QUARTERLY REPORT ON PATHOLOGY AND MEDICINE. By EDWARD H. SIEVEKING, M.D. Fellow of the Royal College of Physicians, Physician to, and Lecturer on 1. Clinical Illustrations of the Pathology and Treatment of Delirium Tremens. By T. LAYCOCK, M.D., &c. (Edinburgh Medical Journal, Oct. 1858.) This paper illustrates by precept and example the error of the system very commonly, though not universally, pursued of treating delirium tremens by the administration of spirits and opium. Dr. Laycock argues that the withdrawal of the accustomed stimulus in habitual drunkards is not the ordinary cause of an attack, but that it is commonly brought on by a prolonged debauch, giving rise to an intensely alcoholized state of the blood. His own cases certainly bear out this view; in only one of twenty-two cases treated by the author in the Edinburgh Infirmary during the past summer was there any shadow of evidence of the delirium having been due to a withdrawal of the alcohol; in all the others the patients, when admitted, were under its immediate influence. If the disease be due to the blood being overcharged with alcohol, Dr. Laycock argues that it would be illogical to increase the force of the disease by multiplying the cause, and in support of this theory brings forward statistics, furnished by his own experience and that of other observers, to prove positively the advantage of the entire absence of alcoholic stimuli in delirium tremens, and, negatively, the pernicious effect that results from their administration. Of 403 cases treated in 84 years in the Royal Infirmary, according to the routine system, with spirits and opium, 101, or 25 per cent., died; of Dr. Laycock's 24 cases, treated in the Infirmary, none died, and he quotes Dr. Peddie's method of treatment without opium as equally successful, 80 patients who were under that gentleman's care having all recovered. With reference to the usual argument in favour of narcotics in delirium tremens, drawn from the patient's sleeplessness, Dr. Laycock states that experience abundantly shows that sleep, and "therewith return to health, will come on naturally in delirium tremens without the use of any narcotics, or even any drugs whatsoever." In addition to his own cases, he refers to the experience of Kühn, Esquirol, Calmeil, and Ware. The latter "treated 29 cases on the expectant method, 1 died; 12 by emetics, 1 died; 8 with opium, 4 died." The state of the patient being one of great excitement, he should be placed in circumstances favouring repose, and the elimination of the alcoholic poison by the natural emunctories be promoted; food is necessary, because in almost all cases the absence of proper food has been one of the causes of the supervention of the seizure, and the complications, which mainly consist in subinflammatory states of the stomach, duodenum, liver, or kidneys, should be attacked by mild sedatives and depurants. The chronic inflammation of the chylopoietic viscera, so commonly associated with delirium tremens, is treated by Dr. Laycock with small doses of calomel, nitrate of silver, and morphia, combined in the form of pill; but where no such disorder exists, he finds the hygienic treatment sufficient to restore the balance of the circulating and nervous systems, and sleep ensues without the administration of medicinal narcotics. II. Is the Chorea of Abyssinia, or Tigretier, a Distinct Form of Disease? By Dr. LE ROY DE MÉRICOURT. (Archives Générales de Médecine, Août, 1858.) Those who have read Hecker's Epidemics of the Middle Ages' will remember that he classes Tigretier with the dancing mania, and gives the sanction of his authority to the description of an affection under that name by Nathaniel Pearce, an Englishman, but not a medical man, who lived in Abyssinia from 1810 to 1819. Dr. De Méricourt does not appear to have had any opportunities of witnessing the phenomena under discussion, nor to have been in Abyssinia; but, after analysing the details given by Pearce, who was not a medical man, and examining the accounts of more recent travellers in that part of the globe, especially of Lefebvre, Petit, and Dillon (two of whom were medical men), he arrives at the following conclusions:-1. There is not in Abyssinia, nor in the Tigré country, a special endemic disease which deserves a separate place in nosology under the name of Tigretier. 2. The description of Mr. Pearce does not prove that he was witness of a species of mania analogous to the dancing mania of the Middle Ages. 3. His description presents no symptom characteristic of the neurosis known as chorea. 4. It is nothing but a more or less faithful account of the superstitious practices employed in Abyssinia for the cure of diseases generally, and often doubtless used as means of fraud. III. Memorandum of New Facts relating to Epilepsy consecutive upon Lesions of the Spinal Cord. By Dr. E. BROWN-SÉQUARD. (Journal de la Physiologie, Numero iii., Juillet, 1858.) Our readers will remember that Dr. Brown-Séquard has demonstrated the occurrence of epileptiform seizures in animals in whom a horizontal section of part or the whole of the spinal cord has been made; section of the portion intervening between the seventh or eighth dorsal and third lumbar vertebra being particularly liable to induce the phenomenon. The author now adds, that having been doubtful whether in these cases there was a complete loss of consciousness, he has since found that in certain cases no signs of pain or reflex action can be elicited during the attacks-viz., when the transverse section of the spinal cord is made on a level with the last dorsal vertebræ; he therefore concludes that the convulsive disease thus produced is genuine epilepsy. Dr. Brown-Séquard next discusses whether there is a form of epilepsy which deserves the name of spinal epilepsy, and he maintains that there is a variety of epilepsy which deserves this name, but which is distinct from that described under the term by some authors. He supports this statement by reference to experiments and to cases observed by himself and others in man. He observes that when the spinal cord has been nearly or entirely divided in the dorsal or upper lumbar region, the reflex movements that occur in the posterior paralysed portion of the body put on an alternately tetanic and epileptiform character. The two posterior extremities will become perfectly stiff, and subsequently be affected with violent, irregular clonic convulsions. These attacks last from two to eight minutes. The tetanic stiffness is sometimes so great that in attempts to overcome it forcibly, Dr. Brown-Séquard has broken the bone." The two posterior extremities are not affected in the same way at the same time; one may be in a state of rigid extension, while the other is violently agitated by clonic convulsions. If the anterior portion of the body is attacked with epileptiform convulsions, the posterior extremities are also involved in the convulsions. Dr. Brown-Séquard, in the same paper, adverts to a third point of importance connected with the production of epilepsy, the occurrence of a contraction of the vessels of the cerebral hemispheres, and the circulation of black blood after this contraction has ceased. He intends shortly to publish new researches on these and allied points, but makes the preliminary announcement that he has seen the contraction of the cerebral vessels in epileptic animals at the commencement of a seizure, and that this contraction has been absent when the cervical sympathetic has been divided. IV. On the Practical Use of a Laryngeal Speculum in the Diagnosis and Treatment of Diseases of the Tongue. By Dr. SEMELEDER. (Zeitschrift der k. k. Gesellsschaft. der Aerzte zu Wien, July 12, 1858.) Garcia, Czermak,† and others, have employed a speculum for the examination of the fauces and the neighbouring parts; a strong light is necessary, which, whether it be sunlight or artificial illumination, must be thrown on to the speculum, while the observer protects his own eye from the glare by a shade, similar to that of the ophthalmoscope. The speculum is to be warmed, to prevent its being dimmed by the patient's breath, and its temperature may be tested by being applied to the observer's cheek. In patients whose velum palati is not adherent, the soft palate should be pressed firmly upwards with the mirror, in order to prevent it from slipping down behind the speculum, and also because by this means the fauces will not be irritated and reflex action excited. The patient's tongue offers numerous impediments, and some management and experience is requisite to manipulate properly. When making an observation, the patient should quietly take a deep breath, and hold it as long as possible. The slanting direction of the speculum will enable the observer to see the root of the tongue, the epiglottis, and the introitus laryngis. Within the larynx the superior thyro-arytenoid ligaments, the chordæ vocales, and through them, with a good light, the inner surface of the trachea may be seen. Dr. Semeleder agrees with Dr. Czermak, that occasionally the bifurcation of the trachea may be recognised. The amount of control which patients can exercise over different parts of the fauces varies, and accordingly the extent of surface reflected in the speculum varies also. The case which Dr. Semeleder reports is as follows:-A girl, aged fourteen, came as an out-patient, with ulcers of the soft palate and fauces, and was cured with a solution of iodine in glycerine, applied locally. Ten weeks after, she returned, with a hard tuberculated nodule on the middle of the tongue, two lines long, covered with enlarged vessels, which in a fortnight was converted into a large ulcer, with hard, thick edges. Mercurial treatment only aggravated the disease; improvement took place on returning to iodine treatment locally and generally. "On the 8th of April the author commenced the use of Garcia's laryngeal speculum. In the middle of the tongue was a large nodule, and in front a small one; on the right side of the nodules was a deep, ulcerated fissure, curving posteriorly towards the mesian line, and terminating three-quarters of a line behind the point of union between the anterior papillæ vallatæ, like a button-hole or loop-hole, in a hole which was three lines in diameter; from this hole asteroid fissures were given off, which were partly lost at the sides, partly disappeared behind the epiglottis. The papillae vallate of the right side occupied this fissure, and could not therefore be seen. The epiglottis and epiglottic folds, as well as the chordæ vocales, were somewhat reddened." Dr. Semeleder found that he was able to make the local application of the solution of iodine in glycerinet with much more precision by the aid of the speculum, and that the curative process was thus much accelerated. Fresh granulations formed, and a gradual contraction and cicatrization of the cavity ensued. Dr. Semeleder remarks that negative results-i.e., the proof of the parts shown by the speculum being in a normal condition—are also useful, and concludes his paper by observing that by proper manipulation the use of the speculum faucium may be continued for a considerable period at a time without giving rise to any inconvenience to the patient, whereas the awkward introduc * See British and Foreign Medico-Chirurgical Review, p. 229, Jan. 1856. + Sitzungsbericht der Math. Physik. Classe der k. Academie Wissenschaften. 1858. Iodinii gr. iij, potassii iodidi gr. xvj, glycerinæ 3j. 45-XXIII. 17 tion of the instrument would at once give rise to retching in the same individual. Since the appearance of the paper from which the foregoing extract has been made, Dr. Semeleder has, in the same journal (19th July, 1858), described an improved illuminating mirror instrument for examination of the fauces, to be worn as an eyeglass or a pair of spectacles by the observer. It is described as follows: A metallic, highly-polished concave mirror, eight centimetres in diameter horizontally, and with a focus of twenty to twenty-five centimetres, is provided with a central opening, to the posterior surface of which a metallic nut is attached, with a perforation corresponding to that in the mirror. The nut is held by two cups, which are pressed against one another by two springs given off at the back of the mirror; the nut is moveable on two axes, but is sufficiently fixed to retain any given position. A concave disc corresponding to the circumference of the eye is attached to the posterior surface of the cups, and fitted into the frame of an eyeglass or spectacles; this disk is also perforated, so that there is a continuous channel from the mirror to the eye of the observer. V. Remarkable Case of Aneurism of the Thoracic Aorta. By JOHN H. PACKARD, M.D. (The American Journal of Medical Sciences, July, 1858.) This case is related by the author because, as he thinks, the sternum had perforated, and become enclosed within, the aneurismal tumour. It occurred in a coloured porter, aged thirty-eight, who in February, 1858, came under Dr. Packard's care, with a lump as large as a foetal head at the upper part of the sternum, somewhat to the right of the median line, which had first begun to form in July, 1857. The treatment, of course, was palliative, as there was no doubt in regard to diagnosis. An eccentric or expansive pulsation was visible all over the tumour; but there was no bellows-murmur nor anything like a thrill. The clavicles seemed to disappear at about an inch and a half from their sternal extremities, but the sterno-cleido-mastoid muscles could be traced on each side, passing over the upper part of the tumour as if to its point of insertion. The man continued at his work till March, towards the end of which month a rapid increase in the tumour ensued. On the 2nd of May it measured eleven inches transversely and ten inches and a quarter from above downwards in semi-circumference. The upper part was discoloured, and on the 6th of May rupture took place externally, followed by severe hæmorrhage, and death in the ensuing night. Autopsy ten hours and a half after death, the tumour only examined. The anterior wall of the sac was extremely thin, the skin was easily separated from it, except at the point where the sterno-cleido-mastoid were attached; their lower part was converted into fibrous tissue, and their bony connexions were destroyed. The sac contained an enormous clot, very firm behind and below, but the consistence gradually diminishing, and its red colour deepening towards the external orifice. On introducing the hand into the cavity, Dr. Packard found several pieces of roughened bone. "Two of these, evidently remnants of the sternum, lay free, surrounded and supported by half-coagulated blood; they were irregular in shape, bare, and eroded, as if by a solvent action of the blood; the line of separation between them was irregular, oblique, and much like a fracture. The end of the right clavicle, and the upper two ribs on the same side, in a similar condition, projected through the wall of the sac; both sterno-clavicular articulations were absorbed. Above the second rib the sternum was entirely gone, except a slender strip which had formed its border on the left side; the inner edge of this strip was bevelled off internally by absorption. The outer and front surface of the first rib on the right side was laid bare, and slightly hollowed out by the pressure of the aneurismal sac. It would seem that the dilatation had gone on so rapidly that the bones, so to speak, were not absorbed quickly enough, and the walls of the sac, even in the act of giving way to them, formed adhesions round them." The aorta was the vessel affected from about an inch above its origin; the trachea was flattened, and the lungs perfectly healthy. The author has examined the records of the profession without meeting with a similar case. He explains the occurrence thus: "The periosteum covering the inner surface of the upper piece of the sternum was absorbed beneath the pressure of the tumour, adhesions meanwhile forming between the sac and the periosteum around the edges of the bone; then the anterior wall of the sac itself being broken down, the bone was loosened from its anterior periosteal layer by the insinuation of the contents of the sac between them, and dropped into the cavity, the anterior wall of which thenceforth consisted of two layers -skin and periosteum-the latter becoming lined by a sort of serous membrane, perhaps by the organization of coagula.” VI. Ulceration of the Aorta. By A. N. TALLEY, of Orangeburg, South Carolina. (Charlestown Medical Journal and Review, Sept., 1858.) In a female about fifty years of age, who was under Dr. Talley's care on account of pulmonary phthisis, and in whom death ensued suddenly and unexpectedly, the autopsy revealed, in addition to the disease in the lungs, the following conditions. The pericardium was greatly distended and of a dark chocolate hue, it was occupied by a large coagulum surrounding the heart and moulded to it. The heart itself was healthy in appearance, but on opening the aorta a circumscribed ulcer was found as large as the end of the middle finger, which had perforated the vessel. From this point to the origin of the vessel, a distance of an inch and a half, the lining membrane was of a dark red colour, coated with lymphy deposits. The semilunar valves were free from disease. From the character of the ulcer, its indurated edges, and the general aspect of the lining membrane of the vessel, Dr. Talley concluded the disease to be of long standing. The coats of the aorta were somewhat thickened close to the seat of ulceration, but the calibre of the tube was not at all increased, so that the disease presented nothing resembling aneurism. The symptoms having been eminently those of the third stage of phthisis, the author's attention was not directed specially to the state of the heart during the patient's life, so that he is unable to inform us whether the condition of that organ revealed by the post-mortem was attended by any peculiar phenomena during life. VII. Aneurism of the Hepatic Artery. By Dr. HEINRICH WALLMANN. (Archiv für Pathologische Anatomie und Physiologie, Band xiv., Hefte 3 und 4.) The extreme rarity of aneurism of the hepatic artery justifies our placing the following case briefly before our readers. Mrs. P—, widow, a native of Bohemia, aged thirty-six, had always enjoyed good health until three months before she came under Dr. Wallmann's care. Since then she had frequent severe attacks of pain in the epigastrium, with free intervals, without jaundice or disturbance of the secretions or catamenia; she lost flesh, and the severity of the pains increased. On admission to the clinical wards of the Joseph's Akademie, Feb. 3rd, 1858, she was much emaciated; heart and lungs normal, the spleen enlarged, the liver projecting three finger-breadths below the ribs, and with hard edges; no ascites or fever; she had never had a blow in this |