it on the external ear, and then it seemed to pass from the tonsil through the Eustachian tube. The patient first suffered from a distressing ear-ache, and then a diphtheritic membrane formed in the external ear.

Relapses occurred in four cases of the seventeen, and some of these were a second and third time visited with the characteristic effusion, and one of them, three weeks after the first attack, threatened a fatal termination in the relapse, although mild in its first attack. Partial paralysis of the muscles engaged in deglutition occurred in two cases.

In a few children, and in two adults, I saw about all the other symptoms, with no diphtheritic secretion. I have not counted these among my cases of diphtheria; but they happened in the same families, and were treated successfully with the same general treatment, with the marked cases of that disease. Here I may say, that in this malady we shall find remedies addressed to the constitution, or general treatment, much more curative than local remedies.

The most striking peculiarity of this disease appears to be its depressing or anæmic sequences, so rapidly following its vigorous phlogistic onset. For instance, I was called to a girl of five years, who had, the day before, been seized with convulsions, which she had never before had, vomiting occurred at intervals, with high fever, and rapid pulse, stupor alternated with fits of screaming. I cleared out the bowels promptly with calomel and rhubarb, followed by enemata of salt and water; and the prevalence of diphtheria in the neighborhood having put me on my guard, I placed her at once upon quinine and the chlorine mixture. Yet within four days she was found with an irregular pulse, cold extremities, and feeble reaction. I gave her quinine in three grain doses, twice in twenty-four hours, and all the stimulating broths the stomach would retain. The dipththeritic membrane did not appear in this girl's mouth until the ninth day from the attack, after which she slowly recovered. In this, and some other cases, it peeled off, and formed two or three times. It looked not unlike flakes of yellowish white-paint scales, after its separation from the throat and roof of the mouth. A croupy cough, which began on the tenth night, gave me much uneasiness; this was combated by applying nit. argent. forty grains to the ounce of water, and by blowing into the throat and fauces, through an ivory tube, exsiccated alum, pulverised with an equal quantity of tannin. I also induced emesis, at two different times, with a solution of alum, of which I gave a saturated sweetened solution, half a table-spoonful once in ten minutes, until vomiting took place; this relieved, for a time, the croupy symptoms, and perhaps the alum was useful in preventing future adventitious formations.

Of the seventeen cases seen and treated by me, all of which had the diphtheritic secretion and recovered, two were seized with convulsions, and one child had convulsions during the collapsed stage of the disease. It seemed probable to me, that in these and some other patients cerebro-spinal congestion was a leading feature of the dis

ease.

This induced me to make stimulating applications to the nape of the neck, and in some cases, where albuminous urine occurred, to the lumbar region.

In giving briefly the treatment I found most successful, I would claim no other merit but that of having somewhat early learned, that we must at the outset sustain our patients by specific constitutional remedies, and not rely too much on local treatment. In a few cases where the tongue was foul and the bowels loaded, I gave calomel and rhubarb, or castor oil and turpentine, followed by injections, promptly cleaning out the primæ viæ. After this, no reducing means were used, but the patients were at once put on the use of the following mixture:-Chlorate of potash 3 ij., hydro-chloric acid (dil.) 3 ij., water 3 viij., sweetened to the taste, giving from a dessert spoonful to a large spoonful, according to the age of the patient. In some cases I added to this a minute quantity of sulph. morphia, twice or three times a day, if the child was very unquiet. In cases where vomiting was not troublesome, I added to the above quantity of chlorine mixture, from one

quarter to half an ounce of the muriated tincture of iron. I also tried, in some cases, from five to fifteen drops of this preparation of iron in sweetened water, once in three or four hours, but oftentimes it did not agree with the stomach, and I fancied it was better borne in the chlorine mixture, and that in sensitive stomachs the iron had better be omitted. I used, in many cases, chlorate of potash and gum guiacum, equal parts, in powder, in doses of from five to ten grains once in three or four hours; this frequently seemed to act well, not only by sustaining the strength, but also on the local disease. I usually gave quinine on the second or third day, in a large dose, in the afternoon, and in cases where the pulse faltered, or became abnormally slow (as it did in some patients in the collapsed stage), I also gave the quinine in the morning. It is better given in one or two large doses than in small doses more frequently repeated. I only observed the unpleasant effects of an over-dose of quinine in one case, and that soon passed over; in no disease have I seen quinine so well borne.

In many cases vomiting gave us much trouble, by interfering with a most essential indication, viz. sustaining the patient by good broths and food of easy assimilative capacity. I found nitro-muriatic acid (equal parts of each acid) given in doses of six or eight drops in water, and taken after food, well borne in some patients, who did not bear either the iron or chlorine mixture well. Cathartics, or emetics, and depressing expectorant mixtures, are not admissible in this disease, except at the outset, and their utility even then is doubtful, except in the cases before mentioned.

In one case of diphtheritic croup I gave bromide of potassium in a strong decoction of rad. seneka, and the result was very satisfactory. I added to each teaspoonful dose of the decoction half a grain of bromide of potassium, and gave it once in three hours. The patient was aged nine years, and as I had failed to induce vomiting by the use of the alum mixture, I did not feel justified in giving calomel and ipecac, or the antimonial preparations which often prove efficient remedies in idiopathic croup. I was much gratified with the recovery of what seemed a dangerous case of secondary croup, under the use of the bromide of potassium and seneka. The diminished vitality which is usually found in these cases where croupy symptoms follow diphtheritic fever, makes them fearful cases to the physician, as well as to the parent. These cases cannot safely be treated as we would treat primary croup. It would be the veriest lack of wisdom in me to deduce from one successful case, a rule of general treatment; but from the experience recorded by others, I would hereafter try the bromide of potassium in secondary croup, with debility as a symptom.

The stage of collapse, which, in some of our patients, appeared within a day or two from the attack, was sometimes attended by a diminished secretion of urine. This, on being tested, we found in three cases to contain albumen. In these patients external stimulation over the kidneys, such as dry cupping, sinapisms, and turpentine stupes, were used with good results. Alcoholic drinks in aid of quinine, general stimulants and nourishing broths seemed useful in some cases. But in some we found that the free use of "good sound cider," as the farmers call it, agreed better than ardent spirits.

We used in one family, where two cases of albuminous urine appeared, cider freely, which had been kept from passing into the stage of acetous fermentation, by adding to each barrel two or three quarts of bruised horse-radish roots, after the cider had been three weeks barrelled. This, like mustard-seed, and the sulphite of lime, seems to prevent further changes in the cider for a long time. The patients usually crave a stimulant and an acid drink, and the cider relishes finely. In the cases of albuminous urine it operated with marked remedial effects. The soured cider, containing more alcohol than that in which fermentation has been arrested, was more useful where the patients required free stimulation. It was given either

diluted with water and sweetened to please the taste, or where its diuretic effect was chiefly sought in effervescing draughts, made by adding to it bicarbonate of soda or potash.

As an article of diet, remedial, and yet palatable, I would recommend, where they can be obtained, sour baked apples, mixing the tender pulp with sugar, or giving them alone if the patient so prefers them. For many

years I have used apples in this way as the diet par excellence in scarlatina, and how many grateful little ones, nauseated with pap, porridge, and panada, have risen up to call me blessed, for the grateful change to the apple diet.

In regard to the local treatment in diphtheria, after consulting physicians who have seen much of the disease in the city of Syracuse and the village of Geddes, and adding their experience to my own, candor compels me to confess, that the so much used and commended "nitrate of silver often fails to remove the false membrane, and change the abnormal action of the secreting surface to a condition of health." In mild cases it is needless, in severe ones too often useless. However, in those terrible sequences of diphtheria, secondary membranous croup, it must be used often, if at all, at least once in three or four hours, and of a strength not less than from forty to sixty grains to the ounce of water, and applied with a curved probang.

To prevent the secretion from forming again after removal (as it often does), I would use tannin and dried alum, applied with a soft linen rag or on the moistened finger to parts within reach, and blown into the throat through an ivory or glass tube, or two or three quills introduced into each other, answer a good purpose; no harm follows inhaling this powder, as a short paroxysm of cough clears all out again.

In

I apply externally over the throat salt pork, moistened with turpentine, and quickened with pulv. sem. sinapis, or capsicum, if need be. For a gargle, the following is my preference, after trying a variety: B. Hyd. Chlor. Ammoniæ 3ij.; Soda Muriat. 3 iv.; Pulv. Capsici 3 ij.; Vinegar 3ij. Add one and a half pints hot water; cool, and use it freely. If any is swallowed, no harm follows. children too young to gargle, apply with a soft linen rag. In cases where the secretion from the nose, throat, or ear, is offensive, I have used the following: B. Chloride of Soda 3 ij.; Chlorate of Potash 3i.; water, four ounces: with good effects. I tried mur. tinct. ferri as a local application to the throat, and believe it is not as good as nit. argenti.

I have used in a few mild cases, as an internal remedy, a solution of vinegar and muriate of soda in water, covered and quickened by the addition of a little capsicum or piperine, and I must acknowledge that these cases did as well as any that I treated. If I could not get the chlorine mixture before described, I should feel able to find in the farmer's pantry, a mixture neither destitute of chlorine nor remedial virtue. The chlorine mixture is usually so well borne by the stomach, so compatible with the use of sustaining food, and, by many years' experience, I have found it so well adapted to the treatment of that congener of diphtheria, scarlatina, that I used it in most of my cases from the first; adding a little morphine, or paregoric, if required, and increasing the proportion of acid, or adding the iron if my patient tended downwards, and the stomach would bear this addition.

From what I can gather from the recorded or narrated experience of others, and my own knowledge of the disease as gleaned from a limited number of cases, I have concluded that diphtheria is a blood-changing disease, and that lesion of function in the spinal nerves occurs early in grave cases; that we must not wait for sinking, but if possible anticipate and prevent it; and finally, that to oxygenate the blood, and rouse and vitalize the nervous system, are the leading indications to be sought.

RICORD.-M. Ricord is said to have the largest practice in France; it is worth 300,000 francs a year.

CIRCUMSCRIBED ENCEPHALITIS,

TERMINATING IN RAMOLLISSEMENT AND PURULENT INFILTRATION,

WITHOUT PARALYSIS.

BY NELSON S. DRAKE, M.D.,

OF BROOKLYN, N. Y.

THE particulars of the following case appear to me of sufficient importance, and its features of sufficient practical interest, to engage the attention of the profession.

The patient, a Scotchman, aged thirty-two years, of robust constitution, had been engaged in mercantile pursuits, but having met with severe reverses during the last panic, he was reduced to a subordinate position. His mode of life had been rather generous; he was accustomed to the use of liquors, but not to excess; of tobacco he was inordinately fond, both smoking and chewing; his general state of health had, however, been good up to the commencement of his late illness, which is alleged to have taken place in the early part of October last, when he evinced signs of mental difficulty. The family informed me that during a period of about three weeks the patient had become somewhat incoherent, thoughtless, and loquacious; that furthermore his memory had decidedly failed him; that he had been deprived of nocturnal rest, whereas he had passed his days in somnolency from which he could be roused but for a few moments; that his attention could be engaged upon any subject but temporarily; and that he also complained of fulness and heaviness of his head. This is about the substance of his previous history. The family having become apprehensive of the state of his mind, my professional services were chiefly required in relation to that question.

I found the patient at eleven o'clock A.M., on the last day of October, apparently soundly asleep upon a sofa, with a full pulse of sixty; the temperature of the skin above the ordinary standard; his head being still warmer and somewhat flushed; his breathing was rather heavy and moderately stertorous, which, however, was alleged to be his ordinary mode of sleep; his respirations were fourteen per minute. I had some difficulty in arousing him, when he seemed bewildered and embarrassed; he excused himself, apologizing for his condition, properly and intelligently. Although he recognised me at once, as a person he had seen, and knew me as the physician to his family, he was still unable to remember my name. In our conversation he made continual misstatements; mentioned occurrences which had no reality; his answers were ready and prompt, but given without reflection; it was with great difficulty that I could engage his attention for any length of time upon any subject; he would either turn to other matters, or fall asleep; the latter symptom was obviously prominent. His gait was erect, but slovenly; his speech slightly impeded, a kind of thick, hurried, irregular articulation; he put out his tongue towards the right side; his mouth was also slightly drawn in the same direction, while ptosis of the left eyelid was present; the eyeballs, however, moved correctly; both pupils were slightly contracted without readily dilating, but there was no intolerance of light; there were no noticeable deviations of the other senses. At this time he had been detained from his business only a few days, and that by the earnest solicitation of his family; his time was passed when not sleeping, and generally in the night, in roaming about the house, reading the daily newspapers, smoking, and chewing tobacco; his appetite inordinate, and his bowels very sluggish. The case appeared to be one of vascular turgescence of the brain, associated, probably, with centric lesion of a more grave nature.

With this view of the disease, I could expect but little from medication; the treatment, therefore, simply consisted in fulfilling, as far as was possible, the indications presented; the diet was restricted; derivation upon the bowels

was promptly instituted; cold applications were made to the head; local depletion was moderately employed; counter-irritation was resorted to; and a mild mercurial impression was obtained endermically.

As had been anticipated, this medication made no impression upon the progress of his disease, and my friend, Dr. H. S. Smith, was requested to join me in the further management of the case. It is gratifying to me that the counsellor coincided with my views and in the plan of my treatment, to which opiates and gentle stimulation were incidentally added. The progress of the disease, however, induced the family to request further counsel, and Prof. Willard Parker was consequently invited to see the patient; but neither in diagnosis nor in treatment was any alteration suggested by him; in fact, there was perfect unanimity on every point, and especially in the prognosis of a speedily fatal issue. This event occurred on Thursday, November 12th, thirteen days from the commencement of the treatment. It should be stated here that a few days before his death the patient gave signs of great cerebral excitement; however, no convulsions or extended muscular paralysis presented themselves.

The post-mortem examination was kindly performed by Dr. Louis Bauer, and it is to his accurate dissection that I am indebted for the following precise account of the pathological changes which had taken place. Since the disease had evidently its seat in the brain, the autopsy was restricted to an examination of the cranial cavity. The removal of the scalp showed the integuments rather pale and bloodless; the calvarium being removed and exposed to light appeared also pale and bloodless; the sinuses of the dura mater bled only moderately, and that membrane parted easily from the bone; the whole surface of the large hemispheres was vascular and evidently congested; the arachnoid was raised by oedematous effusion and separated readily; the various slices of the large hemispheres were punctated with blood, and the general consistence was rather below the ordinary firmness of this substance; the softening became more evident towards the roof of the cerebral ventricles, which were filled with bloody serum; the right ventricle, however, contained the largest quantity, and was almost distended thereby; the choroid-plexus was highly vascular, somewhat thickened, and at its entrance below the posterior margin of the corpus-callosum, large vessels could be discerned; both striated-bodies and optic thalami were considerably softened; the left, however, in a higher degree; the surrounding parenchyma of the posterior and middle lobe of the left ventricle was so much softened as to be considerably broken down; the commissures, the septumlucidum, the fornix, the central portion of the corpuscallosum, the corpora-quadragemina, and the crura cerebri, were of ordinary appearance and consistency; the aqueduct between the third and fourth ventricle was open, the latter contained but a few drops of bloody serum; probably it had contained more, for its size exceeded the ordinary dimensions and emptied anteriorly by the horizontal position upon the table; a communication between the fourth ventricle and the spinal theca could not satisfactorily be shown by a fine probe; the roof of the fourth ventricle and the hemispheres of the cerebellum were moderately softened; not so, however, the crura-cerebelli. The pineal gland presented nothing abnormal. The brain was now turned, and its base exposed to view; the middle lobe of the left hemisphere was found to be entirely broken up, softened, and discolored in as far as the grey substance, at least, was concerned; the material contained small coagula of blood, and was so soft as to be compared to inspissated purulent matter; it could easily be extended, and its general character was that of purulent infiltration; the pons-varolii and the medulla oblongata were intact. At the corresponding portion, in the left middle fossa of the cranial cavity, the dura mater had lost its shiny, fibrous, and bluish-white appearance by discoloration and superficial destruction. At the basis cranii there was a great deal of bloody serum more or less mixed with the broken-down material of the

left hemisphere, and a considerable quantity of that serum oozed out from the membranes of the spinal cord.

From the results of this post-mortem examination, it is evident that the patient suffered and died from acute and circumscribed encephalitis, which resulted in ramollissement and purulent infiltration; that the disease was chiefly restricted to the cortical substance of the affected lobe; and that the more central and essential structures were intact or but moderately affected. Whether the occlusion of the spinal theca, at its superior termination in the fourth ventricle, had caused the disease, is very doubtful; whereas it cannot be denied that it has accelerated its fatal termination, and all these facts account very readily for the absence of serious mental aberration or muscular paralysis; that the cerebrum was extensively involved in this case was very evident; but a specific diagnosis of the seat of the disease could not be easily made, in consequence of the almost entire absence of paralysis, or of convulsive actions in circumscribed parts of the nervous system. From the general character of the symptoms, however, I decided upon the inflammatory type of the disease; and considering the youth of the patient and his robust constitution, I should have resorted to active antiphlogistic treatment, had not the patient himself opposed it. From the results of the postmortem examination I have, however, become convinced that no medication, however systematic or energetic, could have changed the course of the already initiated disease, for it is more than probable that the softening of the cerebral substance had already commenced before the patient came under my care. The interesting fact, nevertheless, remains that the brain could have been disintegrated to so large an extent without paralysis and without extensive qualitative mental aberration.

Reports of Hospitals.

BELLEVUE HOSPITAL.

THREE CASES OF TETANUS.

CASE 1. Idiopathic Tetanus.-Symptoms temporarily relieved by Quinine.-Permanent relief by the administration of whiskey in large quantities.-(Reported by P.C. BARKER, MD., House Physician.)—Thomas McAdams, æt. nineteen, born in Ireland, of healthy constitution and temperate habits, was admitted to Bellevue Hospital October 22, giving the following history.

History. For four months during the past summer and fall he worked at Haverstraw in a brickyard. Leaving there about the 1st of October, he came to New York, and went to work as 'longshoreman. While at work in the hold of a schooner October 14, he got very warm, and sat down in a current of air covered with perspiration. During the following night, he was seized with violent substernal pain, and cough. At the same time a severe pain began in the left groin. On the next morning, trismus was developed, slight at first, and attended by some stiffness of the muscles of the neck, abdomen, and legs. From this time till that of his admission, the stiffness steadily increased. The substernal pain, which was at first superiorly, moved down towards the ensiform cartilage. No pain in the back or head. The pain in the groin continued, showing no tumor or discoloration. He perspired profusely during the paroxysms which occasionally occurred, from the first.

Symptoms on Admission. He walks with difficulty, being unable to flex either the thighs or legs. He moves his arms very well. The abdominal muscles are rigid. He suffers from occasional startings and increased rigidity of the muscles from which he sweats profusely, has considerable dyspnoea, and suffers great pain. His countenance exhibits the true risus sardonicus. The trismus is complete. All the food taken must be fluid. Two or three days previous to his admission he received a fall when attempting to walk,

and broke one of his central incisors. Through this opening he receives all his food. Bowels very slow; pulse normal; sleeps very little. Physical examination of thorax reveals the existence of bronchitis. Coughs a little, raising a tenacious sputum.

Mor

Treatment.-Coming as he did from a region notorious for its miasm, it is decided that quinine in large doses shall be given. Ord. 3i. daily in divided doses. The diet to be generous. Oct. 24.-The paroxysms return less frequently, are milder, and the rigidity is much less marked. He can open the mouth a little. Oct. 25.-Rigidity nearly disappeared. Slept very well last night. Ordered dry cups to spine. Oct. 26.-Since yesterday's note the rigidity and spasms have returned fully as severe as at first. The teeth are again closed, the sardonic grin again overspreads his face, and he lies as stiff as if frozen. It is deemed advisable to resort to the stimulant treatment, as quinine has been carried to cinchonism. Ordered whiskey ss. every fifteen minutes. Beef-tea and eggs as before. Oct. 27.-Paroxysms a little less severe, and less frequent to-day than yesterday. Treatment continued. Oct. 29.-Very little better than on the 27th. Ordered whiskey reduced to 3 vi. daily. phine to be given in sufficient quantity to bring him fairly under its influence, and maintain it. Oct. 30.-No spasms; rigidity less marked; the sweating still continues. Respiration 14, sleeps considerably. Nov. 1.-Rigid again; whiskey resumed, 3 xxx. to be given daily. Nov. 2.-The rigidity is again less marked. He lies on the side and can flex his legs somewhat. Spasms infrequent. Appetite good, bowels still very slow; enemas given on alternate days. Sleeps very well. Nov. 4.-Whiskey increased to 3 xlviii. daily. Nov. 5.-Last night for the first time he showed the usual effect of intoxication, became very hilarious, and made considerable noise. Same quantity of whiskey continued. Nov. 7.-Did not sleep very well last night, still he is improving, No more symptoms of intoxication. Nov. 9.-Improving steadily. Whiskey reduced to xxx. daily. Nov. 12.-He can walk by holding on to something. Complains of cold feet, and believes that this condition excites spasms. The abdomen still very tense. Nov. 14.-Walks about. Had a momentary spasm last night. Says he feels well to-day. Nov. 30.-He has steadily improved since the last note, so much so that only a little stiffness remains in the legs. The abdominal walls, however, are still rigid. No whiskey has been given since the 21st; having been steadily diminished since the 9th inst. Dec. 3.-Discharged, well.

CASE 2. Lacerated Wound of Fore-arm-Tetanus-Death. (Reported by HOWARD PINCKNEY, M.D, House Surgeon.)Thomas Hughes, aged sixteen, born in Ireland, laborer, admitted September 13, 1860 (service of Dr. Meier), with a wound of fore-arm caused by a circular saw. The muscles

and tendons on radial side of fore-arm were very much lacerated, and the radius was cut completely through; the radial artery was not injured, but there was considerable hæmorrhage from the inter-osseous artery, which was controlled by strongly flexing the fore-arm, and confining it in that position by a roller bandage, thus making pressure upon the brachial at the elbow. Sept. 14.-The fore-arm was placed upon a splint, and cold water dressings applied. Sept. 23.-Patient has been doing well until this morning; he complains of some stiffness in moving the lower jaw. Ordered brandy. Sept. 23, 6 P.M.-Patient can only open his mouth to a very limited extent, head thrown back, but no rigidity about the neck. Profuse perspiration; pulse 140, and feeble. Ordered brandy 3 ss., and tr. opii gtt. xv. with beef tea every hour. Patient was placed in a warm bath with potass. carb. iv. dissolved. Sept. 24.-Patient slept pretty well last night; he is unable to bring his head forward this morning; pulse 140; same treatment continued with dry cups over spine. Tetanic physiognomy well marked. Consultation was held this morning, when amputation of fore-arm was decided upon, but the mother of the patient would not consent to the operation. 6 P.M. -Tetanic symptoms growing more marked. Ordered,

B Ext. cannabis indica grs. ij., every three hours. Brandy and beef-tea as before. Sept. 25.-Patient has a general convulsion, which was partially relieved by inhalation of chloroform. Opisthotonos well marked. Ord., B. Tr. assafoetida and camphor, 3 ss. q. h. The patient has had two convulsions since morning, and at 4.30 P.M. he died. No autopsy allowed.

CASE 3. Trismus following the Opening of an Abscess of the Thigh.-Recovery under the Use of Stimulants and Anodynes. (Reported by WALTER T. COLES, M.D., Senior Surgeon.)-Wm. N., æt: twenty-seven, a native of Ireland, unmarried, a shop-keeper's clerk, entered the Hospital on the 25th of August, 1860. He was then suffering with pain and tenderness about the right trochanter; the pain was felt in front between the pubes and the trochanter major. Fluctuation was at length discovered a little below the trochanter, and an opening was made at that point. The abscess discharged freely for several days, when suddenly the flow of pus ceased, and symptoms of trismus appeared. An attack of bronchitis occurred about the same time. He was treated with tinct. opii gtt. x. every hour, administered in an ounce of brandy, the amount being diminished as the symptoms improved. The symptoms returned when the treatment was omitted. These remedies were therefore continued for several weeks, in gradually diminished quantities. The symptoms at length disappeared.

NEW YORK MEDICAL COLLEGE.
PROF. GARDNER'S OBSTETRIC CLINIC.
January 9, 1861.

REMARKS UPON INTRA-CERVICAL METRITIS.

CASE 1.-Mrs. P, æt. about 30, the mother of one child three years old, since which she has had three miscarriages between the periods of two and a half and three and a half months of utero-gestation. Complains of great pain in sacral region, in the pubes, with sensations of weight and dragging in the inguinal regions.

The Professor stated the rational systems in the case indicated unquestionably some chronic disease of the uterus. Of course it was impossible to make an exact diagnosis among the various affections of the organ which might be the cause. Nevertheless, one might imagine, and in this case he thought that the group of symptoms, their commencement immediately after the first pregnancy, the repeated abortions at about the same period of gestation, indicated fissure of the cervix. This difficulty was not an unusual one. The os uteri was frequently torn during labor; some marked instances of which the Professor narrated from his experience. Sometimes these were imperfectly healed. They never united by first intention, the tissue not being sufficiently vitalized for this. They frequently left a granulating surface constantly secreting pus, a nidus for any inflammatory disease, needing but a small irritation to be developed, and when this occurred in connexion with a subsequent pregnancy an abortion was apt to be the result. This sometimes occurred from the inflammatory excitement being transmitted to the parenchyma and tissues of the body of the uterus, sometimes from the fact that the uterus in its development dragged open the fissures, thereby producing either such an excitement that contractions are gradually produced; or more frequently the tearing apart of the fissure is followed by slight sanious weeping, gradually become more and more deeply tinged with blood, until finally such a hemorrhage is set up that it seriously interferes with the normal functions of the parts, by the loss of blood, destroying the life of the ovum, ending in uterine contraction, and its expulsion. This may be the cause of the frequent abortions of the patient now before us. I will now institute a vaginal examination to see if the physical signs correspond with this view.

Gentlemen, the theory for some abortions which I have just presented to you is unquestionably often correct, but in the case before us it is not the true one. The finger finds the os somewhat hypertrophied and tumefied, but with no evidences of fissure; the os presents no evidence of any previously existing or present laceration, and we must seek further for the diagnosis, and (introducing the speculum) here it is plainly perceptible, and if you will pass around, you may, in turn, all see the os tincæ exposed to view, and note its peculiarities.

In the first place you will note the contrast which this presents to those which I have previously shown in the unimpregnated female. The os is not, as in them, round, of a regular circular shape, but oblong, almost crescentic in form, and having its length from one side to the other. This is the well known and almost invariable result of a full uterogestation. I say of a "full utero-gestation," because I have frequently noticed that such alterations in the shape of the os are frequently not produced when an abortion has occurred even as late as the end of the third month.

Next, you will perceive that the entire vaginal cervix is hypertrophied, so that its entire extent is not displayed by this quite large glass speculum; that it has a turgid appearance; and although it is entirely free from any abrasions, erosions, or ulcerations, that it is the seat of chronic congestion evidenced by its deeper hue as contrasted with the vagina, and even with the outermost portions of the cervix itself.

Finally, you will note more particularly the os itself, somewhat everted, and the protruded membrane of a dark red, livid color, and the pellucid, tenacious albuminous secretion exuding from it. In these symptoms we have the material for the diagnosis of the case. It is one of pure uncomplicated endo-metritis. I wish you especially to note the symptoms here presented, for it is a type case of a disease which will form the subject of one of my next week's lectures. I will now make an application of the solid nitrate of silver, by passing a piece into the cervical canal.

You will now observe that I have passed this piece into the canal to the depth of an inch and a half, and that the stick, which was an inch long, is now reduced to almost twothirds of an inch in length. This was not effected by its being dissolved, but by the extremity being broken off, owing to the brittleness of the stick. This portion is now an inch within the cervix, but it is of no consequence. Formerly it was supposed to be a dangerous thing to break off the crayon thus, but experience has taught me to disregard it entirely, because in the majority of cases the irritation caused by the caustic will generally result in such contractions of the cervix as to expel the small piece as a foreign body. I have even seen it ejected with so much force as to be thrown through the speculum a foot or two from the person, and as rapidly as it could be inserted; and even where there is so much hypertrophic infiltration into the parenchyma of the os that it has lost its contractility, the bit of lunar caustic is speedily surrounded by a covering of coagulated albumen, which every moment becomes more dense and dry, and by abstracting the moisture from it, it is soon reduced to a brittle condition-sometimes the centre remaining unchanged-and thus isolated, it remains till expelled from the cervix by the uterine exhalations collected above. This process is often a matter of some time, even of days, and not unfrequently its exit is accompanied by some uterine pains resembling those of labor. Even if the nitrate is entirely dissolved, no ill result is to be feared; the caustic properties of this preparation are so limited that the residence of this bit produces no more cauterization than was effected when the portion to which it had been attached was withdrawn. This is not, however, the case with some other caustics used in these diseases, as the caustic potash and the potassa cum calce, which continue to destroy the tissue so long as they remain in contact.

The patient will return next Wednesday, and we probably will find her much relieved, and in a few weeks she will be entirely cured. She needs no medication, and no treatment

during the interval till her next appearance, except injections of cold water, as cold as can be pleasantly borne, alike for cleanliness by the removal of the secretions, and also for its antiphlogistic properties.

A member of the class, while passing round, has inquired how often such application should be made? The inquiry is a pertinent one-an undeviating rule cannot be given; but the following facts will serve for a guide. The effect of the caustic is to cover the diseased portion with an eschar-that produced by nitrate of silver scarcely deserves so strong a name, as it but little more than forms a film of albumen, with an accompanying stimulating and astringent corrugation and contracting of the inflamed tissue-this remains closely adherent for several days, and not until this is removed can a new application be usefully made. When the disease is upon the exterior of the vaginal cervix, this falls off in from three to seven days, and the application may then be repeated. If it is desirable to hurry the case the applications may ordinarily be made as often as every five days.

The same rule holds good when the applications are intracervical, but the eschar is not thrown off nearly so quickly as when upon the exterior. The coagulated albumen in the form of a plug is found, often on the eighth day after, protruding from the cervix. This may be seized and sometimes pulled away, and if not attached, the application may then be repeated. Oftener, however, at this date, it is but partially loosened, and any attempt to withdraw it, is followed either by its breaking off, or worse still, by detaching it, when its withdrawal is followed by a free flow of blood from the hypertrophied papillæ or ovule Nabothii which stud this canal, and thus the too early attempt to repeat the treatment is defeated. If there is much irritability of the cervix, or much uterine secretion, then this plug is thrown off in a week's time, but ordinarily, in chronic cases, ten days must elapse between the applications.

And how long does it take for a cure to be effected? Ordinarily, we may say, in three or four months, although this may be protracted by various causes, by the patient "catching cold," falls, shocks, etc., ad libitum to a twelvemonth.

The applications, however, need not be applied so persistently after the second month. Bear in mind, that even when making the application every week there are but three opportunities for the topical treatment of the menstruating woman. The tendency of this disease is to cure itself, and it would do so, as is seen in parturient, and especially nursing women, were it not for the hyperæmia of menstruation. Like the frog in the well who jumped up three feet every day, and fell back one every night, the patient is getting well three weeks and getting worse one in every month. My rule then is, to make the applications as frequently as possible for the first two months, say six or seven times; by this time the disease has diminished materially, and the patient would speedily get well were it not for the menstrual week, and my efforts are mainly limited to overcoming their effects, which I do by a single application each month, after each period, and this even when the disease is apparently entirely cured-unless pregnancy ensue, which is very apt to occur-for if any disease is left, it is very apt to be nursed and renewed by some disturbance in the catamenia, or by a severe cold, extra physical exertion, or mental or moral impressions. More frequent applications than these, I am convinced, may benefit the physician's pocket, but surely will not benefit, but even retard the cure of the patient. Time is requisite to procure the absorption of the effused material, causing the hypertrophic condition which is retarded in this stage by too frequent interference.

The professor then showed a case of double inguinal hernia, in a woman of sixty, resulting from the straining during her pregnancy many years since. The hernias were as big as oranges, easily reducible, and only needed a truss to support them. The same patient also had a vesico-vaginal fis