Pathological Society is reported to have said that "in tinea tonsurans the fungus is probably not the essence of the disease, even though it may be always present." To this view I entirely assent, and chiefly for the following reasons:1. What we know generally of the growth of these kinds of vegetable parasites is not in accordance with the assumption that they attack and feed upon perfectly healthy growing structures; their food is generally dead or dying tissue. 2. From an examination of a large number of cases, I have been led to the conclusion that the development of the fungus is not always in proportion to changes present in the skin and hair, showing that other causes are at work. 3. That in many cases of tinea tonsurans the comparatively healthy hair of the whole scalp loses its lustre, becomes harsh, dry, and brittle, and more opaque than in health, without the growth of fungi beyond the ringworm patches; and the same condition of hair sometimes remains for months after all parasitic growths have disappeared. 4. If the fungus were the essence of the disease we should expect the malady to be less capricious in its nature. Two children in whom ringworm has appeared at the same time may be treated in exactly the same way, but in the one it will disappear quickly, while in the other it may last for months, or even years. On the whole the balance of probabilities seems to me in favour of the view that the fungus plays a secondary though important part in the development of the ordinary patch of tinea tonsurans.

INDUCTION OF PREMATURE LABOUR.

By JOHN C. LUCAS, L.R.C.S.E.

THE various means which have been proposed from time to time for the purpose of effecting expulsion of the contents of the gravid uterus have each their advantages and drawbacks-some are more effective, more rapid and certain in their action; while others are not only slow and uncertain, but likewise affect the child-bearing function of the woman, if she happen to escape with life; so that the choice of one or other mode of procedure becomes of very great practical importance, especially in cases advanced in utero-gestation, where, in addition to the viability, we obtain evidence of the vitality of the child, and our aim is consequently directed to save it if possible. The modus operandi of all, of course, is based, as we know, upon the contractility possessed by the uterine muscular fibres, by the aid of which, on the application of stimulus or the introduction of a foreign body in utero, the ovum or foetus finds its exit as in labour at full term. The operation, therefore, for inducing premature delivery or abortion in the earlier months is effected either by directly acting upon the womb and its contents, or indirectly by secondary reflex irritation through the medium of the breast, larger bowel, etc. The measure most frequently had recourse to in the present day is that originally taught and practised by Hamilton in the beginning of this century. This operation-namely, of detaching the membranes used to be performed rather roughly in those days by the forcible introduction of the digit through the cervix uteri, but modern obstetricians have improved upon Hamilton's method by taking care to avoid puncturing the bag of membranes by the careful introduction of a flexible instrument between the uterine wall and the membranes, without tearing through the latter.

In a case which not long ago came under my observation-that of an out-patient of the West London Hospital, who was a little less than eight months advanced in the gravid condition, in which case premature delivery was urgently demanded, after getting the consent and preparing my patient, and placing her in the usual obstetric position, I employed a long flexible gum-elastic bougie, passing it in a spiral manner across the fundus, without puncturing the bag of waters. I left it in situ, and labour, as desired, was brought on within nine hours; both mother and infant did remarkably well, without any evil consequences to either. The operation is by no means a difficult one, is perfectly free from danger to maternal structures, and not unfrequently saves many a patient from the perils of forceps, version, etc., and many more infants from death in utero or by the painful resort to embryotomy, by which the mother has to run the risks of post-partum hæmorrhage, metritis, peritonitis, etc. Therefore the timely induction of labour before the full term, in properly selected cases, would tell materially upon the statistics of parturient mortality.

REPORTS OF HOSPITAL PRACTICE

IN

MEDICINE AND SURGERY.

LONDON HOSPITAL.

[For notes of the following cases we are indebted to Mr. R. Kershaw.]

CANCER OF PELVIS, OMENTUM, ETC.-THROMBOSES. OF LEFT JUGULARS, OF SUBCLAVIAN, OF THE SUPERFICIAL VEINS OF THE FRONT OF CHEST, OF THE INNOMINATE AND SUPERIOR VENA CAVA, AND ALSO OF THE BRANCHES OF RIGHT PULMONARY ARTERY.

(Under the care of Dr. RAMSKILL.)

Six

THIS patient (E. D., aged fifty-three), when admitted, gave the following history, for which we are indebted to Mr. Walker. She said that she had suffered a good deal from so-called bilious headaches, that she had had a hard life, having usually worked from eight in the morning until eight at night as a sewer in the book trade, and often did not leave the house for days together. She had been subject to constipation for years. During the last year she had had "great agitation and bother," having lost several relations during that period. Six monthsago she began to experience an aching pain in her loins; she said it was at the commencement of her illness, and that it began in the right side of her abdomen after a hard day's work at washing. When admitted into the hospital she was not wasted, but was very anæmic-looking, and her hair was grey (this having changed colour, she said, when she was twenty-six years of age). Her tongue was pale and flabby, her urine had a specific gravity of 1020 and contained lithates, but no casts nor crystals. On examining the chest, it was found that expiration was prolonged everywhere, and the percussion-note flat at the posterior apices. There was no indication of the heart being diseased, but the first sound was feeble. The dulness of the liver and spleen was normal; there was no ascites, no oedema. There could be distinctly felt a hard cord-like substance along the course of the left external jugular, and thrombosis of this vein was diagnosed. weeks after admission there was oedema of the left arm. The thrombosis did not cause pain, nor had it been preceded by pain. She said her legs swelled once, but they were not swollen when she was admitted into the hospital. On the following day the superficial veins over the left pectoral muscle were very distinct and distended, and minute ones were seen ramifying in all directions over the upper part of left chest. The left arm remained oedematous, and the external jugular hard and swollen. After a few days she said she felt better, but that the pain continued in her loins and both sides of her abdomen, being reproduced each time she ate or drank. Her tongue was clean at the edges and red; in the mornings it was very dry, and she complained of having a nasty taste in her mouth. The left arm began to feel more tense, and pitted on pressure. It was further observed that she had a tumour in the Ĵower part of the abdomen on the right side, the seat of pain; this, in the course of a few weeks, seemed to enlarge greatly, and was thought to be cancer. About a week before she died her eyelids became very oedematous-so much so, that she could with difficulty open them; her chest-wall was also cedematous, and everywhere over it the small veins seemed unusually distinct and distended. Her lips were blue, and her right arm. seemed somewhat swollen, but not appreciably edematous. It was particularly noticed that her pulse at the wrist was at this time very small and feeble; her breathing was laboured, it seemed as if she was at each inspiration endeavouring to take a deep breath. On listening to the chest, a loud, harsh inspiratory note was heard everywhere, there were no moist sounds, and the resonance was clear; there was nothing to show that there was any obstruction to air entering the lungs. She did not complain of headache. The optic dises were examined, and the veins were found to be somewhat distended and the arteries small, but these changes were not very greatly marked. There was no oedema in the lower part of the body. She complained that her breath was "so short," and it was at this time thought that there was thrombosis of the superior vena cava, and that the clot had extended continuously from the left side of the neck. Owing to this condition of the cava, the venous circulation in the upper part of the

body was obstructed; hence the oedema of the chest, face, and arms. And owing to this venous obstruction, there was a lessened quantity of blood entering the arterial system; therefore the small, feeble pulse, and the blood being largely cut off from the lung, the air entering the pulmonary cells could not obtain access to it, and hence the increased besoin de respirer. Her circulation became gradually more and more arrested and her breathing more laboured until she died.

At the autopsy, which was conducted by Dr. Sutton, the body was found to be much wasted. There was oedema of the chest and arms, but not of the legs. In the chest-wall the veins ramifying through the pectorals were found to be completely plugged with a blackish clot. The left external jugular contained a quantity of serous-looking fluid and completely decolorised softened clot. The left internal jugular was filled with partly decolorised clot, which was firmly adherent to its lining membrane. The left subclavian vein, and the branches extending over the front of the chestwall, were similarly plugged. The left innominate vein contained a large, dirty grey, moderately firm clot, which completely filled it, but was not adherent to its surface. This extended down to the superior vena cava, which was also filled with a similar substance, and to the right auricle, where the clot became black, the portion nearest the cava being partly decolorised. The right ventricle was also filled with a black but less firm clot. The inferior vena cava was not plugged; but the right subclavian and right jugular were completely full of black clot. The left ventricle was contracted and almost empty; the valves and orifices were normal; but the heart was smaller than natural. The brain was healthy, except that the convolutions of the anterior two-thirds were wasted; the sinuses did not contain clots. In the right pleural cavity there was found a considerable quantity of opaque serous fluid, which by its pressure had caused collapse of the lower lobe of the right lung. There were no indications of pleurisy. On section, the right lung was seen to be paler than natural, and injected posteriorly, and some old pigmented calcareous matter, in the form of small masses, was found in the lower lobe. The trunk of the pulmonary artery was free from clot; but in one of its large branches in the lower half of this lung there was a decolorised clot adherent to the endothelium, and a branch in the upper lobe also contained a small clot. On the left side the pleura was normal. The lung on section was pale, and at the apex there was some thready fibroid thickening, which did not completely consolidate the part. The abdomen was not much distended; there was no ascites. The liver was much enlarged, pale, soft, and fatty, and it reached some inches below the ribs. The peritoneum was venously congested, but otherwise healthy. The right half of the omentum was invaded by cancerous matter, and there was a large cancerous mass rising up from the right side of the pelvis, surrounding the upper part of the uterus, and invading one of the Fallopian tubes, which was much dilated, the cancerous growth having extended along its inner surface. The bladder and rectum had escaped; but the left ovary was apparently destroyed, being converted into a cyst filled with a yellowish-looking lymph and opaque serum, and just outside of it there was a large nodular mass of cancer. The spleen was dark in colour as in heart disease, and the kidneys were somewhat venously congested. The mesentery was much invaded by the cancerous growth, also the lumbar glands, forming masses along the course of the aorta; these masses, however, did not much compress the aorta nor the vena cava. HEART DISEASE-PLUGGING OF THE AXILLARY ARTERY-GANGRENE OF FOREARM-RECOVERY

AFTER AMPUTATION.

(Under the care of Dr. RAMSKILL and Mr. COUPER.) This patient, a man (J. H. W.) aged fifty-two, was admitted into the London Hospital in February, 1873, under the care of Dr. Davies. He then said he had not had good health since he was seventeen years of age, and at that time was laid up with rheumatic fever in St. Thomas's Hospital several months. He further said that his heart had been affected ever since, and he had had a cough for years. Whilst in the London Hospital there were physical signs of bronchitis and of mitral regurgitation, and the second sound of the heart was markedly doubled. After being in the hospital several weeks the chest symptoms diminished considerably, but the abnormality of the heart-sounds remained. He seemed much better, and was therefore sent into the country; but his breath was nevertheless very short on exertion, especially on going upstairs, and

he had a sense of numbness in his feet and legs. Whilst in the country he seemed to improve, but felt depressed and miserable, having an impression that he had "done something very wrong, and could not shake it off." This feeling "used to make him cry." He lost all power of enjoyment, and for some time was very wakeful at nights, though quite free from pain. He returned to London on September 1, feeling quite as well as usual; said he was "laughing heartily" on the evening of that day, and at night slept for several hours-in fact, had a better night than he had had for many weeks. At about eight o'clock next morning, whilst sitting upon the edge of his bed, he was suddenly seized with severe pain in his left arm, which caused him to feel faint, and he had to lie down again. He vomited two hours later, and several times during the day; the pain also persisted with great severity. During the afternoon of the same day he first noticed a slight discoloration on the back of his left hand; he said "it looked as if bitten by frost." This change extended, and the pain continued so as to prevent sleep, and after two days he was again admitted into the hospital. On admission, his hand was cold and the skin shrivelled and bluish; from the wrist to the elbow it was swollen and tense, but pitted slightly and doubtfully on pressure. There were a number of hæmorrhagic spots on the skin of the forearm, and a dark red patch on the back of the forearm which extended to the front of the radius. The colour did not fade on pressure, and was to be seen more or less throughout the entire forearm, its tint being that of dark-red rust. The sensation of touch was lost in this part, but just above the dark-red portion the arm was very tender on pressure-in fact, hyperesthetic,-and the skin warmer and of a pink appearance. He was unable to move the left arm, and said he lost all power in it at the moment when he was first seized with pain. No pulsation could be felt in the axillary artery, whereas it was distinct, though feeble, in the right radial. On the following day the condition of his arm was much the same. His cheeks were slightly flushed, and he appeared somewhat depressed, being disposed to groan and cry. He had no facial or ocular paralysis; the pupils were rather contracted; there was no loss of power in his legs and right arm. His tongue was moist, but thickly coated with fur; bowels regular; no tenderness on pressure, except over the epigastrium, where moderate pressure caused him to shrink; there was no oedema of the lower extremities; no ascites. His respiration was diaphragmatic and laboured, 20 per minute; though when asked to take a deep breath his chest expanded, but not well. The heart's dulness extended half an inch outside the left nipple, and half an inch to right of sternum, and upwards to the margin of the third rib; its apex-beat was very irregular. On listening, a forcible beat was heard, accompanied by a well-marked murmur, followed by two or three feeble ones during which the murmur was very faintly heard. This murmur was soft and blowing, and slightly preceded and accompanied the sharp knock of the apex-beat; it was heard loudest over the region of the apex-beat. The second sound was much intensified over the second left costal cartilage. The physical signs showed that the lungs were emphysematous. The liver dulness reached the sixth intercostal space, evidently diminished by the emphysematous lungs. After a few days, loss of sensation was found in that part of the forearm where hyperesthesia had previously been very marked. The darkred colour had extended almost to the elbow; the skin was cold, and the hand entirely devoid of sensation. The pulse in the right wrist was very small and feeble. He slept badly, waking up frequently, but he complained only of pain in his arm. The limb was enveloped as high as the shoulder in thick folds of cotton wadding, and the pain began to abate at the same time that a distinct line of demarcation formed two inches below the elbow. The dead, mummified skin partly detached itself from the living; and a thin, offensive discharge came from the line of separation.

Mr. Couper was now consulted as to amputation. He declared a regular amputation inadmissible on account of the patient's extreme exhaustion, and advised removal of the gangrened limb immediately below the line of demarcation, and the subsequent removal, bit by bit, of the fragments of slough left attached to the living parts. This measure was adopted forthwith. The patient was not removed from bed, nor was he informed that an operation was contemplated. All the dead parts, excepting two inches of radius and ulna, were speedily removed without shock, without pain, and without bleeding. No anaesthetic was needed. In a few days a clean truncated surface was obtained, covered with granulations,

from the centre of which projected the necrosed stumps of the radius and ulna. No attempt was made to obtain flaps. The wound slowly contracted and healed around the bones. The sequestra were gently detached at the end of two months, and a few weeks later the wound had closed. Although little more than an inch of the shafts of the radius and ulna remained, perfect voluntary movement of the elbow was preserved. The articulation itself was not implicated at any period of the attack. A longer and more useful limb was thus retained than if the alternative of amputation three inches above the elbow had been successfully adopted. No doubt a very unshapely stump has resulted. There is a puckered scar glued to the ends of the bones, but there is no lack of covering. and no retraction of soft parts. The stump, though tender for a long time, is now painless.

Most probably the gangrene arose from embolic plugging of the axillary artery, or of the brachial at or near its bifurcation, the plug being probably due to detachment of a vegetation or clot from a diseased cardiac valve. The history of the attack accords with this hypothesis, while, on the other hand, in its suddenness, as well as in the extent of limb affected, the gangrene differs completely from the ordinary senile variety arising from degeneration of small vessels. The lower limb is the favourite seat of this latter affection. The most outlying part-the terminal phalanx of a toe, for instance --is generally the first to perish, and from this point upwards the affection spreads very slowly, often with little pain and no constitutional disturbance. In this case the circulation of the forearm and hand was instantaneously either arrested or so impeded that the whole speedily perished.

MIDDLESBOROUGH COTTAGE HOSPITAL.

CASE OF HEPATITIS.
(Under the care of Dr. VEITCH.)

E. C., aged forty-three years, six feet high, rather thin, of very active habits; lived freely, rarely to excess, his beverage being generally the lighter kinds of wine, although latterly he has preferred sherry. He has resided in Paris and Warsaw, but has never been out of Europe. While at Warsaw, fifteen years ago, he suffered from inflammation of the bowels. Numerous cupping marks remain to attest the severity of the disease; and he has since had several attacks of dysentery. During the last four or five years he has been subject to catarrhal diarrhoea, occasionally accompanied with icterus, always occurring during the cold (generally cast) winds; the changing temperature bringing with it relief.

November 29.-While entertaining visitors the previous night he was suddenly attacked with stabbing pains in the right side in the region of the liver, followed by severe frontal headache, retching, sleeplessness, thirst, and an intolerable parched sensation in the mouth. Morn.: He is jaundiced; tongue moist. On auscultation and percussion the heart and lung sounds are found to be natural. The liver is enlarged in an upward direction to within an inch of the right mamma. There is great tenderness over the liver and very great tenderness over the gall-bladder. Pulse 80. Even. Pulse 90. Urine scanty and high coloured. Bowels have not been relieved since yesterday.

30th.-Morn. More jaundiced; skin moist; tongue white, furred, and moist; abdomen tense; retching has ceased; bowels have been relieved of a pint of flocculent mucus fluid mixed with green fæces, smelling offensively. Had rigors during the night, one paroxysm lasting an hour. Has had no sleep. Was slightly delirious; is now calm. Urine copious; high coloured. Pulse 70. Even.: Skin dry and hot; tongue dry. Passed three more stools; first-half-pint of white opaque stringy mucus; second-like last, chopped up; third-half like last, and remainder white relaxed fæces. Had several rigors during the day, which were milder and of shorter duration than those during the night. More delirium. Pulse 120. Urine normal quantity; high colour. Diagnosis: Enlarged congested liver; inflammation of surrounding viscera, probably duodenum, common and gall ducts.

December 1.-Morn.: Skin moist: tongue moist. Purging ceased. No more shivering. Was rather delirions during the night; had short naps; is now quiet. Pulse 70; temperature 98°. Even.: Pulse 68; temperature 98'. Has been no delirium during day.

2nd.-Morn.: Appearance as before. Has taken largely of

milk and soda-water. Pulse 60 temperature 985. Even.: Mouth still occasionally parched; skin itchy; abdomen less tense; pain at hypochondrium less. Has been restless during the day. Pulse 80; temperature 100.

3rd.-Morn.: Skin moist; tongue moist. Has passed a motion of fair consistence, slightly coloured with bile pigment. Has slept four hours. Pulse 60; temperature 98°. Even.: Skin dry; tongue dry. Complains of pain in the right shoulder; is occasionally slightly delirious. Pulse 88; temperature 102°.

4th.-Morn. He is more sallow; abdominal muscles flaccid; less pain on pressure over the liver. Pulse 80; temperature 99°. 5.30 p.m. Seen in conjunction with Dr. Ellerton. Pulse 110; temperature 101·1°. He has just had a rigor. 12.15 midnight: Tongue moist; skin moist. Has had a stool less fluid than the last, and darker coloured. Pulse 70; temperature 98.2".

5th.-Morn.: Less jaundiced; less pain on pressure over hypochondrium. Passed a healthier stool. Has taken freely of milk and soda-water. The respiration slightly hurried. Has had a short rigor; slept a little; has been no delirium. Pulse 88; temperature 98.2°. Even.: Skin moist; another small motion darker coloured. Pulse 90; temperature 102°; respirations 32. Had another slight rigor.

6th.-Morn.: Less jaundiced; tongue moist. Had another small stool containing more colouring matter. Slept two hours and a half, and had frequent naps; another slight rigor.. Respiration easier; pulse 64; temperature 97. Even.: Skin moist; tongue dry; abdomen remains flaccid. Bowels have been twice moved; last stool contained undigested pulp of grapes; both stools are more fluid, and of natural colour. Respiration easier; has been rather delirious; pulse 100; temperature 102.1°.

:

7th.-Morn. Icterus less; skin moist: tongue moist; abdomen still flaccid; less pain on pressure; there is very slight bulging near ensiform cartilage. Passed a quieter night, and had no delirium. Pulse 72; temperature 99.5°. Even.: Had three shivering fits during the day. Pulse 70; temperature 98.1°. Urine copious; high coloured.

8th.-Morn.: Appearance as before. Had two stools, both nearly natural. Respiration natural: slight pain when lungs are fully inflated. Has coughed up a small piece of rusty sputa the size of sixpence; has been rather delirious during the night, is now calm; slept three hours; had shiverings. Pulse 80; temperature 98-2'. Even.: Pulse 90; temperature 100°. Slept three hours; has had a rigor.

:

9th.-Morn. Skin sallow and dry; tongue moist; respirations rather quicker; more pain at hypochondrium on pressure.. Passed a stool nearly natural in colour, containing some mucus. Slept two hours: had two rigors. Pulse 110; temperature 102.2°. Even. Seen in conjunction with Dr. Charlton, or Newcastle. We found the patient in a severe rigor of half an hour's duration, during which the temperature was 985. On reaction setting in it was 102.2°; pulse 90. Bulging near ensiform cartilage is slightly diffused; diagnosis of hepatitis confirmed.

10th.-Morn.: Tongue dry; has been delirious during the night; is now quiet. Takes less food. Urine scanty. Pulse 96; temperature 1011'. Even.: Appearance pale and anxious; respiration natural; pulse 64; temperature 95.5°.

11th.-Morn.: Skin moist; more jaundiced; has not been delirious. Slept a little during the night; had a rigor at three o'clock. Passed a copious light-coloured stool. Pulse 92, weak. Has just had another rigor, during which tempera ture was 98, afterwards rose to 1015. Swelling at ensiform cartilage more apparent. Even.: Slept a little; has been quiet. Pulse 80; temperature 97°; respiration natural.

12th.-Even. More jaundiced; slept very little over night, being slightly delirious at times: had two rigors; had three trivial motions. Pulse 68; temperature 94.5'. 10 p.m.: Tongue parched; is extremely restless: respiration much quicker. Pulse 124; temperature 101. Has had two fluid motions.

13th.-Morn.: More emaciated, more jaundiced; tongue moist. Has taken very little support. Perspired freely during the night; respiration calm; been delirious at times during the night; had two rigors, milder in character. Pulse 92: temperature 992. Even.: Had a slight rigor during the day. Pulse 88; temperature 96°. Retention of urine.

14th.-Morn. Increased icterus; tongue moist; respiration calm; perspired a little. Has been very restless during night; had two long rigors. Takes more support; passed urine copiously, containing large quantities of lithates. Complains

of stabbing pain at the liver. Ensiform swelling slightly increased. Pulse weaker, 72; temperature 96°. Even.: Tongue dry and parched; has been lying on right side for first time; has been quiet during the day, except two shiverings. Respirations 32. Passed two stools-one healthier and more solid, the other fluid; urine copious. Pulse 110 (weak); temperature 100°.

15th.-Morn.: Tongue moist and furred. He has been lying upon each side. Had restless night and two long rigors. Passed per anum twenty ounces of fluid, mostly pus, with numerous triple phosphate crystals; had great pain in passing it. Most of the pus corpuscles are unaltered, leading to the conclusionin which Dr. Charlton agrees-that the abscess has burst into the colon. Urine examined at the same time, contained no such crystals. Respiration natural; pulse 70; temperature 95°. Even.: Countenance pinched. Has had a very quiet day; slept more and taken more food. Bulging at ensiform cartilage has disappeared; had a rigor, during which temperature 101°, afterwards 104°; pulse 110.

16th.-9.30 a.m.: Had a restless night; two more rigors. Respirations 56; pulse 160, feeble. Passed loose stool, containing pus cells. 1.30 p.m.: Pulse 130; temperature 101°; respiration hurried. 9 p.m. Has been quiet; slept half an hour; respiration easier. Passed loose stool, still containing pus. Taken freely of milk and brandy. Pulse 80; temperature 95°. Urine copious. He is now quite unconscious. 17th.-Morn.: Lower jaw moves constantly up and down, snapping; respiration hurried. Had two loose stools, containing pus cells. Taken freely of milk and brandy. Slept half an hour during night; had two rigors, the first lasting an hour. Pulse 130; temperature 101.5°. Even.: Has had occasional naps; slept an hour and a half; one rigor; respiration easier. Passed a stool of darker colour and more consistence. 100, very weak; temperature 98.5°.

Pulse

18th.-Morn.: Peculiar movement of jaw continues; had one rigor during night, lasting half an hour. Has passed three loose dark-coloured stools. Pulse 96; temperature 95°. Takes freely of milk, brandy, and soda-water. Even.: Respirations 32. Another loose stool, darker coloured. Pulse 90; temperature 96.5'.

19th.-Morn.: Had during night an attack of epistaxis, some of the blood passing into the air-passages and stomach, afterwards coughed and vomited up; had two rigors, followed by great prostration; had three loose dark-coloured stools. Pulse 116; temperature 99.5°; respirations 40. Even.: Tendency to coma. Passed a stool, lighter coloured. Pulse 92; temperature 97°; respirations 36.

20th.-Morn.: Passed restless night, taking little or no nourishment; pupils dilated; tongue parched; sordes upon the teeth; skin moist. Pulse extremely feeble and quick; temperature 104-5°, which gradually came down during the day to 100° at 5.15 p.m. He died at 8.40 p.m.

Treatment. To stimulate, allay thirst, and modify the formation of pus (?), effervescing draughts-dilute hydrochloric acid, lemon-juice, and carbonate of ammonia. One grain of opium to be given during the rigor, and one grain and a half of quinine three times a day; bismuth and limewater when purged; seidlitz-powders as an aperient when required. Poultices applied to hypochondrium.

Diet.- Milk and soda-water; beef-tea; calf-foot jelly; grapes were given until passed undigested; soups; and arrowroot. Towards the termination of the case, when stimulants were needed, brandy and soda-water and champagne were administered as required.

Post-mortem, forty-eight hours after Death. It was made in the presence of Drs. Ellerton, Crowe, and Veitch. He is in appearance rather thin, tall, and sallow. Fair amount of adipose tissue in abdominal parietes. Stomach distended with gas. Omentum loaded with fat. Spleen normal, adherent posteriorly. Kidneys natural in size, rather congested. Duodenum congested and containing mucus. Liver very much enlarged, weighing seven pounds and three-quarters, easily separated from diaphragm. Upper surface appears healthy, excepting that in the left lobe there are several dusky spots, two of which are almost black. A cretaceous gall-stone, weighing 8xty grains, impacted in shrivelled-up, almost obliterated, gall-bladder, the wall of which is very much thickened and indurated. Bile-duct occluded and embedded in a mass of adhesions, containing duodenum, pancreas, omentum, and transverse colon, the latter firmly adherent to the gall-bladder and communicating with it by a sinus passing through the gall-bladder into the centre of the right lobe, communicating

with many abscesses. A small abscess, the size of a hazelnut, situated just above the gall-bladder in the substance of the liver. The right lobe in section is studded with abscesses to infiltration, and burrowed with sinuses, the substance of the liver being in many places near the base completely disorganised. The left lobe contains three large and many small abscesses, evidently of recent formation.

Remarks. This case presents several interesting points worth remarking. Jaundice was present more or less during the whole of the attack, which Frerichs says is rather rare. The rigors during night came as a rule in couples, the second being an echo of the first, these rigors setting up peristaltic action, and causing evacuations. The comparative absence of perspiration, pain in the shoulders, and vomiting. The extreme irregularity of the temperature, even during the rigors. The peculiar motion of the lower jaw, due probably to some reflex action through the pneumogastric, which I have never read of or seen before. From the repeated occurrence of catarrhal symptoms previous to this attack, the mucous discharge at the commencement of the disease, and the presence of cretaceous matter in the gall-bladder, it is probable that there was inflammation of the duodenum, which, extending, caused contraction of the biliary passages (Rokitansky) and ultimate obliteration. The calculus increasing the irritation, “giving rise to abscess in the liver, and establishing fistulous passages."

THE LAW OF HOMICIDE.

OUR readers will recollect that a Bill to amend the law relating to homicide was introduced to the House of Commons last year, but was not proceeded with. The subject is one of extreme interest, however, and must yet be dealt with, and we gladly note an admirable address on it by Dr. Bucknill at the West Riding Asylum.

Dr. Buckuill quoted from the recent Select Committee of the House of Commons the statement that the law of homicide is not to be found in books or statutes, but in a kind of oral tradition and understanding amongst lawyers which can only be acquired by practice, and that to any but practising lawyers it is impossible to declare what the law of homicide is. Dr. Bucknill affirmed that this Select Committee

had gone far to determine that this condition of the law was an anachronism and a scandal. He considered that the action of Parliament in choosing a mixed committee of lawyers and laymen to analyse the law of homicide justified a layman in commenting upon the subject. Mr. Fitzjames Stephen had been entrusted with the command of the draft Bill for the amendment of the law of homicide; and after being read a second time the Bill was submitted to a Select Committee of eighteen members, comprising some of the ablest men, lay and legal, of the House of Commons. It was finally agreed that it was not desirable to proceed with the Bill; but the lateness of the determination may have had something to do in fixing the resolution of the Select Committee. Dr. Bucknill argued that the objections of the Select Committee may have had more to do with the form than the substance of Mr. Stephen's Bill. His method, notwithstanding the inherent difficulties of the subject, appears to have been scientific, and most of the changes which he proposed to introduce seem to have been humane and wise. The responsibility of leaving things in their present state must weigh heavily on someone's shoulders. There can be no doubt that the conclusions arrived at by the Commission with regard to the law of homicide show that it is impossible that the law could exist one unavoidable day after it had been reported on to the House of Commons in the terms employed by the members of the Commission. The old definition of murder (said Dr. Bucknill)—that it was killing with malice aforethought-is quite obsolete as far as the forethinking or premeditation is concerned. Mr. Stephen and the judges quite concurred on that point. With regard to the materials collected by the Parliamentary Committee, Dr. Bucknill adduced the following heads as indicating matters of special interest to the medical profession :-1. The definition of murder and manslaughter. 2. The difficulty of proving infanticide. 3. The difficulty of surgeons operating without consent. 4. The plea of insanity. On the first head the lecturer touched upon the point of definition already referred to, and then made some special observations on the plea of insanity, and the liability in the administration of anaesthetics. He showed that from Mr. Fitzjames Stephen's observations the latter had only an imperfect understanding of the relation between drunkenness and homicide, inasmuch as he concluded that "a man who was so drunk as not to know what he was about would hardly be likely to commit a murder.” Mr. Stephen seemed to show an appreciation of only two conditions resulting from the use of drink—namely, conscious exaltation, in which a man was responsible; and delirium tremens. The conditions under which a man could commit murder in the latter state were imaginable, but not very probable; but lawyers were as yet comparatively ignorant of the condition of delirium in potu arising from the continued excitement of the stimulant, and not from the exhaustion springing from

excess.

With regard to the point considered by the Parliamentary Committee, as to the responsibility of surgeons operating without consent, Dr. Bucknill quoted some amusing illustrations, and finally stated that before long a statute must be passed to render the law of homicide intelligible and precise. He commented keenly on the fact that, if lawyers are apt to cast in the teeth of medical witnesses that they utterly disagrec, this investigation into the law of murder has led the distinguished and experienced lawyer who conducted the inquiry to state, with regard to the judges who have been examined by this very Committee, that "they flatly contradict each other."

WAR IN ITS MEDICAL ASPECT. DR. CHENU, the well-known medical statistician, has just brought out a most interesting and instructive work on the FrancoPrussian war, which is worthy of study as giving appalling

information on the disastrous influence of warfare-influence felt not only by individuals, but by whole nations. (a) The work is an entire history of the Franco-Prussian war-that is, the medical aspect of it, and many of the facts there brought out would make the stoutest heart shudder, and the most ambitious sovereign think twice before exposing his subjects to such wholesale murder. If facts are stubborn things, figures are none the less so, at least in the present case, as they have been worked out with the most unimpeachable sincerity and disinterestedness. The accounts given in the work speak with the sincerity of a photograph and all the eloquence of statistics; and what adds interest to the information therein contained is, the author gives the names of the sick and wounded who have survived, with the nature of their illness and the operations and the treatment they were subjected to, thus affording living testimony of the correctness of these reports. But notwithstanding his most strenuous efforts to obtain precise information, Dr. Chenu has never been able to ascertain the total number of French losses caused by this terrible war; and, indeed, he tells us the information respecting the German armies is not more complete. It is, however, unquestionable that the casualties of the French army were considerably more numerous than those of the Germans, as is shown by the following figures:-The number of deaths computed in the French army is 138,871, whereas among the Germans it amounts to only 64,779. In this last number the mortality from diseases is included, and amounts to 12,174; whereas on the French side the mortality would be considerably increased by this latter item. "This," according to Dr. Chenu, "may be explained by the difference of hygienic circumstances. The enemy were in free communication with their own country; independently of what they extorted or requisitioned from the French, they received from Germany regular supplies of food and clothing. They were not decimated by small-pox as we were, nor were their hospitals or ambulances so overcrowded as ours." A French writer commenting on these lines makes the following interrogatory remark:-" Have we not here a terrible lesson?" "In the ambulances on the field of battle," continues Dr. Chenu, "no medicine was used, and the patients got as a common drink wine-and-water, hot or cold, according to the season." Dr. Chenu, moreover, recalls the fact that the Prussian army was provided with pocket-books, containing printed instructions on the most elementary principles of hygiene, on the life of soldiers in the field, on their food, their drink, the manner of cooking their meat, rules respecting their clothing, boots, etc. The French have, at least, we may hope, learned one lesson, which is-that in the field the soldier ought to be well fed, the quantity being increased beyond what he receives in garrison; and it should, as far as possible, be of the best quality, and varied in its nature. "By these means," observes Dr. Chenu, " you will secure moral and physical force, good health, and good spirits "; and he is certainly far from exaggerating the requirements of a good soldier as proved by the experiences of the Americans in their last suicidal war. "All the force of the infantry," he adds, "is in the legs the infantry soldier must, therefore, be well shod; he ought to wear strong ankle-boots with thick soles, and comfortably loose, so as not to interfere with the soldier's movements." "When a regiment of cavalry is about to move, the horses' hoofs are examined, and those that are too long are pared. When a regiment of infantry is about to proceed on a long march, the soldiers' feet ought in like manner to be examined, and those that are affected with corns and bunions, or ingrowing of the nails, or long nails, ought to be attended to:" the force of which may be seen by the statement made in Dr. Chenu's book, that the number of men who were obliged to

(a) "Aperçu Historique, Statistique, et Clinique sur le Service des Ambulances et des Hopitaux de la Société française de Secours aux Blessés pendant la Guerre de 1870-1871."