recommended by the late Mr. Bryce of Edinburgh, deserves to be more generally adopted than it has been.

6. The number of punctures to be made on the arm must vary, according as the lymph employed is more or less active. Dr. Heim of Wurtemburg, and, we believe also, Dr. Gregory of London recommend ten or twelve insertions of the lymph in ordinary use. When the lymph is unusually energetic, as seems to be frequently the case when it has been recently derived from the cow, two or three punctures will often produce as much local and constitutional irritation as ten or twelve punctures with the lymph that has been used successively for a number of years. On this subject we must refer to the work of Jenner himself, to the memoir of M. Bousquet (vide Med.-Chir. Rev. April 1837), and to the very interesting report of Mr. Macpherson from Moorshedabad (vide Trans. of Med. and Phys. Soc. of Calcutta, vol. vi.).

Fresh fluid lymph, taken directly from the vesicles, is always preferable to that which has been kept and become dry; and lymph from a vesicle in its early stage is certainly more active than that from one that is more advanced.

Whatever be the number of punctures made, it is desireable that a certain degree of constitutional disturbance be induced by the operation. It is probable that, when this does not occur, the system is not so thoroughly protected, as when it does.

7. Recurrence should be had occasionally to the cow for fresh supplies of lymph, especially when that, which is in use, appears to lose some degree of its intensity.

It is to be remembered however, that by far the greater number of experiments, made with lymph procured from the cow, have hitherto failed. Whether this arises from the genuine disease in the cow not having been properly discriminated-(for it would seem that the animal is subject to various anomalous eruptive complaints, like to, but in reality different from, the genuine Variolæ Vaccine)— or from other causes, cannot well be decided. It is a curious fact that in France, upon one occasion only since the first introduction of vaccination, has the genuine lymph been derived from its original source: this occurred about three years ago at Passy, near Paris. Dr. Gregory too, in his last Report of the Small-pox Hospital, alludes to the subject in these words: "We have received indeed from Bristol, Aylesbury, and the North of Scotland, supplies of matter recently taken from the Cow, with which experiments have been made, but as none of them appear to exceed, or even to equal in intensity, the Lymph now in use, it has not been thought advisable to make any alteration. Recurrence to the Cow for fresh Lymph is not a measure lightly to be had recourse to, nor should it be advised until the old and tried stock has obviously degenerated."

The question therefore of the propriety of occasionally renewing our supplies of lymph from its original source requires to be more extensively examined, before we can arrive at any positive conclusions on the subject. Still there is information sufficient to warrant us in recommeuding the practice.

8. In taking lymph from the arm of a vaccinated child, one or two of the vesicles should be left unopened and undisturbed.

9. The protective influence of vaccination against small-pox contagion is only temporary or limited to a certain number of years. It appears to remain almost complete for ten or twelve years; and then progressively to become less and less decided.

The effects of

10. It is therefore proper to have recourse to Re-vaccination. this operation vary much in different persons. In some, the punctured wounds only become slightly irritated and then heal up; in others, an imperfect attempt at the formation of pustules takes place; and in a third set, regular normal vaccine vesicles are formed, as after the first operation. Fresh fluid lymph should always be used for re-vaccination.

How far the susceptibility to be affected by re-vaccination is a test or indication of the susceptibility in the person of catching the variolous contagion-a

question certainly of the very highest practical importance-has not yet been determined; although it seems probable that it is so. Dr. Jenner in one of his latest publications, distinctly states, "if the constitution shews an insusceptibility of the one, it commonly does of the other."

11. The number and character of the cicatrices on the arm afford no means of judging whether the person is susceptible either of the vaccine or of the variolous inoculation.

12. Almost all the cases of very severe, certainly of fatal, small-pox after proper vaccination have occurred in persons upwards of fifteen or even twenty years of age.

13. No case of small-pox has, according to the German authorities, occurred in any re-vaccinated person.

14. We have no very accurate or sufficiently extensive data to ascertain the average frequency of secondary small-pox, after the natural disease or after inoculation with the variolous virus.

Dr. Baron, in his Life of Jenner, goes so far as to state that the number of cases of secondary small-pox is as great as that of small-pox after perfect vaccination. He appeals to a series of observations made at the Royal Military Asylum at Chelsea. From 1803 to 1833, it appears that 5592 children were admitted into that institution; of these 2532 were reported to have had smallpox, and 3060 to have been vaccinated.

The number who had small-pox after reputed small-pox was 26; and the number who had small-pox after vaccination was 24. The number vaccinated at the Asylum subsequent to admission was 628, of which number three only caught the small pox. The number who died of small-pox at the Asylum was four boys and one girl; of these five children, three had the disease after reputed small-pox, and two had neither been vaccinated nor undergone the small-pox before. (See Appendix to Report from Select Committee on the Vaccine Board.) The statements in this document, if taken by itself, certainly warrant the conclusion which Dr. Baron has deduced; and it would seem to be confirmed by some other observations to which he alludes. Thus in the varioloid epidemic, which prevailed in Edinburgh in 1818-1819, a greater number of deaths occurred among those who had formerly suffered from small-pox, than in those who had been vaccinated; and Mr. Cross, in his excellent account of the epidemic at Norwich in 1819, alludes to three cases of fatal secondary small-pox, whereas two only of fatal small-pox after vaccination were heard of. It will be observed also that a statement, made by M. Dezeimeris respecting one of the recent epidemics in Norway, is in accordance with these observations.

Still it is right to bear in mind that we have much need of further authentic data, before we can justly arrive at any sound conclusions on this subject; more especially as we understand that the personal experience of Dr. Gregory is not in conformity with the statement made by Dr. Baron that "vaccination, when duly gone through, does certainly afford as complete immunity from subsequent attacks of small-pox, as that disease itself can do."

The number of cases of secondary variola, whether after inoculation or after the natural disease, which have come under Dr. Gregory's personal observation has been very few-not more than three or four unequivocal cases in all. He is of opinion that in very many reputed instances of secondary small-pox, the disease has been, the second time, either varicella, porrigo, or lichen varioloides.

15. Almost all the cases of unequivocal secondary small-pox have, according to the statements of some writers, occurred at from twenty to thirty years after the date of the first attack.

16. With respect to the effects of vaccination on persons, who have had the small-pox, it is stated by Dr. Heim of Wurtemburg, that of 297 such cases, the operation succeeded perfectly in 95, produced modified vesicles in 76, and failed altogether in 126—a proportion not dissimilar to what has been stated in some reports to have been the results of re-vaccination.

NOTICE OF THE GERMAN JOURNAL Zeitschrift fur die Gesammte
Medicin; ITS CONTENTS.

The eighth volume of the above periodical, edited by Drs. Fricke and Oppenheim, was recently sent to us for inspection; and we have been much pleased with the perusal.

It contains several original contributions from Professors Osiander, and Dieffenbach, and from Drs. Ruppius of Freiburg, Dubigk of Berlin, Nathan of Hamburg, Oppenheim, and Fricke.

The second part is occupied with analytic reviews of most of the important medical works, which have, within the last year or two, been published, not only in Germany, but also in Britain, France and Italy; such as Wardrop on Diseases of the Heart, Marshall Hall on the Nervous System, Guy's Hospital Reports, the Medico-Chirurgical Transactions, the Memoirs of the Royal Academy of Medicine at Paris, the Clinique Medicale of Bouillaud, Statistical Researches on Foundlings, Illegitimate Children and Orphans in France and other countries of Europe, by MM. Gaillard, Terme, Montfalcon, and Remache, Clinical History of the Cholera Morbus in Italy, by Drs. Renzi and Rotondo of Naples, &c. &c.

The third part comprises numerous valuable notices and extracts from almost all the leading medical journals of Europe, being similar to, but less complete and extensive than, the Periscopic Department of the Medico-Chirurgical Review; and the concluding part is occupied with miscellaneous notices, and intelligence about medical books, institutions, and so forth.

EXTRACT FROM M. GENDRIN'S LECTURES ON DISEASES OF THE HEART.

"A vertical line, passing along the articulations of the cartilages of the left ribs with the sternum, represents the anterior edge of a vertical plane, which divides obliquely the heart into two unequal halves. The posterior edge of this plane will be found to correspond with the posterior edge of the inter-ventricular septum; the part of the heart situated to the right of the plane will comprehend the base of the right ventricle, and the right auricle; and the part to the left, will comprehend the inferior part of the right ventricle, the whole of the left ventricle, and also the left auricle.

The pulmonary artery may be considered as the axis of the heart it springs from the base of this organ; and, passing somewhat upwards and sinistred, it crosses in front of the aorta.

If a horizontal line be drawn along the lower edge of the third rib, and a perpendicular line be then made to cross it, so that it passes over the sternal articulations of the left ribs, the point of intersection will be found very nearly to correspond with the origin of the pulmonary artery; and the horizontal line to indicate the loose edge of the pulmonary and aortic semilunar valves. The point of intersection of a second perpendicular line, drawn about half an inch exteriorly to the former one, points out the left segment of the pulmonary artery.

The aorta, on springing from the heart, passes from behind the pulmonary artery, somewhat to the right side, and reaching the median line, it is situated immediately behind or dorsed to the sternum.

If a needle be inserted midway between the second and third sterno-costal articulations, and pushed directly backwards, it will probably be found to pass through the point where the ductus arteriosus was given off from the pulmonary artery.

The apex of the heart corresponds-in the recumbent supine position of the body-to the interval between the fourth and fifth sterno-costal articulations, at about an inch and a half from the mesial line of the sternum.

Occasionally the apex of the heart is lower down than what we have now mentioned, and reaches to the interval between the cartilages of the fifth and sixth ribs. In general, it is a little higher up in women than in men.

The point of attachment of the pericardium to the large blood-vessels, which spring from the heart, is on a level with the arch of the aorta and behind the second sterno-costal cartilage. This fibrous sac is fixed inferiorly to the centre of the diaphragm, and extends to the left for about two inches: posteriorly, it rests, in an inclined position, upon the bodies of the sixth and seventh dorsal vertebræ.

We have already stated that a horizontal line, drawn along the inferior edge of the third left rib, corresponds to and indicates the position of the free edges of pulmonary and aortic semi-lunar valves: this line will be found also to pass on the level of the two auriculo-ventricular orifices.

Sounds of the Heart.-The heart is the seat of two principal movements, which follow each other alternately the movement, which corresponds to the propulsion of the blood from the ventricles into the arteries, is the systole; and that, by which the empty ventricles become refilled with blood, constitutes the diastole.

These two movements of the heart coincide with two distinct sounds, appreciable by the car when applied over the precordial region: the first sound corresponding with the systole, and therefore called systolic, and the second one with the diastole, and called the diastolic.

M. Gendrin subdivides each of these sounds and movements into three periods, the pre-systole, the systole, and the peri-systole; and the pre-diastole, the diastole, and the peri-diastole-to indicate more exactly the consecutive changes immediately before, during, and after, the contraction and dilatation of the ventricles.*

To the alternate movements of the heart are to be attributed not only the coinciding sounds to which we have alluded, but also the phenomena of the arterial pulse. If a finger be applied over the trajet of an artery, we perceive a succession of beats, which are isochronous with the systole or contraction of the cardiac ventricles. This isochronism is not however quite perfect, except in those arteries which are very near to the heart: the interval between its systole and the arterial pulse becoming gradually greater and greater, according to the distance of the vessel from the centre of the circulation.

The arterial pulsation corresponds to and indicates the dilatation or diastole of the vessel, during which it becomes not only fuller, but is also somewhat lengthened, and its curvatures are increased.

The shock or force of the pulse is usually proportionate to the systolic impulsion of the heart it is communicated along de proche en proche comme par reptation, becoming feebler as the arteries are more remote from the centre of the circulation. The arteries do not present, in a healthy state, a double beat like the heart. The swell or heaving, which they communicate to the finger, is produced by the diastole of the vessel; its systole being unattended with any impulse.

This absence of a systolic impulse is just what we might expect, when we consider that the arterial systole consists only in a return of the vessel to its normal calibre by the elastic power of its middle coat. We recognise then in the arteries, as well as in the heart itself, a diastolic and a systolic movement; and we

We should deem this sub-division a very unnecessary and perplexing attempt at refinement.-Rev.

divide each of these movements into three periods, which we designate by the terms arterial pre-diastole, diastole, and peri-diastole, and arterial pre-systole, systole, and peri-systole."-Journal des Connoiss. Medic.

OPENING BETWEEN THE VENTRICLES OF THE HEART IN AN ADULT, WITHOUT ANY SYMPTOMS OF MORBUS CERULeus.

A shoe-maker, 26 years of age and of a weak lymphatic constitution, had been subject to palpitations of the heart from his infancy, and had twice suffered from attacks of acute rheumatism. His present attack is pneumonia on the left side, the pericardium being probably affected at the same time. The attack proved fatal.

Dissection.-There were old and firm adhesions between the left pleura; the lung too, on this side, was partially hepatised and tuberculated.

On opening the pericardium, about two spoonfuls of serosity were found within. The heart was extremely large and hypertrophied, and was coated with patches of albuminous deposit on its outer surface. All the cavities and orifices were very wide and open. On carefully examining the ventricles, it was found that there was an opening immediately under the mitral and tricuspid valves, between the left and right sides. It was about an inch in diameter, with smooth and rounded edges,-indicating that it was an old formation. It was almost quite plugged up with the yellow coagulum, so frequently found after death within the heart. The foramen ovale was perfectly closed.

Remarks.-Cases similar to the preceding have been observed by Richerand and Meckel in persons of 40 and even 60 years or age.

MM. Louis and Bouillaud very justly remark, that in cases, where an abnormal communication exists between the two sides of the heart, either in the auricles or in the ventricles, there is often little or no cardiac distress, provided there be no contraction of any of the natural openings, or thickening or other lesion of the valves, to obstruct the free egress of the cavity from the different cavities.

The patency of the foramen ovale in adults, who perhaps have never suffered from heart disease, is well known to all pathologists. If, however, any disorder accompanied with difficulty of respiration, such as pneumonia, bronchitis, &c. supervene, such patients are very apt to sink, often quite unexpectedly, under the attack. It is a good rule therefore in practice, always to watch with double care any chest complaints in persons, who have been subject to palpitations or other disorder of the heart.-L'Experience, Jan. 1838.

CYANOSIS;

ORIGIN OF THE AORTA FROM THE RIGHT VENTRICLE, &c.

An infant, who had exhibited in a very marked degree the symptoms of morbus cæruleus, died in the second week after birth.

Dissection. The cerebral vessels were extremely gorged with blood: the lungs also were very highly congested, and did not crepitate firmly on pressure. The heart was very large, and shaped somewhat like that of the turtle. The right ventricle was highly muscular; from this cavity the aorta, as well as the pulmonary artery, was found to arise. The latter vessel, however, was nearly closed up; and no trace of the ductus arteriosus was visible.

The left ventricle was atrophied, and exhibited no appearance of aortic opening or of mitral valve. In the septum cordis there was a large round aperture, which