DR. MARSHALL HALL ON EPILEPTIC TORTICOLLIS. the records of the cases thus treated by my colleagues and myself, and will watch, even sceptically, the further examples which this large hospital is sure to offer to your notice during your stay amongst us, you will be convinced that it is an efficient and a very beneficial operation in certain cases. You will be pleased to understand that I have purposely selected for your instruction in these lectures some cases which in the course of treatment have presented unusual drawbacks. I have done so to make you familiar with the possible contingencies of the operation, and prepare you to compete with its difficulties. I could have adduced other cases, which would have placed it before you in a much more favourable light, by their being deprived of such untoward casualties, but my wish and my anxiety have been that you should possess a truly practical estimate both of its merits and of its demerits. In my next lecture we shall go into the examination of some cases of fracture at the base of the cranium. CLINICAL NOTES. BY MARSHALL HALL, M.D., F.R.S., &c. NOTE V.-ON EPILEPTIC TORTICOLLIS. FEW Symptoms of epilepsy are so marked and so common as torticollis, the most marked form of trachelismus. One patient was lying on his back on a sofa, when he was seen suddenly to turn his head to the left, as if to look at some pictures hung up on the wall on that side of the sofa. Some time ago an epileptic patient was found dead early in the morning in the Hanwell Asylum, lying with his face on his pillow. It was a question whether he had turned on the pillow and been suffocated, or whether he had died suffocated by laryngismus. My view has always been that the poor patient had been taken with trachelismus (torticollis) and laryngismus; had turned on the pillow; that when the laryngismus and trachelismus had ceased, he was too comatose to admit of a voluntary change of posture, and that pressure of the face on the pillow had completed the asphyxia which laryngismus had begun. A young gentleman, a medical student, came to consult me for epileptic seizures some months ago. Whilst we were conversing together, he suddenly uttered a loud cry, was taken with torticollis, and not only turned his head, but the whole frame rigidly to the right side, so that he would have fallen had I not forcibly held him on his chair. The very next morning he was found with his face enveloped in his pillow, asphyxiated! No doubt, the very events which I had witnessed in the day recurred in the night-viz., torticollis and contorted frame-and he had turned on his pillow, and there remained, on the cessation of the spasm, in the state of coma, followed by asphyxia, and terminated by death! All such events would, in more modes than one, be obviated by TRACHEOTOMY! Every case of epilepsy with torticollis ought to be watched, at least, with special care. ON THE POSITION OF THE PATIENT BY T. H. TANNER, M.D., &c. IN performing the operation of paracentesis abdominis for the purpose of evacuating the contents of an ovarian cyst, or of giving exit to ascitic fluid, it has hitherto been almost constantly the practice to place the patient in a half-sitting posture upon a couch or chair, and, a broad bandage with a slit over the part to be punctured having been passed around the abdomen, to make a small incision through the skin with a bistoury or abscess lancet in the linea alba, about midway between the umbilicus and pubes, and through the incision to plunge a trocar and canula. Less frequently, in cases of ovarian dropsy, the part chosen for the puncture is through the linea semilunaris, a practice, however, which should only be adopted when it is known with certainty which ovary is affected, the semilunar line of the same side being chosen; the risk of wounding the epigastric artery or one of its branches by this proceeding, as has been done with a fatal result, must not be forgotten. The same remarks apply against the selection of that point where a line drawn from the lower edge of the last false rib to the crest of the ilium is intersected by another line drawn from the navel to the back. For reasons which will be presently scen, it has lately 463 been proposed, by Dr. Simpson, of Edinburgh, to modify the usual proceeding by placing the patient in the recumbent posture upon the edge of a bed; and an opportunity having offered itself to me for testing the efficacy of this plan, I did so a few days since. The principal features of the case are briefly these: M. S-, aged forty-six, married twenty-four years, never been pregnant, applied to me, as an out-patient at the Hospital for Women, on the 13th October, 1852. Has always enjoyed good health, though she has never been very strong. Catamenia first appeared at seventeen, without pain; they continued regular until her marriage, since which time they have been slightly irregular, and attended with suffering; has always had leucorrhoea. Until eight months ago she was in her usual health, and, as she says, free from any complaint. At this time, however, while lifting a heavy weight she felt something give way at the lower part of her abdomen, and for half an hour afterwards experienced great agony, which then slowly ceased, and was almost forgotten until one month afterwards, when she began to complain of a constant aching pain in the same situation, especially over the left ovarian region. She then noticed that her stomach was enlarging, the enlargement appearing equal over every part, not more on one side than the other, and shortly afterwards she became an out-patient at one of our metropolitan hospitals. During her attendance at this institution, she took the iodide of potassium in rather large doses, and rubbed some iodine ointment frequently over the abdomen. This course of treatment, without in any way diminishing the size of the tumour, materially injured her general health, and she rapidly became very weak and emaciated. On discontinuing her visits to the hospital, her health improved; but as she suffered much pain and inconvenience from the distention of the abdomen, she at the end of three months put herself under my care. At this time she still appeared in bad health, was weak, and could only walk with difficulty; she suffered from dyspnoea, which occasionally became urgent. On examining the abdomen, it was found enlarged to about the size of a woman's at the full term of pregnancy; the enlargement was uniform, and fluctuation could be distinguished over every part; there was also universal dulness on percussion. She measured thirty-two inches and a half in circumference at the umbilicus, and nine inches from the umbilicus to the pubes. She complained of great pain and tenderness at the upper part of the abdomen, especially over the region of the liver; the pain was increased by pressure, and by any movement requiring much exertion. On making a vaginal examination the uterus was found to be healthy. There was no difficulty in diagnosing the existence of cystic disease of one of the ovaries, and it was considered clear that there was either only one cyst, or a large cyst with smaller ones at its base, near the pedicle. With the view of improving her health, and relieving her sufferings, she was ordered some ammonia in a bitter infusion, with small doses of opium, and directed to live well and carefully. Under this treatment she gained a little strength, but still complained so much of the distention of the abdomen, and had, occasionally, such alarming attacks of dyspnoea, that I determined to give her relief by tapping, to which operation she was most anxious to submit. On the 25th October, therefore, assisted by Mr. Sanderson and Mr. James Rice, this proceeding was carried out, the patient being placed on a bed in the recumbent position on her right side, and, as the contents of the cyst flowed out, being turned over gradually on to her face, so as completely to empty the sac. On then examining the abdomen it was found that the tumour was a multilocular one, but that by far the largest cyst had been emptied. A bandage was applied round the abdomen, and the woman expressed herself as feeling comfortable; she had previously complained of being cold, but had not been at all faint. The fluid removed was rather more than nine pints in quantity, dark-coloured, resembling linseedtea, and was in part gelatinous, so that the canula occasionally became obstructed; it was of neutral reaction, had a specific gravity of 1030, and contained a large quantity of albumen, becoming almost solid on the application of heat or nitric acid. The advantages which appeared to result from the position of the patient are these:-First, that it is a comfortable one, free from restraint, and one from which the patient has not afterwards to be moved; secondly, that the belly-bandage, and the two assistants necessary to tighten it, in order to promote the flow of the fluid when the sitting posture is adopted, can be dispensed with; thirdly, that the cyst is more completely emptied than in the usual way; and fourthly, that syncope is much less likely to occur; for as this takes place from the want of support which the diaphragm experiences, owing to 464 MR. GAY ON RUPTURE. the shrinking of the tumour, so this want is less felt in the recumbent posture. It is only necessary to mention, that this woman has derived great relief from the operation, is stronger than she was, and has been freed from all feeling of distention, pain, and dyspnoea. Of course this relief can only be regarded as temporary; for it is much to be feared, that not only will the sac soon refill, but that the smaller cysts will not long remain dormant. Charlotte-street, Bedford-square, Nov. 1852. CONTRIBUTIONS TO THE SURGERY OF BY JOHN GAY, F.R.C.S., SURGEON TO THE ROYAL FREE HOSPITAL, ETC. ETC. During this and the operation are called into requisition. period of experimentalizing, be it remembered, some of the most important and delicate structures of the body are exposed to the inroads of the most rapidly and surely fatal lesions to which they can be subjected. Let us look for a moment at what the taxis has achieved under the best value of this mode of reduction in cases of strangled hernia. auspices, and endeavour to arrive at a true estimate of the For this purpose I might have appealed to the results of my own practice, which certainly are most unfavourable to its employment; but in order to avoid any doubt as to the premises, I have constructed a table from Mr. Poland's interesting and able report of the cases of hernia that were admitted into Guy's Hospital, from September, 1841, to December, 1842.* (See opposite page.) From this table it will be seen that the taxis was employed in twenty-six cases of hernia, in which strangulation had existed for periods varying from two hours to seven days. In five of these cases the taxis is reported to have been successful, so far as reduction was concerned; whilst in the remaining In one of the FOUR years have now elapsed since I proposed to the profession a new method of operating in cases of strangled hernia.* I was induced to do so in obedience to my conviction, that the twenty-one, it failed altogether of its purpose. rate of mortality was (and it is still) unnecessarily and fear- five successful cases (38) strangulation had existed about twelve lully high, and that this fatality was in great measure due in-hours; the taxis (which had been employed by the patient directly to the operation usually resorted to for their relief; himself) was again used; then a warm bath and an enema; its severity and the comparative difficulty of its performance and afterwards ice, which was kept applied apparently for being such as to have led to the conclusion that the herniated two hours, when the parts were reduced "without difficulty." parts, under almost any circumstances, had better, if possible, The man had been labouring under some abdominal combe returned without, than by division of the stricture. I pro- plaint for the previous fortnight." Ile died the following day; pose an inquiry into the merits which these two methods and the post-portem inspection revealed the existence of respectively possess, and trust I shall be able to show that general peritonitis, with considerable bloody and serous were almost black; (the tumour on admission was "enormous” a reversal of the rule of practice, which still very exten- effusion into the abdominal cavity. Three feet of intestines sively prevails, would, if acted upon, lead to a considerable saving of human life. If we reflect for a moment on the con- and "elongated.") The intestines, both large and small, ditions of a portion of intestine or omentum strangled by its contained a quantity of grumous blood, and their lining of this patient on admission were not severe; the tumour having found its way into a straightened ring or canal, it must membrane was much congested and soft. The symptoms be conceded that these could rarely be such, per se, as neceswas "rather tense, but not tender," and he suffered from sarily to give rise to fatal consequences; but that, on the other hand, if the constriction be promptly and effectively sickness, considerable pain, and general distress. There can than abortive-that, in fact, it caused those lesions which terremitted, its effects would, in the great majority of instances, be little doubt but that in this case the taxis proved worse as quickly and completely subside. ture had been relieved by operation as soon as symptoms of minated the patient's life; and, moreover, that if the stric strangulation showed themselves, the life would have been saved. In case 39, a portion of the contents of the sac, prothe patient obtained relief, but the whole was not returned bably the intestinal, was reduced by the first manual effort; until after the expiration of eight days. The case was not severe at first; but to the taxis certainly belongs the credit On this occasion of its reduction. In the third case (41) the patient had been operated upon five months before. the tumour became rather large, tense, and moderately tender; the constriction at its neck being very tight. The taxis was first employed, then the warm bath with calomel were returned without much difficulty, when the opening of and opium, and subsequently ice. The contents of the sac the ring was found to present an oblong slit, with hard, unyielding edges. In all probability this state of the ring, the In case 43 the symptoms were result of the former operation, furthered the good offices of the taxis in this case. moderately severe; and after the application of ice for the space of two hours, the taxis proved successful. The causes of death after strangulation of some portion of the abdominal viscera are almost invariably either shock, a low form of peritonitis, or mortification of the strangled parts in some one of its stages. The former of these causes have been known to dispose of the sufferers within twenty-four hours, and the fatal termination cannot perhaps in any case be averted, inasmuch as other and still more formidable lesions are found to co-exist in some department of the organic system, which contribute the greatest share in determining the common result. With regard to the other cause of death-disorganization of the strangled parts-this would appear to be a consequence not so often of the mere act of strangulation as of its persistence, and is induced with a rapidity generally proportionate to the tightness of the stricture, and in some degree to the power of the parts involved to resist the encroachment of the fatal change. Cases have occurred in which sphacelus of a portion of bowel has been induced in the course of two hours; whilst in other cases this result has not followed, although symptoms of strangulation have existed for a period of ten or twelve days. I am not aware of a case in which such changes have been known to take place in a less period than that just mentioned; but I am inclined to think that in those cases, which must be familiar to every surgeon, in which the coats of the bowel have been cut through by the stricture, as though by a cord tied tightly around it, this result must have obtained in a still shorter period of time. If the circulation be completely arrested in a knuckle of intestine, I quite conceive, with Sir Chas. Bell, that half an hour would determine its destruction. With these facts before us, is the rule of practice which generally prevails such as their urgency can upon reflection justify? I think not. The first remedy, in every sense of the word, according to the place it holds in the general routine of practice, is the taxis, repeated again and again, with the aid that one or more of its ordinary adjuvants, the warm bath, bleeding, ice, enemata, &c., can give it. Every effort is strained to procure a reduction of the hernia by these means; and it is not generally until the patient is supposed to have reached his climax of toleration both of the disease and of the remedy, that chloroform Although averse to the use of new terms, I cannot but think the term "strangled," applied to hernia, much more suggestive than "strangulated." The import of the former is self-evident; whilst the latter derives its force almost entirely from its alliance. † Larrey, Mémoires de Chirurg. Militaire, tome i. In the fifth case (44), the symptoms of which were moderately severe, an enema was given, and ice applied to the tumour, after which reduction was effected by taxis. Four cases only could be said to have had a favourable termination, and in one of these it might be questioned whether this result was not in great measure attributable to the accidental and peculiar condition of the ring at the time the taxis was em ployed. In twenty-one instances the taxis failed altogether, although it was, with a few exceptions, undertaken by most competent surgeons; in cases of, for the most part, moderate severity; and persisted in, with judiciously ordered intermissions, for periods varying from two hours and a half to twenty-nine hours. In eighteen the stricture was ultimately divided; but of these nine died, and the inspection discovered in each those irreparable lesions which are well known to be occasioned by violence or protracted strangulation, or by both causes combined. There were no grounds for suspecting in any one case about the fatal result; but much reason for thinking that the that the operation itself had the slightest share in bringing lives of most of these patients would have been saved had the operation been substituted for the first manual efforts at re Guy's Hospital Reports, April, 1843. CASES OF STRANGLED HERNIA. From MR. POLAND's Report in Guy's Hospital Reports, No. I., April, 1843. 1 Oblique inguinal. About Several 12 hours. times. Oblique 15 hours. inguinal 8 Femoral. 48 hours. 10 Ib. 48 hours. 11 Ib. 32 hours. Ib., violently, by patient. Moderately. Repeatedly. A very short time. 10 hours. 17 hours. 1 At first refused; afterwards assented to. Ileum highly congested Post-mortem.-Ten inches of ileum ex- Recovery. Death. No post-mortem examination Death. No post-mortem examination Death. Intestines healthy at time of operation; no Death. post-mortem examination. Death. Recovery Death. Intestine of a dark colour, with ashcoloured spots; slit up during operation. A portion of omentum sloughed. Portion of omentum submitted to taxis congested, black, and crisp; intestine also congested; post-mortem examination, low peritonitis. Operation refused; gangrene and faecal infiltration. Death. duction. In those cases in which recovery followed the operation, the periods of time allotted to the trial of desultory measures varied from two hours and a half to (in one case) seventeen hours; clearly showing that the success of the operation was, to a certain degree, associated with its comparatively early adoption. It is evident, then, that but little confidence can be placed in the best efforts at manual reduction of the parts in cases of strangled hernia, apart from division of the stricture; whilst, on the other hand, the evil effects of the force used, as well as of the protracted constriction which its employment necessarily occasions, give rise to an amount of fatality that fearfully counterbalances the presumed advantages of its being occasionally successful. The truth and importance of these observations are well attested by the following extract from Mr. Hancock's interesting and able work on Hernia:- | "Between the years 1834 and 1839, M. Boyer never operated until he had made prolonged attempts at reduction, and during that period nine cases were operated upon, of which eight died and one recovered. From 1839 to 1843 he employed the taxis to a much more limited extent. Seven cases were submitted to operation, of which four died and three recovered. From 1843 to 1846 he had almost entirely abandoned the use of the taxis; and out of fourteen cases upon which he operated, four died and ten recovered. Mr. Manee, on the contrary, during the same period, almost always pro ceeded to operation without employing the taxis. Out of twenty-eight cases operated upon, two died and twenty-six recovered."-(p. 65.) But the results of the taxis are often disastrously fallacious, as Mr. Cock, Mr. Teale, and others, have, in common with myself, observed. Not only has the sac with its strangled contents been together returned within the abdominal or pelvic_boundaries, but it has frequently happened that a portion of the fluid contents of the sac, or of the intestine, has been forced back beyond the seat of stricture; the patient has been relieved, and the surgeon has been led to entertain a hope that the urgency of the case is at an end. A few hours, perhaps a night, have been allowed to pass, the symptoms have recurred with greater severity than ever, and, despite of the release of the parts by operation, the life has been lost. What then should be the ule of practice? Clearly, that in cases of strangled hernia the parts should be freed without the least possible delay; and by the use of those means which give the greatest promise of success. Is a trial of the taxis justifiable in any cases? 1st, Clearly not in those in which, however recently the contents of the sac might have become strangled, symptoms of constitutional disturbance have developed themselves; 2nd, Neither in those in which, from the existence of local pain or tension, we infer the encroachment of those lesions which, if unchecked, must prove fatal, and that possibly in the shortest space of time; 3rd, Nor in those cases in which strangulation has been protracted beyond a few hours, seeing that of all the circumstances that are known to compromise the safety of the patient, none is more insidious, more replete with peril, than delay. observed, that it is better to reduce the parts by any other method than by an operation; and that consequently this should be delayed until every other shall have proved futile. The fact is, a very strong and general antipathy exists against the operation abstractly; and probably by those who have a lingering impression on their minds of the large incisions, the tedious dissections, and the wholesale exposure of parts which its performance some years since was wont to involve, this antipathy might be entertained with some considerable show of reason. It is not, however, warranted by the more than necessarily elaborate mode of dividing the stricture, which was adopted in the time of Pott and Hey; for these surgeons averred, that the operation, if well done and in due time, did not prove the cause of death once in fifty times. Even now the usual operation has many defects; and in order to remove the prejudice referred to, it appeared to me, that in its place a mode of dividing the stricture was required, which should be simple of execution, free from danger, and still effective for all purposes; a method which should claim to be preferred to all other methods of effecting the reduction of a strangled hernia. The defects of the old operation are-that (if I may so express it) it is too anatomical, and not sufficiently surgical; and that in securing a very simple end, it is too prodigal of the means. The knowledge and skill required for its performance have not only served to lull all suspicion as to the actual necessity of so elaborate a procedure, but have so captivated as well the aspiring student as the practised surgeon, that its real elements of danger are commonly looked upon as its greatest charms. The simple objects of the operation should be, of course, the division of the stricture, wherever situated; the method, that by which a knife can be brought most readily to bear upon it. According to the old operation in femoral hernia, the form and extent of the preliminary incisions are to be determined by the size and shape of the hernial tumour; but what relation these latter circumstances have to the seat of stricture, so as to necessitate such a modification of the operation for its division, I cannot divine; seeing that under every conceivable condition of the tumour, the seat of stricture, according to the variety of hernia, might be, and is for the most part, the same. This, and other unintelligible absurdities appertaining to the method referred to, quite suffice to account for, if not to justify, the dread that has generally been entertained with respect to it. The method of operating to which I have called the attention of the profession is, I believe, free from these objections. By it the seat of stricture is reached through a small wound made in healthy structures, immediately contiguous to the neck of the hernia, and so as not in any way to interfere with or to disturb those parts of the protrusion not directly impli cated in the act of strangulation. It has nothing to do with the size, shape, or even direction of the tumour, for it deals with the stricture, and with that alone, so long as that comprehends the seat of the mischief; whilst, at the same time, it allows of any modifications that extraordinary circumstances or conditions may in the course of the operation be found to demand. It is not, as some have alleged, a species of subcutaneous section, for the whole process may, if required, be distinctly seen; although, with a moderate acquaintance with the anatomy of the region, the sense of touch is alone necessary for its safe execution. From the table adduced, which certainly places the taxis in the most favourable light, as well as from my own and the concurrent testimony of those who have seen much hernial practice, I confess myself indisposed to place any reliance upon it in a case of strangled hernia, especially whilst I am I have now operated according to the plan advocated many prepared with a surer remedy, being persuaded that that sur-times, and have only had to repent of the use of the taxis and geon will save most lives who trusts to the division of the of delay. In favourable cases, where the stricture has been stricture, and to that alone. If the taxis be tried at all, it outside the sac, the operation has only taken from one to a should be tried on cases exceptional to those I have just very few minutes for its performance; whilst the recoveries, classified, whilst the patient is under the influence of chloro- in comparison with those after the old operation, have been, on form, and after both the patient and friends have been an average, as seven days to thirty. The operation has been, warned of the nature of the case, and of the course it is I am pleased to learn, adopted by several of our leading surnecessary to pursue, so that in the event of its failure the geons, but it is not without the utmost gratification that I exoperation may at once be proceeded with. Moreover, this tract the following remarks from a clinical lecture by the distrial should be limited to the most gentle pressure, continued tinguished Professor of Surgery at King's College; for not only but for a very few minutes, and concentrated towards the do they confirm the opinion I have never ceased to entertain axis of the ring. The ordinary adjuvants of the taxis are of the method of operating which I have advocated, as well as unequal, in point of efficacy, to chloroform vapour, and would of the principles upon which it is based; but, coming from so thus be dispensed with, together with the mischievous delay high an authority, and after so long and deliberate a trial as that their trial occasions. that which Mr. Fergusson has done me the honour to give to my views, they abundantly justify me in still claiming for them the serious attention of my professional brethren. For a case of strangled hernia, then, there is but one remedy on which the surgeon can depend-the division of the stricture. This is no discovery of mine; it has again and again been reiterated, but every day's experience, and the revelations of practice in the various journals, show that the doctrine is still far from being generally believed in; or if believed in, is not acted upon. The rule of practice which appears very generally to prevail, even at this moment, is, as I have already Mr. Fergusson says, after giving a very clear account of the method of performing this operation: "Now this I consider a most simple proceeding, ..... and I think it deserves much more attention than it has already obtained at the hands of practical surgeons. I have for the last few years rarely performed any other operation. MR. R. CARTWRIGHT ON THE IMPULSE OF THE HEART. The incision in the skin admits of the sac being opened or not, as may be found advisable. I feel certain that those who see this operation performed, will confess that there is some advantage over that which is usually done, both from the facility with which it is accomplished, and from the simple aspect of the whole process. I shall avail myself of other opportunities of calling your attention to this method, as I deem it worthy of your careful consideration; in fact, I should not be doing my duty as your teacher, if I did not bring before your notice what I myself deem a very great improvement in connexion with hernia, as the proceeding referred to is really not much more than the simple operation of the taxis." OBSERVATIONS ON THE IMPULSE 467 gravity, and not in consequence of the elastic reaction of the arterial walls. When the contraction of the ventricle ceases to dilate the commencement of the aorta, the elastic reaction of the artery begins, and exactly at that point where the muscular substance ceases; consequently, the sole effect of this elasticity is to pass the blood forwards, and not one single drop backwards. The closing of the semilunar valves takes place during the second stage of the diastole, just when the ventricle is completely dilated. I take the liberty of again referring to Professor Skoda's valuable case, where the sternum was deficient in a child a few days old. "By applying the hand, one could easily perceive that the heart was vertically placed, and moved with each systole downwards and forwards, with each diastole upwards and backwards. The impulse was felt with each systole of the heart immediately above the insertion of the diaphragm; with each diastole, on the contrary, as high as the second rib, if the fingers BY ROBERT CARTWRIGHT, Esq., Surgeon. were sunk sufficiently deep towards the spinal column, &c.; the heart during each systole glided about an inch downwards." SINCE my last communication in THE LANCET, Oct. 23rd, I Cruveilhier says, that in his case the heart projected downwards have opened another dog, and Mr. Blaikie agrees with me, that during the ventricular diastole. It is evident that Professor in this case, also, the first sound occurred during the diastole, Skoda did not see the naked heart, but merely felt the moveand that there was not the slightest tilting or turning of the body ments through the pericardium, and it is equally evident that he or apex of the heart during the systole, but there was a slight has misapplied the terms systole and dyastole. I have seen the jerking movement during the diastole. The systole commences naked heart, the pericardium having been slit up, in five rabbits, instantly, the very moment the ventricles are fully dilated; it two dogs, and two asses; and in each instance, without the does not begin at the basis, as stated by Valentin, for that would slightest deviation, during the diastole the apex projected downbe the very means to prevent the expulsion of the blood; nor is wards, and during the systole it was again drawn upwards; that it by a simultaneous contraction of all the fibres, for that would is to say, taking into consideration the normal position of the tend to have a similar effect, though in a less degree. Some phy-human heart, the heart moves with each diastole downwards and siologists consider that the heart, by its contraction, is shortened, forwards, and with each systole upwards and backwards; an and the base, by the swelling of the muscular substance, becomes impulse being felt during the diastole at the apex, and during the broader and larger, so as to raise a weight, and give a distinct systole at the base, for the base is very slightly enlarged during impulse to the finger; but the error, so far as there is any, can the diastole, but considerably so during the contracting of the be satisfactorily explained. The contraction begins at the apex, heart, as before stated, by the passage of the blood, giving a dissqueezing the blood onwards to the base, which thus becomes en- tinct shock to the finger. larged during the contracting of the heart, not by the swelling of the muscular substance, but by the additional blood passed into it; the base then contracts, and when the heart is completely contracted, it is diminished in all its dimensions. The systole of the heart is a successive act; even in its quickest motions, there is still a successive, and not a simultaneous, contraction of all its fibres. The diastole begins about the middle of the heart. I am inclined to this opinion, because in the two rabbits which I examined last year, and in which the heart's action was not only vigorous, but identically the same in each, the spiral fibres about the midd'e appeared first to unroll themselves, and then the apex shot out, and then the whole heart appeared to be suddenly enlarged in all directions; in the two dogs the action was very similar, though not so distinctly marked. The diastole may be divided into two stages, but I consider that the dilatation in each stage is active, and that the contraction of the auricle has merely the effect of slightly increasing the tension of the walls of the ventricle, and thereby perhaps serving as a stimulus to its immediate contraction. The first stage of the diastole is to admit the blood from the auricle towards the apex; in the second stage, the muscular fibres at the base and along the septum unravel themselves, a beautiful illustration of which statement I saw in an ass; the animal being only six weeks old, sank under less than a drachm of chloroform, so that on opening the pericardium there were only the apex and auricle in action, passing the blood backwards and forwards between them; there was not the slightest action perceptible at the base, nor along the median line. In the diastolic theory of the impulse, the movements and sounds of the heart, and the course of the circulation, all harmonize together; the dilatation of the ventricles instantly followed by their contraction, and then a pause; the first sound instantly followed by the second, with a slight interval, sufficient to separate the two sounds from one another, and then the pause. Diastole. DIASTOLIC THEORY. Pause. 1st sound. {tlight two sounds.} 2nd sound. What is this pause? It appears to me, that the heart remains after the systole in a state of contraction, thereby serving as a base to the column of blood, which would otherwise immediately fall back, the body being in an upright position, by its own The first sound is caused by the passage of the blood from the auricle nto the ventrige towards the apex; and the second sound by the forcible propulsion of the blood against and through the semilunar valves. It is unnecessary to recapitulate my reasons for believing that the impulse occurs during the diastole; the proof hinges entirely on the point-Does the first sound occur during systole or diastole? Dr. C. J. B. Williams's extraordinary "fifth Observation," as quoted in my last letter, must prevent, in the present state of our knowledge, any man, however prejudiced, from placing any reliance on his and Dr. Hope's experiments with reference to the first sound. November, 1852. ON A SIMPLE BOOT FOR ATROPHY OF BY ROBERT CHARLES CROFT, Esq. It not unfrequently happens in infancy, that paralysis of a limb occurs during dentition, but, generally speaking, as soon as the irritation caused by teething has been removed, the limb thus affected resumes its proper functions. Sometimes, however, paralysis takes place without any perceptible or assignable cause; and it is to a case of the latter kind the reader's attention is invited. M-, a little girl seven years of age, has always enjoyed excellent health from her birth; the period of dentition was passed through easily, without any unusual constitutional disturbance, and, to the best knowledge of the mother and nurse, she has never had a convulsion or fit of any kind. When she was a few months old, her right leg was observed to be somewhat smaller than the left; and when she began to walk, it was noticed that she appeared to have less strength in it. From this time the right leg seemed to be imperfectly nourished, and grew very little compared to the left. When the writer first saw her (now six or eight months ago), the condition of the right leg was as follows:-It was an inch shorter than the left. The thigh, although considerably atrophied, was not so small in proportion to the other thigh, as the lower part of the leg, from the knee downwards, which was very small in proportion to the other leg. In walking, she threw the leg forward, swinging it over, as it were, and bringing the inner part of the heel to the ground. At this time, too, she had been wearing for some time two iron bars, running for a short distance up either side of the leg; an apparatus resorted to, to cause her to put her foot flat to the ground. On carefully examining the leg, it was found, tha |