of 2 /2
1028 losis. Heart weighed 10 oz ; right auricle contained a large B firm white clot; valves competent. Liver, spleen, and kidneys s I amyloid ; in the liver and kidneys there were several minute purulent collections. Superficial caries of the fourth and fifth lumbar vertebræ anteriorly, and connected with the tare bone about 3 oz, of pns, thick, not mixed with bone fragments, in eauh psoas muscle, running in the direction of the muscular fibres, and causing considerable destruction of tissue. The carious cavity on the inner surface of tibia reached deeply into the head of the bone. , CASE 4. CCtries of dorsal sp ne; paraplegia. -Mary H-, aged sixty-eight, was admitted Dec. 8th, 1880. For three weeks she had felt ill, and on admission exhibited symptoms of gastro-hepatic derangement, foul tongue, tenderness on pressure over stomach and liver, nausea and constipation. The urine was slightly alkaline. On Dec. 14th she had neuralgic pains in the left upper part of abdomen, relieved by blisters applied near the spine. Two days later there was pain on pressure over the lower dorsal vertebræ. On Jan. 27th there was some loss of motor power in the lower limbs, attended with cramp; the bowels were confined. On Feb. 2nd there was complete motor paralysis of inferior extremities, abolition of sensation, sole reflex subnormal, patellar phenomenon normal, painful involuntary flexions of the limbs (pain referred to spine, hips, and abdomen), and loss of sensation in lower part of abdomen ; incontinence of urine; bowels moved only by enemata. On Feb. 9th there was flatulent distension of the abdomen. The pain was relieved by opium. Later the patient had a bedsore; for the last month the bowels acted spontaneouslv. Death took place from oedema of the lungs on April 24th, 1881. A daughter died of hip-joint disease, and a son of hæmo- ptysis; no history of injury. Necropsy.—After removal of the spinal arches, on raising the dura mater, it was found adherent anteriorly to the body of the seventh dorsal vertebra, much thickened at this part, and encrusted with caseous pus. At the seat of this lesion the cord was slightly softened and considerably lessened in bulk, but not adherent to the membranes; carious cavity in seventh vertebra. A small soft tumour behind the descending aorta indicated the situation of the affected vertebra, and was due to a local collection of thick pus and bone fragments occupying the cavity in the body of the seventh vertebra, and bulging anteriorly. With the exception of the upper and lower epiphysal plates, the body of this vertebra was almost entirely removed; the inter- vertebral fibro-cartilages not affected. Lungs emphysematous and cedematons at dependent parts; weight of uterus two ounces, a multilocular par-ovarian cyst on the right side, size of a large orange; the left ovary was implicated in a -simple cyst of like dimensions. Great intestine much longer than normal. Fourth ventricle of brain small, central canal not patent at the calamus scriptorius. Remarks.—It is held that in spinal disease, if cartilage be primarily affected, there is less likelihood of suppuration than when disease commences in bone, and hence the non- occurrence of suppuration is regarded as diagnostic of car- tila,ge disease. The practical value of this distinction is limited by the fact that until pus reaches the surface the state of parts as to suppuration is conjectural. The above cases sufficiently indicate that pointing of pus on the surface of the body is a consummation that may never take place. Reviews and Notices of Books. Neurological Contribittions. By WILLIAM A. HAMMOND, M.D., assisted bv WILLIAM J. MORTON, M.D. No. III. New York : G. P. Putnam’s Som, 1881. THE third part of these " Contributions " consists of papers entirely by Dr. Hammond, Dr. Morton having disappeared, except from the title-page. The essays are of considerable interest. The first is on "Thalamic Epilepsy." By this term Dr. Hammond designates cases of epilepsy in which there is little or no convulsion, but which are preceded by a visual hallucination. Several of the cases narrated are very striking, but, except in the variability of the warning, they differ little from the not rare cases of epilepsy with a visual aura, and certainly do not possess the unique character which is here ascribed to them. The name given is an embodiment of the theory, put forward in the paper, that the attacks depend upon a morbid state of the optic thalamus. The evidence that this is the seat of the disease is not satis- factory ; it certainly is far too slight to justify the designa- tion. The chief support is derived from one or two patho- logical cases in which hallucinations were associated with actual disease of the thalamus, but this does not at all exclude the possibility that the morbid process underlying the hallucinations occurred in the convolutions, which were in one case also diseased. There is no ground for Dr. Ham- mond’s absolute and dogmatic assertion that "the cortex, or intellectual centre for any sense, cannot form a real or false sensorial impression," but can only judge of the reality or falsity of impressions formed in the optic thalamus, so that the difference between a visual delusion believed to be true and a visual hallucination recognised as false, is that in the former case the cortex is diseased, in the latter it is healthy. We are very far at present from such a knowledge of the physiology of the brain as would justify any similar distinc- tion, but the preponderance of evidence is stronaly against the theory, and tends to show that many illusions re- cognised as false may take origin in the cortical sense centres. The second paper, on Neuralgia of the Testis, is of a more practical character. The paroxysmal character of the pain, and its relief by firm pressure, are the points relied on by Dr. Hammond in the distinction from the irritable testis of previous writers. The object of the paper is specially to point out the thrapeutical importance of compression of the spermatic cord, which, it is said, will effect a cure without causing any damage to the organ. The pressure must be firm, as a slight degree increases the pain, while greater pressure will arrest it. After a description of an interesting case of myxoedema comes a startling paper on the therapeutical use of the magnet. The results obtained in France are equalled, if not exceeded, in New York. Attention is drawn to some curious observations by Dr. John Vansart, formerly of the United States Arrny, on the influence of the different poles of the magnet on hyperæsthetic parts, and which appear to have led Dr. Hammond to use it largely in the treatment of neuralgia. The facts described in this paper relate to chorea and paralysis. In seven out of nine cases of chorea no result followed. In the other two cases " complete cures were produced in a few minutes." In one, for instance, we are told that a little girl, aged ten, came under treatment with chorea of seven weeks’ duration. There were "violent jactitations of all the limbs and of the muscles of the trunk and face. She had lost the Dower of speech." Very large horseshoe magnets were applied to the spine and the sternum at 1.30. At 1.55 all choreic movements had ceased, at 1.57 she spoke a few words, and at 2 spoke well. The magnets were then removed and the cure was permanent’ Even more astonishing, however, were the results in cerebral hæmorrhage. We are told of complete anæsthesia from this cause removed entirely in seven minutes, and hemi- plegia in three hours, by the application of a horseshoe magnet ! Dr. Hammond, however, recognises, at the end of his paper, that the results may possibly not be due to any specific influence of the magnet, but may be owing to the strong mental impression, or may have been coincident, a recognition with which some of the language employed in an earlier part of the paper is scarcely con- sistent. The concluding papers are a series of useful suggestions regarding the management of the insane in asylums, and an account of some " cases of obscure abscess of the liver; their association with hypochondlia and other forms of mental derangement, and their treatment."

Reviews and Notices of Books

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1028

losis. Heart weighed 10 oz ; right auricle contained a large Bfirm white clot; valves competent. Liver, spleen, and kidneys s Iamyloid ; in the liver and kidneys there were several minutepurulent collections. Superficial caries of the fourth andfifth lumbar vertebræ anteriorly, and connected with thetare bone about 3 oz, of pns, thick, not mixed with bonefragments, in eauh psoas muscle, running in the direction ofthe muscular fibres, and causing considerable destruction oftissue. The carious cavity on the inner surface of tibiareached deeply into the head of the bone. ,

CASE 4. CCtries of dorsal sp ne; paraplegia. -MaryH-, aged sixty-eight, was admitted Dec. 8th, 1880. Forthree weeks she had felt ill, and on admission exhibitedsymptoms of gastro-hepatic derangement, foul tongue,tenderness on pressure over stomach and liver, nausea andconstipation. The urine was slightly alkaline. On Dec. 14thshe had neuralgic pains in the left upper part of abdomen,relieved by blisters applied near the spine. Two days laterthere was pain on pressure over the lower dorsal vertebræ.On Jan. 27th there was some loss of motor power in thelower limbs, attended with cramp; the bowels were confined.On Feb. 2nd there was complete motor paralysis of inferiorextremities, abolition of sensation, sole reflex subnormal,patellar phenomenon normal, painful involuntary flexions ofthe limbs (pain referred to spine, hips, and abdomen), andloss of sensation in lower part of abdomen ; incontinence ofurine; bowels moved only by enemata. On Feb. 9th therewas flatulent distension of the abdomen. The pain wasrelieved by opium. Later the patient had a bedsore; forthe last month the bowels acted spontaneouslv. Deathtook place from oedema of the lungs on April 24th, 1881.A daughter died of hip-joint disease, and a son of hæmo-

ptysis; no history of injury. _

Necropsy.—After removal of the spinal arches, on raisingthe dura mater, it was found adherent anteriorly to thebody of the seventh dorsal vertebra, much thickened at thispart, and encrusted with caseous pus. At the seat of thislesion the cord was slightly softened and considerablylessened in bulk, but not adherent to the membranes;carious cavity in seventh vertebra. A small soft tumourbehind the descending aorta indicated the situation of theaffected vertebra, and was due to a local collection of thickpus and bone fragments occupying the cavity in the bodyof the seventh vertebra, and bulging anteriorly. With theexception of the upper and lower epiphysal plates, the bodyof this vertebra was almost entirely removed; the inter-vertebral fibro-cartilages not affected. Lungs emphysematousand cedematons at dependent parts; weight of uterus twoounces, a multilocular par-ovarian cyst on the right side,size of a large orange; the left ovary was implicated in a-simple cyst of like dimensions. Great intestine much longerthan normal. Fourth ventricle of brain small, central canalnot patent at the calamus scriptorius.

Remarks.—It is held that in spinal disease, if cartilage beprimarily affected, there is less likelihood of suppurationthan when disease commences in bone, and hence the non-occurrence of suppuration is regarded as diagnostic of car-tila,ge disease. The practical value of this distinction islimited by the fact that until pus reaches the surface thestate of parts as to suppuration is conjectural. The abovecases sufficiently indicate that pointing of pus on the surfaceof the body is a consummation that may never take place.

Reviews and Notices of Books.Neurological Contribittions. By WILLIAM A. HAMMOND,

M.D., assisted bv WILLIAM J. MORTON, M.D. No. III.New York : G. P. Putnam’s Som, 1881.

THE third part of these " Contributions " consists of papersentirely by Dr. Hammond, Dr. Morton having disappeared,except from the title-page. The essays are of considerableinterest. The first is on "Thalamic Epilepsy." By thisterm Dr. Hammond designates cases of epilepsy in whichthere is little or no convulsion, but which are preceded bya visual hallucination. Several of the cases narrated are

very striking, but, except in the variability of the warning,they differ little from the not rare cases of epilepsy with avisual aura, and certainly do not possess the unique character

which is here ascribed to them. The name given is anembodiment of the theory, put forward in the paper, thatthe attacks depend upon a morbid state of the optic thalamus.The evidence that this is the seat of the disease is not satis-

factory ; it certainly is far too slight to justify the designa-tion. The chief support is derived from one or two patho-logical cases in which hallucinations were associated withactual disease of the thalamus, but this does not at allexclude the possibility that the morbid process underlyingthe hallucinations occurred in the convolutions, which werein one case also diseased. There is no ground for Dr. Ham-mond’s absolute and dogmatic assertion that "the cortex, orintellectual centre for any sense, cannot form a real or falsesensorial impression," but can only judge of the reality orfalsity of impressions formed in the optic thalamus, so thatthe difference between a visual delusion believed to be trueand a visual hallucination recognised as false, is that in theformer case the cortex is diseased, in the latter it is healthy.We are very far at present from such a knowledge of thephysiology of the brain as would justify any similar distinc-tion, but the preponderance of evidence is stronaly againstthe theory, and tends to show that many illusions re-

cognised as false may take origin in the cortical sensecentres.

The second paper, on Neuralgia of the Testis, is of a morepractical character. The paroxysmal character of the pain,and its relief by firm pressure, are the points relied on byDr. Hammond in the distinction from the irritable testis of

previous writers. The object of the paper is specially topoint out the thrapeutical importance of compression of thespermatic cord, which, it is said, will effect a cure withoutcausing any damage to the organ. The pressure must be

firm, as a slight degree increases the pain, while greaterpressure will arrest it.

After a description of an interesting case of myxoedemacomes a startling paper on the therapeutical use of the

magnet. The results obtained in France are equalled, ifnot exceeded, in New York. Attention is drawn to somecurious observations by Dr. John Vansart, formerly of theUnited States Arrny, on the influence of the different polesof the magnet on hyperæsthetic parts, and which appear tohave led Dr. Hammond to use it largely in the treatment ofneuralgia. The facts described in this paper relate to choreaand paralysis. In seven out of nine cases of chorea no resultfollowed. In the other two cases " complete cures wereproduced in a few minutes." In one, for instance, we aretold that a little girl, aged ten, came under treatment withchorea of seven weeks’ duration. There were "violent

jactitations of all the limbs and of the muscles of the trunkand face. She had lost the Dower of speech." Very largehorseshoe magnets were applied to the spine and thesternum at 1.30. At 1.55 all choreic movements had ceased,at 1.57 she spoke a few words, and at 2 spoke well. The

magnets were then removed and the cure was permanent’Even more astonishing, however, were the results in cerebralhæmorrhage. We are told of complete anæsthesia fromthis cause removed entirely in seven minutes, and hemi-plegia in three hours, by the application of a horseshoe

magnet ! Dr. Hammond, however, recognises, at theend of his paper, that the results may possibly not bedue to any specific influence of the magnet, but may beowing to the strong mental impression, or may have beencoincident, a recognition with which some of the languageemployed in an earlier part of the paper is scarcely con-sistent.The concluding papers are a series of useful suggestions

regarding the management of the insane in asylums, and an

account of some " cases of obscure abscess of the liver; theirassociation with hypochondlia and other forms of mentalderangement, and their treatment."

1029

Medical Education and Practice in all parts of the World.By HERBERT JUNIUS HARDWICKE, M.D. London :J. and A. Churchill. 1880.

WE are constantly asked questions about the regulationsin foreign countries touching medical qualification and

graduation. This book contains a fund of information onsuch matters, as well as on the regulations of British medicalauthorities. The whole is preceded by an introduction,which is worth the attention of all persons taking a broadinterest in medical education, in the international recogni-tion of degrees and other qualifications. The arrangementof matter admits of some improvement. The index is im-

perfect. Some weaknesses in home and foreiga regulationsare too lightly passed over. And it may well be that sucha mass of statement will, on experience, be found to bedefective at points. But we accept it gratefully, as an

attempt to supply a very great want, and we commend someof the reflections of the author on the defects of our own

system to all whom it may concern.

THE NEW ST. MARYLEBONE INFIRMARY.

THE new infirmary buildings at Notting-hill, which are tobe formally opened on the 29tii inst. by the Princess ofWales for the reception of pauper patients of the parish ofSt. Marylebone, are the latest addition to the series of sickasylums which have been erected under the provisions of whatis best known as the Gathorne Hardy Act of 1867, a statutewhich THE LANCET was mainly instrumental in promoting.Previous to the passing of that Act the condition of sickpaupers in the crowded, dark, dingy, ill-ventilated infirmarywards attached to the workhouse buildings was most de-plorable, the medical attendance was very inadequate, and thenursing almost entirely entrusted to pauper helps. Atten-tion was repeatedly drawn in our columns at that time tothe grave abuses that existed, and the articles of the lateDr. Anstie, who conducted the inquiry on our behalf, rousedsuch a feeling of indignation and horror among all classes ofthe community, that a large measure of reform was at onceinsisted on. So that before the provisions of the Act could becarried out by the erection of new infirmaries it was apparentthat public opinion had made itself felt, and even in the closeovercrowded wards of the old buildings improvements wereeffected which made the condition of the inmates more toler-able and successful medical treatment possible. Since, how-ever, the opening of the new sick infirmaries, distinct fromthe workhouse buildings, which now afford accommodationfor over 10,000 of our sick poor, nothing is left to be desiredwith regard to the sanitary and hygienic arrangements andgeneral management, and the provision of necessary appliancesfor the sick. Pauper nurses are things of the past, and trainednurses under responsible supervision have taken their place,whilst resident medical officers are appointed whose duty it isto devote themselves solely to the work connected with theinfirmary ; instead, as was too often the case under the oldsystem, of the medical officer living away from the buildingsand giving what time he could spare from the demands ofhis private practice. And although the salaries attached tothe posts have not been calculated on a very liberal scale, itis satisfactory to find that hitherto they have proved suf-ficiently attractive to induce good men to come forward forthem.Some surprise has been expressed that such a wealtby and

influential parish as St. Marylebone has been so tardy infollowing the example set by other, and in many cases

smaller and poorer unions. It had long been relt thatthe infirmary wards in the present workhouse were sadlyinadequate for the purpose; whilst during the severe

winters of 1878, 1879, and 1880 the wards were dangerouslyovercrowded-indeed, often so overflowing that cases had tobe sent to the infirmaries of other workhouses. The delay,we are assured, was not caused by any desire to evademakins; adequate provi-don for their sick inmates, but arosefrom the difficulty that was found in obtaining a suitable sitefor the new buildings. This, we believe, was a matter ofanxious consideratiou, since sufficient space could nut be ob-

tained in the parish itself without incurring great cost, and itwas ultimately determined to erect the infirmary at some dis-tance from the workhouse. The present site seems in everyrespect a suitable one. It is situate at the western extremityof the Ladhroke-grove-road, and the time occupied intransit from the door of the workhouse to the new infirmaryby the L’nderground Railway is about half an hour. The

neighbourhood, too, is not yet encumbered by buildings, andthe western and northern aspects of the infirmary still lookover green netds, the former over Wormwood Scrubs, thelatter towards Kensal-green. The infirmary stands on

the top of a slight ridge which slopes abruptly down to thefields below. The buildings are arranged on the pavilionplan in the form of blocks, communicating with each otherby means of covered ways. Each block contains two

pavilions, and each ravilion three wards. The wards areall of the same size and arranged on the same plan.Each contains twenty-eight beds, and its cubic capacityis 24,192 feet, or 864 cubic feet for each bed. The wardshave fourteen windows, seven on each aspect, nearly duewest and east, fitted with venetian blinds. The walls arecotoured French grey, with a shade of Indian red, and arelight, cheerful, and well proportioned. The bedsteads are ofiron, furnished with a straw palliasse and a hair mattress, abolster, and a feather pillow. Two or three large chairs,made of polished pine, after a design of the Master of theMarylebone Workhouse, are placed in the centre of eachward and give it a furnished look. Strips of grey" calmuck " are laid over the floor, and add greatly to theappearance of general comfort. The wards are heated bytwo of Mr. Saxon Snell’s "thermhydric" stoves, which alsoserve as means of introducing fresh air continuously fromwithout into the wards. In addition, each pair of beds isprovided with a system of ventilation of its own. If anyp3ir of beds be moved forwards into the room, it will beseen that next the wall there is a skirting-box with apanelled front, and that the panels immediately under thebeads of the bed are formed of perforated zinc. This boxcovers an aperture in the floor, from which a ventilatingpipe descends in slanting direction to the outside of thewall, through which the external fresh air is admitted. Inthe ceiling over each pair of beds there is another perforatedzinc panel running the whole width of the ward, covering achannel (depth 12 inches) which communicates with a largeshaft running up the wall like an ordinary chimney flue.Bv this the foul air is removed. At the end of each ward isa lavatory, with two closets, sink, washing-basin and warm-water bath, all in separate compartments. In addition, eachward has a "separation" room for the treatment of noisy ordelirious patients, or for the isolation of infectious cases.The nurse, too, has a

" duty " room, where the materials andrequisites for ward work may be kept in store ; whilst forevery two wards there is a day-room for convalescent patients.The nursing is entrusted to a staff of nurses under the

Nightingale system. Each pavilion will be supervisedduring the day by a head nurse, who will have under hercharge three ward nurses, one for each ward. The nightnursing will be, for the whole building, entrusted toone head nurse, with one night nurse for each pavilion,a scanty allowance, though it will be eked out nodoubt by the employment of scrubbers and cleaners.Over the whole stair will be placed a lady superintendent.Each nurse will have a separate bedroom, and these apart-ments have been placed in the administrative part of thebuilding away from the wards-a wise and wholesome pro-ceeding. The medical staff consists of a resident superin-tendent, and an assistant medical officer and a dispenser.The general domestic arrangements seem to be excel-

lent, and all the necessary appliances have been liberallysupplied. The kitchens, larders, laundries, &c., are all con-structed on the most approved principles. Each pavilionhas its own hydraulic lift, and each floor of each pavilionis furnished with a powelful hydrant. The mortuary andpost-mortem room are distinct from the blocks containingthe wards ; they have, however, been erected a little tooclose to the administiative block. The water-supply of theestablishment is obtained from an artesian well sunk on thepremises to the depth of 500 feet, of which 211 feet are inthe chalk. In this way a supply, which it is reckoned willyield 4500 gallons per hour, of pure and excellent water isobtained. ln this respect the paupers of St. Marylebone havean advantage over the ratepayers, who have still to put up

! with sewage-tainted Thames water purveyed to them by theWest Middlesex Water Company. The drains from each