accounts to interfere as little as possible with the vein; and cases are not wanting to show that the vein is often permanently obliterated after pressure. Besides this latter possibility, there can be no doubt of the injurious effect of that engorgement of the whole limb which is often caused by the temporary or incomplete obstruction of the vein, and therefore of the great advantage of any plan which can be limited as far as possible to the artery only. Mr. Holmes, following Mr. Walker of Liverpool, urges the importance of what Mr. Walker has called the "one artery system" of pressure. It is not well, by varying the point of pressure from the common to the superficial femoral, to change the course of the anastomosing circulation. In practice, too, digital pressure has been found to be much less painful than pressure by tourniquets or by the weight. Vanzetti records a case in which the pain in the aneurism, which had been very acute, was at once relieved by digital pressure; and Mr. Holt one in which the patient slept during the application of the pressure.

Fischer refers to seventeen cases in which instrumental pressure was so painful that it had to be given up, and in eleven of these digital pressure was successfully carried out. In Broca's work, twenty-nine cases are given in which instrumental pressure was intolerable; in fact, the invention of digital pressure seems to have been due in great measure to the pain caused by the instruments.

The applicability of compression in cases of disease of the artery itself must not be lost sight of. It is illustrated by numerous instances of aneurism, and in all parts of the body. Cases which, on account of atheromatous disease of the vessels, could never have been treated by ligature with any hope of success, have been cured by pressure. Pressure in such cases is far more safely applied by means of the finger than by any tourniquet, since it is of the last importance not to use any excess of force over an atheromatous or ossified artery.

The rapidity of cure by digital pressure is one of its greatest advantages, closely connected with the less force which it requires and the less pain which it produces. In Fischer's table an average has been struck of the length of time occupied in the treatment of the successful cases of digital and instrumental compression rospectively. It shows that 34.7 per cent. of the cases of digital pressure were successful in the first twenty-four hours, whilst only 10.1 per cent. of those of instrumental pressure were so. The mean time required for cure in the list of cases of digital pressure was about three days, and of instrumental pressure about fourteen days.

The difficulty in making effectual digital compression varies much in different cases, some persons possessing more knack and more strength of fingers than others. Pressure which is easily applied is also, as a rule, easily borne. Unless some assistance is given to the fingers-such as was employed in a case of Mr. Holden's, by means of a bag filled with twelve pounds of shot,-few persons can keep up pressure for more than ten minutes or a quarter of an hour. Digital pressure should always be made with sufficient force to stop the pulsation of the tumour, and no more. The plan of allowing a perceptible amount of circulation to go on through the tumour, which was recommended by the Dublin surgeons years ago, is now allowed to have no advantage. It is quite possible that some blood may be passing through the sac, even though no pulsation can be felt; but however this may be, it is certain that the total obliteration of pulse in the aneurism does not retard, but, on the contrary, greatly hastens the cure, and that in some cases the disease has been cured in a very short time, the shortest time probably being three hours and a half of compression, though pressure was continued for four hours more as a precautionary measure. The cure in this case was permanent. In about one-third of the cases the cure has been obtained in the first twenty-four hours, and it is almost always possible to keep up continuous pressure for this length of time. But after this, if success has not resulted, pressure must be suspended, and digital pressure must be either supplemented with instrumental pressure, or it must itself be employed in an intermitting manner for about two hours at a time twice a day. The sac will by this time probably have become well lined by fibrine, so as not to yield to the distending force of the circulation when readmitted, and fresh accretions will be added with each compression until the whole tumour is obliterated.

WE understand that all men-of-war carrying a medical officer will be supplied with an apparatus for analysing the water for the ship's use.

ORIGINAL COMMUNICATIONS.

OPERA CLINICA.

ON BLOOD-LETTING AS A POINT OF SCIENTIFIC PRACTICE.

By BENJAMIN W. RICHARDSON, M.D., F.R.S.

(Continued from page 230.)

EFFECT OF BLOOD-LETTING IN PROGRESSIVE PNEUMONIA. In the year 1851 a case came under my observation at Barnes. It was that of a strong man, about twenty-six years of age, who suffered from pulmonary congestion, induced by exposure to cold and wet, with exhaustion from want of food. He had been to London on a visit of "pleasure," got wet through during his journey to town, stood about in his wet clothes all the day, and finished up by going to the play, and returning home on foot. This occurred on October 15, and on the 16th he had what he called a cold. He continued to grow worse, and on the fourth day I was called to find him suffering from congestion of the left lung, with fine pneumonic crepitation at the posterior part. He was treated with salines, and was sustained, as far as possible, by food, but he did not progress, and on the sixth day a dozen leeches were applied to the chest, the dyspnoea having become very severe. A few hours later, at my evening visit, I discovered that the congestion had extended to the right lung. The face now was bronzed, the breathing very difficult, the action of the heart laborious, and the pulse tense. The patient was, in fact, in the same condition as Mr. C., the history of whose case is given at the close of my last communication, but with this disadvantage, that he had struggled through a progressive course of the disease, had fasted longer, and was feebler. I determined, nevertheless, to take blood cautiously from the arm, and when I had drawn rather over ten onnoos I was obliged to desist, owing to the occurrence of faintness. This condition of faintness was of short duration, while the relief gained by the abstraction of the blood was most perfectly demonstrated in the instant freedom that was afforded to the hard and laborious breathing, to the oppressed heart, and to the loaded blood. From this time improvement was steady and sure, and on October 26, ten days from the commencement of the attack, the man was convalescent.

EFFECT OF BLOOD-LETTING FOR THE CURE OF COMA AND
CONVULSION AFTER LABOUR.

In the close of the year 1847 I was called to the village of Radwinter, in Essex, to see a young woman who had recently been delivered of a first child. A midwife had attended her, and had rendered every necessary assistance. The labour had been marked by only one striking peculiarity-viz., the enormous quantity of liquor amnii that escaped; the placenta had been thrown off naturally, and the uterus had contracted well. For some days preceding her labour the woman had been unusually dull and oppressed, and within an hour after the delivery, comatose symptoms with convulsions set in. At the time of my arrival there was complete unconsciousness, with stertorous breathing, strabismus, and active convulsions recurring every fifteen or twenty minutes. The patient was quite unable to swallow, and I found that free counter-irritation, in the way of a turpentine stupe, had been employed without result. To bleed in this case, and to bleed freely, was the practice I had been taught; and therefore I carried out the practice without delay. I drew off one pint of blood, with immediate effect in stopping the convulsions; but as the coma continued, I ventured, at the end of an hour's time, to repeat the venesection, and drew off nearly a pint more blood. After this I waited until, from a restless state resembling the awakening from sleep, the woman became partly conscious. I left directions that she should be fed moderately, and should have no stimulant. I also directed that the child should be put to her breast so soon as she was able to take it by her side. On the following day this patient was perfectly conscious at the time of my visit. She had suffered no return of convulsion, and she was not feebler than women generally are after confinement. She made a rapid and perfect convalescence, without resort to any other medical treatment than the venesection.

EFFECT OF BLOOD-LETTING IN A CASE SIMILAR TO THE ABOVE. On May 29, 1873, Mr. Burton, of Richmond-terrace, West Brompton, summoned me to see a lady whose symptoms were

nearly the same as in the case immediately described above. In this lady the most marked peculiarity of the labour, so Mr. Burton told me, was the excessive discharge of amniotic fluid. After delivery she became comatose, insensible, and vehemently convulsed. Her face was congested, her veins tense, her pupils fixed, and her temperature high-103° Fahr. Before my arrival the patient had been bled freely from the arm, and the more alarming symptoms had subsided; but the jugular veins were still tense, the temperature was 102° Fahr., and the unconsciousness continued, with an occasional convulsion. Confirming fully the treatment that had been pursued, I recommended the abstraction of still more blood by leeches, together with continued application of a collar of ice around the neck. I learned afterwards from Mr. Burton that the amendment in the symptoms continued, and that recovery took place without any interruption. Mr. Burton was so good as to take me to see this patient a few months ago. I found her quite well, and I could gather nothing from her that could lead to the remotest suspicion of her having suffered one single harm from the remedy which, I am morally sure, saved her life.

Note.-The phenomena of coma and convulsion after labour, in cases such as are here described, are, I believe, phenomena of uræmia. The symptoms are identical with those of uræmic coma, and the cause is not far to seek. The kidney, subjected to intense pressure during the latter term of pregnancy, is suddenly relieved by the escape of the excessive amount of amniotic fluid and birth of the child. Thereupon into the half-paralysed vessels of the kidney there is an influx of blood, a temporary but effective congestion, and a state of things analogous to that which occurs when the nervous supply of the kidney is divided. The effect of the abstraction of blood in this condition is to afford immediate relief to the congestion of the vessels, to enable the kidney to resume function, and to let the order of the economy proceed.

EFFECT OF

BLOOD-LETTING IN CASES OF UREMIC COMA. (4.) In the close of the year 1850, I attended a boy, seven years of age, for scarlet fever. He recovered from the fever, but in January, 1851, he took cold on being exposed to wet, and on January 21 I was called, to find him in a state of profound uræmic coma. Some urine he had passed was rich in albumen; his body was cold, his pulse small, his consciousness altogether lost. Convulsions of a severe character had set in, involving the muscles of the neck, the face, and the limbs. The pupils were widely dilated and fixed; the breathing was catching and irregular. I tied up an arm and opened a vein. The blood at first flowed feebly, but by-and-by came in a full stream. Under this depletion, the pulse rose and the convulsions ceased. I took sixteen ounces of blood without producing a sign of faintness in this little patient, and I left him composed and conscious. A purge was afterwards given, and occasionally a warm bath. On February 1 he seemed to have recovered entirely, and the urine was free of albumen.

It is worthy of note that this boy, after passing some weeks in good health, playing, eating, and sleeping naturally, after partaking of too hearty a meal, was again seized with convulsions, and died. On the occasion of this fatal attack he was not submitted to venesection.

(B.) In the beginning of the year 1873 I was called to a young lady eleven years of age, who, after an attack of scarlet fever, was seized with uræmic coma. I found her partly unconscious, with convulsions, with slight strabismus, with the pupils widely dilated, and with the temperature of the body normal. The urine she passed was richly albuminous. I suggested the immediate abstraction of blood from a vein, but was so strongly opposed I did not urge the practice. As the symptoms in a few hours became much more imminent, consent was given that I might take blood by leeches. I seized the opportunity, and I carried out the bleeding as effectively as if blood had been taken from the arm, removing by relays of leeches applied over the loins fully eight ounces of blood. The relief afforded was immediate, and, the temporary congestion relieved, the patient continued to improve until she had made a perfect and rapid recovery.

(c.) In 1847 I was attending for Mr. Brown, of Saffron Walden, an aged man who lived near to Littlebury, in Essex. This patient had for some time complained of symptoms of suppression of urine, with drowsiness, which symptoms I knew practically were most easily removed by a Late one night I was summoned to see him because he had been taken in "a fit." He was profoundly comatose and

purge.

frequently convulsed. I knew then very little about uræmic coma, and I was beginning to share in the general panic which was seizing the profession respecting the horrors and dangers of blood-letting. So I refused-though the friends of the sufferer, good old-fashioned people, remonstrated with me-to bleed. In lieu of bleeding, I ordered a blister to the nape of the neck, applied cold to the head, and tried ineffectually (for the man could not swallow) to administer a purgative. I expected nothing less than a fatal termination, and left with that honest impression. The next morning I received a message not to visit this patient again, "as another doctor had been called in." Having to pass the house, however, a day or two afterwards, I ventured, notwithstanding the prohibition, to make an inquiry as to the state of the sick man. He was sitting up in bed perfectly conscious, and a day or two later I saw him leaning on his staff at the door of his house, as well in health as he had been for a period long past. I have learned since that the old gentleman lived several years after I had left the neighbourhood, and that he had many a laugh at my expense, which in truth I deserved quite as richly as he enjoyed.

The history of his recovery is full of interest. His friends believed him to be suffering from a stroke of apoplexy," and having formed that reasonable diagnosis, they came to the practical conclusion that he ought, therefore, to be "blooded." As I left him, giving no hope, and refusing the desired remedy, they called in a neighbouring medical practitioner who soon afterwards was seen riding past their house, and asked him to give his aid. My friend thus summonedfor I am happy to say he still lives-had none of my fears. He opened his lancet, tied up the arm of the dying man, and drew blood freely. With the flow of blood the cloud of unconsciousness began to clear away, the convulsions subsided, and perfect recovery crowned the treatment.

I was on the wrong side of the hedge that time, and, at the moment, felt sufficiently humiliated; but I profited by the lesson, and have never regretted the humiliation.

(To be continued.)

ON LEPROSY AND LUPUS AS SIGNS OF
INNUTRITION.

By GEORGE GASKOIN, M.R.C.S.,
Surgeon to the British Hospital for Diseases of the Skin.

THE mission of Dr. Milroy to the West Indies results in the conclusion that leprosy is due to innutrition. It becomes a food question pur et simple. The Colonial Office has henceforth a test by which it may judge of the physical wellbeing of its lieges that is to say, of their alimentary condition. The conclusion of the envoy is such as approves itself to every mind that has given itself with earnestness to the subject. In all these things there are degrees, but whichever way you look at it, to the ruling power a leprous population is a disgrace. That lowest degree of disgrace we have fortunately got rid of in this land, with the very barest remnant left. Among pathological conditions, elephantiasis in England is most rare. We can no longer count, then, on this test; and the suggestion no doubt will arise that we have no further need of it, our sanitary condition being so much improved. As to that there is something to be said. The great inequality of wages at present existing leads to experience of many a case among us of dearth in food, if not of downright starvation. Is there any test by which to form a sanitary estimate on the side of sustenance, independent of the balance and chemical analysis, independent too of vulgar dictation? In lupus exedens, I affirm, there is such a test. Whenever in country districts, or among the employed in labour, either in country or in town, this lupus exedens is found (at least, in more than single instances), there food falls short in quality or quantity; that trade or country may be generally suspected or impugned as not affording the proper means of support, at least to those in tender years. I have to allow for carelessness and neglect of food in operation among the rich, for wilfulness in opinion, for ignorance, for superstition, all active in production of disease; but I say that innutrition, quasi starvation, lies at the root of this complaint-insufficiency of means of support as applied to the individual of necessarily varying constitution. And here, let it be remarked, the effect of this is not immediate, but lasts for a long term of years; and these

subjects of innutrition are not commonly lean in flesh, especially in childhood, but round-limbed, and often fresh-looking, though having meat but once a week, or living on wages incredibly low. I offer, then, the existence of this disease in more than single cases to the notice of the sanitary official, as an excellent mark or test to be inquired after and to be made account of, holding it as sure a sign as leprosy of insufficient supply of food. There is no necessity for giving cases to show this, nor can I reasonably ask for space to prove it in extenso. I place lupus exedens in the same category with the other; and whatever may seem overstrained in the argument is owing to the brevity with which the subject is treated. I here lay down a principle and submit it to correction; all minor respects I put aside.

Ir is now generally admitted that the effect of the venom of the Indian snake is a temporary suspension of function, not a permanent injury to structure; so that, if the individual who has become impregnated with it can be kept alive for a certain time, the function affected will, when the action of the poison has subsided, recover itself. This fact is most encouraging, and cannot therefore be too widely known. To keep the patient alive, not only are remedies of a stimulating nature required in view of rousing him from the extreme depression which follows in such cases, but something that shall counteract, as much as possible, the action of the poison, as strychnine does that of curare. This is now the admitted position. Of course, in cases where a large dose of the poison has been injected, the result will, in all probability, be fatal.

I have myself made many experiments with snake venom, some of them in the presence of the now head of the Indian Medical Department, Dr. J. C. Brown. Thirteen years ago, when stationed in Lucknow, I satisfied myself that a mungoose (Herpestes Malaccensis) if properly bitten would die, and that, although harmless snakes succumbed to those with venom, one cobra could not kill another. And I have been called upon to treat several cases of alleged snake-poisoning. Of these three were certainly the result of cobra-bite. The individuals were taken with all speed to the hospital (which was close at hand) of the 2nd Bengal Fusiliers (now 104th), and of which I was then in medical charge, and were at once put upon the liquor ammoniæ plan of treatment, and prevented from going to sleep. The treatment was conducted under my own superintendence, and, in my absence, under that of the apothecary and his subordinates. All recovered, at intervals varying from twelve to twenty-four hours. Liquor ammonia is now kept at every police-station in Bengal and Assam, and returns of snake-bite treated by it are periodically submitted through civil surgeons to Government, but the results are untrustworthy. Nor is liquor ammoniæ a certain remedy in all cases. Whilst, therefore, we recognise in its action the good effects of a stimulant plan of treatment, coupled with artificial respiration and remedies to keep up the temperature, etc., there is yet left to be discovered the main factor-an antidote.

most

Respiration is not impeded by the venom of rattlesnakes and Australian serpents, but it evidently is by that of the cobra. If strychnine be antagonistic to the effects of curare, which acts upon the peripheral extremities of the motor nerves concerned in respiration, why should it not act in the same way in the case of cobra poisoning? The pathology is probably not the same in each case; hence the reason. It occurred to me, however, that further experiments might be made with this drug in view to ascertaining if there really be any efficacy in it or not. Our object, I apprehend, is to discover an antidote which is readily attainable by the people. Nux vomica (vernacular, Koochla) is indigenous to the soil in some parts of India, and the nuts (seeds) are to be found in every bazaar. If strychnine were found to be useful, a proportionate dose of nux vomica would probably answer the same end.

On referring to Dr. Fayrer's experiments recorded in his "Thanatophidia," it is seen how exceedingly susceptible the animals bitten were of the influence of strychnine. In each experiment (see Nos. 5, 6, 7, and 8) a large quantity of strychnine-from one-sixth to nearly half a grain-was injected. In all the four it seemed as if death was caused by

the intended remedy. Experiment 10 shows us how extremely susceptible the cobra itself is of the influence of strychnine. Although the hypodermic syringe which had been used for injecting solutions of this drug into venomous snakes had been most carefully washed several times before being used for injecting some poison from one cobra into another, tetanic symptoms displayed themselves in the head and neck of the subject of the experiment in two minutes after the injection, and in twenty-seven minutes more it was dead. Might more favourable results be obtained with smaller quantities of the drug?

Experiment 16 is rather antagonistic to this view, onesixtieth of a grain of strychnine having been injected without arresting the course of the poison; but the antidote was introduced eight minutes after the latter. It also struck me that monkeys might be utilised, not having yet, so far as I am aware, been included amongst the numerous lower animals already sacrificed. The two kinds common to our Indian jungles are the Rhesus Innuus (vernacular, Bundur) and the Presbytis Entellus (vernacular, Lungoor). Neither are large animals; indeed, the former is usually small. The Lungoor (vide the experiment recorded by Dr. T. Ringer in the Indian Medical Gazette for May, 1870) would appear to have a relish for strychnine, eating several grains enclosed in fruit with enjoyment, but succumbing to cyanide of potassium; whilst the Bundur readily falls a victim to it. I therefore experimented with the latter.

There were present on the occasion Surgeon Mitchell, 96th Regiment; Surgeon B. Simpson, Civil Surgeon of Patna; and several other medical (and military) officers.

Experiment 1.-A Rhesus Innuus was bitten in the thigh by a powerful cobra (Naja Tripudians) at 1.42 p.m. At 1.43 p.m. one-sixtieth of a grain of strychnine was injected into the opposite thigh by Dr. Simpson. At 1.44 p.m. the monkey, which had been previously lively, lay down frightened, defæcated, licked its wound, and was evidently exhausted. The respiration was hurried. At 1.48 p.m. the sleepiness had increased. At 1.49 p.m. the animal rolled about on the ground. At 1.50 p.m. one-sixtieth of a grain was again injected. At 1.51 p.m. was lying still; one-thirtieth of a grain was now injected, making a total of one-fifteenth of a grain of strychnine. At 1.55 p.m. the monkey died, after a very slight convulsion. There were no manifestations of the effect of strychnine.

Experiment 2.-At 2.3 p.m. a monkey of the same kind was bitten in the thigh by a fresh powerful cobra. At 2.3 p.m. one-twelfth of a grain of strychnine was injected into the opposite thigh. Hurried respiration and restlessness at once supervened. At 2.5 p.m. these symptoms became more prominent, accompanied by a disposition to lie down-now on one side, now on the other. At 2.8 p.m. another one-twelfth of a grain of strychnine was injected, making a total of one-fifth of a grain. At 2.10 p.m., or two minutes afterwards, tetanic spasms supervened. At 2.15 the monkey died in a tetanic state. Sleepiness was the principal result of the poison in this monkey.

From the evidence of these two cases, it would appear that one-fifteenth of a grain of strychnine was too little, whilst one-fifth was too much; but this evidence is worth very little. Further experiments are required; but I am afraid that we cannot expect anything satisfactory from a drug which is an antidote (?) in one dose, and a poison in another. No more monkeys being available, the experiments with strychnine were not continued.

Experiment 3, with Carbolic Acid.-At 3.37 p.m. a strong, though undersized, pariah dog was bitten in the thigh by a powerful cobra. Immediately afterwards ten minims of carbolic acid were injected into the opposite thigh from a graduated hypodermic syringe. 3.38 p.m.: Leg seems paralysed; limps. 3.39 p.m.: Licks the wound; whines; sits down. 3.40 p.m.: Gets up; restless. 3.41 p.m.: Lies down again; respiration becoming hurried. From 3.44 to 3.50 p.m. quiet. 3.52 p.m.: Gets up, but lies down again immediately; licks his wound; has a thoughtful look. 3.55 p.m.: Defæcates; tries to rise; falls back again. 3.56 p.m.: Slightly convulsed. 3.58 p.m. The convulsions increasing. 4 p.m. Ditto. 4.3 p.m.: Dead.

Nothing was done to this dog (who throughout wagged his tail when addressed) beyond injecting the carbolic acid. The quantity injected was small. It is well known what a strong influence carbolic acid exerts upon cobras. At the conclusion of the experiments I brought the nose and mouth of one in

contact with a drop of this fluid. Instantly the reptile writhed violently, its body becoming doubled upon itself in numerous folds. When taken up by the tail it seemed as if cast in metal. It remained in this state of convulsion for four clear days, when it died.

Experiment 4, with Garlic.-At 3.23 p.m. an undersized and rather weakly pariah dog was bitten in the thigh by a fresh cobra. Salt was at once rubbed into the bitten part, a mixture of milk and essence of garlic was forced down his throat, and the dog was trotted about. More of the mixture was given at intervals, until, at 3.42 p.m., all had been administered. The dog limped slightly at first, and licked the seat of the bite, but the limping gradually wore off. 3.48 p.m.: No unusual symptom had shown itself. 3.53 p.m. Made water, the fluid emitting a strong smell of garlic. 4.5 p.m.: Vomited. Begins to drag the bitten leg, and to show symptoms of exhaustion. At 4.37 p.m., vomited and passed urine. From this time it was clear that the poor animal's life would soon ebb away. Although still walked about, he preferred lying down; and, if unnoticed, would retire to a secluded part of the garden, evidently wishing to be left undisturbed. ̄At 5 p.m. he was found in one of these spots dead.

Garlic was tried in this case upon the recommendation of a native gentleman, who stated that he had seen some surprising cures with it. Beyond a powerfully stimulating effect, which can be better procured with liquor ammoniæ, there is evidently nothing of value to be obtained in snake-bite from garlic.

All the cobras employed were in full vigour (they had been kept for several weeks, it is true, in perforated earthen vessels, but they had been taken out from time to time, and regularly fed with mice, which all devoured greedily); but it is more satisfactory to extract the poison from the poison-sacs, and preserve it for use. It is the fashion with some people to ridicule the idea of any further experiments being made with snake-poison; but surely when so many thousands are sacrificed annually (it is calculated that in one district alone that of Burdwan-the annual mortality is 1000) to its deadly virulence, it behoves all medical men who have the opportunity, to endeavour, in the cause of humanity, to discover an antidote. It would be well if there were more inquirers in the field, and emulating the fine example of Dr. Fayrer, who is labouring even at home.

Dinapore.

[Communicated by Mr. SHAPLEY, Junior Resident Medical Officer.] (Concluded from page 212.)

Case 3.-Bronchocele and Proptosis of seven months' durationDischarged after four months' treatment much Benefited. (Under the care of Dr. FENWICK.)

FANNY S., aged 33, married, was admitted to Davis ward, on March 5, 1874, under the care of Dr. Fenwick. On admission, the following history was obtained :-No goître in family, but it is common in the neighbourhood where she was brought up-Godstone, near Dorking. Lived there for the first twenty years of her life, since which she has frequently been there. Has been accustomed to drink largely of water from a spring that came through the chalk. Very healthy up to twenty years of age, when she began to have children, since which she has suffered a good deal from neuralgia and general debility. Observed no special symptoms until about eight months ago, when her health began to fail, she felt weak, lost all appetite, and frequently suffered from palpitation of the heart; she also retched on rising in the morning, and fainted occasionally. At the latter end of July, 1873, her neck began to swell, and her breath became very short, especially on stooping, or after exertion. In August she was told by her friends that her eyes were getting prominent, and she found that she could not see quite so well as formerly. She had no pain or throbbing in the head, nor noises in the ears. In September the catamenia ceased, after which she was much better for a time.

State on Admission.-Patient is sallow and anæmic, tolerably

Her

well nourished, with a rather mournful appearance. eyeballs project, and are luminous and transparent. Her nose often bleeds, and there is a slight discharge from the nostrils. There is a large goître, and over it the veins are much distended. The right side is much larger than the left. The swelling is firm and elastic to the feel, pulsating with a dis tending, heaving motion, and moves with the larynx on swallowing. On measurement, the right side of the neck was found to be 9 inches, the greatest circumference being 16 inches. The length of the right lobe was 4 inches, and that of the left 4 inches. Sight good. No diplopia or musca volitantes. Has flashes of light occasionally. Much troubled with singing noises in the ears, which are increased on lying down. Has occipital headache, but not constantly, which is very severe whilst it lasts, and is worse after exertion or on reading. Complains of neuralgic pain shooting through the chest from breast to back, and of pain at the "small of the back." States that the left arm-in which she has had rheu matism badly-is weaker than the right, also that she feels melancholy, and that little things worry her. Sleeps a good deal, but is restless. Feels very hot, and does not know how to bear any clothes on her at night. Flushes frequently, but does not perspire much. Heart's impulse is increased at apez, quick and sharp, not heaving. First sound dull at apex, with a slight murmur; second sound loud. Pulse 111, soft and good; occasional palpitation. A loud, continuous humming murmur can be heard over both lobes of the tumour, becoming fainter towards the middle line, where it ceases entirely. Her appetite is ravenous ; "feels as if she wanted to be always eating." No discomfort after food. Is very thirsty. Diarrhas and constipation alternate. Catamenia ceased for seven months. Has leucorrhoea, which is due to prolapsus uteri. Urine feebly acid; phosphatic crystals; specific gravity 1030; no albumen or sugar.

Patient was ordered Easton's syrup (phosphate of iron and quinine with strychnine), which she continued to take upwards of two months, but without any material improvement in her condition, except that her eyes were a little less prominent, and that she complained less frequently of palpitation. She was then ordered to take citrate of iron and quinine three times a day, and an ice-bag to be kept applied to the bronchocele. After about five weeks of this treatment she was observed to have improved very considerably, not only in her general health, but the size of the neck had decreased about two inches, and the proptosis had almost disappeared. It might be stated that after she had been in the hospital about a month she refused to take any exercise, giving as a reason that she "comes over in such a perspiration when she exerts herself."

Continuing to improve, she was discharged about the middle of July, after having been in the hospital more than four months. She promised to return at once should a relapse take place.

Case 4.-Remittent Bronchocele from Childhood-Proptosis of one month's duration-Discharged after four months' treatment without apparent Benefit.

(Under the care of Dr. FENWICK.) Matilda C., aged 25, was admitted to Davis ward, under the care of Dr. Fenwick, on March 17, 1874. No family history of goître could be ascertained, nor is the complaint known in the neighbourhood where she lived (Laxfield, near Framlingham, Suffolk) until the age of seventeen. She has since lived at Tunbridge Wells and Bournewell (Hants). No peculiarities of diet to be detected. Has had slight goître ever since she was two years of age, but it never troubled her until within the last twelve months. During this time it has been getting larger, with remissions and intermissions, some of which were very marked. At one time it decreased in size suddenly, remained small for two or three weeks, and then suddenly enlarged again. Within the last fortnight it has been grow ing much bigger without apparent reason. About a month ago her eyes began to protrude. For two years she has suffered from frontal headache, and also from palpitation of the heart. The headache has been very severe, especially during the summer, and in the afternoon; it used to keep her awake at night, but it never made her sick. About two years ago, dyspnoea came on gradually, which was increased on exertion and relieved on lying down. Her appetite also left her, and has remained bad ever since. She has lost flesh a good deal.

State on Admission.-There is marked enlargement of the thyroid body implicating both lobes and the isthmus, but

chiefly the right lobe. The swelling extends from the upper edge of the sternum to the lower body of the thyroid cartilage in the middle line, and from the same point to within an inch of the angle of the lower jaw on the right side, and within two inches of the corresponding angle on the left side. The tumour is firm and elastic to the touch, pulsates freely, and pushes the sterno-mastoid muscles outwards. Her face is moderately florid and healthy looking, eyes bright, remarkably prominent, and widely open. The lower lid is two lines below the margin of the cornea; the upper lid is on a level with the margin. She can, however, readily shut the eyes, and habitually does so during sleep. Her eyesight is good, and has continued so throughout. No diplopia, myopia, hypermetropia, er musca volitantes. Smell, taste, and feeling normal. Suffers no pain, except headache.

On March 10, and twice since, she has had a tingling and numbness in the left hand, which spread from the arm to the left side of the face, but did not affect the right side. Describes it as "a funny feeling." Has no giddiness. There is slight psychical disturbance. Says she is very irritable, and that little things put her out of temper. Area of cardiac Zulness normal. A very loud musical humming murmur to be heard everywhere all over the tumour, loudest at the posterior border and over the great vessels. The sound is increased on lying down. Pulse 120, small, feeble, and rather jerky. She frequently flushes, feeling at the same time very hot all over. At night she is too hot to sleep, and can hardly bear any clothes on the bed. Has considerable dyspnoea on exertion, but not at other times. Appetite very bad, the sight of food makes her feel sick. Urine feebly acid; specific gravity 1025; no albumen or sugar; no deposit. On examination with the ophthalmoscope, pulsating veins were observed in both eyes. The size of the vessels was larger than normal, and they were extremely numerous.

As in the preceding case, this patient was ordered Easton's syrup, which she took for several weeks without benefit. She afterwards took citrate of iron and quinine, and ice was applied to the tumour at various times, but this treatment was not followed by such improvement as was observed in Case 3. She also was discharged about the middle of July, having been under treatment nearly four months. Her condition on leaving was much the same as on admission, the only improvement being a marked diminution in the palpitation.

On August 20 the patient called at the hospital to report herself. After leaving the hospital she went to Brighton, where she resided for six weeks. She has considerably improved in her general health, and the catamenia-after having been arrested several months-have returned. The proptosis is now scarcely noticeable; the size of the bronchocele, however, remains about the same, being only half an inch smaller than when first observed.

He was

DISLOCATION OF THE HIP IN A WOMAN SEVENTYTHREE YEARS OF AGE.-Dr. Kline, practising in Ohio, communicates to the Medical Record (June 15), through Professor Hamilton, the particulars of a very remarkable case. called to a woman aged eighty-six who had fallen down while crossing her room. Instead of the fracture of the cervix which he expected, he found a fracture just above the condyles of the femur. Extension was made by means of a four-pound weight and a pulley, balanced by the weight of the body. The case went on very well, so that by the sixtieth day union was quite firm. There was no excoriation of the limb or body, and as a matter of precaution the weight and splints were continued a little longer. This firm and prompt union in one so aged is sufficient to render the case one of interest; but the reason of its being recorded is, that while Dr. Kline was examining the limb under the supposition of intracapsular fracture, he discovered that the head of the femur was resting on the pubes, and pushed up towards the anterior inferior spinous process of the right ilium. She stated that thirteen years before (when seventy-three years old) she had fallen down a flight of steps about three feet high, and dislocated her hip. No attempt was made at reduction; and she said that she had often pushed the lump down in the groin, thereby moving the whole leg. She always walked with the foot so strongly everted that it formed a right angle with the other, having commenced walking six months after the dislocation. Prof. Hamilton believes that, with the exception of a case reported by Gauthier (eighty-eight years), this is the oldest person recorded in whom this accident has occurred.

We find that in the leading article last week on Professor Tyndall's Belfast address, our pen made an unlucky slip, and wrote "De Naturâ Deorum," instead of "De Rerum Natura," as the title of the great philosophical poem of Lucretius. Anyone who has ever read Cicero "De Naturâ Deorum," and who knows the mischances of hurry in writing, will know the chain of thought which led to the mistake, and accept our apologies for it. But the incident prompted us to take Lucretius from the shelf, and to read once again his first book. Then came the idea, Why should we not write a leading article on it for next week? At any rate, we will try.

All that is known for certain of the author is, that he was a Roman gentleman, living in the society of M. T. Cicero, Memmius, and others of the highest rank; that he wrote a poem on the philosophical system of Epicurus, and died at the age of forty-five, before it was published. Tradition says that he was insane before he died, and wrote his work in his lucid intervals; and it is added that his insanity was caused by a drugged potion given him by his wife to make him love her the more.

The poem itself is distinguished for the clearness with which it sets forth doctrines in themselves abstruse and difficult, and for the rich poetical glow and fervour which light it up; for a kind of antique austerity and solemn grandeur in the language; and for an abundance of those emphatic sentences which have caused the work to be from the first a mine of quotations.

He describes the human race as lying oppressed by superstition until Epicurus arose, and, undismayed by ghostly terrors, determined to explore the secrets of Nature. And the vis vivida-mark the term, still in use-of his mind penetrated beyond the starlit boundaries of this world (flammantia mænia mundi), and conquered Nature, so that we now know from him what is and what is possible. Don't think, he says, that this search into nature is impious, for it is superstition which is the