obtain accurate details, and finds that in 48 cases only the first attack occurred without the presence of an appreciable exciting cause, or could be regarded as resulting from a progressive increase of the hysteria; that in 206 cases it was brought on by an exciting cause, and that these causes were as follows: emotions, 54; fright, 47; disappointment, 30; painful menstruation, 23; illtreatment, 16; witnessing convulsions, 9; venæsection, 8; anger, 4; convalescence from serious illness, 4; magnetisation, 2; and with equal frequency, coitus, application of the speculum, cauterization of a chancre in the vagina, extraction of a tooth, a fracture, an attack of intermittent fever, and erysipelas of the face.*

Dr. Briquet combats the Hippocratic doctrine that hysteria is essentially of uterine origin. He finds that in all hysterical convulsions pain appears to emanate from some point of the body; and that out of 221 patients whom he examined minutely on this point, only 2 appeared to indicate the uterus as the point de départ, whilst in 165 the epigastric region was the seat of diseased sensation, in 29 the head, in the others the neck, the extremities, or some part of the trunk. After analysing the various symptoms of a complete attack of hysterical convulsions, he concludes that it is nothing more than a manifestation of those acts by which the emotions and painful sensations are made palpable; and that the convulsions are a secondary effect resulting from the pain, and their character varies according to the susceptibility, habits, age, constitution, or the passions of the patient. "Hysterical convulsions are nothing but the unregulated, involuntary repetition of all the complex movements which may be executed during the ordinary acts of life; the mental disturbance is merely a repetition of the moral impressions or of the ideas which have influenced the brain in its lucid condition; it is a reminiscence or reproduction analogous to what we see in dreams." All this has nothing to do with the uterus. The distinction between the convulsions of eclampsia or epilepsy and those of hysteria consists, according to our author, in the limitation of the movements of the former, and in their presenting no analogy with the ordinary acts of life, which is so characteristically the case in hysteria. The other distinctions between the two forms of convulsive action are gone into by Dr. Briquet, but need not detain us. His treatment of the hysterical attack consists in the administration of chloroform by inhalation, so as to produce sleep-a plan which he has adopted for twelve years with almost uniform success, the effect being to arrest the convulsions; neither coma, somnolence, nor dangerous syncope resulting from the procedure. He also recommends the employment of topical applications of chloroform to those parts of the surface that are painful during the free intervals, by which means the pain itself and the attacks it originates may be arrested.

IX. On the Sudden Increase of the White Blood-corpuscles during the last staye of Cachectic Diseases. By Dr. GUBLER. (L'Union Médicale, July 2, 1859.) The author relates two cases in which, after the proportion of white and red corpuscles had been observed during a cachectic malady to remain normal for a long time, the number of the former suddenly increased to such an extent as to constitute well-marked leucocythæmia.

The first was a man, aged twenty-one, of scrofulous habit, who six months before admission to the Hôpital Beaujon, under Dr. Gubler, was attacked, in July, 1858, with intermittent fever, which would not yield to quina. He was then treated with karapa, a substance that has been proposed as a substitute for quina. The spleen being enlarged, the blood was examined microscopically on the 17th and 20th of March, 1859, when there was no increase of white

* It is to be observed that the numbers do not tally with the author's totals.

corpuscles, about a dozen being counted in the field; on the 24th, pneumonia of the right lung supervened, and there was now an increase of from thirty to forty in the field; on the 25th, from fifty to sixty were counted. Death ensued from pneumonia on March 27th. The post-mortem confirmed the diagnosis of pneumonia and hypertrophy of the spleen.

The second case was that of a young man, aged eighteen, admitted into the hospital with Bright's disease, April 9th, 1859. He remained for a week, and the blood examined at this time was normal as regards the proportion of white and red corpuscles. He returned in a state of general anasarca a week later, and when the blood was examined on May 13th, the red corpuscles were found to be ill-formed, not forming the ordinary rouleaux; and of the white from fifty to fifty-five were counted in the field, instead of the twelve or fifteen previously seen. The latter had undergone a still further increase on May 13th, and there was then noticed a number of amorphous masses of a white colour and irregular shape, apparently consisting of coagulated fibrin. Death ensued on May 14th. The post-mortem showed the kidneys to be granular and contracted, the liver and heart enlarged, and the spleen atrophied and flabby.

X. A Case of Progressive Muscular Atrophy. By Dr. RODET.
(L'Union Médicale, March 3, 1859.)

Although the case related by Dr. Rodet was of a much more acute character than those commonly classed under the name of progressive muscular atrophy, and although the diagnosis was not verified by the galvanic test, it is sufficiently interesting in the present state of our knowledge to deserve notice. A gentle man, aged fifty-six, came under Dr. Rodet's care for a hard chancre, for which he was subjected to mercurial treatment on February 9th, 1856. He soon complained of unusual weakness and dull pains in the legs, about the calves and articulations; but the mercurial treatment was continued, with sundry intermissions. On July 25th, the fingers of the right hand were observed to be feeble and incapable of being completely closed; the thenar and hypothenar eminences had much diminished; the prominence between the forefinger and thumb, when these were closed, had disappeared. The muscles of the forearm were much diminished in size, as well as the biceps and triceps. The right calf and thigh were also atrophied, and the foot of this side was thinner than its fellow. All the affected niuscles were the seat of fibrillar movements, that might be compared to feeble electric discharges, the intensity of which in each muscle appeared to be in the direct ratio of the rapidity with which the atrophy had occurred. The patient, who had weighed 115 kilogrammes (about 250lbs.) before his illness, now weighed only 100 (about 225lbs.). The muscular degeneration advanced. In the meantime secondary symptoms made their appearance, and iodide of potassium was commenced from August 29th, together with quinine, and frictions of the atrophied parts with a stimulating liniment. The iodide of potassium was increased up to fifteen grains for a dose, and then gradually reduced. A gradual improvement of all the symptoms took place; the cramps and pains ceased, the strength improved, and on January 29th, 1857, the report states that the patient could walk better and write; that the members of the right side were almost equal to those of the left, and that the thenar and hypothenar eminences had almost recovered their size; the fibrillar movements no longer existed, the head was well, sleep was restored, and the patient had gained two kilogrammes in weight. On June 18th, no atrophy remained; the strength was the same on both sides of the body, and no syphilitic symptom had returned. His weight was then 105 kilogrammes (about 236lbs.), or three kilogrammes more than at the previous report. The recovery was permanent. We may well congratulate Dr. Rodet on his success.

XI. On Diabetes. By W. GRIESINGER. (Archiv für Physiologische
Heilkunde, Jahrg. 1859. Erster Heft.)

In an elaborate article on Diabetes, Professor Griesinger inquires into the pathology and treatment of this disease. We extract some of his remarks in reference to the theory that the liver is the organ mainly at fault, which has been specially revived since Bernard's discoveries regarding the glycogenic function of that organ. The author denies the correctness of Andral's observation, that in diabetes there is post-mortem evidence of over-activity in the glycogenic function. In none of his cases was there any enlargement of the liver detected during life, and only in one of five cadaveric inspections was the organ found to be somewhat hypertrophied. In this case it was very convex, with a sharp edge, eleven inches and a half in the longest diameter, six inches in the transverse diameter, and the weight, with the gall-bladder, was sixtythree ounces; on the surface were a few asteroid injections; in the interior, many small, pale, dirty-yellow spots; the tissue generally was exsanguine, friable, and granular, and the gall-bladder contained much brown bile. A careful examination in the other four cases showed no anomaly of the liver. A comparison of sixty-four cadaveric inspections confirmed the author's observation that diabetes mellitus is not characterized by any peculiar morbid condition of the liver. Dr. Griesinger does not appear to have noticed any microscopic changes in the hepatic tissue, and the evidence he quotes with reference to the increase or diminution of the oily contents of the hepatic cells is contradictory; thus Frerichs states that the absence of oil is characteristic, while the reverse is affirmed by Beale; Forster, again, maintaining the tissue to be perfectly normal. It certainly is remarkable that if the liver is the organ mainly at fault in diabetes, we so rarely meet with it directly indicative of hepatic disease. Among 225 cases analysed by the author, there were only two that exhibited hepatic symptoms, both having been preceded by icterus immediately before the appearance of saccharine urine. As an apology for pathology, Dr. Griesinger quotes some apparently contradictory statements by physiologists who have specially worked at the subject, and which it may not be uninteresting to reproduce:

Exclusively animal diet does not diminish the quantity of sugar in the liver; exclusively amylaceous diet does not increase it." (Bernard.)

66

With a mixed diet (partly amylaceous) there is much more sugar in the liver than with an exclusively animal diet." (Stockvis.)

"After an exclusively animal diet there is more sugar in the liver than after vegetable diet." (Figuier.)

"The liver of graminivora contains much more sugar than that of carnivora." (Bernard.)

"There is no material difference in the amount of sugar contained in the liver of graminivorous and carnivorous animals." (Poiseuille and Lefort, 1858.) A careful examination of the evidence regarding the influence of treatment leads the author to the conclusion that, with the exception of alkalies, none of the remedies commonly used exert any directly curative effect. Nor did the exhibition of the carbonated alkalies do more than reduce the quantity of sugar secreted; they did not arrest the secretion or cure the disease. The details of these therapeutic observations are of much interest, and deserve a careful study. Still, though drugs can do little, the author is willing to admit that by avoiding injurious influences, by a suitable hygienic regimen, and by a generally tonic proceeding, much may be done to improve the patient's condition and to prolong life.

QUARTERLY REPORT ON SURGERY.
By JOHN CHATTO, Esq., M.R.C.S.E.

I. On the Operation for Artificial Anus in Children. (Bulletin de l'Académie, tome xxiv. pp. 423 and 445.)

A SHORT discussion upon this subject, of some interest, recently took place at the Academy of Medicine. It originated in a communication from M. Rochard, of Brest, who, referring to a former debate, during which some members of the Academy had expressed doubts whether the subjects of operation for artificial anus ever attained the adult age, now adduced tive instances in which this had been observed. The reason why M. Rochard has been able to record so great a number of cases seems to be, that since the successful operation by Duret, in 1793, great numbers of children suffering from congenital deficiency of anus have been brought to Brest. The first case referred to by M Rochard is the above case operated upon by Duret, the subject dying in 1836 only. 2nd. A woman, operated upon by Serand, in 1813, is still alive and robust, suffering but little inconvenience from the artificial anus. 3rd. A lady operated upon in 1816 is still living at Brest, the mother of four children, and in the perfect enjoyment of life. 4th. A woman, who died at the age of thirty; and 5th, a lad, who died at fourteen, both of causes independent of the infirmity. All these operations were performed by Littré's method. In all the cases there was eversion of the lower end of the intestine. The tumour was only in part reducible, but it was insensible to the touch, and the mucous membrane covering it, in spite of exposure to the air and to contact with the bandages, &c., never became inflamed. M. Robert, who reported upon this paper, agrees with its author in recommending that whenever in a case of imperforate anus no fluctuation can be detected in the ano-perineal region, no operative procedure should be attempted in this direction, but recourse immediately had to forming an artificial anus in the groin. Malgaigne, Velpeau, and others joined in the discussion on the subject, but for this we must refer to the original

account.

II. On Traumatic Lesions of Nerves. By Professor LARREY. (Moniteur des Hôpitaux, 1859, No. 30.)

In his clinical lectures, M. H. Larrey indicates that wounds of the nerves may give rise to three orders of phenomena. 1. Traumatic paralysis of motion and sensation, whether complete or incomplete, and which may disappear at the end of a certain time, or may remain persistent for an indefinite period, atrophy of the parts being then one of the results. 2. Neuralgias, whether immediate or consecutive, intermittent or continuous, these frequently being exceedingly obstinate. 3. In some rare cases, a true neuropathy is produced -i.e., general nervous accidents of various forms, among which are sometimes observed convulsions of a completely epileptiform character. M. Larrey, relying upon the incontestable proposition that traumatism produces very marked nervous phenomena, which are evidently influenced by the lesion or the cicatrix, does not hesitate admitting a traumatic epilepsy. He quotes two cases. A soldier having had the lower extremity of the radius fractured by a ball, was seized, some months after the complete healing of the wound, with well-marked epileptic paroxysms, a distinct aura proceeding from the thumb and the cicatrix. In another case, a soldier, aged twenty-six, of robust constitution, was struck in the haunch by a shell, and hospital gangrene following, the wound required five months to heal, leaving a large, irregular cicatrix,

attended with but little pain. In this man, well-marked epilepsy became developed about a twelvemonth after the accident, although prior to this he had not manifested the slightest disposition to it.

III. On Acute Inflammation of the Membrana Tympani. By Dr. KRAMER. (Gazette Médicale, 1859, No. 18.)

Among 6840 detailed cases of disease of the ear in the possession of Dr. Kramer, inflammation of the membrana tympani occurred in 1687, but it manifested itself in the acute form only in 177. Still, the affection is not so rare as these numbers would seem to indicate, for in many cases it is unperceived by the patients, and in others misunderstood by the practitioner. In the 177 cases it existed on both sides in 13, and in 164 on only one side. It never disappeared on one side to arise on the other, and never occurred suc. cessively in the two ears. In 151 cases there was more or less severe pain, this symptom being completely absent in only 16. In 38 only the pain gave rise to febrile reaction. The membrane was perforated in 40 cases, in 34 instances of the 151 accompanied by pain, and in 6 of the 16 painless cases. Noises in the ears were observed in 113 of the patients.

Symptoms.-The affection usually comes on suddenly, and especially at night, after the operation of some local cause, the first symptom being more or less severe pain, which seldom much diminishes until a sanguinolent or serous discharge takes place from the meatus; the secretion of cerumen entirely ceasing until after the inflammation has been relieved. The discharge after awhile becomes creamy or whitish, containing brilliant flakes or even firm false membranes. It seldom becomes purulent and fetid, unless in old cases. Noises in the ear are a very early accompaniment; but neither in intensity, timbre, nor duration, have they any relation to this particular inflammation, which always persists longer than they do. The sense of hearing becomes very soon remarkably influenced. Usually the meatus is found healthy; while the membrane presents some shade of redness over more or less of its surface, having lost its brilliancy and concavity. It may indeed be the seat of obvious tumefaction, projecting into the meatus, giving it sometimes the appearance of a polypous excrescence. It is not rare for the membrane to become perforated within the first twenty-four hours, a pin's head aperture being usually situated below.

Left to itself, acute inflammation only terminates favourably in some of the slightest cases; for even after the pain and discharge may have ceased, examination will show that the diseased state of the membrane continues, and the deafness is unrelieved. The inflammation may spread, according to its intensity, to various parts and depths of the cavity of the tympanum, and in very bad cases even to the brain or its membranes. As a general rule, the inflammation passes into the chronic stage. The prognosis of the affection is in general favourable. The diseased part is very accessible to sight by means of the speculum, and for the application of remedies. Suitable treatment may be attended with success, even in cases that have been neglected for weeks. The prognosis is in general, however, much more serious when the inflammation arises during the course of an acute exanthem; and that chiefly because the disease is overlooked until great destruction of the ear has taken place. In scrofula, syphilis, or arthritis, it is also very unmanageable.

Treatment.-Above all things, the membrane must be protected from the impressions of cold and of sonorous vibrations. Cold water must never be employed in cleansing it, cotton wool should be introduced into the meatus, and the patient must be maintained in complete quietude, the room or even the bed being kept when there are severe pains and fever. In all cases the diet must be mild, and cooling purgatives should be administered. When, however,