tural in frequency. The tongue was covered with a dirty white fur, pale, soft, and flabby. These symptoms continued with but little relief from remedies; sleeplessness, and great restlessness and jactitation were present during the whole of the attack. The patient sunk, and died six days from the date of the sting. The remedies prescribed were sinapisms to the epigastrium, the free use of brandy and opiates, mercury in the form of calomel and hydr. cum cretâ, and quinine. The attack differed from any of the gastro-intestinal diseases peculiar to the season of the year, and Dr. Nivison's impressions were strongly in favour of the belief that it resulted from the cause specified. He thinks that had the danger been anticipated, by the free and early exhibition of powerful stimulants and anodynes, the result might have been averted.—New York Journal of Medicine, May, 1857, pp. 339–341.

QUARTERLY REPORT ON PATHOLOGY AND MEDICINE.
By EDWARD H. SIEVEKING, M.D.

Fellow of the Royal College of Physicians, Lecturer on Materia Medica,
and Physician to St. Mary's Hospital.

I. Embolic Apoplexy from Detachment of Fibrinous Coagula in an Aneurism of the Carotid. By Dr. FR. ESMARCH, Director of the Surgical Clinique at Kiel. (Archiv für Pathol. Anat. und Physiologie, Band xi. Heft 5.)

CAPTAIN C. H., from Sweden, consulted a medical friend of Professor Esmarch, concerning an attack of angina tonsillaris, and at the same time drew his attention to a tumour of the left side of his neck which had formed suddenly three years previously, without appreciable causes, and had now attained the size of a hen's egg. It occupied the upper triangle of the neck, was slightly diminished by pressure, and communicated a distinct thrill to the touch. It was at once diagnosed as an aneurism of the common carotid. On repeating the examination a few days later, and exerting pressure upon the tumour for the purpose of reducing it, the patient suddenly fell back with symptoms of apoplexy. He was at once bled and conveyed to the hospital, where he was placed under the care of Dr. Esmarch, on the 8th of May, 1855.

The patient was well built and robust; in a state of coma, from which he could only be roused momentarily; the pulse was moderately full, heart normal. The whole right side of the face was paralysed, the right cheek was distended in expiration; there were spasmodic movements in the facial muscles of the left side. The pupils reacted to the stimulus of light. The tongue, which was much furred, pointed to the left. Respiration was stertorous. The thoracic muscles and diaphragm acted well, but only the left abdominal muscles moved in respiration. Both right extremities were completely paralysed. Deglutition, defecation, and micturition were normal. The tumour pulsated isochronously with the carotids, but presented no murmurs.

Professor Esmarch diagnosed the detachment of fibrin from the aneurismal sac, and a consequent obliteration of the left cerebral carotid. Ice was applied to the head, sinapisms to the legs, and an enema with vinegar was administered. Some improvement ensued; the paralytic symptoms diminished, and the patient was able to converse with a countryman; a relapse, however, followed, and on the 11th of May profound coma ensued; the pulse was very quick, the skin cool, the complexion livid, the right pupil was somewhat drawn out transversely, but both pupils continued to react to the light; both lips were distended by expiration; urine was passed involuntarily. The livor increased, the pulse became too quick to be counted, respiration slow, and accompanied by screams in inspiration; and death ensued at midnight.

The cadaveric examination was made the day after by Professor Weber. The aneurism had a spindle-shaped form, and commenced about four centimetres above its issue from the aorta; the external and internal carotids quitted the upper end of the aneurism, preserving their normal size. The internal jugular vein was pushed outwards, the vagus lay between the vein and the aneurism and was unaltered, but the descending branch of the hypoglossus was adherent to the tumour, and much altered in appearance. The whole internal surface of the carotid from its origin was in a state of atheromatous degeneration, and contained enormous chalky formations; both below and above, a portion of the inner coat of the artery formed a projecting ridge in the aneurismal sac. The sac was partly lined with a smooth red membrane, partly with more or less firmly-attached, ragged, fibrinous coagula; much loose fibrin, irregularly interwoven, was also in the sac; a firm coagulum was drawn out of the internal carotid, which tore off from its continuation within the carotic foramen. There was no coagulum in the external carotid. Within the cranium there was found considerable hyperæmia of the vessels of the pia mater, a moderate effusion of serum under the arachnoid; the whole middle portion of the left hemisphere, including a part of the corpus callosum, was converted into a pulp of a greyish-yellow colour. Beneath the aquæductus Sylvii, in the mesial line of the pons Varolii, was a perfectly recent extravasation of blood of the size of a bean; a smaller one, a centimetre in front of the former, and in the vicinity several small capillary extravasations. Normal cerebral tissue could not be discovered in the softened portion; it consisted of granular matter and short fragments of broken-up fibres, with capillaries containing shrivelled corpuscles. In the extravasations at the pons, the blood corpuscles were unaltered. The cerebral carotid, the arteria fossa Sylvii, and the arteria ophthalmica, were completely blocked up with coagula of a dark-brown colour, inclosing numerous red and greyish-white plugs, which evidently were derived from the aneurism. Their identity was proved by the microscope. The thoracic viscera presented no marked disorganization, except that the ascending aorta exhibited extensive atheroma; the same was the case with most of the large arteries.

Professor Esmarch, in his concluding observations, dwells upon the danger of much manipulation of aneurismal tumours, as being liable to give rise to such consequences as those above described. He particularly discusses Mr. Fergusson's mode of treating aneurism of the subclavia, recently brought before the Medico-Chirurgical Society, which consists in forcing the coagula contained in the tumour into the axillary and brachial arteries.

II. On Edema Glottidis. By Professor PITHA. (Prager Vierteljahrsschrift, Jahrgang xiv., 1857. Band liv.)

In an interesting article of considerable extent, on the whole subject of tumefaction of the glottis (which applies rather to the epiglottis and the aryepiglottic folds than the true glottis), we find the following instance of acute cedema, assumed to have been brought on in a healthy person by an article of diet.

Madame Grabinger, a robust ruddy woman, aged thirty, on a hot summer's day felt poorly and faint immediately after her dinner, which she had enjoyed in perfect health. She lay down on the sofa and went to sleep quietly. After about half an hour the children observed that their mother breathed laboriously and noisily, so that they roused her. She awoke with difficulty; her face was distorted, pale, and swollen; the voice hoarse; the respiration became more laborious; the patient complained in broken words of constriction of the throat, and a sense of suffocation. A few minutes later, Professor Pitha found the

patient wringing her hands in a state of most distressing dyspnoea. The features pale and frightfully swelled, and the whole neck alarmingly swollen. The voice had entirely disappeared, and the patient implored assistance in the most painful manner, constantly pointing to the larynx. The Professor could obtain no clue from the children, but on looking round the room he perceived a plate with a few strawberries; on pointing to them interrogatively, the patient nodded violently, evidently gratified by his suspicion. He at once prescribed an emetic of tartrate of antimony, which put an end to the symptoms as speedily as they had supervened. After the first spoonful copious vomiting ensued, accompanied by a discharge of masses of mucus, upon which respiration at once became easy, and voice and speech returned. The tumefaction of the face and the other symptoms gradually disappeared, and on the following morning the patient was quite recovered. Professor Pitha analyses the symptoms, and while he admits that the presence of cedema was not absolutely proved, he maintains that all rational signs of the affection showed it to be there.

III. A Case of Perforation of the Interventricular Septum. By Dr. OULMONT. (L'Union Médicale, No. 95.)

A needlewoman, aged sixty-nine, was admitted into the Lariboisière Hospital on March 16th, 1857. She had for several years been subject to dyspnea on going upstairs and walking fast, but had suffered from palpitations only for the last two months; on admission the palpitations were severe. The patient lost her breath on the slightest movement; there was cough without constant expectoration. There had been oedema of the legs since the palpitation; the appetite was poor, and she had diarrhoea for some days previous to admission. The complexion was purple, especially the cheeks, the nose, and the lips; the patches of colour were seen to be made up of dilated vessels; the tips of the toes and fingers were of the same hue. There was no enlargement in the region of the heart; the impulse was of medium intensity. There was a distinct frémissement cataire throughout the precordial region; a very strong rasping bruit replaced the first sound of the heart, occupying even the entire interval; the second sound was dull and indistinct. The abnormal sound was audible throughout the entire precordial region, but was most intense at the base. The pulse was feeble, small, compressible, and not intermitting. marked change took place, and the patient died on the 10th of April.

No

The parts that were cyanosed during life remained so after death. The pericardium contained from sixty to eighty grammes of a reddish serum; the surfaces were intact. The anterior surface of heart showed to the left of the interventricular fissure a round projection, three centimetres in diameter, offering to the touch the sensation of fluctuation. An incision carried through it entered the left ventricle, which was full of black clots. On removing these, a species of entonnoir was perceived on the side of the interventricular septum, at the bottom of which was an opening one centimetre broad. On opening the right ventricle, the fact of a large communication existing between the two ventricles was confirmed; it occupied the most anterior part of the septum, near its upper third. At the left orifice there were a few warty excrescences. The parietes of the left ventricle varied much in thickness; at the left edge of the heart it was fifteen millimetres, on a level with the point which was thinned it was only three millimetres in thickness. The other cavities of the heart presented no abnormity of any importance; the arch of the aorta contained a cretaceous patch. Except fatty degneration and congestion of the liver, and hypostatic congestion of the lungs, the other organs exhibited no abnormities.

IV. Case of Cirrhosis of the Liver and Bronzed Skin. By CHARLES FRICKE, M.D. (North American Medico-Chirurgical Review, July, 1857.)

An Irish labourer, aged twenty-five, was imprisoned in Baltimore, in April, 1856, at which time he appeared in good health, except that the skin of his hands was in a hypertrophic condition. On the 1st of September following, Dr. Fricke found him failing in strength, suffering from nausea, tympanitic distention of the epigastrium, more or less headache, and constipation, but without fever. He improved after a few days' rest, but at the end of the month was attacked with jaundice, and oppression in the region of the liver. The symptoms abated under treatment, and recurred from time to time. In December, the jaundice was universal, without perceptible enlargement of the liver or derangement of the digestion. "As the case progressed, the principal phenomena exhibited were dropsy, hæmorrhage, black urine, and bronzed skin." The fæces were hard, rounded, white balls for the last six months before death. "The bronzed skin, the most interesting phenomenon, and the one to which I wish to direct attention more particularly, was first remarked in January. At the commencement it was not well defined, nor more decided than is often observed in cases of cirrhosed liver; but after a time the tinge became so deep as to attract decided attention. It was limited to the forehead, face, and neck, and almost as deep in hue as is found in the livers of remittent fever patients. One fact is worthy of notice. The demarcation between this colour and that of the rest of the body was not clearly defined; but they merged into each other by degrees. He died April 29th, 1857, after a convulsion." The abdominal cavity was found to contain about a gallon of serous fluid, and the intestine was filled with dark liquid blood. The kidneys were congested and somewhat large, but otherwise healthy; the supra-renal capsules of normal size, hue, and consistence, presenting no alteration whatever. The liver, one-third smaller than usual, was of a bronze hue externally, with an irregular nodulated surface. The cut surface was pea-green, and examined by the microscope, showed much hypertrophied fibrous tissue, and cells filled with "the same" colouring matter.

V. A Knitting-needle found in the Liver. By Dr. LANGWAGEN. (Archiv für Physiologische Heilkunde, 1857, Erstes und Zweites Heft.)

The following case occurred in the hospital of St. George, in Leipsic, under the care of Dr. H. Clarus:

Mrs. R. O., aged forty-six, married, was brought to the hospital on the 2nd of September, 1856, in a state of maniacal delirium; she had never been previously ill. The excitement and sleeplessness continued; she took no food, gradually lost strength, and wasted away; diarrhoea ensued, and she died on the 29th September.

Post-mortem.-The dura mater thickened, adherent to the pia mater at several points; about three ounces of serum escaped on opening it. The superficial veins were much congested; the cerebral tissue presented a reddish hue on section, the ventricles contained about half an ounce of clear serum, the choroid plexuses were beset with cysts. The lungs cedematous, the lower lobe of the right lung presented hypostatic congestion. The liver was generally normal, but the left lobe was a little atrophied. At the point of juncture of the left and right lobes there was a white callous cicatrix, which followed the longitudinal direction of the furrow intervening between the two lobes. cicatricial tissue was three inches and a quarter long and two lines broad, very dense, and contained two inches of a knitting-needle, which was so closely invested by the tissue that it was difficult to separate them. The needle, after separation, was found to be much rusted, and only at one point round

The

and smooth. Almost immediately beneath the needle was a large but healthy vein. Neither on the abdominal surface, nor in the stomach, nor in the liver itself, was any trace to be found of a former injury. The friends of the patient were unable to give any information on the point.

VI. On Indian Fevers. By J. B. SCRIVEN, Esq., First Assistant-Surgeon, Presidency General Hospital. (Indian Annals of Medical Science, April, 1857.)

It is commonly taught that in India, and in tropical regions, typhus and typhoid fevers are unknown. In a valuable paper on the subject of the fevers occurring in India, Mr. Scriven disproves the correctness of the doctrine, by giving several cases and post-mortems. As the question is one of importance, we proceed to give a brief summary of each of the cases reported.

1. A. B., European, had bilious purging on November 17th, 1851, attributed to drinking beer, and afterwards playing at cricket. It continued to the 19th, when there was slight irritative fever, much weakness, and undefined pain in the head; 20th: diarrhoea during the night, motions watery and bilious, much weaker, pulse weak and quick, tongue white and irritable at the edges; 21st, 5 A.M.: pulse frequent and irritable, considerable heat of head, general heat of surface, pupils slightly dilated, considerable restlessness, tongue dry and furred. Delirium supervened, the diarrhoea continued, and death ensued on the 22nd. Much meningeal congestion, subarachnoid and interventricular effusion, softening of cerebellum, lungs congested, great injection of stomach and duodenum. Patches of ulceration in Peyer's glands, particularly in lower portion of intestine, involving extensively the upper surface of ilio-colic valve. The mucous membrane of the large intestine was injected, but not ulcerated.

2. B. C., aged eighteen, European, January 12th, 1853: tenderness in right iliac fossa, purging, tongue clean. Skin rather hot, slight headache, improvement. June 15th: more fever, tongue furred, tendency to delirium, no eruption, abdominal tenderness. Tongue became dry and brown, he vomited everything, symptoms continued, death on eighth day. Ilium much injected, solitary and Peyer's glands much raised, white; the latter had lost their characteristic pits and ridges; the disease less marked in approaching jejunum ; mesenteric glands enlarged, spleen and lungs congested.

3. C. D., European, aged twenty-one, July 2nd, 1853: Post-mortem only given, but symptoms stated to have resembled those of No. 1. Slight traces of peritonitis, great vascularity of mucous membranes of stomach. "The first one or two of Peyer's patches showed no disease, further on a few white spots, like solitary glands enlarged, were seen on the surface of the patches; lower down the agminated glands became more distinctly diseased, being surrounded by inflamed mucous membrane, which here and there assumed a greyish colour. Still further down they appeared very considerably raised, of a dirty white colour, having protuberances on their surface, and little pits scattered over them." In the lower half of the ilium the most elevated points of the agminated glands showed signs of mortification. There were many ulcers, with partially separated sloughs, on the upper surface of the ileo-cæcal valve, where, as well as on the under surface, they caused an appearance of transverse ridges. There were some ulcers in the colon; spleen gorged. Nothing of consequence in other organs.

4. E. F., August 5th, 1853: Ill twelve days, violent delirium, rose spots, no diarrhoea, a doubtful case; nothing found after death but engorgement of