of the ureters; for the bladder, as well as the anal opening, was wanting; but a little above the genital processes were found, in a sort of depression, two openings, one of which corresponded to the termination of the small intestine, and, after a course of about one inch and a half, terminated in a short sac.

This child further presented two club feet.

After the cessation of respiration, the heart continued to beat in a manner nearly regular for the space of two hours; the examination of this action, however, could be made regularly only for half an hour. Eight hours after delivery certain contractions were still manifested; but they were very weak, and took place only at rare intervals. After the lapse of seventeen hours, under the influence of a slight puncture, the auricles still underwent contraction; but all action had ceased in the ventricles. These beatings of the heart were few,-about thirteen in the minute, but perfectly regular in rhythm. The following is what was observed.

The auricles and the ventricles were dilated; the auricles were ob served to contract with a brisk and sudden movement, and making a movement of withdrawal, which did not allow the muscular fibres to become manifest. Immediately these auricles returned to their original volume and to their state of immobility. Immediately afterwards, the ventricles were contracted. This contraction, which was very different in its expression from that of the auricles, was made in a slow and gradual manner, from the apex of the organ to its base; it might be said that the blood was slowly expressed out of the ventricular cavities. Between the contraction of the auricles, however, and that of the ventricles, there ensued an interval which was more easily appreciable by sight than by the ordinary chronometrical instruments. The amount of time which intervened between these two contractions might be estimated at about one quarter of a second. After their contractions, the ventricles were filled without sudden movement; it might be said that their muscular fibres were relaxed. The ventricular cavities were then swelled and filled with blood before the contraction of the auricles. Then followed a time of immobility of some extent.

During the contraction of the ventricles, the apex of the heart was carried forward and to the right side; at the same time the heart performed on its axis a true rotation, an actual rolling or whirling motion; and here it is necessary to bear in mind the species of inversion which the heart had undergone. The contraction of the ventricular fibres took place from the apex to the base; it was very strong and very distinct at the apex, but diminished from below upwards, so that, at the base, this contraction was not very perceptible. During this contraction of the ventricles, the heart presented, with sufficient distinctness, the figures represented by M. Gerdy upon the muscular structure of this organ. In each ventricle, the contraction of the fibres appeared to be independent of those of the neighbouring ventricles; each system underwent contraction in an isolated manner; and it was towards the median line of the heart, at the point which corresponded to the interventricular eptum that the movement appeared to stop. The contraction is then particularly energetic over the lateral margins of the heart. This defect in harmony is then translated into this fact, that the ventricle of the left side in this infant was the first which was raised and carried forward. We endeavoured to perceive, by the stethoscope or by the ear, some murmurs in this heart. `Three persons heard distinctly, and at several times, dry and parchment-like murmurs; one of these thought that he heard them double at each time; but it was impossible, in consequence of the rapidity of these contractions, to connect them to one or the other among them. This examination was always made without resting the stetho

scope upon the heart. When the movements of the heart became feeble, we observed often two ventricular contractions for one of the auricles; then by little and little, the ventricular contractions ceased to take place, and the auricles alone continued to beat. All sensibility and all movement had for a long time disappeared in this infant, in which the heart alone continued to evince a vital action.

Articular Rheumatism, terminating in Suppuration and Death. (Archives Generales de Medecine, 4ieme serie, T. xxiv. Septembre 1850. Pp. 99-101.)

At the meeting of the Academy of Medicine, 6th August 1850, M. Andral gave an account of a case of acute articular rheumatism, which terminated in death eight days after the commencement of the attack, without any complication capable of explaining this so speedily fatal issue, and presenting this peculiar circumstance, that the affected articulations were the seat of intense hyperemia, with formation of purulent

matter.

The following is the account of the case.

A woman, aged sixty-seven years, pale, and of feeble constitution, entered the hospital of La Charité, during the first days of last July, labouring under inflammation of the left lung, which had proceeded to the state of hepatization of the lower lobe. After one single bloodletting, she was afterwards subjected to the employment of tartarized antimony, of which she took, in the course of each space of twenty-four hours, for five or six days in succession, thirty-five centigrammes in a suitable vehicle. She became rapidly well.

This woman was convalescent from her attack of pneumonia, and was taking food. She was, however, recovering strength very slowly when, under the probable influence of a current of air, she was all at once attacked with acute pain in the two shoulders, with swelling and slight redness of the skin round each scapulo-humeral articulation. The right humero-cubital articulation (elbow-joint) was also painful, but in a slighter degree, and without swelling. Fever was at the same time intense. This female was therefore attacked by acute articular rheumatism, void otherwise of any other complication. No symptom in particular manifested its presence in the respiratory apparatus, recently delivered from a severe disease. One blood-letting was immediately performed; and the clot, contracted, small, and strongly separated from the serum, showed a white thick crust, as usual.

Meanwhile, M. Andral found the patient next day so much weakened that he thought it would be improper to repeat the blood letting. He made trial of the administration of sulphate of quinine, which he exhibited several days in succession, to the amount of sixty centigrammes in twenty-four hours. The disease, contrary to the ordinary law of rheumatism, did not the less proceed to the fatal termination with frightful rapidity, without the supervention of any complication, without any apparatus presenting phenomena which could explain the progressive exasperation of the disease, without any abnormal murmur being heard in the action of the heart, and without the rheumatic disorder being extended to other articulations. The patient died eight or nine days after the attack of her pains, having presented no other symptom, except pain of both shoulders so acute as to make her utter continual groanings, the pulse more and more frequent, and a general state of anguish and rapid debility, which resembled most that which is usually observed in acute peritonitis.

Inspection showed, without any manifest lesion in any important organ, only a rare termination of acute articular rheumatism.

All the organs within the skull, chest, and abdomen, were free from

change. The blood examined in the heart and in the large vessels possessed its ordinary qualities. Nowhere was there any trace of phlebitis, nor anything which could justify the belief in the existence of purulent absorption.

After these negative results were ascertained, the examination of the articulations furnished the following facts.

The interior of the two scapulo-humeral articulations was filled by white homogeneous purulent matter, which had all the characters of phlegmonous purulent matter. The synovial membrane presented, throughout its whole extent, redness most intense; and in it were seen innumerable vessels wonderfully injected, and forming a very close network. This injection suddenly stopped on the articular cartilages, which had preserved their ordinary aspect. Among the numerous bursæ mucose which surround the shoulder-joint, there were on each side two or three which were in like manner filled with purulent matter. All of these communicated with the cavity of the joint, as is the case with several of these bursa in the physiological state; so that, by pressing on them, matter was forced into and filled the articulation, and reciprocally. Outside these cavities all remained in the normal state. The muscular fibre, the ligaments, the tendons, the cellular tissue, had undergone no lesion. The changes were perfectly similar in nature, in intensity, in the two articulations. The articular cavity of the right elbow-joint contained a certain quantity of a liquid a little turbid. All the other articulations were carefully examined, but they presented nothing abnormal.

It may justly become a question in this case, was the disease really articular rheumatism, or was it not rather from the commencement inflammation of the articular tissues, that is synovhymenitis and desmodia?

III. SURGERY AND SURGICAL OPERATIONS.

The Use of Chloroform before and during Surgical Operations. (Operative Surgery, by FREDERIC C. SKEY, F.R. S. London, 1850.) One of the most interesting questions connected with the subject of operative surgery relates to the use of anaesthetic agents employed for the purpose of suspending the function of sensation. This question has assumed a moral as well as a medical type. It has been urged that sensation is a natural function of the living organism, and that to suspend it by artificial agency is to set at nought the ordinances of nature; and that man is born to suffering, as evidenced by the sensibilities of his body. If the soundness of this argument be admitted, it would be difficult to draw a line which would define the boundary at which moral and immoral suffering meet; or to say in what form of suffering our remedial agents may be justifiably resorted to. The sensibilities of our frame are not given us by nature to the end of promoting pain, but to enable us to avoid it. Corporal suffering is no part of the discipline of the mind; nor can it even be generally asserted that its excess exercises a salutary influence on the character. Every movement of our body instinctively points to the avoidance of bodily suffering; why, therefore, should we not as readily and unobjectionably employ the agency of anesthetic medicines for the purpose of suspending bodily pain, under the circumstances of an otherwise painful operation, as we endeavour to mitigate the bodily suffering of any other patient, cast down on a bed of sickness? Will not the objection to the anaesthetic action of opium to a region affected by a neuralgic pain, or to the system generally, hold as strongly as that of another agent of the same principle given to avert the pain of an operation?

The medical arguments against the use of anaesthetic agents have a

somewhat better foundation. That great and sudden determination to the brain, and an unnatural circulation of venous blood, results from their employment, is undeniable.

It is undeniable, if the quantity administered be large, and long continued, that symptoms resembling those of apoplexy present themselves, in the form of extreme congestion of the vessels of the face, stertorous respiration, and total insensibility; and it cannot be denied that occasionally its full administration leads to headach, vertigo, and languor of some days' duration; and cases are recorded in which even death itself has followed in the course of an hour or more after its employment. It must be observed, however, in pursuing this question in strict accordance with the laws of evidence, that we have no proof, in the cases above referred to, that death was the direct effect of the supposed cause. The parties administering it were not fully experienced in the mode of its application. They entertain the opinion, that death was referable to it, while it cannot be disputed that the fatal issue may have been attri butable to other causes; and, in one example, it appears more reasonable to refer the death of the individual to a suspension of the function of respiration by violence, than to any obnoxious agent circulating through the lungs or brain. On the other hand, the records of St Bartholomew's Hospital point to its successful administration in upwards of nine thou sand cases; in not one of which, including the aged and the young, the healthy, the infirm, and the asthmatic, has its employment left a stain on its character, as an innocuous agent of good. Under all circumstances, its careful employment may be unhesitatingly resorted to in all cases, excepting only such as are marked by determination to the brain of an apoplectic type; secondly, under circumstances of great and serious exhaustion from loss of blood; and, thirdly, in diseases of the heart. In these conditions of the system, it is perhaps better avoided.

The agent in general use is chloroform, and one word may be added as to its administration. It appears indisputable that its influence on sensation precedes that on consciousness. I have employed it on seve ral occasions in which a patient has been conscious of all that has been passing around, and yet who has declared himself to have been totally insensible to pain. This state of his system has arisen from the moderate use of the agent, ample, indeed, for all purposes of utility, though somewhat difficult to regulate in quantity sufficient for the required object.

I prefer its gradual administration. I do not think it desirable to exclude atmospheric air, employed as a diluent during the process of inhalation. Its influence should be gradual, not sudden. I consider its

application through the medium of a cambric handkerchief laid on the face, preferable to the use of instruments made for the purpose of excluding atmospheric air; and food should be rigidly avoided hefore its administration, otherwise sickness will frequently follow.

Against the occasional convictions or objections of others to its employment, I place the strong, and to my own mind the unanswerable, fact, that it has been successfully used in so large a number of cases in St Bartholomew's Hospital since the period of its introduction; that these cases have been indiscriminately taken, and that its objections have not yet made their appearance before the observant eyes of the medical staff of that institution, either by promoting danger during the operation, or protracting the recovery of the patient after it. In one class of cases its employment is especially applicable, viz., in that form of disease in which the pain of an operation is the chief warrant for its non-performance, and in which the recovery from a chronic disease is left to nature that might be greatly hastened by the hand of art; such, for example, as the removal of a piece of dead bone.

Up to the period of the introduction of chloroform, a surgeon was very unwilling to subject a patient to the painful process of sawing and chipping away portions of dead bone, with a view to reach the medullary cavity, because the operation was both a painful and a protracted one. The consequence was, that an hospital bed was occupied by a patient thus affected, for many months, to the exclusion, perhaps, of three or more claimants who would have successively occupied it. By the aid of chloroform the operation is now performed unconsciously to the patient, and the period of his recovery greatly abridged. With the three exceptions above mentioned, I cannot hesitate in strongly recom. mending its administration in all cases of large surgical operations, believing its discovery to be the greatest blessing conferred on the profession of surgery during the last century; and although I have seen its employment pushed, on many occasions, to the apparent verge of apoplexy, I cannot say, even in such examples, that the good has not largely predominated.

Case of Subclavio-Axillary Aneurism treated by Operation, terminating favourably notwithstanding the occurrence of Phlebitis. By Mr SKEY. (Operative Surgery, &c. 1850.)

In the month of January 1841, I was consulted by the Rev. Mr P———— for numbness of the left hand and arm, which had existed for a period of about two months. He had observed it also to be more susceptible of cold than the opposite limb, and that it required the application of artificial warmth to enable him to use it while dressing. The hand was pale, more especially that part which is supplied by the median nerve, the little and ulnar half of the ring-finger being affected in a less degree. No pulsation was felt in the radial artery. The brachial artery, especially at the lower part, beat languidly, and pain was felt in pressing the finger along the track of the vessels. Above the clavicle, just half-way between the two extremities of the bone, I perceived a small tumour, pulsating synchronously with the heart, about the size of half a hen's egg. Its contents were partly fluid and partly solid. Pressure on the tumour reduced it greatly in size, and stopped the circulation in the brachial artery. I could trace the line of the trunk of the vessel above the tumour, to the extent of three-quarters of an inch upwards, to the scalenus muscles.

On the following day a consultation with Sir B. Brodie determined the necessity of an early operation, and in this opinion Mr Travers also concurred.

On Mr P's return to town, after a necessary absence of four days, I found the tumour to have increased one-third in size, and the numbness in proportion, and it had encroached in the same degree on the trunk of the artery above. He suffered considerable pain along the side of the neck and arm, particularly when in a recumbent position. The peculiar situation of the aneurism, involving the portion of the vessel which lies on the lower edge of the first rib, and yet more subclavian than axillary, and the positive advance of all the symptoms during the short period of four days, determined me to perform the operation immediately; for I considered, that if deferred, sufficient space would not be left to apply the ligature with safety around the artery, without detaching or dividing the scalenus anticus muscle, a course I did not look upon with indiffe rence, notwithstanding its recommendation by Baron Dupuytren.

I performed the operation on the 26th of January, assisted by Sir B. Brodie and other gentlemen.

I commenced an arched incision about three inches above the clavicle, close to the outer border of the sterno-mastoid muscle, and carried it a little outwards, curving it in towards the clavicular origin of the muscle, hich I exposed to somewhat more than half its length. This flap,