EDWARDS THE ORNITHOLOGIST. TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. SIR,-I find that one of your correspondents, in the Medical Times and Gazette of December 26, wishes to know something of Edwards the ornithologist. He will find some account of him in Beeton's "Dictionary of Universal Information," in Maunder's "Treasury of Biography," and a fuller account in the "Imperial Dictionary of Universal Biography." I am, &c. H. S. MAYSMOR, M.D., Cliftonville, Brighton, Sussex, Jan. 14. ON LOOSE CARTILAGE IN THE KNEE-JOINT. TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. SIR,-Mr. Alfred Poland relates an interesting case of loose cartilage in the knee-joint in your journal of the 9th inst. In his remarks on the case he observes, "The open incision has still an advantage over the subcutaneous. If we look to facts, we must admit there are deaths and permanent stiffness recorded after open wounds in the knee-joint." So far as I am aware such results have not followed subcutaneous incision. If failures are recorded in the last-mentioned operation, I believe it would be in consequence of the means used by the operator, rather than of the principle itself. For a long time I have felt the necessity of modifying the subcutaneous method, and for this reason I showed some years ago to a meeting of the British Medical Association an instrument by the use of which the subcutaneous operation is much simplified, and the result successful. Wimpole-street, January 19. I am, &c. HENRY DICK. QUERIES ON CHLOROFORM. TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. Sia,-The following questions have been addressed to me by a foreign Professor of Surgery, and I should feel obliged by your answer : 1. Where can a drawing and description of Dr. Snow's inhalation apparatus be obtained? 2. Is it a fact that the inhalation of more than 5 per cent. of chloroform to 100 of atmospheric air is dangerous? 3. Where is the report of the Chloroform Commission or Committee published? 4. What is the reason that, notwithstanding the registering apparatus similar to Dr. Snow's, chloroform is still empirically applied by pouring it on a cloth, and the patient still exposed to the danger of a fatal effect? January 14. I am, &c. MEDICUS. 1. In Snow's work on anesthetics, edited by Richardson. London: Churchill and Sons. 1858. 2. The argument that over 5 per cent. of chloroform, diffused in air, is dangerous to inhale, was sustained, with much force, by Snow. But the view cannot be accepted as a proved fact without qualification. 3. In the Medico-Chirurgical Transactions. 4. Convenience is one reason. Another is that some of the first authorities on chloroform maintain that observance of the symptoms produced is the true and only method of avoiding danger, and that all apparatus are embarrassing in action and delusive in respect to safety. COMMUNICATIONS have been received from Dr. MAYSMOR; Dr. WHITMORE; MEDICUS; Mr. BRUCE; Mr. C. J. Fox; Mr. C. MORRISON; Mr. OXLEY; Mr. JOHN ST. S. WILDERS; A SUB8CRIBER; Dr. T. HIRSCHBERG; Dr. W. HARGRAVE; Mr. JONATHAN HUTCHINSON; Dr. HENRY CARNLEY; Dr. HENRY DICK; Mr. H. G. LIDDELL; Mr. E. POCKNELL; Mr. P. LE NEVE FOSTER; Dr. ALEXANDER GIBB; Dr. LORY MARSH; Dr. JEFFREY HARDESTY; Dr. W. D. MOORE; Dr. GERVIS; Mr. J. Z. LAURENCE; Dr. WILKS; Mr. W. ADAMS; Dr. OPPERT; Mr. J. CHATTO; Dr. E. J. SYSON; Dr. EDWARDS CRISP; Dr. HENRY KENNEDY; Dr. HUGHLINGS-JACKSON; Mr. H. SMITH; Dr. TILBURY FOX; Mr. COUPER; Inspector-General GORDON, C.B. 1490 76 50.9 33 1 40.4 0.23 23 Estimated Population in middle of the year 1869. Persons to an Acre. Births Registered during Registered during * 8=Eä the week ending Highest during Jan. 16. Lowest during the Week. 24 QOCA Mean Daily Values. In Inches. London (Metropolis) 3170754 40 7 2270 1462 Vienna (City). 320762 32 9 145, 158 6546587 35.5 4582 3244 (1863) 560000! 185 50 3 37 7 43.50 31 31 51.5 35.6 41.5 0.37 37 50-6 37 0 41-60-38 38 ... 49.5 36'0 41.7 0.42 42 55 0 34 0 41-20-51 52 52 0 37 0 42-40-16 16 47.0 33 0 38-90.38 38 48.0 32.0 39.1 0.09 48.7 33 0 41-0 0-10 10 48.6 36 3 42-40-88 89 56.8 39 6 46.9 1.07 108 At the Royal Observatory, Greenwich, the mean height of the barometer in the week was 29'894 in. The barometrical reading decreased from 30-34 in. at the beginning of the week to 29 47 in. on Friday, January 15. The general direction of the wind was S.E. Note. The population of Cities and Boroughs in 1869 is estimated on the assumption that the increase since 1861 has been at the same annual rate as between the censuses 1851 and 1861; at this distant period, however, since the last census it is probable that the estimate may in some instances be erroneous. The deaths in Manchester and Bristol include those of paupers belonging to these cities who died in Workhouses situated outside the municipal boundaries. APPOINTMENTS FOR THE WEEK. January 23. Saturday (this day). Operations at St. Bartholomew's, 1 p.m.; St. Thomas's, 9 a.m.; King's, 2 p.m.; Charing-cross, 1 p.m.; Royal Free, 14 p.m. ROYAL INSTITUTION, 3 p.m. Prof. Odling, "Hydrogen and its Analogues." 25. Monday. Operations at the Metropolitan Free Hospital, 2 p.m.; St. Mark's Hospital for Diseases of the Rectum, 14 p.m.; St. Peter's Hospital for Stone, 24 p.m. MEDICAL SOCIETY OF LONDON 8 p.m.: Casual Communications. 8p.m.: Mr. Wm. Adams, "On Subacute and Chronic Rheumatic Affections of the Joints, their Pathology and Treatment" (2nd Lettsomian Lecture). 26. Tuesday. Operations at Guy's, 13 p.m.; Westminster, 2 p.m.; National Orthopedic,' Great Portland-street, 2 p.m. ETHNOLOGICAL SOCIETY, 8 p.m. Mr. Hyde Clarke, "On the Proto-Ethnic Condition of Asia Minor, the Chalybes, Idaei, Dactyli, etc., and their Relations with the Mythology of Ionia."" ROYAL MEDICAL AND CHIRURGICAL SOCIETY, 8 p.m. Adjourned Debate on Drs. Gull and Sutton's Paper "On Rheumatic Fever." And Papers by Mr. John Wood or by the late Dr. Hillier. ROYAL INSTITUTION, 3 p.m. Mr. Westmacott, "Fine Art." 27. Wednesday. Operations at University College Hospital, 2 p.m.; St. Mary's, 11 p.m.; Middlesex, 1 p.m.; London, 2 p.m.; St. Bartholomew's, 13 p.m.; Great Northern, 2 p.m.; St. Thomas's 1 p.m.; Ophthalmic Hospital, Southwark, 2 p.m.; Samaritan Hospital, 2.30 p.m. HUNTERIAN SOCIETY (Special Council Meeting, 7 p.m.), 8 p.m. Dr. H. G. Sutton, "On the Difficulty of Diagnosing Rheumatic Fever from Pyæmia." 28. Thursday. Operations at St. George's, 1 p.m.; Central London Ophthalmic, 1 p.m.; 29. Friday. Operations at Westminster Ophthalmic, 14 p.m.; Central London Ophthalmic Hospital, 2 p.m. ROYAL INSTITUTION, 8 p.m. Mr. Ruskin, "Flamboyant Architecture of the Valley of the Somme." RIGOLLOT'S MUSTARD LEAVES Combine Cleanliness, Efficiency, and Convenience. They are as portable as a Card-case. They have been adopted by the Administration of the Paris Hospitals, and by the Imperial Navy of France. See THE LANCET, Feb. 22nd, 1868 : "In the Mustard Leaves of Mr. Rigollot we have, it is believed, a reliable and very ready means of obtaining the epispastic effects of mustard." See MEDICAL TIMES, Feb. 8th, 1868: "This preparation has the advantage of being portable, cleanly, convenient, and effective." Sold in Tin Cases and Packets by all Chemists and Druggists. Special prices for Hospitals and Charitable Institutions. Wholesale-23, HENRIETTA STREET, COVENT-GARDEN. THE ONLY GENUINE PARRISH'S CHEMICAL OR Is imported by his Sole Agents, P. & P. W. SQUIRE, FOOD, CHEMISTS IN ORDINARY TO THE QUEEN AND THE PRINCE OF WALES. Mr. SQUIRE introduced into Medicine (Vide "Lancet," March 4th, 1839) SOLUTION OF BIMECONATE OF MORPHIA, Which has been employed by all branches of the Medical Profession. Dr. Roots thus writes of it:-"I have taken it myself daily now for very nearly four years, and during that period I have frequently prescribed it in my private practice. The result of my observations on its effects on myself and others amounts to this-namely, that it disturbs the head less, that it distresses the stomach less, and that it constipates the bowels less, than any other preparation of Opium. I have taken every other preparation of Opium, but from none of them have I obtained the same degree of quiet rest that I have enjoyed from this Bimeconate of Morphia." WATER BEDS AND CUSHIONS, (obtained the only Prize Medal, 1862). H.M. ARMY AND NAVY, HOOPER, Operative and Manufacturing Chemist, 7, Pall-mall East, and 55, Grosvenor-street, London. LECTURE XX.-PART II. INDUCTION OF LABOUR CONTINUED.-DISCUSSION OF THE VARIOUS PROVOCATIVE AGENTSDANGER OF THE DOUCHE -ACTION OF THE VARIOUS DILATORS. WE have divided the agents at our command for effecting delivery at will into the provocative and the accelerative. Let us first examine the means we possess of provoking labour. These are numerous. In a course of lectures designed to be practical rather than historical, it is not desirable to discuss them in detail. I have endeavoured to do this in a memoir "On the Indications and Operations for the Induction of Premature Labour, and for the Acceleration of Labour. (a) It may be stated as a general fact that all the means employed act by stimulating the spinal centre to exert itself in causing contraction of the uterus. Some of these agents act directly upon the spinal marrow, being carried thither in the blood. Such are ergot of rye, borax, cinnamon, and other drugs. Some evoke the energies of the diastaltic system by stimulating various peripheral nerves. Such are rectal injections, the vaginal douche, the colpeurynter, the carbonic-acid douche, probably the irritation of the breasts by sinapism and the air-pump, the cervical plug, the separation of the membranes, the placing a flexible bougie in the uterus, the intra-uterine injection, the evacuation of the liquor amnii, and galvanism. The artificial dilatation of the cervix, the evacuation of the liquor amnii, and the intra-uterine injection act in a more complicated manner, and not simply through the diastaltic system. Some of the above agents are altogether uncertain and untrustworthy; some are in the highest degree dangerous; and some are both efficient and safe. Ergot, borax, cinnamon, and all other drugs may be dismissed on account of their uselessness or uncertainty. Ergot is not only uncertain, but when it acts it is liable to prove fatal to the child. Rectal injections may be harmless, but cannot be relied upon. Irritation of the breasts often fails, and it is liable to be followed by inflammation and abscess. The vaginal douche (Kiwisch's plan), which consists in playing a stream of water against the cervix uteri, is often tedious, and is not free from danger. It requires to be repeated at intervals during one, two, or more days. It is liable to cause congestion of the lower segment of the uterus. Serious shock, metritis, and death have followed. The intra-uterine douche, sometimes described as Kiwisch's plan, was in reality introduced by Schweighäuser in 1825, and by Cohen in 1846. (b) It is known in Germany as Cohen's method. It was recommended by Schweighäuser as a better means of detaching the membranes than the use of the finger or sound adopted by Hamilton. Cohen thought the injected fluid acted, not by detaching the membranes, but through its being absorbed by the surface of the uterus. Professor Simpson (c) says that he at first used the vaginal douche of Kiwisch, but "he soon found it a simpler and more direct plan to introduce the end of the syringe through the uterine orifice;" he became convinced that the douche was liable to fail, unless the injected fluid accumulated and distended the vagina, so as to expand that canal and enter the os uteri, and that its efficiency was great in proportion to the extent to which it separated the membranes. The intra-uterine douche, although more certain, is even more dangerous than the vaginal douche. Lazzati relates two fatal cases. Taurin saw, in January, 1860, in Dubois' clinique, such grave symptoms follow that death was apprehended. Salmon, of Chartres, related to the Académie de Médecine (July, 1862) a fatal case. Depaul communicated to the Parisian Surgical Society (1860) a case of death occurring suddenly from the uterine douche. Blot had to deplore a similar accident in the (a) Obstetrical Transactions, 1862. (b) Neue Zeitschrift für Geburtskunde, Band xxi. VOL. I. 1869. No. 970. Clinique d'Accouchements. Tarnier relates two similar cases. Esterlé relates a case (Annali Universali di Medicina, March, 1858) in which serious obstruction to the cardiac circulation, ending in death, occurred. Two eminent Physicians have informed me of a fatal case which occurred within their knowledge in the neighbourhood of London. It may be askedHow is it that the injection of a stream of water into the vagina or uterus can prove fatal? The cases cited, and they are by no means all that are known, leave no doubt as to the fact. It seems to me that danger results in three ways. The first is by shock. If water is injected into the gravid uterus, it can only find room by stretching the tissues of the uterus. This sudden tension is the cause of shock. It has been supposed that some of the fluid finds its way through the Fallopian tubes into the peritoneum, causing shock. And the following case, related by Ulrich, (d) suggests another solution :— "H. W., aged 29, was, at the end of her second pregnancy, carrying twins. Three vaginal douches were used to accelerate labour-the last one by a midwife. The temperature of the water was 30 R. The clysopompe' was used. Eight hours after the injections had been going on, the patient got up in bed, and instantly fell down senseless, and died in a minute at most, with convulsive respiration-movements and distortion of the face. Five minutes afterwards crepitation was felt on touching the body. Venesection was tried in the median vein. Only a few drops of blood came. On section, the cerebral sinuses were found full of dark fluid blood; the membranes not very hyperæmic; the brain normal. The heart was lying quite transversely, the left ventricle strongly contracted, the right ventricle quite flaccid; the coronary vessels contained a quantity of air-bubbles. The left heart contained scarcely any blood; the right had a little; it was quite frothy." It is probable, then, that air may get into the uterine sinuses. Dr. Simpson relates the following(e) :-" He had been greatly alarmed by seeing a patient faint under an injection, probably from some of the fluid getting into the circulation. And he had seen two more alarming cases still where both the patients died. In both, only a few ounces of water were injected; and yet rupture of the uterus took place. The occurrence of the rupture was to be explained by the fact that the uterus, being already fully distended, could not admit the few ounces of fluid without being stretched and fissured to some extent; and during labour these slight fissures might easily be converted into fatal ruptures. In one case the patient died before labour was completed; in the other, in twelve hours after its termination." Another objection by Dr. Simpson is, that in injecting water we have no control over the direction it will take in the uterine cavity, and that the placenta may be detached. Cohen's cases show that this accident may happen. It is also apt to displace the head, and cause transverse presentation. Of course no degree of efficiency could justify the use of a method fraught with such terrible danger. But the douche does not possess even the merit of certainty. It has been repeated many times during several days before labour ensued. Lazzati, having tried it in thirty-six cases, found that the number of injections required ranged from 1 to 12; the quantity used was about forty pints; the duration of the injections was from ten to fifteen minutes at a time; the temperature of the water 28° to 30° R. The time expended from the first injection to labour varied from one to fourteen days, the average being four days. It has also been found that a large proportion of the children were lost. The douche, therefore, whether vaginal or intra-uterine, ought to be absolutely condemned as a means of inducing labour. I think it necessary to repeat this emphatically, because, notwithstanding the warnings conveyed by many fatal catastrophes, I find that the use of the method is still taught and practised. Mr. James, formerly Surgeon to the City of London Lyingin Hospital, described (f) a plan of intra-uterine injection which he had practised since 1848. He passes an elastic male catheter to the extent of four or five inches through the os, between the uterine wall and the membranes, and then injects about eight ounces of cold water. Of eight children, only two were stillborn. Recently (see Obstetrical Transactions, 1868) Professor Lazarewitch, of Charkoff, has explained, modified, and given more (d) Monatsschrift für Geburtskunde, 1858, (e) Edinb. Med. Journal, 1862. (f) Lancet, 1861. precision to this method. He proves by observations and experiments that the nearer to the fundus of the uterus the irritation acts the more speedy and sure is the result, and vice versa. He contends that the frequent failure of the douche was due to the stream not being carried much beyond the os. He found that when the stream was carried up to the fundus one injection was commonly enough. He therefore introduces a tube as near to the fundus as possible, and then injects several ounces of water. The cases he relates (twelve in number) sufficiently establish his proposition that this method is more sure than other modes of applying the douche, but they are too few to prove that it is more safe. I feel very sure that if it be at all frequently adopted fatal catastrophes will ensue. It may, moreover, be doubted whether, in cases managed according to the principle of James and Lazarewitch, the injection of water was not really superfluous. The passage of a catheter five or six inches into the uterus detaches the membranes along its course, and this, it has been seen, is usually quite enough to provoke labour. Why not, then, rest satisfied with that portion of the proceeding which is efficient and safe, and discard that which is superfluous and dangerous? In It is instructive to compare the histories of some cases of intra-uterine injection with those of accidental or intra-uterine hæmorrhage depending upon detachment of the placenta. Sudden severe pain in the abdomen at the seat of effusion, shivering, vomiting, collapse, are all observed in both cases. the case of hæmorrhage these are certainly not in proportion to, or due alone to, the loss of blood. They seem to be the direct effect of injury to the uterus from sudden distension of fibre. The uterus will grow to keep pace with developmental stimulus of a body contained in it; but it will not stretch to accommodate several cubic inches of fluid suddenly thrust into it. Yet this is what it is called upon to do when water is injected. If the water escapes as fast as it enters, the shock may be avoided, but the operation is also liable to fail in inducing labour. The injection of carbonic acid gas or even common air is more dangerous still than the injection of fluids. Scanzoni has related two fatal cases from the injection of carbonic acid, and Professor Simpson relates one where the patient died in a few minutes after the injection of common air. Another agent is galvanism. Herder suggested this as a direct stimulant, to cause the uterus to expel its contents, in 1803. In 1844, Hörninger and Jacoby brought on labour by this agent. Dr. Radford showed the value of galvanism in labour and in controlling hemorrhage. In 1853, I published (Lancet and L'Union Médicale) a memoir on this subject. I succeeded, in three cases, in inducing labour by it. But the method is tedious, and sometimes distressing to the patient; I have, therefore, abandoned it. Another exciting or provoking agent consists in the insertion of some form of plug or expanding body in the os or cervix uteri. A great variety of contrivances for this purpose have been proposed and tried. It is unnecessary to describe the greater part of them. Those most in use are the sponge-tent, the laminaria-tent, and the elastic air or water dilator. There is no doubt labour can be induced by these agents. But it appears to me that their use to provoke labour is not based on a rational view of the physiological or clinical history of the process. I agree with Lazarewitch that irritants applied to the cervix are slow and uncertain. And I believe that in most cases some further means, such as rupturing the membranes, will be necessary. The laminaria-tent is, however, extremely useful in expediting the dilatation and evacuation of the uterus in some cases of abortion. The method known as Professor Hamilton's, which consists in detaching, by means of the finger or sound, the membranes of the ovum from the lower segment of the uterus, has the recommendation of safety; but it is uncertain in its operation. The success that commonly attends the plan of introducing a bougie into the uterus between the ovum and the uterine wall is perhaps evidence of the truth of Lazarewitch's proposition that irritation should be applied to the fundus. I find that the bougie should be passed at least six or seven inches through the os uteri in order to insure action. Probably, in many cases where it has failed, the bougie has only penetrated a short way. By passing the bougie gently, letting it worm its own way, as it were, it will naturally run between the membranes and the uterus where there is least resistance, turning round the edge of the placenta. Dr. Simpson says we may always avoid the placenta by ascertaining its position by the stethoscope. Some use an elastic catheter supported in its stilet, and withdraw the stilet when the catheter is passed. The stilet converts the catheter into a rigid instrument, which is objectionable. An elastic bougie answers perfectly. If a rigid instrument be used, there is great likelihood of rupturing the membranes; and although this may happen at some distance from the os uteri, premature escape of the liquor amnii may follow. The bougie owes part of its efficacy, no doubt, to the necessary detachment of the membranes from the uterus, but not all, since it is found that labour more surely supervenes if the bougie be left in situ for several hours. I believe this method is now the one most generally adopted. No other method combines safety and certainty in an equal degree. Puncturing the membranes as a provocative of labour is practised in two ways. The direct puncture at the point opposite the os uteri is probably the oldest method of inducing labour. It is one of the surest. The immediate effect of draining off the liquor amnii is to cause concentric collapse of the uterine walls, diminishing its cavity in adaptation to the diminished bulk of its contents. This involves some disturbance, probably in the utero-placental circulation. The parts of the fatus come into contact with the uterine wall. Hence uterine contraction is promoted both by diastaltic excitation and by the impulse given by the concentric collapse. In certain cases, the puncture of the membranes is the most convenient, as where the object is to lessen the bulk of the uterus, and to insure labour quickly. But it is open to the following objection:--It is an inversion of the natural order of parturient events. Some uterine action, lubrication, and expansion of the cervix ought to precede the evacuation of liquor amnii. If this order be not observed, the child is apt to be driven down upon the unyielding cervix, and the uterus, still contracting concentrically, compresses the child and kills And this is all the more likely to happen in premature labour from the greater liability to shoulder-presentation and descent of the funis. it. This objection is to some extent obviated by a modification of this method. Hopkins (g) recommended to pass the sound some distance between the ovum and the uterine walls, and then to tap the amniotic sac at a point remote from the os. By this mode it was sought to provide for the gradual escape of the liquor amnii. This operation may be regarded as a compromise between the direct evacuation of the liquor amnii and Hamilton's method of detaching the membranes. It is an important improvement, and is still successfully adopted in this country and in Germany. Vaginal Dilatation.-In 1842 (h) Dr. Hüter described a method for exciting labour by placing a calf's bladder, smeared with oil of hyoscyamus, in the vagina, and distending it with warm water. This proceeding he repeated every day until labour set in, which usually happened in from three to seven days. Professor Braun (i) substituted a caoutchouc bladder, to which, from the purpose to which it was devoted, he gave the name of colpeurynter. Von Siebold, von Ritgen, Germann, Birnbaum, and others adopted this modification. Another form of vaginal dilator is the air-pessary of Gariel. The earlier trials with this instrument seem to have been especially unfortunate, since six mothers died out of fourteen; and Breit saw inflammation of the genitals and death caused by it. I do not think these dangers are inherent in the method, if carefully pursued; but the principle of vaginal dilatation and excitation is certainly untrustworthy. Direct Cervical Dilatation. For the last fifty years various contrivances for mechanically dilating the cervix have been tried. The idea of dilating the cervix by sponge-tents was announced by Brünninghausen in 1820. This was again advocated in 1841 by Scholler. It has since been in constant employment at home and abroad. From personal observation I am in a position to affirm that this method is very uncertain as to time. Symptoms like those of pyæmia have ensued from the absorption of the foul discharges caused. This accident may possibly be obviated by the use of tents charged with antiseptic agents. Osiander, Von Busch, Krause, Jobert, Dr. Graham Weir, Rigby invented other forms of dilatatorium more or less resembling the urethral dilators which have lately come into use. These numerous contrivances attest the strength and prevalence of the opinion that it was desirable to possess a power of dilating the os and cervix uteri at will. The subject attracted the attention of Dr. Keiller, in Edinburgh, early in 1859, and in March of that year he, Dr. Graham Weir assisting, accelerated a labour which had been provoked by other means, by intro(g) "Accoucheur's Vade Mecum." Fourth edition. London. 1826. (h) Neue Zeitschrift für Geburtskunde, 1843. (i) Zeitschrift für Wiener Aerzte, 1851. ducing within the os uteri the simple caoutchouc bag, and gently distending it. The case of Mr. Jardine Murray (i) is the first published case I am acquainted with in which fluid pressure was used to dilate the uterus to accelerate labour. It was a case of placenta prævia. Mr. Murray first detached the placenta from the cervical zone after my method, then introduced a flattened airpessary between the wall of the uterus and the presenting surface of the placenta, and inflated by means of a syringe. Dr. Storer published a case in 1859 (k) in which he introduced "the uterine dilator" within the cavity of the uterus. He especially insisted that the dilatation "was from above downwards." I saw inconveniences in the use of elastic bags expanding inside the uterus, even more serious than those attending the vaginal dilator or colpeurynter of Braun. The cervix it was that required dilating, and a bag expanding below it in the vagina, or above it in the uterus, could only act upon it indirectly, imperfectly, and uncertainly. Besides, the uterine dilator seemed unsafe; during dilatation it must distend, stretch the uterine walls at the risk of injury and shock, and it was very likely to displace the head from the os uteri. I had long felt the desirability of bringing the further progress of labour with placenta prævia, after having arrested the hæmorrhage by detaching the placenta from the cervical zone, under more complete control. I had always strongly insisted upon the danger of forcibly dilating the cervix with the hand, and when I read Mr. Murray's case I was engaged in devising an elastic dilator capable of expanding the cervix with safety. The first form I devised was an elastic bag with a long tube mounted on a permanent flexible metal tube, having apertures at the end inside the bag. The metal tube served as a stem to introduce the bag inside the cervix, to keep it there, and to carry the water for distension. This form was modified and adopted by Tarnier, of Paris, and others, when I had abandoned it for the fiddle-shaped bags, which are now in general use. The constriction in the middle is seized by the cervix, whilst the two ends expanding serve to prevent the instrument from slipping up or down. This instrument imitates very closely the natural action of the bag of membranes. By its aid it is very possible in many cases to expand the cervix sufficiently to admit of delivery within an hour, although generally it is desirable to expend more time. I have completed delivery in five hours, in four hours, and even in one hour from the commencement of any proceedings. In many cases of placenta prævia where there was scarcely any cervical dilatation I have effected full dilatation in half an hour. In the paper in the Edinburgh Medical Journal (1862) I proposed that the first step in the induction of labour should be the full dilatation of the cervix uteri, and after that to proceed to further provocation and acceleration. I related cases in which I began with dilating the cervix, afterwards rupturing the membranes, further dilating, and turning. I am now convinced that, although this rapid method is very feasible, and is even proper under some circumstances where prompt delivery is urgently indicated, it is desirable under ordinary conditions to prepare the uterus by some preliminary excitation. Ir has been thought by some that pneumonia is a definite disease easily recognisable, and much the same in all patients. I very much doubt if any single name in nosology includes such a variety of conditions. It may be the most trivial or the most serious disease. There are a vast number of cases of real pneumonia which have only to be let alone to recover. There are others that no treatment can bring to a favourable termination. The whole character of the malady, its progress, and fatality, depend so much upon the age and strength of the patient, the extent and portion of lung affected, and the complications, that no statistics, unless more carefully framed than any hitherto published, can be accepted in evidence of the superiority of one plan of treatment over another. Simple sthenic pneumonia of a part of one lung in adults is rarely fatal, especially if it involve the lower lobe. With or without treatment, nay, in spite of bad treatment, it will recover in the vast majority of cases. Double pneumonia is much more dangerous, especially if the apices of the lungs are affected. Certain diseases seem to predispose to pneumonia, and to render it more fatal, more especially diseases of the kidneys, spleen, perhaps of the skin, malarial poisoning, and fevers.-Dr. Davidson's Report of the Antananarivo Dispensary for 1865-6. (i) Medical Times and Gazette, 1859. (k) American Journal of Medical Science, July, 1859. Canaliculi not Processes of a Cell.-The view concerning the formation of lacunæ and canaliculi above given is very different from that generally taught, for most authorities look upon the lacunæ as cells, the canaliculi as processes from them, and the osseous tissue as an intercellular substance. Virchow and many other observers consider that the canaliculi are formed as offshoots from the mass of germinal matter, and these offshoots are supposed to gradually bore their way through the calcified intercellular substance, and in some quite unexplained manner to meet the processes from adjacent cells and become continuous with them. The appearances which have led Virchow and other observers to maintain that the lacunae and canaliculi formed a cell with its offshoots can be satisfactorily explained without resorting to such a view, which is quite incompatible with many facts which have been conclusively demonstrated, while all attempts to show the supposed offshoots boring their way have signally failed. The stellate appearance of the nucleus, which was supposed to indicate the commencement of the shooting-out operation, has nothing whatever to do with the formation of the canaliculi; for the "offshoots" never correspond in number with the canaliculi. Virchow, however, talks of the processes which are to become the canaliculi "boring" their way "through the intercellular substance like the villi of the chorion do into the mucous membrane, and into the vessels of the uterus"-forgetting that the canaliculi exist before the formation of the socalled "intercellular substance is complete, and that the end of each villus of the chorion is a mass of germinal matter, while nothing of the kind exists in the case of the canaliculi. The notion of cells shooting out processes which meet those of other cells is a most fanciful one, and totally unsupported by observation. The idea as applied to the bone-cells is purely hypothetical, and would never have been advanced had it not been first assumed that the lacuna with its canaliculi was a stellate cell. Such an assumption necessarily required new assumptions to support it, and so the unfortunate hypothesis of boring processes" had to be invented. Myeloid Cells.-Wherever cancellated structure is to be found, spicule and cylindrical processes and flattened plates, consisting of small masses of germinal matter separated by soft formed material, are found in considerable number. In some cases, too, structures of the same kind are met with beneath the periosteum as well as beneath the medullary membrane. These, in fact, represent the early stage of the formation of bone tissue, and ordinarily undergo ossification. In some forms of disease, however, they grow and multiply very rapidly without becoming condensed or calcified. They may accumulate so as to form a vast soft and rapidly increasing spongy tissue, which has been truly considered as closely allied to certain forms of cancer. The masses above described vary much in size and form in the healthy state, and from the circumstance of their being found in great number in close proximity with the marrow, they have been termed "myeloid cells." In no structure of this kind do we meet with anything to justify the idea that the lacunæ and canaliculi are stellate cells. Each mass is oval, and usually smooth on the surface. |