12

Patience alone can clear up the diagnosis in cases similar to (

the above, and a few days will usually suffice for the surgeon (

to be enabled to form a correct opinion on their nature. It, ]

however, happens in practice, that cases exactly the reverse 4

of the last may occur to obscure diagnosis, one of which I willrelate: °

4

A nobleman’s butler, sent to me by Mr. Toller, of Conduit- lstreet, complained of slight discharge from the meatus, which ihad existed four days: the case was in mv opinion so clearly Ione of simple gonorrhoea, that I took no notes of the complaint, . iand treated the patient with nitrate of silver injections, andcopaiba. On the fifth day, the yellow discharge had ceased,but my patient complained of slight pain at the end of thepenis; and on looking at it, there was considerable thicken-ing around the meatus, which felt hard under the finger,and putting on all the characters of induration. I entertained Ia hope that this thickening was not of a specific character, butit was so very like it that time alone could clear up thediagnosis. I lost sight of my patient, as his discharge wascured, and not having seen him since, I trust my suspicionswere not correct.

Since the above case occurred, I have seen induration of themeatus, in two cases, where it was impossible to decide if I had ito treat an indurated chancre or an inflammatory condition

of Btissue.These obscure points in diagnosis are not even hinted at by

the most practical writers on syphilis; and my readers mustpardon me if, at the risk of fatiguing the patience of some, Idwell on points which in private practice I have found verydifficult, and the treatment of which, even now, it is almostimpossible to lay down rules for, as another instance may show.A gentleman consulted me, on account of several sores on theprepuce; in the belief that they were’simple excoriations, hehad taken some cooling medicine, and applied a weak solutionof superacetate of lead, yet still these ulcers got neither betternor worse for the space of a fortnight: it was at this period Iwas consulted as to what was their nature. I observedfour ulcers, as large as split peas; two were hard, theothers without any attendant induration, the surface red andhealthy. I hesitated to give any decided opinion, but recom-mended several local applications, with little avail; at theend of a fortnight they got well, all induration went away,and although some time has elapsed, yet secondary symptomshave not followed. The practical results flowing from theobservation of these cases seems to be, that the surgeon,although he may be convinced that true induration is followedinvariably by secondary symptoms, and requires mercury forthe cure of the local as well as general contamination, shouldyet pause before submitting his patient to a course of mercury,or he will subject a number of cases unnecessarily to themineral, when a little patience would clear up the diagnosis;for true induration has no tendency to disappear thus readily;it will remain for long, if not indefinite periods, to warn thesurgeon, as well as the patient, of its importance.

. PROGNOSIS.

The appearance of induration around or beneath a sore is.always to be regretted, as the consequences can never be fore-seen. In the first place, as I have above shown, the sorewill not be likely to heal, but tend to remain in statit quo, orthe ulceration or induration be likely to increase, and the iduration of one or both may be almost indefinite. I have-seen induration last more than a twelvemonth. If it heals,the cicatrix is liable to take on ulceration on the slightestcause, and a very intractable sore results; if these are amongthe local effects of indurated sores, the general ones areno less to be dreaded: a few weeks only will elapse beforesecondary symptoms may show themselves, attacking theskin or mucous Bmembrane, and if cured, will probably befollowed by relapses in the manner alluded to at page 69 ofvol. i. of THE LANCET for 1846. It is very true, that unless thecase is mismanaged, neither rupia nor phagedaenic affections ofthe throat will generally follow these indurated sores, but thepatient will again and again (perhaps for years) have chronicaffection of the skin.* It would be satisfactory, could I bringforward the opinions of various writers who pursue differenttreatment, to show that these relapses depend upon bad manage-ment ; but, as I have shown in the paper above alluded to, wemust come to the conclusion that this is the inevitable course

* And here I must agree with Mr. Carmichael in his belief that induratedsores will be followed generally with a peculiar form of secondary symp-toms. These are usually found to be scaly, and attended with sequelae,which seem to have a strict rela’ion to induration ; and t believe to thatgentleman we must give the credit of having called public attention to thesubject, and which subsequent experience has confirmed. (See Carmichael’sClinical Lectures, p. 15 1.)

of the disease, not the result of treatment, and that by judi*cious management we can only hope to cure the majority, butmust despair of immediately relieving all from the conse-quences of indurated chancre.The writer who takes the most sanguine view of indurated

chancre is Mr. Key, in the Gny’s Hospital -Repo2-ts. At p. 426he says,

" When combined with the other evidences of poison,induration is of some value in determining the nature of thesore; but alone, it is indecisive of the poisonous character ofan ulcer, especially when seated in the cellular membranedeep beneath the cutis....... The deep chronic chancreof the corona glandis, mild in its character, and usuallyharm-less in its effects, will last for months, and acquire a degreeof induration that gladdens the heart of a soi-disant discipleof Hunter, grieved to find the good old chancre fast disappear-ing from the land." Almost all other authors that I haveconsulted agree in the importances of induration; but I haveintroduced Mr. Key’s words, that rrf, ’ adera may hear bothsides of the question; however, let them, before coming to aconclusion, remember the doubtful cases alluded to under thehead of diagnosis, when that gentleman’s views will prettynearly coincide with those of other practical writers.The surgeon must then, I think, view induration as a very

serious inconvenience; for my own part, when a patient con-sults me, and induration has already appeared, I tell him atonce my opinion of his case. I point out its existence, andinform him of the consequences; and in this way indurationis of value; for long ere secondary symptoms appear, theiroccurrence may be foretold, and the patient is not unaware ofthe probability of their appearance. Induration is of valuelikewise as the touchstone for the surgeon to know whenmercury should be given: it likewise tells us for how long aperiod it should be given; it is our hydrargyrometer, as Ricordcalls it, and a very valuable one it will be found, as I shall ex-plain in dwelling on treatment.Queen Anne-street, Cavendish-square, Dec. 1846.

Reviews.

The Seventh.Annual Report of the Registrar- General of Births,Deaths, and fflarriages, in England. (Abstract of the TzvoYears, 1843, 1844.) London, 1846: Clowes. 8vo, pp. 348.

THis is not nearly so bulky a work as some of its predecessors,it being, for the most part, confined to reports and tables rela-tive to the United Kingdom; whereas that of the previousyear, especially, contained copious references to the popula-tion, mortality, &c., of foreign countries. Great endeavourshave recently been made by the Registrar-General to induce themedical profession at large to aid his endeavours toward theattainment of still greater accuracy in the returns successivelyput forth respecting the increase of the population, the com-parative prevalence of mortal diseases, the localities in whichthese respectively prevail, the age, sex, and condition of lifewhich each principally affects, &c. Circular letters have beenissued to the authorized medical practitioners throughout thecountry, with books of blank certificates, to be filled up so asto afford information as to the duration of disease previous todeath, and other particulars calculated to afford much morevaluable materials for correct conclusions on vital statisticsthan have hitherto existed. We do earnestly hope that ourmedical brethren will universally and zealously second theseefforts, by reason of their real importance in both scientificand philanthropic points of view. We say universally, for itappears, from the following passage, that some to whom cir-culars have been sent have declined to cooperate in this na-tional undertaking.

″ An inconsiderable number-perhaps fifty persons-of themedical profession have refused to return the causes of death,for very various reasons; one gentleman, because a FactoryInspector had displeased him, another because he had not beenelected a medical officer under the new Poor Law, another becamethe remuneration under that law is insufficient, another becausehe 1’S not specially paidfor- sigrzing the written certificate. Thatit is the duty of the State to require from the medical at-tendants, and to register the cause of every individual’s deathwhich takes place in the country, appears to me incontestable;and, as I have stated, I have found that the profession as a body

13

comprising more than ten thousand qualified medical prac-titioners, and all the most eminent men im all branches of theprofession-physicians, surgeons, and general practitioners-have expressed their readiness to return the causes of deathin the best way the present state of medical science and theirmeans of procuring information will admit. I have given ex-plicit instructions that no certificate shall be received from per- Isons known to be unqualified, or to have no diploma from eitherthe halls, colleges, or recognised Universities ; and I havedetermined not to attempt at present to compel the few-medical practitioners who have refused to sign certificates,to return the causes of their patients’ deaths ; as, althoughthey may have diplomas, it is probable that the infowraationthey would be inducecl to furrnish. would be of little comparativevalue, and might mingle errors among the facts spontaneouslysupplied by enlightened, accurate observers."-pp. 2, 3.The italics are our own, and the passages in them both re-

veal some curious motives, and a severe, though probablycorrect, opinion; and, on the other hand, some circumstancescalculated to inspire a rational satisfaction. First of all, weare pleased to see a distinction broadly laid down betweenqualified practitioners and unqualified pretenders; and weseem to have some kind of earnest that the Government willnot be tardy in drawing the line of demarcation still more

stringently when we observe the enunciation of sound prin-ciples on the subject from an office in immediate connexionwith the State. It is also gratifying to find that the " profes-sion as a body" so warmly concur in the laudable objects im-pressed on their notice; and it speaks well for the enlarge-ment of their views-trumpet-tongued, in fact, of the advance-ment of the general practitioner. But the objections abovespecified to the making returns are ludicrously irrelevant, ab-surd., and wholly unworthy of their authors. It is a matterof just regret that they should have emanated from the cul-tivators of a liberal science. Reform them altogether, gen-tlemen !We fully concur in the following remarks of the registrar-

general :-″ To secure a complete statistical account of the move-

ments’ of the population, the census lists should be revisedannually, and registers should be kept of those who leave orenter the country, as well as of births and deaths. In the ab-sence of the information which such a system would furnish,it is impossible to determine the precise extent of the deficiencyin the registration of births."We really know of no good reason why the census should

not be taken annually instead of decennially, as at present;the utility of such a measure would be soon apparent in all ofthe thousand branches of political, commercial, and medicaleconomy.The remaining extracts we shall make are those of the most I

general interest to be found in the report :-"The population (female) increased 1.335 per cent. annually

from 1831 to 1841 ; it increased very regularly at rather afaster rate from 1801 to 1831; and from the known circum.stances of the country in the present decennium, the inferenceis probable that the mean rate of increase has hitherto beenas high as that which prevailed from 1831 to 1841. The

population of England estimated at that rate of increase was16,684,600 on January 1st, 1845; and will be 17,000,000 beforeMidsummer, 1846. About 222,000 souls are added to the popu-lation of this part of the United Kingdom annually."-pp. 4, 5." The increase of the population of the United Kingdom in

10 years is 10.79 per cent., which is at the rate of .01030, orof 1.030 per cent. annually.

" Speaking in round numbers, the population increased 11per cent. in the 10 years 1831-41, which is very nearly at therate of 1 per cent. annually: at this rate the population willdouble in 68 years. The increase of males was 1.033, offemales 1.028 per cent. annually, a difference exceedinglyslight." The population, at the same rate of increase, will be

30,000,000 in January 1852. The increase was 2,639,817 inthe 10 years, June, 1831-41, or on an average 263,932 annually."- p. 9.The following fact is somewhat startling and humiliating

for a country which professes to be in the van of civilization.

″ Persons when they are married, are required to sign themarriage register; if they cannot write their names, they signwith a mark. The result has hitherto been, that nearly oneman in three, and one woman in two, married, sign with!marks."-pp. 14, its.

It shows that there is need for the schoolmaster 11 at home"as well as " abroad."

Statistics present themselves to most minds as a dry andrepulsive study; they form not the chain in which Psychecan be bound, although, perchance, that in which Proteus

may be fettered. Nevertheless, to the unerring test they arecapable of affording, we must eventually turn for a guide tothe solution of numerous problems in theoretical and practicalmedicine, which are at present the subjects of wide differencesof opinion. Numbers form a most important element of mo’dern reasoning, and their utility, when carefully and accu-rately elicited, is exactly proportionate to the dangerattending their use when erroneous. Making allowance forthe incompleteness which still attends some portion of thedata whence they are drawn, but which is continually inprocess of rectification, the correctness of the Tables whichissue from the Registrar-General’s office, and of the deduc-tions therefrom, is, we believe, unimpeached; and we have nodoubt that a progressive approximation to truth is made ineach additional year’s report.

Foreign Department.

MEDICAL ORGANIZATION IN SPAIN.

AGREEABLY to a government decree, dated Sept. 5th, 1846,five faculties of medicine are established in Spain-viz., atMadrid, Cadiz, Valencia, Barcelona, and Santiago. The me-dical college of Madrid is judiciously seated in a noble edificeclose to the general hospital, and has on the ground floor, fourspacious theatres, two dissecting-rooms, &c.; and above stairs,the museum and library. At present, the duration of medicalstudy in Spain is fixed at nine years, in order to obtain thedegree of doctor, or only seven years for that of licentiate, inmedicine; but the latter degree confers the privilege to prac-tise in any part of Spain with the title of medico-cir2crjans, orphysician-surgeon, (the " one faculty" being thus fully re-cognised even in the designation of the practitioner.) Onlythose who possess the doctorate, however, are eligible to pro.fessorships and as agrégés, and to practise at watering-places;and the same degree will probably be hereafter required toenable its possessor to hold the appointment of hospital phy-sician. At the end of the fifth year of study, the studentacquires the title of bachelor of medicine, but this confers noright to practise. The following is the course of study aspursued at Madrid.

First year.-Medicine and medicinal chemistry, three timesweekly, Prof. Usera; general chemistry, three times weekly,Prof. Masarnan; colloquial examinations on osteology anddissections, from eleven till two daily; descriptive and.generalanatomy, daily, Prof. Castello, jun.Second year.-Natural history, daily, Prof. Obrador; phy-

siology, theoretic and experimental,* five times weekly, Prof.Ysorn; hygiene, twice a week, Prof. Perez; dissections, fromnoon till two P.M.; general and descriptive anatomy.Third year.-General pathology, four times weekly for four

months; clinical medicine and hospital practice, for four othermonths; morbid anatomy, twice a week, for eight months,Prof. Lopez; therapeutics, materia medica, and prescriptions,five times weekly, Prof. Capdevila; dissections as during thesecond year.Fourth year.-Pathology and clinical medicine, morbid

anatomy, bandaging, surgical anatomy, operations, Prof. Toca;surgical pathology, daily, Prof. Fran; practical exercise ofthe foregoing.

Fifth year.- Surgical hospital practice, Profs. Argumosaand Solis; visceral pathology, Prof. Drumen; midwifery anddiseases of women and children, Prof. Saura, all daily; prac-tical exercises, as in the fourth year.Sixth year.-Surgical and medical practice, daily-profes-

sors of the latter, Senor Gutierrez, Dean of the Faculty, and* Under this head we are told-by the help of a "hundred vivisections"

on dogs and sheep, the professor illustrates the functions of the nervoussystem, and of respiration, circulation, digestion, vomiting, &c.