convexity of the cornea, but upon a diminished sensibility of the retina, (for the perforated card does not completely remedy it,) and upon a preternatural dilatation of the pupil, as the patient can read better through the card than by the unassisted eye. But we still have to inquire into the cause of this dilatation. It is evident that, for the contraction of its pupil, the right eye requires the assistance of the left, and the optic nerve, or the fifth pair, must therefore be the agent of this reflex action. If it is the optic nerve of the left side which transmits the impression to the third pair of the right, which induces the contraction of the pupil, we may inquire why the optic nerve on the right side is incompetent to this, (seeing that the state of the retina proves it is not paralysed,) when in all ordinary cases one eye suffices to induce the contraction. If, on the other hand, we suppose that a kind of local paralysis exists in the sensitive ciliary nerves of the right side, we can explain the necessity of the intervention of the ciliary portion of the fifth pair of the opposite side. It is true that, in this hypothesis, we admit that the stimulus of light acts upon the fifth pair, and not upon the optic nerve, at least as far as the contraction of the iris is concerned, and that it is the fifth pair which transmits to the third the contractile movement which takes place. We consider this opinion very near the truth, and have elsewhere (l'Expérience, 1844) exhibited the arguments which may be urged in its favour. In this case, in fact, the patient was the subject of a severe and obstinate ophthalmia for 18 months, and it is easy to imagine that the ciliary nerves spread among the affected tissues may have participated in the pathological condition, and their vitality have become consequently modified. Besides this, there existed great pain of the eyes and photophobia, so that, during the long duration of the disease, a neuralgic condition of these nerves, ending in paralysis, may have easily been produced.-Annales d'Oculastique, t. xv., p. 27. MIDWIFERY STATISTICS. The Reviewer in the March number of the Archives Générales gives the following general results of Midwifery Statistical Tables, recently published in the Italian and English journals. In 47,116 labours, twins occurred 446 times (9 per thousand,) and triplets four times (1 in 10,000.) There were 40,233 head presentations (969 per 1000,) of which 40,046 were vertex, and 187 face. There were 1065 breech or foolling presentations (27 per 1000,) and 154 transverse ones (4 per 1000.) Of these labours, 46,632 terminated naturally (989 per 1000,) and 484 (11 per 1000) artificially, viz., 321 by means of the forceps, 89 by craniotomy, 54 by turning, and 20 by vaginal or uterine hysterotomy. CASE OF PELVIC ABSCESS OPENED THROUGH THE RECTUM. The subject of the case was a lady, 37 years of age, who had borne two children. She had enjoyed excellent health until 10 years since, when her husband infected her with gonorrhoea, from the secondary effects of which she suffered and recovered; a severe lumbar pain, however, then making its appearance, and continuing to annoy her at intervals. During the last 18 months this pain had increased in severity, and when first seen, 4th April, 1844, by Dr. Compérat, it had become very intense, occupying all the right side of the abdomen and genital organs. We need not pursue the detail of her sufferings, and of the measures which partially relieved them; but may observe that, by a recto-vaginal examination, a tumefaction was felt on the posterior part of the right side of the body 1846.] CASE OF PELVIC ABSCESS. 261 of the uterus, seeming to be seated exactly at the recto-vaginal partition. Passing the index-finger high up into the rectum, its pulp was just able to reach the projecting part of another large swelling at the right posterior portion of the gut. All the parts were hot and irritable, and the examination gave excruciating pain. MM. Amussat and Fouquier saw the case, and believed it to be one of abscess, which the great constitutional irritation would seem to indicate, although they could not detect fluctuation, which Dr. C. believed he had felt. As the point of the finger could only just reach the swelling, the surgeons wished to defer opening it, and ordered cataplasms, the simultaneous injection of the rectum and vagina with emollients, and other palliatives. On the 19th, fluctuation had become distinct, and as the patient's general condition was now truly alarming, they determined to operate. M. Amussat having passed his finger into the rectum as high as the fluctuating tumour, slid along its palmar aspect a pair of very sharp-pointed scissors, very like those contained in dissecting cases, but having the backs of the blades rounded and the branches very much longer. The puncture was made and the blades then separated, so as to enlarge the aperture by tearing rather than cutting. During this period, an assistant pressed upon the belly, so as to project the tumour as far towards the rectum as possible. A lithotrity catheter was now substituted for the scissors, and guided along the finger, still left in the rectum. A considerable quantity of healthy, and scarcely sanguinolent pus flowed out. The cavity of the abscess was carefully injected with tepid water, and the rectum cleaned out, and the access of air prevented by ascending douches of the same. These last gave great relief. In order to keep the aperture of the abscess patent, the index-finger was introduced several times during the first day. The next day, however, it had nearly closed, and the finger could not pass through the thickness of the walls of the abscess, which M. Amussat had observed seemed like cutting into the substance of the uterus itself. He enlarged the opening by means of a longer and stronger pair of scissors, the blades of which were notched near their extremities, so as to give the instrument a lance form, and prevent its escaping during the attempt at enlarging the wound. The edges were kept separate by occasionally expanding them by means of a brise-pierre. The case eventually did very well. Dr. Compérat observes that, although numerous cases of abscess forming in the cavity of the pelvis are on record, (M. Bourdon gives an account of 23 of these in his paper "on fluctuating abscesses of the pelvis, and their discharge by an aperture practised in the vagina," in the Rev. Médicale, 1841,) yet the present, as far as he knows, is the first case in which an opening has been made for the evacuation of the pus by the rectum. The surgical procedure in each case must depend upon the direction which the projecting portion of the swelling takes. Of course, the difficulties to be surmounted are less in the vaginal incision. One of these, the danger of hemorrhage, was met in this case by using very pointed scissors first as a trocar, and then tearing, rather than cutting, the parts with them. The edges of the aperture also were effectually dilated by means of the brise-pierre as long as requisite. The introduction of instruments, however, at last induced severe irritability of the anus, which continued for hours, and caused the patient to dread its repetition beyond everything M. Recamier, who saw the case, promised her, if she could bear very severe pain for a short period, to effectually relieve her. "Having well oiled his fingers and thumb he formed them into the shape of a cone, and thrust them altogether through the anal ring, impressing upon the entire hand slight movements of supination and pronation in order to facilitate its introduction. The margin passed, the fingers were bent so as to increase the size of the imprisoned mass, and then drawing them out at once in this position, he forcibly dilated the sphincter, thereby causing excessive pain for some minutes. The anus spasmodically contracted during several hours, and then all became quiet. From this period, the sphincter offered no obstacle to the intro duction of the finger and brise-pierre, and the patient suffered no pain whatever from it. I do not know whether M. R. has published his ingenious expedient; but all I can say is that, from the surprising manner in which it relieved the excessive sensibility of the anus and the anguish of the patient, it cannot be too strongly recommended in all cases where the permanent or frequent introduction of instruments irritates the sphincter."—Revue Médicale, t. I., 193. ON THE SURGICAL TREATMENT OF CROUP. By M. GUERSANT, Jun. I agree in the opinion of MM. Bretonneau, Trousseau, Guersant, Sen., Blache, &c., that to constitute croup the presence of false membranes in the larynx is essential. The disease may commence at the tonsils, in the bronchi, or suddenly in the larynx itself. In the first case there is more or less redness of the pharynx with swelling of the tonsils, and, what is of vast importance to notice, these last are covered with little white patches, which sometimes extend as far as the velum or uvula. The medical means for treating croup are very limited. Depletion, once so freely employed, under the idea that the disease was a simple iuflammation, is very rarely of any utility in croup, and oftentimes injurious. Emetics have proved far more useful as adjuvants, by favouring the detachment and expulsion of the false membranes; but alone they are not to be relied upon. Mercurials, especially when used early, have often exerted excellent effects upon the disease; but for these to be of service the dyspnoea must not be very urgent, or the patient very enfeebled, and when used alone they have effected but few cures. It is upon surgical treatment we must usually most rely, and by it we mean the application of caustics to the pharynx, as well as the operation of tracheotomy. Various fluid or solid substances of this nature have been employed, but we prefer the nitrate of silver. Weak solutions suffice at the earliest stage of the disease, when there is little else than the pseudo-membranous deposit upon the pharynx. There are indeed cases in which these are not seen at all, the false membranes being at once deposited in the larynx, but these are rare; and frequently the membranes are not detected in the pharynx, because the first period of the disease has already passed away. At an early period the symptoms are but little urgent, and the physician, little accustomed to treat children, often neglects to examine the throat. With M. G., whenever a child manifests any febrile re-action, such examination is an invariable rule, and in this way he has frequently been enabled to detect the approaching disease, which would not otherwise have been suspected. He instances a case in which M. Trousseau was induced fortunately to examine the throat by observing the surface of a blister to be covered with a slight fibrinous layer-such false membranes being liable to form on the surface of any wound in those who are the subjects of diphtheritis. At first, and while the tonsils are covered with this plastic exsudation, the symptoms are not severe, so that attention is not directed to the throat. But this is a precious moment for the surgeon: for he may now frequently arrest a disease, which if allowed to go on is usually beyond his art. While employing the solid caustic, the child should be held by a strong assistant; for it is rare that the practitioner can effect this operation unaided. The tongue must be held down by a very large spatula, or by the handle of a large spoon. If a small instrument be used you cannot effect your object. We generally employ a large wooden tongue-depressor. The caustic should, for fear of accidents, only project very slightly from its case; and many practitioners, on this account,prefer using solutions. We have already said that,at the earliest stage, the use of even a weak solution three times a day suffices. We should apply the caustic beyond the margin of the false membrane as well as to itself, as this 1846.] GUERSANT ON TREATMENT OF CROUP. 263 will prevent its extension. In serious cases the solution must be very strong (1 part to 3 or 4 water,) but then need only be used once daily. It may be applied by means of sponge fixed at the end of a piece of whalebone by sealingwax. The caustic frequently dissipates the false membranes upon the amygdale, and yet they extend to the epiglottis. Caustic is still our best means. A larger sponge is now required, which must be fixed upon a strong whalebone, bent at an obtuse angle. The surgeon places himself on one side, and introducing the sponge right to the base of the tongue, executes some semi-rotatory movements. Sometimes the epiglottis is raised, and the fragments of false membranes detached from its inferior surface, which may be known by the paroxysm of dyspnoa this gives rise to. The caustic requires to be repeated three or four times in the twenty-four hours. When, in spite of the energetic use of these means, success does not follow, we must have recourse to tracheotomy. M. Guersant has, next to M. Trousseau, performed this operation more frequently than any one else, and speaks unhesitatingly of the propriety of undertaking it, and believes that numerous failures arise from its being too long deferred. When the child will certainly die asphyxiated without, why should we hesitate to open the trachea ? for cases have occurred in which the patient has lived, although false membranes have penetrated even into the larger bronchi. The vital point which cannot bear the slightest presence of these is the corda vocales. Practitioners who are aware that a certain number of these cases have proved successful cannot doubt the propriety of operating. M. G. usually employs a straight bistoury, and has several small sponges mounted on whalebone and a curved ring-forceps at hand. If the morbid productions do not reach into the trachea we have only to maintain the aperture patent; while, when they extend lower down, their removal may be attempted by means of the bent forceps. Among the numerous modifications of canula employed to maintain the wound open, that of M. Trousseau is an excellent one. It consists of a double canula, so that, when obstruction occurs, the inner one may be changed without disturbing that which remains in the wound. This practitioner, as well as M. Bretonneau, prior to introducing the canula, passes small sponges, moistened with a solution of nitrate of silver, into the trachea but unless false membranes are obviously present, M. G. doubts the propriety of any such interference, and does not have recourse to it. The canula may usually be removed at the end of from eight to twelve days, but sometimes requires to be retained for 20 or 30. The air of the chamber should not be kept too dry and hot. To render it sufficiently humid it is a good practice to evaporate some emollient decoctions in the room several times a day. It is a difficult thing to maintain an equable temperature about the child, but for a long period I have experienced the utility of wrapping around the neck, without tightening it, a light woollen comforter having its meshes very widely knitted. By this contrivance, the air, before it reaches the trachea, becomes sufficiently warmed. When the canula becomes obstructed, the inner canula should be removed and cleansed, instead of thrusting sponges into it, which may only increase the obstruction. When it is deemed proper to cleanse out the trachea, only the most delicate whalebones must be employed. When indurated concretions form, both canule should be removed and the patient encouraged to expel them by coughing. I have never removed the canula before the tenth day, but M. Trousseau has done so on the third or fourth. He advises us not to remove it suddenly, but for one, and then for several hours daily. Finally, let us observe that croup is so grave and so constantly mortal a disease, that we should frequently have recourse to this operation before it reaches its last stage. "While tracheotomy was almost always a powerless weapon in my hands," says M. Trousseau, "I always recommended its performance as late as possible; but now I have met with numerous instances of success, I always say it should be performed as early as possible, as soon in fact as no other chance of success remains." Of 136 children operated upon, M. T. has saved the lives of 32; and, without being so fortunate as that practitioner, in 36 cases I have met with four successful ones-a success sufficiently great for us to lay it down as a law that we should interfere rather than allow the infant inevitably to die.-Gazette des Hôpitaux, Nos. 48 and 52. (The practice of promptly examining and cauterizing the pharynx may doubtless prevent the extension of the disease in some cases, and is not enough attended to in this country. So, also, an unreasonable prejudice against Tracheotomy prevails among us. Death stares us in the face, and why not resort to means which has rescued many lives, albeit these may be few compared to the numbers operated upon-many of whom were in extremis. Dr. G. does not notice the external application of heat (to rubefaction) so useful at the outset of croup.-Rev.) PHOSPHATE OF AMMONIA IN GOUT AND RHEUMATISM. By Dr. BUCKLER, Baltimore. Dr. Buckler thus states the grounds upon which he recommends this substance to notice: 66 Taking into account these two prominent facts above stated, namely, the excess of lithic acid found in the urine at the period of convalescence from an attack of acute gout or rheumatism, and the subsequent deposit of soda and lime in the white tissues, it occurred to me that, during the existence of these diseases, the lithic acid might exist in the blood in a state of combination with soda and lime, in the form of insoluble compounds, which the kidneys and skin refuse to eliminate. If then, any agent could be found capable of decomposing the lithates existing in the blood, and of forming in their stead two soluble salts, which would by voided by the kidneys and skin, we should thereby get rid of the excess of fibrin in the blood, the symptomatic fever and the gouty or rheumatic inflammation, wherever seated, which have been excited by the presence of these insoluble salts. It occurred to me that phosphate of ammonia might be the agent, provided it could be given in doses sufficient to answer the end without producing any unpleasant physiological symptoms. If our theory were true, phosphate of ammonia seemed to be the proper re-agent, for it would form, in place of the insoluble lithate of soda, two soluble salts-the phosphate of soda, which is remarkably soluble, and the lithate of ammonia, which is also solubleand both capable of being readily passed by the skin and kidneys. The excess of uric acid would thus be got rid of in the form of lithate of ammonia; and the soda, floating in the round of the circulation (instead of being deposited, as it were, like an alluvial formation in the substance of the fibrous and cartilaginous tissues) would be taken up by the phosphoric acid, and eliminated from the circulation." The particulars of thirteen cases of gout and acute rheumatism are briefly related, in which this medicine (in doses of from ten to twelve grs. ter in water,) seems to have wrought a speedy cure. Dr. B. has also found it an excellent remedy in old hospital chronic cases, which had resisted iodine and other medicines; and in those instances in which the deposits and deformities are such as to be irremediable, the acute attacks which supervene may be effectually relieved. "In reviewing the cases which I have published, it will be noticed that thickening of the white tissues, of long standing, has disappeared under the use of the phosphate. Now, it is in such cases that the lithic acid diathesis generally prevails, and this agent seems to act here by depriving the blood for a long time |