other parts which were not in contact with pus. The case is of course different with the ventricular surfaces, which have long been exposed to the action of the fluid dropsical contents of the ventricles. These are reduced by softening to the well-known white pappy substance."

A second kind of softening occurs not unfrequently, around small extravasations of not movable blood-points, in the white substance of the brain; this softening usually forms only a slender softened zone around the blood-point which was not, in the cases examined by Dr. Klebs, of embolic origin.

If diffuse encephalitis be looked upon as embolic, this change must be reckoned rather among the complications of the process giving rise to the epidemic meningitis.

Forget, of Strasbourg, alludes to implication of the heart; articular affections are more common. Dr. Klebs, however, only found moderate increase of thickness in the synovia in a case where the knee-joint was said to have been extremely painful.

On the other hand, Corbin gives four cases of purulent affection, von Jacquenin gives two, and Ziemssen and Zenker another similar case.

Klebs regards Boudin's views as to the likeness between epidemic meningitis and puerperal fever in the tendency to form pus, as drawn by Boudin, as exact only in reference to the septicemic precursors in the puerperal process.

Pathological changes of the other organs.-External Skin.Petechia or roscola-like exanthem. In many cases which ran a rapidly fatal course I found small bluish spots, scarcely as large as the head of a pin, appearing as extravasations of blood in the upper layer of the corium, and mostly in the vicinity of the duct of sudoriparous gland.

As to the blood, the French have found it rich in fibrin, and have consequently referred the disease to the phlegmasiæ.

Forget has found a thick crust on blood taken from the arm, and from his experience advocates bleeding. Maillot likewise found increase of the fibrin, especially in the further course of the disease, but has also perseveringly bled, though he makes the remark that the first bleedings often did not improve the pulse, and that the patients who recovered had lost less blood than those who died.

The author remarks that when we consider how rapidly, even during venesection, the quantity of fibrin increases, all the statements, such as the above, that have been made possess but little

value.

In the dead body we find the blood in very different states; Gaz. de Paris,' 1848. “ Hộp. Milit. d’Instruction de Lille.

but in the great majority of cases that proved rapidly fatal, it has been found fluid, or containing only a few soft fibrinous coagula. The colour of the blood in the vessels was very dark; both conditions met with, also, in other so-called infectious diseases, especially in typhus and spotted fever.

The large abdominal glands and muscular system Dr. Klebs states show highly important pathological changes. The spleen was generally rather small, very flabby, the pulp dark-greyish red, the follicles in one case small and few, in another numerous and enlarged; only in some very recent cases was there a considerable recent splenic tumour.

The changes of the kidneys and liver are much more uniform. These organs are seldom enlarged; and when they are so, the enlargement appears to be of older date. The kidneys present a very characteristic condition: more flaccid than usual, capsule easily separable, surface smooth, of a grey or greyish-red colour. On section, the medullary portion is usually found very full of blood, and the cortical portion presents an alternating sanguineous and turbid greyish-red condition.

In many, even very recent cases, the cortex is pale, greyish, yellow and opaque. The convoluted tubes contain often a very large quantity of fine fat granules, rendering them dark to transmitted, and white and shining to reflected, light. The same change exists in the thicker variety of loops, while the straight canals and finer loops remain free or often contain fibrinous cylinders and fibrinous scales.

In cases of longer standing there is, also, usually well-marked papillary catarrh. The more minute changes in the liver are analogous; here, also, affecting the secretory elements, which consist in granular, albuminous, or fatty turbidity.

The macroscopical changes in the liver are like those seen in abdominal typhus :-The liver is scarcely, if at all enlarged, very flaccid, its section being always of a dirty greyish-yellow, or greyish-brown colour, dry as if " boiled." These changes, from which that of the kidneys is distinguished by an alternating, usually moderate amount of albumen in the urine, is attended with an extremely extensive and early affection of the voluntary muscles, an affection the results of which are seen most plainly in convalescence.

In recent cases we find granular depositions in the muscular fibres distinguished from those in other toxæmic diseases—such as typhus and phosphorus poisoning-by the greater fineness of the fatty molecules, the fibres appearing to be sprinkled or filled with an extremely fine dust. The change of colour is, in this case, also less characteristic. Thus, while in the greater degrees of phosphorus poisoning the muscles acquire a dirty greyish-red

pale appearance, in CO poisoning a cherry red, in abdominal typhus a dry dark violet-red aspect, in meningitis epidemica they are mostly rather dry, flaccid, brownish-red. With this change is combined enormous emaciation of the muscular tissue.

Similar changes are found in the heart, but on the whole slight fatty infiltration; the heart is usually flabby, its substance is of a rather greyish-red colour.

The lungs are generally not much altered; in more recent cases they are usually highly hyperamic. The lymphatic system is not much affected, its glands are usually somewhat reddened, but are otherwise normal; the swelling of the solitary glands of the intestine is too slight and too inconstant to possess a special importance.

The lesions of the organs of sight and vision stated to occur in this disease appear to be rather sequele developed only in protracted cases without fatal result, and they therefore do not often come under the cognizance of the pathological anatomist.

The Position of the Epidemic Meningitis in the Pathological System. The earlier writers, who had an opportunity of observing the disease in the commencement of the present century, brought it into close relationship with typhus (" tifo tetanicoapoplettico" of the Italians, Hildebrand's cerebral typhus). This is owing to the undue extension of the terms "typhus fever," "status typhosus," &c. Griesinger speaks most decidedly against the identification of the cerebral typhus of earlier writers with epidemic meningitis. The author looks upon the phenomena of the latter disease as passive lesions of nutrition." In conclusion he gives a brief résumé of the cases of meningitis noted in the records of the Pathological Institute since the beginning of 1861. This exhibits a great increase of the disease in the years 1864 and 1865. The following table presents a clear view of the course of the two epidemics in these years. The cases are those of acute primary meningitis, proved by dissection to have been such. In the month of—

1864.

66

1865.

It will be seen that the epidemic began in the coldest season of the year, and extended with diminishing intensity into the

summer.

"The first case in the year 1864 from the civil population died on the same day, as the first from the military did, on 13th

February; from that time the disease lasted in both divisions of the population until May and June respectively. With the year 1865 an epidemic begins affecting, as it seems, exclusively the civil population. It would be very desirable if the results thus obtained were verified by the publication of as many cases as possible observed in this place. Nevertheless, this result is probably essentially reliable, that the disease has confined itself to the first five or six months of the year. This agrees with Boudin's statements, who in a report including 172 cases, reckons 109 in the first half of the year and sixty-three in the second. The maximum fall in the months of January (26), February (29), and December (20), and the minimum in August (3). It cannot be denied, therefore, that the coldest seasons of the year are specially disposed to produce the disease. Two elements may come under consideration with respect to this point: the local effect of cold and the condensation of a portion of the population in confined spaces. Comparison with the years 1861 to 1863 shows that in those years, too, isolated cases of quite analogous nature occur; thus, in 1861, cases 1 and 3; in 1862, case 3; in 1863, cases 1 and 2 (?) may belong to this disease. It is very remarkable that in these sporadic cases also distinct indications are met with, in the reports of dissections, of the presence of parenchymatous organic diseases, and this circumstance may still further confirm the identity of the cases in question with the epidemic affections of the last two years.

(To be continued.)

REVIEW VII.

1. Diseases of Children: a Clinical Treatise based on Lectures delivered at the Hospital for Sick Children, London. By THOMAS HILLIER, M.D., &c. London, 1868. Pp. 402. 2. A Practical Treatise on the Diseases of Children. By D. F. CONDIE, M.D. Philadelphia, 1868. Pp. 783.

3. The Surgical Treatment of the Diseases of Infancy and Childhood. By T. HOLMES, M.A., Surgeon to the Hospital for Sick Children, &c. London, 1868. Pp. 648.

4. Leçons Cliniques sur les Maladies Chirurgicales des Enfans. Professées par M. J. GIRALDÈS, Chirurgien de l'Hôpital des Enfans malades, &c. ler-3ème fascicules. Paris, 1868. Clinical Lectures on the Surgical Diseases of Children. By Dr. J. GIRALDÈS, Surgeon to the Hospital for Sick Children. 1st-3rd parts. Paris, 1868.

Or the four works whose titles we have just enumerated two deal with the medicine, and two with the surgery, of early life. They represent almost entirely the state of science with regard to the most important of all our specialities, and we should be wanting, therefore, in our duty to our readers if we did not give some account of them.

Dr. Hillier's book is so good in one way as to be disappointing in another. By modifying lectures delivered at the Hospital for Sick Children, he has produced what he rightly describes as "a series of short monographs," which testify to so much careful observation and study as to give us serious grounds for complaining that he has not published the results of his experience with regard to many other infantile diseases of importance. Thus, gastric, intestinal, hepatic, and renal affections are not noticed, scrofula is only incidentally referred to, and syphilis dismissed in a dozen lines. We trust that Dr. Hillier has only postponed these subjects for a second edition of this valuable work, in which case room might be, perhaps, made for them by curtailing the articles on pleurisy, pneumonia, and scarlatina, which, although not too long for the importance of those diseases, are out of proportion to the size of the work. Where all is instruction, it is difficult to select anything for special praise; but, to our minds, the articles on tuberculosis, pyæmia and otorrhoea, and acute and chronic hydrocephalus, are the most interesting. In his account of diphtheria he argues strongly against those who (as Sir Wm. Jenner and Mr. Squire) would distinguish between croup and diphtheria. One very commendable feature of the volume is the formulary for prescriptions; another is the large number of illustrative cases, of which many are very valuable.

Dr. Condie's book is, in many respects, the most striking contrast to Dr. Hillier's. The English author avoids, even more than most clinical lecturers, quotations from other authors, and seems to rely almost exclusively on his own experience, while Dr. Condie is profuse in his references to others, and keeps his own judgment and experience too much in the background. Were his subject philosophy, and not medicine, we should say that he is a syncretist, and not an eclectic-that is to say, he collects and registers various, and often conflicting, opinions, without any effort to conciliate or systematise them. This tendency is most notable in those points where the progress of science has led to the abandoning of opinions which were formerly held. Thus, we believe that the accounts of lung-collapse and gastro-malacia would be unintelligible to any one who has not studied those questions, simply because contradictory statements, introduced into successive editions of the