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An Introductory Lecture TO A COURSE OF MILITARY MEDICINE & SURGERY
529 present between the nbrillae in nerve lating to the care and preservation of the wounded in the hour up longitudinally in an extraordinary of combat, or in connexion with the prevention of destructive None of the cells lying amongst the muscular tissue diseases in military, naval, or civil life, must be acknowledged manner. as not less important to Government than those of their military have at all a suspicious look. "The property of infiltrating surrounding textures being and civil compeers; how have their services and counsels been usually regarded as a peculiar feature of malignant growths; the neglected and ignored, both in the civil and military systems of evidence of its existence in this fibrous tumour is a point of this country? In the Sanitary Boards, established for the considerable interest with reference to the circumstance of re- executive duties of promoting public health, their usefulness currence. has been limited, and their efforts for good shorn of public FiG. 2. responsibility, by being entirely subject to the guidance and caprice of political amateurs in sanitary matters; and who, while they hold their places on the principle of political expebut
even
appear to be
fibres, which
are
split
diency, know little of the physical laws which govern disease or regulate health, beyond the dim and indefinite conception that the removal of cesspools, the construction of good drains, and the extra-mural interment of the deceased of large towns,
necessary for the welfare of the living. But the science of which has a wider and more comprehensive scope than the art of the architect or engineer, is based on physiological knowledge of the functions of the living organism; and shows us how such may be affected, both in health and disease, by the various physical and moral agencies, both within and without the body, that promote nutrition or facilitate the inroads of decay. It teaches how the organic power of functional resistance may be best secured, in order to ward off the usual destructive consequences of both local and general causes of disease. It shows, by statistical data, the relative healthful or deteriorating influence of age, modes of life, climate, and locality; the morbific agencies of unwholesome food and bad water; of intemperance, overcrowding, retained surface drainage of particular soils; and of concentrated septic exhalations, from animal and vegetable matter in states of decomposition: while, along with such instruction, it conveys a knowledge of the healthful or morbific influence of elevated and depressed temperature, of atmospheric dryness or humidity, of particular seasons, winds, and countries, in relation to the peculiar topographical features of the latter, and their geographical distribution into latitudes of special diseases. The importance and utility of such knowledge are acknowledged and provided for, in the civil and military organization both of France and Germany, by its academical teaching in public institutions, and by publicly associating medical counsellors with the higher officers of State, in the constitution of civil and military Boards of- Health. Yet what have been the systematic public provisions in England for thus profiting by the experience and counsel of the best men in the medical profession, in this age of intellect and progress ? None, positively none, deserving of the name. Temporary expedients of limited extent, and unstable public utility, have been adopted to meet the exigencies of actual public service, and the defective organization of the civil and military medical systems of this country. Amidst a frightful outbreak of destructive cholera, a Board of Physicians and Surgeons is summoned together to aid, by their counsel and advice, the largely-paid health officer of Government, and are permitted, when no longer required, to return inadequately rewarded to the domestic obscurity of private life. Though medical education, too, in this country, no way provides instruction in the principles of sanitary science, but leaves the over-worked medical attendant of the poor to pick up, here and there, such crude notions of it as may be gathered from desultory reading, this same health-officer of Government, as if£ to ignore the idea that the preservation of public health was, in any way, an integral part of medical science, dispenses altogether with medical counsel or medical supervision in his own immediate department, and consigns, by a legislative enactment, the important matter of national sanitary improvement to local boards of health, composed, as they must be, of that very class of ratepayers, whose self-interest and prejudices have, hitherto; offered the most successful opposition to the removal of those public nuisances which are known to affect so injuriously public health. But if the destructive agencies be great which collectively injure the health and welfare of the civil population, those banded together to produce sickness amongst soldiers, and decimate armies in the field, are yet greater; and still no wellorganized system of medical council, or permanent sanitary commission, has been adopted for a comprehensiveconsideration of questions relating to the medical economy and health of the British army-destroyed as it has been by war and the urichecked career of preventible disease. That the ravages of these diseases might have been stayed by suitable measures of prevention, may be gathered from the facts stated in Mr. Guthrie’s late lecture at the College of Surgeons,-that the ratio of death amongst commissioned officers in the Crimea was 4 ’12 per cent., and of non-commissioned officers, rank and file, 17.16 per cent. are
public hygiene,
FIG. 3.
FIG. 4.
FIG. 5.
An Introductory Lecture TO
A
COURSE OF
MILITARY MEDICINE & SURGERY Delivered at St.
BY JUST in
JAMES
Mary’s Hospital,
BIRD, M.D.
proportion as the more politic and powerful governEurope have found that the public safety, and the well-being of society, are dependent on the efficiency of the Army and Military Medical Departments, so have such establishments been objects of national care and attention, and those who administer their affairs with vigilance and devotion the recipients of royal favour and public honours. The importance and utility of the soldier’s and seaman’s services, in their individual and collective relation to the order of society, and the prosperity of the state, have ever been generously acknowledged and amply rewarded in this country, by a due amount of public emolument and public honour. While the physician’s judicious counsel, orthe skill of the surgeon, in all rements of
530 While most of the disastrous results by which this army has British service; and such advantages are of no small account, been so painfully reduced in efficiency can be traced to the in as far as they encourage a constant increase of professional general want of system and perfect organization of its medical professional zeal amongst the medical staff, arrangements in relation to other departments, no portion of whose selection, social position, pay, and promotion, on the such arrangements has been the source of more mischief than and fitness, are regulated on the same definite than that which takes away both authority and means from of equity. What wonder, then, that they should be military medical officers, to provide for the care of the sick found ever ready to extend the dominion of professional knowand wounded; while it at the same time permits of their repre- ledge, or rise equal to the exigencies of professional utility, sentations, on sanitary measures necessary for the troops, being when the prize of both honours and emolument rewards the altogether disregarded by military authority. However much labours of well-educated gentlemen. The failure of our own interested the medical officer may be in the welfare of his sick, ungenerous and defective system of military and naval medical he has here no means of obtaining suitable diet, clothing, or organization may teach us something from the success of our transport, for their comfort; and finding that his requisitions neighbours. for necessaries cannot be complied with, or that his remonWith these preliminary observations, naturally suggested to strances are unheeded, he resigns himself to an apathy and me by recent events in the Crimea, and by the unfavourable indifference not unnatural to men thwarted in their efforts for contrast of our own army medical organization there, as drawn good, and who tacitly yield to evils they cannot prevent. But from the comparisons made between the health of the French while a well arranged plan of military medical organization, and English troops, I now appear before you in this, the providing against such mischievous consequences, has been long youngest, though, we would fain hope, most improved Medical enforced in all the great armies of Europe, coupled with a well- School of this metropolis, to place before you the principles as digested system of supplementary instruction on military medi- well as the practice of military surgery, medicine, and hygiene cine and surgery, what measures have been taken in this country -subjects that have long been deemed desiderata of an army to prevent a repetition of the military medical disasters com- medical education in other countries, though not yet sufficiently mitted in the expedition to Walcheren and the West Indies appreciated in our own. While I am the first in this metropolis during the last war ? Let the recent painful events in the to attempt a separate and complete course of lectures on those Crimea be an answer to the question. subjects, I enter on the duties I have undertaken with no ordiMore than eighty years ago, Coloinbier, a great authority nary sense of my own responsibility, and of their great importon military medicine and on the special nature of military ance, viewed in their relation to the interests of medical and diseases, when speaking of the medical military establishments surgical science, as well as the interests of humanity. We have now fairly entered on a conflict of no ordinary of France, wisely and truthfully observed, that, in order to obtain all the benefits they were meant to confer on the soldiers magnitude, and with a military power of the first order, and of and the army, it is not only necessary to secure for the hospitals boundless resources in respect to men and the munitions of all the salubrity of which they are susceptible, and to give the war; the health of our gallant soldiers and seamen has already sick most prompt assistance, but it would be also important to suffered severely from the usual contingencies of such a contest, learn the kind and nature of the diseases, and, above all, the and as their welfare may be still more deeply implicated, by causes which multiply them; and, in short, by prevention, to other expeditions not yet thought of, it behoves us as a nation, lessen the heavy losses which happen chiefly in times of war. and as a government of practical patriots, to lay aside preIt is a fact not questioned, that in war, more soldiers perish by judices of both a political and professional nature, and to estadisease than in combat, and if our failures and medical experi- blish such a military and naval medical organization in both ence, during the last war, could have taught us humility to services as will provide for the comfort and most efficient learn for the future, we ought ere now to have had a system of system of medical treatment of our sick and wounded. These both prudence and forethought, in all that concerns the pre- have surely greater claims on national gratitude, to be supvention, as well as the improved treatment, of military diseases. plied with the best medical and surgical advice procurable, This also would have conducted us to an improved system of than have the paupers of our voluntary charities and hospitals, army medical organization, and a more perfect curriculum of who are not denied such privileges; and it will be no unimprofessional education of the candidates intended for the army, portant step, in furtherance of this object, to provide an navy, and East India medical services. But an overweening efficient system of supplementary military medical instruction spirit of national conceit and prejudice has only encouraged us in all those branches of professional knowledge that should be’ to contemptuously reject the one, and to strengthen our minds familiar to the army and naval medical officer. But if governagainst the conviction that there can be any absolute necessity ment and its advisers desire not to perpetuate evils that attach for the other. The consequence has been, that, in our systems to the present defective medical organization of either branch of medical education, academical teaching of scientific hygiene of the service, or may hope to secure for their ranks men of has been utterly neglected; and, notwithstanding the useful distinguished merit, they must not only place their medical labours and eminent services of Mr. Guthrie and Sir George officers in the same relative social position and condition that. Ballingall, in regard to improved instruction on military are conceded to other officers, but must hold out to them worthy surgery and military medicine, for this country, many will objects of ambition, for encouraging professional zeal and imneither see nor be convinced of their necessity, for army and proving professional knowledge. It is well known, from Greek and Roman history,-that the navy medical officers, as supplementary to the civil medical education of England. But the diseases which arise, in filthy classical nations of antiquity, in their days of splendour and and malarious camps, in the hot climates of the East and West glory, while they maintained disciplined troops, introduced Indies, on the coast of Africa, and on ship-board during long into their military systems the greatest order and regularity; voyages, are never met with, and quite unknown in this and though nothing very instructive or in detail regarding the temperate climate. Young army and navy medical officers, prevailing epidemics in their camps, or the health of their who, in London or Edinburgh, may have had the best civil troops, has been handed down to us in separate works of milimedical education in medicine and surgery, but who have tary medicine and surgery, we are not left altogether in the neither instruction nor experience, as to the nature and modifi- dark concerning these interesting subjects. We learn from cation of these diseases, must find themselves in situations of Homer that both military medicine and military surgery were great difficulty and embarrassment, when called on to, treat in use as far back as the war of Troy; and though the military multitudes of sick affiicted by them. The modifications and men of those days were most imperfectly cared for by either of types of diseased condition, which, under such contingencies these professional departments, the military surgery of these and circumstances of naval or military life, present themselves times appears to have had a preference to the medical art of in connexion with internal or medical diseases, come no less curing internal diseases. as Homer chiefly eulogizes those who frequently under observation in external or surgical maladies. took charge of the wounded. Xenophon, in his " Cyropsedia," Though many works of research and authority, on the or the education of Cyrus, (extracts from which are given in subject of military medicine, have been of late produced by Dr. Richardson’s first number of the " Quarterly Journal of medical officers in the French and other continental armies, Public Health,") particularly notices the medical department yet no English ones of note have appeared amongst us since the of the Greek and Persian armies, but which, as then, had not days of Pringle; and the very absence of such, embracing the been properly organized. Not only are the medical attendants improved medical pathology and research, of the present day, on the Roman armies made mention of by Latin authors, but offers no small reproof of the faultiness of the now existing in the works of Quintus Curtius, Tacitus, Livy, and Vegetius, education of medical officers in the British army. The schools some accounts are given of the prevailing epidemics, the proof education for the medical department of the French army phylactic measures then in use, and the mode in which the may be reckoned amongst the most useful and prominent ad- sick were cared for. During the barbarism and disorder that vantages which their more perfect medical instruction affords succeeded the inroads of the northern nations, and the downfall the officers, beyond those of their medical compeers in the of the Roman empire, we have nothing but a long dark night
knowledge and ground principleof merit
531 of ignorance concerning both diseases and disasters, by which our instruction on all subjects of military contingencies and those numerous and undisciplined armies, which swept Europe military diseases. While speaking of the diarrhceas, dysenteric with the rapidity of a torrent, were decimated, and sometimes and scorbutic affections, as well as the severe forms of camp almost destroyed. Glimpses of information concerning them itch and maladie pédiculaire amongst the French soldiers of are met with in some of the minor Latin writers of the Byzanthose days, one would almost slippose that he had only of late tine empire; but as Greek medical knowledge and science soon sat down to write, for our instruction and guidance, on the after passed into the hands of the Arabs, under the celebrated subject of all those affections which have so recently and painCaliphs of Bagdad, the only complete account we have of then fully afflicted our own troops in the Crimea. With great truth, reigning epidemic diseases is that which Pvhazes gives of small- he observes, in his fifth chapter, that in the first part of his pox and measles, and which has been made familiar to us by work he had pointed out how particular kinds of food, fatigue, the Sydenham Society’s publication of Dr. Greenhill’s transla- intemperance, and other such injurious contingencies produce tion into English. constitutional cachochymia: " and if," says he, "we would but Modern military medicine, however, or the special internal watch over these things with special attention, so as to endeadiseases of soldiers, produced by the hardships and contingencies vour, on the least to guard against its conseof military life, only began to attract particular notice about quences, nearly three-fourths of the diseases which afflict the middle of the sixteenth century. A little before this soldiers might be prevented." Had those armed with power period, as well observed by Hecker, the darkness of the middle and authority to obviate the injurious consequences of an unages had receded, more creativeideas and stupendous events mixed diet of salt provisions,- of unsuitable and insufficient aroused the spirit of mankind, and the castles and strongholds clothing for our troops, of undue exposure, too, of unacclimated of petty barons and their feudal retainers were obliged to yield soldiers to cold, wet, and over fatigue in the trenches before before the artillery of standing armies, and become obedient to Sebastopol, we should not have had, as now, to mourn over the princes and their imperial cities. But, with the establishment loss of so many brave men, whose bones on the heights of Balaof regular armies, which were composed of mercenary adven- klava must ever reproach us from their tomb. The warning turers, new sources of disease and disaster arose from the voice of our professional brethren of the army was timely raised, constant dispersion of such adventurers, throughout the length to prevent a hecatomb of victims, but fell unheeded, and was and breadth of Europe. Pernicious influences of various kinds raised in vain. now doubly endangered the health of the inhabitants of towns, Military surgery, regarded as a distinct department of the and rendered disorders, naturally slight, in the highest degree healing art, had its origin about the same time as Military malignant. It was at this time that Lang, who, in the capacity Medicine. Though both be grounded on a knowledge of the of physician to the imperial army of Germany, commanded by same principles, both must take into consideration the partiFrederic Count Palatine against the Turks, gave an account of cular causes and contingencies which render special the external, a peculiar fever called "Causus," or ardent remittent fever, as well as the internal, diseases of military life. In so far, howwhich resembled, according to Sennert, that afterwards known ever, as such principles instruct us in laws, under which all by the name of Hungarian ptechial fever. This same disease, diseases take their origin and are diffused, or can teach us rules in 1566, spread itself with great mortality through the ranks for their practical prevention, they haveacloser and more defiof another army, in the camp near Komorn, under the command nite connexion with medicine than with surgery, but cannot be of the Emperor Maximilian II., while servingagainst the Turks neglected or lost sight of by either army surgeons or physicians. in Hungary; and though its ravages were at first confined to The inexpediency, therefore, as well as impossibility of followthe troops, it was afterwards propagated by contagion through- ing out an arbitrary division of labour, in distributing duties to out Europe, and by those who returned from this expedition, the army medical officer, are at once so apparent, that any other proving very fatal in its course. Such was the only military plan than that of training the military physician, through the malady which appears to have attracted much attention till knowledge and duties of the military surgeon, has but little the beginning of the following or seventeenth century; and chance of adoption, as beingutterlyimpracticable; or, if adopted, though the works of Schniberg and Fortius, on military would only lead to inextricable difficulties and confusion in the medicine, are the only ones of merit, it does not appear that a execution of military medical duties, that arise from general exiknowledge of efficient prophylactic measures, to limit the gencies. The greater, then, must be the existing necessity for an extended and comprehensive system of professional education and spread of such diseases, had yet made much progress. The seventeenth century, fertile alike in producing works of knowledge for military and naval medical officers. It is a subject general literature and of military medicine, gave birth to many open to question and doubt, whether the modern multiplication writers of note amongst the latter class. Amongst these we of professional specialisms, in limited departments of medicine may mention the names of Willis, Sennert, Ramazzini, Stahl, and surgery, has been attended with all those advantages to Zwinger, and Lancisi, who have bequeathed to us various the interests of medical science, and the sound practical applicamedical treatises, many articles of which embrace the diseases tion of principles for the cure of localized diseases, which it of armies, and the prophylactic measures necessary. These professedly promises; as such has frequently led to a mere were followed, in the eighteenth century, by the works of mechanical system of routine for using local appliances, withHoffman; but when our own celebrated Pringle, in 1752, gave out a due conception of those philosophical inductions of medi. his military medical observations to the world, " all that had cal research, by which the difference, as well as the community, been written before him," says Colombier, "appeared but a of various localized diseases can be properly ascertained or sucrough, unimportant" outline, to which it was scarcely necessary cessfully treated. At all events, though such divisions of proto make reference. Employed as he had been, in the capacity fessional labour may be called for by the wants, the wishes, of chief physician of the English army in Flanders and and the wealth of civil communities, they are inexpedient, if Germany, he has left behind him a model for all future works not impracticable, in the military medical organization and of this kind, which has at once secured the admiration and the duties of an army. For the effective performance of army of how particular causes of disease gratitude of his professional brethren. To this succeeded the medical duties, a abridged work of Van Swieten on Army Diseases, and the yet modify the vital functions and produce specific results are of more importance than even special dexterity in operative surmore excellent one of our own Monro, published in 1764, and founded on the collective observations made by him in the gery, or special diagnostic tact respecting certain diseases. British military hospitals in Germany, from 1761 to 1763, Ambrose Pare, the father of systematic military surgery, was combined with the observations and practice of other most at once a physician and a surgeon, and had an accurate and eminent physicians in cases of similar diseases. In his preface, ready knowledge of his profession in all its branches. He was he takes particular notice that the Marquess of Granby, then prepared to avail himself, when circumstances rendered it eommander-in-chief of the British troops, as well as the generals necessary, of that collateral aid which surgery must ever derive under him, paid the greatest attention to the sick soldiers in from the science of medicine; and every military surgeon the hospitals, and observes, "that we, as a commercial nation, should be precisely but comprehensively educated, so as to have strong political inducements, superadded to those dictated acquire decision and manual dexterity, associated with a highly by humanity, for carefully attending to the life and welfare of cultivated medical mind, possessing powers of quick observa. all such individuals." The maxim so wisely inculcated has tion and sound judgment. been lately in some measure lost sight of, and may be now Somewhat vague and imperfect notions exist as to the scope acted on with advantage to the State. and objects of military surgery. Some seem to think that a Very soon after the publication of Monro’s work, the " Code course of military surgery can only embrace the surgical prinde Mêdecine Militaire" of Colombier appeared, in 1772, followed ciples and mode of treatment applicable to gun-shot wounds, by the " Traite d’Hygiène Militaire" of this most distinguished or to the operations requisite on the field of battle. But, as I physician. Bred amid camps, and well acquainted with the have before pointed out, the modifications and types of diseased habits, prejudices, and peculiarities of the soldier’s mode of condition, which render wounds of soldiers and sailors formidlife, he was well fitted to write the valuable treatise left for able and imperil life, are seldom met with in temperate
indisposition,
knowledge
532 or amongst ordinary civil communities, and so limited view of the nature and purpose of military surgery would take from it more than half of the surgical diseases with which its disciples should be familiar; while it would bar it from the domain of prevention for those which only become destructive to life or limb through ignorance and neglect. It is here again that medical and conservative military surgery trenches on the scope and objects of pure military medicine, where sound regarding the constitutional treatment of diseases is more important than manual dexterity, and where, without it, the military surgeon may be humiliated by failure after the most dexterous operations. In short, military surgery, in its most comprehensive meaning and utility, must embrace military medicine and hygiene. (To be concludedJ
there is no distinct hardness; indeed, when she her back, though the swelling is pretty hard, it appears more that of corpulence than of the circumscribed tumour, the outline of which is sometimes so well defined in pregnancy. At midday she takes a glass of wine, which relieves a sort of " sinking." The varicose veins of the leg are fast disappearing; they can in a place or two be felt, and scarcely felt, through a. thin stocking, and she can now walk without being affected by the pain of her leg. She looks five years younger; and her. friends and visitors, as well as her mother, who herself had six children, are all satisfied of her pregnancy; and although I am myself much inclined to the same opinion at times, yet I still have very strong doubts, and refuse to pronounce for pregnancy. The embonpoint is very considerable-quite a contrast. to her former appearance. Her morning cough has for some time left her; and she who was before marriage always in the habit of taking physic, takes very little now. I looked forward anxiously to her next monthly illness, which commenced on the 26th of March, and lasted the usual time. Her illnesses, the last three times, came on a day or two before the expi. ration of the fourth week, and she remarks that the flux, al. though as profuse, has not the consistency of former discharges; of this I satisfied myself from its appearance on the cloths,. through which it seems to penetrate more, and it is lighter in colour. A blue pill, and some magnesia and rhubarb, is pre-
climates,
men
a
lies
knowledge
ON
SPURIOUS
PREGNANCY.
ILLUSTRATED BY CASES.
BY W. BURKE
RYAN, M.B. Lond. (Concluded, from p. 430.)
CASE 4.-Mrs. -, aged forty, married in October, 1843 ; a spare habit of body; generally for years past, of delicate health, which she attributes to fatigue consequent on attending a sick brother during a long illness. She has laboured under a relaxed state of the uvula and fauces, and been leeched, blistered, &c., which perpetuated this state of things, and of which she was subsequently cured by astringents and stimulant gargles with tonics. -Her stomach has been generally out of order, her tongue loaded. The first six or eight weeks of her marriage she laboured under a kind of hard, dry, barking cough in the morning, which had been habitual. Previous to marriage she was also affected by varicose veins of the right leg, easily observable when she wore a silk stocking, which she therefore avoided. From these she suffered considerable pain if she walked any distance, and used a bandage for them. Breasts flaccid and very small. On or about February 12, 1844, four months and nine days after marriage, she observed considerable abdominal swelling, which prevented her stooping in superintending the laying-out of some flower-beds. On examination, I found the abdomen as large as it usually is at about the fourth month of pregnancy. The catamenia had continued up to this time. It struck me as possibly being a case of dropsy supervening on pregnancy, menstruation occurring simultaneously, and I was unwilling to prescribe until the next monthly period, which came a fortnight afterwards, bringing the menstrual flow as usual. The breasts were a little enlarged and painful to the touch. The abdominal swelling was not uniform, being much larger about the right iliac region than any other part : this raised a fear of ovarian dropsy of the right side. There was no particular areola observable, as the colour of the disc seemed like that of the remainder of the breast; but surrounding the nipple was a ring rather dark, a line and a half in breadth. Ordered powders of bicarbonate and biborate of soda with rhubarb night and morning, and, to relieve great lowness of spirits and weakness, a mixture of aromatic spirit of ammonia, four drachms; compound tincture of cinnamon, four drachms; infusion of calomba, a pound and a half: mixed. The sound on percussion was quite tympanitic over the right iliac region. The powders affected the bowels, and the mixture relived the other symptoms. Having continued the powders during six days, all symptoms were alleviated, and the swelling much reduced. Her skin, which before marriage was dry, is now moist, and a general fulness and plumpness pervades the whole body, with an unusually, for her, healthy feel of the dermoid system. There are dark rings or marks beneath the
of
eyes.
enlarging; the abdomen is grathe ring round the nipple getting darker; blue veins also observed traversing the breasts, which were not previously noticeable. She formerly used butter, which she now dislikes. Ale, which she could never before use, she now must have for supper-can drink two glasses, of a strong home-brewed kind, without any injurious effect, which much surprises her, and is quite ashamed of her powers in this way. She also takes her wine, and thinks she should die of lowness if she did not take these good things. Cheese, which before always disagreed with her, and which therefore she seldom ate, she now likes, and partakes of heartily and with impunity; she likes and eats plentifully of beef. No morning sickness. Though the abdo. March 20th.-The breasts
dually enlarging;
enlarges,
on
scribed
occasionally. 12th.-I to-day notice that part of the areola, outside the narrow ring mentioned above, but instead of a rose or darker colour, it is whiter and more delicate, with a silvery appearance, and stretched out, as it were, by the subjacent fulness, more than the surrounding skin.The narrow circle alluded to is also darker, and spreads in one direction. Within the disk is a growth of four or five hairs, of considerable length and thickness, not before observed. From my not pronouncing for pregnancy, she at this time seemed much alarmed lest she might labour under some abdominal disease, of which she had.
April
heard so much. 18th.-Four days since she was attacked with profuse ptyalism, the salivation lasting two days. Yesterday and the day before she took a glass of strong ale before twelve o’clock, ’’ which would have killed her a year ago." The salivation. returned yesterday evening, followed by severe retching. Severe retching this morning; vomited a glairy fluid of intensely sour smell; the circle increasing and darkening round the nipple, but the outer part of the areola is whiter than the other part of the breast. Although the retching comes on so violently, she does not vomit the ale taken shortly before. Feels occasionally very peevish and fretful; bowels open daily; eats
ravenously.
have, since the last date, frequently noticed the mucus in the urine; salivation to-day and yesterday. On Monday last, (22nd,) menses again appeared, lasting only two days; not so deep a colour as usual, more watery, and saturates the cloths more. Size of abdomen some. 29th.-I
floating
as
if of
times much smaller than at other times. I cannot detect the womb through the abdominal walls. Breasts get softer and smaller at the monthly period, and again increase and harden in a day or two afterwards; areolæ still white, the brown ring not increased: appetite bad during menstrual discharge, but the retching is then altogether relieved. Sometimes takes three half-pints of ale daily, without affecting her head; "feels a greediness in eating never before experienced, and even while eating could cry from peevishness;" has taken a strong desire for sausages; has sometimes felt a quick shooting pain in right iliac region. May 19th.-Monthly illness commenced to-day; little if any alteration in areola; abdomen tympanitic, and much enlarged within the last eight hours, since menses made their appearance ; almost fainted at an evening party, and had to leave the room-never before affected so. On applying the ear to the abdomen, and at the same time moving the bowels, a gurgling sound was heard; stomach, as usual, very little affected during the catamenia. Repeat the powders and stimulant mixture. 31st.-Assuming, in my opinion, a darker tint around the nipples; abdomen firmer to the feel; breasts enlarging. Now
fancies pickles, gooseberries, and many different things; peevish; cannot do without ale; feels quite sinking and faint if she do
not take it
as well as meat. June 14th.-Catamenia commenced and lasted from
Friday
* "It is often difficult," says Dr. Gooch, (Diseases of BB’omen,) "to tell whether the darkened colour of the areola exists or not in persons of light complexion." Dr. Montgomery (Cyclopsedia. of Practical Midwifery) considers colour of the areola of all other signs the most liable to uncertainty; and Dr. Rigby (Library of Medicine, vol ii.) agrees with him that it is one upon which we cannot depend with any great certainty.
even
appear to be
fibres, which
are
split
diency, know little of the physical laws which govern disease or regulate health, beyond the dim and indefinite conception that the removal of cesspools, the construction of good drains, and the extra-mural interment of the deceased of large towns,
necessary for the welfare of the living. But the science of which has a wider and more comprehensive scope than the art of the architect or engineer, is based on physiological knowledge of the functions of the living organism; and shows us how such may be affected, both in health and disease, by the various physical and moral agencies, both within and without the body, that promote nutrition or facilitate the inroads of decay. It teaches how the organic power of functional resistance may be best secured, in order to ward off the usual destructive consequences of both local and general causes of disease. It shows, by statistical data, the relative healthful or deteriorating influence of age, modes of life, climate, and locality; the morbific agencies of unwholesome food and bad water; of intemperance, overcrowding, retained surface drainage of particular soils; and of concentrated septic exhalations, from animal and vegetable matter in states of decomposition: while, along with such instruction, it conveys a knowledge of the healthful or morbific influence of elevated and depressed temperature, of atmospheric dryness or humidity, of particular seasons, winds, and countries, in relation to the peculiar topographical features of the latter, and their geographical distribution into latitudes of special diseases. The importance and utility of such knowledge are acknowledged and provided for, in the civil and military organization both of France and Germany, by its academical teaching in public institutions, and by publicly associating medical counsellors with the higher officers of State, in the constitution of civil and military Boards of- Health. Yet what have been the systematic public provisions in England for thus profiting by the experience and counsel of the best men in the medical profession, in this age of intellect and progress ? None, positively none, deserving of the name. Temporary expedients of limited extent, and unstable public utility, have been adopted to meet the exigencies of actual public service, and the defective organization of the civil and military medical systems of this country. Amidst a frightful outbreak of destructive cholera, a Board of Physicians and Surgeons is summoned together to aid, by their counsel and advice, the largely-paid health officer of Government, and are permitted, when no longer required, to return inadequately rewarded to the domestic obscurity of private life. Though medical education, too, in this country, no way provides instruction in the principles of sanitary science, but leaves the over-worked medical attendant of the poor to pick up, here and there, such crude notions of it as may be gathered from desultory reading, this same health-officer of Government, as if£ to ignore the idea that the preservation of public health was, in any way, an integral part of medical science, dispenses altogether with medical counsel or medical supervision in his own immediate department, and consigns, by a legislative enactment, the important matter of national sanitary improvement to local boards of health, composed, as they must be, of that very class of ratepayers, whose self-interest and prejudices have, hitherto; offered the most successful opposition to the removal of those public nuisances which are known to affect so injuriously public health. But if the destructive agencies be great which collectively injure the health and welfare of the civil population, those banded together to produce sickness amongst soldiers, and decimate armies in the field, are yet greater; and still no wellorganized system of medical council, or permanent sanitary commission, has been adopted for a comprehensiveconsideration of questions relating to the medical economy and health of the British army-destroyed as it has been by war and the urichecked career of preventible disease. That the ravages of these diseases might have been stayed by suitable measures of prevention, may be gathered from the facts stated in Mr. Guthrie’s late lecture at the College of Surgeons,-that the ratio of death amongst commissioned officers in the Crimea was 4 ’12 per cent., and of non-commissioned officers, rank and file, 17.16 per cent. are
public hygiene,
FIG. 3.
FIG. 4.
FIG. 5.
An Introductory Lecture TO
A
COURSE OF
MILITARY MEDICINE & SURGERY Delivered at St.
BY JUST in
JAMES
Mary’s Hospital,
BIRD, M.D.
proportion as the more politic and powerful governEurope have found that the public safety, and the well-being of society, are dependent on the efficiency of the Army and Military Medical Departments, so have such establishments been objects of national care and attention, and those who administer their affairs with vigilance and devotion the recipients of royal favour and public honours. The importance and utility of the soldier’s and seaman’s services, in their individual and collective relation to the order of society, and the prosperity of the state, have ever been generously acknowledged and amply rewarded in this country, by a due amount of public emolument and public honour. While the physician’s judicious counsel, orthe skill of the surgeon, in all rements of
530 While most of the disastrous results by which this army has British service; and such advantages are of no small account, been so painfully reduced in efficiency can be traced to the in as far as they encourage a constant increase of professional general want of system and perfect organization of its medical professional zeal amongst the medical staff, arrangements in relation to other departments, no portion of whose selection, social position, pay, and promotion, on the such arrangements has been the source of more mischief than and fitness, are regulated on the same definite than that which takes away both authority and means from of equity. What wonder, then, that they should be military medical officers, to provide for the care of the sick found ever ready to extend the dominion of professional knowand wounded; while it at the same time permits of their repre- ledge, or rise equal to the exigencies of professional utility, sentations, on sanitary measures necessary for the troops, being when the prize of both honours and emolument rewards the altogether disregarded by military authority. However much labours of well-educated gentlemen. The failure of our own interested the medical officer may be in the welfare of his sick, ungenerous and defective system of military and naval medical he has here no means of obtaining suitable diet, clothing, or organization may teach us something from the success of our transport, for their comfort; and finding that his requisitions neighbours. for necessaries cannot be complied with, or that his remonWith these preliminary observations, naturally suggested to strances are unheeded, he resigns himself to an apathy and me by recent events in the Crimea, and by the unfavourable indifference not unnatural to men thwarted in their efforts for contrast of our own army medical organization there, as drawn good, and who tacitly yield to evils they cannot prevent. But from the comparisons made between the health of the French while a well arranged plan of military medical organization, and English troops, I now appear before you in this, the providing against such mischievous consequences, has been long youngest, though, we would fain hope, most improved Medical enforced in all the great armies of Europe, coupled with a well- School of this metropolis, to place before you the principles as digested system of supplementary instruction on military medi- well as the practice of military surgery, medicine, and hygiene cine and surgery, what measures have been taken in this country -subjects that have long been deemed desiderata of an army to prevent a repetition of the military medical disasters com- medical education in other countries, though not yet sufficiently mitted in the expedition to Walcheren and the West Indies appreciated in our own. While I am the first in this metropolis during the last war ? Let the recent painful events in the to attempt a separate and complete course of lectures on those Crimea be an answer to the question. subjects, I enter on the duties I have undertaken with no ordiMore than eighty years ago, Coloinbier, a great authority nary sense of my own responsibility, and of their great importon military medicine and on the special nature of military ance, viewed in their relation to the interests of medical and diseases, when speaking of the medical military establishments surgical science, as well as the interests of humanity. We have now fairly entered on a conflict of no ordinary of France, wisely and truthfully observed, that, in order to obtain all the benefits they were meant to confer on the soldiers magnitude, and with a military power of the first order, and of and the army, it is not only necessary to secure for the hospitals boundless resources in respect to men and the munitions of all the salubrity of which they are susceptible, and to give the war; the health of our gallant soldiers and seamen has already sick most prompt assistance, but it would be also important to suffered severely from the usual contingencies of such a contest, learn the kind and nature of the diseases, and, above all, the and as their welfare may be still more deeply implicated, by causes which multiply them; and, in short, by prevention, to other expeditions not yet thought of, it behoves us as a nation, lessen the heavy losses which happen chiefly in times of war. and as a government of practical patriots, to lay aside preIt is a fact not questioned, that in war, more soldiers perish by judices of both a political and professional nature, and to estadisease than in combat, and if our failures and medical experi- blish such a military and naval medical organization in both ence, during the last war, could have taught us humility to services as will provide for the comfort and most efficient learn for the future, we ought ere now to have had a system of system of medical treatment of our sick and wounded. These both prudence and forethought, in all that concerns the pre- have surely greater claims on national gratitude, to be supvention, as well as the improved treatment, of military diseases. plied with the best medical and surgical advice procurable, This also would have conducted us to an improved system of than have the paupers of our voluntary charities and hospitals, army medical organization, and a more perfect curriculum of who are not denied such privileges; and it will be no unimprofessional education of the candidates intended for the army, portant step, in furtherance of this object, to provide an navy, and East India medical services. But an overweening efficient system of supplementary military medical instruction spirit of national conceit and prejudice has only encouraged us in all those branches of professional knowledge that should be’ to contemptuously reject the one, and to strengthen our minds familiar to the army and naval medical officer. But if governagainst the conviction that there can be any absolute necessity ment and its advisers desire not to perpetuate evils that attach for the other. The consequence has been, that, in our systems to the present defective medical organization of either branch of medical education, academical teaching of scientific hygiene of the service, or may hope to secure for their ranks men of has been utterly neglected; and, notwithstanding the useful distinguished merit, they must not only place their medical labours and eminent services of Mr. Guthrie and Sir George officers in the same relative social position and condition that. Ballingall, in regard to improved instruction on military are conceded to other officers, but must hold out to them worthy surgery and military medicine, for this country, many will objects of ambition, for encouraging professional zeal and imneither see nor be convinced of their necessity, for army and proving professional knowledge. It is well known, from Greek and Roman history,-that the navy medical officers, as supplementary to the civil medical education of England. But the diseases which arise, in filthy classical nations of antiquity, in their days of splendour and and malarious camps, in the hot climates of the East and West glory, while they maintained disciplined troops, introduced Indies, on the coast of Africa, and on ship-board during long into their military systems the greatest order and regularity; voyages, are never met with, and quite unknown in this and though nothing very instructive or in detail regarding the temperate climate. Young army and navy medical officers, prevailing epidemics in their camps, or the health of their who, in London or Edinburgh, may have had the best civil troops, has been handed down to us in separate works of milimedical education in medicine and surgery, but who have tary medicine and surgery, we are not left altogether in the neither instruction nor experience, as to the nature and modifi- dark concerning these interesting subjects. We learn from cation of these diseases, must find themselves in situations of Homer that both military medicine and military surgery were great difficulty and embarrassment, when called on to, treat in use as far back as the war of Troy; and though the military multitudes of sick affiicted by them. The modifications and men of those days were most imperfectly cared for by either of types of diseased condition, which, under such contingencies these professional departments, the military surgery of these and circumstances of naval or military life, present themselves times appears to have had a preference to the medical art of in connexion with internal or medical diseases, come no less curing internal diseases. as Homer chiefly eulogizes those who frequently under observation in external or surgical maladies. took charge of the wounded. Xenophon, in his " Cyropsedia," Though many works of research and authority, on the or the education of Cyrus, (extracts from which are given in subject of military medicine, have been of late produced by Dr. Richardson’s first number of the " Quarterly Journal of medical officers in the French and other continental armies, Public Health,") particularly notices the medical department yet no English ones of note have appeared amongst us since the of the Greek and Persian armies, but which, as then, had not days of Pringle; and the very absence of such, embracing the been properly organized. Not only are the medical attendants improved medical pathology and research, of the present day, on the Roman armies made mention of by Latin authors, but offers no small reproof of the faultiness of the now existing in the works of Quintus Curtius, Tacitus, Livy, and Vegetius, education of medical officers in the British army. The schools some accounts are given of the prevailing epidemics, the proof education for the medical department of the French army phylactic measures then in use, and the mode in which the may be reckoned amongst the most useful and prominent ad- sick were cared for. During the barbarism and disorder that vantages which their more perfect medical instruction affords succeeded the inroads of the northern nations, and the downfall the officers, beyond those of their medical compeers in the of the Roman empire, we have nothing but a long dark night
knowledge and ground principleof merit
531 of ignorance concerning both diseases and disasters, by which our instruction on all subjects of military contingencies and those numerous and undisciplined armies, which swept Europe military diseases. While speaking of the diarrhceas, dysenteric with the rapidity of a torrent, were decimated, and sometimes and scorbutic affections, as well as the severe forms of camp almost destroyed. Glimpses of information concerning them itch and maladie pédiculaire amongst the French soldiers of are met with in some of the minor Latin writers of the Byzanthose days, one would almost slippose that he had only of late tine empire; but as Greek medical knowledge and science soon sat down to write, for our instruction and guidance, on the after passed into the hands of the Arabs, under the celebrated subject of all those affections which have so recently and painCaliphs of Bagdad, the only complete account we have of then fully afflicted our own troops in the Crimea. With great truth, reigning epidemic diseases is that which Pvhazes gives of small- he observes, in his fifth chapter, that in the first part of his pox and measles, and which has been made familiar to us by work he had pointed out how particular kinds of food, fatigue, the Sydenham Society’s publication of Dr. Greenhill’s transla- intemperance, and other such injurious contingencies produce tion into English. constitutional cachochymia: " and if," says he, "we would but Modern military medicine, however, or the special internal watch over these things with special attention, so as to endeadiseases of soldiers, produced by the hardships and contingencies vour, on the least to guard against its conseof military life, only began to attract particular notice about quences, nearly three-fourths of the diseases which afflict the middle of the sixteenth century. A little before this soldiers might be prevented." Had those armed with power period, as well observed by Hecker, the darkness of the middle and authority to obviate the injurious consequences of an unages had receded, more creativeideas and stupendous events mixed diet of salt provisions,- of unsuitable and insufficient aroused the spirit of mankind, and the castles and strongholds clothing for our troops, of undue exposure, too, of unacclimated of petty barons and their feudal retainers were obliged to yield soldiers to cold, wet, and over fatigue in the trenches before before the artillery of standing armies, and become obedient to Sebastopol, we should not have had, as now, to mourn over the princes and their imperial cities. But, with the establishment loss of so many brave men, whose bones on the heights of Balaof regular armies, which were composed of mercenary adven- klava must ever reproach us from their tomb. The warning turers, new sources of disease and disaster arose from the voice of our professional brethren of the army was timely raised, constant dispersion of such adventurers, throughout the length to prevent a hecatomb of victims, but fell unheeded, and was and breadth of Europe. Pernicious influences of various kinds raised in vain. now doubly endangered the health of the inhabitants of towns, Military surgery, regarded as a distinct department of the and rendered disorders, naturally slight, in the highest degree healing art, had its origin about the same time as Military malignant. It was at this time that Lang, who, in the capacity Medicine. Though both be grounded on a knowledge of the of physician to the imperial army of Germany, commanded by same principles, both must take into consideration the partiFrederic Count Palatine against the Turks, gave an account of cular causes and contingencies which render special the external, a peculiar fever called "Causus," or ardent remittent fever, as well as the internal, diseases of military life. In so far, howwhich resembled, according to Sennert, that afterwards known ever, as such principles instruct us in laws, under which all by the name of Hungarian ptechial fever. This same disease, diseases take their origin and are diffused, or can teach us rules in 1566, spread itself with great mortality through the ranks for their practical prevention, they haveacloser and more defiof another army, in the camp near Komorn, under the command nite connexion with medicine than with surgery, but cannot be of the Emperor Maximilian II., while servingagainst the Turks neglected or lost sight of by either army surgeons or physicians. in Hungary; and though its ravages were at first confined to The inexpediency, therefore, as well as impossibility of followthe troops, it was afterwards propagated by contagion through- ing out an arbitrary division of labour, in distributing duties to out Europe, and by those who returned from this expedition, the army medical officer, are at once so apparent, that any other proving very fatal in its course. Such was the only military plan than that of training the military physician, through the malady which appears to have attracted much attention till knowledge and duties of the military surgeon, has but little the beginning of the following or seventeenth century; and chance of adoption, as beingutterlyimpracticable; or, if adopted, though the works of Schniberg and Fortius, on military would only lead to inextricable difficulties and confusion in the medicine, are the only ones of merit, it does not appear that a execution of military medical duties, that arise from general exiknowledge of efficient prophylactic measures, to limit the gencies. The greater, then, must be the existing necessity for an extended and comprehensive system of professional education and spread of such diseases, had yet made much progress. The seventeenth century, fertile alike in producing works of knowledge for military and naval medical officers. It is a subject general literature and of military medicine, gave birth to many open to question and doubt, whether the modern multiplication writers of note amongst the latter class. Amongst these we of professional specialisms, in limited departments of medicine may mention the names of Willis, Sennert, Ramazzini, Stahl, and surgery, has been attended with all those advantages to Zwinger, and Lancisi, who have bequeathed to us various the interests of medical science, and the sound practical applicamedical treatises, many articles of which embrace the diseases tion of principles for the cure of localized diseases, which it of armies, and the prophylactic measures necessary. These professedly promises; as such has frequently led to a mere were followed, in the eighteenth century, by the works of mechanical system of routine for using local appliances, withHoffman; but when our own celebrated Pringle, in 1752, gave out a due conception of those philosophical inductions of medi. his military medical observations to the world, " all that had cal research, by which the difference, as well as the community, been written before him," says Colombier, "appeared but a of various localized diseases can be properly ascertained or sucrough, unimportant" outline, to which it was scarcely necessary cessfully treated. At all events, though such divisions of proto make reference. Employed as he had been, in the capacity fessional labour may be called for by the wants, the wishes, of chief physician of the English army in Flanders and and the wealth of civil communities, they are inexpedient, if Germany, he has left behind him a model for all future works not impracticable, in the military medical organization and of this kind, which has at once secured the admiration and the duties of an army. For the effective performance of army of how particular causes of disease gratitude of his professional brethren. To this succeeded the medical duties, a abridged work of Van Swieten on Army Diseases, and the yet modify the vital functions and produce specific results are of more importance than even special dexterity in operative surmore excellent one of our own Monro, published in 1764, and founded on the collective observations made by him in the gery, or special diagnostic tact respecting certain diseases. British military hospitals in Germany, from 1761 to 1763, Ambrose Pare, the father of systematic military surgery, was combined with the observations and practice of other most at once a physician and a surgeon, and had an accurate and eminent physicians in cases of similar diseases. In his preface, ready knowledge of his profession in all its branches. He was he takes particular notice that the Marquess of Granby, then prepared to avail himself, when circumstances rendered it eommander-in-chief of the British troops, as well as the generals necessary, of that collateral aid which surgery must ever derive under him, paid the greatest attention to the sick soldiers in from the science of medicine; and every military surgeon the hospitals, and observes, "that we, as a commercial nation, should be precisely but comprehensively educated, so as to have strong political inducements, superadded to those dictated acquire decision and manual dexterity, associated with a highly by humanity, for carefully attending to the life and welfare of cultivated medical mind, possessing powers of quick observa. all such individuals." The maxim so wisely inculcated has tion and sound judgment. been lately in some measure lost sight of, and may be now Somewhat vague and imperfect notions exist as to the scope acted on with advantage to the State. and objects of military surgery. Some seem to think that a Very soon after the publication of Monro’s work, the " Code course of military surgery can only embrace the surgical prinde Mêdecine Militaire" of Colombier appeared, in 1772, followed ciples and mode of treatment applicable to gun-shot wounds, by the " Traite d’Hygiène Militaire" of this most distinguished or to the operations requisite on the field of battle. But, as I physician. Bred amid camps, and well acquainted with the have before pointed out, the modifications and types of diseased habits, prejudices, and peculiarities of the soldier’s mode of condition, which render wounds of soldiers and sailors formidlife, he was well fitted to write the valuable treatise left for able and imperil life, are seldom met with in temperate
indisposition,
knowledge
532 or amongst ordinary civil communities, and so limited view of the nature and purpose of military surgery would take from it more than half of the surgical diseases with which its disciples should be familiar; while it would bar it from the domain of prevention for those which only become destructive to life or limb through ignorance and neglect. It is here again that medical and conservative military surgery trenches on the scope and objects of pure military medicine, where sound regarding the constitutional treatment of diseases is more important than manual dexterity, and where, without it, the military surgeon may be humiliated by failure after the most dexterous operations. In short, military surgery, in its most comprehensive meaning and utility, must embrace military medicine and hygiene. (To be concludedJ
there is no distinct hardness; indeed, when she her back, though the swelling is pretty hard, it appears more that of corpulence than of the circumscribed tumour, the outline of which is sometimes so well defined in pregnancy. At midday she takes a glass of wine, which relieves a sort of " sinking." The varicose veins of the leg are fast disappearing; they can in a place or two be felt, and scarcely felt, through a. thin stocking, and she can now walk without being affected by the pain of her leg. She looks five years younger; and her. friends and visitors, as well as her mother, who herself had six children, are all satisfied of her pregnancy; and although I am myself much inclined to the same opinion at times, yet I still have very strong doubts, and refuse to pronounce for pregnancy. The embonpoint is very considerable-quite a contrast. to her former appearance. Her morning cough has for some time left her; and she who was before marriage always in the habit of taking physic, takes very little now. I looked forward anxiously to her next monthly illness, which commenced on the 26th of March, and lasted the usual time. Her illnesses, the last three times, came on a day or two before the expi. ration of the fourth week, and she remarks that the flux, al. though as profuse, has not the consistency of former discharges; of this I satisfied myself from its appearance on the cloths,. through which it seems to penetrate more, and it is lighter in colour. A blue pill, and some magnesia and rhubarb, is pre-
climates,
men
a
lies
knowledge
ON
SPURIOUS
PREGNANCY.
ILLUSTRATED BY CASES.
BY W. BURKE
RYAN, M.B. Lond. (Concluded, from p. 430.)
CASE 4.-Mrs. -, aged forty, married in October, 1843 ; a spare habit of body; generally for years past, of delicate health, which she attributes to fatigue consequent on attending a sick brother during a long illness. She has laboured under a relaxed state of the uvula and fauces, and been leeched, blistered, &c., which perpetuated this state of things, and of which she was subsequently cured by astringents and stimulant gargles with tonics. -Her stomach has been generally out of order, her tongue loaded. The first six or eight weeks of her marriage she laboured under a kind of hard, dry, barking cough in the morning, which had been habitual. Previous to marriage she was also affected by varicose veins of the right leg, easily observable when she wore a silk stocking, which she therefore avoided. From these she suffered considerable pain if she walked any distance, and used a bandage for them. Breasts flaccid and very small. On or about February 12, 1844, four months and nine days after marriage, she observed considerable abdominal swelling, which prevented her stooping in superintending the laying-out of some flower-beds. On examination, I found the abdomen as large as it usually is at about the fourth month of pregnancy. The catamenia had continued up to this time. It struck me as possibly being a case of dropsy supervening on pregnancy, menstruation occurring simultaneously, and I was unwilling to prescribe until the next monthly period, which came a fortnight afterwards, bringing the menstrual flow as usual. The breasts were a little enlarged and painful to the touch. The abdominal swelling was not uniform, being much larger about the right iliac region than any other part : this raised a fear of ovarian dropsy of the right side. There was no particular areola observable, as the colour of the disc seemed like that of the remainder of the breast; but surrounding the nipple was a ring rather dark, a line and a half in breadth. Ordered powders of bicarbonate and biborate of soda with rhubarb night and morning, and, to relieve great lowness of spirits and weakness, a mixture of aromatic spirit of ammonia, four drachms; compound tincture of cinnamon, four drachms; infusion of calomba, a pound and a half: mixed. The sound on percussion was quite tympanitic over the right iliac region. The powders affected the bowels, and the mixture relived the other symptoms. Having continued the powders during six days, all symptoms were alleviated, and the swelling much reduced. Her skin, which before marriage was dry, is now moist, and a general fulness and plumpness pervades the whole body, with an unusually, for her, healthy feel of the dermoid system. There are dark rings or marks beneath the
of
eyes.
enlarging; the abdomen is grathe ring round the nipple getting darker; blue veins also observed traversing the breasts, which were not previously noticeable. She formerly used butter, which she now dislikes. Ale, which she could never before use, she now must have for supper-can drink two glasses, of a strong home-brewed kind, without any injurious effect, which much surprises her, and is quite ashamed of her powers in this way. She also takes her wine, and thinks she should die of lowness if she did not take these good things. Cheese, which before always disagreed with her, and which therefore she seldom ate, she now likes, and partakes of heartily and with impunity; she likes and eats plentifully of beef. No morning sickness. Though the abdo. March 20th.-The breasts
dually enlarging;
enlarges,
on
scribed
occasionally. 12th.-I to-day notice that part of the areola, outside the narrow ring mentioned above, but instead of a rose or darker colour, it is whiter and more delicate, with a silvery appearance, and stretched out, as it were, by the subjacent fulness, more than the surrounding skin.The narrow circle alluded to is also darker, and spreads in one direction. Within the disk is a growth of four or five hairs, of considerable length and thickness, not before observed. From my not pronouncing for pregnancy, she at this time seemed much alarmed lest she might labour under some abdominal disease, of which she had.
April
heard so much. 18th.-Four days since she was attacked with profuse ptyalism, the salivation lasting two days. Yesterday and the day before she took a glass of strong ale before twelve o’clock, ’’ which would have killed her a year ago." The salivation. returned yesterday evening, followed by severe retching. Severe retching this morning; vomited a glairy fluid of intensely sour smell; the circle increasing and darkening round the nipple, but the outer part of the areola is whiter than the other part of the breast. Although the retching comes on so violently, she does not vomit the ale taken shortly before. Feels occasionally very peevish and fretful; bowels open daily; eats
ravenously.
have, since the last date, frequently noticed the mucus in the urine; salivation to-day and yesterday. On Monday last, (22nd,) menses again appeared, lasting only two days; not so deep a colour as usual, more watery, and saturates the cloths more. Size of abdomen some. 29th.-I
floating
as
if of
times much smaller than at other times. I cannot detect the womb through the abdominal walls. Breasts get softer and smaller at the monthly period, and again increase and harden in a day or two afterwards; areolæ still white, the brown ring not increased: appetite bad during menstrual discharge, but the retching is then altogether relieved. Sometimes takes three half-pints of ale daily, without affecting her head; "feels a greediness in eating never before experienced, and even while eating could cry from peevishness;" has taken a strong desire for sausages; has sometimes felt a quick shooting pain in right iliac region. May 19th.-Monthly illness commenced to-day; little if any alteration in areola; abdomen tympanitic, and much enlarged within the last eight hours, since menses made their appearance ; almost fainted at an evening party, and had to leave the room-never before affected so. On applying the ear to the abdomen, and at the same time moving the bowels, a gurgling sound was heard; stomach, as usual, very little affected during the catamenia. Repeat the powders and stimulant mixture. 31st.-Assuming, in my opinion, a darker tint around the nipples; abdomen firmer to the feel; breasts enlarging. Now
fancies pickles, gooseberries, and many different things; peevish; cannot do without ale; feels quite sinking and faint if she do
not take it
as well as meat. June 14th.-Catamenia commenced and lasted from
Friday
* "It is often difficult," says Dr. Gooch, (Diseases of BB’omen,) "to tell whether the darkened colour of the areola exists or not in persons of light complexion." Dr. Montgomery (Cyclopsedia. of Practical Midwifery) considers colour of the areola of all other signs the most liable to uncertainty; and Dr. Rigby (Library of Medicine, vol ii.) agrees with him that it is one upon which we cannot depend with any great certainty.