The changes that take place in the synovial membrane in subacute and chronic synovitis remain now to be noticed. They are essentially of the same pathological character as are those we have just been considering, but they differ in this great point that the synovial membrane is not destroyed, but becomes changed. It becomes thickened in various degrees by the infiltration of inflammatory product within its walls and upon its surface. This thickening may be so great that the synovial membrane may be represented by a tissue an inch in diameter; but this will only be found in cases in which repeated attacks of inflammation have taken place, and many layers of lymph have been deposited upon and in the affected tissue. These layers may not be deposited rapidly one after another by consecutive attacks of chronic inflammatory action, for they may be the result of disease which has spread over many years, but they will always represent an inflammatory action of a chronic nature which has at uncertain intervals attacked the joint, and on each occasion left behind it pathological evidence of its presence by an inflammatory infiltration. It is with such changes as these that all cases of the gelatiniform or gelatinous disease of the synovial membrane, as well as the pulpy disease of Sir B. Brodie, are unquestionably to be classed. Both are of the same nature pathologically and clinically-at least, all my own investigations have led me to this conclusion. Ten years ago, when writing upon the point, I suggested that such might be the case, but did not feel sufficiently certain to assert it. All experience since then has, however, led me to the conclusion, and I know of nothing that militates against the idea. In the present papers I shall therefore employ the word pulpy disease of the synovial membrane to designate the disease. It is short and as expressive as any other. It is likewise a term with which the Profession is familiar.

The Clinical Features by which these Pathological Changes may be recognised.

It will have been remarked that, in all the pathological changes we have been describing, excess of secretion, or effusion into the joint and synovial membrane, invariably occurred. It may, moreover, have been observed that these changes were the earliest, or, at any rate, were very early, results of the inflammatory action. Clinically, therefore, the most marked symptom that characterises synovitis in any of its forms is enlargement of the joint, either from effusion into the articulation, thickening of the synovial membrane itself, or both conditions combined. In the superficial joints, such as the knee, elbow, ankle, wrist, all these changes are readily to be seen, and when seen, are readily recognised. In the deeper joints they are also present, and are to be made out on a careful clinical examination.

This is the main point I would wish to be remembered in connexion with this subject.

On the Pathobical Changes the Articular Cartilages undergo from Disease.

The most important point the practical Surgeon has to recognise when considering the pathology of the articular cartilages has reference to the fact that there is no primary disease of this structure, for pathological anatomy teaches us that all the changes that are to be found in it are secondary to some other affection, and in the generality of cases to disease in the articular extremities of the bones. There is no such thing, therefore, as primary "ulceration of the cartilages," and when the cartilages are diseased they are so from the extension of mischief from the bone beneath or from the synovial membrane about them.

Much has been written about diseases of the cartilages, under the idea that they were liable to special diseases; and much error in joint pathology has crept in as a result. The authority of great names, such as Brodie, Key, and others, has helped to encourage this idea. But modern investigation, as carried out by Redfern, Goodsir, and others, has corrected this erroneous notion, and an improved pathology has clearly shown that the diseases of the cartilages are due to diseases of other tissues.

When describing the results of my own investigations ten years since, I divided these affections into the fatty, the fibrous, and the granular degenerations, and nothing that has been observed since has led me to doubt the accuracy of this division; indeed, additional experience has confirmed me in its truth. I am not about to enter, however, in this place into a minute description of these different changes, for they are to be read elsewhere; but it will suffice for my present purpose to remind my readers that the fatty degeneration of the articular cartilages is found in joints that have been deprived of their natural functions from any cause-from non-use in the majority of cases, but in many from bad nutrition-that it is found in

common with the same change in the bones or other tissues. This fatty degeneration is to be recognised with tolerable facility by the naked eye, for the cartilage, instead of possessing its natural white pearly aspect, will appear somewhat transparent; its surface will probably present an undulating, unequal, although smooth, surface; it will, when cut, feel softer than usual, and may be three or four times its natural thickness. At times it may even be pulped by firm pressure with the finger, and it may be separated from the bone with more than usual facility. Microscopically it will present also charac teristic features. The natural cartilage corpuscles will have become changed into fat and granule cells in various degrees; the hyaline matrix will be filled with cavities, varying from the healthy standard to large cells. These cells will be filled with more or less of the elements of fatty degeneration, in which the healthy corpuscles will have changed into fat cells, and the hyaline matrix will have changed more or less into an irregular cellular fatty matrix. This fatty degene ration takes place in most joints that have not been used, but rarely from disease of the joint itself. When present in a joint that becomes the subject of inflammation, disorganisation of the articulation rapidly follows, for such a lowly organised degenerated tissue has no power of resisting disease, and when brought in contact with it rapidly disappears.

The Fibrous Degeneration of the Articular Cartilage is a disease of a peculiar character. I believe it to be associated with only one disease of a joint, and that is the so-called "chronic rheu matic arthritis." It is very gradual in its progress, and is not characterised by any definite symptoms. It is to be recognised pathologically in a joint in its earliest stage by the loss of the natural glistening aspect of the cartilage, the smooth surface of which disappears, and it looks rough. Small fissures next appear, involving more or less of its thickness, and sometimes these extend down to the bone. These fissures are, as a rule, thicker in the centre, and at times radiate outwards; the cartilage seems gradually to thin, and after a time to disappear, exposing the articular surface of the bone, which will probably have undergone the calcareous degeneration. Microscopically the chief change that is seen in this disease is the gradual alteration of the hyaline structure into fibre. The cartilage corpuscles at the first are found interspersed between these fibres, but at a later date these corpuscles will be seen to have changed into granules. At the last stage nothing but fibres may be found, and when this condition exists, the rapid disappearance of the structure altogether will not be far distant.

The Granular Degeneration of the Articular Cartilage is the most important affection of this tissue we have to study. It is the one most commonly found in joint affection, and seems to be the direct consequence of a perverted nutrition in the bone or synovial membrane, the result of disease in one or both of these structures. Although of a simple nature, it shows itself in many ways, and without microscopical investigation must have appeared unintelligible. In its different forms it has doubtless led good observers to describe it as an ulceration of cartilage, for under certain conditions the cartilage presents a worm-eaten excavated appearance, not unlike that which ulceration might produce.

The disease is essentially a granular degeneration, first of the natural cartilage cells which are imbedded in the hyaline matrix, and, secondly, of the hyaline matrix itself. Let a cartilage cell undergo this granular degeneration, and the granules by accumulation and multiplication form a cavity in the hyaline matrix; then let this cavity burst on the surface of the cartilage into the joint, and an excavation which can be seen by the naked eye becomes at once visible, and a so-called ulcer is produced. Let this change take place towards the margins of the articular cartilage, and we find an explanation of Mr. Key's observations upon socalled ulceration of this tissue in certain forms of inflammation of the synovial membrane of the joint. Let this change take place near the bones as a result of disease in the epiphyses, and we find an explanation of the general condition of the cartilages in the bulk of joint diseases; for when the bones entering into the formation of a joint are so affected as to interfere with the nutrition of the articular cartilages, the cartilage may either present the worm-eaten appearance all over or in part, or it may have been shed from its bony attachment, when it will be found to be lying upon the bone as a foreign body in the joint. In an early stage of disease, this granular degeneration may only be detected by a microscopical examination, although, when the bone is the cause, it will always be found to peel off its articular facet with unusual facility.

In synovitis also the surface of the cartilage in contact with the inflamed membrane will be found similarly involved.

Should the disease be local, as is at times seen in cases of injury to an internal ligament, such as the ligamentum teres, the change in the cartilage will be local only, but when general, the whole surface of the cartilage may be involved. In acute disease acute degeneration follows, as daily practice gives good evidence.

On the Pathological Changes in the Bones the Result of
Inflammation.

Inflammation of the articular extremities of a bone is a very common disease; it is probably the most common we have to deal with in connexion with joints, for it would appear to be the cause of most, if not all, of those cases of disease of the articulations which we find in children, and which have been described as strumous or scrofulous disease of a joint. Ten years ago, when describing the results of my investigation of this affection, I stated that "I cannot for one moment doubt that the majority of the cases which are described by Surgeons as strumous or scrofulous disease of a joint and of the articular extremities of the bones depend upon a chronic inflammation in the bone," and all the experience I have gained since has tended to confirm me in this opinion. I believed then, as I believe now, that the disease is in its origin and progress inflammatory, and that it is as curable as any other local affection. I am convinced that the presence of tubercular deposit in the bone is a very rare occurrence, and that, when present, it alters but little the natural progress of the disease, although it may render the case less amenable to treatment. It is important to bear this truth, if such it may be called, invariably in mind when examining or treating a case of disease of a joint, particularly when it is found in a so-called strumous or cachectic subject, for if we regard the disease as a constitutional one we are too apt to think that it is to be treated on general principles and to neglect the local means by which alone a good recovery is to be secured. For my own part, I would abolish the term strumous disease of a joint altogether. It is based on a wrong pathology, and unquestionably suggests a wrong treatment. Let the Surgeon recognise the true inflammatory nature of the disease, and be convinced of its curability by local and general treatment. He will then surely be more successful in his practice, and better results by treatment on the expectant principle will unquestionably be obtained.

Let us now, then, proceed to inquire into the changes that the bone undergoes during this inflammatory or wrongly called

strumous affection.

The most striking is probably the earliest, and that is the expansion of the articular extremity. In some cases the enlargement will be very great, and it is generally uniform. The articular extremity of the bone affected, and, indeed, the epiphyses of all the bones entering into the formation of the joint, will appear to be rounded and generally enlarged. Upon making a section of a bone thus affected it will be found softer than natural; it may probably be so soft as to allow a knife to divide it. It may even break or crush on firm pressure being made upon it. To the eye the section will appear more vascular than natural, the cancellated portions to be more cancellated, the cells to be enlarged, and the bony septa to radiate from the shaft in a broad palm-like fashion. cells also will be found filled with a pinkish serum.

The

Should the disease continue, and the inflammation be of a healthy type, parts of the bone will appear denser and more indurated than the remainder. The cancelli will have been filled with inflammatory product that has organised, and will appear on section as a dense and apparently bloodless mass, surrounded by other vascular cancellated tissue. Should the inflammation be of an unhealthy character, diffused suppuration within the bone will take place, and death of the bone, wholly or in part, follow.

Under these circumstances, the disease will probably have become a genuine joint affection—that is, it will have extended to the synovial membrane of the joint, and have set up disease within its substance. This extension of disease will show itself by effusion within the joint, and by pulpy thickening of the synovial membrane and of the cellular tissue around the articulation. Up to this point the disease has been a local one, involving only the articular extremities of the bones, and has not attacked the proper joint structures; it appears also to be perfectly curable. But at this stage of the disease the articular cartilages will probably become affected; for when the inflammatory action has continued for any period, and has not shown any indications of subsidence, but, on the contrary, has either assumed an unhealthy character or has interfered with the nutrition of the articular lamella of bone upon which the cartilages rest, the articular cartilage will to a certainty undergo

the granular degeneration upon its surface in apposition with the bone, become loosened from its attachment, and be thrown off or shed, or it may degenerate in patches, and present to the eye an irregular excavated surface. If the disease be slow, the cartilage will degenerate slowly, and be as slowly loosened from its osseous base. It will then be readily lifted off the bone by any instrument. If the disease be more rapid, the cartilage will be shed likewise more rapidly, when it will be found lying upon the bone as a foreign body in irregular patches, which, under the microscope, will appear to have undergone the granular degeneration.

When the disease is acute the cartilage may disappear altogether, having been shed from its osseous base and become rapidly degenerated.

The articulating surface of the bone during this time may appear in some cases only extra-vascular, as in inflammation; in others it may be rough, or so-called ulcerating; in a third class the articulating facets will have been shed wholly or in part. In another, pieces of necrosed bone involving more or less of the articular extremity of the bone will be seen. another, an abscess will have made its way into the joint from the diseased articular extremity. But in all these conditions the cartilages will have disappeared and the joint become disorganised.

In

All these different changes of the bone, etc., from disease will be illustrated by cases in future papers, my object in this being to consider only the general pathology of a diseased joint.

I propose to illustrate the diseases of the different joints seriatim, commencing with diseases of the hip-joint. I shall regard each from a clinical point of view, making the scientific illustrate the practical, and applying the general pathological facts which have just been given to special cases. I shall follow up the papers on hip-joint disease by others on the knee, ankle, and foot, illustrating the diseases of the joints of the upper extremity in a like manner.

The cases I shall quote to illustrate these subjects will all probably be from my own experience, and they will necessarily be brief, for they will be copied from the short notes I have been in the habit of taking at the time when the patient was under observation, in which all extraneous matter has been omitted. They were not taken with any view of publication, nor will the cases be specially selected from my note-books. They will be quoted as fair illustrations of the different forms of disease which we meet with in practice, and as such may be of more value than special cases selected for special purposes.

LOW FEVER IN SPAIN.

By GEORGE GASKOIN.

IN foreign journals no less than in our own, regret has been expressed that nothing is to be ascertained of the fever that is now raging in Spain, and comments have been made on the reticence observed in this conjuncture by the whole of the Spanish press. Patriotic and prudential motives have had their weight, no doubt, in dictating a certain restraint at so critical a period of their political life to those who have at their command the springs of public opinion. There is indeed existing in Spain a fever of vast gravity and extension, yet travellers through the country do not hear of it, nor do our newspaper correspondents mention it; it intrudes not on the ordinary observer, nor forces itself upon conversation. What we learn about it is by snatches and by scattered scraps of information which it requires some industry to collect, and which, when collected, seem to defy concentration. Only occasionally the plain truth bursts out. "In no other eventuality," we read, "have persons of culture, and to a marked extent Physicians, paid an equal tribute to death, doubtless," it goes on to say, "because of the share the nervous system has in this the reigning complaint, and the appreciation which exists in the Medical faculty of its terrible and mortiferous nature." But, to be more precise, let us consult the published reports of the General Hospital of Madrid which reach us on April 11. "Up to the present time," says the report, "the Hospital has lost five of its professors, eleven Medical officers, one apothecary, and of the brethren who are Hospital orderlies four of the first class (hermanos), and twenty-one of the second (mozos). Not even in the days of cholera have we known such mortality." Less particular is the announcement that of Physicians practising in Madrid "more than a dozen" have died. In Placencia, a province of limited extent, forty Physicians have fallen victims to this "lamentable hecatomb" (sic), and still "the complaint keeps on." The deaths

of D. Foribio Guallart and D. Antonio de la Fuente y Berche, two of the Professors aforesaid, occurred in the month of March, 1869. In the department of military health, the deaths of two distinguished men, Senors Barrera and Farrerous, are the subject of recent notice, and the General Hospital is crowded. The sources of beneficence are taxed. From the provinces there is a defect of systematised information. In Orcagna two men of high rank in the Profession (titulares) have died. In a small circle within a league of Presencio (Lerma), four Physicians and a Surgeon are lost to their friends, and two besides have made bad recoveries, one of fifty-four days. Every new journal brings more casualties from the Medical class in Spain. "This typhoid epidemic," says one account (of April, 1869), "which now for some time has afflicted us, goes on repairing its strength, the number of casualties being considerable. Improved ventilation, a more equal temperature, and vegetable food, so favourable to the poor in spring season, should lessen the tale of victims, but this is not the case. The ill condition of the poor, and the present paralysis in trade, has been disastrous to the lower classes. Post famem pestis."

To begin with the present year, it is remarked that the winter months were mild; the winds were chiefly south, which may have had a bad effect "as blowing over the drains"-but this by the way! In January, the Medical constitution was typhoid, and small-pox in a confluent form showed itself "in as bad a type, or even worse, than did the typhoid fever." There were many gastric and catarrhal fevers, and “some that were pure typhus.' We treat them, says the Hospital report, with mineral and vegetable acids, revulsives, and tonics-chiefly those that are antiseptic, for of the fevers "the adynamic prevail over the ataxic." On February 28 ends there a bad week. The mortality is excessive. North and north-east winds prevail. With fevers there are measles and small-pox. As to the month of March, attend to this report:- "The admissions have been so many, that for many years the like has not occurred, to which no doubt atmospheric conditions have contributed, but still more the too general indigence. After a mild winter, the month (March) has been cold and stormy. The same fevers that began to develope themselves in December (1868) increased greatly in this month, so far, indeed, that they constituted twothirds of the acute affections. Of the fevers, many are gastric, a fair number catarrhal; the predominating are those we are agreed to name typhoid. In Hospital, of acute calentures (fevers) 869-that is to say, of the gastric 265, of catarrhal 130, of typhoid 430, of other types fewer. Of such fever cases during the month 85 died; the cures are 262 in the month. The treatment not uniform (it has been before indicated) was generally successful, seeing the gravity and postponement of the cases. During the month, eruptive fevers were severe but few; variola badly confluent, agues diminishing, rheumatism frequent, affections of muscular and nervous systems prevail over the systems digestive and respiratory. Of acute affections, 1345 admissions, 148 deaths; of chronic, 340 admissions, 72 died."

On April 14, we are told of this fever "Truly it is as bad in Madrid as elsewhere. The General Hospital is the place to study it. Observe its masked course, its hidden etiology, its chaotic therapeia. While in the Hospital reigns this mortiferous plague, nothing informs us of what is going on in the town. Political folks are silent over this tyrant of the hour. It is little noised in conversation. At any other time than this what would have been said? Yet it is curious, too, when in 1865 the cholera was at our doors, we stood at the brink of revolution, but the cholera then absorbed attention more than anything else. What a difference now! A tame subject truly." In our latest, which is May-an irregular month as to weather in Madrid-this year it is spoken of as stormy, like March; but, curiously enough, intermittents that generally abound in this month are wholly absent. The weather is considered favourable to public health; the typhoid considered "perhaps not so bad;" rheumatism and eruptions.

In the Pabellon Medico last autumn, in a paper by D. Juan Herrero "On the Medical Constitution and that now prevailing," he says:-" Misery displays her livid face; the want of work and capital has paralysed trade; transactions are scanty, and tranquillity precarious. The operatives stand with folded arms. This has lasted a year, with bad unsettled weather. Crowded in garrets, with no cheering lights, the state of the people is bad enough; or, with the hog, or mule, or ass, and the filth they accumulate close upon them, what must result from this concubinage? Such, you say, has ever been the

case.

But a biliary condition, with adynamia, is thus generated. Such we saw last year (1867), but most since June (1868), so that purging, tonies and support have been the order

of the day, with little of bleeding and antiphlogistics;" and then he says towards the last solstice excessive heat, fevers predominated of the biliary type, inflammations with the biliary element, rheumatism (articular and muscular), eczema in children, neuralgia in women. He then goes on to give typical cases of fever, with rose and lenticular spots, petechiæ, gargouillement, and other symptoms.

If we go back now to an account of the public health in November, 1868, we learn from the Siglo Medico the first half of the month was mild, the second damp and wet. The Hospital report says "there were observed many gastric and typhoid fevers, and some of real typhus developed in the Hospital from the wards being too full, the number of admissions constantly increasing through the present winter, as has occurred in the past, exceeding the capacity of the establishment already entrenched on by demolitions and extraneous buildings. Where 1000 might go we have to put 1500." There are also accounts of fever in certain gaols of the Spanish Peninsula. We read also of drought; the last year but one, 1867, is spoken of as a dry year. In a journal of the year past, 1868, I find : "A drought, such as has rarely been experienced since the month of March in the previous year, 1867, continued with slight interruptions till last September, 1868. The first days of which were also hot." Hygiene in Madrid is confessedly at a low point of execution, not so the exercise of charity. There is the Casa de Beneficencia, an admirable central institution, which publishes reports of health; subsidiary to this are the Casas de Soccorro, which I would willingly recommend to the attention and consideration of Londoners, as has been done by a correspondent in Paris already for the Parisians-see Union Médicale, March 23, 1869.

This is what I have been able to gather from sources at my command as to the extent and prevalence of these fevers; it will be observed that catarrhal and rheumatic disorders run with them, side by side. What lets most light on the severity of the epidemic is the repeated adjournments of the discussion of the Academy of Medicine on the question of alimentation in typhoid fever, which is now there the question of the hour and comprises much besides. The Portuguese papers inform me they are in suspense in that quarter about quarantine. The authority for the above statements will be verified chiefly by the Siglo Medico and the Pabellon Medico, papers of the soundest character. The nature and treatment of these fevers may be the subject of another notice.

7, Westbourne-park.

THE WATER SUPPLY OF HOLLAND, AND CHOLERA.

By Dr. A. M. BALLOT, of Rotterdam.

In general, the water of the Maas and Merwede, which rivers contain the waters of the Rhine and Maas, have the effect on strangers of producing diarrhoea and cholera nostras (diarrhoea and vomiting); so in Rotterdam, Schiedam, and Delftshaven this effect is called the Rotterdammer, in Dordrecht the Dordtenaar. All the sewage of our towns, and especially in the lower countries, gets into the rivers, directly or indirectly.

It is believed that the sewage and other organic matter in our canals are often the cause of diarrhoea and typhoid fever. In the preceding year, many cases are mentioned by our Medical inspectors. Many cases are narrated where, in the vicinity of houses wherein many cases of typhoid fever occurred, there were dunghills, ditches with sewage matter, etc.

The propagation of cholera matter by the rivers is more investigated than the two other questions. Directly proved the influence is not, but there exists a great probability as to the propagation of cholera from one town to another by means of the drinking water.

I begin with the cholera epidemic of 1853, where I read in the report on the said epidemic(a) :-Outbreak of the cholera in Rotterdam, August 22; Charlois, one English mile down the river at the other side, August 29; Schiedam, at this side of the river, four miles down, September 6; Dordrecht, fourteen English miles the other side (but the Maas is a tidal stream), and Delftshaven, next to Rotterdam, September 12; Brielle, twelve miles down, September 15; Ysselmonde, three miles the other side, September 16; Hellevoetsluis, September 19.

(a) "Verslag omtrent de ziekten welke in 1853 hebben geheerscht." Dr. Sybrandi in Nederl. Tydschr. voor Geneeskunde, 1855.

1, Rotterdam; 2, Charlois; 3, Schiedam; 4, Dordrecht; 5, Delftshaven; 6, Brielle; 7, Ysselmonde; 8, Hellevoetsluis; 9, Lekkerkerk; 10, Maassluis; 11, Gouda; 12, Vlaardingen; 13, Oud Beijerland.

Just as in 1853, the outbreak of cholera in 1859 began in Rotterdam. I will make use for this epidemic of an excellent report of one of our most esteemed Medical brethren, Dr. Zeeman, of Amsterdam ("Geschiedenis der Cholera gedurende 1859 in Nederland."-Nederl. Tydschr. voor Geneeskunde, 1860): -Day of the outbreak at Rotterdam, August 16, 1859; Ysselmonde, August 19; Kralingen, August 25; Schiedam, September 2; Gouda, September 3; Charlois, September 6; Lekkerkerk, September 7; Dordrecht, September 12; Hellevoetsluis, September 14; Oud Beijerland, September 17; Maassluis, September 18. Amongst other things, he says:"Now, on the isle of Ysselmonde (opposite to Rotterdam), there were attacked six bordering communities, situated next to the much-made-use-of waterway between Rotterdam and Dordrecht, and the entire population of these communities drank the water of this river. The mortality was 13 per mille. In Charlois and Katendrecht (opposite to Rotterdam) it was said that the mortality was greater amongst the better class; but their houses were on a dyke nearer the river, the water of which they drank. So also it was with the towns near other rivers. One town was attacked, and soon after the communities on both sides of the river were attacked."

I now pass to the epidemic of 1866, in which epidemic the mortality was 19,691 in 3,530,047 inhabitants. There does not yet exist a more extended report from the side of the Government; but there was installed by the King a commission for the investigation of the drinking water, and its influence on the cholera. (b)

In 1866 the cholera began at Rotterdam on April 8; in a short time our country was infected, and, as usual, the epidemic spread along the waterways also for a great deal.

In the above-mentioned report to the King from the commission for the investigation of the drinking water, we find that in Delftshaven, those who drank the contaminated Maas water were attacked by cholera, while those who drank rain or other water were spared for the greatest part-one Doctor says "were all exempt from cholera."

In Hardinksveld the cases of cholera occurred to those who drank water out of the canal in which cholera matter was thrown In Hoogeveen the cholera dejections of the first patient were thrown into the canal; the inner part of the village, where rain water was drunk, remained free; the outer part, where there was much shipping and contamination of water, was very severely attacked.

In Rynsburg the mortality was 71 per 1000; the wells were contaminated with sewage matter.

In Ham, Hasselt, Meppel, with great cholera mortality, the drinking water of the canals was very much contaminated with cholera dejections.

In Oostdongeradeel (Friesland), there was a case of cholera in a ship; the dejections were put into the water; those who

(b) This report appeared after my article of May 1, in the Medical Times and Gazette, was in print.

drank the water were attacked, those who drank other water were not.

In Vleuten the dejections of a cholera patient were thrown into the Rhine. In the next house lower on the river two were attacked by cholera, six by cholerine; in the house next to the second a servant was heavily attacked. In a third and a fourth house also down the river there occurred cases of cholera, and between these houses many cases of cholerine and diarrhoea.

In Heinenoord the influence of cholera matter in the water was very distinct. On July 12 there came into the haven a ship from Delftshaven. The skipper was attacked by cholera; the dejections were thrown into the haven (canal). The inhabitants took their water out of this haven by flood (high tide), and just at this time the evacuations were thrown into the haven. On the 15th, 16th, and succeeding days many were attacked and died of cholera, some of which it was certain, and of others almost certain, that they had drunk the water out of this haven.

In Groningen eight houses had their water out of the same well, in these houses 24 cases of cholera occurred; in the other seventeen houses who drank water out of other pits only 4 cases occurred. The Commission is certain that cholera matter must have come into the first well, but how is uncertain; all the investigations of this Commission were taken after the cholera epidemic had ceased, therefore also it was too late to search after the cholera matter itself.

Of Utrecht (where the cholera mortality was 27 per mille in 1866), Dr. Vos states in his dissertation that, in a subdivision of the town through which the river (the Vecht) passes, after having been very much contaminated with sewage, and naturally also cholera matter, in its passage through the town, the inhabitants who drank of this water were very much visited by cholera; they who drank other water not.

Dr. Snellen, a very acute observer, gives an example which has much resemblance to the history of the Broad-street pump. (c) Ina certain block of houses there occurred a case of cholera; the dejec tions were thrown on the little street before the houses. This was June 11; on June 13 another case occurred, and in twenty-five days there occurred 32 cases among 106 inhabitants, of which 23 were fatal, therefore a mortality of 25 per cent. There were two pumps with sparkling water, but after investigation it was found that the wooden part of the pump was rotten; the cholera matter had soaked from the street, which was very sloping, into the water of the pumps. On July 4 and 5 the pumps were closed, and after July 6 there occurred no more fresh cases. Very close to this was the Stevens Foundation with 260 inhabitants; here one case of cholera occurred. The condition of these persons was not so good as the former. The two houses were separated by a little stone wall; on one side there occurred 33 per cent., on the other 0-4 per cent. cases of cholera.

In 1867 the cholera began again in Rotterdam, and the first cases there were amongst the inhabitants of the quays, Blaak, etc., people who belonged to the better class, and, amongst others, two elderly people who lived very retired; but there were stationed before their door ships from Cologne, where the cholera was, and at other parts ships of Dusseldorf, etc., where the cholera was. Now here in Rotterdam the water is drunk from the river, or the havens, or canals, or wells, but these wells contain only surface-water, the same as the canals, rivers, etc., into which all sewerage matter gets. I will add a map to show you how horribly contaminated these waters must be. What is white is land, what is shadowed is water. Rotterdam is divided into three parts-I., the side between the river and a dyke (a); II., the inner part between this dyke and a surrounding canal, cingel (enceinte) (b); and III., a yet lower part, the Polder city, between the first-named canal and another cingel (Nieuwe wetering) (e). The fresh Maas water gets near 6 and 5 into the cingel, and from the cingel by several little canals into the Polderstad, and from this into the surrounding ditch, the Nieuwe wetering (c). You perceive that this wetering contains, therefore, nothing but sewage matter. Two powerful steamengines, 1 and 2, pump this foul water into the river, one near 4, the other near 3; but, unfortunately, when the river ebbs this contaminated water by 3 near the entrepôt gets not into the river, but passes the whole city by the Nieuwe-haven, Blaak, and Leuvehaven. These havens abound with ships, whose sewage matter is thrown into the water, and in time of cholera always many shippers are attacked.

Moreover, two little streams, Rotte and Schie, throw their water, when the river is ebbing, through sluices, into the Maas, the Rotte near 7, the Schie near 8. The Schie passes, amongst

(c) This case has already been mentioned in my previous article.

Black is water-for instance, the River Maas, and the various havens, docks, canals, and rivers; white is land. The double line, a a, shows the dyke that bounds the Boutenstadt, or outer town, I., which lies between it and the Maas. The black lines, b b, show the cingels which bound the Binnenstadt, or inner town, II. (Philologists point out the words "Bouten" and "Binnen" answering to our words out and in, but more closely corresponding with the but and the ben of the Scotch. Outside this up to the Nieuwe wetering, c c, lies the Polder town, III. 1 and 2 Aare the steam-engines which pump the waters of the cingels back into the Maas at the ebb. The two black lines which converge in III. are the Rivers Rotte and Schie.

PROPAGATION OF TYPHOID OR SCARLATINA THROUGH POTABLE WATER. By W. E. C. NOURSE, F.R.C.S., Surgeon to the Brighton Hospital for Sick Children.

I HAVE had but little opportunity of observing the effects of drinking river water, and have never known typhoid or scarlatina to be communicated from person to person through any kind of water. But I have observed typhoid to follow the use of foul drinking water in the following instances:

1, 2. Typhoid (mild) in a girl aged 11; and, in the same house, eighteen months afterwards, typhoid succeeded by typhus, in a man aged 22. Drinking water procured from a shallow well close to the cesspool of a privy used by the inmates of seven cottages.

3. Severe typhoid in a boy aged 8. Drinking water derived from a water-butt never cleaned out.

4, 5, 6, 7, 8, 9. Typhoid in six inmates of one house, of various ages; severe in three of the cases, one of which ended in death. The drinking-water had a foul taste, and came from a cistern which had never been cleaned out. No sign of the disease being communicated by infection.

10, 11. Two cases of fever (remittent type) in a house where the drinking water was procured from a well, ten or twelve yards from which were two large cesspools in a sandy subsoil. District malarious.

These are all that I can remember with certainty. 11, Marlborough-place, Brighton.

THE LEIPZIG PHYSIOLOGICAL LABORATORY.-A letter from Leipzig states that not only those specially qualified to appreciate it, but the whole of the inhabitants, are full of wonder and pride at the new laboratory which has been erected entirely according to the ideas and wishes of Professor Ludwig. It is said to surpass the new Prussian laboratories, and is the finest institution of the kind in Europe.

REPORTS OF HOSPITAL PRACTICE

IN

MEDICINE AND SURGERY.

ST. THOMAS'S HOSPITAL.

LITHOTOMY AND LITHECTASY IN CHILDREN. [Communicated by Mr. F. CHURCHILL.]

FOUR very interesting cases of stone in the bladder in children have recently been operated upon in St. Thomas's Hospital with success, two of them by Mr. Solly, the patients being a boy and a girl, the other two by Mr. Sydney Jones, both being boys. The comparative immunity of children from renal or other complications is now recognised as one of the principal reasons why this operation is so much more successful in children than in adults. It will be seen by the details given below that each case terminated most favourably; not a single untoward symptom occurred in any one of them, the progress towards convalescence being quite satisfactory. As they have now left the Hospital quite well, it may be interesting to contrast the history and treatment in each case. In Mr. Solly's second case, that of a little girl aged 6, the stone was extracted through a previously dilated urethra. Although the comparative success of this operation in children would warrant the Surgeon in interfering as early as possible, the inexperienced lithotomist must understand that this success is mainly due to a careful tactus eruditus during the second stage of the operation-viz., the cutting into the bladder; for the prostate gland, being in an undeveloped condition, cannot serve as a guide to the groove in the staff. Then, again, additional impediments to the Surgeon in reaching the neck of the bladder are the pyriform shape, and the position of the bladder, which is higher up in the pelvis, and consequently less fixed, than in the adult. In neither of these cases, however, was there any difficulty during the first or second stages. In the case of lithectasy, although the stone had been detected by the sound when the patient was laid on the table, Mr. Solly could not detect it with the forceps, the reason being that with the first gush of urine the bladder had formed an hour-glass contraction at its centre, and, this constriction being felt, Mr. Solly passed the forceps well upwards and backwards, and found the stone lying at the fundus of the bladder. It was then removed without any difficulty. In Mr. Solly's first case the boy had been operated upon twice before, and on each occasion he had been troubled with a fistulous opening in the perineum for some months after, ultimately it closed completely. It is now three months since the last operation, and the fistulous opening has almost entirely closed, only a few drops of urine passing this way during each micturition, but not at any other time. In neither of Mr. Jones's cases had the patient been previously operated upon for stone. In the first case, that of a cripple, aged 18, the stone originally was an ordinary mulberry calculus, but it had become coated over with some large crystals of triple phosphate. Properly speaking, this lad, being beyond the age of puberty, should be classed with stone in adults, but from the remarks which we have made it will be seen that the general features of the case may be better compared with those occurring before puberty. The stone in the second case was about the size of a small hen's egg, and was found to consist for the most part of large conglomerate masses of uric acid crystals intermingled with layers of phosphatic deposit, especially towards the base, where the stone was flattened by resting upon the bas-fond of the bladder.

Phosphatic Calculus-Lateral Lithotomy-Recovery.

(Under the care of Mr. SOLLY.)

J. B., aged 14, residing at Greenwich, admitted January 12, 1869, with symptoms of stone of four months' duration. Mr. Solly removed a stone from him when he was two years old, and again five years ago. During the four months previous to his admission he had been suffering from the usual symptoms of itching about the prepuce and along the course of the urethra, with scalding and pain when micturating. There does not seem to have been much constitutional or vesical irritation. He occasionally passes gravel with his urine. He has no difficulty in passing water, but the stream is sometimes arrested when passing pleno rivo. Experiences relief when the bladder is empty. Micturates four or five times daily. The last drops. of urine are generally loaded with a whitish sediment, which,