be hypo-dicrotous. With this form of pulse the temperature of the body seldom exceeds 100° Fahr.

When the notch sinks to the level of the curve basis, the first secondary wave having almost disappeared, and the dicrotism being still more retarded, the pulse is called dicrotous or perfectly dicrotous. In this condition the temperature is about 103° F., and the pulse-rate about 100 per minute. When the aortic notch sinks below the level of the curve-basis, and the dicrotism appears partly blended with the line of ascent of the next pulsation, the pulse is called hyper-dicrotous, and the temperature usually ranges above 104° F. The value of these researches of Wolff can scarcely be overestimated, and the lectures delivered by Dr. Anstie at the College of Physicians, were of interest as confirming and popularising such important information. Other signs occur in acute febrile diseases besides the modifications of which we have spoken, and afford useful indications on points of vital interest. On account of the low state of arterial tension in these maladies, the heart while acting well, gives a lofty and vertical line of ascent, terminating in a sharp apex. On the other hand a short and non-vertical ascension-line with a square or blunt summit indicates weak and failing heart-action. The occurrence of irregularity in the pulse-curve at the height of the pyrexia is another grave sign. In its mildest form the irregularity betrays itself in a want of exact similarity in the successive pulsations, which affects the systolic portion more particularly and tells of a varying vigour of ventricular systole. When, however, there is an undulatory irregularity of the general line of the pulse-trace, we have a sign of still graver import which informs us that the power of the ventricle is momentarily changing. This form of irregularity has no relation to the respiratory movements, and must not be confounded with that undulation of the general line of the tracing which is produced by the varying tension of the arterial system caused by respiration. In the latter case the undulations form a series of equal curves occurring at regular intervals, characteristics not to be recognised in the former.

When the hyper-dicrotous pulse changes at an advanced stage of the fever into the monocrotous or imperfectly monocrotous form, both Wolff and Anstie concur in regarding it as an almost certain indication of death.

Such are the chief points on which the sphygmograph informs us in acute disease. Dr. Anstie has certainly not overestimated its value in the following words which form part of the conclusion to his first lecture:

"Let me conclude this lecture by again enforcing the general estimate of the prognostic value of the sphygmograph in acute

discase, which I expressed at the commencement. Used in conjunction with the strictest and most diligent observance of other means of clinical research, I believe that the instrument affords us an additional test of the progress of acute disease, and the patient's chances of safety, which is of very high value."

The action of alcohol occupied Dr. Anstie's second lecture, and some of the observations on its influence on the pulse deserve much attention. Alcohol seems to modify the pulseform in accordance with its action as a stimulant or narcotic. When given in the typhoid stages of acute diseases its effect is to diminish the dicrotism, and to slow the pulse, in other words to increase the arterial tension. On the contrary when alcohol acts as a narcotic it quickens the pulse and increases the dicrotism. These observations of Dr. Anstie's, which we can ourselves confirm, are very important, and point out what a ready guide the sphygmograph may become in the treatment of acute diseases. Hitherto we have been sadly in want of some rule to help us in the administration of stimulants, and some means of ascertaining their effects when administered. The sphygmograph seems to promise this aid, and if it were proved useless in the investigation of all those other problems concerning which it has already told us much, and has given us good reason to expect still more, this one result of its use is surely sufficient to earn for it our gratitude, and to induce all who seek to advance medicine to apply it to the study of disease at the bedside.

REVIEW II.

Études sur les Causes du Cretinism et du Goitre endémique. Par le Dr. J. SAINT-LAGER. Paris, Baillière. 1867.

On the Causes of Cretinism and Endemic Goitre. By Dr. J. SAINT-LAGER. Paris, Baillière. 1867.

It is remarkable enough that the old saying, "obsta principiis, sero medicina paratur," is more generally accepted now, in spite of the marvellous and continued progress in the art of healing, than at any previous time in the history of medicine. Its truth is most strikingly illustrated by the case of acute specific diseases; for, while our increased knowledge of them has led us to adopt heartily the principles of treatment laid down by the English Hippocrates, we can no longer endorse his say.. ing, that God is the author of acute diseases, and we ourselves of chronic ones; we are convinced that the former are the

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well-merited and natural results of a general abuse and neglect of the gifts of Providence; and that, although care would prevent the formation of animal poisons, we are powerless to do much more than watch their effects upon individuals.

Again, a more careful study of the phenomena of local diseases has shown us, that we very frequently cannot hope to effect a substantial cure, and that our efforts should be directed to averting those anatomical changes which, when once made, we cannot alter.

For the purposes of preventive medicine, a thorough knowledge of the causes of disease is necessary, and hence the importance now attached to the study of ætiology even where no immediately practical result is to be anticipated.

The work before us would commend itself to us by its subject, if it treated only of morbid causes, which from their nature and complexity, were beyond human control; but goître and cretinism are so very probably dependent on the quality of water drunk in the districts where they prevail, that the discovery of their origin would be a certain prelude to their suppression. It is difficult to overestimate what humanity would gain by such a result; but, to give some idea of the extent of the evil, we may mention that in France alone, at least 450,000 persons suffer from goître, and about 30,000 from cretinism. In our own country, though we are comparatively free from this latter scourge, bronchocele is common in some of our most favoured and otherwise healthy counties; and both are endemic in many parts of our Indian and American possessions.

We believe, therefore, that our readers will be interested in learning the conclusions to which Dr. Saint-Lager has been led by a very careful study of this important question. They are novel, and it will be scen that, without somewhat extensive observation and experiment, we should not be in a position to do more than present an analysis of the book; but we are bound to say at once that its author is evidently a man of great industry and care, whose statements, so far as we have verified them, are accurate, and whose conclusions appear to be warranted by the premises.

He begins by some general remarks, such as that goître is much more common in women than men, while, on the other hand, there are more male than female cretins.

Some modern writers have supposed that these are two

1 The excess among women is very much greater here than in France; evidently because the French statistics are compiled with a view to exemption from military service, so that men would register more carefully than women; while in our dispensaries and hospitals, women present themselves more readily than men.

essentially different diseases, but our author points out that exact observation will show that some amount of bronchocele almost invariably accompanies cretinism (when it has been overlooked, the tumour has developed laterally and posteriorly, and is to be detected rather from its interfering with respiration than from its external projection), and that, on the other hand, many who have goître are, if not cretins, at any rate, weak-minded and eccentric. Cretinism would appear to be the ultimate result of a poison which, in a less degree produces goître; thus, in the Alps and Pyrenees, on entering the regions where these diseases abound, goître is first met with, and cretins are only found in any number near the centre of the district.

Dental caries, albinism, stammering, and deafness, are unusually common in those suffering from goître or cretinism, and in the countries where these are endemic; where the proportion of deaf and dumb people is also greater than elsewhere. These disorders seem, therefore, to be symptoms of what our author calls the "cretinous diathesis," modified by circumstances of which we at present know nothing. The conditions, whatever they may be, which produce goître in man, affect the lower animals in the same manner. Thus, dogs, cats, pigs, sheep, horses, mules, oxen, have all been observed to have bronchocele; the wool or hair at the same time becoming rough, the voice hoarse, the hearing obtuse: the animal falls at last into a state of torpor, and dogs have even been noticed in a state of true cretinism.

Many authors (among others Mead, White, S. Cooper, in England, and Bazin, in France) have supposed that goître is only an extreme form of scrofula. But the weight of authority is against this opinion, which is disproved by the different geographical distribution of the two diseases, bronchocele being on the whole common, where scrofula is rare, and vice versa, and by the different pathological characters of the two affections; thus, goître is by far most common between the ages of twenty and thirty, is rare before puberty, is not hereditary, has no connection with disease of bones, or of other glands, the mind is dull or imbecile, instead of being precocious, and the tumour does not suppurate,-in all of which points it differs from scrofula.

Cretinism, again, has been looked upon by some Italian physicians as a result of pellagra; but nothing (according to the Lombard commission and other authorities) can be more unfounded, since there is even a sort of antagonism between the two diseases, at any rate as to the places of their occurrence.

The cretinous diathesis attacks alike each of the chief races

of mankind; it is not inherited, since healthy parents, who have previously borne healthy children, on going to live where cretinism is endemic, have often had other offspring who were cretins. Nor has intermarriage any apparent influence; for, in Italy especially, the inhabitants of affected districts are in the habit of marrying among their more fortunate neighbours; while in many other villages not a single cretin is to be seen, though all are connected by ties of marriage.

So much for the indirect evidence that goître is an endemic disease, due to local conditions. As direct evidence, we have the testimony of Pliny, Vitruvius, and Juvenal, that it existed in the Alps and in Lombardy in their day. In medieval times the references to it become more numerous and precise, so as to leave no doubt that it has always prevailed in many of the places on the continent of Europe, where it is now observed. What are the local conditions producing the cretinous diathesis?

De Saussure, Demme, and Güggenbuhl believed it to be unknown at a greater height than 1200 metres (nearly 4000 feet) above the sea-level. The fact is true as far as regards the Swiss Valais; but that the connection is merely accidental is proved by its existence at very much greater altitudes in the Himalayas and Andes, and by its prevalence on one bank of several rivers (as the Isère and the Aral), while the inhabitants of the other bank enjoy perfect immunity.

The popular idea that mountainous gorges are the favorite habitat of this disease is equally unfounded; witness the plains of the St. Laurence, Danube, Ganges, and Po, and the flat country of Piedmont, Alsace, the Palatinate, and Ceylon. When it does occur in valleys, it is not confined to those which take any particular direction, or which are open to any particular wind.

Nor can climate and electric conditions have any effect on the development of a diathesis which is observed alike in the oases. of the Sahara, in Ceylon, Java, and Brazil; in the perpetual spring of the "tierras templadas" of Mexico; in the variable temperature of the Himalayan valleys, and in Europe; and in the wintry climes of Canada, Finland, and Siberia.

A favorite opinion at the present day, and one supported by the authority of Vingtrinier, Morel, Virchow, and Koeberlé, ascribes the production of cretinism and goître to some aërial miasm, either ordinary paludal malaria or some independent poison. Now, on the whole, malarial fevers are most common in low, marshy countries, and the cretinous diathesis in hilly ones; but they may coexist, so that there is evidently neither connection nor antagonism between them. And if an aërial