SOUTHERN MEDICAL AND .SURGICAL JOURNAL EDITED BY L, A. DUGAS, M D., tROFESSOR OF SURGERY I.N THE MEDICAL COLLEGE OF GEORGIA, AND HENRY BOSSIGNOL, M. D. Medical College of Georgia^ Jc prends le bien oicje le troitve* VOL. XI 185lj--? NEW SERIES, AUGUSTA, GA.r JAMES McCAFPEKTY, PRINTER AND PUBLISHER. 1855, SOUTHERN MEDICAL AND SUBGICAL JOURNAL. Vol. II.] NEW SERIES. JANUARY, 1855. [No. 1. ORIGINAL AND ECLECTIC. ARTICLE I. Typhoid Fever. By R. B. Gardner, M. D., of Barnesville, Ga. Mr. Editor I propose to give your readers a succinct state- ment of the opinions I have been led to adopt, relative to Typhoid fever as it prevails in this section of Georgia, together with a summary account of the results of my experience in its treatment with large doses of Quinine. I would not thus submit my pri- vate views to the inspection of the profession at large, were it not for the great practical value which the truth, if it be such, possesses to Southern physicians, that, there are remedies calculated to shorten the duration of fevers, which run a long and tedious course under expectant treatment. But before the practitioner can fully appreciate the promptness and efficacy of the invaluable agent employed to curtail the exist- ence of continued or typhoid fever, it is indispensably necessary that he possess a sound and an accurate understanding of the na- ture and causes of this disease, as it prevails in his own climate or arises in his own locality. Without this knowledge, as far as it may be in his power to obtain it, he cannot be considered many removes in the practice of his profession from the hideous deformi- ties of empiricism and charlatanry. With it he may dispense the blessings of an intelligent physician throughout his community, and reflect the light of philosophy upon every action of his life. After examining carefully the various accessible sources of information, and after a close enquiry into the subject, and N. 8. VOL. XI. NO. I. 1 g *ij \ X8 Gardner, on Typhoid Fever. [January, some observation of the disease, no theory seems more rational than that which locates the seat of the fever essentially in the cerebro-spinal system. The deficiency of nervons power, and the amount of morbid innervation observed in the course of this mala- dy, show clearly that this hypothesis is not entirely destitute of foundation. IIow the nervous system becomes implicated, is a question, an enquiry into which may somewhat gratify curiosity, notwithstand- ing the vague uncertainty of the conclusions at which the mind may arrive. An serial poison, which in compliance with usage I will denominate Malaria, effects its entrance into the blood by imbibition through the cutaneous surface and the walls of the pul- monary air vesicles, and is transported upon the bosom of a thou- sand currents to every portion of the body, coming in contact with every particle of the same, and exerting its malign influence in some degree throughout the entire organism. This being the case, it is not surprising when the cerebro-spinal system the centre and origin of all vitality, whether of sensation, voluntary or involuntary motion, and presiding over the various functions of health is found giving evidence by its sufferings of the pre- sence of this poison, so extremely attenuated as readily to be diffused throughout its entire mass, and penetrate to its utmost ramifications. The action of this noxious material, however, I do not pretend to have ascertained ; yet I do feel fully persuaded, that in some unknown way, it perverts innervation, either re- ducing it below its healthy standard, exalting it above, or in some other manner rendering it morbid. ' The various organs of the body, then, that have any concern in the processes of health, be- ing entirely dependent on the nervous system for that supply of energy indispensable to the performance of their physiological functions, are necessarily deranged and disqualified for the proper discharge of their duty, and disease is the inevitable result. Such are some of the leading views I entertain of the origin of Typhoid no less than Periodic fever; and their probability, I may here remark, is favored by the success which follews its treatment with large doses of quinine. I will now consider what I believe to be the essential cause of Typhoid fever, and to which I have already incidentally alluded, as it has occurred to me in my field of practice. In this latitude, our warm weather is not confined exclusively to the summer months, but is often experienced early in the spring 1855.] Gaedxer, on Typhoid Fever. 7 and late in the fall, being no stranger even during the winter. That portion of the year, in which the temperature is sufficiently high for vegetation to put forth, cannot be estimated at less than nine months, during much of which time the solar heat is intense. Heavy floods of rain occur in connection with this protracted state of warm and often hot weather. Our rivers, creeks, and smaller streams ; our marshes, broad flats, and extended bottoms all are surcharged at various times, and in repeated instances, with water from the clouds. The low lands are overflowed, the hills satura- ted, and the plains steeped in the same element. The vegetable products of a fruitful soil live out their " brief span of existence," and perish under obedience to the laws of nature. Animal life soon, too, becomes extinct, and putrefaction ensues. Here we have combined, protracted heat, great moisture, and an immense quantity of decaying animal and vegetable matter. Now, whatever other agencies may share in the origin or modification of our febrile diseases, it is exceedingly difficult to understand how, under the circumstances, a case of continued or typhoid fever can arise uninfluenced by the all-pervading malaria. Notwithstanding its s}*mptoms be often precisely the same as are observed in the typhoid fever of France and New England, as well as others of our Northern states ; still I must contend for the existence and it intimately associated with the nature and con- cerned in the origin of this disease as it occurs in Southern lati- tudes of another and an important element, fundamentally allied to, if not constituting part and parcel of miasm itself, that invisi- ble sentinel of darkness breathing its deadly poison upon the still bosom of the serene night air. This material, too, may be evolved not only in low damp situations, but also from the surface of plains and elevated table lands ; and although possessed of a spe- cific gravity greater than that of the atmosphere, and having a tendency to collect in bodies and flow in currents after the manner of streams; still, under the full persuasion of its light aerial nature, I must believe, with the evidence before me, that it abounds in the air at varying distances from the earth's surface. The facility, too, of its transportation for short distances by means of winds is .clearly shown in the books. The conclusion, then, forces itself with almost resistless power upon the mind of the philosophic physician, that typhoid fever can rarely occur in so low a latitude as ours, altogether free from malarial influence. The theorv, too which I believe to be the most probable respecting the origin of 8 Gaedxee, on Typhoid Fever. [January, all fevers prevailing in this region, goes far in support of this conclusion. Some of the most eminent observers of disease at the South maintain likewise, with much plausibility, and no little showing of truth, the convertible nature of all fevers originating in Southern localities, indicating how the continued form may- assume the remittent or intermittent type, and vice versa. Now to what does all this amount, if it fails to establish the identity of origin of all our fevers? the intimate relation they bear to one another ? and the just inferences to be drawn relative to their therapeutical management ? Whatever may be said of the lesion of Peyerrs glands, which I believe to be always secondary, never primary invariably an effect, in no case a cause of the disease ; still I must contend for the agency of malaria as the great radical cause, constantly in operation, and predisposing to an attack of continued as well as periodic fever. For the benefit of those who may question the existence of Typhoid fever in this part of Georgia, I will detail concisely a few of its leading symptoms. The prodromic symptoms, of which many may be often absent, consist of languor and indisposition to exertion, loss or caprice of appetite, headache, sometimes hebetude, alternations of chlilliness with flashes of heat, wandering pains, muscular soreness, torpidity of the bowels, and sometimes epistaxis. These premonitory signs may continue from a day or two to a week or more, the onset seldom being abrupt. The attack may commence with or without a chill ; oftener without any perceptible sensations of coldness, as far as my observation extends. The pulse now ranges in differ- ent attacts from 90 to 120, 130, and sometimes as high or even higher than 140 strokes in the minute, and is nearly continuous, varying but little until the fever begins to yield. It may possess considerable force and frequency, but is often feeble and com- pressible from the commencement. The surface and extremities may be either warm or hot ; they are sometimes cool or cold, and somewhat bedewed with perspiration. Some gastric uneasiness is often present, not unfrequently amounting to vomiting; the stom- ach, however, is often composed, and when emesis occurs sponta- neously or is produced by art, the matters discharged are either viscid and glairy looking, colored with the medicine used, or tinged with bile. Pain under pressure, sometimes independent of it, is often felt in some portion of the abdomen, and in the same *> 1855.] Gardner, on Typhoid Fever. 9 way gurgling may in many instances be produced in the right or left iliac fossa. Cephalalgia, felt in the frontal region, now be- comes severe; and the epistaxis may be repeated. Delirium seldom makes its appearance so early in the attack ; but there may be a listless inattention from the beginning, sometimes amounting to stupor. The urine, as in other fevers, is most gen- erally scanty and highly colored. These symptoms, under the expectant plan of treatment, con- tinue in varied degrees of severity or moderation until the fever runs out its usual course. In mild cases they slowly and gradu- ally abate, but remain obstinately persistent, or grow even more formidable in severe attacks. Usually from the sixth or seventh until towards the fourteenth or fifteenth day, or later, tympanitis occurs ; and about the same time the rose- colored eruption, often absent, makes its appearance on the chest and arms, and occasionally in other localities. Still later in the disease, close observation will sometimes detect suda- rnina on the neck. During the second or third week, and not unfrequently later, where abstinence has been observed towards cathartics, diarrhoea in most cases sets in, and is sometimes ex- ceedingly difficult to manage. About the same time, if not earlier, a low form of delirium supervenes, from which, however, the pa- tient may be roused, though sometimes with difficulty. I omit, purposely, a minute description of the symptoms, or to trace this disease to its termination, as my chief object is simply to establish the correctness of my diagnosis. In the treatment of Typhoid fever I shall be brief^ and confine myself to what I believe to be the best method of forcing the dis- ease to abort. About eighteen months or more since, my attention was called to the articles published by Dr. Fenner, in the New Orleans Medi- cal and Surgical Journal, and in conversation with one or two other medical friends, relative to the " abortive treatment," as there set forth by him, it was thought probable that quinine mioht abridge the duration of this fever. Determined to give his method a, trial, I commenced, cautiously, by giving this graat febrifuge in loses varying from 5 to 8 grains several times in the course of twenty-four hours. At first I was somewhat bafflled, yet felt encouraged by the results. Discovering no ill effects from the remedy, which I had been taught to use in exceedingly small quantities, I decided to administer larger doses and push the ex- / 10 Eve, on Chloroform. [January, periment more boldly ; and thus far I have had every reason to be satisfied with the competency of quinine to cut short the course of typhoid fever. I fully endorse the opinion of Dr. Fenner, however, that the abortive treatment will likely be of little or no avail after the first few days of the fever, when, in all probability, some local lesion will be added to the other symptoms. My usual plan is to begin with an emetic, more especially if there be any gastric distress ; and, as soon afterwards as the stom- ach becomes a little composed, to exhibit a large dose of sulphate of quinia, say from 10 to 20 grains, in solution ; at the same time, or early after, giving a moderate portion of calomel, to be follow- ed by castor oil or sulphate of magnesia, if there be any evidence of bilious disorder. Some mild diaphoretic in connection with the more important application of cold water, by sponging and affusion, should be used to moderate the fever when high ; and an anodyne, when necessary, may be prescribed. My principal reliance, however, during the first few days of the fever, is on quinine given in the above doses, at regular intervals, two or three times a day. In this quantity it acts as a powerful sedative on the circulation, reducing quickly the force and frequency of the pulse, and sometimes inducing speedy and copious perspiration. My opinion, however far-fetched it may seem, is that it produces this effect by its stimulant and tonic influence on the brain and spinal system, thus enabling them to impart to the organs and tissues generally, the ability to eliminate rapidly the noxious material by which they are infested, and resume the processes of health. When the disease is seen early, and before any local lesion is set up, this treatment, if fearlessly adopted and boldly practiced, rarely fails of success. And should any rising complication cause it to fail, no injury is left behind, and recourse may be readily had to expectant therapeutics. ARTICLE II. Report " on Chloroform in Surgical and Obstetric Practice." By J. A. Eve, M. D., Professor of Obstetrics, &c, in the Medical College of Georgia. So much has been written on Chloroform in Surgical and Ob- stetric Practice, that it may be considered an exhausted subject, 1855.] Eve, on Chloroform. 11 and further remarks upon it may prove uninteresting and tiresome to many present ; but at the requisition of the Society, and con- fessedly for the benefit of the junior members of the profession, I will endeavor to discharge, briefly, the task assigned me. The question of the morality of the use of anaesthetic agents in Obstetrics, is too absurd at present ; nor is this the time or place to consider the philosophy and science of the subject. The safety of Chloroform in Obstetric practice, and the mode of its administration will be considered first, and then the cases to which it is applicable, and the indications to be fulfilled by it. As Chloroform has almost entirely superseded all other anes- thetics in Obstetric practice, and is, we believe, preferable, refer- ence will be made to this article alone. The safety of Chloroform in all departments of Medicine may be regarded as established, by the almost perfect impunity with which it has been of late years, so extensively and indiscriminate- ly used, or I might, perhaps with more propriety, say abused. It may be unhesitatingly affirmed, that no remedy, of even half the power, has ever been so generally and recklessly employed, with so few fatal results. In Obstetric practice, although it has been prescribed very free- ly, often, doubtless unnecessarily, and sometimes immoderately, there are very few, if any, well authenticated cases of death from its use. In many cases of reported death from this agent, which have been investigated, it has been found that Chloroform has not been administered, or else that, dissolution might be fairly attributed to some other cause. A report was circulated last summer that death had occurred from Chloroform in the practice of my friend, Dr. Miller : on writing to inquire into the truth of this statement, the following note was received: "Home, Oa., April 1st, 1853. "Dear Sir Yours of the 30th ult. is before me. I know of no case in which Chloroform in Obstetric practice produced death or any injurious effects immediately or remotely. I have employed it in many cases of labor, but have neA~er iound it necessary to induce the same degree of anesthesia, as in Surgical practice, and hence, (in part) perhaps its greater exemption from danger. " I did not attend Mrs. B in her confinement, but have learned from the attending Physician and from her friends, that the Chloroform was given only for a short time in the early stage of labor, and was suspended several hours before the birth of her 12 Eve, on Chloroform. [January, child, during which time she was perfectly conscious and suffered in the usual manner. I saw her the first and second days after her delivery, and never was she more cheerful or her intellect more unclouded. On the third day, she was attacked with puer- peral inflammation, of which she died five or six days subsequent- ly. There was nothing in her case which could justify the sus- picion that the Chloroform had any agency in her death. I had myself given it to her in some of her previous labors, and with the happiest effects, and would most certainly have done so again had I been present, nor do I know why it was suspended but such is the history of her case. I am, very Kespectfullv, "H. V. M. Miller." All or nearly all the popular reports of death from Chloroform in Obstetric practice, would, we believe, be found to have no more foundation in truth than the above. During the last year or two, there have been reported in the Northern journals two or three cases, the authenticity of which we would not call in question, nor would we be understood as regarding the use of Chloroform in Midwifery entirely free from danger; it is only contended that it is comparatively safer than in Surgical or Dental practice. We would desire most earnestly to impress on our younger brethren the importance of the greatest care and circumspection in its administration. Instead of concealing the fact that fatal cases have occurred, we would rather point to them as beacons to warn the unwary of the danger that may result from the careless and indiscriminate use of this truly potent and valuable agent. The comparatively greater safety of Chloroform and other anes- thetics in Obstetrics, than in Surgical or Dental practice, may be accounted for by the mode of administering it, the circumstances of the patient at the time, and the nature of the pain it is intended to relieve. It ought to be administered slowly, the patient being gradually brought under its influence. It should be given intermittently during the pain, and withheld during the interval so that the patient may recover partially or entirely from its influence, which can be renewed or deepened whenever the pains return. Its effect ought seldom if ever to be rendered so profound, or continued so long as in Surgery. Full anesthesia, except perhaps in some cases of operative Midwifery, is neither necessary nor proper ; it is sufficient to obtund sensibility, so as to diminish very 1855.] Eve, on Chloroform. 13 much or annul the perception of pain, without the total abolition of consciousness. The patient inhales the Chloroform not only willingly but with great avidity she is in the horizontal position and therefore less liable to syncope and more easily recovers from it; her stomach is generally empty, which condition obviates another source of danger that might result from, vomiting when that organ is full of food. But perhaps the safety of Chloroform in this branch of medicine, depends chiefly on the character of the pain for which it is given. This pain is not altogether morbid, but is attendant on a natural process, alternately intermitting and recurring, which has a tendency to arouse the patient and prevent the anesthesia from becoming as profound and continuous as it otherwise would be. Unless the administration be carried too far, the patient will be partially or fully awakened by the occurrence of each pain. Although very much opposed to the administration of Chloroform for the extraction of teeth, at the very urgent solici- tations of a lady of nervous temperament, I allowed her to inhale a small quantity to prepare her for the removal of a tooth the effect of which was so sudden, that respiration was suspended almost immediately, and the pulse rendered nearly, if not- entirely imperceptible ; for some seconds (which appeared like minutes or hours) the application of the strongest ammonia to her nostrils, and dashing cold water in her face produced no effect. Most serious apprehensions were entertained, that this would be added to the numerous instances of death from Chloroform given for the extraction of teeth. Notwithstanding her great fright, some two years after found the same lady extremely desirous of taking Chloroform during parturition to which request, I did not object, feeling perfect confidence in the comparative safety of its use in Midwifery. Its effects were in all respects most pleasant and satis- factory. I would not be understood as regarding Chloroform or any other anesthetic agent, entirely devoid of danger in Obstetric practice, or that it might be given recklessly and with impunity in all cases, but I believe in almost any case it may, with proper care and caution, be safely administered so as to ameliorate to a considerable degree, the pains of labor, and in many instances to cause painless parturition. Chloroform may be administered by a piece of sponge held in a towel or half a drachm to a drachm at a time may be poured on a towel or handkerchief held very near but not in immediate con- tact with the mouth and nostrils, thus preventing excoriation of 14 Eve, on Chloroform. [January, the lips and nose and admitting a free ingress of atmospheric air to the lungs along with the Chloroform. Its effects are developed much more promptly when it is inhaled through the mouth, than by the nostrils alone. The most economical mode of administration is by inhalation from a bladder, gas bag, or inhaler, but I believe, economy as well as safety, will be ensured by pouring a small quan- tity on a towel thickly folded, holding it alternately to the mouth and nose daring the pain and withdrawing it during the interval, the cloth being firmly compressed in order to prevent waste and evaporation. In protracted cases it is advisable not to administer at every pain, but sometimes to allow several pains to pass without, and occasionally to withhold altogether for fifteen or thirty min- utes, so that the effects may pass off entirely then resume its use again. Although patients have been kept in a state of uncon- sciousness for many hours by Prof. Simpson and others, such prac- tice certainly cannot be safe ; the desirable point is to carry it just far enough to annul the perception of pain without rendering the, jDatient unconscious ; it is sometimes extremely difficult, if not im- possible, to hit this happy point. Its effects on all persons are not the same; on some, large quantities have very little influence, while others are affected suddenly and profoundly by a very minute portion. We might judge from their expressions that some individuals retain the perception of pain after the loss of consciousness ; but on awakening, they remember nothing that has passed, not even the expulsion of the child. It should always be exhibited cautiously, and never when the patient is excited her mind should be calm and composed before inhalation is begun otherwise its effects might prove very unpleasant, if not dangerous Though a firm believer in the safety of Chloroform in the prao tice of Obstetrics, when given with proper care, I would not ad vise its indiscriminate use in all cases. In perfectly natural, and what are termed by comparison easy labors, it is certainly not necessary and might be dispensed with. In such cases I withhold it, unless the patient earnestly solicits it, apprehending that its general use might lead to its abuse, for it is absurd to suppose that so powerful a remedy may not produce dangerous results in the hands of careless practitioners. But in the more difficult and painful cases it is of inestimable value. Its introduction into Obstetric practice is surely one of the greatest blessings ever con- ferred on suffering humanity. As it is not always convenient to have another physician pres- Eve, on Chloroform. 15 ent, tie accoucheur may himself administer the Chloroform when not particularly engaged in obstetric services to the patient, and even when thus employed, he may direct and superintend its ad- ministration by the nurse or any intelligent person present. The accoucheur should observe the patient attentively while under its influence, especially in reference to the state of her pulse and respiration. Whenever the former becomes much depressed, or the latter stertorous, the Chloroform should be suspended until they become more natural. When the effects of the anesthetic seem to be more profound than may be considered desirable or safe, it is advisable to dash cold water on the patient's face and heart, and apply strong aqua ammonia to the nostrils. When respiration is suspended, insufflation is advised either by the mouth of another person or by means of a bellows. Galvanism might succeed well if it could be brought to bear on the case in time. It is seldom proper to administer Chloroform early in the first stage of labor. It is best, generally, to defer its exhibition until this stage is considerably advanced, or the second commenced, lest if the labor be protracted, you may be compelled to keep the patient too long in the anesthetic state, for when once its use is begun, it is very difficult to induce her to suspend it while the labor is progressing. But to this general rule there are some ex- ceptions. At times, the nervous system is so affected that the sensation of pain is morbidly acute ; the patient suffers excrucia- ting agony from very moderate uterine contraction. This state we sometimes find in patients who have usually borne the pains of parturition with exemplary fortitude and patience. This con- dition of the nervous system is generally most happily corrected by Chloroform, and- the same patient is often willing to dispense with its use in the second stage, bearing the more violent actions of the uterus, with comparatively little or no complaint. Chloro- form is said to exercise a decidedly relaxing influence in cases of rigidity of the os uteri. While I am willing to believe it may have this effect, I am not prepared to testify to the fact from my own experience, for in my practice this cause of impeded labor seldom occurs which I think will accord with the observation of all Southern practitioners. When, from irregular or spasmodic action of the womb, the patient suffers inordinately, while there is little or no progress in the labor, Chloroform meets most admira- bly the indications in practice, to relieve the patients sufferings and correct that state of the nervous system upon which the mor- 16 Eve, on Chloroform. [January, bid action depends. Whenever, in the first or second stage, rup- ture of the uterus is threatened by its violent action, it would be advisable to put the patient more profoundly under the influence of Chloroform, than in ordinary circumstances, for the purpose of diminishing uterine action, until measures can be taken to avert the danger ; rupture, however, is rarely threatened in this stage, except in cases of rigidity, in which it would also act beneficially lay virtue of its relaxing influence. In the whole course of ob- stetric practice, there is perhaps no instance in which Chloroform evinces more valuable results than in the prevention and subduc- tion of convulsions, whether occurring before labor, during the first or second stage, or after the process is over. It is especially for the fulfilment of this indication that we consider Chloroform indispensably important, and chiefly on this account that we would not be willing to attend any case without having it in reach ; the use of Chloroform in puerperal convulsions is referred to now, because we believe they occur most frequently in anticipation of labor or during the first stage. When convulsions are imminently threatened, this may often be warded off by the sudden induction of a moderate degree of anesthesia before venesection could be performed we would not however, propose Chloroform as a sub- stitute for blood letting in this dangerous affection. When time is allowed, and especially when there is severe headache, we would advise venesection first, and then the gentle administration of Chloroform to compose the nervous system, conjointly with mor- phine or some other opiate, say, } gr. Morph. or 1 gr. Opii., every three or four hours. Although we do not think that Chloroform can obviate the necessity for depletion, we do most firmly believe, judiciously used, it may prevent the excessive expenditure of blood, (to which such patients were formerly subjected) to their very great benefit, thereby rendering their convalescence much more rapid. By the use of Chloroform, convulsions may not only be averted when remotely threatened by the usual premonitory symptoms, but may sometimes be arrested when their immediate supervention is evinced by spasmodic twitchings of the facial and orbital muscles ; when actually commenced, their duration may be curtailed and the succeeding coma rendered less profound. Were it not transcending our prescribed limits, and digressing from the subject proposed, cases might be adduced illustrative of the views advanced. It is true there are some instances in which all resources fail, in which every effort is unavailing, and we be- 1855.] Eve, on Chloroform. 17 come impotent spectators of destruction we cannot prevent ; but we consider Chloroform, a most important and valuable addition to our means for the treatment of this truly terrific disease, in which it will greatly reduce the number of fatal cases. It is for the relief of the more violent and exhausting pains of the second stage, that Chloroform is more particularly appropriate and requisite. The benefit derived is not simply from its diminish- ing the patients suffering, but inasmuch as pain itself exhausts the energies of the nervous system ; in the same proportion as this remedy lessens pain, it also saves strength. Chloroform, unless when carried very far, does not diminish the force of the contrac- tions of the uterus or abdominal muscles it is altogether by obtunding sensibility, that it thus saves strength and prevents or lessens the nervous shock attendant on labor; hence it is, that those who take Chloroform, generally have a much more rapid and favorable convalescence, than those who are allowed to pass without relief or mitigation through a violent and protracted la- bor. It is true, some very eminent obstetricians have objected to the use of this great remedy, but we think that a careful analysis of their objections, will satisfy us of the fallacy of their reasoning. Professor Meigs, obj ects to Chloroform in Midwifery 1st. Because he regards the -pain in parturition as physiological, and thinks it ought not to be suppressed ; and 2d. Because in the employment of instruments, he considers it necessary to know how much the patient suffers, to avoid doing harm. But even admitting (for the sake of argument) the pain to be physiological why not relieve the patient, if we can do so, with- out interference with the process or injury to the patient? In what are styled easy labors, or whenever the suffering is not intense, anesthetia is certainly unnecessary ; but pain, when inordinate, is itself a great source of danger, as it may destroy life, directly or indirectly, by inducing convulsions or causing exhaustion; it should therefore be at least abated, whether physiological or pa- thological. Professor Meigs' second objection does not appear to me, much more valid' than the first. The degree of pain actually felt, is not always in proportion to the injury sustained, and the expression is a still more fallible criterion. Some complain excessively when suffering comparatively very little, while others make very little complaint, however intense their sufferings may be. Nothing can compensate the accoucheur for a want of a most minute and accu- 18 Eve, on Chloroform. [January, rate knowledge of the material structures and the positions and relations to them of the foetal head. He should always operate by art and not by force, graduating the power employed by his knowledge of what may be applied and safely borne, and not by the resistance to be overcome : he should always know that he is using no destructive violence inflicting no injury, whether the patient be sensible of it or not. It would certainly be a very un- certain and unsafe reliance, to depend on the patient to inform us whether we are applying and using instruments properly.. One great source of embarrassment and danger in operative midwifery, is the difficulty often encountered of controlling the voluntary movements of the patient, which is entirely obviated by the anes- thetic influence of the Chloroform. ISir* It is in instrumental deliveries, during the perform- ance of version and other obstetric operations, that I consider its administration peculiarly appropriate "and advantageous. In con- clusion, we do affirm that the discovery of the anesthetic proper- ties of Chloroform, and its employment in obstetric practice, constitute a new and glorious era in the history of our science. Who can contemplate the happy and wonderful effects of this heaven-blest agent, without the most lively thrill of joy, and the most profound and heartfelt gratitude to Him, who is the author and giver of every good. Is it not delightful to behold woman's primal curse in part annulled, her heavy burden lightened, and her condition ameliorated? What can be more gratifying to every humane heart, than to witness the most intense agonies almost instantly, as by magic, relieved, and to behold the female who, a moment before, was suffering the most excruciating tor- tures, now sleeping calmly, or awake and conscious, expressing her joy and gratitude, while labor is progressing and delivery ACCOMPLISHED WITHOUT PAIN. Case I. Called to see a negro woman at Mr. Blackwood's in Hamburg, S. C, October 30, 1849. She had already passed through seven convulsions and was now lying in a state of unconsciousness, with incessant jactitation. On examination the os tincae was found to be dilated, and the child's head propelled through the superior strait of the pelvis. In consultation with Doctor Taylor, of 1ST. C, it was determined to deliver at once with the forceps, used during anesthesia. It only required half a drachm to a drachm of Chloroform to put this patient in the condition desired ; the effect was immediate and profound ; all jactitation ceased in- stantly. The instruments were readily applied, and while the 1855.] Eve, on Chloroform. 19 mother was lying perfectly motionless, a large and living child was extracted. Convulsions did not return, and the convalescence was very favorable. The subsequent death of the child from Trismus Xascentium, we do not think, in the least attributable to the mode of delivery. Some writers advance the opinion, that the children of women who have had convulsions are most liable to nervous affections ; my experience does not confirm this ; the only case of Trismus I have known, subsequent either to convul- sions or instrumental deliver}', is the one just mentioned. In regard to the cause, as well as to the treatment of this form of Trismus, our knowledge is very inrperfect. We would only in addition remark, concerning the case of puerperal convulsions detailed above. The patient had not intelligence enough to con- trol her movements voluntarily, and so great was the muscular action, that even a resort to force would hardly have sufficed to keep her still and motionless, enough to apply the forceps accurate- ly. Dr. Taylor and myself were fully convinced that the favora- ble termination of the delivery, as well as the facility and expedi- tion with which it was effected, depended very much on the administration of Chloroform. It is also probable that the Chloro- form prevented the recurrence of convulsions. Case II. Mrs. Q. of Graniteville, S. C, primipara, about 30 years of age, was taken with labor, March 28th, 1850, attended by Dr. James H. Murray. Labor continued during the 28th, 29th and 30th ; about midnight of the 30th she had a strong convul- sion, for which she was bled copiously ; three hours after, another convulsion occurred, and venesection was again resorted to, fol- lowed by the administration of an opiate, after which she had no more convulsions. I saw her early Sunday morning : labor was still active, but her pulse was extremely feeble and frequent, beat- ing 1-10 strokes per minute. In consultation with Dr. Murray, it was determined to place her under the influence of Chloroform, and deliver by the perforator and crotchet, inasmuch as extrac- tion with the forceps was deemed impracticable, and the child's death ascertained as satisfactorily as possible, by auscultation. As soon as anesthesia was completely induced, her pulse became much less frequent, but increased in fulness and force. Such great advantage was afforded by the .motionless condition conse- quent upon the inhalation, that the perforator was pushed through the foramen magnum, firmly fixed upon the base of the cranium, and a large fcetus extracted, in a very short time, without the least injury to the mother. In this case, the convulsions had ceased some time before the Chloroform was used, owing, ho doubt, to the copious abstraction of bloodv and the administration of the opiate a strong proof of the great and indispensable importance of these remedies in the treatment of convulsions averting them, when threaten- ed before actual labor has commenced, and in some cases even 20 Eve, on Chloroform. [January, arresting them while parturition is progressing and before its ter- mination. The value of Chloroform in this case was evinced, in facilitating and rendering the delivery safer, preventing the further infliction of pain and exhaustion of strength in a patient already much prostrated, by the long continuance of labor and the necessary abstraction of blood. Case III. Convulsions occurring after Delivery. Eeported by Dr. S. B. Simmons. Mrs. S., the subject of the following report, was delivered of adherent foetuses by Dr. Joseph A. Eve, 19th October, 1851. (See Dr. Eve's Keport in Southern Medical and Surgical Journal for 1852, February number.) The patient continued to do well, until about four hours after delivery, wheu she was seized with a convulsion. Drs. Eve and Ford met in consultation, bled her copiously, and administered Chloroform. They remained with her for more than an hour, during which time she had two other convulsions. Drs. E. and F. being obliged to leave, sent for, and requested me to remain. I now watched the patient attentively, intending to administer Chloroform as soon as the slighest convulsive movement occurred ; but as the convulsions came on, almost without premonition, I was unable to get her under the influence of Chloroform in time to prevent them ; still its use had the effect of lessening their du- ration and violence. She had had three convulsions since my arrival, making six in all, when I remarked that each interval, or from the commencement of one to the commencement of the next, was exactly forty-five minutes. I therefore determined to antici- pate the next, by commencing with the Chloroform five minutes before the expiration of this interval. I did so, and succeeded in preventing the convulsion. After having administered Chloroform in this way, three times with like success, the patient fell into a gentle sleep ; two hours later, she being still asleep, and having had no symptoms indi- cating a return of convulsions, I left, after having given directions for the farther use of Chloroform, were it to become necessary. Mrs. S. speedily recovered, and has since passed most happily through two accouchments. Case TV. Eeported by Dr. S. B. Simmons of Augusta, who was present and assisted in the delivery. On the 23d of Septem- ber, 1852, Dr. Joseph A. Eve was called by Dr. Maddox, to a negro woman belonging to Mrs. L. of Columbia county. The patient was in labor with her fourth child. On Dr. Eve's arrival, fifty- four hours after the commencement of active labor, the shoulder was found presenting, the cord prolapsed and pulseless, and the uterine pains very feeble and far apart. Taking advan- tage of this state of things, Dr. Eve attempted version, but his manipulations, having re-excited the uterine contractions, Chloro- 1855.] Eve, on Chloroform. 21 form was administered. Finding that the head could be brought down much more readily than the feet, this was done, and the case left a short time to see if delivery might not be effected with- out instrumental aid. As the labor made no progress, and in consideration of the facts that the child was dead, (as evidenced by the prolapsed and pulseless cord,) that the patient's strength had already been greatly taxed, that her pelvis was contracted, and her previous labors had been very slow and tedious, it was the opinion of all present, that the perforator and crotchet should be employed. Extraction was exceedingly difficult, more than an hour being consumed in this alone. Two hours after delivery, the patient was doing well, and when last heard from was in high health. In this case Chloroform was given, with but, few intermissions for more than three hours never to such an extent as to cause stertorous breathing ; still, sufficiently to produce complete insen- sibility to pain. Notwithstanding this long continued use, the patient suffered no unpleasant effects, and her recovery was more speedy than it probably would have been, had Chloroform not been employed. Case V. April 6th, 1853. Mrs. J., primipara, aged about twenty, was seized with convulsions, early in the first stage of la- bor. I saw her. in consultation with Dr. Dearing of this citv. She was immediately bled copiously, and on the accession of each convulsion, was put under the influence of Chloroform, which appeared not only to shorten the convulsion, but to render the consequent coma shorter and less profound and the interval longer. Gentle manual dilation was employed to hasten the termination of the first stage. Convulsions had now ceased to occur, labor was progressing fairly and the patient's condition in all respects so good, that a resort to the forceps was considered unnecessary and therefore improper. In a shorter time than might have been expected, a healthy, living child was born. In this case, the con- vulsions we le arrested by blood-letting and Chloroform sometime before the termination of labor. Mrs. J. had several convulsions before Dr. Dearing saw her: these and the consecutive ones, making in all, about twelve. Case VI. Con v u Isions after Delivery. April 20th, 1851. I was called to Mrs. C, primipara, about twenty years of age. On ex- amination, she was found to be far advanced in labor, and suffer- ing intensely from headache. Nearly a quart of blood was promtly abstracted, with immediate relief to her head : in about three hours labor terminated happily in all respects, but two hours after the delivery, a strong convulsion came on. The vein was re-opened and blood allowed to flow to the extent of about sixteen ounces more. Directions were left to administer Chloroform upon N. S. VOL. XI. NO. I. 2 22 Eve, on Chloroform. [January, the slightest indication of a convulsion. In my absence an hour or two after the first convulsion, another appeared to be coming on, but was averted by the timely application of Chloroform. Yery soon after my return, I observed evident premonitory symp- toms, which were again arrested by the Chloroform. After the lapse of some time, she did have a convulsion, but its duration was materially lessened by the anesthetic, and in all probability it would have been entirely prevented as the others were, had there not been some delay in the administration of the Chloroform ; this was the last. Erom one quarter to a third of a grain Morphine was prescribed, to be taken every three or four hours for several days, until the patient became convalescent. The effect of the Chloroform was certainly most happily evinced in this case, although much ought doubtless to be attributed to the bleeding and Morphine. It is probable too, that if this patient had been bled previous to the coming on of labor, or soon after its commencement, convul- sions would have been entirely averted. Case VII. Mrs. B., primipara, aged nineteen, was seized with convulsions, in the eight month of gestation, at 3 o'clock, P. M., 1st of March, ^ 1854. Chloroform was freely administered, and blood abstracted to the amount of thirty ounces ; Morphine was also given, but convulsions continued to recur. Doctors Jones, H. A. and A. Bignon, Dugas and Ford, were in attendance. All our remedies apparently failing to have the slightest influence in arresting the convulsions, and slight dilatation of the os uteri having commenced, the membranes were ruptured by the introduction of a steel pen. After the discharge of the liquor amnii, there was a suspension of the convulsions for three hours ; labor supervened and the convulsions returned with most frightful rapidity and violence ; Chloroform was given after each convulsion, Morphine exhibited by the mouth, as long as deglutition lasted, and then by enema, and the dilatation of the os was assisted by the fingers; as soon as this was sufficiently accomplished, but before the whole circle was fully dilated, the patient was brought more profoundly under the influence of Chloroform, a very narrow and delicate pair of forceps were introduced and a living child extracted about 2 o'clock A. M,. March 2d. The convulsions nevertheless continued at intervals of fifteen to twenty minutes, until late in the afternoon of this day, notwithstanding the administration of Chloroform, sinapisms to the spine, cold affusions to the head, blister to back of neck, calomel and all other means usually considered most potent, during which time, it is estimated that she had eighty con- vulsions, and that two pounds of Chloroform were consumed. Mrs. B. was ill for some time, subsequently ; had an attack of peritonitis, for which she was blisterd : but after a tedious conva- lescence, recovered very good health. The child though prema- ture and feeble, survived. This case is remarkable for the recovery of the mother, and the safe birth of the child after so many con- 1855.] Eve, on Chloroform. 23 vulsions, and for the continuance of the convulsions after delivery, as frequent and numerous as before. I have never known, nor do I remember ever to have read of a similar case. A patient in my practice, many years ago, survived after having forty-one con- vulsions.* She was delivered, by the forceps, of a dead child. A case also occurs to me, in which, after the patient was to appear- ance, almost in articulo mortis, the number of convulsions she had had not being known, a living foetus was extracted by the forceps. The mother rallied after the operation, lived several days, but afterwards died of peritonitis. + In the case of Mrs. B., the good effect of Chloroform, as well as of all other remedies, was not obvious in arresting the convulsions, for they continued for a long time, apparently uninfluenced by any means whatsoever, and when they ceased, we did not know to what mainly to attribute the result. We do not doubt, how- ever, that it was due in some measure to the powerful agency of Chloroform, but this anesthetic independent of its direct influence on the convulsions, was of great value in keeping the patient mo- tionless and insensible during the application of the forceps, and the extraction of the foetus. As this case was so desperate, and the result beyond all reasona- ble expectation, we think it a fair conclusion, that no one of the powerful remedies could have been safely omitted. Case VJJLL Mrs. C. of Edgefield District, S. C, multipara, aged thirty-two, was seized with convulsions about the commencement of labor, Aug. 23d, 1850. She was immediately bled and a quar- ter of a grain of Morphine given Chloroform was administered on the accession of each convulsion, but they nevertheless con- tinued to recur through the night, becoming however, less severe and less frequent. Dr. Creighton of Hamburg, and Dr. Ford of Augusta, were in attendance with me. As the convulsions had become comparatively slight, and further apart when the second stage commenced, and especially as this stage was progressing very fairly, it was deemed inexpedient to hasten it by the use of instruments. Mrs. C. was soon delivered safely of a thing child ; she had eleven convulsions before its birth and one afterwards. Morphine was then exhibited more freely. The happy result in this case, is certainly in some degree at least, attributable to Chloroform. This case is another illustration of the propriety of trusting to the natural efforts, without resorting to the forceps whenever labor is advancing fairly. In the excite- ment, hurry and confusion occasioned by the occurrence of con- vulsions during labor, it is to be feared, that sometimes instru- ments are used unnecessarily, and not unfrequently to the injury of mother or child, perhaps both, when nature herself, if left alone, would have accomplished the delivery with greater safety, and pro- bably, in as short a time. [Transactions Med. Soc. Stat * See S. M. & S. Jour, for 1847, p. 520. t See S. M. & S. Jour, lor 1843, p, 69. 24 Treatment of Mentagra. [January, TRANSLATIONS AND CONDENSATIONS FROM FRENCH JOURNALS. A simple, prompt and radical treatment of Mentagra, ( Varus Men- tagra). By Dr. Kichart, of Soissons. Whether this affection be acute or chronic, two indications always present themselves : to subdue the irritation, afterwards to use resolvents. For several years, I have fulfilled the first indication successfully by having the diseased surface washed five or six times daily with a warm decoction of chervil and laurel leaves, (prunus lauro- carasus). In order to cause the scabs to fall, I advise my patients to anoint them every night, on going to bed, with fresh cream, or with a cerate made of yellow wax and olive oil melted together. Three or four days' use of the decoction, will ordinarily suffice to subdue the irritation. I fulfill the second indication with equal success, by causing the surface to be washed five or six times a day with the following solution, using a fine sponge, and allowing the part to dry without wiping. ty. Sulphate zinc, - - parts 16. Sulphate copper, - - " 5. Distilled water, - - " 500. Dissolve, filter and add : Distilled laurel water, grs. 15. As to internal remedies, believing that mentagra is caused principally by a chronic suppression of the cutaneous perspiration, I prescribe two large tumblers of water to be taken every mornirig before breakfast, at an interval of an hour. I advise also dry frictions over the whole body every night, and a walk every morn- ing before breakfast, because I am convinced that the stomach being empty, perspiration is freely produced by the slightest ex- ercise. This abundant secretion, I think, is the best purifier of the blood. During winter, as this secretion is sensibly diminished and that of urine increased, I use this latter means for purifying the blood by administering diuretics if they are insufficient, I have recourse to purgatives. These simple means are seconded by alkaline baths and a mode- rate diet, more vegetable than animal. I exclude salted or spiced food, and also alcoholic drinks. In this way I obtain prompt cures, even in cases that had been treated for eight or ten years without success. 1855.] Treatment of Cerebral Congestion- and Apoplexy. 25 I recommend my patients, in order to avoid relapse, not to pluck out the beard, as was formerly proposed, but on the contrary, to let it grow at least three or four months after being cured, or to cut it, not with the razor, but with scissors curved on the side. [Revue de Tkerap. Medico- Chirurg. Mational treatment of Cerebral Congestion, and of Apoplexy with the Alkalies, and particularly icith Bicarbonate of Soda. Dr. Carriere has just published in the Annates Medico- Physiolo- ffiques, an interesting work to demonstrate that congestion and apoplexy may be prevented for a long time by the liquifying properties of alkalies upon the blood. The following will suffi- ciently illustrate his ideas and the modus faciendi. Too strong a diet and a life of inactivity, produce an excess of nutrition, and consequently too great a richness of the blood. The system receives a great deal and expends too little. The sensation of heaviness and of general fullness which result from it, usually indicate a change in the condition of the humors. If acid prevails, it is easily known by the manner in which digestion is performed, by the pains of the stomach, and by the odor of the eructations. To avoid the congestions which would soon be pro- duced, if they have not sometimes already taken place, it is neces- sary to administer alkalies. Bleeding will modify or retard the accidents ; it does not modify the cause which, remaining always active, will end by showing itself more or less violently. The alkaline treatment offers no difficulty. The condition once known, we must act accordingly; with small doses when the affec- tion is circumscribed, and with larger ones when more extensive and serious. The most simple manner of administering the medi- cine is the best, and the alkali to be preferred to all others is the bicarbonate of soda. He recommends the mineral alkaline waters, and believes ammonia useful during the treatment as well as at the most urgent moment. Having given these general rules, he passes to .the details. When the affection is confined to the stomach, a few grranmes of bicarbonate of soda will suffice from a half to one gramme, at most, in a tumbler of water sweeten jd with simple syrup. After twelve or fifteen days, sometimes less, of this treatment, it is rare if the pains and sluggishness of the digestive faculties have not pased away. It is often surprising, that a condition which has 26 Tincture of Benzoin in Chapped Nipples. [January, resisted the series of anti-spasmodics yields as rapidly under the influence of a treatment which seems to possess so little ac- tivity. When the economy presents general symptoms of congestion, and the danger seems yet far off, the time is favorable for com- mencing the treatment. It is scarcely necessary to say that it re- quires time to produce a great change of the blood and other hu- mors, so that when violent attacks are not to be feared immediately, a great amelioration may be relied upon, and perhaps, a complete cure may be effected by means of bicarbonate of soda. The treat- ment should be commenced with one gramme in a little syrup and water, and gradually increased to two, and even more, without increasing the dose too much. By leaving off the medicine after using it regularly for two or three weeks or a month, its effects can be better judged of and its action kept up by using moderate doses. At a more advanced period, that is, on the eve, or at the moment of a simple or apoplectic congestion, it is to ammonia that recourse should be had according to M. M. Page and Gavarret. Twenty- five drops in a half tumbler of water during the attack is enough, but as this is given at intervals, it should be done according to the case. After the attack, instead of giving five drops every hour in a half tumbler of water, it would be better to give two drops in the same quantity of fluid every half hour. This treatment may be disapproved, but it cannot be denied that it is rational. If it does not exclude bleeding, a remedy directed against a secondary effect of the disease, it controls it, because it directs itself to the cause, and not to the consecutive phenomena. [Ibid. Tincture of Benzoin in Chapped Nipples. M. A. Bourdel, Professor of the Faculty of Medicine of Mont- pellier, and Inspecting Physician of the Malon, affirms that he has found the tincture of benzoin to be the best remedy in this disease. He has used it for ten years without ever having had cause to change. This tincture is applicable to all fissures of the breast, whether superficial or deep, large or small, of long standing or recent, and it causes them to heal rapidly, provided they are sim- ple, that is to say, if they are not under a syphilitic or other diathesis. He applies the tincture by means of a soft brush or otherwise, to the fissures until they are coated with the liquid. He generally makes the first application himself, because it is the most painful, and to demonstrate the way in which it should be done ; and he 1855.] Cafeine in Sick Headache. 27 recommends it to be applied every time the child nurses, and oftener if necessary. A few days of tins simple treatment suffices to heal the smaller fissures and render the breast fit to discharge its functions. If the fissures are more extensive, the treatment must be continued longer. He never saw a case which required this treatment more than twelve days. The first application of the tincture causes a certain pain or smarting in a majority of cases, which is pretty acute when the fssures are deep, but it never lasts more than fifteen minutes. After the first application it is not only no longer painful, but gives relief, and forms a covering for the surface which it protects. The child can at any time take the breast without inconvenience cr repugnance, having seen them nurse even before the tincture vas dry. After a short time, the child may nurse without vashing or wiping the breast; and who knows the sufferings Thich are thus spared the mother! [Gazette Med. de Toulouse, Hay 1854, and Ibid. Cafeine in Sick Headache. We read, in the Allgemeine Medizinische Centralzeitung, that Dr. Eulenburg has obtained excellent results from cafeine in the treat- ment of this disease in two cases, one 30 and the other 4-0 years of ige. The disease returned at intervals of from one to four weeks. Kany remedies had been resorted to, but without relief. M. Eu- lenburg began at the first symptom of a return of the attack with 1) centigrammes of cafeine, and repeated this dose every two lours until three doses had been taken. This treatment quieted tie pain and lengthened the intervals. As the price of cafeine is very high, the author suggests in its pnee the extract of coffee, 20 centigrammes of which are equiva- leit to 5 centigrammes of cafeine. [Ibid. Treatment of Hydrocele. By M. Bellucci. The operation for the radical cure of hydrocele is now one of the sinplest and most certain in surgery. It is an operation never- tleless, and as such is not entirely free from accidents; every neans should therefore be employed to arrive at the same end w.thout it. M. Bellucci uses an ointment composed of from 4 to 6 g&mmes of powdered digitalis and 30 grammes of lard. Frictions 28 Treatment of Gangrene of the Lungs. [January, are made with this ointment upon the tumor, being careful to wash the scrotum every five or six days, to cause the absorption of the remedy to be more active. Five cases, one acute and four chronic, reported by the author, are sufficient to show the efficacy of this treatment, which requires from two to three months to pro- duce a complete cure. [II. Filiatre Sebezio et Gaz. Med. de Paris , and Ibid. Treatment of Gangrene of the Lungs. Prof. Skoda, of Vienna, has recently published four cases cf gangrene of the lungs successfully treated by inhalations of the vapor of oil of turpentine and internal use of sulphate of quinine. Under this treatment the cure was rapid, without leaving infiltra- tion, caverns, or any abnormal sounds ; the vesicular respiration having re-established itself. The vapor was inhaled every twp hours, for five or ten minutes, and the quinine given in one grain doses every two hours. In order to render the turpentine vapo: less disagreeable, oil of roses may be added, as did M. Skoda in one of his cases. (Zeitchr. d. K. K. Gesellsch. d. Aerzte.)^[Ibid. New method of administering Cod-liver Oil. By M. SAUVAN. Cod-liver oil being so valuable a remedy, particularly with children, that all means of rendering it less disagreeable is o! great value. The following formula will entirely mask the taste and odour of the oil : #. Yolk of egg, Sugar, .... Orange flower water, Cod-liver oil, Essence of bitter almonds, [Ann. Chir. de Montpellier, and Ibid. 1 . 60 gram. . 30 u . 90 a 1 drop. Simple method of administering Iodine Inhalations. The inhalation of iodated vapor is well known to be inconveii- ent in consequence of its irritating effect upon the air passages aid the cough it induces. In order to obviate this difficulty, M. Ba*- riere has proposed, in the Gazette Medicate de Toulouse, the follor- ing plan : He causes his patient to snuff up pulverized camphor saturatd with iodine vapor. This is done by rubbing together 100 parts >f 1855.] Chorea. 29 pulv. camphor and 1 part of pure iodine, which are wrapped in a bit of gauze and put into a snuff-box. By shaking the box occa- sionally and imparting to it the warmth of the hand, the vapori- zation of the iodine will be produced in a few hours and be recognized by its peculiar color. This iodated camphor occasions sneezing, and even some pungency in the nostrils, but as the vapor reaches the air passages an agreeable sensation is experienced which induces the patient to take deeper inspirations. Those who have tried it become very fond of it, and many even prefer it to snuff. The anaphrodisiac properties of camphor may render it an useful adjuvant, inasmuch as venereal indulgences are among the active causes of phthisis. Chorea. M. Blache read an essay before the French Academy of Medi- cine upon the treatment of Chorea by gymnastic exercises. The author thinks that there are two indications in the treatment of this disease : 1st, to restore to the will its control of the muscles ; 2d, to change the constitution of the patient. The first of these indications is the object of the gymnastic exercises. Of 108 cases of chorea subjected to gymnastic treatnent at the Hopital des Enfans, only six were unsuccessful, although there were chronic cases which 3-ielded only in 120 days and 73 exer- cises. It should be acknowledged, however, that sulphurous baths have been nearly as successful as gymnastics, for it appears that of 135 cases treated with these baths only 18 were not cured. It would seem also that the bath treatment is more expeditious than any other. Yet there are reasons for preferring gymnastics. These exercises are applicable to all cases not complicated with cardiac affections ; whereas the quantity of sulphuret of potass. necessary is so great as sometimes to cause an eruption upon the skin which forbids the bath any longer; nor can they be used if the skin is abraided at any point. During the first days of their use they not unfrequently increase instead of lessening the spas- modic affection, whereas by passive exercise the muscles at once become calm. The state of the general system after each of these plans of treatment, should be considered in estimating their rela- tive value. The appetite is improved, the circulation invigorated, and the nutritive process made more perfect by the sulphurous baths. The muscular power is increased, the skin and mucous membranes become florid, and the arterial sounds vanish. But 30 Menorrhagia. [January, these effects, to which we should attribute in a great measure the cure, are especially worthy of note under the influence of the gym- nastic treatment. Would it not therefore be advantageous to com- bine these two modes of treatment ? This question has been settled affirmatively in a large number of cases. It is not rare, adds Mr. Blache, to see chorea occurring during a too rapid growth. Under such circumstances, the patient fre- quently complains of pains in his wrists and elbows, which are regarded by Dr. See as rheumatic. This kind of arthralgia is re- garded by Mr. Blache as dependent merely upon excessive growth and they disappear very readily by gymnastic exercises. The gymnastic exercises, which might at first appear hazardous, especially for children, are in reality without danger. They should, however, be of two kinds ; first, passive exercises, which alone can be used when the will has no control over the muscles ; second, active exercises, which may be executed voluntarily with or with- out the aid of machines. Menorrhagia. By Edward Eigby, M. D., etc., Senior Physician to the General Lying-in Hospital; Examiner in Midwifery at the University of London. In selecting cases of menorrhagia coming on at that period of a woman's life when the menses are either about to cease, or ought to have done so, and attended with local symptoms and conditions of the uterus which I have considered to be of a suspicious, if not dangerous character, let it be understood, that I by no means point them out as cases of actual malignant disease, but merely as ex- hibiting more or less of a disposition thereto, although still, in many instances, admitting of considerable relief by treatment. If we examine into the history of malignant uterine disease, we shall, in most instances, find that there has been an early passive stage of considerable duration ; that the health has become gradu- ally impaired, the uterine functions deranged ; in women who have been pregnant several times, their two or three last pregnan- cies have probably terminated in abortion, which has come on without any very assignable cause. I am aware that this applies equally well to non-malignant disease, like fibrous tumor ; but it is not the less worthy of note, as it often furnishes us with the earliest data respecting the commencement of the disease, and enables us, in reviewing the history of the case, to trace it back to an earlier period than would otherwise have been suspected. That abortion is not an invariable forerunner of malignant or non-malignant disease, is proved by the well-known fact of pregnancy being associated with every form of it, and running its course undisturbed 1855.] Menorrhagia. 31 to a late, or even the full period, even under circumstances where it could scarcely have been supposed possible. This, however, must be rather looked upon as an exception to the rule, that preg- nancy occurring during the two or three years which precede the outbreak of uterine disease mostly terminates in abortion. I hold, therefore, that abortion coming on without any very evident cause in a woman past 40, is a suspicious symptom, and the more worthy of attention, as the early symptoms of uterine disease are generally too inappreciable to attract even the notice of the patient, and are of a nature about which she would not willingly consult a Medical man if she could possibly avoid it. In most instances, abortion is rather a retrospective symptom, to afford some probable clue as to how long the disease has existed, when the fears of the patient and suspicions of the Medical man have been excited by attacks of menorrhagia. It is to these attacks (of menorrhagia) in their earliest stages and slightest degrees, and more particularly to that group of symptoms which I mentioned in my last report as chiefly connected with chylo-poietic derange- ment, and to the anaemic, chlorotic appearance of the patient, that I am peculiarly anxious to draw the attention of the Profession, because this is the period when treatment will be of most avail, and produce the most striking effects. Mrs. H., aged 50 ; married 21 years ; four children ; aborted in her last three pregnancies ; short and stout ; pale and flabby. Dec. 10, 1849. Profuse bloody discharge, coming on irregular- ly, sometimes bright, at others dark. The periods have varied a good deal of late, sometimes appearing every fortnight, at others only once in five weeks. They last more than a week, and are profuse for the first four or five days ; sometimes preceded for some hours by rather sharp pain about the hips, which she is in the habit of relieving by a sedative pill. These attacks are attended with much nervous depression. Has pain sometimes of one and sometimes of the other groin. Tongue clean, but sulcated. Bowels regular. The catamenia have been gradually becoming profuse during the last ten years, and first showed this disposition two years after her last abortion. During the last year she has had a slight watery discharge, which stiffens her linen. Examination per vaginam. Os uteri high up, small and soft ; cervix short ; uterus much enlarged. The uterine sound would not pass at first beyond one inch, but the dilater passed easily through the os internum, and then the sound passed 3 a inches. A quantity of thick, clotty, dark brown fluid came away. The fundus is inclined to the right side. $. Pil. hydrarg. gr. iij., ferri sulph. gr. ij., extr. hyoscyami gr. v. M. ft. pil. ij. o. n. s. Mist, potassae bicarb: et nitratis ter die. 12th. Catemania coming on. Omitt. mist. $. Acidi gallici, extr. hyoscyami aa. gr. v. M. ft. pil. ij., bis die sumend. 32 Menorrhagia. [January, 15th.-^-Catamenia came on freely, but not profusely, and without clots. The discharge was brown and rather thick. Has not felt weakened by it. Bowels confined. $. Pil. hydrarg. extr. coloc. co., extra, hyosc. aa. Bj. M. ft. pil. xij., sumat ij. h. s. 20th. Was seized during the night with severe pain of spas- modic character in different parts of the abdomen, which feels full and loaded ; she bears gentle pressure, but vomits occasionally ; pulse feeble ; looks very ill. ty. 01. ricini 3 yj. statim ; et repet. si opus sit. Enema magnum. ty. Hydrarg. c. creta, pulv. ipecac, comp. aa, gr. v., h. ss. 24th. Is much better ; has continued the pills every night, and 'Caster-oil every morning ; large quantities of knotty scybala have come away daily with very great relief; still, however, the ab- domen is large and doughy. $. Ext. hyosc, ext. gentianas aa. gr. v., o. n. $. Ferri sulph. gr. xvj. ; magnesias sulph. I j. ; acidi sulph. dil. 3j. ; syrupi rhoeados ss. ; aquas menthas pip. Bvijss. M. ft. mistura, sumat cochl. magn. ij. primo mane. 1852, Dec. 2. Has had no catamenia or discharge of any kind for a year ; is looking better ; has kept the bowels regular with a rhubarb draught and an occasional blue pill. Has pains (appa- rently hepatic) across the middle of the back and right shoulder ; lies best on the right side ; these pains come on every four or five weeks, at which time the right hypochondrium is tender. $. Pil. hydr. ext. hyosc. aa, gr. v. h. s. p. r. n. It. Acidi hydrochlor. dil., acidi nitrici dil. aa. 3j.; liq. tarax. 5j. ; infusi aurantii comp. 5 vij . M. ft. mistura cuj us sumat cochl. magna ij., ter die. ^. Sodas potassio tart, manuas opt. aa. 5ss.; pulv. rhosi 3ss. ; aq. menthas pip. liij. M. ft. haust. sumat demid. primo mane post pilulas. 1854, April 1. Is suffering from pains of a spasmodic charac- ter, commencing beneath the right scapula, and extending round to the left side ; evacuations dark ; urine rather scanty ; no dis- charge of any kind ; the right hypochondrium is tender during an attack. Has taken pil. hydr. three times during the week. Kep. pil. hydr. p. r. n. $. Liq. taraxaci cochl. min. j. om. nocte ex aqua vel lacte. $ . Lin. camph. co. 1 iiss. ; tinci. opii 3 ss. M. ft. linimentum parti dolenti applicand. In this case, it is worthy of the remark, that her three last preg- nancies terminated prematurely in abortion, that the catamenia, in two years after the last abortion, had gradually assumed a menorrhagic character, and latterly had become irregular as to the periods, and variable as to the appearance of the discharge ; more- over, during the last year, she had had in the intervals a watery discharge, which rendered the linen stiff on becoming dry. The uterus was larger and more bulky than natural ; the os uteri inter- 1855.] Eclampsia during Pregnancy. 33 num did not admit the sound ; but, as is frequently seen with the urethra, allowed a larger blunt instrument to pass ; the uterine cavity was increased in size, and filled with dark-brown, grumous fluid. The sum of this evidence is decidedly of an unfavorable character ; it shows that the uterus was much enlarged from pas- sive congestion, and that the upper part of the canal of the cervix was sufficiently obstructed by swelling to retain a quantity of the last catamenial discharge. The bowels were stated to be regular ; I did not, therefore, ven- ture to give a purgative in her exhausted state, and even combined the small dose of a blue pill to a tonic, and as soon as there were evidences that the catamenia were returning, I gave her the gallic acid with good effect ; the discharge, although free, did not become profuse, and she was spared the severe prostration which she had suffered on previous occasions ; further observation, however, con- vinced me that the bowels were much loaded ; purgative medi- cine of mild but effective character was given, and its action still further assisted by a large enema ; great quantities of scybala were dislodged with striking relief, and their evacuation was followed by general improvement of her symptoms. There can be little doubt but that this intestinal accumulation had tended much to aggravate the uterine congestion, and thereby the haemorrhage ; and, vice versa, that the enlarged uterus, thus pressed upon by the loaded bowels, had much increased the constipation by the pres- sure which it exerted upon the rectum. I regret much that I had not the opportunity of making another examination, that I might ascertain what amount of change had taken place in the uterus, and especially how far it had diminished in size ; but her improved state of health rendered it unnecessary. [Med. Times. Brazen on Eclampsia during Pregnancy. This author has recently published a lengthy paper on the above interesting subject, of which the following is a very brief abstract : 1st. Convulsions may arise, during this period, from hysteria, epilepsy, cerebral diseases, poisons, or uraemia, resulting from Bright's disease. 2d. Their most common causes are uraemia and Bright's disease. 3d. The least frequent causes are primary cerebral diseases ; and when these occur in connection with albuminous nephritis, they are the results, not the causes, of the convulsions. 4th. Hysteria and epilepsy may exist, during gestation, in a chronic form, so as to exercise no injurious influence either on pregnancy or labor, or on the life of the child ; and they may be quite unconnected with Bright's disease. 5th. Convulsions in every form may occur from these causes in the unimpregnated female ; and also in men, from all of them, ex- cept hysteria. 34: Eclampsia during Pregnancy. [January, 6 tli. The altered constitution of the blood, and the detention of the venous blood in the kidneys by the pressure of the enlarged uterus, are most commonly the causes of the Morbis Brightii, which occurs during pregnancy. 7th. Convulsions are caused by the urea, which is uneliminated from the blood on account of the renal disease, becoming changed into the carbonate of ammonia. 8th. When, in cases of Bright's disease during pregnancy, we find carbonate of ammonia in the blood, we may prognosticate the occurrence of convulsions ; but when, at this time, the urea in the blood exists merely in small quantities, or chemically unchanged, we need not dread eclampsia. 9th. Parturition and uterine irritation neither cause this chemi- cal transformation, nor occasion urapemic eclampsia. 10th. The abortions which so freqently happen during uraemic convulsions, are the results, not the causes of the eclampsia. 11th. There is no connection between eclampsia and labor-pains. 12th. Albuminuria does not result from convulsions arising from functional interruptions, and does not generally occur in those of an epileptical and hysterical character. 13th. Albuminuria continues throughout pregnancy, although the eclampsia attacks may have ceased ; but when convulsions cease after labor, it soon disappears, provided the renal disease be only in the incipient stage. 14th. The disappearance of the albuminuria after parturition, is principally due to the diminished volume of the uterus. loth. Morbus Brightii (without convulsion) may be palliated, but not removed, during pregnancy, although it readily yields to remedies after parturition. 16th. Albuminuria occurs in all cases of eclampsia which do not depend upon hysteria, epilepsy, primary cerebral diseases, or poisons. 17th. Epiliptic convulsions may occur simultaneously with those from Bright's disease and uraemia. 18th. Uraemic convulsions, when frequently recurring, occasion the death of the foetus ; but its life is not endangered by those from hysteria or epilepsy. 19th. During an attack of uraemic eclampsia, reflex sensibility is almost wholly suspended ; and after it we oftener find sedema and anaemia of the brain, than hyperemia and consecutive apoplexy before it. 20th. Venesection (according to Kiwisch, Litzman, Sedgwick, Blot, and Kink) is injurious in eclampsia; and the author has found its action very uncertain in uraemia. He considers inhala- tions of chloroform to be the best and safest means we possess for subduing and removing uraemic convulsions, both during preg- nancy and after labor. 21st. The most certain diuretics for removing the uraemia of Bright's disease are the benzoic, tartaric and citric acids. 1855.] Nasal Irritation in the Treatment of Ozcena. 35 22d. The artificial induction of premature labor diminishes the danger of uraemic eclampsia alike to the mother and child ; but this practice should not be universally resorted to in cases of Bright's disease during pregnancy, but only when necessitated by the occurrence of convulsions. Braun considers the tampon as the best method for its induction when necessary. [The Editor of the Monthly Journal remarks : The treatment here jDroposed appears to us by no means universally applicable. Where the convulsions occur during pregnancy, or in an anaemic patient, or where, as happens in infantile eclampsia, they depend rather upon a superpolarity of the cerebro-spinal system that on actual toxaemia, we consider the inhalation of chloroform as un- questionably the best treatment for arresting the paroxysms. But when, on the other hand, they occur during parturition, or in the puerperal state, in a robust, plethoric patient, we should be in- clined, from all we have seen of the disease, to place more confi- dence in copious venesection, smart purgatives, and cold to the head. Moreover, for the induction of premature labor in such cases, we should be inclined to prefer the use of sponge-tents and uterine douches to the clumsier method of the tampon.] Edinburgh Journ. Mea\ Science. On the Xa-sal Irritations in the Treatment of Ozcena. By M. Mais- oxneuve, Hopital Cochin, Paris. All physiologists are aware that, in the act of deglutition, the pha- rynx and soft palate close the communication of the fauces with the nasal fossa?, by a combined movement, so as to prevent the alimen- tary bolus from regurgitating into the nostrils ; but no one, so far as I know, has yet mentioned the production of this same phenome- non under the influence of injections of liquids by the anterior nares, nor remarked that injections propelled violently into one nostril invariably escaped by the other, without penetrating into the throat. This fact, to which I now desire to call the attention of surgeons, appears to me to be of considerable importance in the treatment of several serious diseases, and especially in ozaena. Ozama,* as every one knows, is an infirmity consisting in an ex- cessive fcetidity of the nasal secretions, depending on the protracted sojourn of blood, pus, and mucosities, in the recesses of irregular cavities, where they are subjected to the triple action of air, heat and moisture. At each expiration, the air which traverses these cavites, is charged with putrid emanations, and forms a loathsome atmosphere around the patient ; so that the victims of this disease become objects of horror and aversion. * Ozcena; ulceration ofthe mucous membrane of (be nasal fossae, producing fetidi- ty oi the air expired by the nostrils, das stinkende Nascngeschuur. (Palmer.) Ed. 36 Humoral Theory of Epilepsy. [January, Hitherto, our art has possessed only feeble resources against this appalling disorder. With the exception of syphilitic ozsena, in which the preparations of mercury and iodine have a direct action, the graver varieties of the disease have been regarded as nearly incurable. Cauterizations, insufflations of detersive and astrin- gent powders, were employed indeed ; patients were advised to inspire balsamic and emollient liquids, and timid injections were made with small syringes, but these remedies were but insuffi- cient applications, and persons who used them, still exhaled the repulsive odour characteristic of the disease. ISfo one thought of using free and powerful injections, under the persuasion that they would penetrate into the throat. Now numerous experiments have demonstrated to me positively that this opinion is completely erroneous, and that injections pro- pelled with great force into one nostril, will always escape by the other. > It results from this fact, that we can readily wash out the nares, and free them from the accumulated crusts, mucus, and pus, which by their sojourn produce ozama. Xothing can be simpler than this operation. It suffices to in- troduce the canula of a large sj'ringe into one nostril, and to push the piston energetically. A current is presently established, and foreign matters are washed away, The operation is not disagreea- ble, and may be executed by the patient himself. Thus discharges are removed, the fcetor is corrected, and in a short time the morbid condition of the mucous membrane begins to amend, and a durable cure is ultimately effected. [Virginia Medical and Surgical Journal. The Humoral TJieory of Epilepsy. By Robert B. Todd, M. D., Physician to King's College Hospital. A clinical lecture, on a case of renal epilepsy, delivered by Dr. Todd at the Hospital of which he is the physician, was made the occasion of some important and novel suggestions, which we will present in an abridged form to our readers. The frequency of this intractable disorder, its distressing symptoms and its destructive influence on the brain and intellectual faculties of its unfortunate victim, make it worthy of the closest investigation. Dr. Todd alludes to the discovery of the frequent association of epilepsy with renal disease, thus throwing an amount of light on a class of cases which have heretofore been treated almost entirely by empirical remedies, but which are now capable of being suc- cessfully managed on rational and scientific grounds. He proposes from the information thus derived, to construct a theory of the cause of epileptic fits generally. He says: "I hold that the peculiar features of an epileptic disease are due to the gradual accumulation of a morbid material in the blood, until it reaches such an amount that it operates upon the brain in, 1855.] Humoral Theory of Epilepsy. 37 as it were, an explosive manner ; in other words, the influence of this morbid matter, when in sufficient quantity, excites a highly polarized state of the brain, or of certain parts of it, and these dis- charge their nervous power upon certain other parts of the cerebro- spinal centre in such a way as to give rise to the phenomena of the fit. A very analogous effect produced is that which results from the administration of strychnine, which is best seen in a cold- blooded animal, as the frog. You may administer this drug for sometime, in very minute quantities, without producing any sensi- ble effects, but when an accumulation has taken place up to a certain point, the smallest increase of dose will immediately give rise to the peculiar convulsive phenomena. ll This, then, may be considered as the humoral theory of epilepsy. A morbid matter is generated which infects the blood. This mor- bid matter has a special affinity for the brain, just as the strychnia has for the spinal centre. The source of this morbid matter may be in the nervous system, probably in the brain itself. To give a more definite character to this humoral theory, we need to discover a morbid matter in the blood in every case of epilepsy, and this has to a certain extent been accomplished. The clue to a discovery of this kind was first given by the ob- servations of Prevost and Dumas upon the effect of excision of the kidney. They found that a removal of the kidneys was followed by an accumulation of urea in the blood, resulting in convulsions and coma, and an epileptic state. The clinical observations of physicians being directed to this point, soon developed the fact that disease of the kidney was apt to be followed by epileptic symptoms, and that in these cases, urea was found in the blood. 11 A connexion was thus clearly established between the pres- ence of urea in the blood, defective renal secretion, and the epilep- tic condition ; but whether the active poison is urea, has not been yet decided. Frenches has lately affirmed that the morbific agent is carbonate of ammonia, a product of the decomposition of urea. All that we really know is, that in certain states of diseased kidney when the secretion falls below a certain point, urea will accumu- late in the blood, and epileptic seizures will ensue. Should the patient die, we find no brain lesion to account for the phenomena, but unequivocal evidence of diseased kidney. Imperfect as is the present state of our knowledge on this point, may we not see in the facts thus detailed a gleam upon the horizon announcing approach of some brilliant discovery which no doubt the advancing state of organic chemistry will yet develop, and which will throw great light on the obscurest disease in the whole range of maladies which affect the human frame. ?? The experiments of Frenches went to show that the comatose and epileptic symptoms ensuing on kidney disease were attributable to a development in the blood of carbonate of ammonia, arising from decomposition of the urea. This carbonate of ammonia is the poi- sonous matter. Frenches injected this substance into the veins X. S. VOL. XI. NO. I. 3 liyrxtform Vapour, [January, . i, a;:.s, and an opil-opiic condition was induced, which passes a way as soon as the carbonate of ammonia is eliminated from the system. He also found that when urea was injected into the bloodT carbonate of ammonia may be detected in the breath of the animals by holding a rod dipped in hydro-chloric acid under the nose, when the charcteristic white fumes indicate the presence of an alkali, and the blood is likewise found to contain it in an appre- ciable quantity. Dr. Todd instituted a series of experiments in his hospital for the purpose of verifying Freriche's conclusions, but though urea was easily detected in the blood, the tests for carbonate of ammonia were not satisfactory, [Ibid. A 'practical inquiry into the advantages derivable from the Vapour of Chloroform, as a local application to the surface of the Skin and Mucous Membrane under various conditions. By S. L. Hardy, M. D., F.R.C.S., Examiner in Midwifery and Diseases of Women and Children in the Royal College of Surgeons, Ireland ; Ex- Assistant- Physician, Lying-in Hospital, Rotundo ; Physician to the Institution for Diseases of Children, &c., &c. Since the local application of chloroform vapour was first intro- duced to notice, there has existed considerable discrepancy of opinion as to its efficacy. In some instances the results obtained by it have been most satisfactory ; while in others we are told it was perfectly inert. By an inquiry into the advantages derivable from its applica- tion to the surface of the skin and mucous membrane under various conditions, it seems to me that much of the uncertainty which at present prevails as to its utility might be removea, and an amount of knowledge acquired of so practical a nature as would remove the apathy of some who think little of its worth, and direct, with more certainty, the efforts of others who have resorted to it in cases in which it could not have been expected that its influence should have been exerted with any decided effect. In order to prosecute this inquiry, I have collected a number of cases from various sources, which are, in some instances, accompa- nied with observations by men whose opportunities for observing the action of remedies should render their opinions of considera- ble value. In applying chloroform vapour to either skin or mucous mem- brane, it is necessary to attend very particularly to the condition in which those tissues are at the time, as the effect of this agent will be more or less marked according to circumstances. The subject therefore should be considered under the four following conditions : 1855.] Employment of Chloroform Vapour. 39 1st. the effects produced by the vapour of chloroform when" applied to the surface of the unbroken skin". 2nd. ditto, when the cuticle is removed. 3rd. ditto, when applied to mucous surfaces unbroken. 4th. ditto, when applied to mucous surfaces in an abraded condition. 1st. the effects produced by the vapour of chloroform when applied to the surface of the unbroken skin. We are naturally led to expect but little effect from the applica- tion of vapours to the surface of the body, the cuticle being entire. Nevertheless, however contrary it may appear, there seems to be sufficient evidence, from the results obtained in many instances, to prove, that even under such unfavorable circumstances, the vapour of chloroform exerts very considerable influence. The following cases are given in illustration : No. 1. Case of Femoral Hernia. At a meeting of the Surgical Society, held on the 8th of April last (reported in the Medical Press, April 19th), Dr. Forrest detailed the following case : "I was called to a lady, aged 60, who had suffered for several years from femoral hernia. On the present occasion, the tumor protruded a good deal, and was so exceedingly painful that the taxis could not be properly applied. I now directed a stream of chloroform vapour over the part with the happiest results. It completely relieved the patient of the distressing sensations caused by the strangulation, and afforded opportunity for resorting to the surgical manipulations usual in such cases." No. 2. Case of letanus. (Under the care of Dr. Kirkpatrick, Medical Attendant to the North Dublin Union.) , a labour- er, aetat. 30, was admitted into the North Union Workhouse, June 7, 1854, sent from Manchester Infirmary, where he had been a patient, with disease of the right hip. In the workhouse a part of the treatment consisted in a large caustic issue, made with potassa cum calce, over the ileum, an inch external to the seat of pain. On the 12th day the slough came away on the poultice without any suffering. On the morning of the day following he was seized with spasms, which commenced at the right side low down, and rapidly engaged all the muscles of the trunk, both an- terior and posterior. Before two o'clock p. m., the throat and jaws were affected, the mouth being opened with pain and diffi- culty. On the 21st Mr, Eobertson, instrument-maker, spent sev- eral hours applying the vapour of chloroferm locally. On the morning of the 22d he lay on his left side, with the right extremity extended and resting on a stool behind him outside the bed, as he was quite unable to flex or draw it up to him, nor could this be done for him owing to its rigidity. He complained of great pain in the issue, the posterior lower third of the thigh, and 40 Employment of Chloroform Vapour. [January, in the calf of the leg. Chloroform vapour applied by the vapour douche to each of those places relieved him in about ten minutes, and in about twenty he was able to raise and draw his leg into the bed. He then turned on his back, and afterwards during the day was able to rise and sit on a chair. Dr. Kirkpatrick remarks, throughout the course of the disease (which terminated fatally on the ninth day), chloroform was used to relieve agon}' by inhalation and local application of the vapour. The action of the remedy was most satisfactory in producing re- lief. A few drops on a piece of lint held to his face was sufficient to cause tranquil sleep. The local application of the Vapour was of marked service in relaxing severe spasm of the right lower extiemity, also in causing some relaxation of the muscles of the jaw, so that the teeth could be more separated. It also diminished the pain when applied to the ulcer on the hip and to blistered surfaces on the spine and epigastrium. It was confined to the affected parts by means of a glass bell attached to the tube of the douche. It was also caused to surround the pelvis by the use of air-tight drawers : and lastly, it was thrown into the rectum. No. 3. Second Case of Tetanus. (Under the care of Dr. Woods, Physician to the Killyon and Ballybrit Dispensaries in Parsons- town and Koscrea Union. A poor man received a lacerated wound of the thumb and forefinger. On the fifteenth clay after- wards he felt rigidity of the muscles of the neck, with difficulty of swallowing ; in fact, trismus had set in. The disease increased for five days, but with the exception of an occasional spasm, extend- ing from the diaphragm out through the back and up the back of the neck, producing slight opisthotonous, the rigidity and spasm were confined to the neck and jaws. I treated him with Cannabis InTlica, mercurial and belladonna frictions, occasional enemas of turpentine and tobacco, croton-oil purgatives, blisters to the hypo- chondrium, &c; but on Saturday (the day I received the douche) he was in the following state : Neck and jaws quite rigid; so much so, that a piece of wood, which the friends had placed be- tween his teeth, was too firmly held there to be removed; inability to swallow for thirty-six hours; risus sardonicus very marked; occasional spasm of diaphragm, producing slight opisthotonous. Altogether, his state was such that I, as well as another profess- ional man, said there was no hope of his recovery. Under these circumstances I applied the douche. I continued forcing the va- pour of chloroform on the muscles of the neck and jaws for per- haps half an hour. At length the spasm gave way, the piece of wood so obstinately fixed between the teeth came out, and he so far recovered the muscular power as to open his mouth to put out his tongue, and he managed to drink a cupful of broth. I have rarely felt more pleasure than when witnessing the almost miracu- lous effect the douche produced. The rigidity of the jaws and Employment of Chloroform Vapour. 41 neck has i -Teat at all since the douche was used, now twenty-four hours. Pa . igust 6, 1854. In answer to a letter, inquiring from Dr. Woods whether he thought the vapour could have been inhaled while he was apply-' ing to the undtr part of the lower jaw, I received the following reply : 1 L I have just seen the man with tetanus, and although not quite free from it, I have no doubt of his recovery. When I applied the douche to the rigid muscles of his neck, he must have inhaled some of the chloroform, as*I gave it to him liberally (there . no appearance of it as to .sleep, kc.) ; but I made to-day a very satisfactory trial of the douche locally. The spasms in the back were distressing him very much this morning, causing slight opisthotonous and intense pain. I stripped and watched the back for some time, and at every spasm the spine was bent in, just at the lumbar region, the head slightly thrown back, and a beautiful radiation of muscular contraction occurred, having its centre in the lumbar vertebrae, and running up the latissiini dorsi and down the glutaei on each side. I. immediately applied the douche assiduously to the loins, and kept up the action for about a quarter of an hour. He experienced the greatest relief, and longer duration of ease between the spasms. I showed the friends how to use the douche, leaving them a bottle of chloroform,- and this evening, after having it thus applied to the back frequently, and always with marked relief} he has been for some time entirely free from pain, and ascribes the relief altogether to the douche. I asked him particularly about it, and he says he could not be mis- taken. The pain was always soon mitigated, and he hopes now nearly entirely removed by the application. I was careful not to let him get any chloroform by inhalation, in order that the test might be the stronger, and I have no doubt but that the douche acted altogether through the integuments, and most beneficially. The only treatment beside the douche at present adopted is, croton-oil purgatives, combined with a little opium. I am almost sure the man will get well : if so. I will ascribe his recovery to the douche. I remain yours very truly. Pa . August 10. 1864. <' 'Thomas Woor.v My . . The man who had tetanus is now quite recov- ered. I remain, h Thomas Woods. sonstotmi, August 27. 1854 No. 4. Phthisis. A lady, in the ninth month of pregnane v, far advanced in phthisis, suffered very much from the frequency of cough, particularly during the night, which various sedatives failed to relieve. Over the affected lung, where the skin was un- broken, but tender, owing to frequent blistering, I had chloroform vapour applied by the douche, and confined to this part by a bell- 42 Employment of Chloroform' Vapour. [January, shaped receiver. It had the effect of quieting the cough and of enabling the patient to sleep much better. Chloroform manufactured in two different places was used in the treatment of the case ; that which caused the most soothing effect felt more pungent on the skin during its application than the other. No. 5. Case of Neuralgia. The Medical, Press for June 28, 1854, p. 410 (Mems from our London Correspondent), informs us i 'that a long discussion has again taken place in Paris relative to Dr. Hardy's apparatus." M. Bichat says the local action of chlo- roform is proved by results truly surprising ("les resultats vrai- ment suprenants "), and gives two cases of his own which had resisted opiates and quinine : one in particular, of horrible agony in the arm and shoulder from neuralgia, cured by Dr. Hardy's ap- paratus. No. 6. Dysmenorrhea. In the month of July last, I was hastily summoned to an unmarried patient, aetat. about 26. On my arri- val she was in bed, tossing about her limbs and grinding her teeth, her countenance expressive of great suffering, which came on in paroxysms. At each exacerbation, she pressed firmly with her hands over the region of the uterus, which led me to suspect the approach of a menstrual period as being the cause of her distress. One of her friends afteawards told me she was subject to severe pain on these occasions. A sinapism laid over the abdomen had no effect in rousing her, nor was consciousness restored until a handkerchief, moistened with chloroform vapour, was applied to the vulva, which immediately caused her to exclaim, owing to the heat imparted by it. In about five minutes she had no pain whatever. The secretion soon followed without any more dis- turbance. No. 7. Cholera. During the last few months instances of diar- rhoea have been very prevalent in Dublin. The administration of chloroform in frequently-repeated doses of from fifteen to twen- ty-five drops in a little cold water had a most excellent effect in relieving nausea in those cases, and of imparting a sensation oi general warmth ; but as the influence exerted by this method oi exhibiting it was of short duration, a much more decided and per- manent benefit was obtained by applying the vapour by means oi a sponge, moistened with chloroform, and placed in a tumbler. This applied over the epigastrium never failed in giving relief, and could be kept on constantly without the least inconvenience to the patients, who very soon became so convinced of its efficacy, that they anxiously wished for its continuance. (Care was neces- sary not to allow the fluid chloroform to touch the skin, as it felt so very hot ; this, however, was easily accomplished by using a sponge sufficiently large to fill the end of the glass). 1-855.] Employment of Chloroform Vapour. 43 No. 8. Encysted Tumors of the Scalp. My dear Hardy I have just used your anaesthetic vapour douche with such pleasing result that I cannot refrain from letting you know, as I am sure it will gratify you. A patient had four encysted tumors to be removed from the scalp. With the first and largest, I used the douche. She expressed the greatest surprise when informed that it was re- moved. With the second I did not use the douche. With this she experienced considerable pain during the operation, and sub- sequently, even after the other two were excised (with which the chloroform and douche were used, and with equal advantage as in the first) this continued to give pain. Some months ago Dr. Montgomery and I removed an eneysted tumour from the scalp, having previously used the chloroform as you direct ; but as there was but one tumour, and the patient a particularly good one, we could not judge from what amount of suffering she had been re- lieved. Believe me to be yours truly, Merrion-square, October 18, 1854 J. Smyly. No. 9. Gout. (Treated by Dr. V. Rexouard.) On the morn- ing of the 25th the pain was most intense. It increased during the day, and in the evening wrung cries from the patient, who writhed upon his bed, biting and tearing the sheets. The night passed without the least relief, notwithstanding the internal and external use of narcotics. The foot was cedematous ; the skin was tense, and of a shining rose-colour. On the morning of the 26th, having exhausted my resources, and being unable to remain an inactive spectator of such acute sufferings, I proposed the local ap- plication of chloroform, which was at once agreed to. Having pro- cured Hardy's instrument, I commenced at noon the insufflation of the anaesthetic vapours, directing them chiefly to the most painful part. After twenty minutes1 application, which was twice or thrice interrupted, reducing the real duration to sixteen or seven- teen minutes, the patient felt well enough to request its suspension. He did not say that he was free from all suffering, but that he was considerably relieved. The part subjected to the vapour of chlo- roform had become pale and cold, instead of red and burning, as it had been before. Moderate pressure could now be made without exciting the sensibility of the patient, who so short a time before could not endure the slightest touch. The calm lasted an hour and a half or two hours ; the pain subsequently appeared to re- turn, and continued increasing until evening. When I saw the patient again, between eight and nine o'clock, he was suffering much, although less than on the preceding evening ; he was par- ticularly apprehensive about the night. At the same time, the central point of the pain had changed its place a little ; it was nearer the internal ankle. The anaesthetic vapours were again applied uninterruptedly for fifteen minutes. All suffering ceased ; what had been the principal seat of the pain could now be tolera- bly strongly leant on without the patient feeling it After a few 44 Employment of Chloroform Vapour. [January, minutes lie fell into a deep sleep, which lasted two hours. On awaking, he experienced merely a feeble sensation of pain, some transitory twitchings returning at shorter or longer intervals, which did not prevent him from taking several other naps in the course of the night. From this day he quickly recovered. The attack was shorter than those of the two preceding years. The resolution of the congestion appeared to be more rapid than usual. On the foregoing case, the editor of the Revue Medicate ob- serves "We cannot, in this case, fail to recognize the beneficial effects of the vapour of chloroform on the intolerable pain of gout ; but its influence on the resolution of the oedema, although proba- ble, does not appear to me to be sufficiently proved." [Gazette des ffopitaux, 23rd September, 1854, p. 451. No. 10. Rheumatic Gout. On the 26th of October, a gentleman, who had suffered severely from frequent attacks of rheumatic gout, was directed by his medical attendant to have the vapour of chlo- roform applied to his foot, which was exceedingly painful. Mr. Robertson (the maker of the instrument), by means of the vapour " douche, gave a bath of chloroform and warm water vapours com- bined. In a quarter of an hour he felt perfectly easy. Having dined with a friend, and partaken of champagne, his distress re- turned ; and on the 28th of October the bath was repeated. In three minutes all suffering was removed ; and after its use for a quarter of an hour, he said he never was more free from pain in his life. On the 30th he had another bath for a mitigated return of the pain, and with equally favourable results. References. See Dublin Journal for Nov., p. 315 : "The effects of chloroform vapour on the nipple of a female breast." Aso, Case 6 "Its effects when applied to the surface of a breast affected with inflammation." 2nd. the effects produced by the vapour of chloroform when applied to parts denuded of cuticle. When the cuticle is removed, either by abrasion, vesication, ulceration, or incision, the vapour of chloroform is enabled to act with much greater intensity than when the skin is unbroken. Whenever it is first brought in contact with parts in this condi- tion, some patients complain of heat, others say it feels cool ; in a few minutes a sensation is imparted of ease and freedom from pain, which in some instances is of very considerable duration. The following cases are given in illustration : No. 11. Case of Anthrax. (From Dr. Benson, President of the Eoyal College of Surgeons of Ireland.) An unmarried lady, setat. about 36 years, highly nervous, and very impatient of pain, lately consulted me for anthrax, situated on the back of the neck, which was a little ulcerated and most painful. I proposed the in- halation of chloroform, to which she strongly objected, but con- 1855.] Employment of Chloroform Vapour. 45 sented gladly to its local application. The vapour was closely confined to the sore, and first produced a sensation of extreme heat, which was soon succeeded by perfect relief from suffering. A free crucial incision was then made, which did not give her the slightest uneasiness. She said the operation had not hurt her in the least : everything afterwards went on favourably. No. 12. Second Case of Anthrax. (Communicated by E. A. TVhite, Esq., M.R.C.S.I.) A gentleman, aetat. 35, of very excita- ble temperament, consulted me for an anthrax situated on the nape of his neck, which was highly inflamed, ulcerated, and ex- quisitely painful. I applied chloroform vapour by means of the douche, which at first produced a hot sensation, as if a jet of steam had come upon it ; this feeling was but momentary. I continued tne application for about three minutes, then pricked the surface of the tumour without causing any indication of pain, and finally laid it open by an incision of an inch and half in length ; the pa- tient being wholly unconscious of the operation having been per- formed. No. 13. Syphilitic Uulcer. Cases illustrating the Effect of Chlo- roform Vapour when applied to Ulcers. (From Dr. Wilmot. Sur- geon to Steevens? Hospital.) My dear Hardy: Of the cases in which we tried the local application of the vapour of chloroform in Steevens' Hospital, two seem to me more particularly worthy of notice, as showing not alone its efficacy in producing local anaesthesia, but the conditions which are necessary for its complete manifestation. One case is that of a man who suffered from ex- tensive syphilitic ulceration on the forepart of the right leg, accom- panied with superficial exfoliation of the tibia, and some periosteal inflammation along the bone. This ulcer was extremely painful, and in one spot especially, where the ulcer had cicatrized, the slightest touch was insupportable. I thought this an excellent case in which to test the efficacy of the local application of the vapour of chloroform. Your instrument (the one last invented) was accordingly called into requisition. After it had been worked for about two minutes, the patient expressed himself greatly relieved from pain, and in three minutes more the anaesthesia was so com- plete that he allowed the part to be handled, and evinced no pain when firm pressure was made with the fingers along the bone. This tolerance of pressure was very remarkable at the spot where the sensibility had been so much exalted. I am certain that had it been necessary in this case to have made an incision, a little fur- ther application of the chloroform vapour would have rendered the operation painless. The patient stated that the anaesthesia lasted a considerable time. Xo. 14. Ulcer on die Leg. The second case is that of a woman who had an extremely painful ulcer on the right leg, a little above 46 Employment of Chloroform Vapour. [January, the external malleolus. She could not bear it to be touched, and refused to let it be strapped, owing to the severe pain produced by the necessary pressure. Your apparatus was resorted to ; and in a very short time the sensibility of the sore became blunted, and she permitted it to be handled and firmly pressed with the fingers. These two cases strikingly demonstrate the power of the vapour of chloroform to produce local anaesthesia. The employment of it in certain ulcers of the leg, will, I feel confident, be found not the least useful of the purposes to which it may be applied. Every practical surgeon is acquainted with a small irritable ulcer whicn shows itself on the leg, generally above either malleolus. This ulcer is remarkable for being excessively painful, particularly on pressure, so much so that few patients have fortitude enough to permit the adoption of the most efficient plan of treatment strap- ping. Now, in such cases your instrument would prove invalua- ble. By it the ulcer would be deprived of its sensibility, and the strapping (which is beneficial nearly in proportion to the tightness with which the straps are drawn) could be accomplished without any pain. With respect to the conditions necessary for the produc- tion of complete local anaesthesia in any of the external surfaces, it appears to me that the part to which the vapour is applied must be free from cuticle, or merely covered by a delicate pellicle, as in a recent cicataix ; or better still, that it should be in a granulating state. To expect that the agent should act through a thick cuticle, is unreasonable. How many remedies and plans of treatment have disappointed expectations simply from a want of due regard to the conditions essential to their success ? Believe me very truly yours, Samuel Gr. Wilmot. Stephen' s-green, August 3, 1854. No. 15. Chloroform Vapovr in the insertion of an Issue. (By M. D any an.) "M. Kichet said I shall, finally, allude to the hap- py effects of the vapor of chloroform when thrown on ulcerated surfaces, which have been made known to us, by Dr. Hardy of Dublin, M. Moissenet and my colleague, M. Gosselin. M. Danyan said Having had to establish an issue on M. Roux, I made use of Dr. Hardy's apparatus. I employed the Vienna paste. I directed the vapour of ether for ten minutes on the nape of the neck, where the issue was to be formed ; the pain was com- pletely annihilated." [Gazette des Hopitaux, June 13, 1854, p. 280. No. 16. A painful Stump treated by the Application of Chloro- form Vapour. (Under the care of M. Larrey.) What appears certain is, that the vapor of chloroform freely directed to a painful point, immediately allays the sufferings of the patient. Thus at Yal-de-Grace, after an amputation of the thigh, the stump having become excessively painful, M. Larrey made use of Dr. Hardy's apparatus, and as soon as the vapour of chloroform came in con- 1855.] Employment of Chloroform Vapour. 47 tact with the wound, the pains were soothed. [Journal de Mede- cine et de Chirurgie Pratiques, March 1854, p. 99. Reports of three Cases of Carcinoma treated by Local Application of the Vapour of Chloroform. (From Dr. Geoghegan, Surgeon to the City of Dublin Hospital and Hospital for Incurables, Profes- sor of Forensic Medicine, Koyal College of Surgeons, Ireland.) Dear Sir, The appearance of your important observations on the local applications of chlroform vapour has led me to direct its employment in the cases of cancer at present under my care at the Hospital for Incurables. Although the trials which I have been as yet enabled to make have not been sufficiently numerous to furnish a just estimate of the value of your apparatus, I can, how- ever, state, that the results already arrived at have been for the most past decidedly encouraging. I, therefore, feel desirous of submitting some of them to your attention. No. 17. Ulcerated Cancer of the Axilla. In one case of exten- sive ulcerated cancer, involving the pectoral region, the axilla, and lower part of the neck, the application of the vapour (by means of the perforated ivory jet) was followed by speedy relief of pain, which the patient assures me continued for three days. No. 18. Ulcerated Cancer of the Lip. In the second instance, where the disease has swept away the lower lip and chin, and which is attended by severe lancinating pain in the vicinity, the use of the vapour for about a quarter of an hour, was followed (to use the patient's description) by "a cool and numb feeling," ex- tending through the affected part. The pain soon began to di- minish, and in eight minutes had almost disappeared. Belief continued for several hours, when the pain returned severely. A subsequent application was followed by nearly similar results. No. 19. Ulcerated Cancer of the Mamma. Wishing to observe the action exerted through the unbroken skin, I directed an ap- plication to the integument below the axilla of a female laboring under ulcerated cancer of the mamma. In one minute she expe- rienced a sensation of numbness in the part touched by the vapour ; in seven minutes this had spread along the whole arm, "as if streams of water were being poured upon it." The pain by this time had but very slightly decreased, nor was there any further diminution of it. On a subsequent occasion, the vapour was ap- plied to the ulcerated surface ; in one minute a feeling of warmth had spread down the arm ; in seven, the pain was distinctly less, and in seventeen was greatly relieved. Like all other remedies, however, a beneficial action is not uniformly secured. Accord- ingly, in one case of cancer of the anus, perineum, and thigh, the patient states that she experienced no relief. I suspect, however, that in this instance the application was not continued for a sum- 48 Employment of Chloroform Vapour. [January, cient length of time, nor was the vapour maintained by any appli- ance in contact with the surface. It strikes me that some arrange- ment by which the vapour might be effectually secured, and which would permit such continued pressure as would introduce it into the capillary circulation of the part-, and hence bring it more inti- mately in contact with the nervous filaments, would add much to the value of your apparatus, and render the relief of pain more durable than I have found it in some cases. A frequent and care- ful observation of the action of anaesthetics encourages me in this belief; for in some instances where the anaesthesia produced by these agents (introduced by inhalation) has been perfect, the action of the latter would appear to depend exclusively, or nearly so, upon their direct circulation through the superficial textures,, and their consequent, though indirect, application to the fibrillae of the sen- tient nerves of the cutis. This is, I think, sufficiently evidenced by the singular phenomenon which has attracted the attention of operators as regards the action of sulphuric ether, and which I have myself more than once witnessed in a striking manner namely, the total absence of any disturbance of consciousness and volition, or indeed of any of the mental faculties, notwithstanding the completeness of the local effect above alluded to. This result, according to my experience, is much rarer under the influence of chloroform ; and as it is precisely that mode of action which is most desirable, if it can be secured by the local application of the vapour even in but a proportion of the cases where pain is a prominent evil, much will have been gained. As facts accumulate, and a more extended use of local anaesthesia suggests further modifica- tions of the apparatus, your method will, I doubt not, prove of permanent benefit in practice. As respects its application to operative surgery, although the local use of the vapour can scarce- ly be expected to offer an available substitute for inhalation in the greater surgical undertakings, yet from the facts that have come to my knowledge, I cannot doubt its promise of utility in the various minor operations. I remain faithfully yours, York-street, July 5, 1854. T. Gr. Geoghegan. No. 20. Cancerous Tumour in thd Neck. (Under the care of Dr. Mayne, Physician to the South Dublin Union.) My dear jSir, The case to which I yesterday alluded in conversation with you, was that of a lady who lately consulted me for a malignant tumour situated at the right side of the neck. Several consulta- tions with Dr. Ireland, Mr. Cussack, and Sir P. Crampton, resulted in the decision that no operation was justifiable. I have seldom witnessed more poignant suffering than this lady endured for several months. Opium afforded her but little relief. Various other . sedatives and narcotics were also tried in vain, yet I can confidently assert that the chloroform douche never failed to alle- viate her sufferings temporarily ; and of this she felt so thoroughly convinced, that for many weeks before her death she was in the 1855.] Treatment of Cholera. 49 constant habit of using it herself, by means of one of the instru- ments sold by Mr. Robertson. This case ran rapidly into open cancer. Believe me yours very truly, Robert Mayxe. 13, Upper Glocester-street, July 18, 1851. Xo. 21. Cancerous Ulceration of the Forehead, Orbit, dr. (By Dr. Moissexet.) The medical journals inform us that a Dublin practitioner, Dr. Hardy, has just invented an apparatus for the purpose of injecting the vapour of chloroform into the vagina in order to allay the violent pain caused by cancer of the uterus, and that it has completely succeeded. The results obtained by the Irish physician have led to several trials on the part of others, and in a note read at the Medical Society of the Hospitals, Dr. Mois- senet has acquainted us with many very interesting cases, iu which he has obtained, with Dr. Hardy's apparatus, effects truly unlooked for. He has succeeded, especially in a case of cancroid ulcer of the forehead, which had successively invaded the orbit, the eye, and a portion of the cheek, in instantly and repeatedly allaying dread- ful sutferings. which had resisted all known remedies. Gazette des Eopitaux, May 27. 1864, p. 252. [Dublin Medical Press. [To be concluded in February Number.] Success of different methods of treating Cholera. By JoHX CRAW- FORD, M. D., Physician to the Glasgow Cholera Hospital. The different modes of treatment employed in the various forms of choleraic disease, with their respective results, are exhibeted in the following table : Table shoiving the Residts of Five different modes of Treatment. 1. Salines alone. 2 13 5 2. Salines with adjuncts. 3. Calomel. 4. Stimulants 5. Astringenis withopium. Total. Diarrhoea,. . ... Cholera, Collapse, . 9 53 32 0 13 12 6 24 26 29 0 38 114 73 225 Cured. Diarrhoea, Cholera, Collapse, Died. Diarrhoea, Cholera, Collapse, 2 13 0 0 0 5 9 46 0 7 1 25 0 7 3 0 6 9 1 I 2 0 5 22 21 24 0 2 5 0 36 91 12 2 23 61 In reference to this table, the following explanations may be necessary. In the first place, in all, or mostly all cases, counter- irritation to the epigastrium and abdomen, by means generally of sinapisms occasionally of turpentine and ammoniacle epithenis, 50 Treatment of Cholera. [January, and in many cases by blistering was used. It must, therefore, be understood, that the cases in the first column shared the benefit of this practice, though "salines alone" were administered as medicines. The "adjuncts" of the second column were almost exclusively opiate enemata and stimulants wine, brandy, and ammonia ; the opiate enemata being generally given in cases of cholera; and the stimulants though cautiously in collapse, or cases of cholera verging on that state. In choleraic diarrhoea, catechu and opium by the mouth were also occasionally used as adjuncts. The "salines" employed were the following: 1st. The combination of salts proposed by Dr. Stephens, viz., chlorid. sodium, 9i; bicarb, sod., 3ss. ; chlorat. potass., gr vii. These quantities dissolved in water were given every half hour, every hour, or every two hours. 2nd. The saline enema of the same writer ; a table spoonful of chloride of sodium dissolved in warm water employed only in collapse. And here, to avoid recurring to the subject again, I may mention that, although in several cases benefit appeared te be derived from its use, the advantage was only temporary, even when every precaution was taken to administer it properly. 3rd. The bicarbonate of soda, used as afterwards described. 4th. The same followed by acidulated draughts, as afterwards explained. And, lastly (chiefly in cases of choleraic disease, with irritability of the stomach), the ordinary effervescing soda-powders. Calomel was given in various doses in different cases grs. x. Bi. and upwards, to produce in the first instance a sedative effect on the patient (a result which it generally failed to accomplish) ; in smaller doses, gr. i. v., at intervals varying from a quarter of an hour to three hours ; and in some cases in doses of gr. i. every five minutes. Upwards of 110 grs. have been continuously exhib- ited in this way. Under the head of stimulants, I have also included somewhat strangely, it may appear the cases in which creasote and hydro- cyanic acid were given to allay vomiting ; but in almost all these cases, alcoholic stimulants were also given. That both creasote an hydrocianic acid are useful in checking the vomiting in cholera (a combination of the two, 3 drops of the former and 2 of the latter, probably answers best) is undoubted ; but in this respect they are far inferior to the bicarbonate of soda, and the creasote seems frequently to be very nauseous to the patient. As to the effect of stimulants, the fourth column tells its own tale. It is however, to be noted, that a number of cases hopelessly ad- vanced in collapse, and even moribund were admitted, in which nothing could be done beyond endeavoring to keep up the heat and administering stimulants. These cases, hopeless under any treatment, no doubt swell the mortality under this head ; but as a general rule, alike in choleraic diarrhoea, cholera, and collapse, the exhibition of alcoholic stimulants, except in a limited number of cases, and then in small quantities, has not, so far as I have 1855.] Opiate Inhalations and Fumigations. 51 seen, been productive of benefit. They are not even agreeable to the patient. Even in the prostration of collapse, the habitual drunkard will be found to turn with loathing from the proffered wine or spirits, and beg for cold water instead. The astringents referred to in the fifth column, as conjoined with opium, were princpially catechu, aromatic sulphuric acid, and acetate of lead combinations found principally useful in choleraic diarrhoea and the milder forms of cholera. On the whole, I am inclined to prefer the acetate of lead and opium in pill (diacetat, plumb, gr, ii,-iii., op. gr. i.) This was also found very useful in the diarrhoea which occasionally recurs after a smart attack of cholera. In collapse, beyond an opiate enema, if the purging still continued, I would have nothing to do with the opium. [Glasgow Medical Journal. Opiate Inhalations and Fumigations. By Dr. Lombard, of Geneva, I am aware that the attempt has often been made to introduce opium in the nasal fossae, chiefly for the abortive treatment of coryza, either by means of injections of water and laudanum or by making the patient snuff up a powder of sugar and morphine mixed. But the end I wish to attain to is very different ; the greater tenuity of the smoke, not less than its warmth, allows it to penetrate, without pain as without difficulty, into the crevices of the nasal fossae ; a result which cannot be obtained by a liquid, still less by a powder, however impalpable. The method that I am about to submit to your notice, after two years and a-half of clinical observation, seems to me very different from those of which I have just spoken, and I can affirm, without the least fear that experience will contradict my assertion, that the inhalation of opium smoke into the nasal fossae is a most useful therapeutic resource. I shall first mention some of the cases in which it has prospered admirably in my hands. You have, no doubt, met with, in your practice, cases of coryza, accompanied with lancina- ting pain in the frontal sinus ; pain which sometimes becomes very intense. In such cases it is, that I have seen the opium fumiga- tions produce truly marvelous results ; pain has ceased as if by enchantment, and an almost intolerable state has been succeeded promptly by remarkable relief. In a case of this ' kind that was under my care some eighteen months ago, the pain was so intense as to make the patient cry outr and induce him to believe, although of a firm and by no means pussilanimous disposition, that he was suffering from a dangerous cerebral affection. These pains came on in the course of a catarrh, accompanied by intense coryza, produced by a cold blast playing all night on the face of the patient. Two or three fumigations were sufficient to remove the pain. Some slight return of the same suffering yielded promptly to the same remedy, to the exclusion 52 Opiate Inhalations and Fumigations. [January, of all other treatment. A cure so prompt and easy gave me con- fidence in a remedy that I then merely experimented with, espe- cially when my memory recalled a great number of cases in which other methods of treatment had failed, and the frontal pain had continued, in spite of the most varied medication. The opiate fumigations are of use not only in the continued neu- ralgic pain, as in the patient already alluded to, but also in the periodic form of that disease ; for this circumstance does not pre- vent the success of the inhalation of opium. In fact, in the majority of cases I have had to treat, the frontal, temporal, or zigomatic pain accompanying catarrhal coryza is met with under the periodic form ; nevertheless, this method is quite sufficient to cure the malady, without the assistance of any other medicament. Two patients, on whom I tried the effect of opiate fumigation in February, 1852, were both attaked with coryza, complicated with periodic pain. In one of them the access returned regularly at eight o'clock in the morning, and lasted till four o'clock in the afternoon; whilst, in the other, the afternoon was the time at which the return of the periodic frontal pain took place ; in both cases the opiate fumigations, without any other treatment, brought about a prompt recovery. It is not only in the cephalalgia con- nected with coryza, that I have thus employed opium, but also in certain cases where the neuralgic pain was symptomatic of some other morbid affection, or idiopathic. After making mention of a variety of other cases in which Dr. Lombard had adopted this mode of treatment, so as either to cure or considerably relieve his patients, he proceeds to consider the doses of the drug, and the manner in which it should be used. I commenced with five centigrammes (about one grain) of pul- verised opium, mixed with as much sugar, and sometimes an equal part of gum benzoin; later I orderd ten or fifteen centigrammes in each fumigation ; but the intermediate doses often centigrammes seemed to answer all the indications, and produce the desired effect. I have repeated the fumigations two or three times a day, but sometimes having had recourse to them oftener, I did not regret it, having witnessed no bad effect from it. As regards the mode of administration, it is as simple as possi- ble: I heat in the fire a thin plate of iron, as a shovel for example, and I direct the patient to take the powder in small pinches and throw it on the hot iron, taking care to hold the head over it, so as to breathe the fumes freely not only through the nostrils but also through the mouth. I have often employed the smoke of opium, obtained by another method, which consisted in mixing a solution of opium with agaric prepared and properly dried. By soaking a certain quantity of amadou in a known quantity of this tincture, we can administer a dose as exact as of the powder itself. The amadou so prepared is lit and burnt under the nose of the patient. In fine, I do not hesitate to advise the employment of opiate fumi- gations in all cases of neuralgia occupying the frontal, temporal, or 1855.] Benumbing Cold in Operations. 53 zygomatic regions, either of a continuous or periodic character ; although it is to be remembered that it is above all in the catar- rhal neuralgia, often complicating corjza, that the employment of my method is found to succeed most satisfactorily. [Dublin Hospital Gazette, from Gaz. Medicale. Instructions for using Bcnumbir/g Cold in Operations. By James Arnott, M. D. Although there are several modes of employing intense cold as an anaesthetic, I shall here confine myself to the most simple and generally applicable of these viz., the placing a frigorific mixture immediately on the part, or with the interposition only of a piece of thin gauze or tulle containing it.* This piece of gauze (formed for the sake of convenience, into a small net or bag), the compo- nents of the frigorific mixture, a canvass bag or coarse cloth, a mallet or flat iron, a large sheet of paper, a paper-folder, and a sponge, constitute all the articles required for congelation. The common frigorific of ice and salt will generally possess sufficient power ; when greater is required, saltpetre or an ammoniacal salt may be added. Every systematic work on chemistry contains tables of frigorific mixtures, as well as instructions for making ice, which, when but a small quantity is required, may be thus artifi- cially procured almost at as little expense as from the fishmonger. A piece of ice the size of an orange, or weighing about a quar- ter of a pound, will be sufficient for most operations. It is put into a small canvass bag or a coarse cloth, and beaten, by the quickly repeated strokes of a mallet or flat iron, into a fine pow- der. As it is important that the powder should be fine, it is not ridiculously minute to state, that the bag should be turned in va- rious directions during the pounding, and that the pounded ice, squeezed into a cake by the iron, should have its particles again separated by rubbing the bag between the hands. Instead of pounding it, the ice may be pulverized by the ice-plane. The pounded ice having been placed on a large sheet of paper, any loosely-cohering particles may be separated by a paper-folder, and the unreduced large bits removed. Beside it, ofl the paper, about half the quantity of powSered common salt is placed, and tjbey are then quickly and thoroughly mixed together, either by the ivory folder while on the paper, or b}< stirring them in a gutta percha or other non-conducting vessel. If the mixture be not quickly made, the extreme cold of one part of it may again j; other parts into lumps. The mixture is now put into the net (which may be convenient- ly supported and preserved from coi. placing it in the mouth of a jar crewer), and as soon as the action of the salt on the ice appears established by the dropping of the brine, it is readv for us In appl\ ing the net, the part which is to be benumbed should N. S. VOL. XI. NO. I. 4 54 Benumbing Cold in Operations. [January, be placed in as horizontal a position as possible ; and it is well to raise the net for a moment every three or four seconds, in order to secure the equal application of the frigorinc, and watch its effect. If the part be not horizontal, it may be necessary to hold the gauze bag containing the frigorinc against it by the hand covered with a cloth ; and if the net does not cover the whole of the sur- face to be benumbed, it must be passed to and fro over it. A moistened sponged placed lower than the net will absorb the fluid escaping from it, or this, on some occasions, may be allowed to drop into a basin placed underneath. The procedure, as now described, may appear not only trouble- some, but as requiring much time. The truth,, however, is, that after one or two trials it is unlikely that any mistake will be com- mitted, and the time occupied by the preparation of the mixture and its application should rarely exceed five minutes. So simple is the apparatus required, that, in cases of emergency, I have fre- quently procured everything but the ice at the house of the patient. The application of a solid brass ball which has been immersed in a freezing mixture, or a thin metallic spoon or tube containing this (with or without ice), is quite as easy. The effects of this mode of applying intense cold are various, and their succession is as follows : When a well-prepared frigo- rinc mixture is brought in contact with the skin, a certain degree of numbness is immediately produced. The skin is rendered paler than natural, but there is hardly any disagreeable sensation pro- duced, not even of cold. In about half a minute, the whole of the surface in contact with the frigorinc becomes suddenly blanched, evidently in consequence of the constriction of its bloodvessels. This change is accompanied with a feeling of pricking or tingling, such as that produced by mustard. If the application be con- tinued, a third effect is produced ; the adipose matter under the skin is solidified, and the part becomes hard as well as white. The tingling is increased by this ; but, unless in the most sensitive parts of the body, as the hand or lower part and front of the fore- arm, it is rarely noticed or complained of. Although this uneasy sensation soon subsides, there will, if the temperature of the part be not allowed gradually to return, and if the cold has reached the stage of congelation, be a renewal of it on the adipose matter again becoming fluid. This gradual return of the natural heat is ensured by placing a little powdered ice on the part, or a thin bladder containing ice and water. The question how far the refrigeration should be allowed to pro- ceed, or which of the three stages just described should be reached, has been answered differently by different operators. In many of the slighter operations, either of the first stages will be sufficient, and the measure just mentioned for effecting a gradual return of heat will then be unnecessaiy. If congelation of the fat is pro- duced, and the operation is proceeded with before it returns to its fluid state (which is of advantage when it is important to prevent 1855.] B- ations. 55 bleeding), there may be required, as Mr. Paget has observed, a modification in the handling of the scalpel ; not only, however, is there a certainty that the insensibility both in degree and con- tinuance will be then sufficient, whether the incision is made be- fore or after the fat again becomes fluid, but (what is of equal importance) that anti-phlogistic effect is secured, which prevents those consequences which so often prove fatal under common cir- cumstances. On other points there have been great differences of opinion, though probably the results have not been so different as might have been expected. Dr. Wood, of Cincinnati, and M. Eichard, of Paris, use frigorifics differing from each other in power, as much as 30 deg. F. ; and Mr. Ward applies the frigorific for only one minute, while Dr. Hargrave applies it for five. Perhaps the longer congelation is continued (and it may be safely continued for double this period) the deeper and the longer continued the pro- duced anaesthesia may be ; but it were unreasonable to prolong an operation inconveniently in order that there shall be absolutely no feeling. In exhibiting chloroform the surgeon is not authorized to give a very large and very dangerous dose in order that the insensi- bility shall be absolute. But if it should appear that a certain con- tinuance of congelation is necessary to ensure its antiphlogistic pow- er, this would be a sufficient reason for always so continuing it. As respects the credit of the two anesthetics in the deeper operations, not their real character or merit, chloroform has this advantage over cold, that whereas, from the obscure expression of pain during the patient's unconsciousness from chloroform, and his forgetfulness of it afterwards, it is generally supposed that he suffers none ; so, on the other hand, there may be greater com- plaint made in such operations under cold than is justified by the degree of pain felt, owing to the patient's disappointment (if the : has not been explained to him beforehand) in experiencing any degree. It is certain that in the majority of operations, or those only involving the skin, the insensibility produced by cold is greater than that produced by the ordinary dose of chloroform ; and on this account Dr. Wood thinks that it ought, in all suitable to be preferred ; but this is a small advantage compared with its perfect safety, and the power it jx f preventing dangerous inflammation. To its superiority in these important respects must be added the facility with which it may be adminis- tered, the retention of the patient's consciousness, and the absence of his dread of -sudden death, as well as of the sickness and head- ache that generally follow chloroform, the freedom from embar- rassing haemorrhage, and the assistance which the patient may give to the operator in ' assuming convenient postures, instead of its being n . as in using chloroform, to have an assistant to repress his involuntary movements and struggles. A few words may be added, in conclusion, on certain misappre- hensions that have existed in relation to the use of cold as an anesthetic. 56 Benumbing Cold in Operations. [January,. Dr. Wood states, that although congelation has, in most in- stances, fully answered his expectatioms, it has at other times dis- appointed them. If it be expected that the whole of the pain of a deep operation, as to the ampution of a limb, or the excision of a large tumour, is to be thus prevented, the expectation is unrea- sonable. Unless the frigorific were applied after, as well as before, the incision of the skin (and it often may be so with advantage), or unless it were employed of much greater strength, or for a longer time, than has been usual, and after measures have been taken to suspend the circulation through the part, this could not be effected ; and the patient ought himself to decide whether, in such an operation, he shall endure the comparatively slight degree of pain caused by cutting the deeper parts, for the advantage of perfect safety, or undergo the risk of chloroform in order to have the benefit of that degree of insensibihty (for it is seldom complete) which the ordinary dose of this substance is capable of producing. This risk might indeed be lessened were he to have such a mode- rate dose exhibited as is usually given in midwifery, after the severe pain from the cutaneous incision has been prevented by cold-; and this would probably be adequate to the purpose ; but as fatty de- generation or idiosyncrasy cannot be foretold, there is danger in every dose. A death from chloroform in midwifery was lately reported in an American journal ; and in the nearly fatal case, oo- curring in France, alluded to in a precedidg note, the dose was small, and was intended, as in midwifery practice, to produce par- tial insensibility without suspending the consciousness. Whether chloroform is used or not, I am confident congelation will soon be considered indispensable in every important operation, as a preventive of erysipelas .and phlebitis. The fact ascertained by Dr. Eenwick and other statistical inquirers, that one- third of the amputations of the limbs prove fatal from inflammation, leaves no doubt on this point. Others of Dr. Wood's failures can be. differently accounted for. When the part to be operated upon is inflamed, or the circulation through it is vigorous, "a degree of cold only a little above the freezing point of water" is far from being sufficient. A frigorific of greater strength than 5 degs. below Zero (the strengh of ice and salt) may then be required, and it must be kept in contact with the skin until the desired effect is produced There ought to be no failures in this respect, as there are in the use of chloro- form. If the part be sufficiently refrigerated, insensibility of ade- quate degree and continuance is certainly produced. It has been mentioned as a disadvantage of cold, that its appli- cation is painful. In parts which are naturally very- sensitive, or have become so from disease, there may be considerable smarting when the third effect, or actual congelation, is suddenly produced; although even then what the patient feels is little when compared with the headache and sickness often caused by chloroform. Un- der these circumstances, congelation should be gradually pro- Water Strapping in Surgery. 57 duced ; but, ordinarily, there is no occasion for graduation of temperature. It is unnecessary to refer again to the notion, at first entertained by some, that the redness produced by congelation is symptomatic of inflammation. It arises from a state of the bloodvessels incom- patible Ti'ith inflammation. So far from causing this condition, there is little doubt that, however valuable intense cold may be as an anaesthetic, it is as an antiphlogistic that it will be chiefly prized, or as a means of preventing or immediately subduing, with perfect safety to the patient, every inflammation within its reach. [Medica I Times. . Water Stropping as a Surgical AppAiance. By C. Holthouse, Esq. The object of the author of this paper was to direct the attention of the profession to the superiority of wet-strapping over ordinary diachylon plaster, in the treatment of ulcers and certain cutaneous affections of the extremities, as advocated by Mr. Chapman, and to recommend its adoption in injuries and disease of the joints, and in dressing stumps after amputation. * The advantages of this appli- cation over plaster are :-*-l: Its innocuousness, being entirely free from the irritating effects of the latter, and never producing inflam- mation of the skin, or the eruption of pustules or vessicles. 2. The comfort the patient experiences from its application. 3. Its cleanliness. 4. The ease and quickness with which it is removed, from its not adhering to the hairs of the part. 5. Its cheapness. 6. It may be made the vehicle for the application of remedies. The material made use of may consist of linen or calico, bleached, or unbleached ; and the older it is, provided it be not rotten, the better it answers the purpose. It must be cut, or torn into strips of varying length and breadth, according to the part to which it has to be applied ; the strips must be then immersed in water till thoroughly saturated, when they are fit for use. If the disease to be treated be an ulcer of the leg, the strips should be about two inches in breadth, and of a length exceeding somewhat the cir- cumference of the limb ; they should then be applied exactly in the same manner as plaster, each piece overlapping a portion of the one immediately below it ; in fact, the directions given by Mr. Baynton for strapping the limb, may be strictly followed in the application of the water strapping, save and except that his direc- tions to remove the hair from the part may be dispensed with ; a roller must afterwards be applied in the ordinary manner. Four cases in illustration of this method of treatment, and of its beneficial results, were then given; one being an ulcer of the leg of fourteen years' standing, that had resisted repeated attempts to heal at other hospitals ; another, a case of eczema impetiginodes, affec- ting both lower extremities, and of three years and a half duration ; a third was a case of a crushed thumb, followed by gangrene and subsequent amputation ; and the fourth was an amputation of the thigh, for extensive disease of the knee-joint and upper third of the leg. [Lancet. 58 Editorial and Miscellaneous. [January, EDITORIAL AND MISCELLANEOUS. Our Journal for 1855. By reference to the Publisher's prospectus upon the cover of this number, it will be seen that by increasing the dimensions of the page, this volume will contain at least one hundred and twenty pages more of printed matter than any of its predecessors. It will also be per- ceived that the valuable assistance of Dr. Henry Rossignol has been secured for its future editorial supervision. These changes have been made as an ernest of increased usefulness in return for increased patronage. The char- acter of the Journal will continue to be essentially practical ; eschewing theoretical disquisitions as much as possible, avoiding personal controversies, rejecting anonymous communications, and always giving the preference to American over European contributions of equal merit. We do not mean to undervalue foreign medical literature ; but we do mean to foster our own to the utmost of our ability. Some of our contemporaries seem to have a de- cided predilection for exotics, and' contain scarcely an allusion to anything of indigenous origin, while their pages are filled with foreign matter. We will endeavor not to err in the opposite extreme. [Sr. Ed. BIBLIOGRAPHICAL. A Practical Treatise on Foreign Bodies in the Air-passages. By S. D. Gross, M. D., Professor of Surgery in the University of Louisville, &c, &c, with illustrations. Philadelphia : Blanchard & Lea, 1854. 8vo., pp. 468. (For sale by McKinne & Hall. Trice $2.50.) The work before us is, we believe, the only complete Treatise in our lan- guage, upon the subject of which it treats, and it bears the impress of its learned author's judicious and practical mind. It contains an extensive collation of facts, with appropriate deductions therefrom, which impart to it the high value of a clinical monograph. Regarding this work as one of the most valuable contributions to American Surgical literature, and de- siring to convey to our readers some idea of its scope, we beg leave to offer the following general summary in the author's own language : " From the numerous facts and cases adduced in the preceding pages, and from the reasoning founded upon them, the following conclusions may be fairly and legitimately deduced. These conclusions may be arranged under different heads, according to their respective relations, as diagnostic, pathological, therapeutic and operative. I. Diagnostic Signs. Under this division of the subject may be briefly mentioned the nature and mode of entrance of foreign bodies, their liability to be arrested in different portions of the air-passages, and the symptoms commonly induced by their presence. 1. Any substance, whatever may be its form, provided it be not dispro- portionably large, may enter the larynx, and thence descend into the trachea and bronchial tubes. %. The entrance of the foreign body is usually effected during a strong 1855.] Editorial and }Escellaneous. 59 and sudden inspiration, while the epiglottis is off its guard, the glottis ex- panded, and the larynx quiescent. 3. The extraneous substance may be arrested in any portion of the air-pas- I .ut not with equal frequency. Thus, in the larynx, it is, perhaps, most liable to be entrapped in the ventricles of Morgagni ; and, when it descends into the bronchial tubes, it more frequently selects the right than the left. The tra- chea, on the contrary, rarely becomes its permanent receptacle ; and the same is true in respect to the binary and tertiary divisions of the bronchial tubes. 4. The site of the foreign body is materially influenced, not generally, but frequently, by its size, weight, and configuration. Thus, a shot, ball, pea, bead, or pebble will be more likely to descend into the bronchial tubes than a rough, light, sharp, or angular substance. 5. The intruder may shift its place. Thus, it may pass from one bronchial tube into the other, or from these canals into the trachea, or from the trachea into the larynx, in direction contrary to that of its entrance. On the other hand, it may be firmly impacted, either in its first situation, or in some secondary one. 6. The immediate and invariable effect of the entrance of a foreign body into the air-passages is a violent, spasmodic, and irresistible cough, with dyspnoea, and a sense of impending suffocation. The countenance is fre- quently livid, and the patient sometimes falls down in a state of insensibility. 7. The violence of the first symptoms continues from a few minutes to a quarter of an hour, half an hour, or even longer, when it is succeeded by a calm, variable in duration, and again followed by cough and difficulty of breathing, very much as in the first instance. 8. "When the extraneous substance is arrested in the larynx, there will generally be more or less change in the voice, sometimes, indeed, total apho- nia, hoarseness, and croupy cough, with diminished respiratory murmur in both lungs. The latter symptom will be most conspicuous when the body is so large as to impede materially the ingress of theair. 9. When the foreign body plays up and down the windpipe, as it often does when it is light and small, it always excites violent coughing and suf- focative symptoms, very similar to those produced at the moment of its entrance. Under such circumstances, the patient can frequently feel the extraneous substance as it impinges against the trachea and the larynx. It is not so certain, however, as some have alleged, that the surgeon can hear and feel it by the application of the ear and fingers to the windpipe. Such an occurrence, at all events, must be very unfrequent. 10. A bulky body, relatively considered, may entirely fill the bronchial tube into which it may happen to fall, and thus give rise to complete col- lapse of the corresponding lung, as occurred in one of my owu cases. A thin, flat body, as a coin, may produce the same effect, by acting as a son of valve. In general, however, more or less air will pass by the side of it, thereby enabling the respiration to go on, although much more feebly than in the normal state. In both cases, the walls of the chest, on percussion, will emit a clear sound. The respiration in the opposite lung, after the first few days, will generally be puerile. 11. The site of the foreign body is occasionally, but not generally, indi- cated by a fixed pain, soreness, or sense of uneasiness in the Larynx, trachea, or bronchial tabes. 12. The expectoration may be simply mucous, or it may be tinged with blood, or mixed with pus, especially in chronic cases, in which there is also occasionally haemoptysis. 60 Editorial and Miscellaneous. [January, 13. In attempting to establish the diagnosis of a foreign body inihe ait- passages, the practitioner must take into account, first, the history of the case ; secondly, he must carefully examine the condition of the respiratory organs, considering fully the rational and physical signs ; and, thirdly, lie must hear in mind the fact that the foreign body is liable to change its situation, thereby inducing corresponding alterations in the symptoms. II. Pathological Effects. These effects are primary and secondary* the former relating to what takes place immediately after the occurrence of the accident, and the latter to the organic alterations induced in the respiratory apparatus in consequence of the protracted retention of the foreign body. 1. The extraneous substance may destroy life at the moment of its intro- duction, or death may be induced at a variable period afterwards. In either case, the fatal effect may be produced by spasm of the larynx, or 'by mere mechanical occlusion. 2. The foreign body may be expelled immediately after its entrance, in a violent paroxysm of coughing, or it may be expelled subsequently either before or after it has induced serious structural lesion "in the air-passages. 8. Xo patient is safe so long as the extraneous substance remains in the windpipe, whether in the laryngeal, tracheal, or bronchial portion, inasmuch as he may perish at any moment from suffocation, or, at a more or less remote period, from inflammation. 4. The danger from suffocation, when the patient escapes from the first effects of the accident, is generally greatest, all other things being equal, when the foreign body plays up and down the windpipe. If impacted, it may lead to the same result by becoming accidentally detached ; but in such a case it will be more likely to destroy life through inflammatory action. 5. A foreign substance is occasionally comparatively harmless, as when, for example, it lies in one of the ventricles of the larynx ; but, generally, it causes serious structural mischief. 6. The danger of severe and fatal inflammation is greater when the sub- stance is lodged in the bronchial tubes than Vhen it is arrested in the larynx or the trachea. 7. Violent and even destructive disease may be induced in the lungs, bronchial tubes, and pleura when the foreign body is situated in the larynx. 8. The most common structural lesion in cases in which the extraneous substance is retained for any length of time, are inflammation, abscess, and tubercles of the lungs, inflammation of the pleura, with effusion of serum and lymph, or sero-purulent matter. In rare instances there is marked alteration in the conformation of the chest, as happened in one of my own patients. III. Therapeutic and Operative Considerations. Under this head may be mentioned, aphoristic ally, the use of emetics, sternutatories, and other remedies, as expellents of foreign bodies ; the importance of early recourse to bronchotomy, with the manner of performing the operation ; and the various circumstances which should regulate the after-treatment. 1 . Although foreign bodies have occasionally been ejected from the wind- pipe, under the influence of emetics, errhines, and other means, the num- i' such cases is too small to justify the practitioner, under any circum-. stances, in confiding in these different classes of remedies. Generally, indeed, their effect is to increase the respiratory suffering and the danger of the patient, by impelling the intruder against the larynx, where its presence always excites spasm and other unpleasant symptoms. 2. The remarks just made in reference to the use of emetics, sternutato- 1855.] Editorial a 61 re equally applicable to all spont4!ie< a at expulsion, .whether they occur in the form of coughing, vi q, sneezing, vomiting, o althoughtl not elv hurtful and e\ 3. Inversion and >n of the body, with or witho of the --. are generally hazardo- receded by an in the windpipe ; for tl that the or ace, if it be out of its lurking place into the larynx, this portion of the tube, is inevitably folio? . hing and suffocatn i thus greatlv endangering the safety of the patient. The only case in which jlit to be is where' the foreign body is a shot, bullet, or similar substan 4. Inasmuch, then, as no confidence is to be placed in the use of emetics, errhines, and other means, inversion and - of the body, and even in nature's own efforts ; and inasmuch. 1 o patient can be considered as b o long a- ueous substance remains in the air-] k follows, as a ut . iiat bronchotomy affords the best chance of relief, and that, consequently, it should always early as possible, unless there ' scial contraindication ; foT example, serious organic disease of the respirat* 3, The : danger in this accident is spasm of the glottis, which nearly always promptly disappears the moment the artificial opei bed. 5. In" children, and in young or tim: the operation should always be preceded and accompanied by the administration of chloroform, which, while k perfectly calms the patient, greatly facilitates the extrusion of the foreign body, by rendering the respiratory organs tranquil and | sive. . Laryngotomy is always comparatively easy of execution,* and should, therefore, always be selected when there is a p . tainty that the in- trad \ -d iu the larynx. In all otkei I also wh- . ient is very young and the neck very short, tracheotomy, although, in general, a very difficult procedure, should be i.aryngo-tracheoion. rarely necessary or proper, except in cases where the ordinary operations ate found to be inadeqt: 7. The windpipe, as a general rule, should never be opened before there is a cessation of hemorrhage, lest the blood, by falling into the tube, should embarrass the operator, if not seriously compromise the safety of the pa- tient 8. The opening, both in laiyngotomy and in tracheotomy, but especially the latter, is generally too small to admit of the ready escape of the offend- ing substance. To answer the purpose effectually, and this is one of the great oi ' he operation; it shoidd be at least one inch and a quarter in the adult, and not less than one inch in the child. 9. There is no necessity, in any case, for the removal of an elliptical por- tion of the trachea, inasmuch as the retraction of the edges of the wound by means of hooks will generally afford ample space for the ejection of the foreign body and the introduction of instruments. In laryngotomy, a crucial incission may sometimes be advantageously made into the crieo-thyroid membrane. 10. Under no circumstances should bronchotomy be performed without a thorough axploration of the chest and oesophagus. It should be remem- bered that mere spasm of the glottis caused by the lodgement of a foreign 62 Editorial and Miscellaneous. [January, body in the fauaes or gullet, or by derangement of the digestive, respiratory, and nervous functions, may induce a train of phenomena, closely resembling those occasioned by the presence of a foreign body in the air-tubes. 11. Bronchotomy is generally inadmissible when there is serious organic disease of the lungs, attended with marasmus and all the ordinary symp- toms of pulmonary phthisis. 12. The foreign body, both in laryngotomy and tracheotomy, may escape either at the artificial opening, or by the glottis. In either case, it may be thrown to a considerable distance, perhaps the very moment the tube is pierced ; or it may be intercepted by the edges of the wound ; or it may, if it take the natural route, lodge in the mouth, or pass into the stomach. 13. Should the foreign substance not be ejected, or appear at the articial orifice within a few minutes after the tube has been pierced, search should be made for it with the forceps, or hook, with a view to its extraction ; but all such attempts should be made in the most gentle manner, nor should they be prolonged beyond a few seconds at a time ; inasmuch as they almost invariably excite violent coughing and suffocative feelings. The use of chloroform will greatly facilitate this step of the procedure. 14. A much better plan than searching for the foreign substance, at least in the first instance, is to invert the patient's body, and to strike the chest with the hand, or with a pillow. This procedure should be tried in all cases of balls, shot, peas, beans, water-melon seeds, plum-stones, cherry-stones, button-moulds, and other similar articles. Inversion of the body, with pre- vious opening of the tube, is a comparatively safe operation. Succussion and percussion are important auxiliaries in such a case. 15. When the extraneous body refuses to escape, or resists our efforts at removal, the edges of the tracheal wound should be kept apart by means of blunt hooks, in order to favor extrusion. The outer wound should be covered, in this case, with a piece of gauze, arranged in the form of a bag, to prevent the ingress of flies and dirt. 16. Riddance having been effected, the wound is closed with adhesive strips, aided, if necessary, by a few interrupted sutures, care being taken not to carry them through the substance of the trachea. Simple water-dressing is the best application, but even this may, in general, be dispensed with. 17. The after-treatment must be strictly antiphlogistic ; the respiratory organs be diligently watched ; and the air of the patient's apartment must be maintained, throughout, at a uniform temperature, that is, at from 65 to 68 of Fahrenheit. It should be remembered that no patient is safe or out of danger, after this accident, so long as there is inflammation of the respi- ratory organs, whether the intruder has been expelled or not. 18. Finally, it may be necessary to perform bronchotomy a second or even a third time. The same circumstances which induce us to perform it once may compel us to perform it again, at a more or less remote period, upon the same individual. A Manual of Pathological Anatomy. By C. H. Joxes, M. B., F. R. S., fec., &c, and Edw. H. Sieveking, M. D., F. R. C. P., tfec, &c. 1st American edition, revised, with 397 illustrations. Philadelphia: Blanchard & Lea. 1854. 8vo., pp. 735. (For Sale by McKinne & Hall. Price $3.50.) The advances of Pathological Anatomy are so rapid, especially since the extended application of Microscopy to the study of morbid textures, that new works upon the subject become necessary to whoever would keep pace \fisceUartec 63 with them. The work before us appears to have vn up remarkably well adapted to s The nam I well exe- cuted illustrations must very materially facilitate its com} lend to the study an interest which none ell as those who have not enjoyed these : ' info the Pathological Importance of Ulceration of the Os Beino; the Croonian Lectures for the West, M. !:. F. R C. P.. fcc., &c Philadelphia : Blan< - <54. 8vo., pp. SS. (For sale by McKinne & Hall. Price, -SI.) Every medical reader is aware of the i h the lesions of the os uteri have given rise in the learned bodies of Europe dining tfa irs. With Bennett on one side and men equally eminent on the other, the importance of tJ has been very variously estimated, and practitioners have been found at the two extremes of exaggeration and depreciation. The object of the author of this work, is a candid inquiry into the subject. It should therefore be attentively read, and we feel as that none will rise from its perusal without much practical advantage. It is only by examining the arguments upon both sides of this mooted qv. that the truth can b \ve Medical Agents: being a treatise on the new Alkaloid, Besinoid, and concentrated preparations of Indigenous and Foreign medical plants. By authoritv of the American Chemical Institute. New York : B. Keith & Co. 1854. 8vo., pp. 300. We are indebted to the publishers for the above-mentioned work, anony- mous, yet issued " by authority of the American Chemical Ins a body of whose existence we had not before been apprized. We find at the close of the work the following advertisement, which will throw some light upon the object of the book and the end for which the k* Institute" lished : ,k American Chemical Institute. The preparation of the active and con- centrated medicinal principles of indigenous and foreign medical plants, in a pure and reliable form, is the object entertained by the proprietors of the above institution. B. Keith & : Houston street, Xew York, are pre- pared to fill all orders on the best terms. They are engaged in the extensive manufacture of all the agents described in this work, and which are war- ranted pure in all ca The work before us is then nothing more than an ingenious device for bringing before the profession the important fact that B. Keith k Co. are prepared to fill all orders, u of milk went on so freely, that both children derived sufficient nourishment. M. Thielmann says this case was officially certified. [Medico- . ly found ' According to the y. Fetter I for bile only once a positive result. Nitric acid added to the i i only twice an undoubted reaction of bile. He concludes therefore, that as a rule, unde- 1 bile is not found in faeces. s in pathological c The following are some of the results of Ihriag's invesl in the Bri o-Chi- rurgical Renew : Hiring has in I the condition pathological -condi- After taking one ounce of rock-salt, a loo*e acid stool i which contained 20*8 per cent, of solid constituent-, and among these were 6*6 per cent of rock-salt. There was no sulphuric acid or bile ingredients. A large portion of the rock-salt passed off by the urine. Two loose stools, passed by a patient with tuberculosis of the intestines, had the follow n : 11-8 9-5 hoi extract 28*2 35'9 Water extract 4-30 r Insoluble salts 5-8 Chlorine . . 7-3 Chloride of sodium .... 9*0 Phosphoric acid Albumen . . B"4 The stool of an hysterical patient contained a large quantitv of gas. con- sulphuretted hydrogen and carbonic acid : the stool contained, also, albumen, and presented under the microscope manv and muscular fibrillar 66 Editorial and Miscellaneous. [January? Some other analyses of a similar kind are given, and then the following conclusions are drawn from all the observations : The stools may become changed both as to quantity and quality. In diarrhoea, the water is increased, and compared to the water, the solids are diminished, but the absolute amount of solids excreted is increased. The quantity of undigested food is greater than natural. The alcohol-extract, which includes the biliary constituents, is increased; the water extract and ts are always increased ; the earthy phosphates, and especially the magnesia-salts, are always increased. Sulphuric acid is present in bilious diarrhoea; iron is present when purgatives have been given, and always when iron has been taken as medicine. Albumen is not present during purgation by medicine in healthy individuals, but is present in intestinal tuberculosis, in typhus, cholera, and dysentery. Quite a Discovery. Dr. W. B. Powell announces in the Boston Medi- cal and Surgical Journal, " a discovery of the means of determining the comparative length or duration of human life, and other important physio- logical facts." Hear him ! " Extend a line, as suggested by Mr. Cox, from the external occipital protuberance to the most prominent part of the external orbitar pro* the os front is, and the extent of the space that is found to obtain between the line and the meatus auditorius externus, will accurately indicate the comparitive duration of life. From observation I would name an inch, at the meridian of life, to indicate an existence of 80, 90 or an 100 years, depend- ing upon the density of the organization. The average, to the best of my ation, is about half an inch, which may be regarded as corresponding pretty accurately with the known average of human life, in this country, after deducting the mortality occasioned by mechanical and chemical causes. Under the latter I include medical mal-practice. The first head I measured with a view to the discovery, was that of an old man who died of phthisis, and the space between the line and the meatus was but the sixteenth of an inch. The next one I selected was that of a man who had been executed, and the space was one inch and an eighth. In this way I ran through my cabinet of crania, consisting of several hundred, and found nothing but confirmation of the principle here set forth. I then com- menced testing the law in society, and some of those who possessed a space of only a fourth of an inch have since died. In fine. I have discovered no ex- i to the rule. From what has been stated, it follows that a descending developement of the cerebellum and of the middle lobes of the cerebrum secures a corres- ponding duration of life power to resist the usual causes of disease, and when assailed, to re-act and recover. We can now understand what is really meant by the common phrase a good constitution, such as we have illustrated by our octogenarians, who may be of a full habit and in their usual enjoyments of the good'things of the world, or they may be lean and shriveled and satisfied with a crust of bread and a glass of water. I desire that it shall not be supposed that I assign both. vigor and tenacity to the same cerebral convolutions ; on the contrary, I regard the two functions as being independent of each other, and as depending upon seperate convolu- tions, that of tenacity being the inferior." Another of the Doctor's discoveries is thus stated : "I have been frequently asked do the vital forces decrease in old age 2 Miscellaneous. 67 I answer affirmatively, more especially the animal : and I know of but one that does not. and it is the respiratory. During many years. I was unable to n why consumptives, the phthisic-ally constituted and old people, should have the medulla oblongata larger than is common to other people. The fact, to the extent of myflft idin . : been noticed 1 As the forces auxili; iration decline, that upon which it y depends increase. I refer the in o the foramen magnum of the crania of those above ence of the Toison of the Northern Rattlesnake ( Crotalus Bv, on Plants.* By J. H. Salisbury. M. D. It is a curious and well ki feet, that some of our most deadly poisons are animal secretions, and that the very animals the verj ~hese powerful proximate organic principles, are as susceptible to their deleterious influence, when introduced into their circulation, as the ~ i>st harmless animal would be under similar circumstances. It is also well known that many vegetable products are highly poisonous to animals. But the influence of animal and vegetable poisons upon plants, has although asubje \y less interesting in a ph\ - I point of view excited but little atten- tion. The simplicity* of the plant's structure, renders the field one of peculiar interest, in the way of studying the general action of medicinal agents and poisons :iized tissi On the 18th of June, 1851, a large female rattlesnake, which had the N. Y. State Cabinet of Natural Histoiy. for about a year, with- out food, died. On dissection, its stomach and intestinal canal were found entirely empty. The sac into which the poison is emptied was laid and the virulent matter (of which there was little), carefully removed and placed in a poreelain'capsule. About fifteen minutes after its removal, four young shoots of the lilac Syringa Vulgaris, a small fa nut of one growth , a.stamum, a corn plant Zea Maize, a sun- flower plant Holla, and a wild cucumber vin- . erally ted with it. The vaccination was performed by dipping the point of a pen-knife into the poisonous matter and then inserting it into the plant just beneath the inner bark. No visible effect, in either case, of the influence of the poison was perceptible till about sixty hours after it had been i - >on after this the leaves above the wound, in each case, began to wilt. The bark in the vicinity of the incision exhibited scarcely a preemptible change ; in fact it would have been difficult to have found the points, if they had not been marked when the poison was inserted. Ninety-six hours after the operation, nearly all the leaf-blades, in each of the plants, above the wounded part were wilted, and apparently quite dead. On the fifth day the petioles and bark above the incisions began to lose their freshness ; and on the sixth, they were considerably withered. On the seventh day they appeared about as they did on the sixth. On the tenth, thev began to show slight signs of recovery. On the fifteenth, new but sickly appearing leaves began to show themselves on the lilacs, and the < to show slight signs of recovery in the same way. Neither of the plants were entirely deprived of life. It was interesing to mark the progressive influence of the poison. The * The principal facts in this article were formerly published in the Trans, of Amer. Scientif. Assoc, but as through this medium they have obtained a limited cir- culation, especially among medical men, I desire to bring them more directly before the profession by publication in a medieal periodical. 68 Miscellaneous. first indication of the derangement of the healthy functions of the plants was observed in the leaves : these began to wilt and die at their edges and apices; and this death gradually and uniformly advanced on all sides towards the midrib and petiole, till the whole or nearly the entire leaf-blade was de- stroyed. ilJt*A' It is an interesting fact in physiology, that the plants first exhibited of death in the leaves ; and still more interesting, that this death commenced first in the leaves, on the side of the plant, in which the poison was inserted.* The facts materially deducible from these experiments are : 1. That the effects of the poison of the rattlesnake upon plants and animals, when introduced into their circulation, by a wound, are simi- 2. That it requires a much longer time for it to affect the plant, than the animal .\ 3. That the effects were invariably exhibited on the parts above the wound, and in no case affected the leaves below it.| 4. That it invariably affected first the leaves on the side of the plant in which the incision was male. 5. That its influences were first rendered visible on the edges and apices of the leaf-blades. \N. Y. Journal of Medicine. Poisoning by ike external applica senic. A French peasant who had had chronic nicer on his face for fifteen years, was persuaded by a carpenter to allow him to undertake the cure thereof. A plaster was appli- ed, and on the same day the patient experienced general indisposition ; on the following day severe headache" and vomiting and purging manifested themselves; after four days of acute suffering, the patient died. Chemical analysis proved the presence of arsenic. The carpenter was sentenced to three months' imprisonment. [Journal de Chimie. Br. and For. Medico- Cltirurg. Review. Croup. Trarheotomj/. M. Guersant (L'Union, 3 Juillet) gives tin >i' tracheotomy in croup at the Hopital des Enfans Malades. tJp to 1850 the mean numbers of operations were ten (annually) ; in 1861, there were twenty-five ; in 1852, tjiere were thirty ; and in 1853 there were sixty. Of 1131 children operated on, thirty-six were saved, or one in five, and i sant believes that this fortunate result would have been still more mi be operations been performed earlier in the disease than was generally the case. Dr. Archambault (L'Union, 8 Juillet) relates two cases of Group, ar- rived at the last stage, in both of which the operation was ly suc- 'd. M^. * This shews a less perfect system of Anastomosing vessels than exists in the ani- mal. t It is stated on good authority, that the poison of the snake can be taken into the stomach of.ihe animal with impunity : its dangerous effects bein'0. H. 5 70 Howard, on Dysentery. [February, we take all the cases, from the mildest to the gravest, we must con- clude, that the extent of actual disease is very variable. All that> I know of this affection, as already indicated, is that learned from the books and at the bedside. But, if the post-mortem examina- tions of others satisfy me, as they do, that the disease is not neces- sarily confined to one particular part of the intestines ; observa- tion at the bedside, has entirely convinced me that, in one case, the inflammatory action is almost confined to the lining of the rectum or descending colon ; in another, to that of the ccecum and ascending colon, or the last few inches of the ileum ; yet another, to modifications of these, and lastly, to the greater part of the alimentary canal. Where a disease is thus modified, we should, of course, expect a corresponding modification of symptoms; but, when an inflamma- tion affects the same membrane in the same organ or apparatus, though at different points and to different degrees, we should also expect some agreement of symptoms. The characteristic symptoms of dysentery, whether mild or grave, are very correctly stated by Dr. Watson, in the second paragraph of his seventy-third lecture, viz : "griping pains in the abdomen, followed by frequent mucus or bloody stools, straining and tenesmus. * * * The acute form or stage of the disease is attended with fever." The disease, perhaps, never exists without these symptoms being present ; but there is a wide range of modification of them, and thus modified, they serve as good indices to the locality and extent of the disease in individual cases. It will be found, that in inflammation of the mucous tissue, whether in the intestines, the urinary bladder, the bronchia or elsewhere, a quantity of mucus, with or without blood, is almost invariably poured out and this is a law of such tissue. It may be remarked, then, that although the quantity may be small, owing to the grade or extent of the inflammation, there is always more or less with or without blood. And as many substances are received through the mouth, and find their way into the bowels, and other secretions beside mucus are poured into the canal, the discharges are often found to be mixed, and composed of these different secretions. Those cases in which the rectum is the chief seat of disease, pour out a much smaller quantity of mucus than when the greater part of the colon is involved. But, whilst there may be little secretion, and, it may be added, less tormina or fever, the tenesmus is almost constant ; and we sometimes see cases, whether 1855.] Howard, on Dysentery. 71 the pathology indicated be correct or not, in which the patient, for whole days together, has been constantly employed in getting to and from the chamber-pot ; generally discharging a teaspoonful of mucous, though frequently a few drops only, or none at all : yet, at the expiration of two or three days, a reasonable allowance for the fatigue from so frequently getting up and down, will satis- factorily account for the difference in his feelings or general symp- toms. "Where, too, the chief disease is in the last few inches of the ileum, the evacuations will usually be small, or if large, watery ; but the other symptoms will be graver, thus, fulness, and upon pressure pain and gurgling in the right ilia ; fever of a low grade. Lastly, when the disease involves most of the colon, the secreting surface being great, it is reasonable that the amount of mucous should be great also so that in such cases, the discharges are often sufficiently copious to very much reduce the patient's strength in a few clays. In remarking on the discharges, incidental reference has been made to the other characteristic symptoms. But it should be more directly stated that the tormina is no less variable than the other i. e., the discharges ; and in some of the most serious cases it is by no means prominent. The latter, are those in which the chief seat of the disease is in the- last few inches of the ileum ; cases in which the dysenteric symptoms are sufficiently distinct, but not urgent, and, if we could remove those characteristic symptoms without entirely removing the disease, no man accustomed to seeing "typhoid fever" would hesitate to pronounce it such a case. Tormina is a prominent symptom where the colon is extensively involved, and still more prominent, when the greater part of the entire canal is implicated ; or cases in which a green, blue, black, or prairie-mud-like liquid is poured into it ; accompanied by ex- treme nausea, and ejected through the mouth and anus most forci- bly. It may be said, in relation to the tenesmus, that it is a symptom dependent on the rectum, and whether there be inflammatory ac- tion there from the beginning, or the irritation of the liquids passing over and exciting it to extraordinary action produce it, where the tenesmus is obstinate and persisting, local disease of the part is to be very much suspected. Intimately associated with this symptom, is the dull, heavy pains, about the pelvis, and often extending to the thighs. Having noticed the discharges, the tormina and tenesmus ; the 72 Howard, on Dysentery. [February, ! fever accompanying this disease claims attention for a moment. The division of fever into grades, I regard as being very proper . and "useful ; and to this remark it is only necessary to add, that in \ dysentery, sometimes we find the synochal grade ; then the typhoid ; then the intermediate ; again, even modifications of these ; and lastly, and not unfrequently, there is extremely little febrile action of any sort. So also, the fever continues, remits or intermits as the case may be. When one organ or part suffers, the other organs, or some of them, sympathize with, the diseased one. This law of man's being \ is so universally recognized, that all would expect, as we shall find, that with parts having so extensive connections as those in- I volved in dysentery, there will generally be a great deal of sym- pathy ; while, indeed, we could scarcely mention any important j organ that does not at times sympatize with the inflamed mem- | brane, it is only necessary to name the liver, kidneys, urinary r bladder, skin and stomach. That the liver, in the amount and I character of its secretion, soon manifests its sympathy with the j inflamed membrane, every one knows ; but, that its deviations in I this respect are often, if ever, the exciting cause of dysentery, I by j no means believe. I can readily conceive that the chief causes of \ dysentery might directly affect the liver, and my first impressions 8 in the study of physic were with that opinion : but so many cases I occur in which the functional deviations of this organ are so late I in making their appearance in the disease, I am satisfied that ordi- narily, there is no more connection between this glaud and the inflamed membrane, than between the kidneys and it. Indeed, these latter organs, -by their diminished, and highly colored and probably concentrated secretion, usually manifest the earlier sym- pathy. The urinary bladder, either directly or from the irritation of this concentrated urine, not unfrequently performs its office reluc- tantly, and in the most cases strangury often appears comparatively early. The skin is often dry and preturnaturally hot ; though, in many of those cases in which the accompanying fever is of a low grade, it is, particularly of the extremities, cool, and sometimes cold, moistened with a clammy offensive sweat ; nausea and vomiting are not confined to those cases heretofore spoken of, in which the stomach is almost certain early to become involved in actual dis- ease, but occurs under a variety of circumstances. Thirst, though often slight or entirely absent in the commencement of the attack, usually increases very much as the disease progresses. 1855.] Howard, on Dysentery. 73 As yet, no reference has been had to the tongue, as an index in this disease ; and it is scarcely necessary to say, that in the com- mencement it is somewhat furred, white or yellow ; having no more color than is natural to it ; but, in the progress of the disease becoming red at the tip and edges, with a dry brown crust in the middle, which crust finally being thrown off, leaves the entire member very red and often glazed. From the commencement, to treat a case of dysentery, to the close, I never fail to frequently examine this organ ; and making very little allowance even for opium or its preparations ; almost every remedial agent that very decidedly makes the tongue drier will do no good, and when the prescription has that effect, to say the least, the question of the propriety of changing it ought to be considered. Of the causes of the disease, it may be proper merely to give an opinion, and it is this, that they are almost entirely atmospheric ; the simpler and more purely inflammatory being dependent upon changes in temperature, or perhaps continuance of somewhat ele- vated temperature, with a certain degree of moisture. Those of a low or typhoid grade not only upon such changes, but also changes in the constituents of the atmosphere. That filth about small negro houses, with decay of the sappy logs of which they are sometimes constructed, together with certain ingesta ; and I mention particularly the continued and almost sole use of molasses, beef and corn bread ; are decided modifiers of the atmospheric in- fluences, I do not at all doubt. Having made these remarks upon the nature, symptoms and cause of the disease, and passing over the points of diagnosis and prognosis, we come lastly to the treatment. The practice of medi- cine, as a system, although resting in a great degree upon indi- vidual experiment, has certainly attained to the respectability of many well understood general principles. And they ought to lead us to a reasonably successful practice in this disease, though we should -see it far less frequently than we do. There are many remedies and even modes of treatment that have been proposed, and this is not at all strange, if the pathological views herein pre- sented approach correctness. Could any one hope to find a reme- dy, or even a specific mode of treatment for any disease embracing so wide a range ! Should he seek to do so, in my judgement, he must from the necessities of the case only be disappointed. " The only management that can be satisfactory is one based upon gene- ral principles." (Dunglison.) 74 Howard, on Dysentery. [February, Such being the fact, it will be proper to remark upon remedies somewhat in classes and first of bloodletting. This remedy claims an early consideration, both from its capability of effecting great good or mischief, and because, when it forms a part of the treatment, it should be performed early. That it is, in the well developed, purely inflammatory cases; those attended with a synochal grade of fever, a proper remedy, few medical men would dispute. So far from doing so, it appears to me, as not only proper, but absolutely necessary. And about twelve years ago, whilst practicing in the county of Chambers, in this State, I rarely saw a case of dysentery that was not bled in the very commencement of the treatment, and the impression is with marked benefit. But, in nearly all the cases that have come under my observation for a number of years, the grade of the accompanying fever has been entirely different, viz : of a low or typhoid type. And this is not only true of dysentery, but other inflammatory affections. The consequence is, that I seldom bleed in the disease under considera- tion ; and it may be added, or any other. Still, I am not aware of any reason for being less satisfied with the success now, than when the lancet was frequently used. In many, perhaps, most of the cases of dysentery occurring here, the patient for the first few days has very little fever ; it then comes on gradually ; his pulse say eighty or ninety beats per minute ; not at all corded or resist- ing ; but soft and not fuller than in health. There is a certain degree of feebleness, and should the patient rise in bed, the pulse becomes much increased in frequency, and more feeble. Whilst lying down, as in the purer cases of typhoid fever, feels pretty well. But, when he rises to the close stool, feels and expresses strong tendency to syncope, and hurries back to bed. Now, it is asked, shall such a patient, old or young, male or female, be bled ? I answer, no ! and for the following reasons : He has a disease that will not, though he be bled, run its course in a very brief time. The seat of the disease is intimately associated with the blood- making department ; to say nothing then of its first impression, the danger of dying from exhaustion must be very much increased. "What are the objects of bleeding in inflammation? u Although the mere loss of blood per se may be of service (when that fluid is morbidly abundant) by relieving the system from a source of ex- citement, still the principle good effects in bleeding in inflamma- tion depend on its sedative effects on the brain, and through the brain on the heart," (Druitt's Surgery.) It is barely possible 1855.] Howard, on Dysentery. 75 that the case supposed might have a morbid abundance of blood ; but is a sedative effect on the brain and heart thus called for ? and if there is not a morbid abundance of blood, would it not answer as well, for the patient to set up in bed as long as it would ordinarily take a man with pleuritis to be bled, from a large ori- fice, to syncope ; and in this case induce an approach to fainting merely by thus sitting up ? Again: " The necessity for venesection, and its beneficial effects, will be great in proportion as the tolerance is greater." (Ibid.) To apply this rule, which is a correct one, the only conclusion is, that venesection in these typhoid cases promises little. But here is another case the patient without heat, pale without thirst ; pulse 80 or 100 per minute ; feeble ; tending to and actually rapidly increasing in frequency ; tormina, tenesmus, frequent, and pretty free evacuations of mucous, blood, and fecal matter; the dis- charges in a short while becoming more liquid, jprarie-mnd-like ; deathly nausea; vomiting a green, blue or black fluid. After continuing thus a few hours, possibly days ; tongue very red and dry ; thirst inextinguishable ; great abdominal tenderness ; pros- tration. Are not the indications here clearly against bleeding ? But this is the disease as we sometimes have it. In such cases as have the intestinal or mesenteric glands actually diseased, accom- panied with little fever, or fever of a typhoid type, I never bleed. But where the disease is more strictly confined to the mucous membrane, or should the peritoneal coat also be involved in the first period of the disease, as sometimes happens, and the fever is of the purely inflammatory grade, we may not hesitate to draw blood from the arm. Of leeches I know nothing ; but of cups, my opinion, as compared with that expressed in most of the books, is not near so favorable. The next class of remedies to be remarked on is purgatives. And it may first be said, that those long dreaded balls of hardened feces (scybala) are less frequently found in this, than in almost any of the diseases we are he*re called on to treat. It is occasionally the case that a dysenteric patient has his bowels somewhat loaded with fecal matter ; and these full bellied cases that have tormina, with very small discharges, will usually be benefitted by a cathartic, say of rhubarb and magnesia ; preceeded or not three or four hours by a small mercurial ; or, if the grade of the fever approaches the synochal, epsom salts with or without magnesia, or the seidlitz powders or castor oil will answer a good purpose. Nearly all 76 Howaed, on Dysentery. [February, the cases I see now-a-days, however, do not seem to at all require cathartics, and the most of them not the slightest laxative after the first few days. To the facts as touching this point : in many cases there is disgust for all kinds of food ; the patient, therefore, takes nothing of the kind into the stomach ; the bowels frequently expelling mucous with other liquids, the presumption is that the small portion of fecal matter is early suspended in the liquids and thrown off. The abdomen, at the same time, is flaccid and pre- sents not the slightest appearance of accumulation of fecal matter, or even the tenth part of the usual quantity. In certain cases in which the abdomen presents much the same appearance as in health ; the general symptoms indicating that the disease is con- fined to the descending colon and rectum, some fever, the combi- nation of a laxative and opiate will answer a good purpose, as cas- tor oil. and tr. opii, thus : $. 01. Eicini !i. Pulv. Acacia Sacchari. aa 3ij. Tr. Opii. gtt. xl or lx. Aqua Cinnamon diluted 3yj. Dose, a tablespoonful every three or four hours ; or a rhubarb cordial. But one of the most useful still is the blue mass, opium and ipecac, thus : Vf.. Pilulae hydrargyri, grs. xxiv. Pulv. Ipecac, u iv. " Opii, " ij. or iij. Ft. pilulae viij. S. one every three or four hours. In the commencement of the typhoid variety, and in the more purely inflammatory form, after the violence of the disease has been subdued by venesection, a cathartic or emetic, or both, the above pills will usually do good service. But, though the quanti- ty of the first ingredient is small, it will often have to be reduced. Under the circumstances in which the pills have been recommend- ed, I have rarely seen the following powder fail to make a good impression : Vf. Hydrg. cum. oretae, grs, viij. Cretae. prep. " xx. Pulv. opii, " iij. " Ipecac " iv. Ft. Pulv. viij. S. one every two, three or four hours. These medicines modify the secretions, allay the tormina and tenesmus, promote action of the skin, and often the disease in a 1855.] Howard, on Dysentery. 77 few daya entirely yields to them, unaided other than by the warm bath or fomentations to the abdomen. Of emetics, particularly of warm water, aided, if necessary, by ipecac, it may be said that in the commencement of many attacks, especially such as are distinctly confined to the lower bowels, with a tolerably full abdomen and a furred, broad, moist tongue, they will be found useful. A few years ago, the writer was called to a plantation where the disease had been and was prevailing to a .con- siderable extent ; a variety of plans had been tried, not satisfacto- rily successful. During the visit, three or four new cases presented themselves, to every one of which we gave emetic doses of ipecac, with a grain of opium, to avoid purgation and, to say the least, the final issue of the cures was more agreeable. But the remedy alone did not arrest the disease, by any means. In not a few of the cases seen in the last few years, however, vomiting, so far from requiring promotion, is to be combatted with opiates, blisters and such other means as may be suggested but, after all, and before all, ice will be the remedy to address to the stomach ; whilst anodyne and astringent enemata may be repeated as occasion re- quires. Water, iced and thrown into the bowels, is a remedy well worthy of trial. Although mercurials, to a certain extent, are- recommended in this paper, it ought to be observed, that in the typhoid variety, it is only in the first stages, and then in fractional doses, if they are to be repeated, that they should be given ; for, in the advanced stage of the disease, in almost any quantity, they are often poisonous. Opium is a remedy eminently calculated to meet the symptoms of dysentery, if the grade of fever or idiosyncrasy do not forbid its use. Nearly every case that does not at the time require bleed- ing or the action of a cathartic, will not only tolerate, but be very much benefitted by this remedy. That opium and astringents are indispensable in the treatment of many of the cases occurring hereabouts, no one, so far as I know, who has been engaged in their treatment, questions. Though the fever may not be violent, often the patient in a short time is very much run down by the tormina, tenesmus and the discharges ; and nothing in the materia medica promises half so much, or performs the hundredth part so much as opium and astringents. To relieve the tormina, tenes- mus and discharges, they are the sine quae non. Though we have admitted the occasional necessity for cathartics, we read in every department of animated nature this great law rest forms an im* 78 Howard, on Dysentery. [February, portant part of the treatment for inflammations. If the limbs have suffered from external violence, motion is avoided ; if the eye is inflamed, light is shut out ; if the pleura or lungs, the ribs must keep still ; if an organ in the abdomen, the diaphragm must cease its contractions. So, in dysentery, the bowels must be quieted. Opium is the medicine to do it ; and nothing is more erroneous than the giving of medicines to excite the bowels to action to throw off imaginary local irritants, which, if they were present, would not be at all tolerated. This is clearly shown by the fact, that any and all irritants taken into the stomach as food, speedily increase the tormina and discharges. Even the small portions of blue mass, or mercurial chalk, or rhubarb, or castor oil, or anything of tb^kind, may have to be avoided. But the opium, with or without the ipecac and cretae prep., may be given ; or the Hope's mix- ture will often do well, though the nitric acid in it had better be left out at times. The following will prove, in many cases, an admirable anoydyne : $. Sulph. Morphine, grs. ij. or iij. Aqua Camphora, 5viij. S., a tablespoonful every one, two or three hours as occasion requires. The last formula, for certain cases, may be improved by the addition of ess. menth. pip., or the aqua menth. pip. may be substi- tuted for the aqua camphora. Of the astringents, the mineral, at least whilst there is fever, is usually to be preferred ; and of these the acetas plumbi. If the patient has but little fever ; abdomen soft ; bowels comparatively empty ; the discharges frequent, with tormina and tenesmus, the following pills may be expected to do well. $. Acetas Plumbi, grs. xvj. Pulv. Opii, u iv. " Ipecac " iv. Cons. Kosos or Micas panis q. s. Ut Fiant pirulae, xvj. S., one after each discharge, provided they are not required oftener than every hour. If they are not sufficient to restrain the bowels and remove the tormina and tenesmus, an enema of liquid starch or tea of flax seed or slippery elm, say iij., sulph. morphine, gr. $, with or with- out the acetas plumbi, grs. ij. a viij., may be given and repeated according to demand. The lead sometimes nauseates when given 1855.] DuGAS, on Local Anesthesia. 79 by the mouth ; then it is better to give it only in enemata. But even thus, it will occasionally have that effect; then the tannin, which stands at the head of vegetable astringents, may be substi- tuted, and indeed many other astringents. But, when the lead nor tannin does well, other astringents may be doubted. The best form decidedly for giving the lead by the mouth, is in pill. It is scarcely necessary to say, that when the fever is of the synochus grade, or comes on in distinct paroxysms, the sulph. quinine may beneficially be given. Blisters, in the latter stage of the disease, and comparatively early in those cases, attended with tympanitis and much pain, will do great good, and very few cases of dysen- tery ought to be permitted to terminate fatally without their having been used. Fomentations and poultices generally answer best in the early stage of any form, and should never be removed for blisters until they have been fairly tried. Of the former, a flannel bag containing hops, and wrung out of hot water, is light and soothing. Of the latter, a bran or bread poultice, sprinkled with mustard does well ; but I think few local applications are so good, especially in the typhoid variety, as light bran or bread poultices, which, after being spread, are sprinkled with one or two drachms of muriate of ammonia, and renewed every few hours. Though we have written somewhat in detail of the treatment, we close by repeating the quotation from Dunglison, "the only management that can be satisfactory is one based upon general principles." AETICLE IV. A Surgical Operation under the influence of " Local Anaesthesia" induced by cold. By L. A. Dugas, M. D., &c. About 18 months ago, Mr. J. B., of Greene county, perceived a warty growth upon his right arm, over the insertion of the del- toid muscle. Observing that it was increasing in size, he endeav- ored to destroy it by the application of a silk ligature around its base. This, however, only aggravated the case, and the growth was shaved off by his medical adviser, who then applied ineffect- ually various agents to prevent its return. Every application, apparently, served only to add to the rapidity with which the disease extended and assumed the character of an epithelial, car- cinomatous fungus. The patient subsequently placed himself 80 Dugas, on Local Ancesthesia. [February, under several individuals, particularly celebrated as "cancer doctors"; the fungus was repeatedly removed more or less com- pletely by means of the escharotics in common use ; but would always return with renewed activity. On the 2d instant, Mr. B. arrived here, and I found him in the following condition : The fungous growth was about the size of two fists, somewhat globular, with a flattened surface and project- ing a little beyond the circumference of the attachment, so as to constitute this a neck of about four inches in diameter. The en- tire surface of the tumor presented the aspect of a ragged, mucous membrane or ulcer, from which there exuded an abundant dis- charge of the most fetid sero-purulent matter. The fetor was such indeed as to infect the whole apartment, to the very great annoy- ance of the patient and all who came about him. Around the attachment the skin was swollen, red, and evidently yielding to farther encroachments. The axillary glands were enlarged and tender to the touch. The patient's general health was much im- paired, from incessant pain, despondency, and, above all, the in- tolerable stench which destroyed his appetite and kept him more or less nauseated. He urgently solicited the removal of the fungus and was willing even to suffer amputation, if deemed necessary. In view of the patient's age, his cachectic condition, the doubt- ful advantage of the operation, &c, amputation was deemed un- advisable, and the simple extirpation of the offending mass was determined upon. From the extent of skin to be necessarily re- moved, it was evident that the edges of the wound could not be brought in contact after the operation. Yet there was no alterna- tive, and this circumstance having been explained to the patient, as well as the probability that the disease would return soon or late, he very readily consented to the excision. This was a case in which the administration of anaesthetics by inhalation could not have been carried very far without risk, and it was one remarkably well adapted to the use of a freezing mix- ture for the production of. local anaesthesia. Prof. Means was therefore requested to prepare the usual frigoriflc compound of ice and salt and to superintend its application. This was done in presence of the Medical Class, and in less than four minutes the surface was congealed and the operation immediately performed ; a double eliptical incision being carried through the integuments from the acromion process to within three inches of the elbow, and the parts included rapidly dissected away down to the muscles- 1855.] Treatment of Chorea. 81 Under this extensive flaying the patient experienced so little pain that he now declares that the most unpleasant part of the opera- tion was the dressing, or rather the application of the adhesive strips. The congelation was so complete as to have solidified the adi- pose matter to such a degree that the knife felt as if passing through a mass of tallow. Not only was the surface blanched, but we have reason to believe that the effect of the application very ma- terially lessened the amount of hemorrhag'e, inasmuch as this did not exceed a gill, whereas we had expected it to be very profuse. Ligatures were applied to three small vessels, although they bled very little, because it was deemed important to prevent even a small loss of blood under the circumstances. "We regard this case as fully demonstrating the value of Arnott's plan of inducing local anaesthesia. It is now seven days since the operation was performed, and the patient's spirits, as well as general health, have so much improved as to allow him to return home. The wound seems to be doing remarkably well. Augusta, 9th Jan., 1855. TRANSLATIONS AND CONDENSATIONS FROM FRENCH JOURNALS. Treatment of Chorea. The numerous modes of treatment which have been adopted for the relief of chorea, may be divided into two grand classes, accord- ing to their method of application and action. First, are the ex- ternal remedies, viz: 1 Gymnastic exercises; 2 Sulphurous baths ; 3 Cold baths and others ; 4 Electricity ; 5 Cutaneous irritants and revulsives. Secondly, the internal remedies, the most important of which are: 1 Antiphlogistics ; 2 Evacuants (purgatives and emetics) ; 3 Tonics ; 4 Narcotics ; 5 Excitants of all kinds (strychnine, preparations of copper, nitrate of silver, arsenic, iodine and iodide of potassium) ; in short, medicines which are classed or unclassed under the name of contra-stimulants, anti- spasmodics, and alteratives. Before passing in review these various curative methods, it is important to know whether the patient should be left alone, or have recourse to art. The expectant plan seems sufficiently justifiable, by the tendency which the disease has to spontaneous resolution, and by the resources of nature. But, to a certain point, 82 Treatment of Ohorea. [February, this question can be settled by comparing the results of this nega- tive treatment to those furnished by other plans. In two cases, mentioned by M. Eufz, and four which we saw treated on the ex- pectant plan, for four, eight, ten and thirty-two days, the disease, far from diminishing, persisted, or even went on increasing, not- withstanding rest, regimen and other hygienic means which were deemed sufficient to effect a cure. Thus the treatment requires medical art. EXTERNAL TREATMENT. 1st. Gymnastic exercise. In this division, we must place first the entirely new plan of treatment by gymnastic exercises, the result of which we give, after having carefully watched its appli- cation for more than a year. Eecommended by Darwin, and later by Mason Good, muscular exercise was first attempted by Louvet-Lamarre. The patient was a young girl, who was attacked for the fourth or fifth time. After an unsuccessful trial of various treatments, rope jumping every day was advised, at the same time that bleeding was resorted to. From the sixteenth day the agitation was scarcely perceptible, and in twenty days the cure was complete. This vague and complex case proved nothing in favor of the remedy, which remained for- gotten until the physicians of the Hospital for Children, among others M. M. Bouneau, Baudelocque, Guersant and Blache, struck no doubt, as ourself, by the advantages of gymnastics in scrofulous and the other cachectic conditions, conceived the idea of applying it to the treatment of nervous diseases, particularly to chorea, which, besides the perturbations of the nervous system, so fre- quently induces disorders of nutrition and organic functions. The treatment must be commenced with simple and harmonious movements, exercising the larynx at the same time by singing. The patient, standing up, should flex and extend the knees and elbows, keeping time with the music. Such are the first steps necessary to place these movements under the influence of the will. The rapidity of this result will be in proportion to the at- tention, intelligence and character of the patient. It is frequently impossible to do any thing until the patient has been won by kindness. After the muscles can be controlled as above, walking at a slow or quick pace, running, jumping, suspension by the arms, or more complicated movements should be attempted, graduating them however, to the state of the disease, and repeating them every 1855.] Treatment of Chorea. for not more than fifteen or twenty-five minutes, so as to avoid muscular fatigue and palpitations of the heart, which some- times occur after too much exercise. By this treatment, no matter how violent the disease, from the first lessons sometimes from the very first one but not later than the fifth or sixth, a manifest change can be seen in the abnormal movements. At the end of eight days, if the patient cannot stand erect, walk in a straight line or suspend himself by the arms, it is doubtful if this plan will succeed ; it is certain, however, that the treatment will be long or difficult. In all cases, after the first corrections of the muscular actions. there is generally a period of arrest, and sometimes eight, and even fifteen da}~s will pass without progress, after which the movements become more regular and take on their habitual precision ; the functions of nutrition are re-established ; children who were thin and debilitated, recover their appetite, their digestive faculties, their natural color, their strength and particularly their fleshiness. This is one of the most remarkable results of this treatment, and when once produced, it is not long before gayety, good humor, memory and attention are observed; the countenance alone seems to remain unchanged, and this condition often still exists even when all traces of the disease have left the extremities. The arte- rial and cardiac sounds are the last phenomena to disappear ; but, unless these depend upon a diseased condition of the endo-cardium, they yield more readily to this treatment, properly conducted, than to any other. Save the co-existence of an inflammatory or an organic affection of the heart, gymnastic exercises can be resorted to. Of 22 children, 16 were cured completely and rapidly, for the treatment was on an average 29 days. In two others, the treatment was interrupted by a febrile condition which hastened the cure, so that upon the whole, 18 out of 22 cases will recover. When the exercises were combined with other remedies, the results were much less satisfactory. Instead of 18 in 22 recover- ing, the addition of sulphurous baths gave only 8 in 11, and the addition of tonics 3 in 5 ; and besides, these means, called auxili- ary, instead of curing the patients in 29 days, succeeded only at the end of 33 and even 48 days. The most simple means, then, are the most successful, and whenever the condition of the heart will allow it, recourse should be had to this plan. In this manner it will be easy to relieve simple or long standing chorea, cases of relapse or those just complicated with fever. The natural course 84 Treatment of Chorea. [February, ! of the disease aids powerfully in causing the accidents to disappear ; and this is so true, that in 29 cases of recovery, 5 were complicated with fever, 12 relapses, 7 of long standing and 5 recent ; whilst in 9 cases more or less unsuccessful, there were none but recent cases. It is therefore impossible to conceal the difficulty to arrest the disease at its outset, but this difficulty is much greater in the other plans of treatment. That which establishes definitely the superiority of this plan, is: 1st, that it relieves constantly cases of relapse and those of long standing ; 2d, that it shortens very much more the duration of the disease than most of the other treatments. 2d. Sulphur Baths. In 65 cases treated by M. M. Baudelocque, Blache, Eufz and Constant, 58 were rapidly and permanently cured. The baths, which are to be repeated every day, and for at least an hour, must contain 120 grammes of sulphate of potassium to every 8 buckets of water at 26 Reaumur. Generally, from the second or third bath, the patient begins to improve. Sometimes, however, amelioration is not perceptible until after 12 or 15 days, when it commences and goes on rapidly, requiring on an average 22 days to restore the natural functions of all the muscles excepting those of the face. After using the bath for sometime, and occasionally after the first few days, an eruption of little red pimples, sometimes conflu- ent and in large patches, appears on the abdomen and extremities, and occasionally upon the whole surface, accompanied by a certain degree of heat. As soon as this eruption appears, and during its continuance, all medication must be suspended and simple diet and rest enjoined. After it has subsided, the treatment may be continued, but should it appear again, this treatment must be abandoned. Denuded surfaces, as blisters, &c, will prevent the treatment, as the constant irritation of these surfaces produced by the baths counteract their good effects. Acute irritation of the serous membranes, though rare, contra- indicates this treatment. Notwithstanding all these accidents, 50 out of 57 cases were cured on an average of 22 days ; showing a larger number of cures, in a shorter time, by this method, than by that of gymnastics. Adjuvants seem only to retard the cure. The bath, combined with good diet and the use of a little wine, will be sufficient of themselves. 3d. Cold baths, cold affusions, sea baths, vapour baths and others. 1855.] Iron and Manganese. 85 That which seems the most efficacious of these plans, is the cold bath, as used at the Hopital des Enfants. Incontestable success is due to this treatment, 5 out of 6 patients who were bathed in water at from 18 to 20 degrees were cured.* The efficacy of this remedy, consequently, does not appear to be much inferior to the sulphur- ous medication, except in its application, when the latter plan is superior. Children never take the cold bath without extreme re- pugnance, and if they are not administered with great care, the patients may take cold, and the disease, which was until then simple, becomes complicated with a rheumatic or an inflammatory tendency. f This plan of treatment was abandoned at the Hopital des Enfants, in consequence of its disadvantages, the sulphur baths being so much more prompt in its action curing the patients in 22 days, whilst the cold baths required from 40 to 47 days. Simple and vapor baths possess no virtue in themselves, neither do aromatic baths or fumigations. The hydropathic pack and gorging with cold water is equally valueless. The three first methods, viz : gymnastic exercises, sulphur baths and cold baths, are all of any utility that is known of external medication ; but the list is not yet exhausted, and there still remain to be described the treatment by electricity and revulsives of all kinds. 4th. Electricity. This plan of treatment was first brought into notice by de Haen, of Vienna, which had its advocates ; but its effects are so slow, that they might very well be mistaken for the natural efforts of nature. 5th. Liniments, ointments and issues. This plan of treatment has met with such very doubtful success, that it is unnecessary to give the details. The methods which should take or preserve their rank in the external treatment of chorea, are : 1st, gymnastic exercises ; 2d, sulphur baths ; 3d, cold baths ; and, 4th, electricity, which seems to be of some utility in certain cases. (Dr. G. See.) Iron and Manganese. M. De Larue speaks highly of the combination of iron and man- ganese in hematic affections, and says he has frequently proved its good effects at the bed-side. In a certain number of chlorotic *Of these 5 patients, two were treated at the same time with preparations of sul- phur, and another owed its cure, perhaps, to the intervention of a febrile condition. tit is known that a frequent cause of chorea is a sudden immersion in cold water. Dupuytren cites an example. N. S. VOL. XI. NO. II. 8 86 Employment of Chloroform Vapour, [Februarys cases especially -, which had resisted treatment with iron alone, were relieved, as by enchantment, when manganese was added. He gives the following case, taken from among similar ones, to demonstrate the value of this treatment : Miss X,, aged 16; of a bilioso-nervous temperament; delicate constitution ; had been affected with well marked chlorosis for about 20 months ; had not menstruated for two years. He saw the patient in August, 1853,, and advised the continu- ance of iron. After a month of fruitless attempts, he prescribed manganese with the iron, and in less than eight days all the symp- toms were relieved, and very soon the cure was complete. The patient was submitted to this treatment but four weeks, and has continued from that time to enjoy excellent health. He prefers administering the medicine in pills, generally four daily ; two morning and night, and as near the time of meals as- possible. Formula for making the pills : fy. Sub. Carbonate of iron, 30 grammes, Sulphate of Manganese, 10 " Ext. of Licorice, q. s. Divide into 100 pills 4 to be taken daily. [Revue de Therap. Medico- Chir. A practical inquiry into- the advantages derivable from the Vapour of Chloroform, as a local application to the surface of the Skin and Mucous Membrane under various conditions. By S. L. HAKDYf M.D., F.R.C.S.,&c.y&c, [Concluded from page 4T.J 3d. THE EFFECTS PRUDUCED BY THE VAPOUR OF CHLOROFORM WHEN APPLIED TO MUCOUS SURFACES UNBROKEN. Mucous surfaces seem to be particularly eligible for receiving the influence of chloroform vapour. When its local application was first brought before the notice of the profession', I alluded to the sensation of heat which was experienced when those tissues were subjected to its action. In some instances this is so great that it is complained of a good deal, but I have never met with any case in which it was necessary to relinquish its use on that account. Ceasing to propel the vapour for a few seconds was quite sufficient to enable the patient to bear it. The relief afford- e& is in general so agreeable that many would willingly endure a greater feeling of discomfort rather than be deprived of its efficacy- The following cases are given in illustration ; 1855.] Employment of Chloroform Vapour. 87 No. 22. Case of Painful Haemorrhoids. At a meeting of the Surgical Society already alluded to, Dr. Forrest detailed the fol- lowing case : * " A gentleman, setat. about 36, who had suffered from piles on several occasions, sent for me, owing to an attack of his old com- plaint. I found the mucous membrane of the anus, everted with several haemorrhoids attached to it. The pain was so very severe, notwithstanding the use of fomentations which had formerly reliev- ed him, that no pressure could be borne, nor any attempt be made to return them. The vapour of chloroform was them applied by the douche for several minutes, which produced so soothing an effect that I was able to press them within the sphincter without causing him any uneasiness." No. 23. Pain in the Ear. The following case of pain in the ear shows the necessity of having the vapour propelled for a suf- ficient length of time : " A young lady, during the course of an illness, was troubled with very severe pain in the left ear, running down the side of her face, for which I directed the application of chloroform vapour. Next morning she told me it had given her no relief, and she con- tinued to suffer as before. Supposing that the instrument had not been properly used, I applied it myself, and in about from five to ten minutes observed the countenance altering from an expression of pain to one of ease. Presently the lady said she was perfectly relieved." No. 24. Case of Abnormal Sounds in the Ear. The Medical Times and Gazette for June 17, p. 618, contains the report of a Case of abnormal sounds in the ear, which had for six weeks re- sisted various remedies, as syringing, aperients, alteratives, and blisters. A few applications of the vapour of chloroform com- pletely removed the complaint. No. 25. Case of Irritable Bladder. A female patient, aetat. 37, the mother of one child, had suffered so much from irritation of the bladder for two years, but particularly during the month of July last, that her state was most distressing. The calls to mic- turate were incessant, and always attended with very severe pain. By means of a catheter attached to the douche, I threw the va- pour of chloroform into the bladder, occasionally removing the nozzle of the douche from the end of the catheter, to allow the vapour to return. Great heat was at first complained of, but (by ceasing at intervals) the operation was continued for about five minutes. Next clay the woman informed me that after the applica- tion of the chloroform, she was able to walk a distance of about two miles without being under the necessity of relieving the bladder. When she did pass water, it was in much greater quantity than it had been for a long time, and attended with less pain. The 88 Employment of Chloroform Vapour. [February, vapour was used on the second day with like beneficial results. Afterwards hip-baths and diluents completed the cure. No. 26. Case of Spasmotic Pain after Delivery. , aetat. 26, nearly nine years married, had four children and several abor- tions ; suffered much from great irritability of the uterus, which was affected frequently with congestion and excoriation. Pre- vious to, and since marriage, menstruation was always exceed- ingly painful during the first day of-dts appearance. On the second day after the birth of her second child, and while recovering favorably, she was suddenly seized with most excru- ciating spasmotic pains in the uterine region, recurring in parox- ysms, which caused her to scream from intense agony. Fomen- tations, with the internal administration of spt. of turpentine, opium, &c, at length (in the course of about three hours) quieted this distress, and her recovery progressed as before. Within an hour after the birth of her third child, she had similar spasms, in character somewhat like after-pains, recurring in violent exacer- bations, which lasted for about an hour, and again on the fifth day. The inhalation of chloroform was resorted to with good effect, always relieving her when so attacked. On the fifth day after her last (the fourth) confinement, and without anything to account for it, the spasms set in with their usual violence, the distress felt in the situation of the anus being particularly severe, owing to the action of the sphincter. Inhala- tion of chloroform was resorted to, which gave relief so long as the soporific state existed ; but no sooner did this go off, than the paroxysms were renewed. The vapour of chloroform was then thrown into the rectum by means of the douche for about five minutes, by which the spasms were not only relieved at the time of its application, but afterwards there was no return of them whatever, and the recovery was most favorable. This lady when between seven and eight months pregnant on the last occasion, suffered greatly from vesical irritation. The calls to micturate were incessant, depriving her of all comfort by day and of rest at night ; so much so, that her general health seemed likely to suffer. The chloroform vapour thrown into the vagina for a few minutes at bed-time, procured for her so much relief that she was seldom disturbed, and had quiet sleep. In my remarks on Cases 2 and 3 {Dublin Journal for Nov. 1853, p. 311,) I made the following observations : " It is deserving of notice that, in Case 2, the duration of the menstrual period was much lengthened, from which circumstance it may be inferred that the application has not only the effect of saving the patient from her usual degree of suffering, but by sub- duing the spasmotic action of the uterus, tends towards the pro- duction of a more natural secretion. As yet I have not had an opportunity of testing its efficacy thus in the patient of Case 3. It is her intention, kowever, to resort to its use when next about 1855.] Employment of Chloroform Vapour, 89 to menstruate, so that at a future time the results may be laid be- fore the reader." Of Case 3, it is stated, "menstruation, both before marriage and to this time, was always very painful, the discharge scanty, and dysmenorrhceal membrane frequently expelled." Before detailing the progress of the case, I would beg to direct attention first to the following remarks on chloroform as an emmenagogue. On the Emmenagogue Properties of Chloroform. In the Hygeia for February, 1854, p. 98, Dr. Gibson states "that inhalations of chloroform have an emmenagogue effect, and he relates five cases of irregular, insufficient, and wholly suppressed menstruation, in which this remedy was employed with good results. Van Dye confirmed this observation in a case of amenorrhcea, in which he made the patient inhale chloroform on account of spasms accom- panying the amenorrhcea. The spasmotic symptoms which had occurred in various organs were removed, and after some time menstruation set in. Van J)je is therefore also of opinion that chloroform deserves especial attention as an emmenagoge." The Journal de Hygeia, Feb., 1854, p. 98, taking it from the Medical Examiner, adds: "A slightly prolonged inhalation of chloroform excited, at the end of twenty or thirty minutes, the flow of the menstrual fluid." Chloroform is doubtless emmenagogue, like opium, valerian, ether, &c. ; that is to say, it causes a cessation of the nervous al- teration which opposes the menstrual flux. Journal de Chimie Medicate, April, 1854, p. 256. \ % No. 27. Painful and Scanty Menstruation. When this patient (Case 3 continued) perceived the catamenial distress commencing, the application of the vapour was resorted to, and repeated on each return of uneasiness, by which she menstruated without any suffering. On the three following occasions it caused similar re- sults, the secretion taking place in proper quantity, and free from pain. Her last two menstrual periods" were perfectly natural in every respect, unaided by the use of chloroform. No. 28. Case of Painful Menstruation. A patient, aetat 31, married seven months to her second husband. By her first (with whom she lived nine years) she became pregnant soon after mar- riage, and aborted at the second month. Since then she did not again conceive, and menstruation which, previous to her preg- nancy, had been healthy, regular in its returns, and without pain from the time of the miscarriage, had on its approach, and until after the first day of its appearance, been attended with distressing sensations in the back, loins, and particularly in her breasts. The use of chloroform vapour gave her perfect ease, relief on each ap- plication commencing first in the back and immediately after ex- tending to the breasts. 90 Employment of Chloroform Vapour. [February, No. 29. Case in which Menstruation ivas Scanty and Painful, and finally Ceased. , aetat. 35, enjoyed excellent health; men- struated regularly for three days, and free from any discomfort until her marriage, which took place nine years ago. After this event, she gave birth to a male child, which lived for six months. During lactation, the catamenia appeared each month as formerly. From this time her health gradually declined, and in the course of a year, notwithstanding medical treatment, she was in a very debilitated state. I first saw her four years after her confinement. Pregnancy had not taken place ; her menstrual periods in their approach, and while present, were accompanied with severe pains occurring at intervals, and the flow continued for scarcely one day. Ulceration of the os uteri, which I treated her for, soon got well, her health was restored, and she again concevied, but owing to an accident aborted at the third month. Although by the mis- carriage her general health suffered little, yet from this date men- struation steadily lessened in quantity, but was not attended with pain, until at length it entirely ceased, without there being any reason to attribute this circumstance to the existence of pregnancy. As the secretion diminished, her head and chest became very much affected with what she described as a " bursting sensation,*' which was particularly distressing at the time of each expected return of the catamenia. She was becoming very fat, and had a feeling of general discomfort. Various remedies had been tried in order to restore the uterine secretion and to relieve those uncomfortable sensations, but to no purpose. I now directed the vapour of chlo- roform fo be thrown into the vagina when the next period was known to be approaching. On the first occasion menstruation was established and continued for two days : on the three follow- ing, the same means having been resorted to, it flowed for three days in proper quantity, and with the absence of all the uneasy feelings above described. It now comes naturally and without the use of chloroform, and in every respect her health is perfect. No. 30. Case of severe Uterine Pain, with /Suppression of Men- struation, A lady of strong and healthy appearance, residing in the country, consulted me in September, 1852. She had given birth to two children, and had aborted several times. Since her last miscarriage, which was caused by jumping from a height, she felt a disagreeable sensation, of a painful nature, in the uterine region, and menstruation becoming more and more scanty and irregular, had entirely ceased. She was very languid and incapa- ble of much exertion. On examination, the os uteri was found extensively ulcerated and the cervix enlarged. Her health hav- ing improved, and the uterus being healed, she returned to the country, where she made use of shower and hip-baths, and took gentle exercise on horseback, which served her greatly. Again her health declined, and she consulted a neighboring practitioner, under whose treatment she continued for a considerable time. 1855.] Employment of Chloroform Vapour. 91 Afterwards she came to town, and informed me that owing to severe pain in her back and uterus, she was unable to sit for any length of time in the erect position, particularly in the evenings. All those symptoms were greatly aggravated periodically, when menstruation should be present The uterus was rather larger than natural, but had no abrasion, and the cervical canal was pervious. I commenced the local application of chloroform va- pour at the expected catamenial period. The following is the report given in a letter by the patient herself: "It is with much pleasure I tell you the result of the chloroform ordered, by you. While in toAvn it enabled me to walk without pain in my back, or the very disagreeable internal pain, or gnawing feel, which I had for some time I may say for years. I had not a change for the last twenty months; but having used the chloroform for ten days, it came on, which though scanty, I feel is all right There was no pain whatever, as (when I began to feel uneasy) I used the chloroform. It has done wonders for me already." I lately received the following letter from this lady : " I am able to take a great deal of exercise without fatigue, and when I have pain I use the chloroform, which has not in the least lost its effect, but soothes me at once." It is now five months since its application was commenced. No. 31. Violent Vomiting. A patient, setat 20, was attacked in the month of August last with gastric fever. For the first four days, irritability of the stomach was very great, nothing whatever being retained for more than a few minutes. The vomiting was most severe, and frequently occurred in violent paroxysms. The remedies usually resorted to in such cases, as ice, creosote, prussic acid, blistering, &c., were tried in vain. At this time, by means of the douche, the vapour of chloroform was thrown into the rec- tum for several minutes. It felt most agreeable to the sufferer, and in some measure mitigated the violence and frequency of vomiting. At intervals of an hour, the application was twice re- peated. After the third exhibition of the vapour, all vomiting ceased; drinks and medicine were swallowed without exciting any tendency to it, and for a fortnight it did not return. So much relief was felt from first using the chloroform that the pa- tient anxiously requested a repetition of it No. 32. Painful Flatulent Distension of the Intestines. A woman in Steevens1 Hospital, under the care of Dr. Croker, in August last, for flatulent distension of the intestines, suffered so much from pains and disagreeable sensations that, in addition to the treatment adopted, the vapour of chloroform was thrown into the rectum by the douche, for about five minutes, three times daily. The patient for three hours after each application of the vapour, said she felt more ease than she had for months past. It was con- tinued for some time, but whether it had lost its efficacy, or had 92 Employment of Chloroform Vapour. [February, not been properly used, she said it did not afford as much relief as at first. No. 33. Case of Bronchitis in an Infant, attended with Sleepless- ness. (Under the care of Dr. Kingland.) A child, eight weeks old, attacked with bronchitis, through great distress from difficulty of breathing, arising from the enormous accumulation of mucus in the air-passages, as well as from general irritability during a period of seventy-two hours, never slept for a single moment, and was evidently sinking, chiefly from exhaustion from want of sleep. Many remedies were employed without the least benefit ; at length a small quantity of chloroform vapour was injected into the rec- tum by means of Hardy's anaesthetic douche, ranging from six to nine jets. After an interval of less than fifteen minutes the child became more tranquil, and shortly fell into an uneasy sleep, which lasted nearly two hours. When it awoke it took the breast, which it had previously refused for several hours, having been fed with breast milk from the spoon. The vapour was again had recourse to in like manner as before, when the child, after a very brief space, fell into a quiet and almost natural sleep, which continued for several hours, and it became necessary to awake it to take nour- ishment. The chloroform vapour was frequently used in the sub- sequent progress of the case (which terminated favourably) and always with equal advantage. Had not rest been procured, the child must have sunk before there was time for the other remedies employed to have effect. Medical Press, April 19, 1854. [Under the 3rd Division "The effect of Chloroform vapour on Mucous Surfaces Unbroken" the following cases may be referred to in the Dublin Journal for November: Case 2. "Scanty and painful menstruation in which the chloroform vapour enabled the patient to menstruate without pain, and lengthened the duration of it from one to three days." Case 5. "Violent Uterine Pain." Page 317, same number "Case of Pruritus Pudendi." Two Cases of "Pain in the Ear," Medical Press, April 19, p. 242.] 4th. the effects produced by chloroform vapour when applied to mucous surfaces in an abraded or ulcerated condition. The vapour of chloroform when applied to mucous surfaces abraded or ulcerated, generally causes a good deal of the sensation of Heat; but although this feeling is more frequent and of longer duration than where the surface is unbroken, it is not so extreme as to prevent patients from easily bearing it. The following cases will serve to illustrate its influence when applied under these circumstances : Xo. 34. Case of Ulceration of the Os Uteri. A patient, the subject of very extensive ulceration of the os uteri, suffered so Employment of Chloroform Vapour. 93 much from lumbar pain and general distress in the uterine region, that the vapour of chloroform was applied in the usual manner, by means of the douche. The heat and scalding sensation wi great that until after the lapse of half an hour from its application, no beneficial effect could be perceived. Xo sooner had the un- easiness caused by the chloroform subsided, than the relief was complete, and of very considerable duration. . So. Elongation of the Cervix Uteri. On the 20th October ;:.te in the evening. I was called to a patient who was suffer- ing from violent expulsive pains, which I found on examination to depend on an elongated growth from the uterine cervix, so long that it protruded through the os externum. The mucous mem- brane of the uterus was abraded, and the vaginal canal felt ex- tremely painful to the touch. By an opiate suppository and draught, the pains were quieted, and the woman had a good night's rest. On the next day I placed a ligature on the tumour, and until the third day (when I removed it below the ligature by a curved scissors) the pains were on each return perfectly removed by the vapour of chloroform thrown into the vagina by the douche. No complaint whatever was made during its application to the abraded mucous membrane. No. So. Cancerous Ulceration oftlie Rectum. The Msdieal Times and Gazette for August 19, page 195, contains the results obtained by M. Gonzales Conde. It says: "The Spanish professor has, after the example of the originator, Dr. Hardy, tested the local power of the anaesthetic to assuage the pains of cancerous ulcers. The cases were those of ulceration of the interior of the rectum, accompanied by most severe suffering, such as ordinary sedatives were insufficient to calm. M. Conde employed a bottle contain- ing a sufficient quantity of chloroform. Its mouth was occupied by a well-fitting cork, through a hole in which a gum-elastic cathe- ter was passed. The sound was introduced so far, that its aper- tures were in direct contact with the ulcerated surface. The va- porization of the chloroform was commenced ; first, by the appli- cation of the hands to the bottle which contained it, then by bring- ing near it a heated stove. The patient experienced a slight pricking sensation, which took the place of the cancerous pains. This sensation extended upwards towards the colon. From the rectum some gas escaped, having the odor of chloroform. The sufferings were quickly appeased, but the most remarkable cir- cumstance was that the pulse, which at the commencement of the experiment was accelerated, fell first to its natural rythm, and then sunk to sixty beats in a minute. The ease, however, be- stowed by the chloroform, was not limited in its duration by the effect produced on the pulse. For a week the pains did not re- turn, nor was it necessary to reapply the anaesthetic for the whole of that period El Heraldo Medico, June, 1854, page 165. 94 Employment of Chloroform Vapour. [February, [Under the 4th Division see also, in Dublin Journal for Novem- ber Case 1. "Cancerous Ulceration of the Uterus." Medical Press for April 19th " Cancer of the Kectum opening into the Vagina."] General Observations. In making a few brief observations on the cases above detailed, I would direct the reader's attention to the remarkable influence exerted by chloroform vapour in cancer- ous ulceration. I may refer to Dr. Mayne's case (No. 19) in which he says, "opium afforded her but little relief, and various other sedatives and narcotics were tried in vain ;" and (No. 20) where we are informed by Dr. Moissenet that "he has succeeded, espe- cially in a case of cancroid ulcer of the forehead, in instantly and repeatedly allaying dreadful sufferings, which had resisted all known remedies." The duration of relief obtained by the appli- cation of chloroform vapour is very striking, and was one of the first things in its action that attracted my attention. In the Dublin Journal for November, p. 308, I stated, "the relief afford- ed by the local application of the vapour of chloroform is not of a very transient nature;" as examples, see Case 5 in same journal, p. 315; No. 13, in Mr. Wilmot's communication; Nos. 16 and 17 in Dr. Geoghegan's; and Nos. 9, 25, 33, and 35. Although it is stated in No. 32 (Case of Painful Distension) that the relief was not as much after the application of the vapour had been continued for some time, I question whether it was properly applied on each occasion, having never met with another instance of diminished efficacy in its use. (It was the patient herself who generally used the douche.) In the Case of Gout (No. 9) it is stated, "the part subjected to the vapour of chloroform had become pale and cold, instead of red and burning, as it had been before." As some might fear on account of the cold caused by it to resort to its application in gout, I may inform them that this obstacle can easily be removed by using the vapour douche, which has a small metalic ball attached, and by heating this ball by a spirit-lamp, air of any temperature (most agreeable to the patient) may be transmitted with chloro- form vapour. If desirable, moist, instead of dry, vapour can be formed by pouring a little water into the ball, and may be medi- cated by the addition of extract of belladonna, watery extract of opium, &c. The vapour douche is so small that with all its fittings it could be easily carried in a small dressing case. A chloroform bath can be given with it instantly, and hot vapour, moist or dry, in about five minutes (the time required for heating the ball.) See (No. 10). A similar case treated by the combination of chloroform and warm water vapours, the affected part being placed in an air-tight case. As a means of alleviating pain during operations, the local application of chloroform vapour can be of 6ervice in but a very limited number of cases, and those only be- 1855.] Employment of Chloroform Vapour. 95 longing to the minor operations in surgery, where the disease is superficial and the cuticle very thin or abraded. No. 8 (Mr. Smy- ly?s Case) is an example of the first; and Nos. 10 and 11 (Anthrax), of the second requirement. The same remark is applicable also to No. 14 (Issue.) No. 15 (Case of Painful Stump) serves to show of what great advantage it may be in gunshot wounds, where extraction of the ball is necessary. A stream of chloroform vapour passed into the wound might enable the sufferer to undergo the operation without the least pain. It was supposed that as the vapour of ether had caused griping when thrown into the intestines, that of chloroform should have had a similar effect. Nos. 30, 31, and 32, serves to show that this is not so, and we are informed by M. Ehrenreich of Germany (Medical Press, April 12), that "he has found the most marked benefit from the local action of chloroform, more especially in the excruciating pains of tenesmus in dysentery." The influence ex- erted on the uterine system by chloroform in allaying inordinate contractions, is exhibited by Nos. 25, 26, 27, 28, and 29. From this knowledge, a very important step might be taken in the treat- ment of patients who are the subjects of early abortion, and whose cases are so frequently mistaken for dysmenorrhceal affections. If, on the approach of a catamenial period, the vapour of chloro- form be thrown into the vagina, which, acting as an antispas- modic, has the power of keeping the uterus at rest, the presence of the ovum may be prevented from exciting the contraction which otherwise would have caused its expulsion ; or those con- tractions which, established by habit, have the effect of causing abortion, might be kept so perfectly controlled that pregnancy may proceed without interruption. This remedy possesses ad- vantages in such cases over opium and other narcotics, in that it exerts, when applied locally, no unpleasant effects ; so that a pa- tient can enjoy her usual sensations while the uterine system is alone under its influence. In cases of this nature particular in- structions should be given to use the douche very gently. When speaking on the method of applying chloroform vapour (as reported in the Medical Press for April 19), I made the fol- lowing remarks : "If the vapour is not confined, either no influ- ence will be exerted, or to produce an effect, a very unnecessary waste of material must be the result ; but besides confining it, a sufficient quantity should be thrown, and with a force propor- tioned to the extent of surface over which it has to pass." On referring to No. 2 (Dr. Kirkpatrick's Case of Tetanus), a glass-bell was attached to the tube of the douche, that the vapour might not escape. In No. 4 (Phthisis), and in Nos. 12 and 13 (Mr. TVilmot's), the same precaution was observed. In Dr. Geoghegan's observa- tions this point is particularly noticed ; and in a Spanish journal (El Porvenir Medico), it is stated that "M. Figuier, with a view of favoring the absorption of chloroform, proposes to apply it at a 96 Disease of the Heart. [February, temperature of 50 (122 deg. Fah.), and to confine it by means of an impermeable apparatus of gum- elastic." I have been informed by Mr. Brown, Eesident- Surgeon in Stee- vens' Hospital, of a case of ulceration of the cartilages of the knee- joint, in which great relief from pain was obtained by baths of chloroform and hot water applied by the vapour douche. The local application of chloroform vapour recommends itself to our careful attention, not only as a powerfully efficient and rap- idly active agent, but as a remedy which is as safe as efficacious. Twelve months have passed since it came into practice, and the foregoing cases may, in a measure, testify to what extent it has been tried, both at home and in other countries, during that time ; but in no instance that has come to my knowledge has its use been attended or followed by either the slightest accident or injury. [Dublin Medical Press. On the tic-tacfelt by the hand as a means of Diagnosis in Disease of the Heart ; an excerpt from the recent work of M. Eacle on Diagnosis, with a few comments. By Henry Melville, M.D., Edinburgh. During the year 1852, a letter from a friend, at that time re- siding in Paris, made me acquainted with this mode of examina- tion, adopted by M. Bouillaud, in general terms. Since then I have been in the habit of paying some attention to the phenomena so presented by healthy and diseased hearts, but without arriving at any results of diagnostic value. This has arisen, undoubtedly, from the want of sufficient information as to the points to which the observations made should be directed, and the connection between the phenomena observed and their interpretation. It was therefore with much pleasure and satisfaction that I read, in M. Kacle's recent admirable work on Diagnosis, the following account of M. Bouillaud's method ; and believing it to possess great practical advantages, apart from the interest of its novelty, I have endeavored to translate it for the pages of the Monthly, in the hope that" it may be acceptable to its readers. " M. Bouillaud, who has studied this physiological phenomenon during six or seven years only, has not as yet published any of his observations on the subject, and no one else, to our knowledge, has paid any attention to it. The learned Professor has kindly permitted me to make known in this work those results, altogether novel and unrecorded, which he has obtained. " Every one knows that on applying the hand over the precordial re- gion there is felt, what is called, the beating of the heart ; but hitherto we have limited ourselves to establish by this means the stroke of the apex, and to ascertain the force, the extent and the intensity of this stroke ; we have attempted nothing beyond this.* However, if we feel with attention * See a on page 98. 1855.] Disease of the Heart. 97 the heart's action, we shall perceive distinctly two beats, two movements connected one with the other, and which convey a sensation of tic-tac so like that which we discover by auscultation, that it appears as if we heard the heart with the hand. This is by no means an acoustic phenomenon, it is simply the sensation of the double movement of the heart. This percep- tion obtained by the nerves of general sensibility, and which seems to be transformed for the observer into a sonorous phenomenon, is altogether comparable to the perception of vibrating and sonous rales, of the frictions which occur in the pleura, and which v.e can appreciate by the application of the hand ;* it resembles, also, the non-sonorous grumbling of the intes- . we know indeed that it often happens, that on pressing on the abdo- men we think we hear this grumbling, while in reality we only feel the displacement and the movements of the contained gas and liquids, and which other persons do not hear, because they do not feel them. The per- ception of the beatings of the heart of which we now speak, is a phenomenon of this kind ; it falls simply under the category of tactile phenomena, as well as the crepitation of fractured bones, subcutaneous emphysema, I that the instances of women who were reported to 1 1 ed from the grievous pains of child- bearing, without bad Lould have for a time re- duced to silence those unwelcome monitors who pointed to the possible evils of this n< t, and induced the honest but en- thusiastic pursuers of novelty to turn away their eyes from the contemplation of those dropping cases of disaster which soon showed themselves, and to disturb the general jubilation. But it N. s. VOL. XI. xo. II. 8 118 Injurious Effects of Chloroform in Parturition. [February, does seem to me strange, that, amid so wide-spread an experience as I am convinced now exists of the noxious and dangerous effects of chloroform, it should be necessary for me to assemble the proofs of the havoc it has made. Daily reports, however, convince me that this work is called for ; and I have not shrunk from so sacred a duty. Setting aside the mechanical difficulties of labour, the dangers to which parturient and puerperal women are most exposed may be said to be fourfold : 1, exhaustion ; 2, hemorrage ; 3, fever and inflammation ; and 4, cerebral disturbance. The great cause of flooding is languid or deficient contraction of the uterus. We are assured by many that the contractility of the womb is in no de- gree diminished by the action of chloroform. But of this impor- tant position we have as yet received not a jot of proof ; nay, there are innumerable proofs to the contrary. It is expected that we should be satisfied with bare assertion ; and, considering that it was made at a very early period, when not a score of women had yet been delivered under the influence of chloroform, and, moreover, that it is made by those who continue, in the face of the most painful contradiction of facts, to affirm the perfect innocence of this poison, we may be permitted to set aside this evidence without further notice. But I rely not upon d priori reasoning, but on the direct testimony of my own senses, and maintain, with this unerring guide, that the action of chloroform does very mani- festly impede the uterine contractions, and, in some cases, put a stop to them altogether. The wise and skilful practitioner will hardly require my evi- dence to satisfy him that so disturbing an agent must add greatly to the risks whish arise from inflammation and fever. But they who doubt will find reason enough, in the cases I have cited, to pause and reflect ; while the history here given of severe cere oral affection must surely satisfy the most stolid that all the nervous accidents which attend the puerperal condition, and complicate its risks, must be largely increased by this very active poison. Much reflection on the physiological effects, and observation of the pathological mischief of chloroform, leave no doubt on my mind that it ought to be altogether expelled from the practice of midwifery. There are no circumstances in which it can be with utility, none in which it can be with safety, employed. I am con- firmed in this opinion by conversation with the most discreet and experienced practitioners around me; yet I cannot but entertain grave doubts of the result of my present appeal to the good sense of my profession, when I consider the arts used to propagate a faith in this practice. It has become almost an extra-professional question, while there is a systematic concealment of truth by phy- sicians. Appeals are made by others to the natural timidity of women, and the most fallacious promises of perfect safety are boldly held out. Conceited and ignorant women of fashion make a pastime of this, as of other quackeries, especially the speculum, 1855.] Method of Operating upon Polypi. 119 and the cause of science and humanity is placed in the hands of the most presumptuous and frivolous part of the community, while young inexperienced mothers are decoyed to their destruction. It is no unfrequent occurrence that an accoucher should be select- ed to attend a given woman, but previously told that he must use chloroform. This grave question of medical science has been pre- determined by a quorum of old women, instigated, perhaps, by an itinerant cluchess. There are men to whom such propositions are not at all insulting. They are quite ready to steal a march on their wiser and more manly brothers, by the adoption of any humiliating fashion. Thus, the health and lives of patients are sacrificed, and medical science is dishonoured. If I have helped to rescue the medical profession from the do- minion of a great and dangerous error, if I have placed some re- straint on ignominious and disgraceful practice, I shall rest satis- fled that this*essay has not been written in vain." [Amer. Journ. of Med. Sciences. Method of Operating upon Naso-pharyngeal Fibrous Polypi. By M. Nelatox, Hopital des Cliniques. The true points of origin of these polypi are believed, by the author, to be the inferior surface of the basilar process ; the infe- rior surface of the sphenoid bone, and the internal plates of the pterygoid processes. He states that they never arise from the ver- tebras, and that when they descend into the pharynx, their course lies between the muscular and mucous coats. The complete removal of these tumours is an idea of modern origin. Flaubert of Eouen in 1849 removed the whole maxillary bone of one side for this disease. The same . operation has been since performed by Michaux, of Louvain, Maisonneuve of Paris, and Huguiers. M. Mane, a surgeon of Avignon, sometime ago proposed the division of the soft palate, but it was not received with approbation. M. Nelaton, however, adopts the suggestion of M. Mane, but also advises the division of the bony palate also, thus enabling him to reach more completely the disease. His operation is as follows : The palatine membrane is first divided and the bony arch ex- posed. Two openings are then made with a perforator through the bony palate, and Listoirs forceps being introduced into the perforations a large portion of bone is removed. The posterior part of the nasal fossa?, the inferior surface of the sphenoid bone, and the basilar process will be then exposed, and the polypus brought well into sight. The removal of the polypus, under these circumstance, is easy. M. Nelaton drags the tumour, and severs its connection with the knife. He has repeatedly been successful, and certainly his meth- od is preferable, inasmuch as the alveolar border and the teeth are preserved. [Moniteur des Hop., and Virginia Med. and Surg. Jour. 120 Suture of Tendons, [February, Suture of Tendons. By M. Chassaignac. Our readers may recollect a case of successful tenoraphy prac- ticed by Professor Sedillot of Strasbourg, which was reported in a late number of this Journal.* In the Compte Rendu de la Societe de Chirurgie de- Paris, for April, 1854, we rind a second case in which this operation was successfully performed, and which ap- pears to us worthy of being brought to the notice of the profession. It relates to a girl of sixteen years, who, in Nov. 1853, fell on a piece of broken glass, and received a transverse wound on the anterior aspect of the lower part of the fore-arm, which, after sup- purating for a time, cicatrized. Some months subsequently the patient entered the Hospital St. Antoine with the inability to flex the index finger. It was found that the inferior end of the tendon which had been divided was attached to the cicatrix of the wound already described, and that when this cicatrix was moved, the index finger moved also. On the fourth of February, M. Chassaignac laid bare the flexor ten- dons, by dissecting a rectangular flap of integument from the fore- arm, and passed a suture through the divided portions of the flexor of the index finger. The flap was then replaced and secured by stitches, and the hand was strongly flexed. In a fortnight the wound had united, and the patient left the hospital with the per- fect use of her finger. The ends of the tendon were not refreshed. This fact, when considered in connection with Dr. Mayo's case of rupture of the ligament of the patella, f and our observations on tendinous ruptures in the first number of the present volume of this journal, leads to the conclusion that exact apposition is all that is necessary for the re-union of divided tendons, even when separation has existed for a comparatively long period. {Virginia Med, and Surg. Journal. Case of Strangulated Femoral Hernia, containing Ovary and Fallo- pian Tube Operation Recovery. By WlLLAPJ) PARKEE,M.D.r Prof, of Surgery in the N. Y. Col. of Physicians and Surgeons. On the 31st of October, 1854, I was called on to visit Miss F r in consultation with Dr. W. I obtained the following history of the case : Miss F , aged 69, had always been in perfect health, except at times she had suffered from dyspepsia, and had been annoyed by a hernia on the right side. This hernia had existed for many years. She had attempted to keep the parts in place by means of a truss, but had failed to accomplish it. The hernia had always been reducible, and she had usually -succeeded in replacing the protruded mass. About two years ago, she failed to put the parts back, became sick at the stomach, and called for her family physician ; who, after a while, effected a reduction, and she soon became comfortable. * See Vol. ii, p. 311. + Virginia Med. & Surg. Journal, Vol. i, p. 388. 1S55.] Case of Strangulated Femoral Hernia. 121 The patient had now been suffering for three days ; she had nausea and vomiting, but without dejections ; the abdomen was flat, skin cool, tongue moist, pulse small, 90 beats in a minute. The tumor was hard, the size of an English walnut, and tender at its neck, under Poupart's ligament. Dr. W. stated, that yesterday he put the patient under the full influence of chloroform, and succeeded by firm pressure in reducing the tumor, but no relief was manifested. On moving or making a slight muscular effort, the swelling reappeared. I thought of "reduction en masse" I now tried taxis, but failed with the force she would allow me to employ. She was then put into a state of profound anesthesia; and I again made trial of reduction. I could push the whole tu- mor under Poupart's ligament, but it would seem to bound back. It was now decided to operate. I cut down, and exposed the fal- ciform process of the fascia lata, divided it freely, and then at- tempted to reduce, without opening the sac, but could not succeed I could push sac and all up. I proceeded to open the sac : it con- tained some dark fluid and a small loop of intestine, which was also dark, but not gangrenous. In attempting to explore the neck of the sac with the finger, it receded: and to prevent it from slipping back into the abdomen beyond my reach, I passed a ten- aculum into the sac, and gave it in charge of an assistant. The neck was very firm around the strangulated parts, and seemed not more than half an inch in diameter. I divided it freely, and drew down the intestine that I might understand the condition of it ; finding all right, the loop was re- stored. I found something left behind that was dark, shreddy, and vascular, adherent by a small band to the side of the sac. I saw it was not omentum, and concluded it might be the product of some former inflammation. I concluded to dissect away the mass ; it bled, and I carried a ligature around the whole. When I drew upon the ligature, there came into view the ovary: this demonstrated to my mind that the strange portion I had taken away, was the fimbriated extremity of the fallopian tube. I pushed back the ovary and the remainder of the tube, brought the parts together by suture, applied the gradu- ated compress with the single spica bandage. The patient was put and kept fully under the influence of morphine. After four days an enema was administered, and the bowels were moved. A rapid recover}- ensued. In consulting authorities in regard to this anomaly, I find no parallel case; but Dr. Gr. F. Elliot has furnished me with a case from the Gazette Medicale, for February, 1813, in which the Ces- arean section was performed upon the uterus, occupying a hernial sac. " Patient was 4A years old, mother of seven children, had suffered for many years from a reducible inguinal hernia of right side, which during her previous pregnancies had caused her great annoyance. At the sixth month of her eighth pregnancy, the hernia became strangulated, but by emollient and cold applications 122 The Clamp Suture in Cleft Palate. [February, it was reduced, followed, however, by severe abdominal pains. Soon after, the uterus suddenly presented at the inguinal ring, in the hernial sac, forming a tumor of 8 inches in length by 6 in cir- cumference. The patient remained in bed, and went on to the full term. Labor commenced, the os dilated, and the waters es- ca'ped per vaginam ; the tumor at the time being twenty-five inch- es in circumference by twenty-three in length. The Cesarean section was then practiced, dividing the sac and uterine wall ; the placenta presenting, the operator introduced his hand and deliv- ered a well-formed living infant. Patient died on the third day after, of peritonitis or hemorrhage. On postmortem, there was a large quantity of blood in the abdominal cavity ; the inguinal canal was so dilated that the open hand could easily be introduced, and the colon was found detached, and filling the cavity of the sac." The editor of the Gazette severely censures the conduct of the operator in not reducing the uterus when it first escaped, as might have been done ; and also in not waiting longer than three hours before performing the section a complete hysterocele being not incompatible with the spontaneous termination of labor. I find also that Mr. Velpeau, in the second volume of his Traite des Accouchements, mentions a case by M. Saxtorph, in which the uterus at term occupied a femoral hernia, and was spontaneously delivered. In another case by Frank, the uterus protruded through the linea alba. Flamant cites a case complicating umbilical hernia. [N. Y. Med. Times. The Clamp Suture in Cleft Palate. We recently witnessed an operation for this affection by Dr. J. Marion Sims, of this city, in which he used this peculiar method of suture. The case was a bad one ; articulation very indistinct, and deglutition of fluids frequently attended by regurgitation through the nostrils. The clamp suture, composed of very fine silver wire, fastened to small leaden cross-bars, will remain innocu- ously in the tissues for an almost indefinite period, which consti- tutes its great superiority over any other suture. In this case the clamps were removed on the sixth day the cure was perfect. This is not, by any means, the first case of the sort in which Dr. Sims has applied this suture with success ; and it is our opin- ion that the operation of staphyloraphy, by this method, will never fail, if properly performed. It is well known that difficult and tedious labor sometimes re- sults in the most deplorable injuries to the mother: such as lacera- tion of the perineum, bladder, or bowel, and that these affections were wholly incurable till the introduction of the clamp suture by Dr. Sims. It is no wonder, then, that the Profession, both in Eu- rope and America, unite in according to him the highest praise for this great boon to science and to suffering humanity. And now, since he has demonstrated the easy curability of cleft palate 18oS.] Novel mode of Opening an Ovarian Cyst. 123 by the same means, we cannot but hail it with delight as another triumph of American Surgery. [American Med. MontJily. Novel Mode of Opening an Ovarian Cyst. Dr. Sims, of this city, has recently performed this operation in a mode which is new and which seems to possess several excel- lencies. A trocar, fifteen inches in length, curved so as to be the arc of a circle of four and a half inches radius, was, with its canu- la, inserted at the usual place of tapping in abdominal dropsy. After a portion of the fluid was drawn off, the point of the trocar was drawn within the canula, which, after several attempts, was finally carried to the cul-de sac, between the uterus and rectum; and when felt there by the finger in the vagina, the trocar was again protruded, the sac and the vagina perforated, and the ex- tremity of the canula brought out between the labia majora ; thus, in fact, transfixing the patient. A self- retaining catheter was then attached to the canula, and drawn into the ovarian sac, where, being separated from the canula, it was secured within the sac. The canula was then withdrawn, and the external opening closed. In this way the contents of the cyst were allowed to drain entirely away, and it is hoped that obliteration of the sac and the cure of the patient, will be the result. At our present writing, nearly three weeks after the operation, she is going on well. [1 bid. Treatment of Albuminuria after Scarlatina. Formerly it was customary to treat this and all other dropsical affections with diuretics. Prof. Mauthner, however, in the dropsy which occurs after scarlatina, and is accompanied by bloody and albuminous urine, sedulously avoids whatever might overstimu- late the kidneys, as Jikely to cause an acute renal inflammation, or an attack of Bright's disease. He has seen many cases where the swelling increased daily in spite of the administration of squills, digitalis, bitart. potassae, &c, in which a cure was effected by a simple regulation of the diet. In such cases he advises the exclu- sive administration of milk, and rice and milk, or at most of decoct, althea, or of decoct, lini sem. By the exclusive use of milk diet, he has seen the action of the kidneys so regulated, that a copious secretion of urine, free from albumen, was established, by means of which the dropsical condition was removed. When the admin- istration of milk fails to effect a cure, he endeavours, by means of alkaline agents, to alter the condition of the urine ; and, for this purpose, he prefers using the alkali of the urine itself. He accord- ingly administers urea in small doses (either in the form of pure urea, or of the nitrate of urea), giving generally fne third of a grain for a dose, in combination with a little powdered sugar. After six or eight grs. of the urea had thus been taken, he has 124 Editorial and Miscellaneous. [Febrrilry, frequently seen profuse diuresis occurring, followed by the speedy disappearance of the dropsical affection. [Monthly Jour. Med. Sci.} from Jour, fur Kinderkranlcheiten. EDITORIAL AND MISCELLANEOUS. BIBLIOGRAPHICAL. Manual of Human Microscopical Anatomy. By A. Kolliker, Professcr. of Anatomy and Physiology in Wurzburg. Translated by Geo. Busk, F.R.S., and Thos. Huxley, F.R.S. Edited with notes and additions, by J. Da Costa, M. D. Illustrated by 313 engravings on wood. Phila- delphia: Lippincott, Grambo & Co., 1854. 8vo., pp. 802. (For sale by T. Richards & Son.) It is really a treat to be placed in possession of Kolliker's histology in plain English. The learned professor's labors in the productive field of microscopy, have made his name familiar to all enlightened men, and the American medical profession should feel grateful to those who have ena- bled them to become more intimately acquainted with his valuable contri- butions to knowledge. We know of no book that will be found more in- teresting to the student. Transactions of the Illinois State Medical Society, for the year 1854. Chicago. Although too often resulting in strife, because of their conversion into police tribunals instead of being devoted exclusively to the promotion of scientific emulation, the formation of State Medical Societies has, notwith- standing, been productive of much good. The Transactions of the Illinois Society for 1854, comprising about 110 pages, will be found one of the most creditable productions of the kind. It is true that the work contains only three articles, but they are all papers of decided interesfand indicative of a high order of talent. The first is the annual address, by Prof. Daniel Brainard, on the treatment of poisoned wounds by the application of cupping glasses and the infiltration of solutions of iodine. The second is an elsay by Dr. E. S. Cooper, entitled "walking rendered the primary element in the cure of deformities of the lower extremities ; its early adaptation to white swel- ling and coxalgia, with apparatus for carrying out the designs of the same." The third is a prize essay on differences in the physiological and pathologi- cal action of that class of remedies called stimulants, of which alcohol is the type, and tonics, of which the bitter barks and iron may be considered as specimens, by H. Parker, M. D. We regret that our limits will not allow us to notice these papers at present, but we hope to do so hereafter. We have also to acknowledge the reception of the Transactions of the College of Physicians of Philadelphia, No. 6 Vol. 2. 1855.] Editorial and Miscellaneous. 125 A lecture introductory to the course of surgical instruction in the Ken- tucky School of Medicine, 1854-5, by Prof. Joshua B. Flint. A brief sketch of the history of Lexington, Ky., and of Transylvania Uni- versity, delivered as an introductory lecture to the winter course in the medi- cal department of Transylvania University, 6th Nov. 1854, by Rob. Peter, M.D., Professor of Chemistry, &c. A new plan of treating ununited fracture by means of artificial limbs, which combine the principle of Pressure and motion at the seat of fracture and lead to the formation of an ensheathing callus. Illustrated by the history of 4 cases of false joint in the femur, 8 in the leg, and 2 in the humerus. By Henry H. Smith, M. I)., etc., &c. Elkoplasty, or anaplasty applied to the treatment of old ulcers, (a reply to Dr. "Watson's reclamation) by Frank H. Hamilton, M. D., &c. Atlanta Medical College. This institution has been reorganized, and proposes to deliver a summer course of Lectures during the ensuing season. The Faculty consists of: M. G. Slaughter, M. I)., Prof, of Anatomy ; J. W. Jones, M. D., Prof, 'of the Principles and Practice of Medicine ; Jesse Boring, M. D., Prof, of Obstetrics and Diseases of Women and Children ; W. F. Westmoreland, M. D., Prof, of the Principles and Practice of Sur- gery ; J. E. Dubose, M. D., Prof, of Physiology ; G. T. Wilburn, M.D., Prof, of Surgical and Pathological Anatomy ; J. J. Robertson, M. D., Prof, of Chemistry and Medical Jurisprudence ; J. G. Westmoreland, M. D., Prof, of Materia Medica and Therapeutics, and Dean of the Faculty. Successful Gastrotomy. The Medical Examiner contains the details of an interesting case of rupture of the uterus, in which the operation of Gastro- tomy was successfully performed by Dr. John Neill, of Philadelphia. The child was found lifeless. The same Journal contains also a Report by W. H. Merinar, of Missis- sippi, of two cases of successful Cesarean section, which he performed upon the same person in July, 1852, and May, 1854. Case of Hydrocephalus, in which the Head was tapped Eight Time*. By Mr. Brown of Haverfordwest. A child, six months old, with chronic hydro- cephalus, was placed under my care on July 10, 1852. I enclosed the head with straps of adhesive plaster, and persevered in this plan for some time. No good effects were produced. I now proposed tapping, to which the parents consented. Mr. Rowe was called into consultation, and assisted. August 6th : We removed six ounces of serum. The child became a little sick and faint. 7th: The child was apparently much improved; it looked more intelligent, and took greater notice of the nurse. The head was tightly strapped up. 18th : The head was as large as ever. It was tapped to six ounces, with the same results. September 6th : The Ifad was larger than it had been at all ; and it was tapped to eleven ounces, 126 Editorial and Miscellaneous. [February, with the same results as on the previous occasions. 28th : The haad was again larger; and twenty ounces of fluid were removed by tapping, with the same results. October 8th : The head was tapped to eleven ounces. 18th: Tapping was performed, and sixteen ounces of fluid were remvved. 25th : Twelve ounces of fluid were withdrawn. 30th : We now abandon- ed tapping as useless, and inserted a seton of silk through ihe membranes of the brain, running it along the interior for an inch before bringing it out. No immediate result was produced ; but a great quantity of serum flowed fiom the orifices through which the seton passed. At the end of twelve hours, there was no change. At the end of twenty-four hours, there were vomiting, restlessness, and expressions of pain and distress. In thirty- six hours, there appeared twitching of the muscles and startings, bordering on convulsions. In forty-eight hours from the introduction of the seton, the child refused his food. Moaning and approaching stupor were now observed. The seton was now removed ; and these symptoms gave way in a day or two. The head was by this time much decreased in size, and continued so for several days. We now flattered ourselves with hopes of a cure ; but in another day or two, evident signs of secretion manifested themselves, and at the end of twelve days we tapped again, and again the fluid collected. We now gave up all hope, and allowed the disease to take its course. The head attained a frightful size ; and the child died. Examination of the body. A large washhand basin full of serum was taken out of the brain. The containing sac was formed by the brain, which was completely unfolded, and so stretched, that it was no thicker than the dura mater. This fact, in our opinion, accounted for the failure of the treat- ment. Had the water been contained in the membranes instead of in the ventricles, there would have been a better chance of success. I would never hesitate to make similar attempts at a cure, with the hopes of the membranes being the investing envelope of the water. In such cases, a happy termination might be expected. Association Med. Jour. [The Senior Editor of this Journal tapped the head seven times in a case of Hydrocephalus in 183*7, with results similar to the above. In this case a post-mortem examination revealed likewise a complete unfolding of the cerebrum, which constituted the sac containing the fluid. The case was reported in the first series of the Southern Medical and Surgical Journal, p. 440, Vol. i, 1837.] Treatment of Acne. The cases of acne at the Hospital for Skin Diseases are usually classified under the heads of A. simplex, A. indurata, and A. rosacea. The latter, in its best marked examples, often occurs without appreciable derangement of the general health, and is extremely intractable. The long-continued use of tonics and alteratives with the local employment of a mercurial wash or ointment, often effects great improvement, but not unfrequently the disease resists all measures. When the red spots are very persistent and disfiguring, they are touched with the solution of the acid nitrate of mercury, a plan*by which single tubercles may be got rid of, but which does not prevent others from coming out. It is, therefore, best adapted to those cases in which the individual tubercles are very hard and persistent, fresh crops appearing only at long intervals. 1855.] Miscellaneous. 127 Cases of the two other forms of acne almost invariably yield quickly to treatment. In both, the local measures adopted are the same ; any suppu- rating tubercles are punctured or opened by means of a minute drop of nitric acid. The patient is directed never to wash the face with soap ; to be particular to squeeze out any little black points which become visible, and to apply every night to the tubercles a small portion of an ointment of which the chief active ingredient is the ammonio-chloride of mercury, in the proportion of ten grains to the ounce. The constitutional treatment consists in rectifying the cachexia, on which these forms of acne almost always depend. Chalybeates, with aperients, are found the most useful. In the acne simplex, the sulphate of iron, in combination with the sulphate of magnesia and an excess of acid is usually employed ; but in the acne indurata the iodide of iron is preferred. In either case the remedy must be continued for several months, but the patient may be promised as a reward for perseverance, that not only will the eruption disappear, but that the general health will be much improved. The rarity of the simple form of acne in roamed people, is an observa- tion quite borne out by the experience of this hospital. [Medical Times and Gazette. Ccesarian Section thrice upon the same woman. By Dr. Barjavel. In a Jewess, at Carpentras, of scrofulous habit and rachitic appearance, the child presented by the feet at her first confinement. The midwife and two surgeons who attended pulled so hard, that in their efforts at delivery they separated the child's body from the head, which remained alone in the uterus. M. Barjavel (the father of the author) found, when called to the case, the cavity of the pelvis narrowed throughout by exostosis, so that no course remained but the Caesarian section, wrhich he performed, as usual, in the linea alba. In forty days the wound healed. In spite of the danger to which she exposed herself, she became pregnant again in three years, when the operation was again performed, and a living child was extracted, The mother suckled it, and it is now alive. In four years more she be- came pregnant a third time, when a young surgeon attempted the same proceeding, but he was not equally fortunate, for the child, a female, was dead, and the mother sank in a few days from haemorrhage. [Rev. Thir. du Midi. Dublin Med. Press. Salt as a Preservative of Dissecting Material. About the first of De- cember, 1853, a fine muscular subject was injected through the femoral artery with a solution containing 3lbs. of nitrate of potash. It was then packed in a solution of common salt. It was dissected during April, and found to be in excellent preservation ; the muscles being unusually red, a quality, to obtain which, the injection was used. It kept better on the ta- ble than any other subject we ever saw, lying for a month of warm weather without much decay, the muscles drying down instead of softening by pu- trefaction. Another subject was packed in the brine about the 1st of January, the injection being omitted. This subject has stood during the entire summer in a room lighted by a large window, with a southern exposure, the barrel in which it was placed being open to the air at the top. After nearly nine months of this hard usage it is now upon the table in capital preservation. The advantages of this mode of preservation are these : 1st. It is cheap and certain. 128 Miscellaneous. [February, 2d. The tissues are dryer than when preserved in the usual manner, and the dissection consequently cleaner and less obscure. 3d. The nitrate of potash gives a lively red to the muscles. 4th. The subject bears exposure upon the table better, and does not com- municate that extremely offensive smell to the hands, which accompanies ordinary dissections. A cereful washing removes all smell. All good things have their drawbacks. The fault in these subjects is a hardening of the fingers and toes, which renders dissection of those parts well nigh impossible, as they cannot be softened by water to any extent. * This hardening is attributed to the presence of an excess of salt in the solu- tion. If this supposition should prove to be correct, we can conceive of no better means of preserving material for months, or years, than by common brine, as subjects thus preserved are (with the exception we have mention- ed) really more pleasant to dissect than a fresh subject. [Buffalo Medical Journal. Quinic Ether. A discovery which has lately been made in Italy, and which has excited much attention, is illustrative of the results of perseve- rance and industiy. In the month of June, 1852, a young man, M. Louis Manetti, a student of the University of Pavia, happened to witness the death of a patient with congestive fever, who died apparently from the impossibility of introducing into the system, in a short time, a sufficient quantity of quinine. Manetti was struck with the idea that the principle of the bark might be effectually administered through the medium of pulmonary absorption. Encouraged by Professor Pignacca, Manetti began a series of investigations, the results of which are detailed in a letter from Prof. Pignacca to Dr. Stambio of Milan, a translation of which is found in the " Annales de la Societe Medi- cale de Grand." Professor Pignacca has called the new agent for inhalation, Quinic Ether, probably for want of a better name, for it is not, properly speaking, an ether, and its positive chemical composition is not known. It is a liquid of a spe- cial inconstant odor, and is obtained by the distillation of quinate of lime (quinate de chaux) combined with alcohol ; and is analogous to the etherial bodies in general, volatilizing like them. Professor Pignacca states in his letter that he has administered this fluid by inhalation to eight patients ; seven of them had tertian intermittent fe- ver, the last neuralgia of the fifth pair. The neuralgia was of an intermit- tent type. The remedy acted admirably both in the cases of fever and in the case of neuralgia. The quantity of the agent given is about a scruple at a time, repeated three or four times a day. It is administered in the same manner as chlo- roform, and it produces sensations somewhat similar. \N. 0. Medical News, and Hospital Gazette. Effects of Fright on the Unborn Foetus. " I happened, the other day, to meet a most extraordinary account given by Baron Percy, an eminent French military surgeon and professor, said to have occurred after the seige of Landau, in 1*793. If true, it is a most interesting fact, and one well worthy of deep investigation. He says, that ' in addition to a violent can- nonading, which kept the women for some time in a constant state of alarm, the arsenal blew up with a terrific explosion, which few could listen to with unshaken nerves.' Out of ninety-two children born in the district within 1855.] Miscellaneous. 129 a few moths afterwards, he states, that ' sixteen died at the instant of birth ; thirty-three languished for from eight to ten months, and then died ; eight became idiotic, and died before the age of five years ; and two came into the world with numerous fractures of the bones of the limbs, caused by the convulsive starts in the mother, excited by the cannonading and explosion !* " Here, then, is a total of nearly two oat of three actually killed through the medium of the mother's alarm, and its natural consequence upon her own organization." These facts, if such, are indeed interesting; and it is hoped the profession will improve every opportunity of testing the truth of them. [Lancet. Delirium Tremens. Tartar Emetic. I>r. Peddie, (Monthly Journal.) discountenances the treatment by opium, and recommends, from an experi- ence of 80 cases, the use of tartar emetic, in doses of from one-quarter to one-half of a grain every two hours. If the bowels are not opened by this remedy, compound jalap powder is given. The patient is not to be restrain- ed by mechanical means, and light is freely admitted into the room, as by its means optical delusions are prevented. [Medico- Chir. Rev. Dropsy (Ovarian). Iodine. Dr. Simpson (Monthly Journal) refers to seven or eight cases of ovarian dropsy in which, after tapping, tincture of iodine (two or three ounces) has been injected into the sac. In two or three cases the disease seemed arrested, but in the others this was not the case. No great pain followed the injection, and no febrile symptoms, except in one case. [Ibid. Epilepsy. Atropine. Dr. Lange (Schmidt's Jahrb., No. 9, p. 299) has used atropine in 10 cases of eplilepsy (three men and seven women). The three men, who had suffered from the disease for many years, were cured in three, five, and six weeks. Two of the women were not improved, one died, and three appeared to be cured, as, after from five to eleven months, they had had no fresh attacks. In the last case, one of epilepsy and com- mencing idiotcy, the atropine failed. The dose appears to have been about the 1-1 00th of a grain. M. Delasiauve, in his late treatise on 'Epilepsy' (p. 369), states that he has experimented with belladonna for many years at the Bicetre, and that, while he has seen some cases in which the fits were for the time suspended, he has only seen one instance of cure. [Ibid, Hydrocele. Collodion. Telpeau (L'Union, Juillet) applies collodion over the scrotum on the third or fourth day, after the usual operation and iodine injection. The secondary inflammation and engorgement are much lessened in severity and duration. Yelpeau intends to apply the collodion immediately after the operation in the next case he has to treat. [Ibid. Gonorrhoea. Subrdtrate of Bismuth. Both in acute and chronic gonor- rhoea Dr. Caby employs, three times daily, an injection, composed of water mixed with as much trisnitrate of bismuth as can be suspended. It is to be retained five minutes ; it causes no pain. [Ibid. Laryngitis. Nitrate of Silver. Dr. Ebert (Annalen des Berlin Char, Krankheiten,) employs inhalations of nitrate of silver in substance with great benefit, in all inflammations of the lyryngeal mucous membrane. He has employed the nitrate of silver also in solution, after the manner of *30 Miscellaneous. [February, Green, but has never been able to satisfy himself that the larynx was really entered. The mode in which the solid caustic is introduced is as follows : Three grains of the nitrate are mixed with one drachm of sugar ; the pow- der is placed in a steel pen, which is itself firmly inserted in a quill open at both ends. The little apparatus is then put into the mouth, so that the end of the steel pen shall be on the root of the tongue ; then the lips are closed round the quill, and the patient inspires forcibly. The first attempt is almost always a failure, and the nitrate is only tasted on the root of the tongue, but the patient soon learns to manage it very well ; a little cough and irritation follow, but no great uneasiness. For young children this method does not answer, and a special apparatus must be used. [Ibid. German Poison Eaters. Dr. Tschudi has published, in the Wiener Medizinische Wochenschrift two letters, the translation of which is to be found in the Journal de Medicine de Bruxelles, containing some curious details relative to a class of people who are habitual arsenic-eaters. In some countries of lower Austria and of Styria, especially in the moun- tains which separate these parts from Hungary, there exists among . the peasantry the singular habit of eating arsenic. They purchase it under the name of hedri, (hedri, hedrich, hatterrauch) from wandering herbalists, or pedlars, who, on their part, obtain it from workers in Hungarian glass, from veterinary surgeons, from charlatans. These poison-eaters (toxicophagi) have a double aim ; first, they wish to give themselves, by this dangerous habit, a fresh and healthy appearance, and a certain degree of embonpoint. Many of the peasant girls, and even the men, have recourse to this expedient from coquetry and ( a desire to please ; and it is remarkable what success they attain, for the young toxico- phagi are distinguished by the freshness of their complexion and by the aspect of flourishing health. The following is one of many instances. A girl who attended cows, in good health, but pale and thin, was employed at a farm in the parish of H . Having a lover, whom she wished to attract yet more by her personal charms, she had recourse to the usual method, and took arsenic several times a week. The desired result was soon obtained ; and after some months, she became fat, chubby-cheeked, and, in short, quite to Celadon's taste. To carry the effect further, she in- creased the dose, and fell a victim to her " coquetterie ;" she died poisoned. The number of deaths from the abuse of arsenic is by no means inconsidera- ble, especially among the young people. Every ecclesiastic in those parts can speak of several victims, and Dr. Tschudi states that his researches among the clergy were very interesting. He learned that so careful were the victims of this practice to conceal what they had done, that the secret was often revealed only on the death-bed. The second advantage gained by the toxicophagi is, that they become more " volatile," more free in respiration, and able to ascend high moun- tains with ease. Upon every long excursion into the mountains they take a little bit of arsenic, which they let dissolve in the mouth. The effect is surprising. They ascend without difficulty heights which would have been almost insurmountable without this practice. The author adds, that upon this experience, he has advantageously administered Fowler's solution in cases of asthma. The toxicophagi commence with a bit of arsenic the size of a lentil-seed, or about half-a-grain. They keep to this dose, which they swallow several times a week, morning, and evening, for a long period, to become accus- 1855.] Miscellaneous. 131 tomed to it. Then they increase the quantity insensibly, but with precau- tion, until the desired effect is produced. A countryman, named R -, of the commune Ag , a sexagenarian, and in excellent health, was in the haoit of daily taking four grains. He had followed the habit forty years, and had transmitted it to his son. There was no trace of arsenical cachexia in this individual, no symptoms of chronic poisoning. It is to be remarked, however, that, when the practice is dropped, emaciation gene- rally ensues from some cause, either from the withdrawal of the stimulus, or from accidental or acquired disease. The custom does not diminish the sexual passion, as is the ca?e with the opiophagi oi the East, or with those who use* the betel in India and Polynesia. On the contrary, the feeling- becomes more strong. It may be as wellto bring to mind a general use of arsenic in Vienna, among the stablemen and coachmen of the great houses. They mix a good pinch of the powder with corn, put a piece the size of a pea in a linen bag, and attach it to the bit of the horse. The saliva dissolves the poison. This produces a blight aspect of the skin, roundness and elegance of form, and foam at the mouth. The coachmen of the hills adopt the same practice before commencing a laborious journey ; and horse-dealers carry with them small balls of arsenic, to be given to those animals which are being led to market. Should a horse thus treated pass into the hands of a master who does not employ arsenic, he gets thin, loses his freshness, becomes dull, and in spite of abundant food does not acquire his former sleekness. [London Chem is t, from Gaz. des Ho pi ta u x. 0 Variety of the Human Species. Men with Tails. Authentic De-tails translated from the October Xo. of the Gazette Hebdomadaire, by John AY. Green, M. D. Dr. Hubsch, Hospital Physician at Constanti- nople, has addressed a letter on the subject of Men with Tails, which adds many interesting details to those already received from travellers. We will briefly lay before our readers the information, more or less positive, which we possess on the existence of this curious variety of the human species, and of which the earliest indication dates back as far as 1677. Mr. Editor At this time when attention seems to be concentrated on the subject of a tail-bearing race called Xiam-Xiams. it gives me much pleasure to be able to add some observations which I have had occasion to make at Constantinople. In 1852, I saw for the first time one of this race, a negress; struck by this phenomenon, I interrogated her master, a slave merchant. I was in- formed by him that there existed, in Xigritia, Africa, a tribe called Xiam- Tiams ; that all the members of this tribe bear the caudal appendix ; and, as exaggeration is a necessity to the Oriental imagination, he assured me that he had seen tails, two feet in length. The one observed by me, was smooth, and without hair, was two.inches in length and terminated in a point. The negress was black as ebony; her hair was crisped ; the teeth were white, thick, and" inserted upon the alveolar processes, strongly in- clining outwards. The four canines were filed ; her eyes were injected with blood. She ate raw meat with much relish, clothes were disagreeable to her ; " son intelligence etait au niveau de celle des gens de son espece.M Her master had offered her for sale for six months, at an exceedingly low price, but was unable to sell her. The horror which she inspired not re- siding in her tail, but in her taste (which she took no pains to conceal) for human flesh. 132 Miscellaneous. Her tribe eat the flesh of prisoners taken in battles with the neighboring nations, with whom they are constantly at war. When any of them die, the relatives, instead of interring the bock-, eat it; from this cause there are no cemeteries in the country. They do not all lead a wandering life, many of them construct huts with the branches of trees ; they manufacture the implements of war and of agriculture, cultivating maize, grain, &c. Cattle are also bred by them. The Niam-Niams have a language which is altogether primitive, it con- tains many Arabic words. They go entirely naked, and wish for nothing but to satisfy their sensual appetites. Les fils couch ent avec leures meres, les freres avec leurs soeurs, etc. ; there is a frightful pellmell. The Jftrongest among them becomes their chief; he it is who leads them to battle, and it is he who divides the booty. It is not known whether they have a religion ; but it is probable they have not, from the very great facility with which they embrace any that is taught them. It is very difficult to civilize them, their instinct leading them always to search for human flesh ; there are examples of slaves who have killed and then devoured the children of their masters who had been confided to their care. I saw last year, a man of this same race, having a tail one inch and a half long, covered with a few hairs. He seemed to be about thirty-five years of age; was robust, of good constitution, ebony black, and had the same particular conformation of the lower jaw, spoken of above, i. end,. r Huigc joint . 6 Two gum elastic to6es f Spiral spring. e Two metallic tides. g tithsti'c movetxSlt spruig. d Two ivory Knobs ctt outrcU ext/^emities * SOUTHERN MEDICAL AID SURGICAL JOURNAL. VoiTlL] NEW SERIES MARCH, 1855. [No. S. ORIGINAL AND ECLECTIC. ARTICLE V. Cold Water in Acute Dysentery. By JosiAH Browx, M. D., of Gaylesville, Cheroke County, Ala. Case I. J. T. C, Esq., a farmer residing in Cherokee county, Alabama, aged about 40, was severely attacked with diarrhoea on the 22d of May last. I visited him on the 25th. His bowel af- fection had assumed a dysenteric character, as will appear from the following symptoms, viz : Dejection every half hour, attended with violent tenesmus and straining ; passing a variable quantity (from one gill to half-pint) of thick, bloody mucus ; thirst extreme ; no appetite ; tongue dry, with brown coat ; pulse over 140 in fre- quency, quick and small ; extremities varying in temperature, the cold spells being apparently attributable to the depressing influ- ence of his intense suffering. Administered: R. Castor oil, 3SS.; turpentine, 40 gtts. Prescribed, in three hours after, the following anodyne to be taken every 4 hours: R. Morphine, \ gr.; chloric aether, 3 ij.; camphor water, sss.; bi. carb. of soda, x. gr. Also, morning and night: R. Blue mass, v. gr; diet, flour gruel. 26th. Found him somewhat improved in appearance : rested tolerably well during the night, having had one or two evacua- tions of the same character; pulse about 125, and rather fuller. Prescription : Continue anodyne and blue mass. 27th. (morning.) Patient much weaker; represented to have had evacuations about every two hours during yesterday morning N. S. VOL. XI. SO. III. 9 134 Beown's Cases of Acute Dysentery. [March, and much oftener in the evening and night, with considerable in- crease of fever. Extremities, now, quite cool ) pulse feeble and about 120; evacuations about every hour, accompanied with eramp and tenesmus, without change in character, I remained with him to-day. Prescribed quinine, commencing at 7 o'clock, A. M., but failed to prevent the exacerbation of fever, which oc- curred at 10 o'clocky with great aggravation of the dysenteric symptoms. 1 o'clock, P. M. Prescribed the application of coldr wet towels,, to the lower zone of the abdomen, frequently repeated, i. e., when- ever the cloths assumed the temperature of the body also, after each action , the injection into the rectum of one pint of the coldest water, which treatment was continued through the night. 28th. Here, I find the first change in the character of the stools the muco-sanguinolent property being very much dimin- ished, they consist chiefly of concrete fecal masses, suspended in the water which had been injected ; and now, does he experience the first appreciable relief from his dysenteric distress; Prescription ; Continue the external and internal application of the cold water, though less frequently, viz., twice or thrice a- day ; also, continue quinine, blue mass and anodyne,, as before prescribed. 29th. Find my patient very comfortable f pulse improved in force and diminished in frequency ; skin of pleasant temperature and moist ; tongue much cleaner j passages far less frequent, and fecal, though not entirely so, but attended with little pain. Prescription : Continue the cold water. SOth. Patient much better in every respect ; which improve- ment tended to a speedy recovery, the different phases of which, it is unnecessary here to detail. Case II. Mrs. H., of Cherokee county,. Ala., aged 35, of deli- cate constitution and spare habit, was taken with frequent, pfcinful and bloody evacuations, on the 10th of July last, 12th. Called to see her7 and find her with high fever, complain- ing of a continuous dull painT deep seated, in the lower region of the abdomen, and increasing, to sharp griping at each approach of her calls to stool, which occur about hourly. Prescription: ^. Castor oil, 3 i.; turpentine, 3 i. Also, in four hours after, the anodyne dose prescribed in case 1st, every four hours. 1855.] Brown's Cases of Acute Dysentery. 135 13th. Patient had had several fecal evacuations from the oil and turpentine during the night, after which, the bloody mucus passages returned with severe pain and tenesmus ; fever continues unabated, and no improvement in any respect. Prescription : Continue anod^me, and in addition, the repeated application of cold, wet towels to the hypogastrium, as in No. 1, Also, blue mass, grs. v., night and morning. 14th. Patient no better. Pulse 145, and rather feeble ; head- ache ; tongue dry with dark brown fur ; intense thirst with nausea and vomiting ; evacuations rather more frequent, attended with painful straining ; extremities cool ; great nervous irritability and extreme dejection of spirits. Prescription : Continue anodyne, blue mass and external cold applications. Also, inject 1 pint of the coldest water into the rectum after each passage. 15th. Find my patient quite comfortable, having slept pretty well during last night, in far better spirits free from headache, nausea, thirst, &c; pulse not much over 100; dejections much less frequent about 3 hours apart. She had passed during the night, at different times, a considerable quantity of hardened fecal lumps, with but little of the bloody matter. Prescription : Continue treatment ; also, quinine. 16th. She is still improving : no fever; calls to stool greatly diminished in frequency, &c. Prescription : The cold injections to be governed by the fre- quency of the stools. Diet, throughout, flour and milk gruel and some chicken soup. Mrs. H. continued to improve and soon resumed her accustom- ed health. Case III. Mrs.TT., of the same neighborhood, aged 40, ordina- rily of plethoric habit, fell sick on the 28th of July last, with that concomitance of symptoms which would be denominated dysen- tery. Never having had a physician in her family before, she exhausted the whole paraphernalia of domestic medicine Upon her case, without any abatement of its severity, but which, on the contrary, was steadily enhanced with a corresponding diminution of her physical strength, to an alarming extremity. August 7th. Called to see Mrs. W., and find her exceedingly low very much emaciated, with extreme debility, not being able to arise to stool ; entire loss of appetite; tongue very dry ; nausea 136 Brown's Cases of Acute Dysentery. [March, and vomiting; skin hot and dry; pulse quick, small and 130 in frequency; abdomen tumid; alvine discharges small, muco- sanguinolent, and every half hour with excessive tormina and tenesmus. Prescription : The application of cold, wet towels to the abdo- men, and the injection of 3 pints of the coldest water per anum, immediately; and 1 pint injections to be continued after each passage. This administration was attended with the most marked and prompt relief, as expressed by the patient. With the water was expelled a considerable quantity of the muco-sanguinolent, with some feculent matter. Prescription: The anodyne mixture above-mentioned every four hours, and blue mass, grs. v., night and morning. 8th. Find Mrs. W. very weak, but without fever and feeling much better, having had only three or four evacuations during the night, and resting well. The distention of the abdomen has subsided ; her passages recur only about every four hours with much less suffering. Prescription : Continue cold enemata, anodyne and blue mass. Diet, chicken soup, &c. 9th. Patient still better in every respect. Continue treatment pro re nata. The improvement of this patient was steady and rapid, and with the assistance of chalybeate tonics and a generous diet, she soon arrived at her usual robust condition of health. Thus, might be multiplied, cases almost ad infinitum , from my practice of last summer and autumn, if it were necessary ; but the foregoing will suffice to accomplish the object for which they were registered, viz : of calling attention to so simple and con- venient, yet so powerful, safe and reliable a remedy as cold water, in the treatment of so distressing and dangerous a malady as acute dysentery, In the locality in which these cases were noted, this disease appeared with an almost epidemic invasion furnishing satisfactory opportunity for displaying the respective merits of the varied, and I may say, antipodal modes of treatment of the pre- sent day. I cannot say, that the now, Justly, almost exploded practice of narcotising the diseased organ, presented no enticements, or had not its trial ; nor that the recent and rather more rational, purga- 1855.] Brows' s Coses of Acute Dysentery. 137 tive method, was not called into requisition, during my intercourse with this epidemic, both having to yield to the overwhelming superiority of a more simple and more rational procedure. Each of the former modes has its commendatory qualities, as well as its objections, which furnish each a sufficient plausibleness to cause them to be selected by some, for the only plan of treatment in this disease, just as these qualities agree with their conception of the indications presented therein. The opiate treatment relieves tem- porary suffering, but its plausibility consists in a suppression of complaint, without remedying the cause of that complaint. The purgative method, whether by continued drastic cathartics or emollient laxatives, may be considered equally objectionable, for by the former it is attempted (I imagine) to set up an excitement in one portion of the canal, which will counter-irritate that already existing in another, or to relieve the turgid condition of the vessels at the site of the disease by free depletion. And by the latter, the endeavor probably is, to cleanse the canal, remove ail irritating substances and prevent their accumulation without furnishing any additional source of irritation. To answer these indications on this expensive plan, would occasion difficulty in another quarter, which I deem of considerable importance, although it may not be generally so esteemed. In an attack of dysentery, which is usually protracted, the fatiguing and agonizing concomitants which char- acterize the disease, being so detrimental to the physical strength of the patient, it appears unphilosophic to offend the stomach by nauseating purgatives, besides washing away, or rendering the absorbent surface incapable of receiving the little nourishment able to be borne by him, and diminishing his strength, which is of paramount importance here, by intercepting his nutriment, or laying it waste by drastic purgation. I would assign to these two forms of treatment, the place of mere adjuvants, to be used conditionally, in connexion with what I consider a more rational plan. Hence, opiates may be given in accordance with the severity of the suffering, for their anodyne effect, and not with a view of suppressing the evacuations, which should be carefully avoided. It is often best to premise the treatment with the exhibition of one dose of some laxative, as castor oil, to prepare for the dislodg- ment of the scybalous accumulation in the large intestines, and if a more stimulating agent is required to overcome the torpidity of the bowel, there is none more admirably appropriate than the 138 Cooper's Case of Hydrocephalus. [March, turpentine, whose stimulation is independent of any drastic mo- dus operandi. I will now briefly consider the superior advantages of the Cold Water Treatment, as pursued in the foregoing cases, and particu- larly its topical application by enemata. The immediate effect of its introduction is remarkable the patient generally expressing entire relief from the pain and burning sensation, which suspen- sion of suffering lasts for a considerable time. Thus, in its anodyne effect, surpassing, by promptness and completeness, all the ordinary means. The nervous irritability which is excited in these cases, with nausea and intense thirst, especially in females, and the high febrile excitement, yield equally to its sedative and cooling effects. The evacuant and cleansing properties of the measure, are unsurpassed by purgatives, and without the danger of reducing the patient by hypercatharsis or interference with nutrition. While hydragogue cathartics may reduce the inflamed condition, by a draght upon the turgid vessels of the part the cold application, by a more economical process, would suppress the inflammatory action, by contracting these distended vessels, driving out their superabundant-blood and fortifying them against a continuance of the phlogosis. In conclusion, I hope it is apparent, that more efficient, univer- sal and happy qualities, are not to be derived from any other treatment. ARTICLE VI. A Case of Hydrocephalus Spontaneous Tapping Death. By Geo. F. Cooper, M. D., of Americus, Georgia. The following case is not reported for any novelty in the treat- ment, or the presence of any extraordinary symptoms, but, alone, for the unusual manner in which it terminated ; being so far as I know, the only case upon record, where nature sought to relieve herself by the identical operation, not unfrequently practiced by art. On the 15th day of May, I was requested to visit the child of Col. J. J. J., ffit. three months, which had been from its birth re- markably healthy, and exhibiting a precocity unusual to infants of its age. It smiled and observed, with as much intelligence at three and four weeks, as is common to children of as many months. 1855.] Cooper's Case of Hydrocephalus. 139 Its bowels had been habitually constipated, often passing over two, three, four and sometimes five days, without an evacuation, and without impairment of its health, at least up to the time of the attack referred to in this report The mother's attention was first attracted by the occasional and sudden screams of the child, and when moved, it often cried out as if in pain, or some tender spot had been touched. It frequently awoke affrighted, and apparently upon the eve of con vu* ions. The child was found in the condition above described, which had been persistent for two weeks prior to my first visit. The fever was in irregular exacerbations the surface sometimes in- tensely hot, and again scarcely appreciable, the skin remaining all the while pallid, except the checks, and they rarely and very slightly flushed. The f)ulse was accelerated, and continued so even when the heat of surface was normal. There was no delirium, the child, until very late in the disease, being rational, frequently, even cheerful. Its bowels were now disordered, with frequent thin greenish stools, answering perfectly to those often seen in the disease spinach stools. The thumb was not observed to be flexed into the palm of the hand as is often mentioned. Its strength and flesh kept up amazingly ; the failure of both, however, was slowly progressing. In fifteen or eighteen days after my first visit, the spleen was noticed to be enlarged: this progressed rapid- ly until it occupied the left iliac fossa. In this enlargement of the spleen, we had a beautiful exhibition of the truth of the doctrine of Eevulsion, the more satisfactory, because it was developed by nature herself. Pari passu with enlargement of the spleen, there was a measured abatement of the cephalic symptoms and troubles, and a hope that this natural substitution would eventually supersede the original attack upon the brain. In this hope we were forlorn ; in from eighteen to twenty days, the spleen slowly receeded, and commensurate with this diminution was there a rekindling of the original symptoms with increased violence, and it was evident that the case was hastening to a speedy termination. Indications of stupor supervened, its occasional moments of cheerfulness were no more to be seen ; it refused the breast and soon coma was com- plete, and death ended the sufferings of the little patient Six or seven days before dissolution, a sero-sanguinolent matter was observed to be escaping from a small opening immediately 140 DtTGAS, on Prolapsus of the Rectum. [March, below the the posterior fontanelle the opening situate in a small red spot nasvus materni such as is frequently seen upon chil- dren. The suspicion at once excited was, that there must be some connection between this opening and the brain, though the idea was novel to me, that this tapping was nature's operation. There were no precursors of . inflammation at this point, the first thing noticed being the escape of the fluid. The quantity of matter dis- charged daily increased until its death, and1 from the vertex down to between the scapulas, and around the sides of the neck to al- most the middle line in front, became cedematous, from, as I sup- posed, the smallness of the opening, and its being somewhat valvular. Eemarks. The cause of the attack in the above case is not very palpable, though I have always believed that the habit of constipation which obtained with the child, at least precipitated it. Nature rarely fails in making some effort to relieve herself; but, in this particular disease, I do not know that the attempt was ever made before in a similar way, and had she performed her opera- tion earlier, and enlarged the opening somewhat, we have no reason to doubt but that it would have been entirely successful. ARTICLE VII. Extraordinary Case of Prolapsus of the Rectum. By L. A. DuGAS, M.D., &c. Having been recently consulted in reference to an extraordinary case of Prolapsus of the Eectum, I deem it of sufficient interest to record the following notes : Mr. G., a native of Kentucky, but now a resident of Mississippi, about 35 years of age, of athletic frame and fine constitution, is, and has always been in fine health, with the exception of the infirmity to be described. About twelve years ago, during an attack of bowel complaint, he experienced for the first time some prolapsus of the rectum. The bowel affection soon subsided ; but he was left subject to occasional descent of the intestine, which gradually grew more frequent, and finally attended each alvine evacuation. With the increased frequency of the prolapsus, the extent of the protrusion also became greater, and in a few months reached the present dimensions. Mr. Gr.'s state is, now, that of apparently robust health; his 1855.] DUGAS, on Prolapsus of the Rectum. 141 bowels are moved regularly every morning ; his faeces are mould- ed and otherwise of natural appearance ; but each evacuation is preceded by expulsory efforts and the protrusion of 8 or 10 inches in length of the rectum, which is inverted, and so much dilated as to offer a diameter of from 6 to 7 inches. The protruded mass is of the shape of a pear, the smaller extremity being at the anus, which is dilated to from 3 to 4 inches in diameter. In the centre of the larger extremity may be seen the aperture of the upper por- tion of the intestine about an inch in diameter, and from which the faeces issue upon the continuance of expulsory efforts. The mucous surface of the inverted mass appears health}' and the pro- trusion is effected without pain. For some time after the occurrence of this infirmity, the patient would reduce the prolapsus in the usual way, by pressure with the hand ; but he has since acquired the faculty of doing so with- out any mechanical force and by the mere effect of position and volition. He now can, and has for years been able to do so, at any time induce this extraordinary prolapsus by expulsory efforts in a few moments, and reduce it as promptly. For the lat- ter purpose he places himself upon his knees and face, so as to bring the pelvis at the summit of an inclined plane formed by the trunk, and, to use his own expression, draws in the bowel by holding his breath ; when it promptly re-enters the abdomen with a flap- ping sound as though a column of air rushed in with it. The anus then closes, and presents a perfectly natural aspect. I have seen this feat performed repeatedly, and even at intervals of ten min- utes, with surprising facility. The force by which the protrusion is effected is easily under- stood ; that by which the return is accomplished is probably a combination of gravitation, by elevating the pelvis, and of atmos- pheric pressure, by fixing the abdominal muscles at the same time that an effort is made to elevate the diaphragm, and consequently to produce a vacuum in the abdominal cavity. The patient states thaj, unless he has taken some laxative, no fecal matters -ever issue until the prolapsus be complete. We might infer frota. this that some stricture exists to a sufficient de- gree to prevent more consistent matters from reaching the lower intestine ; but this is negatived by the fact that his discharges are moulded of the usual size. The orifice seen when the protrusion is complete, appears normal. Walking, long standing, or any muscular effort, will induce a partial prolapsus, so as to incapaci- 142 A new Haemostatic Preparation. [March, tate the patient for the active duties of life, unless when on horse- back. I proposed to treat his case with the actual cautery, according to Dupuytren's favorite method; but he was unwilling to submit to it, and returned home. TRANSLATIONS AND CONDENSATIONS FROM FRENCH JOURNALS. A new Hcemostatic Preparation. Pagliari's solution, which immediately and completely coagu- lates blood when contained in a vessel, does not act precisely in the same way when applied to a wound where the blood is con- tinually flowing and washing away the coagulum. M. Hannon has been led, from experiments made upon the blood of animals, to the discovery of the following compound, which possesses greater coagulating properties than Pagliari's solution. Benzoic acid, ... 1 part. Alum, 3 " Ergotin, 3 " Water, . . . %. . 25 " This is to be boiled for thirty minutes in a porcelain vessel, agita- ting continually, and replacing with warm water that which has evaporated. This solution is of a deeper color than Pagliari's solution, of a slightly styptic taste and aromatic odor. If it be evaporated to the consistence of an extract, agitating the mass all the while, to prevent the benzoic acid from separating from the rest of the ingredients, it becomes of a chocolate color, has a strongly astringent taste, and the odor of ergotin. This extract is, according to the author, the most energetic hemostatic now known, either applied to the bleeding surface or administered internally. The external application is made by applying a thick layer of the extract to the seat of hemorrhage. When required to be administered internally, as M. Hannon did, successfully, in haemop- tysis, it is not necessary to subject the ingrediente to the above process. They may be prescribed in the form of pills, as follows : $. Benzoic acid, ... 1 gramme. Pulv. alum, ) o Ergotihe, \ aaS ^mmes- Mix, and make sixteen pills one to be taken every two hours. [Presse Med. Beige. 1855.] Actual Cautery. 143 Actual Cautery. Knowing from long experience the great utility of the actual cautery, we have endeavored, says M. Sedillot, to do away with the inconveniencies of the common method, and to substitute one equally advantageous and more convenient. The improvement which he suggests, is to substitute for the moxa and the ordinary heated irons, a pocket-case probe of gold, silver or steel, heated over a spirit lamp. The diseased parts are touched very lightly, so as not to produce blisters or escars. The cuticle alone is affected, presenting a dry, yellowish spot, the size of a pin's head. The impression is instantaneous and scarcely felt by the patient, producing ordinarily only a slight pricking sensa- tion. In by far the greater number of cases this feeling lasts but a short time. If the pain should persist, the number of cauteriza- tions should be lessened and the surface covered with wet lint, which will soon give relief. The number of contacts with the heated probe should vary ac- cording to the nature and extent of the disease, as well as the sensitiveness of the patient, from three or four to thirty, fifty, and even more, and repeated once or several times during the twenty- four hours, or only every two or three days, being guided by cir- cumstances. This plan has proved of decided advantage where the cautery was not used as an hemostatic or destructive agent. The effect of the actual cautery is to draw the arterial blood rapidly into the parts touched. In a healthy part the redness is uniform. If the inflammation is unequally disseminated, the redness will be great- est at those points where the phlogosis is most intense. In those infectious ulcerations, which sometimes occasion dangerous or fatal inflammations of the lymphatics or veins, this cautery immediately modifies the condition of the affected tissues. In ulcerations of a phagedenic or otherwise bad character, these cauterizations yield excellent results ; deep inflammations, compli- cated with affections of the bones, serous swellings and indurations, are equally modified with great rapidity by this cauterization. A patient affected with swelling of the tibia, and deprived of sleep, from excessive pain, for four months, resisting all other treatment, was immediately relieved, and began to improve from the second cauterization. This is the most effectual means of cauterizing in gangrenous affections. [Rev. de Therap. Med. Chir. 144 Iron by Hydrogen. [March, Iron by Hydrogen. The following are the results obtained by M. Quevenne, in the treatment of eight cases of Chlorosis with this preparation : The doses generally administered were from 20 to 30 centigram- mes. Below 20 centigrammes, improvement was slow. When elevated to 40 or 50 centigrammes it was no faster than when only 30 centigrammes were administered. The patients generally bore the medicine well, the greater number feeling no inconveni- ence from it. In one case there were, for several days, cramps of the stomach, gastralgia, and even vomiting. In another, there was, at some times, pain in the stomach ; but as these patients were subject to these accidents, it can scarcely be supposed that they were caused by the iron. In no case was a tendency to con- stipation or purging observed during the administration of the' preparation. The treatment varied in duration from sixteen to seventy-one days ; but the cases in which it was necessary to con- tinue the treatment so long, were complicated with organic affec- tions of the circulating apparatus. From these results, the following conclusions may be deduced: 1st. Iron by hydrogen is the preparation which furnishes the most iron to the system from a given weight. 2d. This preparation is particularly remarkable for its activity; for in average doses of 25 centigrammes the same results are ob- tained as with doses of 40 or 50 centigrammes of other preparations. 3d. These observations negative the general belief, that insolu- ble preparations of iron are less active than the salts of this. metal. 4th. It is therefore not true that insoluble preparations of iron are objectionable, because of their action upon the stomach and gastric juice. 5th.* When iodide of iron is administered, it is immediately de- composed ; the iodine passes off rapidly by the kidneys, say in fifteen minutes whereas the iron is retained in the system and can scarcely be detected in the urine.' [Ibid. Blisters applied to the Head in Typhoid Fever. M. Lebeau, speaks very highly of this plan of treatment in the coma of tjrphoid fever ; the recoveries being in the proportion of 15 in 20. He attributes the success to the very strong revulsive action of the blisters, thereby relieving the brain of the mass of serum which is found in the head of those who die in this condition. He cites numerous cases in support of this plan of treatment. [Ibid. 1855.] Difficult Labors and their Treatment. 145 Prize Esssay, read before the State Medical Society, on Difficult Labors and their Treatment. By M. B. Weight, M. D., of Cincinnati. [Concluded from February No. p. 111.] In the February No. of the Western Lancet, 1851, Dr. B. F. Richardson reports as follows : "I was called to see Mrs. S at 8 o'clock A. M., July 9, 1850, aged 25 years, medium height, robust and compactly built. Upon inquiry of the midwife, (who had been in attendance from an early hour in the night previous) I ascertained that she had been in hard labor during the night, and that the membranes had ruptured seven hours prior to my arrival. Her pains being very strong, with brief intervals, I at once resorted to an examination. I found the right arm in the vagina, with the palm of the hand presenting* towards the inner side of the left thigh of the mother. In the upper portion of the vagina were several folds of the funis, in which I detected strong and distinct pulsations. After having remained with the patient about a half an hour, observing during each pain, whether the child advanced or changed position, (neither of which occurred,) I determined on an exploration, in order to determine the practicability of bringing down the feet. After placing the patient in a convenient position, I slowly passed my right hand into the uterus. As soon as my hand reached the axilla of the child, it encountered considerable constriction from the uterus. After exploring for the neck and head, I directed my hand in search of the feet passing it up, with the palm ap- plied to the right side of the child, until it reached the ilium; beyond this point my hand would not pass, with the degree of force employed, which was sufficiently great to be compatible with safety and advantage. The uterus had firmly and persistently contracted around the pelvis, and over the crest of the ilium. I retained my hand for some time in its position, hoping to be able to insinuate my fingers beyond this point of constriction, and gain the feet, but was compelled to desist and withdraw my hand. and. give over the attempt. My exploration discovered the position of the child to be as follows : its right side presented toward the left iliac fossa inclining somewhat towards the sacrum. The right side of its neck was projected against the pubic arch, near its junction with the right ilium, the head occupying the right iliac fossa anteriorly. In this position it seemed to be firmly and persistently maintained. The impossibility of the expulsion of the child (it being evidently above the medium size), without decided manual interference, the great risk to the motheT from an attempt to turn, so long after the rupture of the membranes, with the firm and consistent constriction of the uterus about the child, induced me at once to propose the advice and co-operation of another physician. By agreement, Prof. M. B. Wright was sent for, it then being between 9 and 10 o'clock. Expecting some delay, (on account of the numerous engagements of physicians generally 146 Difficult Labors and their Treatment. [March, at that time,) I left the patient for the purpose of visiting some cases of cholera : with the understanding that word should be left at my residence, when it would suit Dr. Wright's earliest conveni- ence to meet me in the case. Unexpectedly to me, the attendance of Dr. "Wright was secured immediately a contingency provided for, however, by my request, that should he return with the mes- senger, and before my return, to accompany my partner, Dr. Morgan, and do in the case as they thought best for the safety of the parties concerned. Being absent about one hour and a half attending to prior professional engagements, I returned by the house of the patient, and was informed that Drs. Wright and Morgan had been there aboitt half an hour before, and that Dr. Wright had interposed in the case, being in too great haste to await the uncertain period of my return. I at once made an ex- amination, and found the arm returned and the vertex presenting. The funis was prolapsed, but without pulsation. Observing the progress of the head during three or four pains, I found it disposed to descend, and only delayed by the resistance of the perietal pro- tuberances. I then ordered secale cornutum in twenty-five grain doses every twenty minutes (as she seemed very much exhausted, and the pains inefficient) of which she took two portions. The pains became more energetic, and in about one hour from the time of taking the first dose, the child was expelled lifeless. I judged its weight to be about nine or nine and a half pounds. A careful external examination gave no clue to the probable cause of death. It had been dead but a short time prior to delivery. Mrs. S had a rapid and uninterrupted convalescence. Dr. Wright's mode of manipulation in the case, was as follows : The patient being on her back, across the bed (in the usual posi- tion for turning) he introduced his right hand, passed a couple of loops of the prolapsed funis around the child's arm, and then re- turned it converting it into a shoulder presentation. He then grasped the shoulder and thorax, and pushed the body of the ( child upwards and to the left side, in consequence of which the head was brought near the axis of the pelvis. He then relinquished his hold of the body, and grasped the occiput bringing it down so as to enable the head to engage. The succeeding number of the same journal contains a case of shoulder presentation, reported by Dr. Terry. After giving an account of the first labor of his patient, and of the difficulties en- countered in consequence of the small size of the pelvis, the doc- tor proceeds : " On the evening of October 25th, 1850, about 9 o'clock, I was requested to see the above patient, being one year, three months and eight days from the time of her previous delive- ry, to attend her in her second accouchment. I learned that she had been afflicted with erratic pains for the last twenty -four hours, which at times were quite intense. I found her in bed, lying on her back, the position she felt most disposed to retain, it affording her most rest, and enabling her to endure her pains the better. I 1855.'] Difficult Labors and their Treatment. 147 made an examination in the position I found her. The os tineas was dilated about two inches in diameterT readily yielding to pressure. The amniotic fluid was escaping in moderate quantities, showing evidently the rupture of the membranes, I was con- vinced at once it was not a normal presentation. After waiting three or four hours, the pains became more intenser I made another investigation, and found a shoulder presentation. I now made up my mind that turning must be resorted to the sooner the better." At this time she had full pulse, flushed face, and spas- modic contraction in the body of the uterus. I resorted to bleed- ing, when the intensity of the pains ceased. After waiting a short time, I proceeded to the process of turning. I gradually and easily passed my right hand into the uterus, and with little diffi- culty found the right foot, and brought it down so that the toes were near the vulva. At this point I found a resistance to any further progress in that way. I then made search for the other foot, but did not find it. During this effort, the right hand of the foetus came down, and on withdrawing my hand, the funis pro- lapsed, I now attached a strong fillet to the ankle, after which I passed my left hand into the uterus. I attempted to raise the child up from its present position, but failed, the head lying in the right iliac fossa. At this time the pains had ceased, except when roused by external force. The patient, myself, and attend- ants were much exhausted, from the severe labor and time devoted to effect delivery. After an interval of a few hours, I obtained the able assistance of Professor M, B. Wright. On our arrival the pains had returned, but they were not severe. Upon an ex- amination he found the foetus presenting with the right hand, leg and funis in the cavity of the pelvis, as before described. He at- tempted to turn by elevating the shoulder and making traction upon the leg, which he found already down. Failing in this, he endeavored to introduce his hand into the uterus with a view to obtain control of both feet, but the uterus had contracted so thoroughly upon the child as to render it impracticable. The doctor then decided upon a resort to version by the head. The leg, arm, and funis, were successively returned into the cavity of the uterus, and the vertex was brought into the superior strait,, with the posterior fontanelle behind the left acetabulum. The patient had been previously put under the influence of chloroform- Uterine contractions having ceased, it was deemed advisable to use the forceps, which were adjusted before the hand of the opera- tor had been withdrawn from the pelvis. It was soon found, however, that the instrument could not overcome another promi- nent obstacle to delivery, viz., a disproportion between the head of the foetus and the brim of the pelvis. The perforator was then used, the forceps still retaining their hold. As soon as the cranium was lessened in size sufficient to pass the superior strait, it was brought forward, and delivery was accomplished by means of the forceps." 148 Difficult Labors and their Treatment. [March, In the May number of the Western Lancet, 1851, a case is thus given by Dr. J. P. Walker : " I was called Saturday noon, April 12, 1850, to see Mrs. L , aged 30, in labor with her third child. The membranes had been ruptured on Friday morning, nearly thirty-six hours previous to the time I was called. " I found her with severe pains, but on examination could not reach the os uteri. At eight in the evening, I could with difficul- ty reach the presenting portion. The meconium had been passing freely, and I had been led to expect a breach presentation, but upon close examination I found that the shoulder presented. I sent at once for the assistance of Professor M. B. Wright, who arrived at eleven o'clock Saturday evening." At this time the arm was suspended from near the centre of the superior strait, the fore-arm being partially flexed, and looking towards the left. Dr. Wright proposed cephalic version, as an easy and successful mode of treating the case, which was acceded to. The fore-arm, which could be moved easily by the finger, was extended, and the hand escaped through the os externum, with the back of it anteriorly, and the thumb directed to the right thigh. The arm was brought down with a view to a more satisfactory diag- nosis, and to indicate the proper manipulations for delivery. The presentation, and the hand to be used in changing it, being deter- mined, the Dr. proceeded to the accomplishment of his object. The patient was placed, as in the ordinary way of turning by the feet. The arm which was now in the vagina, was returned so as to ascertain the relative position of the head. It was on the right side of the pelvis, the occiput in front, the face resting on the pos- terior surface of the right iliac fossa, and the right cheek against the promontory of the sacrum. ! The position of the foetus being thus accurately ascertained, cephalic version was commenced. The body of the foetus was moved laterally and upwards, by slight force applied to the presenting shoulder, until the breech had ascended to the fundus of the uterus. The face, by this move- ment, was made the presenting portion. It was readily changed for the vertex, but this change could not be secured without the constant application of the finger to the occiput. This was not deemed advisable, as the expulsive efforts had not yet commenced, and the os tineas was not more than two-thirds dilated. At half- past ten o'clock A. M., eight hours subsequently, the second stage of labor commenced, and when the next examination by touch was made, the face had again presented, and had partially engaged in the superior strait the chin being directed anteriorly, and to the left. It was deemed best not to effect any change, either in presentation or position. As the face, however, passed through the superior strait, the chin inclined more and more backwards, until it was placed before the left sacro-iliac symphisis. Before reaching the inferior strait, the chin had again rotated forwards, without extrinsic aid, and finally it emerged under the arch of the 1846.] Difficult Labors 149 pubis. Labor was then speedily terminated, the second or expul- stage occupying about two hours and a half. The fcetiv dead, and offensive from partial decomposition. It weighed about nine pounds. The patient has been doing well since. This case is not only instructive as to the proper treatment of such cases, but also for the remarkable efforts of nature to - deliver Now after all this, are we not justified in declaring, 1. That at an early period in labor, and especially if called be- fore the uterus has been deprived of its liquid contents, a shoulder may be converted into a vertex presentation more easily than turning by the feet is ordinarily performed. 2. That although the membranes may have been long ruptured, turning by the head can be accomplished with great facility. 3. That delivery by cephalic version may be speedily effected, after repeated and ineffectual attempts have been made to turn by the feet. 4. That cephalic version cliouM re prominent, nay, lead- ing place, as a means of expediting delivery in shoulder presenta- tions. The second of the questions already proposed, is, what mode of proceeding will prove most or the mother ? In his chapter on podalic version, Churchill ol " On the other hand its disadvantages are not to be overlooked. From the distance the head has to traverse, and the difficulty of seizing the feet, and of turning the child in utero, there must ever be a fear- ful risk of injury to the mother." n an examination of the tabular view3 given by Lee, we find that out of seventy-one cases of shoulder presentations, in which turning resorted to, "seven women died from rupture, and three from inflammation of the uteru - . " " Lace- ration and inflammation of the uterus are, therefore, the conse- quences chiefly to be L Four of these cases of rupture red in the practice of c hems, and three in patients under my own care, and where no great difficulty was experienced or force employed in turn: In the hand does not enter the cavity of the uterus, ai its walls, nor any portion of them, are : ut. The foetus is moved comparatively 3, the head b near the superior strait; while i l, the p. :d, is most remote from 1 through which it must pass. In the former, the injury to the mother cannol ithout great awk- wardness on the the obstetrician, while in the other we pe of injury. In turning by the feet the ] rably within th often while it is contracting violently. In turnii ; little, if any, direct contact of the hand In the one .ontusionof the uterus K. S. VOL. XI. NO. III. 10 150 Difficult Labors and their Treatment. [March, by the hand is to be expected in the other case there is no injury, because there is no contact. Turning by the feet may occasion a severe nervous shock. Not so in changing the shoulder for the head. How may the life of the child be best preserved ? is the third enquiry to be briefly answered. In describing the disadvantages of turning by the feet in all cases, Churchill sa}Ts: " The mortality amongst the infants thus brought into the world is very great. As far as our statistics ex- tend, they yield 171, out of 518 delivered, or 1 in 3." The mortality in shoulder presentations is, doubtless, greater than this. In the first place the position of the fcetus weakens its hold upon life. In the second place the hand is more difficult of introduction into the uterus in shoulder than in head presentations,, and whatever force is required is sensibly felt by the fcetus, and upon that part of the body where pressure is made with least im- punity. A timely resort to cepli alic version gives the fcetus almost as much certainty of life as if the presentation had been originally of the head. Why not ? The manoeuvre amounts to but little more than in rectification of deviated head positions. We are informed by Churchill that, "Bush gave an account in 1826, of fifteen cases, in which / .ere born living. In 1827y Ritgen collected forty-five successful cases. Riecke has had six- teen cases." In all the cases treated by myself from the beginning, the children were born alive. The liability to compression of the chord and consequent death of the fcetus, is in proportion to the length of the labor, or rather to the descent of the fcetus in the cavity of the pelvis. Hence to be wholly successful, cephalic ver- sion should be performed a short time before, soon after the com- mencement of the second stage of labor. Can any mode of treating shoulder presentations be relied on exclusively? The answer must be in the negative. We are dis- posed to adopt the language of Cazeaux, "that at the present day it would be improper to embrace either opinion exclusive' some cases are better suited to the cephalic version., while there are others, on the contrary, where the pelvic one is alone practica- ble ; consequently both operations should be retained in practice, leaving the judgment of the accoucher to determine the cases, where the one or the other ought to be preferred." And we will conclude this part of the subject by stating a few of the cir- cumstances under which the different modes of turning may be adopted. Turning by the feet is to be preferred in cases of inefficient uterine action, or exhaustion from long continuance of labor ; in hemorrhage, convulsions, or in any case where there may be a demand for a speedy delivery. Turning by the head should be selected in all cases where diffi- culty arises from mal-position merely ; or in convulsions, hemor- 1855.] Difficult Labors and tJteif Treatment 151 rhage, or prolapsus of the funis, if the uterus should be engaged in vigorous expulsive efforts. In rupture of the uterus our great reliance is in artificial delivery ; and the question naturally sug- gested would be, which will guaranty the greatest safety, podalic version, or cephalic version aided by the forceps? And we would be guided in our action by the answer we gave to the question. Which shoulder presents? The diagnosis of shoulder presenta- tions has been already given, but it is still important to ascertain which shoulder demands our attention, and the relations the foetus sustains to the pelvis and uterus. Either shoulder may occupy the brim of the pelvis, with the back in one case looking in front of the mother, while in the other case it may be directed towards her spine. The head may be in the right, and again the left iliac . the breech occupying the opposite fossa, and the feet being high in the uterine cavity. But how are we to ascertain the actu- al and relative situation of all these par It has been stated that the first vertex presentation (the occiput being behind the left acetabulum) is more frequent than all the others. If we admit that shoulder presentations are deviations from those of the vertex, it would be fair to infer that we were about to adjust the right shoulder with the back in front, and the head on the left of the pelvis. The direction of the axilla would indicate the opposite direction of the head, so also of the elbows. Perhaps the top of the shoulder, the neck, and even the head may be felt. The direction of the back may be known by the scapula and vertebra?, and by the fore-arm lying upon the breast. If the coccyx, anus and iliac crests can be touched, the location of the pelvis is rendered certain. The hand of the foetus being in the vagina, can be used with advantage to ascertain which shoulder presents. If the palmar surface be directed upwards towards the symphisis pubis, and the thumb turns to the right side of the pelvis, we at once pronounce the right hand, and, consequently, the right shoulder as present- ing. The reverse obtains with the left shoulder. Again, when the back of the hand appears in front, and the thumb is nearest the left thigh, the arm not being twisted, we should prepare to act upon the right shoulder, the back in front and the head in the left iliac t The back of the hand in front, with the thumb near the right thigh, indicates the presence of the left shoulder, the spine being in front, and the head on the right side of the pelvis. So little do we consider the presence of the arm in the vagina as an obstacle to turning, we do not hesitate to bring it down, to aid us in our diagnosis if at all doubtful. In this country, turning is performed, the patient being on her back. In cephalic version, we have always selected this position. The hand can be more readily introduced into the uterus, and the 152 Difficult Labors and their Treatment. [March, feet reached, however, with the patient on her elbows and knees, than when on the back or sides. There may be cases in which advantage would be gained, by placing the patient in this posi- tion, preparatory to cephalic version. This is suggested, how- ever, on the experience of only one case, which may be briefly so stated. We were called to a patient in labor, with shoulder presenta- tion, when we learned from the medical attendants present that the arm had descended into the vagina, full sixty hours previously. From three to five respectable physicians had been lending their aid, each, in turn, making ineffectual efforts to bring down the feet. With the patient on her back, we endeavored to pass our hand above the brim of the pelvis, but failed in this. The arm was swollen to an immense size, and, as it was much in the way, it was amputated at the shoulder, the child of course being dead. Still, the hand could not be extended above the superior strait. The woman, greatly exhausted, was placed and supported on her elbows and knees by assistants. With some difficulty, the uterus was then explored, the feet grasped, and delivery accomplished. When our hand came in contact with the presenting portion of the foetus, however, we acted upon it as if to perform the cephalic ver- sion, and were satisfied of our ability thus to change the presenta- tion. But, as labor had continued such a long time as uterine action had, in a great measure, ceased and as every moment of delay threatened an increase of great danger to the woman, a preference was given to podalic version. The hand to be used. The relations of the foetus to the pelvis having been ascertained, and the patient placed in a proper posi- tion for turning, the next question is, which hand shall be intro- duced into the vagina ? We answer, the hand, the palm of which is directed naturally towards the breach of the foetus. It will be seen at once, that if the foetus is to be moved in the direction of the breech, and in correspondence with the right side of the mother, and the left side of the operator, the right hand could be used with most success. In cases in which the head occupies the right iliac fossa, a choice could be given to the left hand. The prolapsed arm. It is generally conceded that, in turning by the feet, it is not necessary, nor would it be advantageous, to return above the brim of the pelvis, the arm, which may have fallen, or been brought into the vagina. In turning by the head, on the contrary, its reposition admits of no doubt ; it is impera- tively demanded. It is not demanded in consequence of any difficulty in moving the shoulder by its presence, but in the ad- justment of the head at the superior strait, and its subsequent descent through the pelvis. By bending the fore-arm of the foetus until the hand is directed to the upper portion of the vagina, and then pushing up the arm, the entire member will soon ascend above the brim of the pelvis, and be no longer an obstacle to com- plete version. 1855.] Difficult Labors and their Treatment 153 The manner of performing cephalic version. The attention of the profession is not now directed to cephalic version as a new subject. - recommended by Hippocrates, and from his days to those of Pare, was attempted in all cases in which the head did not originally present. Presentation of the breech and feet, were not associated with natural labors until a comparatively recent period. The practice and influence of Pare led to the adoption of podalic version, and it has continued the reigning fashion up to the pres- ent time. Instead of changing the feet for the head, in all cases where the former presented, as recommended by Hippocrates, it is now deemed proper, following the example of Pare, to substitute the feet for the head, in many cases of difficult labor. The spirit of progress, however, has not been idle, although it has been slow in making proselytes. Opposing doctrines have been carefully scrutinized, to a certain extent harmonized, and adapted to individual cases. Flamand, professor at Strasburg, recalled the attention of the profession to the utility of cephalic version, and exerted his influence, by argument and illustration, to have it reinstated. Some of the German and French writers have been induced to assign cephalic version a place among obstetric operations; but they consider it applicable to such a small number of cases, that they have bestowed upon it little attention, and have attached to it but a small share of practical importance. Although American minds are ever on the alert, and ready to test the value of suggestions from a practical source, they have not directed special attention to the subject before ns. Indeed, the investigation of it has been prevented, by the expressed opposition of our writers and teachers on the one hand, and their silence on the other. And here I maj* be allowed to advance an opinion, which was openly entertained when a teacher myself, that the mass of the profession think and act too little for themselves. They too often embrace the doctrine of the teacher as true, to the rejec- tion of their own experience. We would say to the lecturer, in- dependence rather than place be a martyr for truth, rather than be false to your profession to appease local jealousy. And we would urge, that while the practitioner awards honor where it is due, he should be true to himself, hy thinking and acting for him- self. A few paragraphs from Cazeaux will express the opinions gen- erally entertained upon cephalic version by European writers : 11 Flamand was also in favor of the performance of cephalic ver- sion, even after the rupture of the membranes and the discharge of the amniotic liquid. He has even gone so far as to point out the particular manceuver for each one of the distinct presentations admitted by him, for the child's anterior, posterior, and lateral planes; but we deem it useless to enter into those long details, more especially since they may all be comprised in this : to grasp 154 Difficult Labors and their Treatment [March, the preseting part, push it up above the strait, and then carry it as far as possible towards the side opposite to where the head is found, and afterwards get hold of. the latter and bring it down, if the efforts made by the other hand through the abdominal walls, have not proved sufficient to make it descend into the excavation." "Flamand himself acknowledges that this operation seldom succeeds, excepting when some region of the neck or upper part of the thorax presents at the strait. As for ourselves, we believe it would be difficult, even under such circumstances ; however, it is barely possible, especially if there is still some water in the uterus, and the contractions are not very energetic." "When a trunk presentation is complicated by the descent of an arm, the cephalic version, recommended by Kuffius, Ehodion, and others, should, in my estimation, be wholly rejected." If we were to be restricted in our manoeuvers by the advice given in some late obstetrical works, we should certainly fail in our object, and sooner or later we should be convinced that lessons given in the absence of experience are liable to errors, even in the outlines. Churchill tells us that, "if our object be to change the presentation for example, to substitute the head for a shoulder, we must gently push up the shoulder, and then seizing the head, bring it down to the brim, and place it in the most favorable rela- tion to the pelvis." A professor representing the difficulties, nay, impossibilities, of performing cephalic version in shoulder presentations, places the leather baby m the manikin, raises the shoulder in a line corres- ponding with the axis of the pelvis, and with an air of triumph asks, "now, if I withdraw my pressure, or if the uterus should contract, will not the shoulder return to its original position?" In reply to the above, let us merely observe, that the expres- sions "raising the shoulder" and " grasping the head" convey a very imperfect idea of the manoeuver constituting cephalic version. And, to shorten discussion, we will present our own mode of pro- ceeding. Suppose the patient to have been placed upon her back, across the bed, and with her hips near its edge the presentation to be the right shoulder, with the head in the left iliac fossa the right hand to have been introduced into the vagina, and the arm, if prolapsed, having been placed, as near as may be, in its original position across the breast. We now apply our fingers on the top of the shoulder, and our thumb in the opposite axilla, or on such part as will give us command of the chest, and enable us to apply a degree of lateral force. Our left hand is also applied to the ab- domen of the patient, over the breach of the foetus. Lateral pres- sure is made upon the shoulders, in such a way as to give the body of the foetus a curvilinear movement. At the same time, the left hand, applied as above, makes pressure so as to dislodge the breech, as it were, and move it towards the centre of the uterine cavity. The body is thus made to assume its original bent posi- 1855.] Difficult Labors and their Treatment. 155 tion, the points of contact with the uterus are loosened, and per- haps diminished, and the force of adhesion is in a good degree overcome. Without any direct action upon the head, it gradually approaches the superior strait, falls into the opening, and will, in all probability, adjust itself, as a favorable vertex presentation. If not, the head may be acted upon as in deviated positions of the vertex, or it may be grasped, brought into the strait, and placed in correspondence with one of the oblique diameters. It will be observed, that we do not act upon the shoulders by raising them. Perhaps a slight elevation would facilitate the movement already described or it might be better to depress them and, again by lateral pressure, without either elevation or depression, our object might be accomplished. Pushing up the shoulders, therefore, does not constitute a prominent part of turn- ing, if by pushing up is meant the mere raising of the shoulders above the brim of the pelvis. As the body of the foetus makes its curved movement under the hand of the operator, it advances upward, as well as laterally, by a combined, rather than a single action, which would give it only one direction. The back of the hand, with which we have been acting upon the shoulder, is toward the head of the foetus consequently, its hold upon the head would be apparently slight yet, after the shoulders have reached the iliac fossa, the vertex may fall upon the palm of the hand in occupying the strait, and its adjustment become easy. If, however, there should seem to be a necessity for grasping the occiput, there could be no reasonable objection to a speedy change of hands. The entire process of cephalic version is to be adopted in the absence of uterine contraction ; or rather, during intervals of ex- pulsive force. And, as it is now a vertex presentation, we must be governed, as to time and manner of delivery, by those general rules applicable to such cases. In all our cases, except the one which terminated as a face pre- sentation, the occiput assumed a position corresponding with the first or second presentations of the vertex. In this case the occiput was before one of the sacro-iliac symphises, and to this fact we have attributed the tendency of the occiput to slide above the brim of the pelvis, and the difficulty in keeping it in place. If there had been the usual degree of uterine contraction, however, the head would, in all probability, have become fixed, and the pre- sentation would have continued as one of the vertex, instead of changiug for the face. It will be seen that we lay no claim to the introduction of cephalic version as a mode of treating wrong presentations, and expediting delivery. A very brief examination of the subject, however, may induce some to award to us originality in respect to the means by which a successful change of presentation may be accomplished. 156 Difficult Labors and their Treatment. [March, That cephalic version, by external manipulation by acting upon the foetus through the parietes of the abdomen and uterus should have few advocates is not surprising. To be successful, it confessedly requires a combination of favorable circumstances not often presented. The tissues both of the abdomen and uterus, must be thin and yielding the liquor amnii must have been re- tained, and in considerable quantity and the foetus must be pro- portionably small. In all the obstetrical works we have examined, in which cephalic version is recommended by internal manoeuvre, it is directed to raise the shoulder as the first necessary impression upon the foetus. Yiewed anatomically or mechanically, men have not been per- suaded into the belief, that raising the shoulder can facilitate the permanent descent of the head into the superior strait. They claim, what is apparent to the eye in viewing a proper engraving, and as it can be demonstrated with the manikin, that the eleva- tion of the shoulder at the brim of the pelvis, tends to increase the long diameter of the foetus, and the transverse diameter of the uterus, and without any favorable adjustment of the head after pressure upon the shoulder has been withdrawn. Suppose we follow out the directions given by some, and after the elevation of the shoulder, attempt to force the body of the foetus in a lateral direction, will not the breach infringe against the walls of the uterus transversely ? To enable the head to en- gage in the superior strait, the body must be entirely removed from it, and this can only be done by raising the breech towards the fundus of the uterus. Eaising the shoulder, therefore, is very naturally considered a means to prevent cephalic version. And we are not surprised that podalic version is almost universally adopted in the treatment of shoulder presentations. If our mode of performing cephalic version is sufficiently clear, in the description already given, it will readily be distinguished from others. We claim for it great importance, on the ground that it is easily executed that the mother and foetus receive no injury that there is little or no danger of subsequent displacement after the vertex has been fully adjusted that, although it is most successful in recent cases, delivery may be accomplished after the membranes have been long ruptured that it may be executed, after ineffectual efforts to bring down the feet. Possibly our time might have been more profitably employed than in writing these pages. If, however, we shall have directed the minds of our brethren into a new train of observations, and aided in giving a true value to cephalic version and, especially, if life shall thereby be preserved we shall consider that an ample reward has been bestowed on our labor. [Ohio Medical and Sur- gical Journal. 1855.] On the Spinal System and its Diseases. 157 Three Lectures on the Spinal System and its Diseases. Delivered at the Chatham-street School of Medicine, Manchester. By Marshall Hall, M.D., F.E.S. L. k E., Foreign Associate of* the Imperial Academy of Medicine of Paris, etc. LECTURE I. THE ANATOMY, PRINCIPLE OF ACTION, AND PATHOLOGY OF THE SPINAL SYSTEM. Gentlemen, I have accepted, with much satisfaction, the invi- tation of your able teachers, to expound to you the Anatomy, Physiology, and Pathology of the Spinal System. In doing this, I shall avail myself of experiment and reference to clinical obser- vation. I wish to demonstrate to you the immediate and intimate connexion between physiology and practice. You may indeed regard these lectures as a specimen of a work which I am preparing for the press, designed specially for the medical student, to be en- titled " Physiology in the Laboratory and the Clinical Ward." I propose, in that work, to effect the separation of mere empiri- cism from medicine for ever. Physiology was divided, by the illustrious Bichat, into two sys- tems, or sub-systems, the animal, and the vegetative. The nervous system has, in a correlative manner, been divided into the cerebrospinal and the ganglionic. Both these divisions are defective. There is a third sub- division of the nervous system, hitherto undetected, which forms an essen- tial link with the other two, and which I have designated the Spinal. Observe this frog. You are all familiar with its natural move- ments. I divide what was termed the cerebro-spinal system just below the occiput. I stop for a moment to call your attention to a most interesting phenomenon. I seize one of the toes of a posterior extremity be- tween my thumb and finger, making a little gentle pressure and movement. No effect is produced. In a minute, or less, you will see how different the result will be. The animal is in the state of shock ; just such a shock as we observed in practice, as the effect of a violent fall from scaffolding, or a crushing accident from ma- chinery. I repeated the experiment. You see the manifestation of returning power in energetic movements. This experiment, repeated with care, would afford the means of investigating the phenomena of shock, and of a principle of prac- tice. For example ; after a violent comminuted fracture, is it bet- ter to amputate immediately or after the lapse of a certain interval of time ? I again call your attention to my experiment. Observe how energetic the movements of the frog now are on exciting the skin of the foot; how similar, too, to ordinary voluntary motions! Who would not be beguiled into the conclusion that in this ani- mal sensation and volition still exist ? 158 On the Spinal System and, its Diseases. [March, Nevertheless, if my experiment has accurately divided the cere- brum and cerrebellum from the medulla oblongata, and if I induce quiet in the animal by gently controlling its movements, as you see, it will never move spontaneously more ! Nay, though I place it in a position which, if sensibility remained, would be the most painful, yet, quiet once induced, and all external excitation avoided, it will never move again. It might be left in such a position, and if so protected from excitement, it would be found the next day in the same position still. But again I rub the toe between my thumb and finger, and again it moves ; it jumps, and it crawls; the latter movement con- sisting, in fact, in a series of movements induced by the renewed contact of points of the cutaneous surface with the surface of the table. What is the rationale, what the relations, of these singular phe- nomena ? Gentlemen, nearly a quarter of a century ago, I was engaged in the investigation of the circulation of the blood in the batrachian reptiles ; I had been examining the pneumonic circulation in the triton ; the animal lay on the table ; I removed the head and the tail. On touching the latter by the point of a probe, it coiled up ! I asked myself the questions which I have just proposed to you. From this simple fact and observation have resulted the discovery, the elaboration, and the application of the spinal system that system which, as I have said, I am about to expound to you in these lectures. I again recur to my question What is the rationale, what the relation to life, to anatomy, and to physiology, of this phenomenon? I have removed the cerebrum and cerebellum ; it does not there- fore depend upon these. But I proceed further; I now remove the whole of the internal viscera, and, with them the whole of the ganglionic system. Still the movements continue as lively as ever ! Observe this physiological preparation well. There is not in the Hunterian Museum a preparation more replete with the deep- est interest. It is the demonstration that when the centre of the cerebral system and when the entire ganglionic system are removed, there still remains a third system, independent of each and of both, sui generis, autocratic ! Place this specimen of the decapitated, eviscerated frog in your museum the demonstration of the distinct and independent spinal system in memory of this day ! Do not be disconcerted that I show you these things in so humble a creature. All physiology exists in the caterpillar or the butterfly , if we could only detect it. The least of God's works is infinite. I began by stating to you that hitherto anatomists and physiolo- gists had divided the nervous system into the cerebro-spinal and the ganglionic. I have analysed these, and I have demonstrated to you, that in the midst of these two there is a third system. As the chemist detects, in a mineral hitherto regarded as consisting of 1855.] On the Spinal System and its Diseases. 159 certain elements say silver and gold a new element, platinum, so I, in the midst of the cerebro- spinal and ganglionic nervous systems, have detected a new element the spinal; and of how great moment this is I must proceed, without further delay, to unfold to you. I revert once more to this interesting preparation : the cerebral centres and the ganglionic system are removed ; what remains ? what is its anatomy, its principle of action, its physiology, its pathology, its therapeutics ? what its relation to life and death f questions of the deepest interest. In the first place, observe me now destroy, in this decapitated, eviscerated frog, by means of this needle, the spinal marrow. Xow all is still ! I irritate the toe in vain. I wait in vain for recovery from shock. All the interesting phenomena formerly manifested are extinct ! They depend, then, on the spinal marrow, their spi- nal centre ! In the next place, I take this preparation, which is similar to the former one viz.. without cerebral, without ganglionic sys- tems, and I denude the lumbar nerves. The excited movements in both lower extremities are, as you see, perfect, I divide this right lumbar nerve ; the excited movements in the right leg, and in that leg only, are extinct ! The excited reflex movements depend, then, not only on the spinal centre, but on the nerves connected with that centre. You observe the phenomena still perfect in the left leg ; I re- move the skin from the foot ; the excited movements are again extinct. They depend, then, in this instance, on the integrity of the integuments of the part to which the excitation is applied. In these integuments, in fact, resides the origin of those nerves on which these excited reflex actions depend. But now, gentlemen, I must beg your best attention whilst I explain more particularly the nature and forms of that nervous structure which constitutes the spinal system. If I either strip off the skin, or destroy the spinal marrow, or divide the lumbar nerve, the phenomena cease. They depend, then, on the oHgin and on the course of certain nerves, and on their spinal centre. But a little more minutely : If I remove the origin of this struc- ture, by removing the integument ; or if, within the spinal canal, I divide the posterior root of the spinal nerves ; or if I destroy the spinal marrow itself; or, if I divide the anterior roots of the spinal nerves ; or, if I divide the nerves in any part of their course to or from the spinal marrow, I annihilate all reflex phenomena. Here then is a new Demonstration : all reflex actions depend on an in-going nerve, with its origin in the tissue excited ; on the spi- nal centre ; and on an out-going nerve, with its termination in the muscles. These constitute a nervous Arc, consisting of parts essen- tially linked together ; a new kind of Anatomy, established and demonstrated for the first time. 160 On the Spinal System and its Diseases. [March, Each special excited, reflex, or diastaltic action (so I have de- signated it, because it is excited through the spinal centre), has its special diastaltic nervous Arc. Of these Arcs there is an extensive series in the animal economy. Together with their continuous centres, they constitute the spinal system of connected eisodic (or in-going) and exodic (or out-going) nerves. Gentlemen, no facts in chemistry or physics are more demon- strable than these ; none more valuable in their relations respec- tively ; whether we contemplate life, disease, or death, the spinal system becomes now our constant guide. Let us now, gentlemen, consider what we have within the spinal theca. The sensations of the hands, feet, &c, imply an uninterrupt- ed connexion between those parts and the cerebrum, upwards. The acts of volition of the hands, feet, &c, imply a similar uninterrupt- ed connexion downwards. There are, then, two nervous conduc- tors, whether distinct fibres, or whatever they may be, along the spinal marrow, which, in this sense only, may be viewed as a spinal Chord of nerves, of sensation, and of volition. But when the cerebrum is removed, when alb sensation and volition are extinct, if we excite the skin of the lower extremity in the frog, the anterior extremity is moved, and vice versa ; phe- nomena which cease either on removing the spinal marrow, or dividing the lumbar nerves. How then are we to view these structures ? The lumbar nerves convey sensation and the mandates of voli- tion to and from the cerebral centre, when that remains ; they convey the eisodic excitor influence, and the exodic excitor influ- ence, when that centre is removed. The spinal centre is the gene- ral kej-stone to the diastaltic arcs. As certainly as the lumbar nerves in the frog convey sensation and volition, so certainly do they convey these other two influ- ences. If Sir Charles Bell has proved that such nerves are double, I have proved them to be quadruple. The posterior roots of the intra-spinal nerves are not only senti- ent, but eisodic excito-motor ; their anterior roots are not only conveyers of the influence of volition, but of exodic excito-motor. There is precisely the same kind of proof of one of these functions, as of the other. The spinal marrow ; the lumbar nerve in the frog ; the sciatic in the human subject ; are each and all quadruple in their mode of action ; I do not say in their structure. There is an additional fact or series of facts : the spinal marrow is the conductor of the 'influence of emotion, and of that of undue acidity in the stomach, when these affect, the first directly, the second in a reflected manner, the action of the heart a subject requiring new and careful investigation. Enough has been said, then, gentlemen, to convince }^ou that the spinal marrow is no mere chord of nerves. Enough has been said to show you that it is intimately connected with the ganglionic system. And especially, enough has been shown to prove to you 1855.] On the Spinal System and its Diseases. 161 that it is the great centre of a series of actions in the animal economy. You will be still more impressed with the importance of the spinal system, when I tell yon that, besides the phenomena which I have brought before you, it is the nervous centre and agent in All the Functi ::stion in the animal econo- my, in the, ? in pathology, in the action of a certain Class of -. and in the whole of that de- partment of medicine denominated 01 Having made these observations, which relate principally to the Anatomy of the spinal system, I must now call your attention to its F Hon. This I have proved, by a series of the clearest experiments, to be th- of Haller. But this celebrated ph; hat, and Professor J. Muller, all laid it down as a Law, that this power acts in the direction downwards only. As long as this idea prevailed, it is obvious that it could have no application to physwlogj/. For how could the spinal mar- row or an exodic nerve be irritated physiologically? Its applica- tion was accordingly limited to But by a sei ::periments on the turtle, I proved that the vis nervosa m: wards and inwards as well as outwards and downwards, and tj.cn its application to physiology became evident. If you remove the head and viscera in' the turtle, and excite an eisodic nerve between the upper and lower part of the animal, all the extremities are moved. The influence of the vis nervosa has been inw .Is, and in all other directions, and not downwards c: It now became easy to explain the various acts of ingestion, retention, egestion. and exclusion, depending, as they all do, on an eisodic exciter. I may now, before entering on this topic, give you a general idea of the Xervous Systrm as we now view it. The cerebrum, the cerebellum,, and, in a certain sense, the me- dulla oblongata, may be regarded as the Centre of the Cerebral m, of the nerves of special sense, and of volition, of intellect and of the passions, of pleasure and of pain. By its means we are placed in relation to all that is i . psychically. By its means we perceive, by its me; ize and use. external obj There is good reason to believe that intellect is seated high, the emotions lower, and the faculty of pleasure and of pain lower still, in their general cerebral cent Below the centre of the cerebral system is that of the spinal sys- tem, and its analogue in the aiticulata, &c. The spinal centre includes the medulla oblongata and medulla spinalis. It may be divided into 1. The Medulla Oblongata, the spinal centre principally of the acts of ingestion and of egestion, by which the preservation of the individual is effected, and especially those of deglutition, respira- tion,