which is at first generally supposed to be rheumatic, but which terminates in the formation of large abscesses, differing in some respect from common phlegmons. M. Civiale states that these cases have escaped the observation of authors, but says that since his attention has been directed to them, he has met with numerous examples. When these accidental pains first make their appearance, the patient complains of a peculiar "empâtement" (?) and numbness of the part, which come on before any swelling is apparent. These local symptoms are accompanied with lassitude, weakness, anxiety, and general constitutional disturbance, which does not correspond at all with the degree of pain, which in the early stages is generally slight and diffused. As the case advances the pain becomes more acute, there is complete loss of appetite and sleep, great prostration of strengh, the pulse being sometimes scarcely to be felt; rapid emaciation, dry tongue, troublesome cough, and lastly delirium. The disease often commences with a febrile paroxysm, which may return at regular intervals or be continued. Together with these symptoms the urine is often of a deep orange colour, and is excessively fetid, and when this state of the renal secretion is met with, the case is always very serious. Local redness and swelling of the painful part, with evidence of the formation of matter, frequently do not make their appearance till a late stage of the disease.

One peculiarity in this affection is a tendency in the local disease to shift its position, and it often appears in different places at the same time. The suppuration in distant organs is often accompanied also with the formation of an abscess in the scrotum, perineum, or neighbourhood of the urethra or bladder, which, however, form no communication with the urinary passages. With regard to the causes of this disease, M. Civiale has not remarked any predisposing circumstances. All the cases occurred in adults. In four there was stricture of the urethra, during the treatment of which affection (in one case by cauterisation, and in the three others by dilatation,) the abscesses were developed. In a fifth case there was serious disease about the neck of the bladder, and in several others there was urinary calculus, which had been broken down by the operation of lithotrity. In all the cases there seemed to have been some considerable irritation or inflammation of the urethra, or neck of the bladder, which appeared to give rise to the distant affection.

The peculiar state of the system, accompanied by the formation of these abscesses, is attended with considerable danger, and M. Civiale lost the first two patients which he treated.

The treatment found most efficacious was scarification of the whole of the affected surface in the early stage (from which a reddish or yellow coloured serum is generally discharged for several days in considerable abundance,) and then the use of emollient poultices. This plan will sometimes cut short the disease, but if the inflammation has reached the deep-seated cellular tissue of the limb between the muscles, this texture becomes indurated, and a vast abscess soon forms; several large deep incisions must now be made completely through the affected parts, which will allow of the escape of the matter, and also unload the distended vessels. The surgeon must not always wait for the sense of fluctuation to be apparent before he makes his incisions, for great relief will be afforded by cutting through the inflamed and indurated tissues before pus has actually been secreted, and the progress of the disease may be thus arrested. M. Civiale does not make any remarks concerning the general or constitutional treatment of the patient, but we presume that this must be conducted on common principles.

Successful Case of Cæsarian Section, with Suture of the Uterus. By Dr. Godfroy, of Mayence.'—On the 27th of March, 1840, Dr. Godfroy was called by M. Renant to a poor woman who had been two days in labour.

'Gazette Médicale, 11 Juillet, 1840; and Br. and For. Med. Rev Oct. 1840, p. 578.

The term of gestation was stated to have passed over by fifteen days. The patient was of small stature, of a slight and rickety constitution, with that malformation of the hips which gives the peculiar characteristic walk to women so affected. She was married to a man of similar constitution, and her age was forty-two. Dr. Godfroy having passed the entire hand into the vagina, discovered a portion of the cranium in the form of a wedge, the bones of which crossed each other at the sutures. The summit of the head was wedged between the sacro-vertebral angle (which was very prominent) and the pubis, this space not exceeding two inches. Delivery even with the assistance of the forceps being therefore impossible, and the woman beginning to give way under the excessive pains, it was necessary that something should be promptly undertaken. Three modes presented themselves: first, to perforate the cranium and remove the trunk piecemeal; secondly, to perform symphysootomy; and, lastly, the cæsarian section. From the peculiar circumstances of the case, the first of these methods seemed fraught with great danger, and the life of the infant being ascertained was another objection. It appeared, further, impossible to afford a sufficient opening to give play to the forceps by dividing the symphysis, and the cæsarian section was therefore attempted. The patient was placed upon a table furnished as a bed, with her head depressed, and her legs raised and everted. Every means being adopted, by emptying the bladder, &c., to render the skin lax and fix the uterus, the operator made a vertical incision from the umbilicus almost to the pubes. The integuments having been divided tissue by tissue, the peritoneum was opened cautiously, and lifted up while the incision was prolonged upwards and downwards. The folds being turned back, the uterus was carefully opened about the median line. The placenta was fixed to the anterior part of the uterus, and was readily recognised, seized, and withdrawn by the hand. The infant was very carefully removed by the feet, and the umbilical cord divided; the child uttered a cry and was saved. Its weight was about six pounds and a half. No vessel required tying. The uterus was held near the abdominal orifice and cleaned, and then being left to itself, contractions immediately came on, and all hemorrhage ceased. The wound in the uterus, however, did not readily unite, but left a considerable space between the edges. Some points of suture were therefore applied by means of common needles, armed with double waxed threads, and passed through the whole thickness of the wound. The reunion was perfect, and then the uterus was entirely abandoned. The abdominal orifice was closed in a similar manner through the whole thickness of the integuments, even including the peritoneum. The edges were perfectly united, except at the lower part, where a small orifice was left for any suppuration which might ensue. Charpie and a strong bandage being applied, the patient was placed in bed with her head and knees elevated.

Some slight fever arose, and the patient was twice bled. During the two succeeding days the usual sanguinolent evacuations issued from the vulva. The dressings were removed on the 1st of April, and were found scarcely soiled by suppuration. Fresh charpie, steeped in cream, was applied and left till the 6th, when the union appearing firm, the threads of the sutures were all divided, and the wound simply dressed till the 24th, when there existed no trace of suppuration. There was no fever, and the patient left her bed on that day, taking care to sustain the cicatrix with a bandage. The cure was perfect.

M. Desormeaux and others have strongly objected to the sutures of the uterus. Dr. Godfroy thinks their danger has been exaggerated. At all events, the rapidity of the cure in this case, without the occurrence of any accident, is very remarkable.

Case of Puerperal Fever, with Unusual Sloughing. By Dr. Löwenhardt, of Prenzlau. The patient was a woman thirty-four years old, previously healthy and strong, who was delivered with the forceps on the 12th of November. Her five previous labours had been natural, and nothing dangerous had occurred in them, except that after the last she had had severe peritonitis.

On the 15th of November all the symptoms of peritonitis, which appeared to be especially severe in the hypogastric region, came on after exposure to cold. On the 16th and 17th she was largely bled three times, and numerous leeches were applied; purgatives and calomel and opium were also administered, but no relief was afforded. Large mercurial inunctions were then added, but the mouth was not at all affected, and the symptoms grew daily worse. On the 21st, no benefit having yet resulted from the treatment, she took thirty drops of the oil of turpentine. It produced considerable pain and heat in passing urine, but on the next day there appeared to be a slight improvement in both the general and local symptoms.

On the morning of the 23d, however, though the general condition of the patient seemed to be improved, the author found a gangrenous spot as large as the palm of the hand three inches below the umbilicus, and on cutting into it to a depth of two inches, he discovered that not the slightest pain was produced. A part of the slough was removed, and pyrolignous acid, with a decoction of bark and aromatics, was ordered to be applied. Bark was also given internally with muriatic acid.

The sloughing, however, continued, and on the 27th it was found necessary to remove a portion of the abdominal walls as large as the whole hand. On the day after, an opening formed into the intestine on the left side, where the sloughing extended most deeply, and a large quantity of fecal matter was discharged through it.

The patient, who had previously appeared stronger than might have been expected, now became much depressed, and as the constant fecal discharge through the wound maintained a permanent irritation, it was determined to try to close the opening into the intestine. The operation undertaken for this purpose was however unsuccessful; the intestine was found to be perforated in at least three places, and no mode of remedying its condition could be imagined. The patient became gradually more and more weak; on the 7th of December a considerable hemorrhage from the uterus occurred, and she died a few hours after.

On examination there was found at the aperture where the sloughing had passed through the abdominal walls, an excessively thickened, inflamed, and partly gangrenous layer of peritoneum, and beneath this the immensely swollen omentum, to which about six inches of small intestine were adherent. In this portion of intestine, which was highly inflamed, there were three apertures, of which the largest was about two inches and a half long, and was directed towards the left ilium; a second opened to the right and upwards; and a third, of an inch in diameter, was situated at the lower part of the intestine. Their edges were uneven and swollen, but appeared cicatrising.

On the Etiology and Treatment of Congenital Luxations and PseudoLuxations of the Femur. By Dr. J. Guerin.2—I have established it as a fact, in my History of Deformities of the Osseous System, that the greater number of congenital articular contractions are the product of primitive muscular retraction. . . .... I conclude: 1. That congenital luxations of the hip-joint are, like club-foot, torticolis, and spinal deviations, the pro

I Casper's Wochenschrift, Mai 16, 1840; and Br. and For. Med. Rev. Oct. 1840, p. 579.' * Gazette Médicale de Paris, No. iv., 1840; and Br. and For. Med. Rev., Oct. 1840,

p. 576,

duct of primitive muscular retraction, and that the kind of luxation depends upon the direction in which the retraction happens. 2. There exists an order of deformities of the hip-joint not hitherto indicated, and to which I apply the term pseudo-luxations, because they look like luxations, although the head of the bone remains in the cotyloid cavity. These vary as do the complete luxations, and from the same causes. 3. The essential treatment consists in a division of the retracted muscles. I have thrice performed this operation with success. The congenital luxations and pseudo-luxations of joints depend in the majority of cases on primitive muscular contraction, which takes place in three different modes: by shortening, by paralysis, and by stoppage of development of the retracted muscles; and the different varieties of these deformities are, like those of the neck, the spine, and the foot, the effect of this retraction differently distributed in the muscles of these parts. In a girl aged fourteen years, Í divided the biceps, semi-tendinous, semi-membranous, and rectus internus, for two incomplete luxations of the knee, produced by primitive retraction of these muscles; on each side there was subluxation of the tibia backwards upon the condyles of the femur, rotation of the limb outwards through the space of about one fourth of a circle, and an inclination outwards of the leg upon the thigh of about sixty degrees. The rotation outwards, the lateral inclination and the gliding backwards of the tibiæ, were reduced on the day following the operation to the simple normal flexion of the leg upon the thigh, and since that period there remained nothing more than a certain degree of permanent flexion of the joint. In order to convince those who feel any doubt respecting the safety with which these operations may be performed, I may add that, on the same day, I successively divided in the young female above mentioned thirteen muscles or tendons beneath the skin, for the relief of certain deformities from which she suffered; on the following day she felt no kind of pain nor indisposition, nor was there any symptoms of inflammation in any one of the divided parts.

On the Funic bellows-sound. By Dr. Dietrich.'-In addition to the placental murmur, and those accompanying the pulsations of the foetal heart, there is a third sound occasionally to be heard in pregnant women, and one which is well ascertained to have its seat in the umbilical cord. It is a single murmur of the bellows species, and synchronous with the first sound of the fœtal heart. Dr. Dietrich is of opinion, herein agreeing with others who have examined this subject, that the sound depends on diminution of the calibre of the umbilical arteries, either through pressure or stretching of the funis, or both combined. He gives cases illustrating its production under these different conditions. In the first, wherein the bellows-murmur is presumed to have been the effect of pressure, the umbilical cord was of the unusual length of twenty-four inches and a half, twisted once round the neck and tightly knotted in its middle third; the knotted part having acquired from its tightness a white, shining, tendinous appearance. In two cases exemplifying the occurrence of the sound in consequence of a tense state of the cord, this was only ten and fourteen inches long, and this unusual shortness led to greater tension in the former instance from the presentation being a breech one; in neither case was the cord twisted round the neck. In the example of production of the sound from pressure and stretching combined, the navel-string was twenty-three inches long, of normal structure, and wound twice round the neck; the accoucheur was obliged to cut it during delivery, finding it impossible to slip it over the head. Here the culiar sound was invariably heard on every examination; an unusual circumstance, attributed to the tightness with which the cord was twisted, whereby change of position or other occurrences, sometimes causing a temporary cessation of the sound, were rendered of none effect.

1 Medicinische Zeitung, No. xxxvii. 1839; and Br. and For. Med. Rev. July, 1840.

pe

ART. I.-HISTORY OF VACCINATION IN CHINA.

BY W. BECK DIVER, M. D.

Macao, May, 1840.

To the Editor of the American Medical Library and Intelligencer.

Dear Sir,

As the discovery of the vaccine virus forms an interesting and important part of the history of medical science, the following sketch of its introduction and progress in China may not be devoid of interest to the readers, or wholly unworthy of a place in the pages of your valuable journal.

In the spring of 1805, and whilst James Drummond, Esq., was at the head of the affairs of the honourable the East India Company in this country, the vaccine was brought by Mr. Hewit, a Portuguese subject and a merchant of Macao, in his vessel, upon live subjects from Manilla;-his Catholic majesty having had it conveyed by suitable means, and under the care of professional men, across the the South American continent, to his settlement in the Phillipine Islands. One of them, Sr. D. F. X. Balmis, stated himself to have introduced the practice of vaccine inoculation into this country; but before his arrival in China, it had been quite extensively conducted by the Portuguese practitioners at Macao, as well as by Alexander Pearson, Esq., chief surgeon to the British Factory, and a tract upon the subject (an abstract of which I subjoin) drawn up by this gentleman had been translated by Sir George Staunton into Chinese, and published several months before his arrival. As the inoculation among subjects connected with the foreign society, or with the settlement of Macao, was deemed nugatory towards an establishment of the practice in China, it was from the beginning conducted, first at some expense, by inoculations at stated periods among the natives,—and of them, necessarily, the poorest classes, who dwelt crowded together in boats or otherwise, so that (the small-pox being, invariably, an annual epidemic in this province,) its efficacy soon came to the test. By the time the British factory removed from Macao to Canton in that season, a degree of confidence had been established in its favour; and in the course of the winter and spring months of 1805-6, and during the raging of the small-pox (of which the annual period of attack is in February, and of its decline early in June,) the number brought for inoculation was great.

At that time it was considered judicious to endeavour to give the practice extension by vaccinating as many as possible, not fully aware of the characteristic apathy of the Chinese to what does not immediately appeal to