iffiraum WC 262 M364s 1871 34711600R NLM Dslb7T3b 1 NATIONAL LIBRARY OF MEDICINE 8 SURGEON GENERAL'S OFFICE $ | IrEB&ARI'. I / f J\ J SYMPTOMS AND TREATMENT OF MALIGNANT DlABfiHffiA, OE ASIATIC CHOLERA. SYMPTOMS AND TREATMENT OF MALIGNANT DIARRHŒA; BETTER KNOWN BY THE NAME OF ASIATIC CHOLERA, AS TREATED IN THE ROYAL FREE HOSPITAL During the Years 1832, 1833, 1834, 1848, & 1854. WILLIAM MARSDBN,. M.D. im~ BOUNDEK AND SENIOB SURGEON OF THE BOYAL PBEE HOSPITAL, AND 03? THE CANCEE HOSPITAL FOURTH EDITION. EDITED BY ALEX. MAESDBN, M.D. F.R.C.S.E STTEGEON TO THE ABOVE INSTITUTIONS. {J2OO/I+. LONDON: WYMAN & SONS, GREAT QUEEN STREET,' LINCOLN'S INN FIELDS, W.C. 1671. 4 tONDON: wsmait Aim sows, veiutebs, gbeat qubbn serket, LurcoLie's-iifif fields, w.c. DEDICATION TO THE FIRST EDITION, 1834. TO HIS ROYAL HIGHNESS THE DUKE OF GLOUCESTER. Sin, Having for seven years beeii the senior surgeon of that excellent Institution, the Free Hospital, over which your Royal Highness presides, I trust that no apology is required for making known the result of my observations on the Nature, or Treatment, of any of those Malignant Diseases which that Institution was more especially designed to treat ; and less so, with reference to that destructive pest, known by the name of Malignant Cholera. In publishing that knowledge, which has 6 DEDICATION. been acquired by a careful, laborious, and long attendance on the sufferers, I am influenced only by a desire to be instrumental in establishing a mode of treatment by which the destructive career of the disease may be arrested. In dedicating this small work to your Royal Highness, it is in the hope, from its being the first attempt at a practical arrangement of the symptoms and treatment of a new malady, that the imperfections may be lightly viewed, and the merit, if any, meet with the approbation of your Royal Highness. I have the honour to be, Your Royal Highness' s Most obedient Servant, WILLTAM MAESDEN. 2, Thavies Inn, September, 1834. b 2 SECOND EDITION. To the ¦'Rev. Edwaed Rice, D.D., Chairman, and the Committee of Management of the Royal FFrete t Hospital. Rev. Sir and Gentlemen, As it is through your exertions and benevolence in maintaining the R-oyal Free Hospital, where so many wretched fellowbeings daily seek relief and succour, so it is by the enormous number of extreme cases of disease that have come under my notice, that I am enabled to arrive at just practical conclusions in the treatment of some of the most malignant affections, more especially that disease called Asiatic Cholera ; a malady little understood by the general body of Medical Practitioners. 8 DEDICATION. In presenting to you the following Treatise, I must beg to remark, that it was during the years 1832, 1833, and 1834, that my deductions were drawn, when your Hospital was the only one in the Metropolis that freely admitted Cholera Patients, — all of whom were intrusted to my care ; and although from 1834 to the present time, October, 1848, there has been an annual average of more than two thousand cases of Diarrhoea, not a single instance of Asiatic Cholera has been met with; but, should the disease have now re-visited this country, as it is thought to have done, and should it become generally prevalent, I feel confident that the doors of the Royal Free Hospital will be again opened, as before, to the sufferers, and I need scarcely assure you of my zealous cooperation with your other Medical Officers in meeting the danger. Permit me to avail myself of the present opportunity of acknowledging, with 9 DEDICATION. gratitude, my sincere thanks to you, and to all those Philanthropic Noblemen, and Ladies and G-entlemen, who have so liberally given their support in aid of such a truly Christian Charity. With great respect, allow me to subscribe myself, Rev. Sir, and Gentlemen, Your obedient Servant 5 William Maesden. Lincoln's Inn Fields, October, 1848. PREFACE TO FOURTH EDITION. "DEPORTS from abroad indicate that J W this country may again, and shortly, be visited by that terrible disease, Asiatic Cholera. Should this misfortune occur, I am afraid there is every reason to fear we shall be found little better prepared to check its ravages now than we were at former visitations. True, the sanitary condition of our towns is better ; the same may be said of our Water Supply ; and the Thames Shipping Inspection Committee are doing all they can, considering the difficulties with which they have to contend. Thus far we have gained, but as regards our scientific treatment of the disease I am not aware that any advance has been made. When this fearful scourge came on us, in the years 1832, 1833, and 12 PREFACE TO FOURTH EDITION. 1834, the late Dr. Marsden, ever ready to grapple with a new difficulty, at once threw open the doors of the Royal Free Hospital to all comers suffering from this disease, and the large experience he then and at subsequent periods gained, resulted in a very successful mode of treatment, the particulars of which will be found in these pages. This success has neither been superseded nor, to my knowledge, equalled : so extraordinary indeed are the records of the cases restored from collapse by the saline injection used by him, that they read more like a tale from the pages of Edgar Poe than real scenes from the wards of a London Hospital. During the Russian War in 1854-5, when I was surgeon to the Ambulance Corps before Sevastopol, our troops suffered terribly from this disease and acute dysentery. I had then, for the first time, an opportunity of testing the efficacy of this treatment on a large scale, with a considerable amount of success. The ratio 13 PREFACE TO FOURTH EDITION. of deaths was greater than that obtained by Dr. Marsden, but the difference between the hardships at the field of war and the comfortable wards of the Royal Free Hospital will more than account for this. In the chapter headed " Precautionary Measures," amongst other matter will be found directions as to what to eat, drink, and avoid, and I merely add the few following remarks on some sanitary points that I think of importance. Watee. — I believe nothing is more important to health than pure water, and as far as the supply from the Companies is concerned I do not think (with one or two exceptions) we have much reason to complain ; the fault lies at home, in dirty cisterns, and I would strongly urge every one to see that these are thoroughly cleaned out, and that the same water is not allowed to remain in them too long ; it is an excellent plan to let each run out in hot weather at least twice a week, permitting the water to run freely through for a short time 14 PREFACE TO FOURTH EDITION". previous to refilling : by this means we have not only our water wholesome and fresh, but our drains kept clean and free. Air and Gas. — The more fresh air the better for health : so ventilate your house freely, particularly the staircase and all rooms in which gas is burnt. Never light the gas in your bedroom till you retire for the night, or, if wanted during the evening } turn it out on leaving the room : nothing is more unhealthy than sleeping in a room in which gas has been burning all the evening, especially in winter time. Use some disinfectant occasionally, — I believe there is no better plan than putting a little chloride of lime on the outside ledge over the doors, and changing the same now and then. Drains. — Flush the drains, sinks, waterclosets, &c. (see paragraph on water), and twice a week throw down each trap and water-closet a little chloride of lime. Dust-bin. — This cannot be emptied too often ; and no animal or vegetable matter 15 PEEFACE TO FOUETH EDITION. should be thrown there, but be burnt on the kitchen fire the last thing every night, and thus destroyed. It would be much better, hower, if dustbins were abolished altogether, and in place thereof, the refuse of each day should be thrown into a box or pail, these to be placed on the edge of the pavement, in front of each house, every morning, and their contents removed in carts for the purpose. This I believe is done, and answers very well, in the City. With these remarks I introduce the work to the public, trusting my father's labours will still be found useful. A.M. Lincoln's-Inn Fields, November, 1871. PRELIMINARY OBSERVATIONS. IN an infectious epidemic, it is of the utmost importance to learn where and by what means it originates, the route it takes from one kingdom to another, and by what medium it is communicated from man to man ; but, in an epidemy which is neither infectious nor contagious, such knowledge is of secondary consequence ; and instead of employing our time in such difficult researches, it would be far better spent by endeavouring to learn the nature, of the disorder and the most efficient mode of arresting the fatal consequences. This is pre-eminently the case with reference to what is called Malignant Cholera. Gentlemen of high professional character, Dr. Barry, and others, were sent by the * 18 PRELIMINARY OBSERVATIONS. British. Government to St. Petersburg, and various parts of the Continent, with a view to gain information on this subject ; — quarantine was established at every port ;* but all was useless. The doctors returned little wiser than they went ; and the disease ran over this, and almost every other country, committing; its dreadful ravages alike in high or low regions, — in hob, cold, wet, or dry seasons ; — baffling all human efforts to arrest its progress, or hardly even to mitigate its horrors. A Government Board of Health was established, and was continued for upwards of two years in operation; and, singular to remark, the Medical department of that Board, on the close of their labours, in the autumn of 1833, afforded the profession not the slightest knowledge on the subject, either physiological or pathological. During the existence of the disease in * Nothing can be more unnecessary than quarantine for Cholera. 19 PEELIMINAEY OBSEEVATIONS. 1832, the directions for treatment, professional and domestic, issued by the Board, were solely founded on empirical principles ; yet, notwithstanding those erroneous measures, much might have been rectified, had the Board, at the time, with every facility for so doing, proceeded to a public and impartial investigation of the nature and treatment of the malady. The disease has now paid us a third visitation ; and it is saying but little for the character of our medical institutions, when I assert that up to the present time, nothing has issued to guide the profession in the treatment of such cases, either from the College of Physicians, or from the College of Surgeons. In a country like England, it is an extraordinary fact, that with all her increased knowledge, and boasted perfection of legislation, she has no permanent watch over the health of the community ; and it is only within the last few weeks of the present year, that a Board of Health has been 20 PRELIMINARY OBSERVATIONS established, but not on anything like just or sound principles. On the first appearance of this unknown disease in London, medical men of every grade, more particularly those practising in the higher branches of the profession, on viewing the afflicted patient, became terrified and panic- struck ; and the public, in consequence of their professional advisers being ignorant of the nature of this malady, were completely bewildered and paralyzed. In this state of things, and as if to produce all the consternation possible, the richly-endowed hospitals of this Metropolis closed their doors against the wretched sufferers, — the affluent inhabitants fled, — and the great and wealthy members of the faculty dared not, or would not, condescend to visit the habitations of the afflicted. It was a scourge that fell first only upon the poor, the wretched, the dissipated, and the destitute. Of the secrets of nature, or the workings of an Almighty power, we 21 PRELIMINARY OBSERVATIONS. know but little. We know not how soon, or to what extent, it may become the fell enemy of the rich and well-fed portion of the community. By neglecting to protect and preserve the indigent from pestilence, the higher grades of society lose their best chance of preserving themselves from the like evils. On the appearance of the so-called "Malignant Cholera," the Governors of the Free Hospital, for the Cure of Malignant Diseases, in Greville Street, Hatton Garden,* in the most prompt and effective manner, made up fifty beds, and threw open their doors to the indiscriminate admission of all sufferers from that disease. In justice to the managers of that Charity, I feel that the warmest thanks of the public were duly merited by every member of the Committee, not only for the care and attention they invariably devoted to the * Since removed to Gray's Inn Road, and known as the Royal Free Hospital for the Destitute Sick. C 22 PEELIMINAEY OBSERVATIONS. comfort of the patients, but for the ample opportunities they afforded to their medical officers, for acquiring a knowledge of treating malignant and contagious diseases in general ; and, more particularly, the disease in question. I have no hesitation in saying that, from the principles on which that excellent charity is conducted, the lives of thousands have been saved; and in arresting the influence of contagious disorders, its benefits are incalculable : since its foundation, in 1828, to the present time, upwards of two hundred thousand persons have been successfully treated, and restored from the most destructive and loathsome maladies to health and comfort. Upwards of three hundred patients suffering from the second stage of Cholera were admitted into the Hospital : at first, nearly every one died, although every plan of treatment that could be recommended was adopted ; and it was only in despair that a mode of treatment, suggested by Dr. Stevens, was tried. Through the effects of 23 PRELIMINARY OBSERVATIONS. that treatment a glimmering ray of hope was first discovered, which led to the practice now pursued, and laid down in the following paper; and on this plan alone do I believe it possible for the life of a single patient to be rescued from the second, or collapsed stage of the complaint. On the other hand, I feel equally assured that confidence and discretion in the use of calomel during the first stage will remove the disorder in ninety-nine cases out of every hundred, without the slightest future injury being sustained by a single individual from this medicine.* During the months of July and August, 1834, twenty- six patients were admitted in the second stage, and only ten recovered ; from which it would appear that more were lost than saved. Unfortunately for the sufferers, scarcely one was ever sent * During the year 1848, upwards of 500 cases of severe diarrhoea have been successfully treated in the Hospital by this plan. C 2 24 PRELIMINARY OBSERVATIONS. into the Hospital until all hope of recoverywas given up by their previous medical attendants ; what chance, then, but the slenderest had any plan of treatment under such circumstances? Notwithstanding this, some of the very worst cases were restored, both by the saline medicine and by the saline injection : and so confidently do I rely on the success of these remedies for combating this extraordinary disease, that we need no longer view with horror and dismay the approach of this enemy to human existence. Several important facts will be noticed in the cases given to illustrate the merit of the treatment ; which, if not satisfactory to some individuals, I trust will be found sufficiently important to the philanthropic practitioner to induce and promote unprejudiced investigation. It is a subject of the utmost importance, both to the profession and the public, to distinguish between infectious and noninfectious diseases ; and I have not, during a practice extending over a period of forty 25 PRELIMINARY OBSERVATIONS. years, met with a single instance controverting the principle that I shall lay down with reference to these points. Infectious disorders never attack a human being a second time ; and those maladies which are communicated from one person to another, through the medium of the atmosphere, such as small-pox, scarlet-fever, measles, and hooping-cough, constitute nearly the whole class of infectious disorders peculiar to man. Plague, typhus-fever, malignant cholera, and a great many other alarming and destructive pests, which are epidemic, but not infectious, may attack the same persons many times. Contagious disorders are altogether of a different class to either of the preceding, and may, by contact only, be communicated an indefinite number of times. Infectious diseases may always be retained amongst us by artificial means, at least so long as human beings are to be found who have not had the disorder ; and contagious maladies may exist for an unlimited 26 PRELIMINARY OBSERVATIONS. period, or be repeated an indefinite number of times in the same individual; while, on the contrary, an epidemic disease, such as Cholera, Plague, &c, cannot be retained by artificial means, nor extended beyond the range of its general influence, nor does the first attack exempt from a second. On the return of the like epidemy, it may again affect the persons who had previously suffered ; hence the folly of quarantine. Some persons may object to the division made in this paper ; but it is of the utmost importance to divide the progress of the disease into two stages, in order that the treatment of the one should not be erroneous, and in direct opposition to that required for the other. After my first paper appeared making this division, in 1832, the Government Board of Health immediately issued a paper making three divisions ; but for all practical and useful purposes, two will be found sufficient. Much time has been devoted to the investigation 27 PRELIMINAKY OBSERVATIONS. of the blood by Drs. Clanny, O'Shaughnessy, and others; others, again, have endeavoured by every means to effect what they term the unlocking of the secretions ; and some have ransacked the Pharmacoposia for the most powerful stimulants, under the impression that to restore the pulse by such means was all that was required to preserve the patient. To investigate the character of the blood was rational, and attended with beneficial results ; but in attempting to unlock the secretions,, or restore the circulation by stimulants, in the advanced stage of the disease, until the volume of blood had been sufficiently restored, was only to shorten still more the life of the sufferer. Some persons relied greatly on external applications, such as mustard-poultices, blisters, camphor-liniments, &c. ; while another, considered more knowing than all the rest, proposed, and absolutely practised, a mechanical mode of arresting the discharge, by plugging up the outlet of the 28 PRELIMINARY OBSERVATIONS. intestines: why this learned gentleman did not close the upper aperture as well as the lower, I am at a loss to learn. I now conclude these preliminary observations, and, with as much perspicuity and conciseness as possible, enter on my views of the nature and treatment of what is understood by the erroneous name " Cholera Morbus." — This name implies a morbid flow of bile : while in this new disease, when fully developed, there is neither bile, nor any secretion whatever from the liver. Cholera Morbus is a disease peculiar to tropical climates, occasionally occurring during the hot seasons in temperate climates, and it consists in a violent action of the liver, secreting morbid bile, accompanied by violent fever, spasm, &c. I therefore take the liberty of giving this malady the name of Malignant Diarrhoea ; for an evil very destructive in its consequences, and not yet obviated, was occasioned through the introduction of this disorder under the erroneous title of 29 PRELIMINARY OBSERVATIONS. Cholera Morbus : every professional man knew what was understood by such a Dame, and many how to treat such a disease ; while, on the first appearance of the malady in question, in 1832, the profession was quite baffled* both as to its nature and treatment, and to this time continue nearly equally in the dark. There can be.no doubt that this disorder has exercised its ravages in tropical climates ; but for want of careful investigation it has been viewed only as a more severe form of Cholera Morbus. MALIGNANT DIARRHŒA; Better Mown ly the incorrect name of Asiatic, Spasmodic, or Malignant Cholera. THIS is an epidemic disease, neither contagious nor infectious ; that is to say, one which cannot, by artificial means, be communicated from one individual to another, but may affect the same person an unlimited number of times. The progress of the symptoms varies, from two causes : one, the extent to which a patient is affected by the poison ; the other, from the powers of resistance occasioned by the good or bad constitution of the individual afflicted. Persons of the same family or living in every respect under similar circumstances, may be, and frequently are, affected simultaneously, or in succession ; 32 MALIGNANT DIAREHGRA. and, were it not for the varied localities, different modes of living, habits, and constitutions of the people, the whole community of any place affected would suffer alike from this or any other epidemy. I believe the poison occasioning this disorder is contained in the atmosphere : how generated, is not known, — but I think it is the atmosphere overcharged with water and miasma, — for we are equally in the dark respecting the origin of all epidemic diseases. By breathing this morbific atmosphere, the blood becomes affected through the medium of the lungs ; and, like all other poisons, it produces its specific effect, which in this malady, is to determine that important fluid, in an extraordinary degree, to the surface of the intestines, where it deposits its thinner and more fluid parts, called the serum or water of the blood. Every production in nature on which we cannot feed, must be considered, more or less, a poison : arsenic, mercury, rhubarb, jalap, prussic acid, 33 MALIGNANT DIAEKHCEA. ipecacuanha, &c, have their specific actions on the constitution; and the squirting cucumber produces effects approaching the disease in question so nearly, as to render it difficult to distinguish the one from the other. The evidence of an approaching attack of malignant Cholera, consists in a sense of pain or uneasiness in the bowels, with purging, nausea, loss of appetite, thirst, and extreme prostration of strength. Now during the existence of this epidemy, all persons experience, more or less, these sensations ; and I believe that all would be equally affected were it not, as before stated, for the variety of constitutional powers of resistance. The half- starved wretch, the emaciated debauchee, also the susceptible and delicate amongst the higher classes of society, are equally liable to the sudden ravages of this disease : while the healthy and well-fed possess the faculty of throwing off the poison by the ordinary functions of the excretory 34 MALIGNANT DIAEEHGEA. organs : and it is only when the action of the liver and kidneys fails in discharging this function, that the second or collapse stage supervenes. It is idle to suppose that an individual cannot be affected by this disease, unless he has got all the symptoms of collapse ; and it is of the utmost importance to know that by attending to the premonitory signs, we should, in ninety-nine out of every hundred cases, prevent the second stage.* On the presumption that in this malady the blood contains the morbific principle, the indications would naturally be to excite the action of both the liver and kidneys, — these organs being especially designed in the animal economy for the purpose of removing from that fluid all useless and adventitious matter. The * At the Free Hospital, during the years 1832-33, out of five hundred patients in the first stage, only twelve ran into the second ; and eventually, only four died. 35 MALIGNANT DIARRHCEA. disease itself, in tlie first instance, more or less irritates the liver, and sufficiently so, in constitutions previously healthy and robust, to carry off the offending matter ; but in delicate habits, assistance in general is required ; and it is astonishing to witness the extraordinary effects of large doses of calomel : indeed, this medicine cannot be administered too boldly, inasmuch as small doses produce no effect, while a full dose acts almost like magic, and the happiest results ensue. All inconvenience subsides in persons whose bowels have been incessantly relaxed from twelve to twenty-four hours together, on their taking from fifteen to thirty grains of this preparation ; and so completely are the distressing symptoms allayed, that in the short space of fifteen to twenty minutes, no further evacuation will occur, unless an active purgative be given, which should be administered four hours afterwards. This purgative must not be of a saline nature, as it would be apt to induce a relapse of 36 MALIGNANT DIAEEHCEA. the same diarrhoeal action of tlie bowels as before, but one of an active vegetable kind — castor oil and tincture of rhubarb have been found the most suitable. Tincture of rhubarb produces a powerful muscular contraction of the intestine, while the oil mechanically lubricates the surface. It is rarely requisite to give a second dose of either medicine, but if otherwise they should be equally potent. Opium, narcotics, and all stimulants of a spirituous kind, irritate, diminish, and eventually destroy the function of the liver.* Consequently they are particularly injurious in this disorder ; and when given, even with calomel, seldom if ever produce the desired effect. Calomel alone must be relied on. When the calomel has subdued the nausea and diarrhcea, and the purgative * Drunkards and persons who had deranged the function of the liver by taking such remedies, were the first victims to this disease. 37 MALIGNANT DIARRHEA. draught lias been taken, stools of a black gelatinous nature, resembling half-melted pitch, will pass off; and, in the majority of cases, no further medical aid is required. During the existence of this stage of the disease, we should rigidly enjoin abstinence from all fluids, beyond a sufficiency to moisten the mouth ; for if copious draughts of barley-water, toast and water, or any other fluid, be taken, vomiting, in all probability, will continue, and preclude the possibility of either the mercury or the draught having their desired effects. It is well to order the patient small doses of simple effervescing mixture, or soda-water, about two table-spoonfuls to be taken with the calomel, and repeated every hour, so long as the circumstances of the case require. The effervescing saline has a powerful tendency to tranquillize that irritable state of the stomach, which generally accompanies the progress of this stage of the disorder. D 38 MALIGNANT DIARRHGBA. SECOND STAGE, OE COLLAPSE. The symptoms of which are, violent vomiting and purging, a total suspension of the action of the liver and kidneys, loss of pulse, livid extremities, clean tongue, cold breath, blueness of the lips, and intolerable thirst. These symptoms do not arise from any sedative effect produced on the brain, or nervous system ; but, from the poison exciting certain nerves,* which determine the circulation to the surface of the bowels, there occasioning a mechanical separation of serum from the blood, and diminishing the volume of that necessary fluid so seriously, as to preclude the * I believe the mesenteric nerves are alone excited ; and the increased vascular action exists only in their corresponding arteries. The fluid contained in the stomach is not given solely from its own service ; but by the spasmodic contraction of the upper intestines, a considerable quantity is mechanically forced through the pylorus. It is more than probable that the pancreas is considerably engaged in secreting this fluid. 39 MALIGNANT DIAEEHCEA. possibility of the heart propelling its contents in sufficient quantity to reach the extremities, or to preserve the action of the excretory or secretory organs, notwithstanding the contracted state of the vascular system. Besides, the blood is in too viscid a state to pass the capillaries ; hence the great vital depression from the want of due action over the surface of the brain and nervous chords. The function of the liver and kidneys ceases, as before stated, not by any sedative effect of the poison, but entirely through the want of a due supply of blood being transmitted to these organs ; and unless we succeed in increasing the volume, either by natural or artificial means, we shall most assuredly fail in restoring a single patient. Several cases will be found in the concluding part of this paper, fully illustrating this principle. There is a considerable desire to drink, from the commencement of this disorder, but the extraordinary thirst does not come d 2 40 MALIGNANT DIAEEHCBA. on until the diarrhoea has continued for some time ; and here nature points out in a forcible manner, as she generally does, the most valuable indication of cure. Drink ! drink ! exclaim the poor wretches ; while at the same instant, the whole alimentary canal, from the termination of the oesophagus to that of the colon, is powerfully distended with a fluid as limpid as water, with the exception of some floccul — this fluid is the poisoned serum of the blood, slightly decomposed. The extent to which a patient has a desire to drink, may be formed by the following facts. In ordinary cases, during collapse, from two quarts to one gallon per hour will be taken ; but ten patients, who were restored in the Free Hospital, in 1832, drank two hundred and twenty-five gallons of water in seventy-eight hours ; and one patient, who. died, took forty gallons within ninety- six hours. Now it appears extraordinary that so intense a thirst should exist under such 41 MALIGNANT DIAURHCEA. circumstances ; but the following seems to be the cause : — That the exudation from the extremities of the arteries over the immense surface engaged in this peculiar action, far exceeds the power of the lacteals to replace in time sufficient to preserve the circulation ; besides, the very fluid absorbed is of a poisonous character, and will, the moment it reaches the arterial system, continue its specific influence, and be again deposited in the intestines. This action continues until the blood has either freed itself from the morbific principle, or until the patient sinks. What then but this can be the obvious inference, either to the scientific or empirical practitioner? Get rid of the offending fluid, and permit as little as possible to be re-absorbed and returned to the circulation. This, in a great many cases, may be accomplished by the most simple means. The moment the patient either vomits or purges, let him instantly swallow as much water as possible. It is of no use 42 MALIGNANT DIAEEHCEA. attempting to give nutritious fluids of anykind, as digestion is completely suspended : let a vigorously repulsive action of the stomach be excited ; and the best means of so doing, is by strong and repeated doses of saline solution. Several important objects are gained by this mod c of exhibiting the saline: first, it instantaneously evacuates the stomach ; and secondly, by some portion of the saline solution descending through the intestines, and mixing with the fluids exuding from their surface, and with the water previously taken, forms with them a compound containing less deleterious matter, consequently better suited to unite with the dark carbonaceous blood that remains in the vascular system. The saline also stimulates the lacteals more powerfully than any other preparation is known to do ; it is also powerfully antiseptic, and a necessarily component part of the blood. These are circumstances of the utmost importance ; for if we succeed in exciting the vessels to take up fluid adequate 43 MALIGNANT DIAERIKEA. to preserve the circulation until the blood has parted with all its morbific properties, we shall then, and not until then, restore the patient. It may be asked, why not give a weak saline drink in place of pure water ? The reasons for not doing so are these : — When the patient finds his stomach so distended by fluid that it is difficult to be ejected, a strong saline solution will instantaneously effect that object ; immediately after which we should give the patient pure water, it is more grateful than any other drink, and is not so readily rejected, but in a great measure passes into the intestines, diluting the deleterious character of the fluid already there. By repeating the saline dose every fifteen minutes we are sure to have some portion pass into the bowels, and, I believe, sufficient to effect the object desired ; while on the other hand, were saline drink only to be administered, however weak, an incessant vomiting would ensue, and little or no water would pass 44 MALIGNANT DIAEBHCBA. beyond the stomach. I wish particularly to impress on the minds of medical men who may have such cases under their charge, that their success in treatment depends on the stomach and bowels being occupied by a more healthy fluid than that deposited in these organs through the diseased action. Suppose, after the administration of the above plan, no restoration of pulse takes place, and the patient continues rapidly to sink, what is to be done ? The answer is evident ; that having failed to restore the volume of blood by the action of the lacteal absorbents, a vein must be opened, and a fluid corresponding in character as nearly as possible to the serum of the blood, must be injected in sufficient quantity to fully restore the pulse at the wrist-; at the same time endeavouring to arrest further exudation from the capillaries of the intestines, by astringents carefully administere — opium and bark are the best; and this is the only period from the beginning 45 MALIGNANT DIAEEH(EA. of the disease at which the exhibition of opium or astringents are recommended. Should, however, the diarrhoea continue, the circulation will, in proportion to that action, again decline, which renders this the most important time for diligently watching your patient, many having been lost by leaving them too long unseen ; for the moment the pulse begins to sink, we must again resort to the injection, and repeat it at periods, proportionate to the urgency of the case and character of the patient. In giving astringents at this time, I advise for an adult, ten drops of laudanum, with one ounce of compound tincture of bark to be taken without any dilution, every half-hour «, until the diarrhoea entirely ceases. If we succeed in sustaining the pulse for twelve hours, and the diarrhoea ceases, we may consider the patient safe ; but the utmost caution must be observed with respect to nutriment. Nothing stronger than gruel and broth must be permitted for the first two or three days ; afterwards 46 MALIGNANT DIARRHCEA. rice, or any other farinaceous puddings, with small draughts of malt liquor, for the space of four to six days; from which time the patient must be managed according to circumstances. Urine will generally be secreted, and evacuated six hours after the restoration of the pulse ; the liver will likewise begin to resume its function, throwing out for the first two days a green fluid, afterwards yellow, and lastly, healthy bile. When a patient is restored by these means, it frequently happens that after the first two days symptoms of cerebral disturbance, of a typhoid character, supervene ; which must likewise be treated according to the urgency and circumstances of the case. With ordinary care, such cases rarely prove fatal. I lost only two patients that had fully rallied by injection ; both lived about twelve days after the injection, and had a powerful pulse nearly the whole time ; I believe they died from cerebral effusion. In giving this disease a place in medical 47 MALIGNANT DIAERHCEA. nomenclature, it would correctly stand in the order of " Spasmi," in the Nosology of Cullen, following simple diarrhoea ; and the most correct name would be Malignant or Spasmodic Epidemic Diarrhoea. I therefore name it accordingly MALIGNANT EPIDEMIC DIARRHŒA. It is an epidemic disease, neither contagious nor infectious, having in the progress of its symptoms two stages.* CHARACTER OP THE FIRST STAGE. A sensation of general weakness over the whole body ; languid pulse ; sickness and pain about the stomach ; purging and twitchings of the bowels ; clammy feeling in the mouth ; and a desire to drink more than usual. * Infectious as well as non-infectious diseases may be epidemic. 48 MALIGNANT DIABEHCEA. CHAEACTEE OP THE SECOND STAGE. Extreme prostration of strength; incessant vomiting and purging of limpid fluid ; total suppression of urine ; intolerable thirst ; cold breath, and general coldness of the body ; sunken eyes ; a dark blue aud corrugated appearance of the skin of the hands and feet, with violent spasms of the extremities and the bowels. In children, — vomiting ; purging ; great thirst ; suppression of urine, and a general restlessness. CAUSE S. EEMOTB. Not known, but presumed to arise from a peculiar constitution of atmosphere. PREDISPOSING. Exposure to sudden changes of atmosphere ; severe mental affliction ; excessive 49 MALIGNANT DIARRHOEA. fatigue ; drunkenness ; dyspepsia ; in fact, every circumstance that tends to derange the system or diminish vital energy. EXCITING. Anything that irritates the stomach or relaxes the bowels. PROXIMATE. Violent purging and vomiting. PEOGNOSIS. f~A diminution of purging and. Favourable | gicknegs; free gecretion of in the < i ~\ j irme; and coloured evacuafirst stage. tions ; a free pulse. Restoration of the pulse; warm breath ; the vomit- Favourable ing and purging of a in the se- <| bilious character ; a secrecond stage. tion of urine ; and the colour of the extremities changing from blue to red # 50 MALIGNANT DIAEEHCEA. TREATMENT. Indications fTo invigorate the functions in the -< of the liver, and suppress first stage. (_ the morbid evacuations. REMEDIES. For children up to four years old : Calomel, five grains. Ginger, five grains. — Mix. This powder to be given immediately, mixed in a little treacle, and two hours after the powder give the purgative draught : Powdered Rhubarb, ten grains. Castor Oil, half an ounce. — Mix. From the age of four years to fourteen : „, -, ( Calomel, six grains. The powder ... J ' ° ( Ginger, six grains. — Mix. C Castor Oil, three-quarters of an ounce. The draught < Tincture of Rhubarb, two drachms. I Powdered Rhubarb, eight grains. — Mix, 51 MALIGNANT DIARRHCEA. From tlie age of fourteen and upwards : mi -, ( Calomel, ten grains to fifteen. The powder . . . 1 . I Ginger, ten grains to twenty. — Mix. ( Castor Oil and The draught ... < Tincture of Rhubarb, I of each one ounce. — Mix. During the progress of this stage, small doses of simple saline mixture or sodawater should be taken every half-hour. fTo free the stomach and Indications I bowelg from morbific «{ contents ; to increase the the second volume of bbod} and to * I restore the circulation. REMEDIES. For children up to the age of four years : Common Salt, one scruple. Bicarbonate of Soda, six grains. Chlorate of Potash, two grains. — Mix. (For one dose.) 52 MALIGNANT DIAEEHCEA. From four to fourteen years of age : Common Salt, one drachm. Bicarbonate of soda, ten grains. Chlorate of Potash, three grains. — Mix. For persons above the age of fourteen years : Common Salt, two drachms. Bicarbonate of Soda, one scruple. Chlorate of Potash, seven grains. — Mix. The above powders, dissolved in a small quantity of cold water, to be given every quarter of an hour until the excess of purging subsides, and the pulse is clearly perceptible : from which time extend the period between each dose, first to half an hour, then to one hour, and so on till both pulse and breathing are vigorous. During the progress of this treatment, as much cold water may be taken as the patient desires ; the more the better. The cramps are greatly relieved by a hot salt-water bath; from seven to fourteen 53 MALIGNANT DIAERHCEA. pounds of common salt dissolved in a sufficient quantity of water to cover the whole body, and the patient to remain in from ten to twenty minutes, at a degree of heat from 110° to 120° ; if the cramps continue, the bath must be repeated every two hours. The patient must be kept in bed between blankets, with bottles of hot water to the feet and legs ; a free current of fresh air should be allowed to pass through the apartment, and, if possible, directly over the face of the patient, the body being kept as warm as possible. To render the atmosphere of the room as healthy as possible, curtains, carpets, and all moveable furniture should be taken away. Solution for the injection :—: — Common Salt, three drachms. Bicarbonate of Soda, half a drachm. Chlorate of Potash, fifteen grains. Water, forty-eight ounces. — Mix. To be slowly injected into the veins, at E 54 MALIGNANT DIARRHOEA. a temperature of 100°; from sixteen to thirty-two ounces will be generally found sufficient to restore circulation in patients under fourteen years of age ; beyond this age, from forty-eight to eighty ounces may be injected, and repeated on the circulation again declining. DIRECTIONS FOR USING THE SALINE INJECTION. Take especial care to have a good syringe, which must be free from oil and kept perfectly clean ; otherwise the saline matter will corrode the metal and render it unfit for the purpose. The syringe I have hitherto used, is a common enema syringe, having a fine silver canula about two inches lorig, slightly curved, and adapted to the elastic tube ; it is better to have the canula of this length, as it can be more readily commanded ; the aperture should be sloped on the side of 55 MALIGNANT DIARRHOEA. the extremity, leaving the point rounded, otherwise some difficulty would be experienced in its introduction into the vein ; the canula must be passed at least one inch within the vein. Any of the superficial veins may be selected ; I have generally chosen the media on the upper extremity, or the saphena in the lower extremity. It is better to make an incision about an inch and a half long through the integuments, at the distance of half an inch from the vein, but parallel with it ; draw the skin aside and cut through the cellular tissue, so as fully to expose the vein, under which pass a probe; raise the vein above the surface, and with the point of a lancet make a small longitudinal incision, into which the canula adapted to the elastic tube, being filled with the solution, must be introduced; it is better to let the probe remain until the desired quantity of solution be thrown in, for by taking it away the vein would bleed and become troublesome; c 2 56 MALIGNANT DIAKRHOEA. ,« when done, return the vein to its place, the integument will cover and protect it from injury; draw the skin together by adhesive plaster and bandage up the arm after the usual manner. If required to repeat the operation the same vein, and aperture will do, even for three or four times ; I have never seen inflammation extend up the vein, nor any evil whatever arise from the operation. The saline solution should be made in a white washhand basin, so that the sediment, if any, may be seen and avoided. When about thirty ounces of the fluid have been injected the patient will experience a general uneasiness and tightness about the chest ; you have only to suspend the operation for a few minutes, that the circulation may equalize itself, afterwards progress slowly till the pulse is fully restored ; in general a severe rigour will supervene, and last from fifteen to twenty minutes, which will be succeeded, in favourable cases, by a corresponding reaction ; the patient must 57 MALIGNANT DIAERHCEA. not be left by the surgeon for more than two hours at a time. When the vomiting, purging, and cramps have subsided, and the pulse and warmth of the body are restored, the patient may be allowed to take broth, beef-tea, gruel, and coffee, for the first forty-eight hours ; afterwards, rice and batter puddings, with a gradual improvement in diet, till perfectly restored ; spirits or wine should be strictly avoided, but good malt liquor in small draughts may be taken with advantage. Brandy, opium, and all such stimulants are most injurious ; nearly every person that died in the Free Hospital had taken one or all of these remedies previously to their admission. 59 MALIGNANT DIAEEH(EA. i CASES RESTORED BY THE SALINE INJECTION. John Scott Mayne, aged thirteen, of Farringdon Street, seized with vomiting and purging at nine o'clock a.m., August 24, 1833. At nine p.m., found him in the extreme of collapse ; requested that he might be immediately conveyed to the hospital ; ordered a saline powder to be given every fifteen minutes, cold water ad libitum, and a hot saline bath. At half-past ten o'clock, the boy quite insensible, and at the point of dissolution ; about thirty- two ounces of saline fluid were injected : before the operation was over, the clock in the hospital struck eleven ; when, to the astonishment of all around, the boy asked, "What o'clock is it?" 60 MALIGNANT DIAEEHCEA. " Ten," replied one of the nurses. " ISTo," said the boy hastily, "it is eleven, for I counted it." The pulse returned ; respiration free ; the countenance resumed a healthy aspect, and animation pervaded the whole frame. The boy continued gradually to gain strength, and after eight days left the hospital, quite restored. This boy enjoyed excellent health afterwards, and is now a strong man. J. Monument, aged thirty-nine, residing at 194, Upper Thames Street,* a bricklayer. This man's habits were peculiarly temperate, having lived chiefly on vegetable diet, being a member of a society who object to eat animal food ; he had long suffered from indigestion, and was of weakly constitution. First saw him at twelve o'clock at night, August 24th. He had suffered from the usual symptoms * This man died in the spring of the year 1865, at the age of 7 1 years. 61 MALIGNANT DIARRHCEA. for two days ; had been treated with opium and carminatives, from the first attack. Found him, as in the other case, advanced far in collapse ; ordered a saline powder every fifteen minutes ; a hot saline bath, and water ad libitum. Nine o'clock on the following morning, vitality only just perceptible ; injected to the extent of forty-eight ounces ; the pulse restored, and animation once more manifest throughout the frame. In this case, the diarrhoea continued, and after four hours the patient sunk almost to the point of death ; he was again injected to the like extent, when again vitality dawned : the diarrhoea still continued, and he sunk a third time. A third injection was given to the extent of sixty-four ounces, and astringents of bark and opium were administered, when a third and lasting reanimation took place. From this time the patient gradually improved ; and on being induced to live on animal food, and altogether on a more generous diet, he has 62 MALIGNANT DIAEEHCEA. been in better health than for several years previous to the attack. Maegaeet Haeeis, aged thirty- one years, had a family of five children, was admitted August 12th, 1833, from Johnson's Court, Fleet Street. The saline powders, and water ad libitum, were taken until one o'clock a.m., of the 13th, when twentyfour ounces of saline solution were injected, and an astringent mixture, consisting of tincture of opium and bark, was taken in small doses. From this time she gradually improved, and was discharged quite well, on the 22nd. "Up to the present period her health continues good. Beian Sullivan, aged thirty years, from No. 7, Richbell Place, admitted August 21st, 1833. He took the saline powders, and was twice injected to the extent of forty ounces each time. An astringent mixture, as in the above case, was taken 63 MALIGNANT DIABEHCEA. after the second injection : he was discharged quite well on the 29th. — This patient had been left for dead after the first injection, and was absolutely measured for his coffin. He has enjoyed excellent health ever since. Four other cases, the names and addresses of which are not correctly known, were restored by injection, in the year 1832. Fifteen patients were restored from the collapsed stage of the disorder by injection, who all afterwards died from the effects of the consecutive fever, at periods varying from four to twenty-one days. Much is yet to be learnt in the treatment and management of injected patients. During the months of June and July, 1832, many patients were treated by large doses of common salt only; and the two following cases are given to show that this plan of treatment (published in the Lancet, on the 9th of August, 1834, by 64 MALIGNANT DIAEEHCEA. Mr. Beaman) was by no means new : it certainly arrested the progress of the malady, but all the patients so treated, died ; yet, the plan approaches nearer to the principle advanced by me, than any other : indeed it is only a modification of the same remedy. Philip Olaek, aged twenty- seven years, by trade a chemist and druggist, from Lincoln, was admitted July 4th, 1832, at ten o'clock a.m. One ounce of salt, dissolved in half a pint of water, was given, every hour, till four o'clock p.m. on the following day, when he expired. Geoege Hill, aged fifty-three years, from No. 14, Fleur-de-lis Court, Fleet Street, admitted at eleven o'clock, a.m. July 6th, 1832. Treated after the like manner — died at seven o'clock p.m., the same day. All the patients treated after this mode had the hot saline bath. 65 MALIGNANT DIAEEHCEA. The following is a List of Patients who were admitted into the Free Hospital, during the years 1832 and 1833, whose names, ages, and residences are known; many others were restored, but, not knowing their places of abode, are omitted. These patients were all in the second or collapsed stage, and many of them had been treated ' and abandoned as lost by their medical attendants previously to their admission. They were all put under the saline remedies as laid down in the preceding' part of this paper. as? n — | ***»«»• D dt of sion. charge. 1832. May 25 Elizabeth Shay .. 37 12, Blue-court, Saffron-hill June 14 Julia Brushney .. 9 Ditto .... 10 Ellen Brushney .. 30 Ditto 10 June 1 Mary Sarnford. ... 55 Ditto .... 8 2 Catherine Ross .. 28 11, Ditto .... 12 3 Mary Higgins . . 19 Onslow-street, Saffron-hi 11 .... 10 Flora McCormack. 51 Nurse at the Hospital 18 July 7 John Day 49 5, Lilley- street, Saffron-hill ..July 10 10 William Taylor .. 26 9, Field-lane 10 1 1 Francis Feathers. . 35 37, Dillon-street 16 12 Margaret Lane .. 2 3, Caroline-court, Safiron-hill . 13 14 Lawrence Denning 35 1, George-alley, Field-lane. ... 28 15 Margaret Newman 7 6, Field-lane 18 Margaret Farrel . . 11 5, Field lane 20 Michael Niven 1 Ditto 3d 16 George Mackie . . 29 38, Fleet-lane 20 William Bonam .. 35 8, George-alley, Field-lane 25 William Moor .... 1 6, George-alley 21 17 Richard Gregory. . 35 West-street Aug. 6 Jane Davies 30 21, Fleet-lane June 25 18 William Roberts.. . 60 Clark's-buildings, St. Bride's. . Aug. 1 Ann C1ayt0n. ..... 35 Black-bear-alley June 22 19 James Dillon 37 24, Red-lion-court, Saffron-hill 23 20 Mary Field 52 8, Red-lion-court Aug. 9 21 Margaret Mahoney 32 New-court, Saffron-hill July 23 Elizabeth Tower. . 32 3, New-court 24 22 Catherine Hughes 30 St. Sepulchre's Workhouse . . 25 Hannah Heading. . 6 2, Greyhound- court 25 23 William Spencer.. 57 Bulls-head-court, Smithfield. . 24 William Clifford.. 4 Saffron-hill 25 or> MALIGNANT DIABEHCEA. sion. charge. 1832. July 24 Mary Wayte 43 4, Portpool-lane July 27 26 John Rolland 12 Duke of York's School 31 29 William Jackson . 36 Workhouse, St. Mary-le-Strand Aug. 3 John Harrison 40 3, Caroline-place, Saffron-hill.. Jl 30 Mary Cook 21 Grays-inn Workhouse 22 Aug. 1 Mary Bough 35 Ditto 22 2 Peter Pedley 48 Ditto 9 5 Martha Mastey .. 10 16, Little Ormond-yard 14 7 George Mills . . (< . . 24 3, Pox-court, Saffron-hill 11 9 Stephen Dyer . >.. 14 2, Saffron-hill 13 H John Smith 23 St. Sepulchre's Workhouse. ... 27 14 Ellen Power 37 2, Union-court 23 18 Marian Isle 20 St. Paul's, Covent-garden .... 30 Jane Dallastone . . 21 110, Great Saffron- hill 27 Rebecca Villiers . . 48 8, Plough-court 27 Elizabeth Wilson. . 64 30, Rutland-court 27 20 Peter Adams 64 14, Glass-house-yard 27 Robert Carter 43 St. Sepulchre's Workhouse 27 Thomas Smith 64 St. Mary-le-Strand Sept. 1 22 Sarah Mercroft .. 55 Church-court Aug. 30 23 Mary Scott 52 20, Fetter. lane Sept. 3 25 Caroline Connor. . 20 8, Caroline-court Aug. 3o James Parry 33 St. Mary-le-Strand 30 26 James Merchant. . 35 6, Plough-court 30 28 Marian Bougard. . 2j St. Sepulchre's Workhouse. ... 31 31 Ann Havcroft 6 Grays-inn Workhouse Sept. 4 Sept. 5 Henry Stamford . . 69 28> Brook-street ' 7 Elizabeth Smith.. 38 14, Portpool-lane 10 7 James Ward 25 Drury-court, Drury-1ane ...... 27 12 Mrs. Smedley 56 54, Saffron-hill 21 Jane Bnant 41 49, Saffron-hill 18 James Sopaci .... 41 6, Nevil's-court, Fetter-lane . . 18 13 Sarah Richards . . 21 7, Saffron-hilL 21 James Davis )6 Glass-house-yard 25 Mary Davis 48 Ditto Oct. 1 21 Henry Allen 77 Deans-court, Old Bailey Sept.23 John Eleneugh . . 27 9, Eyre-street-hill Oct. I 30 Patrick Flinn 14 Saffron-hill 17 Oct. 11 Sarah Jones 13 Baldwins-gardens .......... 22 12 Ann Smith 62 Bear-lane 19 1833. Aug. 10 George Nicholls .. 4o 32, Portpool-lane Aug.2l 12 Margaret Harris. . 31 Johnsons-court 22 18 Charles Watt 27 28, Greenhill's-rents 26 19 Robert Lucas 23 Leadenhall-street 22 21 Sarah Walker 46 85, Theobalds-road 28 Brian Sullivan 30 7, Richbell-place 29 Sept. 15 William Wilson .. 50 6, Black-bear-alley Sept. 21 67 MALIGNANT DIAEKHGEA. The following Statement is from the Lancet of February 2nd, 1833. — The Prescriptions being the same as inserted in the directions for Treatment, are omitted. MALIGNANT CHOLERA. AT THE HOSPITAL IN GREVILLE STREET, HOLBORN. (Communicated by the Central Board.) Guildhall, December 18th, 1832. Sir, — I have this morning received a communication from Mr. Marsden, and transmit the same for the information of the Central Board of Health. I have the honour to be, Sir, Your most obedient Servant, J. F. De Grave, To W. Maclean, Esq. Hon. Med. Sec. 2, Thavies Inn, December 15th, 1832. Dear Sis, — In conformity with your request of the 6th instant, and for the information of the " Central Board," I beg to lay before you the following statement of the number of patients admitted into the Free Hospital, Greville Street, up to the 12th of October last, with the modes of treatment and the results. One hundred and eighty-four patients afflicted with Malignant Cholera, in the second stage — that is, having no pulsation of the wrist, livid extremities, d. A NEW AND SUCCESSFUL MODE OF TREATING CERTAIN FORMS OF CANCER. To which is prefixed a Practical and Systematic Description of all the Varieties of this Disease, showing how to distinguish them one from another, and from Tumours, &c, simulating them. By ALEXANDER MARSDEIS", M.D., F.R.C.S.E. Surgeon to the Cancer Hospital, London and Brompton, and to the Royal Free Hospital, Gray's Inn Road, late Surgeon to the Ambulance before Sevastopol, fyc. S[c. PREFACE. The plan of treatment recommended in this volume has been successful in my own Hands, and in those of many other surgeons who have adopted it. It is not intended to supersede the use of the knife, but to be used for those cases in which that instru - ment would be useless, or in which a good caustic can do the work better; as such I offer it to the profession at large. In the First Part I have endeavoured to give a concise but systematic description of every form of Cancer and Tumour simulating Cancer, in order that practitioners and students, whose opportunities of studying this disease have been limited, may be enabled at once to distinguish each variety by its own peculiarities. lam not aware that this has before been attempted, and must plead it as my excuse for the many shortcomings of the present volume. It affords me great pleasure to acknowledge the valuable services Mr. Hayward, our excellent house surgeon at the Cancer Hospital, has always rendered me in all my investigations; and to our artist, Mr. C. D'Alton, I feel deeply indebted for the beautiful and unique collection of drawings from life his pencil has produced. 65, Lincoln's-Inn Fields, London. CONTENTS. Introduction. Chap. I. — The Five Orders of Cancee. Chap. II. — Lupus, or Rodent Ulcer. Chap. 111. — Non-malignant Tumours, etc., that may be mistaken for Cancer. Chap. IV. — Various Treatments that HAVE BEEN RECOMMEN DID. Chap. V. — The Treatment by Arsenical Mucilage. Chap. Vl.— lllustrative Cases. Formulae. " This disease has always baffled the skill of the medical profession more than any other; but since the establishment of the Cancer Hospital in 1851, by the father of the author of this work, upwards of 8,000 cases have been collected, and a field of observation formed, such as cannot be found elsewhere. The immense experience of Dr. Marsden on this subject entitles his work to a most careful perusal by all interested in the subject. The first part is written in a very clear and terse style, and thoroughly carries out the promise of the title-page. The second treats in the same clear and straightforward manner of a particular and successful mode of treatment, which has now stood the test of 12 years' trial. The book is illustrated with coloured plates, and the details of the treatment of 15 cases." — London Mirror. London: JOHN CHURCHILL & SONS, New Burlington Street. WC 262 M364s 1871 34711600R ¦J NLfl Dslb7T3b 1 NATIONAL LIBRARY OF MEDICINE