No. 418.

LONDON, SATURDAY, SEPTEMBER 3. [1830-31.

TreatiseTreatise on the Excision of Diseased Joints.By JAMES SYME, F.R.S.E. With five

Engravings by Lizars. 8vo. pp. 163.

Longman and Co. London, 1831.AMIDST the numerous contributions whichthe zeal and skill of modern surgeons havemade to the advancement of knowledge inthe healing art, there are few more valuablethan the successful execution of the opera-tion for the excision of diseased joints. To

many individuals, in the humbler classes ofsociety, the loss of a limb is almost equiva-lent to the deprivation of the means of pro-curing subsistence. That surgeon, therefore,who is enabled to preserve so essential a por-tion of the body deserves the respect of scien-tific men and the gratitude of mankind.As to the history of the early cases in whichthis operation was performed, of the sur-geons who performed it, or of the re-

sults they obtained, it is not our provinceto enter into any statement, since with all

these points every surgical practitioner, orstudent is, or ought to be, already familiar.It is sutt:cient for us here to observe, that

though executed with success by Mr. White,of Manchester, in the year 1768, in 1781 Mr.Park, of Liverpool, excised a carious knee-joint, and the operation was followed by sucha happy result that the patient (a sailor),to use Mr. Park’s words, " was enabled to goaloft with considerable agility, and to per-form all the duties of a seaman." The un-fortunate termination of his second opera-tion seems to have deterred Mr. Park from

any subsequent trial; and Mr. Philip Cramp-ton, of Dublin, although remarkably suc-cessful in an operation performed by him ata much later period, did not follow up thesubject in a manner which we should haveexpected from his talent and opportunities.Mr. Syme does not present himself to us as

a discoverer, but not the less praise shouldbe awarded to turn for having establishedthe excision of a diseased joint as a regularsurgical operation, and one which everysurgeon should hold himself prepared toperform under fitting circumstances.From the cases recorded in this volume,

it appears that Mr. Syme has excised four-teen elbow-joints, and that a similar opera.tion has been performed in Edinburgh threetimes by other practitioners. Of theseseventeen cases (only two of which termi-nated unfavourably), a ptain, and apparentlynot exaggerated account, is contained in thepresent treatise. Two cases are given ofexcision of the shoulder, fourteen of theelbow, and two of knee-joints. A curiouscoincidence was here, he remarked, in thenumber and events of all the cases of the last

operation yet performed in this country.Park and Crampton excised the knee-jointin two instances, and each lost one of his

patients ; and the same result has attendedtwo similar operations described by Mr.Syme. The first case recorded in Mr. Syme’swork contains a description of his methodfor excision of the shoulder-joint. The in-

troductory remarks are here so valuable,that we willingly transfer them to our co-lumns :-

" About five venrs ago I met with a casewhich afforded a very favourable opportu-nity of reviving this obsolete proposal, andcarried it into effect with such success asconfirmed me in the opinion of its advan-tages that I had previously been led to en-tertain. Before relating the particulars ofth.s case, it will be proper to make some

general observations on the mode of per-forming the operation in this situation." The humerus is not always affected to

the same extent, but the whole of its head,that is to say, all that part above the at-tachments of the pecloralis major. and latis-simus dorsi muscles oulit to be taken away ;and this should be done in the first instance,

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to afford room for getting access to the sca-pular part of the disease. The glenoidcavity is sometimes affected only in a part ofits surface, but the whole of it ought to beremoved on the general principle alreadystated. The acromion process, though not £entering int6 the formation of the joint,sometimes participates in the disease, andthen, of course, requires removal no lessthan the other parts concerned. The axillaryplexus lies at such a distance below the

joint as to be perfectly safe, provided thesurgeon opens the articulation at its exter.nal or lateral part, and then cuts close to thebones. The only vessel of a size that ren-ders the necessity of a ligature at all proba-ble, is the posterior circumflex artery, whichmay be either tied at the time it is cut, orcompressed by an assistant, until the opera-tion is finished. The joint may be openedby incisions made in various directions; asingle perpendicular one from the acromionwill hardly be sufficient, except in suchcases as Mr. White’s, or in recent gun-shotwounds, where the surrounding parts arenot thickened or preternaturally adherent,and where the comminution of the bone ren-ders its free exposure for the application ofa saw unnecessary. Mr. Bent made a per-pendicular incision, commencing midwaybetween the acromion and coracoid process,and then cut inwards or towards the ster-num from both extremities of this incision,so as to form an oblong flap of the pectoralismajor and elavicular portion of the deltoid.It is difficult to conceive a plan of operatingmore dangerous to the axillarv ulexus thanthis one, or less favourable to the easy andeffectual attainment of the objects in view.Sabatier proposed to extirpate a portion ofthe integuments and deltoid of a V shape,which, though not so objectionable in re-spect to its danger and inconvenience in thefirst instance, must be regarded as extremelyadverse to a speedy and satisfactory cure.Moreau made a square flap of the deltoid,turned it down, and then gained what moreroom was required, by cutting upwards at

both extremities of the transverse incision,so as to obtain another flap. Mr. Morel, inoperating on account of a gun-shot woundof the shoulder-joint, six months after it wasteceived at the battle of Waterloo, made asemilunar incision with the convexity down-wards, so as to form at once a large flapfrom the deltoid. This mode of proceduredoes not appear to have been very conve- ’,,riient, if we may judge from what is stated Iby Mr. Morel as to the length of time re-quired for the operation, which was no lessthan three quarters of an hour, and the

quantity of blood lost, viz. two pounds." I believe that the best way of bringing

the bones completely within reach withleast injury to the soft parts, is to make a

perpendicular incision from the acromion

through the middle of the deltoid, nearly toits attachment, and then another shorter oneupwards and backwards, from the lower ex-tremity of the former, so as to divide the ex.ternal part of the muscle. The flap thusformed being dissected off, the joint will bebrought into view, and the capsular liga.ment, if still remaining, having been di.vided, the finger of the surgeon may be

passed round the head of the bone, so as tofeel the attachments of the spinati and sub.scapular muscles, which can then be readilydivided by introducing the scalpel first onthe one side, and then on the other. Afterthis the elbow being pulled across the forepart of the chest, the head of the humeruswill be protruded, and may then be easilysawn off while grasped in the operator’sleft-hand. The subsequent part of the ope.ration will be conducted on the principlesalready explained, and, as it is of coursedesirable to preserve as much mobility aspossible, no means should be used to re-

strain motion further than are necessary forpreventing irritation and displacement. Thepectoralis 7najor and lalissinzzis dorsi tend todraw the extremity of the bone inwards;but this may be easily prevented by placinga cushion in the axilla.

The result of the second operation on theshoulder-joint was not so favourable, the

patient died of pectoral disease six months

after the excision. For the details we mustrefer our readers to Mr. Syme’s work.

Fourteen cases of excision of the elbow.

joint are next given, which fully establishthe propriety and practicability of substi-

tuting this mode of operation in many caseswhere amputation was formerly consideredindispensable ; only two of the fourteen ter.minated fatally. We select a successful andan unsuccessful case, that our readers mayhave an impartial view of the subject:-" Mr. Y., twenty-fouryears of age, about

fourteen months before asking my assist-

ance, began to feel flying pains in the left

elbow-joint. He could not in any way ac-count for the origin of this complaint, andpaid little attention to it, until after thelaose of several months it became eraduallvmuch aggravated, and accompanied by aweakness of the limb, which at length de.prived him of its use. The joint being nowconsiderably swelled, was tefched, but with-out any relief. Poultices were then appliedfor several weeks, when the practitioner inattendance made an incision over the innertuberosity of the humerus, and evacuated alarge quantity of matter. Other incisionswere subsequently made in different partsof the arm for the same purpose. Though

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somewhat relieved, after the discharge of’these abscesses, he still continued to be tortured with pain, which was particularlysevere during the night, when it not onlydeprived him of rest, but almost made himdistracted." I saw him first in October 1828, and

found his strength, as well as appetite, lessimpaired than might have been expected.His countenance, however, betrayed in-tense and long-continued suffering, and ex-hibited very remarkably that peculiar arixi-ous look which so often accompanies dis-ease of the bones. The limb was perfectlypowerless, and oedematous from the lowerthird of the humerus downwards. Afterseveral unsuccessful trials, I succeeded inpassing a probe into the posterior part ofthe joint, which was then felt to be exten-

sively carious." As the disease appeared to be confined

to the bones, as the patient was young, andas the irritation of the disease was muchgreater than any that could result from anoperation which had the effect of removingthe source-of it, I resolved to cut out the

joint, and accordingly performed the opera-tion on the 3rd of November, in the pre-sence of Professor Russell and Sir GeorgeBallingall." Having placed the patient on a sofa, so

as to present the elbow in a favourable po-sition, I made a transverse incision at onceinto the joint immediately above the olecra-non, and extending to the radial tuberosityof the humerus, but at such a distance fromthe inner one as to avoid the ulnar nerve.I then cut upwards and downwards for aboutan inch and a half at each extremity of thefirst incision, so as to form two square flaps,which being dissected from the subjacentbones, exposed them completely. Havingascertained that the ulna was carious as faras the coronoid process, I sawed it across atthis part, and then insulating the extremityof the humerus, divided it in the same wayimmediately above the tuberosities. I, last-ly, removed the head of the radius, whichwas very much diseased.No vessel required a ligature, but there

was a considerable general oozing from thecut surface. After exposing the wound fora few minutes, and sponging it with coldwater, I brought the flaps together, and re-tained them in contact by means of onestitch in each of the perpendicular incisions,and three in the transverse one. Somfcompresses of lint and a roller were thenapplied, after which the patient was put tobed. Those present were much struck bythe very slight alteration that appeared inthe shape of the limb after the stitches wereintroduced.On the following morning, I found that

the patient had passed an indifferent night,

and was looking rather anxious and ex.hausted from want of rsleep, notwithstand.ing an opiate which he had taken the pre-ceding evening. His pulse, however, wasgood, and he had had no rigor or other un-

pleasant symptom. As his bowels had notbeen evacuated the day before, I directedan injection to be administered without de-lay. In the evening, lie was in all respectswell; a soft pulse, a clean tongue, and acountenance nearly free from the expressionof anxious distress, which had characterisedit previously to the operation, led me toconclude that there was little reason for

’ apprehension." Great part of the wound :healed hy the

first intention, leaving very little deformity ;but the cure was delayed by an oedematousstate of the limb, which distended the

newly-formed cicatrix, and impeded theI contraction of the granulations in those

parts which did not unite in the first in-stance. To counteract this disposition, Iused fomentations with warm salt water,and the pressure of a firmly-applied flannelroller. The joint remained moveable to thenatural extent; but though the patientcould use his hand almost from the first, hedid not regain any command over the elbowuntil the end of several months, and evennow he does not possess much strength init. He is able, however, to use it in givinginstructions in arithmetic, &c. It may beproper to observe, that this individual ischaracterised by an extreme degree of whatis usually called nervous constitution, andaltogether a most unfavourable subject forthis or any other operation."The fifteenth case seems to have termi4

nated fatally, because the patient was un.willing to submit to the operation at a timewhen his constitution had not been under.mined by the disease :-William Rogers, aged 13, was brought

to me at the beginning of last summer, onaccount of a diseased elbow, which seemedto admit of relief by excision. The parentswere dissuaded from submitting to this pro-posal by the representation of a practitioneradverse to the operation, who strongly re-commended amputation in its stead. Asthis proposal was still less acceptable thanthe former, the patient was sent to the

country, and placed under the care of an

irregular practitioner. I was asked to seehim again about the middle of September,hnd then found that a change had takenplace greatly for the worse. The swelling,instead of being circumscribed and confinedto the neighbourhood of the joint, row ex-tended half way both up to the shoulderand down to the hand. There were nume-

rous sinuses, and, in short, an appearance of

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greater derangement of structure than I hadever met with, except in the case of Eliza-beth Johnstone, above related ; but, en-

couraged by the success enperienced in thatinstance, I still deemed it right to performthe operation." On the 21st of October I cut into the

joint, and removed the olecranon as usual.It then appeared that the ulna was veryextensively diseased, the cel1s of its spongysubstance being filled with scrofulous mat.ter. To make as sure as possible of takingaway all the affected portion, I insulatedthe bone quite down to the commencementof the narrow part of its shaft, and cut itacross there. As the boy Wells, who hadan equally large portion of the ulna removed,made a perfect recovery, I hoped that theresult in this case also would be satisfac-

tory, notwithstanding so great a liberty hadbeen taken with it. For nearly a week thishope promised to be realised ; a good dealof inflammation, indeed, succeeded, but notmore than I had frequentiy seen before.The clots of blood, and sloughs of diseasedstructure, separated by degrees, and thenthe swelling and tensior subsided. At this

stage of the case I went to the country toperform an operation, and returned the fol-lowing evening, but did not see the patienttill next morning, as I believed him to bedoing perfectly well. His appearance thenstruck me remarkably. He had all along apale, unhealthy aspect, and quick, uneasyway of breathing; but now his countenancewas much-more thin, pale, and anxious, andhis breathing was performed with a sort ofcatch ; he had refused his food both this dayand the day before. I believe that thelimb should now have been amputated ; butprevious success made me too confident, andI contented myself with palliating s) mp-toms, of which a very disagreeable one thatnext appeared was a tympanitic distensionof the abdomen. On the 30th of September,he was evidently sinking under the irrita-

tion, and I then removed the arm, with theadvice of some of my friends, but certaiulywith very little expectation of preventingthe fatal termination, which to,k place theday following." The result of this case shows that there

are limits determined by the extent of thedisease and the constitution of the patient,beyond which the operation cannot be ex-tended with safety. These limits can beascertained only by experience ; and, there-fore, such exceptions should be regardedas beacons, not to warn us against the ope-ration, but rather to guide us to its safe andadvantageous performance."We now come to the concluding portion

of the work, which is occupied by two casesof excision of the knee-joint ; as we have

already noticed, one of them terminated

’fatally.The length to which our extracts have

extended prevents us from entering moredeeply into the merits of Mr. Syme’s in-structive work. We may, however, hriefly

say, that it deserves the attentive consider.

ation of every practical surgeon, and thatMr. Syme’s example should be followed byall who feel themselves competent to under-take an operation, which demands an ac.curate knowledge of anatomy, and greatskill, dexterity, and self-possession, in theperformance. In conclusion, we are boundto add our warm and willing testimony tothe pathological exactness, and the excellentexecution of the five beautiful engravings

which illustrate and embellish the present

treatise.

History of the Epidemic Spasmodic Choleraof Russia, illustrated by numerous Offi-cial Documents, with a Map, &c. By Bts-SET HAWKINS, M.D. 8vo. pp. 301. Lon.don. Murray, 1831.

’

THE professed object of this volume is " tocollect into a convenient and ready form thescattered information yet obtained" on this

topic of universal interest, in order that in

the event of the outbreaking of the diseasein Great Britain, " country magistrates,.clergymen, and medical practitioners re-siding at a distance from opportunities ofinformation, should be enabled to possessthe painful experience acquired in othercountries."The beneficial tendency of such a work,

if properly executed, cannot be questionedfor a moment. It also appears to us com-

pletely unnecessary that the compiler ofthe requisite materials should have per-sonally witnessed the ravages of the diseaseof which he treats. Dr. Bisset Hawkins,who has never seen a case of cholera, maycontrast and determine on the opposingstatements of the actual observers of the

malady, with the same precision that Dr.Bostock reviews the experiments of distantrival physiologists, or that the presidingofficer in a court of justice decides on the

testimony in a case, with the actual bear.ings of which he is personally unac.

quainted.t

709

It is but strict justice to the author, tostate that throughout this work he manifestsmuch industry, some research, and the mostexemplary freedom from the spirit of parti-zansliip, in the discussion of the questions,connected with the cholera morbus, whichstill remain the subjects of litigation. Someextracts we sbull presently make will fullybear us out in the latter commendation, andit will be seen also that they corroborateand enforce the opinions which, iu formerarticles, we advanced with respect to the

disputed contagiousness of the disease.The principal if not the only fault we

have to criticise in the work itself, is thetotal want of order in the arrangement ofits contents. To the medical reader this is,perhaps, of less consequence, but to the

non-professional part of the community itrenders the work of comparatively inferiorvalue. It is but right to allow that the

author makes a prominent confession of thisfault in his introduction, and exculpateshimself on the ground of the haste in whichthe compilation was prepared.Having said thus much of the general

merits of the volume, we must decline en-

tering into any enumeration of its particularcontents, since, from their desultory andmultiplied character, we should be forcedto copy the index altogether, if we attempt-ed to specify the various topics it embraces.We now proceed to extract some interestingpassages from Dr. Hawkins’s chapter, inwhich the contagious nature of the diseaseis considered." Sir Gilbert Blane has justly observed,

that the circumstance which most obviouslydistinguishes an epidemic arising from mor-bid poison engendered in the human body,from epidemics caused by affections of theatmosphere, whether consisting in altera-tions of temperature, or in contaminationsfrom the soil, is, that the progress of theformer will necessarily be progressive, andtraceable to human intercourse, whereasthe iufluence of the latter will as certainlybe contemporaneous in situations more or

less distant. It will be clearly perceived,by a careful perusal of the preceding his-tory (and of the Indian reports in our ap.pendix), that the spread of this malady hasbeen strictly progressive, and evidentlycarried by human beings from one districtto another; nor is it conceivable that therequisites of temperature and contaminationof the atmosphere necessary to prove anyother than a contagious origin, could have

occurred at those spotg and periods in

which the disease showed itself in its pro-

gress by sea and land, as is historically de-scribed in the previous and subsequent nar-rative. This is no-wbere more striking thanat the Mauritius. Th,is island is near threethousand miles from the other places at

which the epidemic raged ; and can any’mind be so constituted, as to believe that anew disease of the identical nature of thatwhich had ravaged all India, should haveshown itself by mere accident at the verytime when its appearance was in exact coii-

formity with the supposition of its being

imported by a frigate 1"

Of the route which the disease pursuedfrom place to place in Europe, and of thelight thus thrown on its mode of propaga-tion, Dr. Hawkins speaks as follows :-Weshould premise that he is indebted to the

Edinburgh Medical und Surgical Jaurnadfor the facts his statement contains." Cholera first appeared on the frontiers

of the Astrachan government on the 3d of

July, on board a ship of war, which hadarrived from Baku (three hundred and fiftymiles from the Caspian), and lay sixty milesfrom Astrachan. Till the 20th of the monththe disease was confined within the Sed-litooski Lazaretto, whither the vessel withthe sick had been brought. But on that

day four people were taken ill in the city,near the river Kutum, and from this pointthe disease imperceptibly spread over thewhole town, carrying off a great number ofpeople. After the 27th it attacked the sub.urbs, then the nearest villages, and thengradually extended over the whole govern-ment. * * * In reaching Astrachan fromBaku, it passed o er all the intermediatedistricts of the Russian territories. * * *The first places attacked after Astrachanwere several Tartar villages in the imme-diate vicinity, at a distance of from two tofour miles, the inhabitants of which were inconstant communication with the town, andto which also many families fled out of it as

the disease spread. On the 27th July italso appeared in the village of Tschere-pacha, eight miles from Astrachan, on thereturn of some inhabitants, who had beento the town in search of work, and one ofwhom was the first person taken ill. Afterthe 29th, it proceeded through the Cossackstations and the town of Eustacosk, on thehighway to Moscow, up the stream of theWolga, its extension in this direction evi.dently accompanying the fugitives from theplaces successively attacked. In the townof Eustacosk it spread with the arrival of asick boor. On the 29th of July, a barge-arrived at Tchernojar, one hundred and fiftyi miles up the Wolga, with several rowers on

710

board, who were ill of cholera. On the8th August the disease began to prevailamong the inhabitants, and then passedacross the river among the neighbouringKirglies, as well as upwards to the villagesof Solodnikovsko and Vaisovka, in one ofwhich the person attacked was a militaryprisoner, who had been exposed to the dis-ease. On the 2/,th July, the epidemic alsobegan in Krasnojar, situated on the northernmouth of the Wolga, twenty miles fromAstrachan and it first seized a private ofinvalids and a girl of thirteen years of age,who had both recently come from that capi-tal. On the third August, it appeared inthe estate of M. Nekrasov, ten miles fromKrasnojar, and among the Algarine hills, inthe vicinity of the town, from which it

finally extended down to the Cossack Cor-don on the Caspian, between which and

Krasnojar there is constant communication.while the disease prevailed in Astrachan,some fishermen were there from Makovsky .and Schitnisky, two places on the shore ofthe Caspian, where the Wolga opens intoit. These men, terrified at the progress ofthe epidemic, l,astened home to place them-selves, as they imagined, in security; butthey had already imbibed the poison ; somefoil sick on the way, others after arriving attheir homes, and the disease soon spreadthroughout the community to which theybelonged.

" On the 2d August the salt depot ofBasinsk, in the Caucasian kingdom,’ tenmiles off the highway, was subjected to thegeneral pestilence. On the 1st of the monthan Armenian, convalescent from cholera,arrived at the house of a private of thedep6t, who was taken ill and died next day,and other cases occurred afterwards. Atthe salt dep6t likewise of Kijatska, twentymiles from Krasnojar, a private soldier wastaken ill, who had been sent thither fromAstrachan with medicines and instructionsfor the inhabitants in case the disease should

appear among them, and various individualswere attacked subsequently.Many gardens and farms in the neigh-

bourhood of Astrachan remained exemptfrom the epidemic, having broken off all in.tercourse with the diseased districts. In

many villages, too, where similar measuresof security were taken, the issue was equallyfortunate, although the cholera raged allaround them ; for example, in the lordshipsof Smircov, Beketov, and Prince Dolgo-ruki, in Sarepta, eight miles from Zaritzin,and some other places. On the other handthe Kalmucks, who, as soon as the diseaseappeared among them, left their sick cona-rades behind them, and repaired to pastur-age-grounds fourteen miles off and more,did not in this way get rid of their fatal

visitor-fresh cases occurred among the fa.milies who were first attacked.

" At Astrachan many instances occurredwhere the greater part of the members of afamilv were taken ill in succession. Dr.

Sotomow cannot believe that local causescould have produced the epidemic, becausethe two seasons previous to 1830 had beenmuch more favourable than it to the exten.sion of a disease of local origin, as the coun-try had been then much nooded.

" Wherever measures were taken to pre.vent communication in the. Russian domi.nions, there the disease has been totallychecked, or has made but little progress.Petersburgh has not escaped, because a

strict quarantine has not been observed be.tween it and Moscow. The Moravian co-lony on the right bank of the Wolga, andseveral German colonies in the governmentof Saratov, around which the disease wasviolent, adopted the system of exclusion,and were also unhurt. At Caramala.Gu.beewa some Russian peasants living toge.ther, scarcely a hundred yards from the

village, shut up their hamlet on the firstreport of the disease having appeared intheir vicinity, and by enforcing a strict qua-rantine during the prevalence of the epi..demic, remained in health. The large esta-blishment composing the Academy of Mili.tary Cadets at Moscow, was preserved bya similar plan from the scourge, which wasso active on all sides of it. Can we have abetter proof of the contagious nature of thedisease, than that insulation, or separationfrom the sick, is almost universally foundto preserve from the evil?"

Dr. Hawkins next cites the strong facts

contained in Keraudren’s treatise, regard-ing the immunity enjoyed by the Frenchconsul at Aleppo, in consequence of the in.sulation he preserved. He then proceedsto observe .-" At Dantzic we find that the disease has

prevailed for several weeks, having proba-bly been first imported by sea. It has notextended from Dantzic to any of the neigh-bouring towns or districts’of -Prussia. ThePrussian government enforces a very strictquarantine. Can we imagine any noxiouselement in the air or in the earth at Dantzic,which should produce the disease in that

sea-port, and confine it to that alone of allthe towns of Prussia? Is it not a morpeasy solution of the difficulty to presumethat it was communicated to Dantzic bycontagion, and that it has not yet travelledthence through other parts of Prussia, be.cause the evil has been pent up, and hasnot been permitted to diffuse itself, beingrigidly hemmed in on all sides by a strong

711

medical and civil police ? The Cape ofGood Hope has escaped the disease, andfor no better reason that we can discover,than through the very rigid system of qua-rantine which was formed by the Dutch, and Ion the strict maintenance of which they sti-pulated in their articles of capitulation."

’

Some very sensible remarks next occur

concerning the partizan spirit by which it isevident that many of the Indian officers have

been actuated in their rejection of the con-

tagion doctrine. The author then alludes tothe protection afforded by moral courage, anduses the remark as an argument against the

anti-contagion inference derived from the

comparative immunity of the medical menwho superintended the treatment of the dis-ease. He then justly contends that,-,. The middle course of reasoning is, on

this subject, probably the true, as well asthe safe one. There is no necessity for em- bracing either extreme-for becoming en-tirely a contagionist, or an anti-contagionist.We may easily conceive that a disease mayoriginally be produced by local or othercauses, which may not be endued with a

self-communicating power at its birth, butwhich may, nevertheless, acquire the con-tagious element as it proceeds and gathersstrength through the new circumstanceswhich occur in its passage. Let us admit,if it be necesssary, that the disease was uotcontagious in India, or let us suppose thatits original sphere of contagion was so

limited as to be scarcely sensible. Still that

very limited sphere may be gradually ex-tended to a certain degree, and the dis-ease may yet finally remain less powerful inits contagious operation than most of theother diseases which are classed under thatdenomination. We speak of the laws ofcontagion, but who can define them ? As

many shades and varieties may exist in thecoutagious element, as in those fluctuatinggroups of symptoms to which the name of aparticular disease is affixed.

Lastly, after a conclusive exposure of theinfluence of poverty in predisposing to thisdisease, and a humane and practical appealto the benevolence of the richer classes in

the event of its appearing in this country,Dr. Hawkins sums up his conclusions in thefollowing words :-" After carefully reviewing the various

statements and reasonings on the mode iuwhich this disease is propagated, and of the

means by which it may be averted, we can-not avoid arriving at the conclusion, that thedisease in India was probably communicablefrom person to persou, and that in Europe ithas undeniably proved so. Nevertheless,we must allow that its contagious power ismore limited than that of the plague, and ofsome other disorders styled contagious. Itsattacks are chiefly confined to the lowerclasses, and it seems, in a few words, to

9-equire a ptrrticular disposition to receive it.What that disposition is, has been repeat-edly mentioned in the preceding pages, andwill be further illustrated in the appendix.

With respect to merchandise, a generalopinion is entertained in Russia that goodsare not capable of propagating it. This

subject, however, has hitherto elicited.littlesave negative evidence. We know howstrong:y commercial and even political feel-ings are arrayed against a proper circum-spection on this head. Two of the most

prudent and economical governments in Eu-

rope have established a quarantine on mer-chandise, and this circumstance alone shouldbe sufficiently strong to induce others toadopt the same caution, because these aretwo of the states most near to Russia, andmost likely to have obtained ample and cor-rect information. One remarkable fact infavour of its propagation by goods has latelybeen published by the Norwegian govern-ment, which declares that, out of one hun.dred and sixty-nine deaths at Riga, in threedays, an eighth part had been carriers ofhemp.

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° Medical men are usually very reluc.tant to admit anv existence which is notactually visible to their senses, and conta-gion, accordingly, is a principle which theyhave always been slow to admit in an old

disease, and still more tardy in granting towhat may be termed a new one. Dr. Mae-michael has shown how much ingenuity waswasted, in every possible explanation, be-fore even the small-pox was allowed to be

contagious, a fact of which Sydenham doesnot seem to have been aware."

The length to which these extracts haveextended forbids our making them the sub-

ject of any additional Gbservations. We

content ourselves, therefore, by adding thatwith the exception of the French history ofthe disease by M. Moreau de Jonnes, Dr.Hawkins’s work contains more ample re-sources for reference and comparison thanany other with which we are acquainted.