There is a singular inconsistency in the reasoning of M. Civiale, in his estimate of the effects of nitrate of silver applied upon the mucous membrane of the urethra. He says (p. 290,) it has generally been admitted, but without reflection, that nitrate of silver acts simply as an escharotic. If it were so, and if each application destroyed, as is said, a portion of the membrane,-its whole thickness should be destroyed when, as is frequently the case, it is applied many times. This is, however, not the case; for when we have an opportunity of examining such a case after death, no traces of the application can be found. At page 295 he says, whenever it is repeatedly and unguardedly applied it occasions serious disorder, such as false passages, &c. Now it seems to us that if it makes false passages it must very completely destroy the whole thickness of the mucous membrane. On the whole, then, every one will be struck by the gloomy pictures painted by the opponents of each. To a certain extent Ducamp also did so, but still he always regarded dilatation as the ultimate means of cure: his followers have lost sight of that, and advocate the destruction of every morsel of morbid product, and hold dilatation to be an unnecessary and painful expedient. The opponents of cauterization point to cases where persons who have been cauterized have had for the remainder of their lives much difficulty in making water; where inequalities, corresponding to cicatrices, have been produced by it; and where obstinate discharges, complaints of the testicle, and other complications have been the result.

That the methodical treatment by bougies is the surest plan of treatment in ordinary cases, there can, we think, be no reasonable doubt; that it is the necessary complement to the treatment by caustic is equally clear; and it was in accordance with this conviction that Ducamp introduced certain modifications in the form of dilating bodies. He conceived that it was desirable to procure the greatest possible amount of dilatation; that is to say, he wished to make the narrowed portion as wide as it was before it became diseased. As the orifice is the narrowest part of the canal, a cylindrical instrument large enough to effect the complete dilatation cannot be passed without much difficulty and pain. Supposing it be deemed proper to introduce such an instrument, either an incision must be made so as to enlarge the orifice, or a bougie, bellied or enlarged at one point, is the only plan by which it can be accomplished. It is found that the orifice may give way for a moment so as to allow the enlarged point to pass without much inconvenience. To the use of the bellied bougie, or bougie à ventre, Ducamp was accustomed to attach much importance. Mr. Guthrie also thinks the principle an important one. In some cases he "attempts to dilate the diseased part without dilating the whole; without dividing the orifice, to obtain admission for a larger instrument." He says, (p. 74,) "My first attempt in this way was by having a bulb made about an inch from the end of the instrument, which was small at its point and gradually increased to the size desired, from which part it again diminished to a proper-sized shaft;" but as this did not succeed to his wishes he got Mr. Weiss to make a sort of speculum for the purpose. Again: "The opportunity for dilating was in general too tempting to be resisted, and the consequence was that it produced irritation in so many cases that I was forced to give it up." He got a dilator made of softer materials, which was proposed by Dr. Arnott, but

which also failed; and he only mentions those circumstances and some improvements he suggested to Dr. Arnott for the purpose of showing the attention he had paid to the improvement of this part of surgery, and that M. Ducamp had no right to lay claim to an invention which Mr. Guthrie states was long known and used in England.

In science the priority is usually conferred on the man who first records an invention, unless good cause to the contrary can be shown. Now, Mr. Guthrie may have used a bellied bougie in 1821, but M. Ducamp first recorded such an invention, not in 1825, as Mr. Guthrie states, but in 1822. And no later in that year than the 6th of May, Deschamps and Percy reported upon it to the Institute. We think, however, that neither M. Ducamp nor Mr. Guthrie need have taken much credit for the invention, for a more utterly worthless instrument for the majority of cases we could scarcely conceive: we are surprised that a surgeon of Mr. Guthrie's experience should have bestowed a moment's attention upon it. M. Civiale, who has had ample opportunities of estimating the value of these instruments, speaks but slightingly of them:

"The bellied bougies which have been proposed to remedy the inconveniences of the cylindrical instrument, are not so useful as has been supposed. Although we may, in certain cases, have recourse to them, they are far from producing the good effects which have been attributed to them. Spite of the eulogiums of Ducamp, who was not always able to avoid exaggeration, nor to preserve impartiality in the parallel between his own plans and those which experience had consecrated, the bellied bougie is in the present day abandoned. The extraordinary dilatation which is sought to be obtained by them is judged to be useless by all practitioners." (p. 208.)

With reference to forced injection, scarification, puncture, incision, and excision, as means of curing stricture, we shall only remark-that the alleged success of the first plan rests on a fallacy, the idea that in cases of stricture the retention of urine is caused by a blocking up of the contracted part by thickened mucus, which can thus be washed away; that the second and third methods, though practised for centuries, should not, we conceive, be used when the contracted point is too small to admit an instrument; and when an instrument can be passed, the puncture or incision is surely not often necessary.

Whatever be the means employed in the treatment of stricture, it is quite certain that the cure is not frequent. Those who rely upon caustic allege that the sound does nothing more than flatten the morbid product; the partisans of dilatation maintain that caustic is followed by an unyielding cicatrix. The true principle of cure we conceive to be this,to effect the dilatation of the canal with the smallest possible irritation. This principle cannot be carried out by permanent dilatation,—the irritation is too great, and the reproduction of the contraction is often rapid; it can rarely follow the repeated use of caustic, which leaves in the end a thicker tissue than it found. We believe that the principle is best carried out by prudent dilatation; the chances of absorption and the regeneration of the primitive elasticity of the canal is then great; but even this treatment may be carried out too energetically, much irritation may be induced, and the induration increased: and there are cases where the irritability of the surface is so great, that dilatation can only be employed when that irritability has been modified by the application of the nitrate of silver.

ART. XV.

1. Some Account of the Epidemic of Scarlatina which prevailed in Dublin from 1834 to 1842 inclusive, with Observations. By HENRY KENNEDY, A.B. M.B. T.C.D. &C., one of the Medical Officers of St. Thomas's Dispensary.-Dublin, 1843. 8vo, pp. 214.

2. Scarlatina, and its Treatment on Homeopathic Principles. By Jos. BELLUOMINI, M.D.-London, 1843. 8vo, pp. 32.

3. Untersuchungen und Erfahrungen über das Kohlensaure Ammonium und seine Heilkräfte gegen das Scharlachfieber, &c. Von A. W. BODENIUS.-Heidelberg, 1842. 8vo, pp. 170.

Experimental Researches into the powers of the Carbonate of Ammonia as a Therapeutical Agent in the Treatment of Scarlatina. By Dr. A. W. BODENIUS.

Few tasks are more interesting than that of tracing the various changes which diseases have undergone in the course of time. Some maladies, once the scourges of our race, have ceased to exist, or have assumed so mild a form as no longer to excite alarm; while others, which in bygone days were comparatively trivial, are now dreaded as dangerous or fatal. This fact did not escape the notice of the earlier medical writers. "Mutantur quidem morbi," says Van Helmont, "larvantur, augentur, degenerant. Nec veteres morbi respondent amplius descriptionibus avorum. Postremo nuper ad nos venerunt morbi novi, et antiqui deinceps vix amplius respondent ad nomina et descriptiones avorum, quia signa et proprietates alienas induerunt, quibus larvati incedunt." No disease has afforded more striking illustrations of such mutations than scarlatina has done, since the time when it first ravaged Spain and Italy under the name of the Garrotillo. On these, however, we cannot now dwell. Our present purpose only allows us to observe, that about the commencement of the present century, scarlet fever assumed an unwonted malignancy, and spread epidemically, especially in Germany, where its ravages were frightfully severe. Thus, in the neighbourhood of Wittenberg, four hundred persons were attacked in the course of fourteen days, and one in ten died. in London, too, the disease ran a rapidly fatal course, and was distinguished by the severity of the sore throat by which it was attended. It prevailed also in Ireland as an epidemic disease from the year 1801 to 1804, running a fatal course in many instances, and presenting much of the character of scarlatina maligna. It then changed its character, and continued for many years so mild, that Dr. Graves informs us in his lectures," although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution." With that selfcomplacency, so natural to mankind, this diminished mortality was attributed to the altered plan of treatment, to the doctrines of Brown having been discarded, and antiphlogistic means resorted to in place of the stimulating and exciting method which he advocated. In 1834, however, the disease resumed the grave features it seemed to have altogether lost, and Dr. Graves states that the Irish physicians of the present day are

• Schnurrer, Chronik der Seuchen, ii Band, s. 437.

forced to confess that in spite of their boasted improvements they have not been more successful in 1834-5 than their predecessors were in 1801-2. It appears from the account given by Dr. Graves, that scarlatina in Dublin was seldom attended with danger until the year 1831, when a remarkable alteration began to be observed in its character; its previous inflammatory type was replaced by a concealed insidious form of fever, attended with great debility. It now, too, often terminated fatally, and began to extend much more rapidly and universally than before. Neither the state of the weather, nor the abode of the patient, seemed to have any influence in modifying its character or diminishing its prevalence. It is to a description of this epidemic that Dr. Kennedy's little work is devoted. Unfortunately, he furnishes us with no account of its rise, progress, and decline, or of the various fluctuations in character which it displayed at different times, or of how it seemed to be modified by the prevalence of other diseases, though such points should always be related by the historian of an epidemic. He does not attempt any classification of the various forms which the disease assumed; if we except a division he makes when describing the post-mortem appearances into the simply malignant, and the complicated; the latter comprising those cases in which there was very serious affection of the throat. Neither does he give any description of the disease as a whole, but treats of each symptom separately, and then details a number of cases which occupy sixty pages, and from these membra disjecta, the reader is left to form a picture of the disease as he best may. The faults of the book, too, are not confined to defects in arrangement, but the style is obscure and awkward in the extreme. It is, we think, no unreasonable requirement to expect that a gentleman who writes A.B. after his name should be able to express himself in English, but Dr. Kennedy breaks the rules of syntax in nearly every page, and we have often been able to gather the meaning of a sentence only by carefully comparing it with the context.

We will now endeavour to furnish our readers with a sketch of the main features of the disease as we can collect them from Dr. Kennedy's account, which, in spite of all its defects, is evidently the work of an honest, diligent, and truthful observer. In the simply malignant form, the eruption usually faded much after death; but in some cases in which it had not appeared until late in the disease, it went on rapidly increasing until death," and continued to do so for a considerable time after, till at last the body in many parts became black, and taken as a whole was of a very dark colour. In these cases great swelling took place after death, and the signs of decomposition set in very early." (p. 3.) Vibices and petechiae were present it many instances, and a lividity of the extremities as great as in patients who have died of cholera. In many of those parts too, where the body had been exposed to pressure, the integuments were found in a state of slough, which, however, seldom extended for any great distance. The cerebral substance was usually injected, and the ventricles contained fluid. Sometimes, too, there was an appearance of extravasation of blood beneath the arachnoid, such as is occasionally met with in typhus fever. Usually the appearances found in the brain after death, were in exact proportion to the severity of the cerebral symptoms during the lifetime of the patient. The lungs were found highly congested, and often broke down very easily; the bronchi were loaded with frothy serum,

and their mucous membrane was much congested. The heart was loaded with black blood, petechiae were sometimes present on its surface, and its texture was occasionally softened. The blood was usually thin and watery. Congestion in patches, of the different abdominal viscera, was all that was found even in cases where during life the abdominal symptoms had been most striking.

The second, or complicated malignant form of the disease, was characterized by the severity of the affection of the throat, which sometimes came on when the fever was at its height, but quite as often after convalescence had begun. It generally proceeded very rapidly, and usually affected both sides of the neck, rendering the integuments extremely hard, sometimes reaching down to the pectoral muscle, and attended with great swelling, which subsided very rapidly after death. Serum or pus was found infiltrated into the cellular tissue; sometimes the pus was collected into one large abscess, or formed a number of little ones. In all these cases there was a great tendency to sloughing; and when that took place the lymphatic glands sometimes suppurated, and even the upper part of the sterno-mastoid muscle became disorganized. In three instances of this kind the patients bled to death, owing to the vessels of the neck giving way, and in two of these cases the jugular vein was ascertained to have been the source of the hemorrhage. There was another form of swelling about the neck, caused by the effusion of lymph only, which attained a large size very rapidly, was attended with no discoloration of the skin, but with extreme hardness of the integuments, and showed no disposition to suppurate. It does not appear that sloughing of the mucous membrane of the throat was the cause of death in any instance, but diphtheritis seems not to have been an unusual complication, and œdema of the glottis proved fatal in some instances.

"Both of these forms of disease were found accompanied by ulcerations varying in extent and number,-thus there was very constantly one in the upper part of either tonsil; its edges were irregular, and its depth usually very considerable. I also found ulcers in a very distinct form about the chorda vocales; here, also, they were deep, but of a more circular form, and about the size of a grain of large shot; in one instance the ale of the thyroid cartilage had become diseased." (p. 18.)

These ulcerations of the mucous membrane of the larynx seem somewhat analogous to those described by Dr. West as occurring in the course of measles.

Among the sequelae of the disease Dr. Kennedy notices some forms of wry-neck, which he believes take their origin from the affection of the throat and neck we have just described. He distinguishes three varieties of it, and speaks first of

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cases in which, when the patient was to a certain degree convalescent, it was found that the child's neck had become crooked, and that when any attempt was made to bring the head straight, it caused severe pain, referred to the upper part of the neck, and commonly to one side. The pathology of this form of wryneck is yet to be made out. Mr. O'Ferrall suggests that the inflammation of the throat spreads to the neighbouring textures, so as to engage those of the spine, and sometimes in this way causes caries. That this might occur is highly probable, but it must not be forgotten that apparently well-marked disease of this part of the spine may be with, or without any serious lesion, and in proof of it I would refer to what Dupuytren has published on the subject. There are, however, two other affections, of the nature of which I have been able to satisfy myself, both of which