M.-No pain; respiration scarcely affected; gtt. iv. 3 P.M.-Free movement from bowels, after which tympanitis less marked; some vomiting, but nothing of green color; pulse 104; gtt. vj. 10 P.M.-Pulse 128; gtt. vj.

28th, 8 A.M.-No pain, slept very well; passed water three times in the night, still not all discharged; menstrual fluid slowly coming away; gtt. iv. 6 P.M.-Has had a movement from her bowels; vagina now admits index finger; a tumor detected in the left iliac region, character of which is obscure; no pain; pulse 130. 10 P.M.—Pain, 'pulse 135; gtt. vj.

29th, 8 A.M.-Passed her water very well, but catheter

introduced to prevent an accumulation; pulse 120; gtt. iv. 3 P.M.-Fluctuation detected in the tumor of left iliac region. 9 P.M.-Restless; gtt. vj.

30th, 8 A.M.-Pulse 120; rather weak; vagina well dilated. 6 P.M.-Very little pain; gtt. iv.

July 1st, 8 A.M.-Comfortable, but quite weak; had a severe chill during the night, which lasted for an hour; solut. quiniæ sulph. Oss ad iv. 3 ss ter in die, beef tea, eggs, etc.; pulse 125.

2d.-Vaginal injection of a warm solution of the chlorinate of soda for foetor; pulse 120.

3d. Injection repeated; continues much the same; gtt. iv.

5th.-No discharge from vagina; fluctuation distinct in left iliac region; urine still contains blood; treatment continued, with addition of brandy 3 ss. every hour.

6th.-No discharge from vagina; comfortable. 9th-There has been no especial change. Lager beer was substituted for the brandy. Two severe chills to-day, lasting an hour each; has been talking of going out of late; has been up walking in the ward.

10th.-Quinine as before; pulse 125; some pain; gtt. vj. 12 M.-Feeling better, she sat up for some time to have her bed arranged, after which diarrhoea; has had four evacuations since 8 A.M.; ordered tr. op. camph. 3i. after each discharge. 6 P.M.-No discharge from bowels since 1 P.M.; pulse 130, and quite feeble; brandy 3j. and carbonate of ammonia gr. x. every two hours. 12 м.-No pain; has had two more discharges from the bowels; tr. op. camph. 3 ij.; brandy and ammonia as before.

11th. No further movement of the bowels; pulse 132, very feeble; stimulants continued. 10 A.M.-Sinking; pulse barely perceptible. 11 A.M.-Died."

Rigor

Autopsy-Permission obtained with great difficulty, and only after a promise that nothing should be removed, and only the abdomen examined. Weather warm. mortis not very marked. Body moderately well nourished. Abdomen slightly tympanitic. On section no fluid escaped. Omentum firmly bound by adhesions in both iliac as well as in the supra-pubic regions. In the left iliac region, resting upon the peritoneum covering of the iliacus internus muscle, was a collection of pus, not exceeding a drachm in quantity, shut in by walls, composed of omentum and fibrine. The intestinal serous coat was polished and smooth, and not covered with exudation, excepting a portion of the upper part of the ileum, and sigmoid flexure of the colon. The portion of the ileum referred to was adherent to the fundus of the bladder, and presented perforations which corresponded with some of many small perforations which riddled the fundus of the bladder. The vesical mucous, and muscular membranes were softened, and the color very deep. The viscus seemed to be undergoing disintegration. Right kidney contracted and fatty; pelvis and ureter greatly distended, and containing pus. Left kidney large and fatty; ureter and pelvis normal. The sigmoid flexure of the colon was bound down by adhesions, and presented a patch of about two inches in its long diameter where the tissues presented a gangrenous appearance and several perforations. The uterus measured about four inches in length, its os and cervix fully dilated. Os internum not, however, obliterated. Arbor vitæ very distinct. Uterine sinuses presented no abnormal appearances on section. Uterine orifices of Fallopian tubes not dilated. The left Fallopian tube, at about the distance of one inch from the uterus, terminated in a mass formed from the organs contained in the left broad ligament, but so transformed by disease as not to be separable in the limited time afforded by the exigencies of the case. Right ovary the subject of unilocular cystic degeneration, the cyst being about an inch and a half in the long diameter. Other organs not examined for the reasons given.

Remarks.-The extraordinary results of this post-mortem examination lend the deepest interest to this case, and make it, I believe, one of the most remarkable on record. It never occurred to me that the fluctuating tumor in the