otherwise, strangling was produced, and regurgitation took place through the nostrils. Dyspnoea, which also existed, had the effect of aggravating the difficulty of deglutition. The voice, besides a nasal tone, characteristic of the absence of the uvula, had a peculiar laryngeal sound. The dyspnoea was increased by exercise, and also by any exciting moral emotions.

Preceding History.-About three years ago, the patient had primary venereal disease (and the only time, as he asserts) in the form of chancres, bubo, and gonorrhoea. Winter before last, on a voyage from Liverpool, his throat became sore, and on arriving at this port, he entered the Seamen's Retreat on Staten Island, where he remained five months, his throat being extensively ulcerated, and his voice reduced to a whisper during that time. About the 1st July last, the passage of his throat became very much contracted, and the dyspnoea very urgent. On applying to a physician in the city, he passed an instrument down his throat (which patient compared to a catheter, though of larger size). The introduction of it occupied an hour, and was followed by profuse bleeding for three hours. After this, both respiration and deglutition were considerably improved; his general health in other respects was good.

May 22. Our patient being very anxious for relief, especially from the dyspnoea, which had steadily increased, an attempt was made to enlarge the aperture at the root of the tongue, by splitting up the soft palate in the median line, with the view of determining to what extent the obstruction at this point might influence the dyspnoea, and also in the hope of being able to pass the finger on, and explore the condition of the epiglottis and glottis. This attempt, however, produced such an alarming suffocative attack that it was abandoned, and tracheotomy resorted to, and a large-sized, curved trachea tube, perforated on the convex side of the curve, was inserted and secured by a tape around the neck. The relief of the respiration was instantaneous and complete, and afforded the greatest satisfaction to the patient. Deglutition was also rendered much easier.

June 1.-The respiration continues perfectly easy through the tube. Deglutition, however, has been only temporarily relieved by the operation, and is again becoming more difficult. Still, hoping the division of the velum might abate the stricture of the fauces, and facilitate swallowing, I performed the operation, after etherizing the patient by slitting the velum in the median line with a long-handled curved bistoury. I had also hoped that this operation would enable me to pass my finger

through the stricture, to break up the adhesions, and at the same time ascertain the condition of the epiglottis and orifice of the larynx. In this I was disappointed, as I found the base of the tongue drawn so far backwards as not to allow the finger to advance between it and the posterior wall of the larynx. The effects of the operation in other respects were unfavorable. The voice became extinct, and could only be raised to a hoarse-whisper by closing the nostrils at the same time that the outer orifice of the tube was stopped. The difficulty of deglutition was also increased instead of diminished.

June 28.-Deglutition continues so difficult that patient is entirely unable to swallow solid food, and can only get down liquids in small quantities at a time. At his own solicitation, the patient was allowed to pass a silver catheter down through the stricture, for the purpose of dilating it, and found, after a few repetitions, that he was able to swallow easier. On the 8th of July, when he left the Hospital, the improvement in deglutition continued under the use of the catheter. The tube in the trachea could not be dispensed with.

On the 26th November following, Burton returned to the Hospital, still wearing the trachea tube, and obliged to close the nostrils as well as the tube in order to speak audibly. To our great surprise, the edges of the divided soft palate had nearly reunited; the deficiency was at the posterior extremity, but was only slight. He had made a voyage in the capacity of cook on board a vessel, and had earned full wages. After remaining some time, for the relief of certain symptoms of tertiary syphilis, he again left the Hospital, on the 21st December, 1854.

The contracted state of the fauces in this case rendered it impossible to ascertain the condition of the orifice of the larynx. We are therefore still ignorant of the true cause of the obstruction of the respiration. There is, however, good reason to infer that the extensive and destructive ulceration, which involved the velum and fauces, and was followed by contraction in cicatrizing, spread, also, to the orifice of the larynx and epiglottis, and produced there the same results. This inference is strengthened by the fact above noticed, that his voice at the same time was reduced to a whisper.

Observations on Hydrencephaloid [disease]. By NATHAN P. RICE, M. D. Editors of the New York Medical Times:

GENTLEMEN-Excuse me for making what may seem to you a rather tediously long communication. My intention is to make known what

has once or twice been a puzzling cause to myself, and which I know has induced error in others. It may be the means of drawing the attention of others to it who are more competent to judge, and who have seen more cases than myself. The disease in question is just one of those which seem exceedingly grave without perhaps being so, and which by inducing the use of violent measures has led to disagreeable results. In all the text books, but too little mention is made of these minor cases, which produce confusion from their resemblance to some others of great gravity. And this one in particular has, I think, been too much slighted; not enough stress having been put by any author upon its diagnostie symptoms, or its analogy with other disease.

I am yours, &c., with much respect,

NATHAN P. RICE, M. D.

It is a question with many whether the title which has been placed at the head of this paper has the right to dignify an idiopathic disease; and perhaps by the majority of practitioners it is regarded as not constituting one of the many maladies to which we are liable. As a sort of compounding with the opinions of those who deny and with those who think it a disease, the word disease has been generally added in qualifying brackets.

There is no doubt but that its characteristics are signs often of constitutional disturbance and weakness, and are symptoms in other diseases. But still I think that it can occur alone, that is, that what evidences the hydrencephaloid may be the only guides to us in our treatment, and that uninjured health seems to return on their disappearance. Jaundice is a symptom of many different diseases, and as such, is a very valuable assistance to us in our diagnosis; and yet it is also recognized as a malady in propriâ personâ, and has an appropriate place in all our text books. Moreover, as the close identity of appearance which this disease bears to many others of a different nature, locating themselves in the head, might attract the attention of the practitioner to what he would consider a cephalic disease to the exclusion of any other supposition, and as what would be applicable in the one case would be highly detrimental in the other, I think it is but fair to give it a distinctive place in our nosology.

It is not a rare disease; few medical men whose practice lies among the juvenile portion of the community, especially among the children of the poorer classes, pass a month without encountering instances of it. And yet in but few works have I seen it classified by itself, or mentioned

otherwise than as one of the occurrences of sometimes one disorder and sometimes another.

The name of Hydrencephaloid, first, given by Hall to what he was disposed to consider as a disease, is sometimes confounded with hydrencephalus, the equivalent of hydrocephalus internus, although few know it by that title, the most common being spurious hydrocephalus, or Grecized pseudo-encephalitis or pseudo-arachnitis.

Four prime causes seem to be the most prone to excite the symptoms of this disease, all of which, however, have a tendency to produce the same result—that is, a constitutional want of tonicity, a state of exhaustion and debility. The first of these, and by far the most common, is bad and insufficient nourishment, and sometimes a defect in the power of assimilation; for cases are often met with in which, although the quantity of the food is sufficient, it does not seem to fulfill its destined object. The effects of this seem to be the oftenest manifested in the earliest periods of life among nursing children, and to depend upon a lack in the proper supply of milk, or in its quality, and upon a bad selection of articles of diet when they are not fed at the breast. Up to the age of six or eight years, it may occur for the same reasons, but I think not so frequently as earlier, or so often uncomplicated with any other disorder; the peculiar impressibility of infants so much sooner giving evidence of slight disturbing causes.

Serous diarrhoea and dysentery are agents in its production but little inferior to the last; and it is under the description of these diseases in children that we oftenest find mention made of the train of symptoms which characterize this disorder. The discharges must have continued for some time, and have been able to produce a universal depressing influence on the system before it becomes manifest. Something very like it has also been produced by hypercatharsis.

Any other exhausting drain, as the profuse purulent discharge from a burn, extensive ulceration from any of the diseases of the skin, or a great loss of blood, will make it show itself in a more or less marked degree. I have seen one instance of it in a child of about eighteen months, who seemed to have a hæmorrhagic diathesis, and who had always been troubled with frequent and severe epistaxis. She was suffering with hooping cough; and from the violent straining in coughing, she in this way in three days lost a large quantity of blood. For several days after these attacks she was affected with well-marked symptoms.

The sequences of severe operations on children, whether attended or

not with great loss of blood and of subsequent discharge, are in many similarities allied to this disease; in this respect it seems to be much the same as the delirium traumaticum, although, as it occurs in younger subjects, the manifestations are somewhat different.

The symptoms of this disorder are very striking, and are of such a character as to lead the attention to the head first, as the probable seat of the trouble. If the child is a nursing one, the first symptom which is generally noticed by the nurse or mother is, that the child does not seem to nurse so often as usual; that he does not suck so vigorously; that he seems more inclined to doze-to remain quiet upon the lap, or in the bed without moving; and that often, when in the act of nursing, it will allow the milk to run from its mouth as soon as it is taken in, or that it will let it remain for some time without attempting to swallow it. Often, at the same time, the child endeavors to recline its head all the time upon some object-the arm or shoulder; and if raised, the head being free, it will let its head swing heavily about as if it was a weight greater than it could bear. The child, if nothing occurs to disturb it, will remain in a more or less somnolent or comatose state; and yet if spoken to loudly, or vividly impressed by any new object, or the sudden entrance of any one, it will brighten up, look lively, move and act with as much vivacity as is usual. But still, if watched and allowed to become gradually tranquil, it will be found that it will soon relapse intoits previous condition.

In children, who are not nursing, the signs are in some respects the same, but more strongly exhibited. The child shows a total unfitness for all exertion; it cannot be induced to stir itself, to play or walk, but will prefer to keep perfectly quiet, the most often lying at full length; it complains generally of lassitude, and an aching in different parts of the body, sometimes of a pain in the head. But the comatose condition is the one which is the oftenest met with, and the one which is the surest to terrify the parents. This is very distinctly marked, the patient showing from the first, a constant inclination to sleep-to lie without motion or speaking for hours together, without expressing even a wish for food or drink.

With all these apparently grave symptoms, the child's health may be, otherwise, sometimes perfectly good; he may have no diarrhoea, and often shows no signs of suffering in any way. The pulse is usually below the normal standard of frequency, and is soft and compressible. The skin is generally cool, and of the natural character, though I have