pupil when commencing his course of clinical instruction in the wards of an hospital. The first years of medical study ought to be chiefly occupied in observation, rather than reflection. He ought first to lay in the materials, before he begins to think upon them, or arrange them into doctrines or systems. There are a number of speculative subjects introduced into this work, which are calculated to abstract the attention of the student from actual facts before his eyes, and bewilder him in metaphysics. The second part of the volume consists of an "exposition of the medical creeds of materialism and vitalism, &c. &c." This occupies 156 pages of letter-press, and embraces, among other recondite matters, the question, how man was first formed? Now we seriously ask Dr. Thorburn whether he thinks the student, who is overwhelmed with lectures, and his whole time occupied in acquiring elementary knowledge, can possibly dive into these mysterious subjects, without losing the substance, while hunting after the shadow ? Should the work ever come to a second edition, we advise the author to strike out three-fourths of the matter, retaining nothing but those portions that are adapted to aid the student in acquiring elementary and practical informationthe only species of knowledge which he ought to aim at, while in the schools. When he leaves the lecture-room, the hospitals, and the dissecting rooms, to search after private practice, then, and not till then, would we recommend Dr. Thorburn's work, in which he will find a vast magazine of valuable information, mixed up with boundless speculations that will exercise the utmost stretch of his thought and imagination. We have reason to know, that the author is a young physician of great promise, and unwearied industry. When his judgment becomes a little more matured, so as to keep his genius in check, he will produce a less erudite, but a more useful volume than that which is before us. We recommend it, finally, to the practitioner-student, and not to the school-student. INDUCTION OF PREMATURE LABOUR. We select the following melancholy case from the 42d and 43d parts of Dr. Davis's excellent and economical treatise on obstetric medicine. Case. "In the summer of 1819, Mrs. P. became the subject of a profuse hæmorrhage in the earlier part of the eighth month of her first gestation. She was at the time occupying a temporary residence at Richmond in Surry. The amount of the hæmorrhage was so great as exceedingly to alarm her, and to induce her forthwith to return to her house in town. Having previously engaged the author to attend her in her expected confinement, she sent for him immediately upon her arrival in London. The orifice of the uterus was found on examination but slightly dilated, and as rigid as if no hæmorrhage had been sustained, although it was described as amounting to nearly a GALLON of blood. This statement, however, it is to be presumed, must have been much exaggerated. The circumstances of the case were such as greatly to have alarmed her husband and the members of her own family, and it was suggested that it might be desirable to obtain a consultation. It was accordingly arranged that a consultation should be held on the evening of the same day. It was attended by the late Drs. Sims, John Powell, and by the present reporter of the case. After each of the party had satisfied himself that he could feel a small portion of the placenta attaching to, and even in the form of a slender stringy substance protruding a little waythrough the orifice of the uterus, it was resolved to recommend the operation for the induction of premature labour without delay. This resolution was no doubt partly formed on the exaggerated representations given of the amount of the hæmorrhage which had occurred at Richmond. Inasmuch as the author had been pre-engaged to attend the patient in her confinement, the duty of operating of course devolved on him. The operation was performed in the presence, first of one and then of the other of his friends who had assisted him in the consultation; and he believes with as much slowness and caution as could be well practised. It indeed occupied between four and five hours in the performance; which is itself at least a presumptive evidence that the precautions usually observed in such cases were not neglected. After effecting the dilatation of the orifice of the uterus, the presenting ovum was found unruptured, and the lower extremities of the child, which could be felt through the membranes, were brought down without difficulty. After the removal of this child, which was alive and vigorous, although unusually small for its period of supposed uterine growth, it was soon discovered that there was another in the uterus. The membranes of the second child presented as in the other case, and the second birth was completed in about a quarter of an hour after the first. The double placenta, for such was the case, was thrown off in the course of about another quarter of an hour, and no hæmorrhage was sustained after its removal. Both children were alive and vigorous. It was not however supposed they could long survive; and they accordingly died in the course of the forenoon of the day following. The mother was considered next day to be doing pretty well, after having enjoyed a TOLERABLY good night: she nevertheless complained of some headache and fever, and had had little or no lochial discharge. The skin was rather harsh and dry; the tongue was white and loaded; and the patient had drunk very freely of diluent fluids, Her pulse was perceptibly excited: but what she most complained of was a painful throbbing, which she referred to the small of the back. There was also some tenderness of the hypogastric region; for the relief of which, a dozen leeches were ordered to be applied to the part affected. A general bleeding was not advised, in consideration of the very great quantity of blood which had been already lost. Mrs. P. was visited daily till the morning of the fifth day after delivery; when all the gentlemen who had previously met in consultation were sent for in great haste on account of an alarming hæmorrhage with which The reader may readily conceive the distress of mind which this unfortunate termination of a case so interesting ochardly conceal from himself the procasioned to the author; since he could bability that it had arisen from rupture consequence of too much force applied of a part of the orifice of the uterus, in tion with which the operation of preto it, notwithstanding the extreme caumature delivery had been performed. inspect the body after death, it was Permission having been obtained to some satisfaction to find that no such actually been inflicted. The cause of rupture as had been apprehended had the hæmorrhage however became suffibearing incident to the introduction of ciently manifest. The long-continued the hand had produced contusion, inflammation, and suppuration of the os the diameter of a sixpence, had sloughed uteri; and a portion of its tissue, about of the same extent. On examining careoff, and left behind it a deepish ulcer fully this part, several considerable branches of arteries were found in the depth of it, open to the day: and thus was rendered evident the cause of the fatal hæmorrhage." MR. MIDDLEMORE ON PTERYGIUM.❤ Mr. Middlemore is favourably known to the profession by several interesting the eye: the contribution before us meand useful papers on the diseases of rits notice. Pterygium, as Mr. Middlemore obgular figure, generally commencing at serves, is a morbid growth of a trianthe inner canthus of the eye, at that part of the conjunctiva immediately around the semilunar fold and lachrymal caruncle, its point or smaller ex * Prov. Med. and Surg. Transactions, Vol. III. tremity being situated towards or upon the cornea, and its base directed towards the periphery of the eye-ball. This is its ordinary, but not constant situation. For not only may it be seated on some other part of the eyeball, but it may form on different parts at once, and the pterygia converging on the cornea may utterly obscure the pupil. It is not uncommon to observe two pterygia upon one eye-one arising from the inner, the other situated at the outer canthus. "Perhaps," says Mr. M., "I may be allowed to state upon this subject, as the result of my own experience, that the frequency with which pterygium occurs, as respects the various parts of the eye, takes place in the following order: first-the formation of a pterygium upon each eye, arising from the inner canthus ; secondly-the occurrence of two pterygia upon one eye, one arising at the inner, and the other at the outer, canthus; thirdly the formation of one pterygium alone, either at the outer canthus, or at the upper or lower part of the eye-ball, but not at the inner canthus. The occurrence of four pterygia upon one eye, the points of which have met upon the cornea and completely obscured the pupil, constitutes, in the opinion of the celebrated Scarpa, the pannus of the ancients. I have only witnessed one case, and that very recently, in the eye of Joseph Burley, a patient now under my care at the infirmary." Mr. Middlemore agrees with Scarpa in believing that the triangular form of pterygium, is dependent on the increasing strictness of adhesion between the sclerotica and conjunctiva, as the latter approaches the margin of the cornea, and between the conjunctiva and the cornea, as the former advances to the centre of the latter. He disagrees with Scarpa in thinking pterygium a conversion of the conjunctiva, but conceives it to be a growth under it. Having premised this we may present our author's description of pterygium. "The first appearance of pterygium is indicated by a few enlarged conjunctival vessels, proceeding from the inner canthus, (I will assume that to be its situation for my present purpose) and running in a direction nearly parallel to each other; at the same time, there is an appearance of increased thickness in the conjunctiva, just as though a fine web, or film, had been spread upon its surface. In a short time, there is seen a small reddish deposition, situated at about two or three lines from the corneo-sclerotic junction, and the vessels proceeding to, and terminating in it, begin to assume a more definite and distinct arrangement; by very slow degrees this deposition near the cornea becomes more apparent, increases in size, and approaches nearer to the cornea, until it reaches the line of union between the cornea and sclerotica, where it is seen to project above the corneal margin. The vessels proceeding to it, and constituting part of its volume, now become more numerousthe texture in which they are placed increases in density and opacity-and its outline is rendered perfectly distinct by its elevation above the surrounding portion of conjunctiva; it is also quite moveable, and may be raised more or less extensively from the sclerotica, according as its connexion with the texture beneath may be merely filamentous, or by a greater extent of more intimately connected surface. At this stage the nature of the disease is rendered quite evident; there is, in short, a red triangular deposition beneath the conjunctiva, which is gradually acuminated towards the cornea, where it rises in a distinctly elevated projection around its margin. The disease may remain for a long period in this situation, before it makes any discoverable progress upon the cornea; but, after a time, if no measures be employed to impede its growth, it continues its course, acquiring thickness and strength as it advances, until it appear like a triangular muscle, and may extend (gradually tapering as it proceeds) to the centre of the cornea, particularly if a similar pterygium be advancing from the opposite side, when its point is much finer than in those instances in which no opposing pterygium exists." Passing over many pages of diffuse remarks, we arrive at Mr. Middlemore's division of pterygium into three varieties, viz. 1, the membranous, or pterygium tenue, which is merely a thin semitransparent layer, in which the course of the vessels may be distinctly observed;-2. the fleshy pterygium, or pterygium carnosum, which resembles, in outward appearance, the fibrous structure of a muscle;-3. the adipose pterygium, or pterygium pingue, which is chiefly of a white, soft texture much resembling common fat. This latter variety of pterygium is, however, much less common than the two former. In a case of the sarcomatous pterygium which had gone to some extent, and in which Mr. Middlemore removed the morbid growth by the knife, he found the cornea beneath it opaque, and vascular, and thickened. He therefore cautions the young surgeon against anticipating much success in similar cases, in opposition to the opinions expressed by many writers on ophthalmic surgery. He observes, too, that in old cases of large sarcomatous pterygium, when the disease has arrived at the centre of the cornea, it spreads laterally, so as to acquire a very obtuse extremity, and that in this way it may obscure nearly the whole of the pupil, and destroy all useful vision. It does not proceed from the centre directly across the pupil; it does not progress in a direct and continued course; but covers the greater part of the cornea by its expansion laterally when its direct progress has been arrested by its arrival in its centre; so that, eventually, nearly the whole of the cornea becomes concealed and obscured. The prognosis of pterygium is simple enough. The earlier it is taken the more curable it is, for if it has lasted long and extended far on the cornea, it has probably adhered to and occasioned serious alterations of that tissue. For the diagnosis of pterygium the reader or the student has only to refer to the description. We arrive at the treatment. We may sometimes, says our author, arrest the progress of pterygium by the use of astringents and stimulants; and the cases in which they are most useNo. 63 fully employed for this purpose, are, when the pterygium is small and of recent origin, and is actually increasing in size. The common zinc wash, or the nitrate of silver or sulphate of copper drops, in the proportion of two or three grains to the ounce of water, are the best remedies for this purpose; and the patient may be directed to allow a little of the one or the other of these applications, as may be preferred, to be dropped upon the pterygium, from a common capillary tube, two or three times a day. If, by these means, its increase can be checked, then their use may be suspended, (and this is more particularly necessary when the nitrate of silver drops are employed on account of their tendency to tinge the conjunctiva) for it not uncommonly happens that, when once the progress of pterygium is arrested, it will not again increase, or will at least remain stationary for a long time; still, if at any future period it should evince a disposition to enlarge, the same practice may be again employed. Escharotics were much used, bnt they are mischievous; and scarifications have been employed, but they are inefficient. Partial excision is the simple and effectual remedy. Various modes and instruments have been adopted. The following is Mr. Middlemore's. "If the patient should be requested to lie upon a table or sit upon a chair, and, having the eyelids well separated by an assistant, so as to expose the whole of the globe, (which should be steadied by the firm pressure of the index and middle finger on each side) the operator should grasp the pterygium with a pair of hooked forceps, and having raised it from the sclerotica, pass the probe-pointed blade of a wellmade pair of scissors underneath the elevated portion, midway between its base and the margin of the cornea, and having divided that portion, as far as its union with the sclerotica will permit, he turns the scissors to the opposite side, which should be also divided in the same way; with a fine scalpel the pterygium may be then dissected and detached from the sclerotica and the cornea by a succession of careful 17 incisions, taking care that the flat side of the scalpel is directed towards the globe of the eye, so that its cutting edge shall be directed rather away from, than towards it. If an incision be made upon the pterygium from its external side towards the globe, the sclerotica may be either cut or injured, or much unnecessary pain excited by partially dividing the pterygium in various places; or if, with a view of preventing the necessity of making several incisions, and with the intention of severing the whole of the pterygial production at once, the operator, in the plenitude of his courage and dexterity, makes one free section, the eye-ball may be either slightly incised or completely punctured; and if the scalpel be placed underneath, and the pterygium cut from within outwards, as Mr. Guthrie (p. 142) recommends, it may be raised, indeed, nearly half an inch from the eye-ball, and very probably torn from sclerotica or cornea, rather than divided. And this is not merely a theoretical objection, but a matter of the most probable occurrence; and I have myself seen that portion of the conjunctiva situated at the upper part of the eye-ball, and which forms its point of reflection, pulled quite downwards, and nearly the whole of the conjunctive membrane raised, and absolutely stripped from the sclerotica and the eye-lid, during an attempt to detach a pterygium situated at the upper part of the eye-ball, in the mode recommended by Mr. Guthrie. I may further remark, that the scissors employed ought to be rounded at the extremity of that blade which is passed beneath the pterygium and pushed against the conjunctival fold which connects it with the sclerotica, lest it should penetrate or otherwise injure the eye-ball; and the same precautionary remark applies to any, and every, instrument which it may be considered necessary to pass beneath a pterygium for the same purpose, as it is quite impossible to prevent, in every case, by any care and precaution the operator may employ, the sharp point of an instrument from hitching upon or puncturing some important part in an un steady eye, the muscles of which are contracting (as they will do under the excitement of an operation) spasmodically." After the operation, the usual means should be adopted to exclude light, keep the eye-ball clean, and prevent adhesion of the eye-lid to it. After the excision of the pterygium, small portions of loose ragged conjunctiva may remain, as it may be difficult to take away the whole of the pyterygium at once, and in either of these cases it is desirable to remove the loose portions by means of the curved scissors, at a subsequent operation, if they do not contract under the use of astringent applications; at all events, it is not right to attempt to destroy them by the aid of strong caustic and escharotic sub THE ARTICULAR EPIPHYSES FROM RICKETS. BY THOS. BRAYNE, Esq. of Banbury. Mr. Brayne, who appears to be a very intelligent surgeon, has related the following case in the last volume of the Provincial Society's Transactions. He has added to his narrative a sketch of the unhappy patient, which confirms whilst it illustrates the description. Case. T. P., æt. 7. He was born of healty parents, whose seven other children, though of strumous diathesis, were tolerably healthy also. In three or four weeks after birth, the subject of the case became affected with diarrhoa, and with slight stiffness and enlargement of the right elbow. The diarrhoea continued unabated up to the year preceding this report. It then |