I found there was no sign of an opening; and, indeed, the vaginal mucous membrane had completely covered over the parts united, so as to leave no trace of the fistula. She walks about up and down stairs, and the urethra has perfectly recovered its normal action.

CASE 2.-Elizabeth T- æt. 36, from Cirencester, was admitted into Boynton Ward in February, 1855, and gave the following history: In November, 1854, she was taken in labor with her first child, and after forty-eight hours instruments were used, and she was delivered of a stillborn child. She went on pretty well until about the ninth day, when a good deal of pain in micturition came on, and she continued in great pain throughout the next three days, when suddenly, on the twelfth day, she felt something give way, and her urine escaped through the opening and she became quite easy. From that period all her urine escaped in this way. On examination per vaginam, I found a large opening extending transversely completely across the centre of the bladder, and so wide as to admit easily two fingers. The destruction of tissue was so great, and the fistula so gaping, as to render any present attempt at closing it quite out of the question. I therefore determined to adopt a plan recommended by Jobert de Lamballe, viz., to dissect the neck of the bladder from the pubes and its descending rami, thus allowing the anterior half of the bladder to go backwards, and thus relax the fistula. Great success followed this operation, and in April, 1855, I pared the edges and brought them together by Sim's mode of treatment. But little success followed the operation, and she was allowed to return into the country for the improvement of her general health, and in April, 1856, she was delivered of a living child.

On December 19th, 1856, she was again admitted into Boynton Ward, and I performed Bozeman's operation with the result of closing eight-tenths of the opening.

In five weeks I again operated, with but little success.

In six weeks more I operated, and again with little success, as great sickness always followed the use of chloroform.

So, in three days, I again operated without chloroform, and the result was the closing of a third of the fistula. After this she returned into the country. December 7th, 1857.-She was again admitted, and I performed Bozeman's operation, with the result of a further reduction in size of the fistulous opening. She then went again into the country.

On February 15th, 1858, she was admitted into the Boynton Ward, and stated that since the last operation she had been able to retain the urine during the night, and some even during the day, whilst she was sitting quite still.

17th.-I carefully denuded the edges of the fistula, and slit up the coats of bladder all round, and then brought the raw surfaces together by silk sutures and quills.

20th. She felt the sutures give way, and the urine make its escape.

24th. She was taken into the operating theatre for the ninth time, and without chloroform I revivified the edges, and, passing three silver wire sutures, closed them down with Bozeman's button.

25th. No escape.

26th.-No escape. Some headache, and slight pain in the vagina.

27th.-Nurse thinks a little urine escaped last night and again this morning, but I examined and found that it evidently came from the urethra. The sphincter having relaxed from the presence of the catheter.

March 4th.-Bowels were well moved. No escape of urine. Catheter removed.

6th. The button was removed, and the whole opening was found beautifully closed and quite firm.

10th.-On most careful examination, the fistula was found quite closed, and she can pass and retain her urine as well as she ever could before the lesion, and she is consequently in good spirits and very grateful.

CASE 3.-Mrs. N- Rotherhithe, æt. 28, consulted me in March, 1858, and gave me the following history: "Four years and a quarter since was in labor of her first child from Wednesday evening until Sunday morning, when Mr. Peete was called in, and delivered her with forceps of a stillborn child. Di

rectly after she was made comfortable in bed she found the urine to escape through the vagina, and from that time it has always escaped except when lying on her back. Three months after the accident she went into Guy's Hospital, and was there for nine weeks. She then went to a hospital for diseases of women, and was there recommended a large blister to be put on her back so as to make a sore; but as her husband thought that could not heal the hole in her bladder, she did not apply it, and left off attending the hospital. Mr. Peete had repeatedly advised her to see me."

On examination, I found a small fistulous opening at the fundus of the bladder, close up to the os uteri, which was also much torn. The fistulous opening was about the size of an ordinary pocket-case director.

On March 3d I proceeded to operate, assisted by Messrs. Hume, Peete, Philip, Harper, and my son, Arthur Brown. Placing her on her knees and face, without chloroform, I carefully pared the edges, removing as little mucous membrane as possible, and then performed Bozeman's operation; but instead of bringing the edges together transversely, as usual, I brought them together horizontally. The bent catheter, with bag attached, was then introduced, and opium given.

4th. No urine has escaped.

6th.-All well, except sickness caused by the opium, which is therefore discontinued.

7th.-No escape. Bowels opened by an enema.

9th. Still sick. A dose of calomel, followed by a Seidlitz powder. 11th.-Quite well. No sickness and no escape.

13th. I removed the button to-day, and found the opening perfectly and entirely healed.

ART. 140.-On Coagula formed in the veins during the puerperal state, and their occasional transference into the pulmonary artery. By Dr. GRAILLY HEWITT.

(Lancet, Dec. 19, 1857.)

The various morbid appearances presented by the veins and their contents in cases described as "phlebitis," have been always objects of much interest, and up to within a very recent period were taken as evidence of the existence of inflammatory action in those vessels. The author considers that the researches of Virchow conclusively proved that the appearances in question were due to the formation of coagula in the veins, and the subsequent transformation through which these coagula had passed. According to the views of Virchow, the study of the changes hitherto spoken of as phlebitis, is in reality the study of the "thrombus," as the coagulum is termed, and of its metamorphoses. In applying these views to the consideration of those cases of disease of the veins which are apt to occur after childbirth, and taking, with Virchow, the starting point to be the formation of the coagulum, it was necessary to inquire, What are the circumstances which may lead to, or favor, the formation of coagula in the veins during the puerperal state? Amongst these are enumerated:

1. The large amount of fibrin in the blood, both positively and relatively, during pregnancy; a condition predisposing to coagulation; and possibly, also, certain other morbid conditions of this fluid, as uræmia, &c.

2. The mechanical effects of the pressure of the uterine tumor, which, leading to congestions of certain parts-the vagina, rectum, lower extremities, &c.-might favor coagulation; also, the impediment to the descent of the diaphragm leading to distension of the right heart and other parts of the venous system.

3. Pressure, unusual in amount or duration, on the large venous trunks of the abdomen, produced by the head of the child in its passage into the pelvis, the head being too large, or the passage contracted.

4. Deficient contraction of the uterus and of the large venous plexuses situated near or (Virchow) after delivery.

5. The most important, perhaps, the presence of the "physiological coagula," as they may be termed, which close up the uterine veins at the point of at

tachment of the placenta, and which must extend a variable distance, and have a variable size according to the degree of uterine contraction.

6. The morbid conditions of the blood liable to be produced after delivery, owing to the occurrence of hemorrhages, and other causes.

A description is then given of the morbid appearances usually observed in the veins after childbirth. Affections of the veins generally occurred in cases where some of the causes just described as leading to coagulation had been present. In most of these cases the veins first affected were those leading from the uterus and ovaries; the coagulation begins in the veins of these parts, and travels onwards towards the heart. The coagulum always terminates, according to Virchow, whose description is in conformity with those of Dr. Robert Lee and others on this point, in a rounded extremity, which projects a little beyond the next entering vessel, and by further deposition of fibrin the clot extends. The coagulum also travels backwards, occluding after a time the veins which enter an already blocked-up trunk. The iliac, femoral, and other veins of one or both sides may thus become occluded by a coagulum extending from the uterine veins of the same side, producing at this stage the disease called "phlegmasia alba dolens." The "physiological" coagula may then give rise to coagula of a pathological character, other circumstances favoring the production of the latter being present, or certain states of the uterine surface following delivery may occasion a like issue of the case. The clot once formed undergoes two kinds of changes. It shrinks, becomes decolorized, adherent, and, with the vein, is reduced to a cord-like substance (adhesive phlebitis); or it softens, breaks up, and the result is, the formation of a fluid in many respects resembling pus (suppurative phlebitis). The outer non-softened portions of the clot in the latter case remain as false membranes adherent to the vessel wall. The affections of the veins in the puerperal state are only peculiar in respect of their causes; the coagula, once formed, are liable to the same kinds of transformation as in other cases. The observations of Virchow respecting the constant presence of the "continued congestion," are of especial interest in relation to the occasional passage of portions of altered coagula into the pulmonary artery. This continued portion projecting into the still patent vessel, undergoes, but more rapidly under certain circumstances than the other parts, the "thrombus metamorphosis." It becomes adherent to one side of the vessel, and the projecting part may, at a certain stage of its metamorphosis, be broken off and carried away by the current of blood into the pulmonary artery. Death, more or less sudden, and attended, according to Virchow, with symptoms of a peculiar asphyxia, followed the passage of these altered coagula into the vessel, or its branches. Dr. Simpson has collected nine cases in which death, more or less suddenly, occurred a few days after delivery, apparently brought about by the obstruction of the pulmonary artery by transformed coagula introduced from the veins. Probably death more often occurs from this cause than is generally imagined, the cause being overlooked. Lastly, the author concludes that the pulmonary artery might be occluded by clots liable to be formed in puerperal women reduced by hemorrhages, &c., these coagula not having existed as such for a sufficient time to have undergone the transformations previously alluded to, and not having been formed quite in the same way. These clots, at first perhaps small, would increase rapidly by further accretion of fibrin around them, and finally obstruct the pulmonary arteries to such a degree as to produce death.

ART. 141.-Aphthous Fungus on Female Nipple. By Dr. KÜCHENMeister. (Wochenbl. der Gesell. der Aertze zu Wien., June 29, 1857; and Med.-Chir. Review,

April, 1858.)

The author, whose authority regarding parasitical formations is so well known, entering upon the question whether the oidium albicans takes possession of the nipple of the nurse, shows that the sore nipple may be the seat of this fungus. He gives a case in which the aphtha were found on the cracked nipples of a person who bad been sucking an aphthous child. He quotes at length the microscopical description of a fungus found by Hoffman and Leuc

kart, which had a double form, one having all the characters of an oidium, and the other showing slightly septate threads, which in their lateral branches developed sporangia (sporidia), out of which the spores proceed. He states his opinion that the structures known as aphthæ exhibit mostly two forms of fungus; one truly forming sporangia (sporidia) with spores, and one only forming coccidia; the latter exhibiting what was ordinarily termed oidium albicans. This oidium he considers to be only an undeveloped form of the other, which is probably a leptomitus.

(c) CONCERNING DISEASES OF CHILDREN.

ART. 142.-Three Cases of Infantile Apoplexy. By Dr. JOSEPH H. WYTHES, of Port Carbon, Pennsylvania.

(North American Med.-Chir. Review, Jan., 1858.)

CASE 1.-On the evening of May 31st, 1852, I was called to see the child of Mr. Shaefer, about 3 years old, who was complaining of pain in the left ankle. It was not swollen or discolored, but the pain seemed excessive, especially on motion. The parents supposed it to have sprained its ankle while playing on the step. I ordered a stimulating liniment, and, as it had been costive, a dose of castor oil.

The next morning I was informed that the child had been found dead, lying in the bed between its parents, without awaking either. On examination I found the wrists and ankles of the child strongly contracted; the left leg, the arms, and the back considerably discolored with dark purple blood; and the left leg slightly swollen. As it was the wish of the family to have a postmortem examination, I called in Dr. James Parker to assist me.

On removing the calvarium, which was done with as little violence as possible, an extravasation of blood was observed between the cranium and dura mater, perhaps half a fluid ounce. The vessels of the membranes were much injected, and the posterior part of the septum had a large clot of blood in it. The membranes were also in many places strongly adherent. The white substance of the brain was full of bloody dots or points, with the appearance of infiltrated blood in the posterior lobes, particularly on the right side. The right ventricle had in it a clot of blood, with serum.

The viscera of the chest appeared healthy. The liver was much enlarged, and contained a few cysts. The stomach was disproportionately small. The appearance of the intestines was generally healthy, but about one-half of the ileum was distended with gas. A few tubercles were observed in the mesentery.

CASE 2.-Nov. 4th, 1855, was called to see the child of S. Landis, who had died suddenly. I officiated at its birth exactly three months previously. It was a vigorous male child, and had always been in good health, with the exception of occasional attacks of colic, for which no medical attendance was deemed necessary. On Saturday night, Nov. 3d, the family retired to bed at 12 o'clock, and the child seemed as usual. At 5 or 6 o'clock in the morning the mother laid him off her arm, as she supposed, asleep. After breakfast, wondering he slept so long, she went to rouse him, and found him dead.

When I first saw him, about 10 A. M., he was quite cold. The muscles of the hands and feet were quite contracted, but particularly so on the left side; the mouth was drawn slightly awry; and the whole posterior surface from head to foot was of a purple hue. I suspected cerebral disease, and asked for a post-mortem examination, which was granted. I was assisted by my brother, Dr. Wm. W. Wythes, Dr. G. Brown, and in the latter stages by Dr. J. S. Carpenter, the last-named gentleman having arrived too late to inspect the brain. The vessels of the arachnoid and pia mater were considerably congested, and the whole cerebral substance was softened, being about the consistence of melted butter. A little serum was observed at the base of the left hemisphere of the cerebrum, but nothing abnormal in the ventricles. The membranes of the cerebellum and medulla oblongata were strongly congested.

The lungs, heart, and abdominal viscera were quite healthy, though the latter were fully distended with gas.

CASE 3.-Dec. 20th, 1855, was called to make a post-mortem examination of the child of J. R., aged three months, which had been found dead in its bed. Was assisted by Dr. G. Brown.

Muscles of hand and feet much contracted. Foam issuing from mouth and nose. Face purple. Purple congestion of the skin of the back and limbs, probably from gravitation.

The membranes of the brain healthy, but its substance much congested. On slicing, it seemed full of bloody dots. A small clot of blood was found in each ventricle. Lungs congested. A serous effusion observed in the pericardium. Liver large, and intestines full of gas. Stomach and bowels otherwise healthy.

ART. 143. On the lately prevailing Diphtheritic Affection.
By Dr. WILLIAM CAMPS.

(British Med. Journal, March 20, 1858.)

This affection has been variously designated-as croup, croupy disease of the throat, malignant sore throat or cynanche maligna, diphtheritis or diphthérite, throat affection, prevalent sore throat, &c. Under one other of these terms, there could now no longer be any doubt that a disease lately prevailed, and did still exist, with more or less intensity, in various parts of the United Kingdom, including the metropolis. The public health authorities had, in their periodical documents, of late solicited information respecting it, under the term diphtheria. Dr. Camps states that his attention was directed thereto, in the first instance, by noticing in one of the quarterly returns of the Registrar-General an unusually large number of deaths from croup, as having occurred in a rural district, with the population and locality of which he was tolerably well acquainted.

It was well known that a form of pharyngeal inflammation had been investigated and described some years ago by M. Bretonneau, of Tours, and that to this disease he gave the name of diphtherite. It was probably from the analogy observed between the disease lately prevailing here and that described by M. Bretonneau, that the former was now commonly spoken of as diphtherite, diphtheritis, diphtheria, or diphtheritic disease. M. Bretonneau and some other French authorities appeared to have regarded it as almost, if not absolutely, identical with the ordinary inflammatory croup of this country; and Dr. Watson, in his lecture on croup, appeared to regard Dr. West as holding the opinion that diphthérite is a variety of croup-an opinion in which Dr. Camps did not concur. Whether in this country or in France, this disease had heretofore appeared rather as an epidemic than as a sporadic affection; and the author was of opinion that many of the cases of throat disease which proved so fatal not long since at Boulogne, might have been cases of diphthérite. Here it assumed quite an epidemic character; and in all the severer and fatal instances of the disease in this country that had come to the author's knowledge, such cases had occurred in tolerably rapid succession as to time, and in tolerably close proximity as to place. He hesitated to commit himself without reserve to the question of its contagiousness, although he believed that practitioners in France entertained that opinion.

The type of the disease in its severer forms, he considered to be essentially asthenic or adynamic; and, therefore, attended with more or less languor, depression, and diminution or impairment of vitality, thus indicating most clearly the appropriate mode of treatment. Of late, in many of the metropolitan dispensaries and hospitals, stomatitis had been very prevalent; and in the judg ment of the author, there existed between stomatitis and the diphtheritic affection, now under consideration, a very close analogy or resemblance. He regarded the former as the shading off into a milder form of the latter, yet both as the result of the same morbific general cause; so that the difference between the two should be considered as one of degree, rather than of kind. The tendency to the production of plastic, pseudo-membranous exudations, as observed