he will only refer to the registry, he will see that midwifery diplomata are registered, but not certificates; consequently, Mr. Talbot was not "legally entitled to attend a midwifery case"

Within the last few days, the certificate from the Dublin Lying-in Hospital was refused as a qualification by a dispensary committee; and the gentleman was obliged to go in for the midwifery diploma of the College of Surgeons before he was permitted to become a candidate for the appointment of Medical attendant to the district.

Dublin, January 21.

I am, &c.

A REGISTERED MIDWIFERY DIPLOMATIST. MALPOSITION OF THE HEART and Liver.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-In the report of the meeting of the Royal Medical and Chirurgical Society for November 25, 1862, I see a case of malposition of the heart and liver recorded. As there is at present in this city a living instance of a similar case, and as the gentleman himself makes no secret of it, I see no impropriety in my referring to it. His heart is undoubtedly and congenitally placed in the right thoracic region; and he is fully persuaded himself that his liver occupies the left hypochondrium. The subject of this lusus naturæ is a small, but most active man, is one of our most eminent men here, is a specialist, and holds a very high and important position in our Royal College of Surgeons. He enjoys excellent health. I am, &c.

Dublin, January 21.

GIBBON. BUDD.-PHYSICIAN'S FEES.

F.R.C.S.I.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-Allow me to correct a trifling inaccuracy in the report of this action, as it appears in your Journal, and to state that I did not attend the late Mr. Budd for a Surgical injury to the foot, but was called in four months after the accident by his Medical attendant, in reference to the extreme debility and head symptoms from which he was suffering. Had I had anything to do with the treatment of the Surgical disease it would, assuredly, have been pleaded against me; for the defendant left no stone unturned and spared no money in order to quash my claim. In other respects the report is one-sided, especially in not giving the evidence adduced on my behalf. As to the plea that I attended as a friend, the only pretext for it was that I had a passing acquaintance with Mr. Budd; indeed, I proved that he had once paid me for previous Professional services. Unfortunately for me, my attendance on him was abruptly terminated by an attack of typhoid fever, which obliged me to leave London for a considerable time in the autumn of 1861, when other Medical men took charge of the patient np to the time of his decease.

My legal title to recover fees under the new Medical Act will be decided in a few days by the Exchequer Court, as it was stipulated not to carry the question to a Court of Error, on account of the heavy expense it would entail upon the parties.

It may be a mistake, as you say, in a College of Physicians to enact conventional distinctions between the different members of their body; but it would surely be a greater mistake for the Fellows to impose legal disabilities on the members and licentiates without their consent.

"

With every respect for the opinion, or rather feeling, which you appear to share with a majority of the Fellows of the Lordon College,-that the Physicians' fees had better be regarded as a "gratuity" than as "wages," for the most important and valuable services one man can render to another, I must confess, after due consideration, that I cannot agree with you. If there be a moral claim, one would naturally suppose that there ought to be a legal title to remuneration for the inestimable services that we, as Physicians, render to our feilow-men. In a Profesional point of view, we need only to determine whether of the two is the more just and the more politic,-the "honorarium or the "merces" principle of payment. Now, it is difficult to conceive how any injustice can be inflicted either on the patient or his Physician by the " merces principle, but it is constantly done under the "honorarium" system. In some instances, rare I admit, the Physician obtains, either through ignorance or excessive gratitude on the part of the patient, a much larger fee than his services warrant, or than his conscience would accept, were it not from this "honorarium" superstition. But in the far greater majority of cases ho receives no remuneration whatever, or a very inadequate one, for services rendered at the cost of much time, skill, and labour, I more than suspect that the "honorarium" practice is partly the cause of nearly the whole of the public Medical service, in this country, being "honorary." Now, although this is done (except under the Poor-law) in the name and under the cloak of charity, I believe that you, with most other Medical gentlemen, denounce it as unjust and iniquitous.

With the exception of the case of our Hospital out-door paticuts, perhaps this system inflicts no injustice or injury on the pub ic, for, unlike the barrister, the Physician is not paid his fee, or gift, until after he has performed his work: he cannot pocket any number of fees in the morning, on the understanding of seeing cases in the afternoon, and wholly neglect twothirds of them, or send a junior to them to be paid by the patient. Moreover, the Physician can be, and often is, mulet in heavy damages for any want of skill or care he may exhibit in the treatment of his patient; but an unfortunate client has no remedy against the ignorance or carelessness of his advocate.

Turning to the question of policy, it is obviously to the interest of the Bar to keep up a system, enacted, strange to say, by some Roman Emperor, to control the rapacity of Doctors and lawyers, which enables a few to rapidly accumulate fortumes and to escape all responsibility. But what advantage is it to a Physician? It neither fills his pocket nor protects him from being legally responsible for his treatment. If there had been any value in it for such a purpose it would surely have been pleaded in Dr. Semple's case the other day.

Although I do not see it, there may be something in the opinion you express, that "hororarium" upholds the dignity of the Profession better than the "merces" principle of payment would. To take the case of the late Sir Benjamin Brodie, who, during the later period of his life, practised more as a Physician than a Surgeon-do you believe that the dignity and estimation of his professional character were lowered in the eyes of the world by the fact of his holding a legal title to remuneration for his services? The wealth of the Par (i.e., of its more eminent members) is increased, but I doubt whether its dignity is increased by the "honorarium system. The dignity of a calling is propor tionate to its influence and usefulness to the community. I have yet to learn that the dignity of a cabinet minister, an ambassador, a bishop, a judge, a surgeon or dentist, an architect or engineer, is compromised by his accepting wages for his toil as "merces" rather than

"honorarium." It has always appeared to me undignified in Physicians to link themselves to barristers in this matter of fees, when the relation they bear to their respective clients is so different, and help to sanction a system of remuneration which, in the case of the Bar, is universally condemned as unjust.

Your fears that, if we established a legal title to fees, the fee would not be paid at the time, or as soon as practicable, are, I trust, groundless; at least, the consulting surgeon, the dentist, the architect, and the engineer are, as a rule, paid as soon as their work is completed.

The main question to be decided is, whether the remuneration of Physicians would be less if their fees were made recoverable at law. I hold the opinion that it would, in the long run, be much greater. If you hold the contrary opinion, you will do good service in convincing a large number of Physicians. I am, &c. SEPTIMUS GIBBON.

3, Finsbury-square, E.C., January 27.

[We cannot endorse our correspondent's argument. The fee system, as pursued hitherto, has been undeniably to the advantage of Physicians; they are not so often cheated as the General Practitioner. If their remuneration is to be no longer honorary, but is to be canvassed and squabbled for in a court of law, it is certain that the rate of fees will be lowered. What common jury, or even special jury, of tradesmen will be able, for instance, to conceive the propriety of paying a Physician his fee per mile for a railroad journey? The law values the special juryman's time at a guinea a-day, and allows a fee not exceeding three guineas for the day's attendance of a Medical man at assizes. What chance of success would the Physician have who claimed fifty or a hundred guineas for a journey not occupying a longer time? The Con sulting Surgeon's fee is considered honorary by the public, as is the Physician's.-ED.]

IS QUININE (SULPH.) APERIENT OR PURGATIVE, "PER SE?"

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-Allow me to suggest to your correspondent "M. D.," the propriety of testing the above question in his own person before requiring a solution of it from his Professional brethren. Opium invariably acts as a "smart purgative," when taken by the writer of these lines-may it not have a like action on M.D.? I am, &c. January 26.

ANOTHER M.D.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. SIR,-In answer to "M.D.," I think that most of us must conclude that the rationale of his case is purely depending upon idiosyncrasy. I have a case at present of a robust and healthy child, one year old, who lately suffered from a periodic weed every day at 3 p.m. He was put upon two grain doses of sulphate of bibeerine daily, which stopped the weed, but moved the bowels, which were habitually costive. Since then, the nurse has always found two grains of bibeerine the best aperient she ever used for this child. I am, &c. THOS. SKINNER, M.D.

Liverpool, January 26.

MENSTRUATION AND CONCEPTION.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-At what, if any, period after menstruation, is conception impossible? Dr. Prosper Lucas, in his admirable work, "De l'Hérédite Naturelle," states, in the most unqualified manner, that "there is no day, however distant from menstruation, at which a woman may not and does not conceive."-Vol. it., p. 917. Dr. Carpenter, however, in his " Human Physiology," is quite disposed to limit the period of possible aptitude for conception, and can only adduce one instance, from his own experience, in which conception followed connexion occurring so long as seven days after menstruation. (P. 1004, note, 4th edition).

Can any of your readers contribute a single case in which conception certainly took place subsequently to the twelfth day after menstruation had ceased, and not immediately prior to its return? Are there any works or contributions to the journals in which this important question is discussed in addition to those referred to by Dr. Carpenter? (Op. Cit., p. 998, 1004.) It is to be hoped that in the forthcoming edition of his "Physiology" Dr. Carpenter will be able to arrive at a definite conclusion upon the subject. I am, &c. January 24. A SUBSCRIBER. [All such evidence is hearsay, but on such evidence we know one case in which conception occurred on the tenth day after menstruation.-ED.]

FOLLICULAR CONJUNCTIVITIS.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. SIR,-In a recent Number of the Medical Times and Gazette, this somewhat rare, but highly interesting morbid condition of the conjunctiva is very instructively noticed in a review of Dr. Frank's "Report" and of Dr. Marston's pamphlet.

We should be the more especially grateful to these gentlemen for their description of the complaint by reason of the fact, as indicated by their reviewer, that no previous description of it has been given by our systematic writers on the subject.

I confess, that from what I have recently observed, I am inclined to extend the application of the sago-grain-like bodies or obstructed follicles, as proximate causes of ophthalmia, beyond the sphere of regiments or where persons dwell together in large numbers.

The condition, however, of the palpebral conjunctiva in the sporadic cases, as in the detailed, is modified in degree when compared with the typical form which these gentlemen have portrayed; or rather, it would seem that in those cases where there has been no exposure to miasmatic or unhygienic influences, the diseased condition of the conjuctiva stops short of that in which, besides follicular prominences, the connective tissue becomes studded with the grain-like bodies.

He bad

A gentleman, between 30 and 40 years of age, complained of what at first sight looked like a rather painful case of catarrhal ophthalmia, or of irritation from a foreign particle in the right eye. No cause could be assigned, and no trace of intruding substance could be detected. once before suffered from "a cold in the eye." The sensation of grains of sand under the lid had been marked for three days; there was slight swelling of the lower lid; considerable injection of the conjunctival vessels generally; lachrymation and intermitting periods of much intolerance of light. Vision, per se, was unimpaired. Search was at first made for a foreign body, but none could be found. The conjunctiva of the lower lid

was deeply reddened and roughened with distended and projected vessels. The patient seemed confident that there existed some fixed cause of irritation; and I was inclined to ascribe it to a villous projection of the mucous membrane. When, however, I had kept the lower lid everted for some little time, I perceived an indistinct opalescence in two or three spots towards the outer angle. Instead of applying a fine point of caustic to the roughened membrane, as I had intended, I scarified, with a narrow knife, these whitened follicles, producing, as the patient expressed it, instant relief, and, subsequently, an unusually speedy recovery of the eye. Believing these facts to be suggestive of treatment, I beg to submit them to your pages. I feel satisfied that there was no disposition in the case to the formation of pustule, or of minute abscess in the lid ; and I feel equally certain that the lesion described would, in all probability, have escaped my notice, had I not employed both time and patience in seeking it out. I am, &c.

Birkenhead, January 28.

GROANS OF AN ASSISTANT.

ESSEX BOWEN, M.D.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR, While it is held that the Medical Profession is one of the noblest that can by any possibility engage the thoughts or occupy the mind, it is to be regretted that some of its members act in a most disgraceful manner; for instance, two Medical men, holding a large union, club, and private practice, residing in a town in have engaged a dispenser the last month; but what, think you, has been his previous experience? Was it in a druggist's shop? No; but he was an errand-boy in a draper's establishment; and these two worthy Medical men have now employed this young lad, aged 18, without any experience whatever in compounding, and pay him the miserable salary of £30 a-year, out of which he has not only to support himself, but also assist a poor widowed mother.

May I ask, is this the way to support the honour and dignity of a Profession which they have sworn to maintain? And it is to be regretted that every dispenser employed by these gentlemen has nearly been of the same stamp as the one they have now. Of course, when the dispensers get a sufficient knowledge of compounding, they leave them, and they see no reason why they should not become members of the Profession themselves, just like the last dispenser they employed, who, after over two years' hard work for a miserable salary, commences lectures next winter at one of our London schools. Of course, the poor dispenser looks to his own interest, and, as soon as he considers himself competent, looks out for a better shop, which, heaven knows, he can easily get. By acting as these two Medical men do, they admit men into the Profession who never otherwise would have a chance of getting in. Of course, they would not give them a certificate of apprenticeship. However, any one who is acquainted with the regulations at the Hall must be aware that it can be easily got over, as it is only required to have a certificate of having served after the manner of an apprentice.

I

You will say, perhaps, these Medical men cannot afford to give a fair salary, so as to employ a really competent assistant. I say, with truth, that they have one of the best practices in, and one of them I have alluded to was, some years ago, lecturer at one of our London schools. trust they may read this letter, as they cannot contradict a word I have stated. Some principals care not if their dispenser was starving, so as they get the work done; no thought whatever of his comforts; and if they could get a dispenser to work for nothing, they would gladly do so. Indeed, there resides a certain M. D. in who boasts of kicking his assistant, but he often finds that more than he can manage.

As long as Medical assistants are treated badly by employers, and Medical men employ grocers' and drapers' boys to compound medicinethis, together with Medical men injuring each other by every mean act, lowering fees, etc., makes one ashamed to belong to such a Profession. I am, &c. A WELL-TREATED ASSISTANT.

[We may sympathise fairly with the misfortunes of assistants, but the laws of political economy will not be set aside; and whilst there are a large number of persons willing to do the work for little or nothing, their position cannot be improved.—ED.]

CHILDREN SUFFOCATED IN BED.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-As a preventive measure for this class of fatality, I wish to direct your attention, and that of your readers, to an apparatus called the Nursing Basket," invented by Mr. C. E. Wright, of Birmingham. It has been highly approved by the Medical Profession, but not sufficiently made public. I am so well convinced of the value of the basket, that I have ordered several of them, and they are now in use among the poor of this town. A child, when laid in the basket-which is very light and portable -and placed by the side of the mother's bed at night, or on the bed, would be warm and safe, and not liable to be overlaid or suffocated, which is so often the case when mothers and nurses are in the habit of going to sleep with an infant on the arm. By the use of this admirable contrivance, safety, cleanliness, health, and comfort are promoted. It has many other advantages, some of an industrial kind, to the mother, of which I cannot now stay to speak. I merely add, that a specimen of the "Nursing Basket may be seen at South Kensington Museum, at the Economic Museum, Twickenham, and at Madame Caplin's Museum, London. It is a subject worthy of the profound attention of the Medical Profession and of all philanthropists, not only to discover the true causes of such accidents, but to devise some efficient measures for their prevention. I am, &c.

Brighton, January 23.

M. A. B. A SINGULAR CAUSE OF ASPHYXIA OF A CHILD DURING BIRTH. TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE. SIR, The occurrence of such accidents as the one recorded below is, I am inclined to believe, very rare in obstetric practice, because I do not find in the works upon obstetric subjects any mention of it, excepting in Burn's "Principles," where mention is made of the membranes being carried forward by the head of the child-"like to a cap or cover"forming, I suppose, the once valued caul. Nor have I been able to ascertain that it has been met with in the obstetric practice of some of my f.iends. From these circumstances, as well also from the medico-legal interest attached to the case, I am induced to suppose that a report of the case is not undeserving of a space in the pages of the Medical Times and Gazette, and thus ensure the attention of the Medical jurist.

It has occurred to me on other occasions, owing to several causes-e.g., toughness of the membranes, etc., to find the child's life in jeopardy at

the birth; but I have never met with a case of a child, quickly and easily born, cut off from life owing to a portion of the membranes being carried forwards with it, and closely applied over its head, face, and neck, like to a tightly-fitting oiled silk cap, so as completely to exclude the air from entering the lungs through the mouth or nostrils, and thus preventing the first inspiratory efforts being made.

Had this accident occurred to an illegitimate child, the mother, although anxious to avoid exposure, yet not altogether indifferent to the well-being of her child, certainly not desiring its death, would be exposed to serious suspicions. For supposing the birth to be sudden-almost unexpected, as in this instance-did she, when recovered from the shock, endeavour to ascertain the condition of the child and remove the membranous bag from the head and face, she would, if early, probably ensure the child's life; but if, as in this case, some minutes had elapsed, its death would be certain, and no statement the woman might make would secure her from the suspicion of infanticide.

May not some of the cases of presumed infanticide find an elucidation from the occurrence of accidents similar to this? If so, it must be confessed that such cases are deserving of consideration.

Mrs. W., married, required my attention January 17, 1863, she being in labour of her third child.

I may here remark that this patient has hitherto experienced lingering labours, owing to some slight deformity about the sacral prominence: on the two previous occasions she experienced severe pains, accompanied by the discharge of much fluid two or three days before actual labour commenced.

On January 15 I received notice of her condition, she having, whilst at dinner, experienced considerable pain a short time: during the continuance of this pain she felt something give way within her, and much watery fluid escaped from her. The remainder of the day she passed comfortably in her room, and when I saw her on the evening of the 16th she was moving cheerfully about, and was comparatively easy. On the evening of the 17th she became rather more distressed, and, experiencing some three or four decided and sharp uterine pains, I was at once sent for, she having now resumed her couch. I reached her in ten or twelve minutes, and found her on the bed in the usual obstetric condition. I was surprised to learn, in answer to some queries as to her state, that the child was born, and that it had been so almost before she could properly dispose herself upon her bed; it was very quiet, but it had moved its feet slightly once or twice.

Concerned as to the extreme silence of the child, I at once proceeded to ascertain its condition, and found the infant all but fully born, lying upon its back, motionless, warm, and perfectly white; the face, head, and body covered with sebaceous matter, but looking very smooth and glistening, as if varnished; the month and eyes firmly closed, and the lips very pale in colour. On feeling for pulsation over the region of the heart, and finding it absent, the cord was appealed to, and about an inch or so from the body the umbilical arteries could be felt distinctly, but slowly and feebly, pulsating. That the child was in a condition of asphyxia was evident, but from what cause was not so evident, for there was no exclusion of air by the pressure of the clothes, nor had any restraint been imposed on the child from the position of the mother: the cause was allowed to remain unexplained for a time, and endeavours were at once employed to restore life to the child. Hot and cold water were both abundant and at hand.

As a preliminary to the employment of measures to effect the restoration of suspended animation, I proceeded to cleanse the child's face with a sponge from warm water, and was surprised to meet with some difficulty about the mouth, the entrance of my finger being resisted by the interposition of a very transparent membrane, which, puckering up about the chin, enabled me to seize it and to draw it from off the entire face and head, to which it had been closely applied, giving to the surface a glistening appearance, and completely cutting off the air to the lungs through the mouth and nostrils. On removal of this membrane from off the child's head and face, endeavours were made to recall life by the employment of the Marshall Hall method: hot and cold water, the introduction of the tracheal tube-these and other expedients proving futile after twentyfive minutes had elapsed, no respiratory movement being excited in the child, and it having become cold, and the pulsation of the cord having ceased through its entire extent, the connexion between the placenta and child was divided, a few drops of blood, dark coloured, escaping. The placenta was readily removed in twenty minutes later. The mother subsequently did well.

In conclusion, it is to be regretted that her nurse was absent, an inexperienced friend being only present at the birth. I have also to deplore my absence, for, had I been in time, the membranes would have been much earlier ruptured, so as to have permitted the child's head to have entered the world entirely free from them. I am, &c. Jermyn-street, S. W. FREDERICK HALL, M.R.C.S., etc.

ON THE TREATMENT OF DIABETES.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

"Case

SIR,-In the Medical Times and Gazette of Saturday last appears a of Diabetes Successfully Treated by the Saccharine Method," contributed by Mr. Ussher, of Canterbury. In connexion with this case there are one or two points concerning which I, and possibly some others of equally dull apprehension, would like some more information, as, on reading and re-reading the contribution, I cannot light on a single word or passage touching the administration of sugar, which, in this instance, is set forth as the curative agent by the author. Of this, however, more hereafter; and, in the meantime, I would beg to inquire what was really the condition of the patient when first seen? Under what particular disease was he labouring so heavily that he was in bed; face very much flushed; eyes glazed; tongue hanging from the mouth; lips covered with sordes; skin harsh and dry; intense thirst; inability to sleep or take a morsel of food; sternal pains severe and constant; bowels constipated?"

From this enumeration of symptoms, apparently so fatal, are we to understand that the man was dying of diabetes; and that by a combination of "spt. junip., liq. hydrarg. bi, chl." with "inf. tiles Europ.," he was. happily restored to life even when in the jaws of death? At the risk of being considered impertinently curious, and even disgustingly hypercritical. I would like to have some light thrown on the therapeutic effects of this. combination of remedies-as to how the "spt. junip." (by which, I presume, is meant the spt. junip. co.), with the inf. tile Europ." (by which is probably indicated inf. tilia) and the "liq. hydrarg. bi. cbl.," acted so well together in bringing round a patient apparently dying of diabetes. In my humble opinion this mode of treatment savours much of the motto -"Similia similibus," etc.-But there are such strangely ingenious

remedies turning up now-a-days, that we can only open our eyes, and express our thanks for all the mercies.

The patient was, no doubt, diabetic, and no doubt he was, as reported, restored to comparatively good health by a highly-varied system of tonics, and by a proper and nutritious dietary, including glycerine; for I take leave to question whether this substance contributed to the cure in any other way than by supplying nourishment, just the same as, though in a lers degree than, cod-liver oil would.

If glycerine be claimed as the chief remedial agent in this case, and as illustrating, as it is evidently meant to do, the saccharine mode of treatment, I would beg to ask in what way it can exert any curative influence further than by supplying nutrition to a wasting body? Does it, sugar of oils though it be called, go to supply the place of the grape sugar, which is being rapidly eliminated from the diabetic patient? I cannot subscribe to the notion that the exhibition of glycerine is an illustration of the saccharine method" of treatment. "To furnish him," says Mr. Ussher, "with this sugar in the quantities that he can appropriate will stop the downward progress as it did in this case; while the other constituents of glycerine will help to restore the general decadence." I would beg to inquire, what are the constituents of glycerine that remain after the appropriation of the sugar; and in what manner these constituents "will help to restore the general decadence?"

The pathology of diabetes is, doubtless, hard to be understood; but, thanks to the talented Pavy, whose researches on this subject are worthy of all praise (though I do think it has been meted out to him rather niggardly), it is becoming more intelligible; and he who would spin fine theories on the dogma-that the normal function of the liver is to form sugar, either ignorant of, or wilfully ignoring, Pavy's most conclusive I am, &c. experiments, ought to be "sent to Coventry." HYPERBOREUS. January 21,

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-In your valuable Journal of the 17th inst. a case appeared, which "is a capital illustration of that cardinal defect in Medical reasoning which the Medical Times and Gazette ånds its special vocation in correcting." The case I allude to is one by H. Ussher, M. B., of "Diabetes Successfully Treated by the Saccharine Method, and Remarks thereon." The writer terms his method the "saccharine," but from first to last not a particle of sugar, or of anything allied to sugar, was administered. Glycerine is, no doubt, sweet, but so is hyposulphite of silver, and also sugar of lead, but yet no one ever dreamt of applying the term "saccharine" to either of these two latter substances. Glycerine has no resemblance whatever to sugar of any form, but is, in reality, an alcohol of the teratomic type, its formula being CoH8O6. whereas all true sugars possess an equal number of equivalents of hydrogen and oxygen. But even granting that glycerine is or contains sugar, as asserted by the writer, it does not at ali follow that the good effects observable were due to it alone; for, in addition, the patient got a regular hotch-potch of quinine, iron, nitric acid, hyposulphite of soda, acetate of zinc, cod-liver oil, chiretta, hyoscyamus, strychnia, Dover's powder, alterative pills, and, lastly, a regulated diet. Some of the prescriptions in this case are so reculiar as to deserve a passing notice. Take, for instance, the following:- Quinæ dis., gr. viij.; ferri am. tart., gr. x; acid. nit. dil., 3j.; tr. hyoscyami, 3j.; glycerinæ, 3ij.; aq. ad 3viij., M. Now, in this most of the iron will be thrown down as sesquioxide, in consequence of the decomposition of the salt by the acid, so that the mixture will be. to say the least, inelegant. But six days later we find a far greater blunder committed, viz., the adding to this acid mixture gr. xij. soda bicarb. In order to ensure the whole of the iron being converted into as inelegant and inert form as possible, we find a new remedy introduced into a precisely similar mixture, viz., tincture of chiretta, the proper and peculiar action of both the acid and chiretta being thus impaired. May 19 we find a prescription which nothing but a very decided predilection for homoeopathy could have induced him to write. B Ferri am. tart., Oj; liquoris strychniæ, gr. j. ad Oj. 3j.; quinæ dis., gr. vj. ; acid. nit. dil., 3j.; aq. ad 3viij. How this is to be taken is not stated, but taking it like the preceding, at the rate of 3ss. ter. die, the strychnia in each dose would be exactly 1-2560th of a grain; so that it would require at least fifty-two days before the patient would have ingested the amount of one ordinary dose (1-16th gr.), even allowing that this drug is cumulative in the highest degree.

Ou

As to the method by which the writer estimated the amount of sugar, it is one which has been repeatedly proved to be so variable and fallacious in its results, that the figures stated by him cannot be relied upon. In many cases, indeed, the "companion phial" will not yield even an approximation to the truth. Thus, on April 27, the specific gravity of the urine was 1035, yet in two specimens of it the amount of sugar per ounce was respectively eighteen grains and seven grains. Now, it would be hard to account for this great difference except by supposing that some very great increase of urea had occurred, which would, of course, keep up the specific gravity, though scarcely to such an extent as would reconcile the writer's results with those of experience.

In the remarks which follow, there are one or two curious assertions made, which it would be interesting, as well as instructive, to have more fully elucidated. Thus, the connection of the liver with the skin has not, I believe, been noticed by any anatomist up to the present time. Nor does it appear from observation that proximity of any organ to the surface of the body renders it co-ordinate in use to the skin, so that the "numerous illustrations" of this fact as regards the liver would be extremely valu

able.

In the last paragraph but one of his paper, Dr. Ussher, not content with asserting glycerine to be a sugar, states that the other constituents will help to restore the general decadence." This manifestly implies that glycerine consists of sugar and certain other flesh-producing and calorifacient materials, a fact previously as unknown to chemists as the connection of the liver and skin to anatomists. These being the chief points of interest in this curious case, and apologising for the length of this communication, I am, &c. A FOURTH YEAR'S MAN.

COMMUNICATIONS have been received fromHYPERBOREUS; Dr. J. LANG; Mr. J. HAZARD; A REGISTERED MIDWIFERY DIPLOMATIST; L. L. G. F.; F R. C.S.; A. B.; A WELL-TREATED ASSISTANT; Mr. LE GROS CLARKE; F.R.C.S.I.; A FOURTH YEAR'S MAN; M.D.; Mr. F. HALL: Dr. HOGG; OLDHAM; A FATHER; ANOTHER M.D.; A SECOND WHO WAS THERE; MANCHESTER; Dr. G. JOHNSON; Dr. BARRIE; Mr. STONE; Dr. GIBBON; Dr. ESSEX BOWEN; Mr. F. L. CRUMMEY; THE SECRETARY OF THE LONDON MEDICAL SOCIETY; Dr. E. ELLIS,

Operations at the Metropolitan Free Hospital, 2 p.m.; St. Mark's Hospital, 1 p.m.; Smaritan Hospital, 2 p.m.; Lock Hospital, Dean-street, Soho, 1 p.m. MEDICAL SOCIETY OF LONDON, 8 p.m. Dr. Cockle, "On the Conditions of the Aorta Simulating Aortic Insufficiency." Mr. Streeter, "On Disease of the Brain by Extension from the Ear." Dr. Greenhalgh, "On a New Metrotome." Dr. Richardson, "On Nitrate of Amyle." Communications from Drs. Gibb and Thudichum, Mr. Baker Brown, and others.

ODONTOLOGICAL SOCIETY OF LONDON, 8 p.m. Meeting.

ORIGINAL LECTURES.

A CLINICAL LECTURE

ON THE

DIAGNOSIS OF HERNIAL AND OTHER TUMOURS OF THE GROIN AND SCROTUM.

DELIVERED AT THE

Westminster Hospital.

By CARSTEN HOLTHOUSE,

Surgeon to the Hospital, and Lecturer on Anatomy in the Medical School.

GENTLEMEN,-From what we know of the anatomy of the parts in the groin, it should follow that inguinal hernia would occur most frequently in the male, and femoral hernia in the female, and this is fully borne out by the statistics of the two affections; indeed, so true is it, that, knowing the sex, we are apt to prejudge the nature of the hernia, and sometimes erroneously, as happened in the following case, with which most of you are familiar. A man, 47 years of age, was lately admitted into Luke ward with strangulated hernia, supposed to be inguinal. A tumour of an oblong form occupied the left inguinal region, its long axis was parallel with Poupart's ligament, and it projected a little above this structure. It differed, however, from an inguinal hernia in the following important particulars:-1st. Its outline was more defined. 2nd. It was more prominent. 3rd. It was more superficial. An inguinal hernia in this situation must have been wholly or in part within the inguinal canal, and, therefore, beneath the aponeurosis of the external oblique, which, owing to its unyielding nature, would have prevented such a prominence and such a definition of the tumour as was here apparent; but the decisive test for determining whether it were an inguinal or a femoral hernia, consisted in carrying the finger into the inguinal canal. This you saw me do: invaginating a portion of the skin of the scrotum on the end of my forefinger, I passed it into the inguinal canal, and found this passage free, and the tumour lying in front of my finger. There could be no doubt, then, that this was a femoral hernia, -one of those cases I have before spoken of to you, in which the hernia, having presented itself at the saphenous opening, and continuing to increase, takes the course in which it meets with the least resistance, viz., upwards. The taxis having failed to return the hernia, the usual operation was performed, and the patient, as you know, left the Hospital well a few days ago.

In the female, the demonstration of the variety of hernia is less perfect than in the male; this arises from the impossibility of carrying the finger into the inguinal canal, owing partly to the absence of any lax skin like that of the scrotum, partly to the small size of the inguinal canal, and partly to the existence of a large quantity of subcutaneous fat; this is so abundant in some women, that the different outlets through which a hernia may protrude are with difficulty made out. In these cases, you must be guided in your diagnosis chiefly by the duration, position, and size of the hernia a recent one could not be situated above Poupart's ligament, unless it were inguinal, and in this case it would be small, ill-defined, and little prominent, causing a fullness rather than a tumour; while a small and recent hernia below that structure (Poupart's ligament) would show it to be femoral. A large and old femoral hernia might, as already seen, turn up over Poupart's ligament, and so occupy the inguinal region, but it would produce no alteration of the labium pudendi of the same side; whilst, on the other hand, a large and old inguinal would pass down into the labium, and produce a marked contrast between it and its fellow. There is, however, a variety of inguinal hernia which descends into the thigh instead of into the scrotum or labium, and so resembles a femoral hernia; but this is so rare an affection, that I need do no more than call your attention to the fact that such a hernia has been described. Its diagnosis from a femoral hernia might probably be established by a careful examination of the tumour and by the history of its origin and progress.

I now come to the second and more important part of my subject, viz., the diagnosis of hernia from other swellings which bear some resemblance to it, and these may be classed under two heads:-1st. Those situated in the neighbourhood of the VOL. I. 1863. No. 658.

groin, including the region immediately above and below Poupart's ligament; and 2nd. Those met with in the scrotum or labium. Among the tumours in the former situation may be enumerated enlarged glands, abscesses, imperfectly descended testis, hydrocele and hæmatocele of the cord, adipose tumour of ditto, the fibrous tumour of the iliac fossa of M. Nélaton, occurring, for the most part, only in females, aneurism, dislocation of the femur upon the pubes. The three last of these may be fairly dismissed from our consideration, as their characters are too well marked to be likely to be confounded with hernia. The tumours in the scrotum or labium which bear some resemblance to hernia, are hydrocele, common and encyated, hæmatocele, varicocele, sarcocele, and other tumours of the testis or cord; and, in the female, cysts and chronic abscesses of or in the labium.

Enlarged glands have been mistaken for hernia, and vice versa. Here are two casts, one of a direct inguinal hernia, and the other of a chronically enlarged gland, and, as far as appearances only are concerned, they certainly bear a very close resemblance to each other; but there was no other point of similiarity: the one was reducible or disappeared on pressure, the other did not; the one was soft and elastic, the other hard and unyielding; the one had an impulse communicated to it on coughing, the other had not; the one first appeared suddenly, the other had been slowly growing. And here I must caution you against relying implicitly on the statements of patients. A widow, 66 years of age, presented herself among the out-patients, when I was Assistant-Surgeon to this Hospital, with a tumour in the left groin, which she called a rupture. She said she first observed it about nine months ago after carrying a heavy load, and that till quite lately she had been able to reduce it; she was now unable to do so, and, therefore, came to the Hospital to have it reduced. On examination, I found a large red, irregular shaped tumour, evidently composed of a mass of diseased glands, and on further investigation I discovered that the source of this enlargement was carcinomatous ulceration of the uterus and vagina: yet so prone is poor human nature to deception, and so loth to be undeceived, that this patient went away dissatisfied that her so-called rupture was not returned, and, as I afterwards learnt, she declared that her case was not understood.

Abscesses, one would imagine, could scarcely be mistakenfor hernia, did we not know by experience that the contrary is the fact. You have all, I believe, seen a case now under my care, in which this mistake was committed. The patient, a mariner, 29 years of age, presented himself at the Surgery, with an oblong swelling, extending obliquely from near the right anterior superior spine of the ilium to the spine of the pubes; the skin over it was of a natural colour, but it was. slightly tender on pressure, especially towards its iliac extremity; it distinctly fluctuated, no impulse was communicated to it on coughing, and it could not be made to disappear on pressure. The history the patient gave of the tumour was the following:-About two weeks ago, on going aloft, he felt some stiffness in the hip-joint, and, on examining his groin, found a small swelling, as large as a walnut. He immediately consulted a Medical man, who told him it was an enlarged gland, and prescribed accordingly; but, at his next visit, on finding it larger, it was pronounced to be a rupture, and a truss was applied. This the patient was wearing when he came to the Hospital.

Only a few days ago, I was requested by a Surgeon in the country to see a female, who had a swelling in the right groin, about the nature of which he was doubtful, though he suspected it to be a femoral hernia. It was soft and elastic, and partly reducible; but it was also dull on percussion, fluctuating, and slightly tender on handling. It was a psoas abscess. But not only are abscesses sometimes mistaken for hernia, but the latter for abscesses. Some years ago, while I was Assistant-Surgeon to this Hospital, a female, 46 years of age, was sent here from the country, with a large tumour in the right groin; the skin over it and around it was dis coloured, having a bruised or ecchymosed appearance, as if the tumour had received a severe blow, or been roughly manipulated. This discoloration, together with its great size, and the absence of any definite history, led the Surgeons who saw it to doubt whether it were a hernia, and one of them inclined to the opinion that it was an abscess. However, as the bowels had not acted for three days, it was determined to make an exploratory incision into it. Extravasated blood escaped from the incision, and, on cutting deeper, the sac of a large hernia was opened, from which escaped a