Digitized by the Internet Archive in 2012 with funding from LYRASIS Members and Sloan Foundation http://archive.org/details/southern1856medi SOUTHERN MEDICAL AND SURGICAL JOURNAL. EDITED BY L. A. DUGAS, M. D., PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF GEORGIA. AND HENRY ROSSIGNOL, M. D. MEDICAL COLLEGE OP GEORGIA. C 4 1 Q X ;: - , v* -jfc -c'^ifl1 prcnds le men ov. je ic trouvi VOL. XII. 1856. NEW SERIES. AUGUSTA, GA: McCAFFERTT'S OFFICE-J. MORRIS, PRINTER. 1856. V Oo SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. XII.] NEW SERIES. JANUARY, 1856. [No. 1. ORIGINAL MJ) ECLECTIC. ARTICLE I. On Scarlatina. By Columbus W. Smith, M. D., of Jonesborough, Georgia. In attempting to write upon this subject, I am fully aware bow difficult a task it is. Many learned and experienced men bave endeavored to present it in its true ligbt, and yet scarcely any two agree. It is my design to present tbe disease as it bas recently appeared under my own observation. Tbe simple form of tbis disease, termed Scarlatina Simplex, was generally usbered in witb chill, pain in tbe bead and back, follow- ed by fever; some slight stiffness about tbe neck and lower jaw. Tbe tongue was very variable in its appearance: it was generally furred white, with papillae; of a red cast showing themselves through the fur, more or less numerous ; in a few cases it was a bilious or brown fur, with red edges and without the pimples ; but when it bad this appearance it was always attended with vomiting of a bilious character, and it assumed more of a general redness after the vomiting bad subsided. In some cases tbe patients were at- tacked witb vomiting and diarrhoea, one or both at tbe same time. The fauces were invariably red, inflamed and tender, and at times pain was experienced during deglutition," but by no means very acute. No catarrhal symptoms were present ; the pulse was gen- erally full and frequent, and the skin hot and diy, although a perspiration would come on once in 24 hours, and last a longer or shorter time ; frequentlythis would occur in the night, after which N. S. VOL. XII. NO. I. 1 Smith, on Scarlatina. [January, the fever would be somewhat moderated. The appetite was occa- sionally impaired ; at other times it seemed as good as in health. In some individuals an eruption would make its appearance, of a red or scarlet color, with innumerable pimples or small eleva- tions over the skin. This took place usually within the first forty-eight hours : it commenced on the thighs and body, and ex- tended over the whole trunk. By rubbing the finger over the eruption it would feel rough, and by depressing the skin with the finger, a white spot would appear and the red would immediately return. The face was somewhat swollen. This eruption is very irregular in its duration; it generally continues growing thicker and redder until the fourth day, and then gradually declines until the seventh or eighth, when it entirely disappears with desquam- mation of the cuticle. About the fourth day the fever and inflam- matory symptoms begin to decline ; but the eruption did not show itself in half the cases we saw, and when there was no eruption there was no desquammation ; the fauces would at times be red and tumid previous to the attack in either variety of the disease. Scarlatina Anginosa.' This variety of the disease might be described in a very concise manner, for in truth it seems to be nothing more than an increased or aggravated degree or form of the preceding; but we will try and lay it down more particularly. It was most frequently brought on with chill, high fever, head- ache, pain in the back, loins, &c. The pulse was rapid, and much more feeble than in the preceding variety ; the temperature of the surface was much higher ; fauces and adjacent parts were much more inflamed and tumid. There was also considerable difficulty in deglutition ; hoarse voice ; a tough mucus was secreted or thrown off by the tissues, which appeared to impede respiration more or less in fact, where the tonsils were much swollen and prostration very great, some seemed to sink from suffocation. The prostration in this variety was much greater than in the preceding. The tongue was generally furred white, and the pa- pillae were very manifest upon it The fur soon left the tongue, and at once it became red and dry, and continued so until an abatement of the symptoms supervened ; it then grew moist and paler until it lost its florid hue. Ulcers were formed on the ton- sils, on the tongue, inside and at the corners of the mouth ; in a few instances, two-thirds of the tongue were covered with a scurf 1856.] Smith, on Scarlatina. 6 or scab which yielded to mild astringent gargles. The catarrhal symptoms were absent in every case occasionally vomiting and diarrhoea were present in the beginning; in others the diarrhoea did not set in until the latter stage. It was then beyond the reach of remedies, and dissolution soon took place. In the latter part of the disease, when fatal, the patients became very restless, rolling and tossing about on the bed ; in many of the cases which recov- ered, the cervical and other glands about the lower jaw became enlarged, suppurated and discharged a large quantity of pus. In those who died, the glands did not become swollen, from which cir- cumstance we were at first led to think it a favorable symptom. It was always six days before any abatement took place, and more frequently not until the eighth, but always on the tenth an abate- ment was manifest, perspiration came on, and a subsidence of the more distressing symptoms was obvious. One of the most re- markable things connected with it was, in several cases, no loss of appetite occurred through the course of the attack. The eruption was more irregular and uncertain than in S. sim- plex ; some recovered with the eruption, others recovered without, while others died, with their skin as red as flannel. Delirium was present in a majority of the cases. Scarlatina Maligna. This grade of the disease differs from the others, and is indeed what its name indicates, malignant, in eve- ty respect. It usually appears with chill, followed by fever, head- ache, pain in the back, loins and extremities, with stiffness in the neck and lower jaw; the pulse is feeble ; the reaction is not very j great ; the heat of the skin is not very high it is lower than in j S. simplex or in S. anginosa. The tongue was red from the be- i ginning, and also the fauces and adjacent parts were highly i inflamed and swollen ; a mucus was secreted which interfered with respiration, and the parts were so tender and tumid, that deglutition was performed with difficulty. Ulcers were early j formed on the tonsils, of rather white appearance, which soon I gave way to others of a dark brown color, and altogether more i malignant. The tongue and roof of the mouth became very dark and extremely dry ; the lips also put on a very dark, dry, parched appearance. The nose ran a watery mucus, and the breath bore a very offensive odor. The rash or efflorescence was so variable that it is unnecessary to speak of it : it was frequently absent, and 6 Smith, on Scarlatina. [January, so uncertain that it was of no practical importance -whatever. In a few hours from the commencement, delirium occurred, the vital powers gave way, the patient fell into a state of collapse, and death ensued. Death took place in one case in twenty-four hours, and none survived through the sixth day. Sequela?. The diseaseT in the epidemic of which we speak, was followed by anasarca, and in one case rheumatism of the joints of the upper extremities. These were the only diseases that suc- ceeded it. Prognosis. In this epidemic the prognosis was not very difficult. In S. simplex all recovered, and many did not take their beds from it. In S. anginosa, when delirium supervened and continu- ed without intermission, with a high grade of inflammation about the throat, pulse quick and feeble, at times the surface would get cool, great restlessness, often turning in bed and attempting to rise or get out of it, cold sweat, diarrhoea, &c, death was the result. In the cases that recovered, about the eighth or tenth day a general abatement of the symptoms was obvious ; less fever, with perspiration ; delirium began to moderate; appetite improved, and countenance brighter ; the tongue was moist on the edges, which gradually increased until it covered the whole mouth : the florid hue at the same time was disappearing, convalescence was fully under way, and by the fifteenth day they were able to sit up at short intervals. The prognosis in S. maligna is generally easy. In twenty-four or forty -eight hours the delirium was complete ; the prostration great, the pulse feeble, respiration hurried, great restlessness ; the skin was under the ordinary temperature, with dark, congested spots about on the body and below the eyes; the countenance was of a peculiar ghastly appearance, indicative of great distress and anxiety. We saw no case without a majority of these symptoms, and they all died. Those who died were from one to thirteen years of age, and none died who was over that age. Treatment. Most authors teach us that scarlatina is a disease of the skin, and their treatment is predicated upon this belief. We are decidedly of the opinion that it is not exclusively a disease of the skin, and that the eruption should be taken into very little ac- count in determining our practice. Our attention should dwell 1856.] Smith, on Scarlatina. xrpon the particular symptoms attending the case, and our treat- ment should be directed accordingly. In the simple variety it was hardly necessary to do any thing all recovered ; but when a treatment was adopted it was the mild- est and least irritating. In the beginning, a light laxative of sulph. magnes., Seidlitz powder, or oleum ricini; during the day, small doses spirits nitre every two hours, or spiritus mendereri, or any mild diaphoretic; at bed-time a warm pediluvium; a dose of paregoric to a child, or of Dover's powders to adults, if the fever is not too high, and all will be well. Treatment of S. Anginosa. If any variety of scarlatina demands close attention and careful treatment, it is this. S. simplex will get well if let alone, and S. maligna almost as certainly kills; and if any good can be done, it is in S. anginosa. In the incipient stage, an emetic of ipecacuanha was given, and followed by warm infusions, until full emesis was produced. This was done to remove, if possible, the tendency to visceral conges- tion, after which the stomach was quieted with an opiate, and then a gentle saline laxative, or oleum ricini or any mild aperient was administered, being careful not to induce active purging; after which diaphoretics were given as vinum ipecac, one-third, and spts. nitre, two-thirds every two hours, in warm, weak infusions of balm, sage, &c. ; or nitrate potash, three grains ; ipecac, one grain, intimately mixed, and given as above, and in doses sufficient to nauseate. Spts. mendereri may also be used, or any mild dia- phoretic, with the exception of antimonials; at night, warm pedi- luvium. If the fever was not too high, and the sensorial functions too much disturbed, a Dover's powder was administered ; when the skin became cool and pale and the pulse feeble, the mustard foot-bath was used three or four times per diem, and also a sinapism to the spine. If a reaction did not come on, carb. ammonia was given in doses sufficient to raise the pulse as often as the case de- manded it When this did not answer, brandy and water, or other stimulants, were substituted. An application of sinapisms was made to the stomach and bowels if they were disturbed. Much has been said and done respecting the use of cold water. In the epidemic of which we speak, no good was effected by it : in some instances injury followed its use, and it was altogether improper to use it in either variety. Gargles were wholly useless in the early stages, and with chil- 8 Smith, on Scarlatina. [January, dren they did barm ; but in the latter stages, when ulcers were present, they were of great benefit. The mild astringent gargles were best, such as alum, infusion of sage, honey and borate of soda; a strong infusion of cinchona, with or without tinct. myrrbae. Strong and irritating gargles, such as salt and capsicum, &c., &c, were injurious, and cannot be too strongly condemned. Blisters were used to the throat and nape of the neck in the incipiency, if inflammation ran high in those parts, but their use was not attended with much apparent good. They should be used with great caution. Treatment of S. Maligna. This variety of the disease ran its course so rapidly that scarcely anything could be done. When time was given, it was treated in the same way asS. anginosa. If the reaction was high, an emetic was given, followed by gentle aperients; in the sinking state, counter-irritants and stimulants, carb. ammonia, wine, brandy, elixir vitriol, &c., always selecting such as seemed best adapted to the case. During the stage of excitement, in each variety, cold water was allowed in small quantity, and acidulated if desired. The diet was mild and nutritious; the rooms were ventillated, and the clothing and beds were kept clean. From our observations in this affection, we have been led to the following conclusions : That scarlatina is not strictly a disease of the skin, the eruption being merely an effect or an occasional symptom. We could with as much propriety call typhoid fever a disease of the skin, because an eruption accompanies this affection. We think that scarlatina is a modification of the blood, producing great prostration of the nervous system, followed by inflammation of one or more of the internal organs, occasioned by some occult effluvium in the atmosphere, of which we know nothing. These facts considered, it is but reasonable to conclude that the treatment should be mild and unirritating, as the attack sets in with so much violence as to prostrate the patient at once. We there- fore deprecate calomel purges, antimonials in any form, blisters, venesection, &c. They cannot, in our humble opinion, be too strongly condemned. As respects the application of cold water, we have ever been taught that in no disease of the throat or tho- racic viscera should it be used, and we know the throat and fauces are invariably sore, inflamed, tumid, &c. This reason, of itself, is 1856.] Holt's Letters upon General Pathology. 9 sufficient to proscribe it. We therefore place all of the last named articles in the same category. Those strong and burning gargles never do good, and often do harm, especially with children. ARTICLE II. LETTERS FROM SAUL. D. HOLT, II. D., UPOX S01IE POIXTS OF GEXERAL PATHOLOGY. LETTER NO. 7. Montgomery, Ala., Nov. 25th, 1855. Messrs. Editors Notwithstanding the advancement which has been made in the science of medicine, and especially in physiolo- gy, pathological anatomy, and animal and vegetable chemistry, there has been nothing like a proportionate advancement made in the art of curing diseases; and one of the principal reasons for it, I think, is to be found in the fact, that most of our young physi- cians set out upon their professional career without having been sufficiently indoctrinated in the principles of general 'pathology. They may have been well instructed in the causes, symptoms, diagnosis, prognosis, treatment, &c, of diseases, as they are taught in the medical schools, and from their text-books, according to the most approved and correct nosological arrangement and classifica- tion, and they go forth into the world impressed with the idea, and confident belief, that they are fully prepared for every emergency, and that nothing remains to ensure their success, but to apply those rules to practice. But they often find themselves doomed to disappointment and defeat, and sooner or later discover that the systems of practice founded upon the nosological classification of diseases which they had regarded as the standards of excellence and perfection, are unsatisfactory, unreliable, and often inappro- priate to the man3r changes and modifications which diseases are constantly undergoing, from the influence of climate, seasons, at- mospheric changes, conditions, &c, which can be met and provided for only by a correct knowledge of general pathology. Now, I am not opposed to the nosology and classification of diseases, as taught in the schools, and by systematic writers generally ; but I am opposed to the systems of practice founded upon the simple de- tail and enumeration, in their order, of the symptoms which char- acterize the diseases to which they respectively belong, according to their most approved nosology and classification, and I fear that 10 Holt's Letters upon General Pathology. [January, it will be a long time before we shall see much advancement made, or have any thing like a uniform and reliable system of practice established, unless the present system is changed, and diseases come to be treated, not according to their name, or the class to which they may belong, but according to the condition which they present, and the symptoms upon the merits of their real pathology. If proof is wanted in support of the truth of the assertion, that the practice of medicine has not advanced in proportion to other branches of medical science, it is only necessary to examine the history of some of the most common diseases, as described by the systematic writers of the present day, and compare them with those diseases as described by the old systematic writers who named and classified them. Take Pneumonia, for example, and what neiu features of the disease do we find, which they did not notice, what new indications of treatment have we to fulfil, which they did not recommend, and what new remedial agents have we which they did not possess. We have the lancet, emetics, cathar- tics, diaphoretics, expectorants, blisters ; so had they. We have calomel, tart, emetic, opium, quinine, &c. they had calomel, tart, emetic, opium and cinchona. We have phosphorus, bryonia, bel- ladonna and aconite ! Alas, they died before the days of Hahne- mann and Homoeopathy. We have steam, lobelia, composition and number six ! but to them, the powers of steam and Doctor Thompson were alike unknown. Yet, with all the improvements suggested by these two great luminaries, it cannot be perceived that the disciples of either have made any great advancement in the healing art, or that they have improved much upon the old method of treating pneumonia, and other diseases. What success those old practitioners had in the use of the lancet, calomel, and other time-honored remedies, we have no exact means of ascer- taining, unless we take as evidence the fact, that the testimony which the}- have given of their value and efficacy m the treatment of certain diseases and conditions, has had the endorsement of each age and generation through which it has passed; and it cannot be considered uncharitable in us to suppose, that they were as suc- cessful in the treatment of pneumonia, with those remedies, before the time of Hahnemann, as his disciples claim to be with phospho- rus and aconite. Now, my idea is, that these old pioneers and fathers in physic, who named and classified our diseases, under- stood pretty well their special patholog}', and also the power, 1856.] Holt's Letters upon General Pathology. 11 efficacy, and value of the remedial agents which they placed in our hands to be used, with a sound judgment and discretion, (in which manner, no doubt, they used them,) each one in its proper time and place, according to the symptoms indicating its use. But there is one great desideratum which they could not supply, name- ly, a quick perception, and a sound and discriminating judgment, to make the proper use and application of those remedies, the want of which has not only brought some of the most valuable of them into disrepute, and led to their rejection, or discard such, for in- stance, as calomel and the lancet but has rendered these two arti- cles if not the ivorst used, at least the best abused, of any other two in the materia medica. It is true, that diseases are subject to such changes and modifications, in their general character, as to require a corresponding change or modification of treatment, for which our old authors made ample provision for supplying us with the means and remedial agents best suited to those changes and modifications not supposing, I dare say, that they were to be used after the manner of the backwoodsman, who sat down to dinner at a fashion- able hotel, and finding a bill of fare before him, thought it incum- bent upon him to eat through it in regular order ; or, perhaps, like a certain disciple of Hahnemann, not a hundred miles from this, who being called upon by a lady for something to ease an aching tooth, after palling often, and prescribing a great quantity of reme- dies, it finally became easy. Upon his next visit, finding such to be the case, he exultingly exclaimed, "Ah, ha, dat ish goot dat ish it." But, said the lady, why did you not give me your last remedy at first, and spare me from so much pain ? " Oh no, ma- dam, dat ish not goot, dat will not do, it ish not goot; it will not do to skip." And so it is, I have no doubt, with many who essay to practice the healing art, according to the most approved nosolo- gical arrangement and classification of diseases. They find a bill of fare before 'them which they feel bound to go through with, believing that "it will not do to skip." And it is often a long time, and not until they have had a regular surfeit, before they find out how to make a proper selection, or discover that it will not do to slcip. Now, I do not wish to impeach or impugn the character of the medical profession : on the contrary, I wish to defend it ; and I would ask, in all sincerity and candor, of those members of the profession who have raised their voices in denunciation of cer- tain remedial agents namely, calomel and the lancet whether 12 Holt's Letters upon General Pathology, [January, their opposition is of a negative sort, not founded so much upon experience, or observation of their use, as upon the fashionable sentiment of the profession. Whether their opposition is founded upon a conscientious belief of their inefficiency, their inappropri- ateness, and their dangerous or destructive tendency, after oft- repeated and unsuccessful efforts to apply them to those diseases in which they have been most highly recommended; or whether it is founded upon a reckless use and consequent abuse of those remedies, which by their indiscretion and want of judgment they have aided in bringing into disrepute, and from mercenary motives, or a desire to shield themselves from just and well- deserved cen- sure, and maintain their place in popular favour, that they have joined the general crusade against these remedies? This maj^ be considered a harsh criticism, but it is, nevertheless, a true one, and will apply to every practitioner in the South, who has publicly denounced the use of these remedies, and especially calomel, as be- ing unsuited to the treatment of bilious diseases ; and I care not which horn of the dilemma he may take. If it is to follow fashion, his opinion is worth nothing; if it is from a want of confidence, from the want of success, or the apprehension of danger, from the lack of a knowledge of its proper uses, he is to be pitied ; and if it is to foster popular prejudice, from selfish and mercenary motives, he should be despised. For no physician, however well founded may appear to be his objections, can be justified in publicly de- nouncing a well-known remedy, because he may have been unfor- tunate or unsuccessful in its use ; for, by so doing, he is only exciting and fostering a popular prejudice against a remedy which, in more skilful hands, would prove most efficacious and useful. And until some course of experiments and observations are insti- tuted, to show that the liver has no material agency in the pro- duction and aggravation of the malignant forms of diseases in hot climates, and a set of arguments adduced to' prove that calomel is not the most certain and reliable remedy known to the profession for regulating and controlling the functions of that organ, I shall be compelled to continue in the belief, that the sins charged to the account of this remedy belong not to the remedy itself, but to those who have misused and abused it. But let us go back awhile and see how matters stand with our bill of fare friends. Well, some get through with it, though they find it generally, " a hard road to trabble, I b'lieve," and find out, 1856.] Holt's Letters upon General Pathology. 13 after awhile, that they have consumed a vast amount more than was necessary and proper ; because they did not know when, or where, or even that it was proper for them to "&ikp" but finding out that they are at liberty to make selections, and becoming better acquainted with its contents and arrangement, they are satisfied to let it remain as it has been furnished to them, and are opposed to rejecting or discarding any article from the bill, because it may not, under circumstances, have agreed so well with their powers of digestion. It is among this class that we must expect to find, and do find, our most scientific and best practical physicians men who are soundest in judgment, freest from prejudice, most liberal in sentiment, and who take a common view always, as the best view of things. Such men find the lancet as efficient for good, and as potent for evil, to-day, as it was ten, twenty, or fifty years ago, and the same of calomel, tart, emetic, &c, and if in their use, they should fail to accomplish the objects and purposes intended, the failure will be attributed to the true cause the want of a pro- per application and use of the remedy. There are others, again, who, by the time and even before they have gotten through with the bill, either from fastidiousness of taste, from feebleness of diges- tion, the loss of appetite, or a surfeit from the too free and liberal use of certain articles in the bill which they desire to have changed by striking them out and substituting something better suited to their appetites and tastes. They have gone out among the foreign restaurats and cook-shops, and found a few fancy articles in the establishments of Hahnemann, Doctor Thompson and Graeffenburg (institutions which appear to be under the peculiar fostering care and protection of the legislature of Alabama) which they wish to have inserted in the bill of fare, in lieu of the rejected ones. Now, I do not wish you to consider me as belonging to the "Hard-shells," or so "old Fogyish," as to be opposed to all pro- gress and reform, especially as I am willing to adopt the sentiment of your journal, " Je prends le bein oil je le trouve," provided we confine our researches to the legitimate domain, and do not have to descend too low to get the good; nor do I consider all move- ments as a sign of progress, as we may discover in the motions of a sea-crab, whose progress is generally backwards. And so it is with most of the ph}*sicians of this class ; having neither con- ceived or adopted any well digested and reliable opinions, as their own, and having no fixed rule or principle of action, and as little 14 Holt's Letters upon General Pathology. [January, confidence in their own judgment and the efficacy of the remedies which they use, they are perpetually shifting their ground, advo- cating a doctrine or a theory one day which they combat the next, extolling a remedy at one time and denouncing it at another, but always u aufa.it" and well posted in all new inventions and dis- coveries, but never make any themselves. These are they who have endeavored to bring into discredit the lancet, calomel, and other valuable remedies, and attempted to foist upon the profession, as their substitutes, such articles as aconite, phosphorus, and bry- onia. No, no ! call me Fogy call me Hard-shell ; but let me not progress in that direction. Give us what you please, gentlemen, but do not compel or ask us to discard or strike from the bill, our first principles, as our "backwoods" friend termed his bacon and greens. There are yet others who have labored to get through the bill of fare as it has been served up for us by the old fathers in physic, but have not succeeded, for the reason that they have seized with too much avidity upon a single article, which they could not be induced to relinquish until they had gorged them- selves beyond satiety. To this class belonged the famous Doctor Sangrado, who, though he may have but few disciples, so far as blood-letting is concerned, in the present day; yet there are plenty of Sangrados in many other respects besides that of blood-letting, and if their work is to be judged of by the same rule, namely, the number of widows and orphans in Valladolid, it might be a difficult matter to determine which had been the most successful, the ancient or the modern Sangrados. The means used by each, though some- what different in character, in principle have been about the same ; for while the Sangrados proper effected every thing with the lan- cet, others have been about as successful with emetics and cathart- ics, upon the principle that man, like a gun-barrel, only required to be kept well washed out, to keep him in good shooting order; and if one washing was not sufficient, it was only necessary to give him another, and so on, to the end of the chapter. Others, again, have gone upon the principle, that man had no room in him for more than one disease at a time, and straightway they commenced crowding in one, which they thought they understood, for the purpose of crowding out one which they knew little about; and so calomel has had its day, and so things have gone on, up to the time of the discovery and introduction of quinine into practice, when all the little Sangrados, acting upon the advice which the 1856.] Holt's Letters upon General Pathology. 15 immortal Gil-Bias gave to his illustrious prototype, resolved to " change their method" and " prescribe chemical preparations, what- ever might be the consequences" have united in one grand league, constituting the present Sangrado family, who see every thing through the medium of periodic spectacles, and who have such strong faith and confidence in the anti-periodic and - proper- ties of the article that it would not be surprising if we were to hear that they had offered to stop the oscillations, and to depress and keep down the sawyers in the Alabama and Mississippi rivers one effect, however, has evidently resulted from the change, name- ly, a positive reduction of the number of widows and orphans in Valladolid. But what is to become of those Sangrados who have " written a book " ? They must either acknowledge themselves " disabused," or fight it out, as Gil-Bias did ; and let nobles, clergy and people perish, but not their reputation. Now, if it is seriously charged and maintained, that the intro- duction of quinine into practice constitutes an era of improvement and progress in the healing art, I would reply, that it is but a tri- umph of chemistry, and that its active and valuable properties were known and appreciated by the profession long before its dis- covery, (in the substance of bark) which they liberally used, and that its discovery has developed no new principle of general or special pathology ; and that while its introduction has had the effect of facilitating the cure of malarial and periodic diseases gen- erally, and of drawing the attention of the profession from the use of other valuable and powerful remedies and diminishing the chances for their abuse, and of substituting a less evil for greater ones, if not a positive good for those somewhat doubtful,, there is danger that the very facilities which it affords will lead, if it has not alread}^ done so, to repeated, if not general abuse ; for so general and indiscriminate has beeomeits application, that the pa- thological condition is seldom considered in connection with its use. Indeed, all that appears to be necessary now in the treatment of disease, is to know that it is periodic, and pathology may go to the dogs. Well, if you call this progress, improvement and re- form, just write me down Old FogyT and let Young America have the field. But if you ask me, where a remedy is to be found, and how it is to be applied, for all the evils of which I complain, I will answer, that it is to be found in the medical schools and colleges through- 16 Holt's Letters upon General Patlioloyy. [January, out the country, and especially those of the South, in which the principles of pathology should be thoroughly taught, both general and special, but more particularly the former, for the reason, that the perpetually changing character of our diseases require it, and nothing short of a long course of observation and experience Avill serve to supply the want or deficienc}r of it, as every practitioner who has been long engaged in the profession is able to testify. And being a comparatively new branch of medical science, and necessarily imperfect in its infancy, it becomes every physician, who desires or expects to see any advance and improvement made in the healing art, to throw the weight of his talents and influence in aid of its development and perfection, which will eventually raise the standard of the profession high above the reach of every species of low and vulgar charlatanism. But would not this "consummation, so devoutly to be wished for," be sooner attained by the establishment of something like a National College of Physicians and Surgeons, which would bring together and combine the best talent from all parts of our land, and which would serve as a sort of regulator to all the other schools and colleges, and finally furnish us with a s}'stem of practice founded upon the most- correct principles of pathology, both gen- eral and special, which would answer for every latitude and climate throughout our widely extended country? But I fear that the sectional prejudice and animosity the rivalship and jeal- ousjr, existing among the medical schools, (which are becoming very numerous in the land, and creating a greater necessity for such an establishment, or institution,) whose province it should be to take the lead in such an enterprise, will prevent them from ever doing so. Until such a work is undertaken and accomplished, I shall never expect to see a much better state of things existing in the profession than I have described, and must remain content with being run over ''roughshod,'1'' by Thompsonians, Homceopath- ists, Graeffenburgers, &c, &c, for whom I entertain a more sincere respect, than for those physicians who try to rob them of their thunder. llaving thus given expression to my opinions, as to the causes which have prevented the proportional advancement of practical medicine with the advance of other branches of the science, but which have tended rather to produce a retrograde movement in the healing art and having ventured to suggest a remedy, or 1856.] DrJGAS. ATon-Cb?igenital Talipes. 17 corrective, for the evils complained of, which many, no doubt, will be disposed to regard as imaginary, and having no real existence, and that my criticism upon the present state of the profession, is but the effervescence of a morbid sensibility or of disappointed ambition, I will leave the subject, and proceed with an examina- tion of some of those much abused and rejected remedies already spoken of, the first of which will be the Laved; for the reason that it very naturally comes first in the order, of remedies, accord- ing to the classification which I have adopted, namely, the "In- flammatory" and Irritant, the Congestive, the Congesto- inflamma- tory, and Congesto-irritant forms of disease. But as this subject must be reserved for my next letter, which I hope to make more interesting and instructive than the present one, I must subscribe myself, as usual, your friend, &c. Saml. D. Holt. article III. Non- Congenital Talipes. By L. A. Dugas, M. D., Sue. The subject of the present case is a daughter of Mr. B., of Li- thonia, in this State : she was born in March 1851, and in Novem- ber 1853 was attacked with Erysipelas, with which she was very ill, and remained feeble for some length of time. I am informed that she had no spasmodic affection during or subsequently to her illness ; but it was observed, when she began to run about again, that she was lame. This lameness gradually increasing, its cause Avas observed to be in the foot, whose distortion grew more and more obvious until I saw her, in August, 1851. The case then presented all the peculiarities of a well-marked Talipes varus, the weight of the body resting upon the external margin of the foot ; one only being effected. By a sub-cutaneous incision the tendo-achilles was divided in the usual way, and a few days after, Dr. Chase's very simple and useful apparatus was applied for the purpose of gradually bringing the toes upwards and outwards. This succeeded admirably, and in a few weeks she was enabled to walk flat-footed. It is difficult to account for the production of such a deformity by an attack of erysipelas ; yet, as the cause of these distortions, whether congenital or otherwise, is still involved in obscurity, it is 18 Observations on the Hoot of the Cotton Plant. [January, well to accumulate facts on the subject. This is the fourth case of non-congenital talipes I have met in private practice. The others have been reported in this Journal for 1853, p. 112, and 1854, p. 210. Observations on the Root of Cossypium Herbaceum, or, Cotton Plant. By Thomas J. Shaw, M. D., of Robertson County, Tenn. Cotton Boot Its Ce., ral Characters. It is fusiform in shape, giviDg off small radicles throughout its length. The size of the root varies, according to the soil from which it is produced. Its length varies from a lew inches to that of a foot. When the root is cut or broken, it displays a white color ; the bark is of a reddish brown ; the taste is pleasant, somewhat sweet and astringent ; it contains more of the latter principle than the root from which it is procured ; it is very mucilaginous in its properties. The root is easily broken when dry, but the bark is quite tenacious, pulling off in strings. This root is too well known in this country to require a lengthy description ; therefore I will pass to the chemical analysis, as pre- pared and furnished to me by my esteemed friend, Mr. H. B. Orr, of Nashville, Tenn. Chemical Examinations of the Root. The result of which, as accurately as might be determined, is as follows, to wit: Gum, Albumen, Sugar, Starch, Tannic Acid, Gallic Acid, Chlorophyle, Iodine, Caoutchouc, Black Resin, Red Extractive Matter, Black and White Oleaginous-like Matter. The latter two abound in this plant. Proximate Principles. Experiments were made with a view to the isolation of the active principle of the root, which were not altogether satisfactory ; for though there was no crj^stalline princi- ple obtained, as was desired, making the existeuce of it palpable and distinct to all ; still there is evidence in favor of a principle existing in it. Time did not admit of an extended experiment in this department of the analysis. The author indulges a hope of having time to examine the active principle more minutely than he has yet done. What he has seen suffices to convince him that the medical properties attributed to it are not fallacious. The attention of the medical profession was called to the medical properties of this root, first by Drs. McGown and Bonchell, of Mississippi; the latter gentleman by an article written in the Wes- tern Journal of Medicine and Surgery, about the year 1812, as well as I recollect. For a want of confirmation, it passed unnoticed by the profession, until the year 1852, when it was again brought into notice in an article written by Dr. John Travis, of Marlbo- rough, Tennessee, in the Nashville Journal of Medicine and 1856.] Observations on the Root of the Cotton Plant. 19 Surgery. He reported but one case in which he tried it, and it was with entire success, restoring the menstrual flow in a short time, after 'an absence of about ten months. I consider this root one of the very best emmenagogues of the materia medica, and I think it should be so classed. My reasons for considering it such, are grounded upon the different experi- ments which 1 have made with it, within the last twelve months. I sometimes use a decoction, and at others an infusion, but most generally a decoction, prepared thus : $. Cotton Root, ?iv. ; Water, lbs. ij. boil down to one pint. S. A vine glass full every hour. This produces the most salutary effect in dysmenorrhea ; it acts as an anodyne in allaying the pain, and as an emmenagogue in aiding or augmenting menstruation ; its action is very speedy ; after its ex- hibition, in this case it produces an effect which, indeed, appears almost natural, that is, almost without pain; the patient, after its exhibition, feels but little inconvenience from pain, which soon subsides, and menstruation is immediately augmented, without acceleration of the pulse or gastric uneasiness. There are few other emmenaa;o"'ues that can claim this feature. DO Its action in amenorrhcea I think superior to any other emmen- agogue belonging to the materia medica, though it would be proper to pay some attention to the general health of the patient before its exhibition. It is superior to any thing that I have tried in the way of emmenagogues. I have had cases in which I first tried the usual emmenagogues, with but little effect, (or success,) when I would determine on trying the decoction of this root, which would far surpass my expectations by acting with the most marked effect ; menstruation being produced on the following day after its exhibition. All of the symptoms disappeared on exhibi- tion of this medicine. I believe this to be the best emmenagogue that we can employ in mere suppressio mensium, where there is no other disturbance in the general health. With the usual emmenagogues, I was enabled to produce the catamenia on a }roung lady, which continued for about twentv- four hours, then suddenly becoming very sparse and painful ; and in a few days after this period had passed, I employed the infusion of the cotton root as a means of exciting this function, which it did on the following day, a plentiful discharge being produced, which continued for live or six days. She has been regular at every period since that time, and has enjoyed good health, with the ex- ception of a few simple attacks, which caused no derangement of the menstrual function. For about twelve months previous to the exhibition of this medicine, her health was very much impair- ed, but she commenced improving, and soon recovered her health. I could detail other cases similar, in which I have tried the decoc- tion with the same effect, but I deem it unnecessary to mention its action in each individual case. N. s. VOL. xn. no. i. 2 20 Observations on the Boot of the Cotton Plant. [January,. As a 'parturient Agent, I think it superior to ergot in one sense of the word, and in another about its equal, its action being about as prompt as that of ergot, and attended with much less danger, I have tried both in parturition, and found the cotton root decoc- tion to act with fully as much efficacy as ergot. In some cases in which I have tried it, the pain was to some extent allayed, and labor promoted with as much speed as when ergot was administer- ed. It appears to be perfectly harmless, from the fact that its ac- tion is almost unattended with pain. It causes neither gastric distress, or acceleration of the pulse; if it does, it is not perceptible ; both of which are occasioned by ergot, to some extent. I have witnessed its action in retained placenta with good effect, which was an expulsion of the mass in about twenty minutes after the exhibition of the first dose. It may be proper to sayr that I gave two doses before the placenta was thrown off. I believe it to be safer as a parturient agent, or an emmenagogue, or at least as safe, as any other article of the materia medica. It should have a fair and impartial trial by the profession gen- erally, because it will prove itself worthy of the time and labor spent in its investigation. It is handy to all, and free of expense.. A few trials by the profession will confirm the truth of this short essay. Give it a trial, and it will prove itself in some case of amenorrhcea, dysmenorrhoea, or probably in some lingering case of labor, which may require the assistance of medicine, to produce contraction of the uterus for the expulsion of the child. I think it worthy of the attention of the profession, in the above cases. Tincture of the Cotton Root oa a Tonic. There is a condition of the system in which this tincture acts as a valuable restorative. These cases are of a leuco- phlegmatic temperament of both sexes, but it is to the female sex that I wish to draw the attention of the reader. Where there is general bad health, accompanied with tardy menstruation, I have used it with the happiest effect ; in a few cases of emansio mensium, caused by anemia, where the pa- tient was troubled with pains in the loins and giddiness of the head, with a derangement of the digestive organs,, such as anorexia, accompanied with an uneasy, depressed feeling at the scrobiculus cordis, every month, which was promptly relieved by the tincture, but not with the effect of producing the menstrual flux, which was afterwards produced by the decoction, I find it necessary to continue the tincture from' two to four weeks. The strength of the tincture that I have been in the habit of using, is prepared thus:. Bark of the Root, (dry,) 3 viij. ; Diluted Alcohol, lb. ij. Digest fourteen days, then filter and give it in 3j. doses, three or four times a day. The tincture which I used was prepared by myself;, and as I have seen no account of its use, I claim the first preparation of it, as well as the first experiment with it. My 1856.] Peculiarities of the Negro Race. 21 : brother, Dr. H. J. Shaw, has since tried it, with the same good effect ; in fact, his experience coincides with mine throughout. In closing this short and imperfect essay, I indulge a hope that it ! will prove of some service to the profession. [Nashville Journal of Medicine and Surgery. An Essay on some of the Distinctive Peculiarities of the Negro Race. By A. P. Merrill, M. D. It will scarcely be deemed necessary, in treating of peculiarities, anatomical, physiological, pathological, and therapeutical, of the negro race, that we should enter upon the discussion of the science of ethnology, which has latterly engaged so much attention from learned men. It cannot be denied, however, that it involves to some extent the questions of physical and mental peculiarities, which are found to differ in different races of men, and to exercise a modifying influence over the animal and moral functions, both in health and disease ; but whether these differences and peculi- arities have arisen from a pleurality of original creations, from the influences of accidental circumstances, or from special provi- dences, it matters little to our present purpose. The subjects which we have undertaken to discuss, have reference merely to the existence of certain facts, in connection with the negro con- stitution, which so influence and control his health, and the diseases to which he is subject, as to constitute distinctive peculi- arities, requiring the adoption of habits of life in health, and the application of remedial measures in sickness, differing, either in kind or degree, from those which are applicable to the white race. And these inquiries are supposed to have reference, especially, to these two races, as we find them existing in our own country at the present time, and principally in the Southern states, in the relations of master and slave. Anatomical Peculiarities are conceded to exercise an important influence over physiological functions ; and may, therefore, be briefly referred to here, as almost necessarily connected with the other branches of our subject. These, although sufficient in the negro, to be readily distinguished and palpable, even to the casual observer, can scarcely be considered of such a decided character, and so widely differing from other races, as to justify the broad distinction which has been drawn between different races by a certain class of ethnologists ; or such as will properly authorize, of themselves, independent of other considerations, the grave conclu- sion that God did not malce of one blood all nations of men, to dwell on all the face of the earth. Nor do these anatomical peculiarities lead us to expect, from any influences which they may be sup- posed to exert over the functions of the body, a wider difference in the character of the diseases affecting the different races, than 22 Peculiarities of the Negro Race. [January, we actually meet with in practice. The color of the skin, and the peculiarities of the hair of the negro, however they may have been originally produced, undoubtedly serve important purposes of protection and comfort, in the climate where he is found in the enjoyment of the fullest health. They are such as are favorable to a high degree of radiation of caloric from the body, which pre- sents to the air a constantly evaporating surface, and afford to the brain the most efficient protection from the influence of the rays of a vertical sun. The scantiness or entire destitution of clothiug, which is the natural result of that improvidence engendered by a hot climate, where little other t^ m vegetable food is desired, and where this is mostly supplied by the spontaneous productions of the soil, renders these provisions of nature essential to healthful functions, and even a comfortable existence, in his native country. In regard to the brain, the peculiarity of the negro consists more in its conformation than in its volume ; the latter being scarcely below the average of some other races of greater acknowledged intellectual endowments, although decidedly below that of the Teutonic and Anglo-Saxon races. The phrenological characteris- tics of the negro, are said to indicate a large preponderance of the animal over the intellectual functions; and such is the inference to be drawn, also, from an acquaintance with the mental constitu- tion of the negro. A remarkable fact, in this connection, not generally noticed by writers, but hinted at by Agassiz, may, we think, be considered as one of his distinctive traits. Negro chil- dren are not, in general, deficient in mental quickness, and acu- men ; and are not unfivquently found to be precocious, and sus- ceptible of successful instruction 'r while the intellect is not only not developed subsequently, as in white children, but appears in truth to retrograde, so as actually to fall below, in many cases, the developments which have taken place in the white race, even in childhood. It is not uncommon, on southern plantations, to meet with children of nearly the same ages, of both sngaging together in childish sports and pastimes; and to notice that the ne^ro children are equal, and sometimes superior, to their young masters and mistresses, in the quickness of their perceptions, and aptness to learn whatever is attempted to be taught them. Negro- children often succeed in learning to talk in advance of the chil- dren of their master, with which they are associated; and we have found, upon a personal experiment, that they can most readily be taught, by a system of oral instruction, simple religious truths, hymns, and forms of prayer, so as to make a very creditable dis- play of proficiency, as catechumens. The children of family ser- vants, which are kept in close association with the older members of the white family, by whom they are apt to be much caressed, frequently exhibit such evidences of smartness, and such readiness of wit, as to afford great promise of future usefulness, in spheres of "action requiring undue intelligence and judgment. With few i 1856.] Peculiarities of the Negro Race. 23 and rare exceptions, however, they lose all signs of -uncommon talents, as they advance in years, and sometimes even become noted for their dullness. No advantage of position or instruction will, so far as we have been able to observe, obviate or retard this tendency to deterioration. The thorax of the negro is less expanded, and his vital capacity for respiration is said to be somewhat less than that of the white man. Indeed it is said to have been proved* that such is the fact, and that a less volume of air is respired in consequence ; but this apparent defect may be compensated for, in some degree, by the greater curvature of the ribs, giving scope for greater mobility of the chest, and consequently a more perfect exhaustion and expan- sion of the air-cells, iu respiration. This curvature causes a deeper depression of the spine, which is a constant peculiarity in the for- mation of the negro skeleton. The scapulas are said to be shorter and broader, and the pelvis somewhat narrower, particularly in the male. The legs are apt to be bowed, and the heels projecting backwards. The muscles of the limbs are short and protuberant, with proportionally longer tendons. The genital organs of both sexes are more largely developed, and the breasts of the females are more conical, with a less extent of base. The nerves have been represented as being larger, and containing a greater aggre- gate of substance, in proportion to the amount of brain and spinal marrow ; but this, perhaps, requires further proof. The liver is said, also, to be larger in proportion to other organs. Tlie Physiological Peculiarities are, in part, such as naturally result from the anatomical. Reason, judgment, forecast, and in- dependence of character, could scarcely be the accompaniments of a brain however large its volume, in which the animal organs maintain a great preponderance over the intellectual and moral. Consequently we find, what might reasonably be expected from the anatomical conformation, that the negro is essentially a degra- ded being, vastly inferior to the Caucasian race, in all the attri- butes of spiritual existence; and only capable of improvement by many ages of contact and association with civilized nations. How far such influences may tend to the improvement of his physical constitution, and to the relief of his mental deterioration, can at \ present be only a matter of conjecture ; but admitting that all his peculiarities of deterioration are the result of forty or more centu- ries of constant decline, while the interval between him and the white man, has been widened by as constant an improvement and elevation of the latter, and it must be admitted as probable, that ! however much may be done by mankind, toward the promotion | of the civilization and christianization of the former, many thous- and years must necessarily elapse, before he can be brought up to ; the present position of the white man. No one who has had proper * Dr. Cart-wright, New Orleans Journal, Vol 1, IX, 196. 24 Peculiarities of the Negro Race. [January, opportunities of observation, and taken the trouble to improve them, can for a moment entertain a doubt, that, of all the provi- dential occurrences, tending to the improvement and elevation in the scale of being, of this degraded race, none could be better suit- ed to the purpose, than the existence of American slavery. It must not be denied, that it is a system which leads to egregious abuses. Of these we are not the apologist. To his own master let every slave-holder render up his account. No fact in psychology is better established, than the inaptitude of the negro mind to improvement. In his native country lie ex- hibits no signs of progression. The rising generation does not aim to improve upon the past, or to profit by a knowledge of its errors ; but taking the place of their predecessors, they are content with doing precisely as has been done by their progenitors for ages. If his forefathers have been accustomed to plow with the rough branch of a tree, the negro has no conception of any other method, and works on with the branch of a tree from generation to generation forever. Nor does he seem inclined to follow the example of the white man. The latter may settle near him, and ploAV his grounds according to the most approved modern plan, and the negro may look on and wonder; but he is not any the less willing, still, to pursue the example of his fathers, and no im- provement is attempted, however promising may be its results. Such has been the stationary condition of the race from the earli- est times, tending more, perhaps, to deterioration than to improve- ment ; and there can be little hope of progression in future, while the negro is left to follow the bent of his own inclinations. Ilis condition and history promise nothing but the extreme of savage ignorance and degradation. By the institution of southern slavery, the negro is brought under a system of tutelage, in contact with a race vastly his supe- rior, and of whose habits of thought and action he is constantly compelled to take notice. By every humane and judicious master he is cared for, as he requires to be, as a child in leading strings; and although he has not yet attained a degree of improvement which would seem to be commensurate with his advantages, it must be considered, that his pupilage has as yet only been a short one, and not sufficient tc test his capabilities of ultimate advance- ment. Time may so far develop these, as to enable him to recover his lost position in the scale of being, and to carry back to his na- tive shores the germs of civilization, and the christian religion, both to be successfully cultivated, to the enlightenment and regen- eration of benighted Africa. Human research and ingenuity have not been able to devise any other available means, by Avhich these blessed results can be secured to an ignorant and degraded people, than by the influence of long association with a superior and dominant race. History affords examples in illustratiou of this position, and our own experience, as well as our reason, confirm3 1856.] Peculiarities of the Negro Race. 25 it. It is an interesting problem, to be solved in the long and tedi- ous future, whether the negro will, even by these means, ever be elevated in the scale of being, to a degree which will realize the anxious hopes of the christian and the philanthropist. Other physiological peculiarities result from, or appear to be intimately connected with, the native climate of the negro. Whe- ther so formed by a separate creation, as some contend, or adapted by long habituation, the negro race is physiologically constituted for the enjoyment of a hot climate. Living mainly, in their na- tive wilds, upon a meagre and vegetable diet, their systems are less abundantly supplied with carbonaceous material, and have less adaptation to the generation of animal heat, than the white race in more northern latitudes. The air which surrounds them within the tropics, being much of the time of an equal or higher temperature than their bodies, and never at any time much below it, there is no necessity for an active reproduction of warmth, to replenish the moderate waste from external radiation. If it be true, therefore, that less air is respired by the negro, and a less amount of oxygen consumed, which appears to be altogether pro- bable, it is because there is less occasion for physiological combus- tion ; and this may be further reduced by the more rapid elimina- tion of carbon by the liver and skin, while the copious supply of perspirable matter and proportionate evaporation from the sur- face, tend to prevent an undue accumulation of animal heat, from the moderate exercise of the functions whence it is derived The negro constitution being thus eminently adapted to the torrid region, it follows that the climate in which we find him in our country, is much too far north for him. Being exposed for a large portion of the .year, to a temperature to which he is ill adapt- ed, and liable to suffer all the while from the operation of those causes, above alluded to, which constantly tend to the reduction of the heat of his body, so sparingly supplied, he can only be pro- tected from the evil influences upon his animal functions, and ren- dered effective as a laborer, by being better fed, and better clothed, and lodged, than in his native country. The changes which take place in his physiological functions, as a consequence of his sud- den transfer to a colder climate, must be counteracted b}' corres- ponding changes in his mode of living, or disease and an abridg- ment of the duration of life, must be the natural result. This remark is, perhaps, scarcely less applicable to the white man of temperate latitudes, when suddenly transferred to the polar re- gions. If he neglected to conform, to some extent, to Esquimaux habits, and indulge in the use of oleaginous food, to furnish addi- tional supplies of hydro-carbon for an increased production of animal heat, he will scarcely be able to endure a succession of cold winters, without a loss of health. The converse of this proposi- tion is equally true. Emigrants from hyperborean to tropical re- gions, require, equally, that their habits of life should be charged, 26 Peculiarities of the Negro Race. [January, and made to conform, in some degree, to those of the fruit-eating people among whom they go. Of these physiological requirements there can be no doubt ; and probabty it will be found upon further and closer observation of the matter, that they are of a more urgent character with the black than the white race; for the reason, that the former is possessed of less resiliency of constitution, and self adaptation to change, than the latter; resulting partly from difference in actual idiosyncrasy, and partly from the greater reason and judgment with which habits of life are controlled. However this may be, it can hardly be matter of dispute, that southern planters Avho study their own in- terests, whether they understand the physiological reason for it or not, have found from long experience and observation, that it is good economy for them to give their slaves a full allowance of fat pork, and also of Indian corn, which abounds in oleaginous prin- ciples wherever it is grown, although to a somewhat less extent rn hot than in cold climates. Every slave in the southern states, who has had opportunities forjudging, is aware of the greater strength of diet afforded by northern, than by southern grown corn ; and of the certainty with which the former will degenerate into the latter by a few years of southern cultivation. Southern corn is always prefered by them, however, on account of its greater palatableness, and lighter color. And it seems to be a providen- tial circumstance, that the whole region of country in which slave labor is profitable, is particularly suited to the production of the two main articles of diet upon which they subsist, corn and pork. The former alone would afford them a stronger diet, yielding them larger supplies of hydro-carbon, than most of the tribes of Africa can command in their native country ; and perhaps it may have been a knowledge of this fact, added to the cheapness of the food, which tempted the original planters of Louisiana, to rely almost exclusively upon Indian corn in feeding their slaves; while they were content to clothe them in the coarse linen goods of tint period, as affording a much better protection from the weather, than they had been accustomed to in their barbarous homes. Cut when some of the large sugar estates fell into the hands of North men who had been accustomed to see the white laborers of the north much better clothed and fed, and performing m* tive labor in consequence, the natural result was a trial of the experi- ment upon negroes; and the large increase of the product of their labors, consequent upon this change, soon caused a complete revo- lution in the system of plantation supplies, leading to a better provision for the slaves from year to year, until, at the present time, they are probably better fed, and better clothed, than are the white laborers in any part of Europe. Still, certain errors arc committed by planters, for the want of *a proper understanding of these physiological peculiarities of ne- groes, adapting them to hot climates. The winter being the season 1856.] Peculiarities of the Negro Race. 27 of comparative rest, as the crops are not then growing, to require extraordinary efforts at tillage, it is the custom of some, to afford their slaves less liberal supplies of meat at this season than at any other ; when, if the views above given are correct, they require more of fatty and hydro-carbonaceous food in cold weather than in warm. On sugar estates, during the sugar making season, this want is in part supplied by the free access which the slaves have to the juice of the cane, and its products. Its physiological effects become apparent in the high degree of health and vigor which is maintained, in spite of the extreme labor imposed by this perpetual day and night process of sugar-making, out of which the slaves come with an increase of embonpoint and buoyancy of spirits. These invigorating and fattening effects of saccharine food, are said to be more perceptible upon the constitution of the negro than the white man. The amount of hydro-carbon furnished by it may, in many cases, be greater than can be obtained by the use of cod-liver and other oils, which cannot always, on account of their indigesti- ble and cathartic qualities, be taken in sufficient quantity to pro- duce these legitimate effects. As a remedial agent, therefore, in phthisis, scrofula, and cachexies of various kinds, saccharine mat- ter is of no mean importance. The inability of the negro constitution to generate heat, com- mensurate with the increased want of it, consequent upon the drain imposed by exposure to unusual cold, is manifest in its effects upon the respiratory organs ; which, from exposure to cold air, without sufficient covering for the body, suffer from a constric- tion and chilliness, which are frequently quite painful. This it is which induces the negro, contrary to the common practice of the white man, to turn his head towards the fire, or to cover his face with a blanket, in preference to his feet, that the air inhaled may first be partially warmed, and thus save him the inconvenience of its chilling effects upon his lungs. Place him in a warm room, with plenty of warm bedding, and he will soon learn to omit this injurious habit, which deprives him of the fresh and uninspired air, so much required by him as a source of vitality, and of vital warmth. The same want of due supplies of animal heat is evin- ced, when negroes are required to sleep in the open air. Upon a hunting excursion, or a military campaign, white men will often inure themselves to the rapidly sinking temperature of the surface of the earth, and sleep with impunity without the interposition of anything to prevent the rapid radiation of heat toward the clear canopy of heaven ; but if their negro servants who may accompany them, partake of the same exposure, they not only show signs of greater suffering, but the effects are apt to tell upon them, in the development of fevers, and of thoracic congestions and inflamma- tions, not unfrequently laying the foundation for permanent ill- health. It is only in our hottest summer weather, or in inter-tro- pical climates, that negroes can undergo these exposures with 28 Peculiarities of the Negro Race. [January, impunity. Indeed, we have but few nights in the southern states, which would not prove injurious to the negro sleeping in the open air, and particularly by the chilling effects of terrestrial radiation of heat upon the temperature of the atmosphere, toward morning. Many of the diseases to which slaves are peculiarly liable, and which form the principal outlets of life among them, are caused by a want of proper attention to this high requisition of their organ- isms for heat, and by the want of proper supplies of fresh air, con- sequent upon the efforts which they are called upon to make, to relieve their bodies, and particularly their lungs, from the painful influences of cold. It is a great mistake, we apprehend, to sup- pose, that because negroes are often found sleeping with their cabins closed, and their heads covered, they do not require fresh air. It is not animal instinct which impels them to forego its use, but want of comfort. Let them be rendered comfortable, by due supplies of warmth, or the means of preserving the warmth of their bodies, and they will be found to enjoy the full respiration of fresh and wholesome air, not less than white persons. And it has seemsd to us, that it is mistaking effects for causes to contend, that the elimination of an undue proportion of carbonic acid, by means of the skin and liver, is certain proof that nature has intended these organs to act as greater depurators of the blood in blacks than in whites. Whenever they do thus act, as is no doubt often the case, it is compensatory for defective action by the lungs, just as an increased action of the kidneys, in all persons exposed to the chilling influences of a cold and damp atmosphere, is compensato- ry for partially suppressed perspiration ; and it remains to be proved, that the decarbonizing power of the skin and liver of the white man, is not just as active and efficient, under the same influ- ences, or smy other influences retarding the action of the lungs to the same extent. To guard against disease from this cause, it is necessary that, in providing lodgings for slaves, great care should be taken to sup- ply them with both ventilation and warmth. It is important that in winter the two should be furnished in combination; and pro- bably there is no better way of doing it, than by constructing their lodgings so as to be warmed by hot-air furnaces, through which air both warm and pure may be supplied in abundance. Upon large plantations, where the saving of fuel is an object, this might be clone, were the dwellings properly arranged for it, at less ex- pense than the same advantages could be secured upon any other plan ; and there are few nights in the year, that the planter Avould not find it his interest to kindle fires in such furnaces. The time lost by negroes in unnecessary sickness, and the cost of medicines and medical aid saved by such arrangement, not to mention the increased average duration of life, would amply repay the expense. Many slave-owners, deeming it important to give their negroes a-" full supply of fresh air, without considering the importance of 1856.] Peculiarities of the Negro Race. 29 warmth, construct their dwellings with openings in the loosely laid floor, and with crevices between the logs or planks which form the walls of the buildings, so that whether the room contain few or many, there is no possibility of any one individual occupy- ing a position, which will not subject him to the constant action of a current of cold air. This induces him to sleep with his head covered, to avoid the painful constrictions caused by cold inhala- tions, and thus subjecting himself to the injury resulting from breathing impure air, even though his room be ever so well sup- plied with it. Full one half of every inspiration is made up of air which has been respired before, and the fresh air with which the dwelling is so liberally supplied, answers \\o other purpose, than to chill the surface of the body, and the extremities, turning in upon the vital organs that mass of fluids, and vigor of circulation, which are required for the healthful action of the cutaneous vessels. The fluids and vascular action thus repelled, lay the foundation of a large portion of those diseases which prove fatal to slaves. But it is not impracticable to secure warmth and ventilation, to a healthful extent, by building close and warm houses, with glazed windows which can be opened at the top, near the ceiling of the rooms, while the lower portion is closed ; and by wanning the rooms by means of large, open fire-places. A plentiful supply of warm blankets, and the enforcement of a wholesome rule, to un- dress on retiring to bed, and lay aside the clothing worn during the da}r, will secure the occupant of such an apartment a free res- piration of pure and warm air, a free action of the skin and viscera, and a great degree of comfort and health. The negroes will be enabled to warm and dry themselves immediately on their return from their daily labors, and thus avoid being chilled after exercise and exhaustion from fatigue. They will lay aside the clothing worn during the day, to be aired and dried in readiness for the morning. They will sleep without tight bands about them, and "without obstruction to cutaneous exhalation. They will have no motive for covering their heads in their blankets. They will en- joy the benefit of tolerably fresh air, without danger of being chilled by its impinging directly upon their bodies. They will enjoy unbroken slumber, and be invigorated for the labors of the ensuing day ; and when they rise and go forth, into the cool air of early morning, it will not be with bodies chilled by cold, or reek- ing with moisture. The selection of a healthful locality for negro quarters, is a mat- ter of not less importance than their proper construction. It is a common practice, upon the highlands, to give preference to some worn-out or barren hill, or ridge of ground, which produces .little or no vegetation, and is, therefore, of little value for purposes of cultivation. And upon the low -lands, where there is no want of fertility and productiveness, the plan often pursued is, to keep the earth around the quarter nearly bare of vegetation. These prac- 30 Peculiarities of the Negro Race. [January, tiees are followed without reference to, or in accordance with, what we consider false views of the causation of d i telluric influences. From long observation and experience in this matter, we are forced to the conclusion, that it is from the bare and naked earth that we have most to fear in this respect. Nature appears to have intended that the earth, or at least the habitable portions of it, should be coated over with vegetation. Accordingly we find, that when it is thus coated by the forests, by the luxuriant grasses of prairie grounds, by cultivated crops, &c, a healthful influence over the inhabitants is exerted. But whenever these natural coat- ings are removed, from any cause, bringing the bare surface to the long continued action of the sun and winds, sickness is nearly the invariable; consequence. Fortius reason ut>gro quarters should be established upon a fertile soil, or one which can be rendered so by cultivation, which should be sedulously shielded, as in a state of nature, by a luxuriant growth of vegetation of some kind. This is in accordance with common experience. In some parts of Mississippi, where the virgin soil has disappeared from the sub- stratum of yellow clay, upon which it reposed, and the fields have been abandoned, and become washed in gullies, and bared of vegetation, sickness, and particularly malarial diseases, prevail to a much greater extent than formerly when these grounds were exceedingly rich in vegetable mold. The same necessity for a coating of vegetation exists when the bare surface of the earth has been exposed, inconsequence of the subsidence of stagnant water, the drainage of swamps, &c, which very generally exert a delete- terious influence until covered by a dense vegetable growth. The health of negroes is scarcely less dependent upon proper clothing, than suitably arranged dwellings. The color of the skin is favorable to the radiation of heat, while the head is protected from the influence of the direct rays of the sun, by the non-con- ducting character of its woolly covering. While these and other constitutional peculiarities serve to qualify him for enduring the heat of a tropical climate, and a vertical sun, they disqualify him proportionally, for a cold climate, and for great and sudden tran- sitions of temperature from heat to cold. They are, moreover, from a want of resiliency and native vigor of constitution, less able to adapt themselves to changes of climate, than white men. These truths are so universally acknowledged, as to require neither argument nor illustration in their support. Consequently the slave population of the United States, occupy a region by many degrees too far north, for the enjoyment of health and long life, without having their bodies specially protected from the depres- sing influences of cold, and from the influence of vicissitudes of the weather, in our capricious climate. The winter season is par- ticularly trying to them, and apt to be productive of the most common and fatal class of diseases to which they are subject. It must be evident, therefore, that the selection of proper clothing is 1856.] Peculiarities of the Negro Race. 31 among the most important considerations in connection with, plantation hygiene. And such is now the cheapness of the coarse kinds of goods most suitable for this purpose, that no good reason can be given for neglecting to clothe them in a manner most conducive to the preservation of health. The danger of the loss of health and life, the loss of time, and the expense of medical aid, and of medicines, arising from a want of proper protection by warm clothing, is much more detrimental to the interests of plant- ers, than the most expensive arrangements, in reference to this matter, which are adopted by the most considerate and liberal slave-holders. Since cotton goods have become cheaper than those made of flax and tow, the materials used for negro clothing are almost exclusively composed of cotton or woolen, or a combination of the two. The coarse cottons commonly used, are well adapted to this purpose for summer, and, with the exception of old and infirm persons, negroes do very well with an exclusive use of such cotton goods for about seven months in the year from April to Novem- ber but for the other five mouths it is safer, and good economy, to provide all who labor in the open air, and are subject to the vicissitudes of the weather, with woolen shirts. The old and feeble should wear them the whole year, and with the addition of woolen drawers in the winter. In all sickly localities, indeed, it is better that this aarangement should obtain with all ; for it has been well ascertained, that the use of flannel next the skin all the year, affords the most certain protection against malarial diseases, of any means known, excepting, perhaps, the daily use of quinine; and it is reasonable to conclude, that its prophylactic agency is more decided with negroes, than white people, on account of physiolo- gical peculiarities to which we have referred, and particularly with negroes living in a climate of unnatural coldness. It is, indeed, a rare thing, according to our experience, to meet with a violent case of fover, cholera, or other malarial affection, so called, in a negro Avho habitually wears tiannel next the person, and particu- lar^ if he sleep with a woolen covering at night, and in a cabin properly warmed and ventilated. Contrary to the common prac- tice of planters, children and youths, for obvious reasons, require suitable clothing, and nightly protection, much more than grown persons. There is no one article of clothing, perhaps, which is more ne- cessary to the health and comfort of field negroes, than the over- coat. This is made of various coarse materials, and sometimes of thick blanket cloth, with a hood to be worn over the head at will, which is a necessary appendage for those who are not supplied with hats or caps. These over-coats cr capots, are useful in the cool of the moruing when starting ^out to work. The negro is roused from his slumbers at early dawn. Perhaps he has been sleeping in a close room, with his head enveloped in his blanket, 32 Peculiarities of the Negro Race. [January, and he goes directly into the cold morning air with his skin reek' ing with moisture. His stomach is empty, and the general languor which prevails predisposes him to chilliness, and a repulsion of fluids from the surface upon the internal organs, to an extent well calculated to excite disease. In point of fact, we believe it is true, that a large proportion of the attacks of diseases in the autumn, and winter, come on, or become developed into notice, at this time. In cotton -picking and some other kinds of labor, a thorough wetting of the clothing takes place, and is kept up for some hours, until the time for breakfast, when that meal is taken in the open air, and sufficient rest allowed, to produce a pretty general chilli- ness of the surface of the body. In view of these physiological peculiarities of the negro, which tend to unfit him lor the endur- ance of cold, no one can doubt, that this exposure is a trying ordeal for him, and that he requires all the protection that clothing can give. At no time, except while sleeping, does a negro re- quire warmth and dryness more, than when resting and eating his meals in the open air, and after active labor. While in the fall ex- citement of exercise, the wetting he receives from the dew, or from the rain, is of little consequence; but the moment he ceases to act, he is in danger of suffering constitutional injury, and unless par- ticular care be taken to guard him against it, disease, and often fatal disease, will result from it. We have already alluded to the fortunate, if not providential, fact, that the two articles of diet upon which our slave population are mainly subsisted, and which are the best adapted to their physiological condition, of all the long list of eatables known to man, are produced in high perfection, and with moderate labor, in all that region of country where slaves are owned and worked. Indian corn may be cultivated upon both sugar and cotton plan- tations, in sufficient quantity for plantation use, without interfer- ing, in any material degree, with the amount of cotton or sugar produced. This article is easily preserved, and affords food for slaves, not only of the most nutritious and wholesome character, but requiring little labor and skill in the preparation. In general it is furnished to all the negroes on the plantations, ad libitum. There are two points in connection with its preparation, however, which, perhaps, are not sufficiently attended to. One is in refer- ence to the grinding. It should not be ground to an impalpable powder, which makes heavy, moist, and soggy bread ; and this it is which constitutes the principal difference between the corn bread of cities and plantations. Steam and Avater power are brought into requisition for the former, and corn meal is met with in their markets in a state of levigation equal to that of wheaten flour ; but plantation grinding is more commonly done by horse power, with less perfect machinery, and the meal is of much greater coarseness. The other matter of importance is the cook- ing. Corn meal requires to be very much cooked, and with & 1856.] Peculiarities of the Negro Race. 33 high degree of heat : the more, of course, when not finely powder- ed. Water and salt are the only admixtures required. Pork, the other article of diet alluded to, is easily and abund- antly produced, under skillful management, in all that region of country in which Indian corn best nourishes ; and the best quali- ties are fattened on southern grown corn. The large amount of pure fatty matter which it contains, is an abundant source of animal heat, so much required by the negro in a climate of lower range of temperature than he is s\iited to. In his native tropics it would be injurious, but when removed into- what is to him a cold climate, such oleaginous food becomes as essential to his health, as is the blubber diet to the Esquimaux and the Lapland- er. The unsuitableness of oily j>ork to people of hot climates in their native region'?, may be the true physiological explanation of its interdiction to the Israelites by divine authority. The consti- tution of the ancient Jews was very unlike that of the negro. His temperament being more sanguine, and ended with a higher degree of nervous excitability, and a greater exuberance of vital- ity, the generation of animal heat was proportionally more rapid. Of course, the leaner meats of the goat and the sheep, with the fruits, the milk and the honey, which abounded in Palestine, were better suited to his physiological condition. But whether this be true or not, true it certainly is, that the fattest pork suits the negro in our country better than any other meat. Upon no other can he be subsisted, with any hope of returning to his owner such large profits of labor. The farther north you go with him, and the colder the climate to which he is exposed, the greater is the necessity for this oily diet ; and with- out a full abundance of it, the negro not only cannot become an effective laborer in cold climates, but must necessarily suffer in his bodily and mental health, become short-lived, imbecile, and unprolific. Too feeble-minded to compete with white men in his struggle for a livelihood, and too improvident to provide, in the heat of summer, for the requirements of winter, he is reduced to the necessity of subsisting upon unsuitable food, and often com- pelled to wear insufficient clothing ; and disease of body and mind, leading to early dissolution, and to deterioration in the bodily and mental vigor of his descendants, are the natural conse- quences. In addition to meat and bread, slaves require milk, garden vegetable, ripe fruits, and sugar or molasses. For adults, sour milk or clabber is most digestible. Garden vegetables, are liber- ally supplied on all well conducted plantations. Figs are the most valuable fruit, not only on account of their easy digestion, but of the abundant saccharine matter they contain, and not less because of the fact, that they cannot be eaten in an unripe state.. Sugar or molasses should be looked upon as essential, to the im- provement of digestion, and on account of their anti-scorbutic 34 Peculiarities of the Negro Race. [January, tendency ; and liberal supplies of good vinegar should be furnish- ed, for like reasons. The negro is, from nature and habit, an uncleanly being. From early infancy to old age, his skin is rarely cleansed of accretions of perspirable matter and dirt, which accumulate so readily upon it, aided by petty copious sebaceous secretions of an odious character. The injurious effects of this habit might easily be prevented, by the construction of artificial ponds or tanks, for the special pur- pose of bathing. The moderate warmth of water thus confined, would afford an inducement for them to practise ablutions at night. Even the habitual application of oily substances to the skin, would be an improvement upon the present neglect of the cutaneous surface. It would, perhaps, be a poor substitute for bathing ; but the cuticle would be softened by it, facilitating excretory action, and preserving a free capillary circulation. In a state of health, with proper food and clothing, and with suitable lodgings and means of rest at night, the negro is very enduring of labor, and will work at a certain slow and regular pace, with few and short intervals of rest, from early dawn until night, in the long days of summer. But he cannot be driven, for any length of time, beyond his natural or habitual movements; and any attempt to do it must always result in ultimate loss to the master. Up to his natural capacity he is not unwilling to work. Beyond it he cannot go without injury. When he is overworked, and becomes exhausted and disordered in consequence, he recov- ers from the effects much more slowhr than the white man ; as he does, also, from sudden prostration by bloodletting, and the action of medicines. His reasoning faculties are dull and inactive, and his judgment defective, but he learns to do his work skilfully, and from long practice becomes very adroit in the use of the im- plements of husbandry, and the tools of the mechanic; but his attention must not be directed to more than one thing at a time, and he needs to be particularly instructed upon every change in his daily tasks. Counseled and dealt with in a spirit of kindness. and patiently directed in his duties as a child, he is easily ruled and governed by white men, to whom he concedes a high degree of mental superiority and judgment ; but becomes restless, and oftentimes depressed and sulky, under an exercise of impatience, and undue severity, on the part of his master or overseer. Vascular and nervous action in the negro is comparatively sluggish, but his senses of seeing, hearing, and smelling, are apt to be acute and active; those of touch and taste, obtuse. He requires less sleep than the white man ; has greater insensibility to pain ; is warm, but impulsive, in his affections; suffers deeply, but not enduringly, from affliction; is strongly imbued with reli- gious and superstitious feelings; a greal lover of music, apt at the .production of musical sounds, and at vocal imitations; and when uninfluenced by superstitious fear, he is courageous and stoical. 1856.] Peculiarities of the Negro Race. 35 His mind is continually exercised npon supernatural agencies, is easily depressed by his confidence in witchcraft, and much of his unhappiness, as well as many of his diseases, proceeds from purely imaginary causes. He venerates age, but mingles with his vener- ation a superstitious dread of the control, which the aged are supposed to possess, over spiritual and ghostly influences; often assigning disease and misfortune solely to these agencies. In his religious devotions, he finds it an easy matter to work himself up to the highest pitch of enthusiasm, and even ecstacy, realizing in his excited imagination the felicity, almost, of the heavenly state ; but the rapid subsidence of the excitement leaves him in the prac- tice of certain vices, to which he is impelled by passion and habit; and from which, under temptation, he is scarcely able to refrain. The venereal excitement is one of these, to which his anatomical and physiological constitution strongly inclines him, and to the promiscuous indulgence of which he is apt to be led, by the habitual disregard of the sanctity of the marriage relation, and the wickedness of its violation. Another vice to which he is addicted, is theft; in which he indulges, with the exercise of the most ingen- ious expedient to escape detection, traveling sometimes many miles during the night, after a hard day's work, and with the prospect of another hard day's work before him, on the morrow, to accomplish a theft of little value to himself, and one which affords him very small remuneration for his labor and risk. Thoughtless of the future, and improvident to a degree, the negro stands constantly in need of counsel and advice, and he is ever ready to place himself under the guidance and instruction of the white man, the superiority of whose judgment and intellect he is always willing to acknowledge. This trait of confiding depend- ance in the negro, is not less remarkable and uniform, than it is in the children of the white race ; and the treatment he requires in return, to make him contented and happy, is the same that our children look for at our hands. In a spirit of parental kindness, he may, in general, be governed and worked to the best advan- tage, and his attachment and devotion to his master, when so managed, know no bounds. We have heard of an attachment which will induce a man to die for his friend ; but if we were to look through the world for practical illustrations of this remarka- ble virtue, among no class of people would we as soon go, as among slaves, who have been reared up in immediate association with the members of the white family to which they belong, and who have been governed as children and dependents, in a spirit of kindness. But slaves are submissive, and effective laborers, under very different treatment. They submit to and bear the infliction of the rod with a ^surprizing degree of resignation, and even cheerful- ness ; and indeed manifest in many cases a strong and unwavering attachment to the hand which inflicts the punishment, particularly N. S. VOL. XII. NO. I. 3 36 On Wldte Swelling. [January 7 if it be the hand of the owner, or some person who has the right to exercise government over them. They are a submissive and yielding race, wholly incapable of bearing malice on account of their degraded condition as slaves ; and equally incapable of form- ing and maintaining, an effective and permanent organization among themselves, to assert their freedom, or to avenge their wrongs. They differ from their white masters in no one particu- lar more than in this. Most of them, perhaps, desire their free- dom, but when obtained, they know so little how to use it, and stand so much in need of the direction of the thinking and reflect- ing white man, as to become wretched and miserable, and often to desire a return to the state of slavery. Whether this be his rightful position in our counfry or not, an unprejudiced observer can hardly fail to arrive at the conclusion, that it is the one above all others, in which he enjoys the highest degree of health, the greatest happiness, and the longest life. [Memphis Med. Recorder. On White Swelling. By M. A. Kichet. M. Richet believes that many erroneous ideas prevail respecting the pathology oi articular 'diseases, which has been retarded by the uncertainty that has so long prevailed in respect to certain points of structural anatomy as, e. g\, the vascularity and nutrition of the cartilages, and their investment with synovial membrane. The microscope has now led to the solution of these questions, and, by availing himself of the results of its teaching, M. Richet believes that he can steer clear of many of the difficulties that beset the path of earlier pathologists. His own researches date some time back, he having published upon the subject of white swelling in 1844. While approving the mode adopted by Brodie and Velpeau, of viewing these affections through the pathological changes they give rise to, he believes that they and other writers have not sufficiently followed the succession of these changes as they are observed in the different tissues. His object is to supply this deficiency, in show- ing that the different stages of the same chronic inflammation have been mistaken for special affections. He believes that all "white swellings" may be included under two fundamental varieties viz., chronic inflammation of the synovial membrane and of the articu- lar extremities of the bones. The changes which take place in the fibrous tissues are, as Brodie has advanced without demonstrating, always consecutive, while ulceration of the cartilages is not admit- ted by M. Richet. The synovitis, osteitis, or osteo-synovitis, may undergo modifications, by the constitution and temperament of the individual, or by the causes that have induced them, such modifica- tions being of the more importance, inasmuch as they often affix a special seal to these affections, causing them to be regarded as dis- tinct maladies. 1856.] On White Swelling. 37 Tlie Pathological Anatomy of White Swelling, constituting the basis of the essay, is given in minute detail ; but we are only able to glance at some of the more salient points. M. Richet has, during several years, taken every opportunity offered by cases of arthritis or experiments on animals, of tracing the progressive changes that take place in the synovial membrane. Between the fifth and twelfth day after irritation has occurred, a pseudo-membranous-like exuda- tion is effused from its surface, and becomes attached to granulations that are there more or less developed. When the chronic stage of synovitis arrives, these granulations may expel the false membrane covering them, and become themselves developed into fungous vegetations ; or the pseudo-membrane may become more and more intimately united to the surface of the synovial membrane, undergo organization there, and prevent the farther development of the granulations. The two cases are respectively termed by the author Fungous Synovitis, and Pseudo- Membranous Synovitis. In Pseudo-Membranous Synovitis, layers of pseudo-membrane, intimately connected with vessels, unite the synovial membrane to the fibrous tissues of the joint ; and when sufficient irritation is not induced "to cause death or amputation, a natural cure may take place through the agency of a fibrous transformation. Retraction ensues, and all the soft parts becoming closely applied around the ends of the bones, the joint then appears less than the opposite one. This form of synovitis is not infrequent after acute rheumatism, and it constitutes one of the varieties of incomplete anchylosis. In Fungous Synovitis the granulations, in place of becoming organized, become, under the influence of a special diathesis (as e.g. the scrofulous,) cedematous and fungoid, and are, after different periods in different individuals, converted into reddish, softish vegetations, analogous to those which spring from carious bone. Containing some arterial vessels, they are chiefly made up of a venous network, in the midst of which is found a translucent jelly, exhibiting small spots like extravasated blood. The vegetations present an epithelial layer at their surface, and within, the fusiform fibres and elongated nuclei characteristic of fibro-plastic tissue. Brodie and other pathologists, from want of having sufficiently studied the alterations of the synovial membrane, have made of this a special affection, of a malignant nature. Occasionally, it becomes arrested in its course, a conversion of the fungosities into fibro-cel- lular tissue taking place, and a more or less complete anchylosis ensuing. In other cases, the fungosities become indurated, having cartilaginous plates diffused amidst their tissue. This induration is, however, only observed here and there, amidst the thickness of the changed synovial membrane, and gives rise to the development of irregular, so-called foreign, bodies, varying in size and density, being sometimes found loose in the joint, or only attached by a pedicle. Brodie admits primary ulceration of the synovial membrane; but the cases he adduces are too briefly narrated to justify the appella- 38 On White Swelling. [January, tion. In M. Richet's opinion, the most frequent sources of ulcera- tion are small centres of suppuration, met with in the altered synovial membrane, which, by breaking both externally and inter- nally, establish sinuses, the extremities of which have all the characters of ulcers. The synovial membrane may also become ulcerated consecutively to the morbid changes taking place in it, while, when much distended with fluid, a sudden movement may cause its rupture. The Fibrous Tissues are endowed with a very feeble vitality. The author's researches lead him to regard the ligaments- as insen- sible, although, as their insertions into the bones are continuous with periosteal or osseous tissues, tearing or stretching these may cause pain. By no experiments has he been able to induce inflam- matory action in the ligaments or capsule, even when the synovial was quite red, and the joint full of pus. When, in exceptional cases, they do become somewhat reddened, it is not the redness of inflammation, and it is almost always consecutive to lesions of surrounding tissues. One of the changes most frequently met with is a puffiness of the capsule and ligaments, produced by serous infiltration into the inter-fibrillary cellular tissue which separates the ligamentous fibres, these assuming, also, a dull tarnished appear- ance. This relaxation allows of great separation of the articular surfaces. At a later period, the fibrous parts become hypertrophied, or even indurated. The Articular Extremities of Hhe Bones. M. Richet believing that, however well osteitis in general has been described by Gerdy and Miescher, the form that affects the spongy tissue in the vicinity of joints is imperfectly known, describes it, from his own observations,, with a minuteness that defies our following him. It must suffice to say, that he admits three stages of primary osteitis. In the Jirst of these, a section of the bore presents a vascular surface and enlarge- ment of the cells, its compact surface being pierced with numerous minute holes for the passags of vessels. The secretions of the periosteum become diverted to the surface, and the bone is increased in size, in consequence of new layers deposited at its surface, as well as by the enlargement of its cells. Although such enlarge- ment of bone is not admitted by Crowther, Russel, and S. Cooper, M. Richet has proved its existence by admeasurement, after sepa- ration of the soft parts. In primary osteitis, periosteal effusion is, however, not constant, occurring only as the inflammation approach- es the surface ; but in secondary osteitis, it is the earliest change observed. In the second stage, the red colour is concentrated at certain points, little collections of blood taking place. The cells become more and more spacious, and true abscesses are formed within the bone. Sometimes, however, hypertrophy of the inter- cellular parietes leads to a diminution in the size of the cells, and 4he spongy tissue is resistant instead of yielding. In the third stage, the pus which had been infiltrated into the cells destroys the 1856.] On While Swelling. 39 vessels, and the lamella?, deprived of nutriment, become necrosed. At other times, ulceration, terminating in caries, occurs, and bleed- ing fungosities, or vegetating granulations, spring from the cells. Sometimes the cartilage is perforated only in places, at the bottom of which bleeding vegetations are seen, an appearance mistaken by Brodie and others for true ulcers. Arrived at this stage, it is rare for the osteitis to be confined to the articular extremities, and, on cleaving the bone, the entire medullary canal is found to exhibit an intense redness throughout its entire extent, while small sanguineous effusions, and the other phenomena of the early stage of osteitis, are observed at the other extremity of the bone, although externally this exhibits no evidence of the change. Consecutive Osteitis. As synovitis may be secondary to an ostei- tis, so this last may supervene upon a synovitis. An osteo-periosti- tis so produced differs much from an osteitis properly so called, there not being the enlargement of the cells or the vivid injection of the spongy tissue, with its purulent infiltration. It is the perios- teum which undergoes the chief alteration, the bone, at a later period, undergoing hypertrophy even to its centre. It is, however, the cartilaginous surface that chiefly suffers, the synovial fungosi- ties rapidly leading to its perforation and destruction, and entering into immediate relation to the bone. The compact lamellae become necrosed, and the pus penetrates into the spongy tissue, inducing more or less deep-seated changes. Vegetations are often found within the cells; but beneath the fungosities the intercellular lamellae are found more resistant than normal, while in primary ulcerative osteitis they are softened. Consecutive osteitis is a less refractory disease than the primary, the aiticular surfaces sometimes becoming covered with fibrous tissue that allows of some movement. There is another change in the bone which, although not rare, has not been described, and to which M. Richet considers no better appellation can be at present applied than fatty degeneration. A few spoonfuls of a sero-sanguinolent or purulent fluid are found in the cavity of the joint, the synovial membrane not exhibitifig changes proportionate to the symptoms observed during life. The articular cartilages are eroded, thinned and perforated by a great number of minute apertures. On raising them, which is easily done, a large layer of blood, having the colour and consistence of currant jelly, is found interposed between the spongy cells and the thinned compact lamellae which is detached with the cartilage. On sawing the bone, in place of finding the cells more or less inflamed and gorged with blood and pus, the section presents a yellow color, deeper as the centre is approached. The cells are enlarged, and pressure by the finger produces slight crepitation, and expels a quantity of yellowish oily fluid. No trace of the smallest vessel can be found amidst the spongy tissue. The medullary canal is abundantly filled with this yellow fluid. The periostemis not in- 40 On White Swelliny. [January, flamed, no trace of the vascularity seen in osteitis existing, while the size of the bone is diminished rather than increased. Changes in the Articular Cartilages. M. Richet regards cartilage as possessing a very rudimentary organization, coming between fibro-cartilage and the products of epidermic secretion. Its mode of life is, as it were, parasitical, living by absorption of the liquids amidst which it is placed, its component utricles or cells operating osmosis. To the question, whether the articular cartilages are sus- ceptible of inflammation, and of participation in the diseases of sur- rounding parts, M. Richet replies in the negative. By no experi- ments can vascularity be induced, and no attempts at reparation are found after old injuries. Amidst the completest change in sur- rounding parts, they exhibit only some roughening or thinning from commencing absorption. Vascularity, supposed to have been seen on their surface, is really due to the development of new vessels in a pseudo-membrane that covers them. Ossification, adduced as a proof of vitality, is never found in the case of true cartilage ; but the eburnation of the bony extremities, after the cartilage has dis- appeared, has been confounded sometimes with this. The articular cartilages are, however, liable to various kinds of alterations, resulting from perversion of their nutrition, or from me- chanical or chemical causes. Among such is a loss of elasticity, noticed by Delpech, and frequently observed by the author. Ra- mollissement, which appears to be another stage of this loss of elasti- city, occurs also pretty frequently, especially in those who have died in advanced years. This change, which has by others been termed velvety, has been the object of much research by M. Richet since 1840, and he thinks there is always coincident with it a diminution of synovia, probably due to a lessened nutritive activity in the bones and articular secretions. A total or partial disai^pear- anceoftJie cartilages seems to be a third stage of these alterations, which, while they cannot be called normal, can yet hardly be de- scribed as pathological, as they are met with in persons whose joints were healthy. As regards the changes in the cartilages of diseased joints, they are due either to loss of cohesion ramollissement or are char- acterized by thinning, inequalities, or erosions. The last especially claim attention, as by some authors they have been termed ulcera- tions. When the cartilage is found roughened and unequal, this is due either to wearing away or resorption exerted at certain points, to a perversion of nutrition due to disease of the bone, or to the presence of abnormal fluid within the joint. As the cartilages live at the expense of the parts which surround and support them, they become more or less changed, according to the duration and severity of the disease of the part. When we examine a joint thai has suffered from white swelling originating in osteitis or advanced synovitis, we almost always find the appearance as if the cartilage had been irregularly punched 1856.] On White Swelling. 41 out. Around these spots it is quite normal, not having even lost its cohesion and elasticity, unless effusion or other altei'ation of the cavity of the joint be present. Generally there is more or less synovitis present ; but when this is not the case, a superficial examination might lead to the affection being considered a primary lesion of the cartilage. But if the bone be so cleft that the saw falls in the centre of the erosions, osteitis will be found occupying the articular extremity of the bone, and most intense where the loss of the cartilage is seen. Brodie and other surgeons have contended that such loss of substance is due to a primary affection of the car- tilage, which, extending to surrounding parts, gives rise to one of the most painful varieties of white swelling. The facts cited by Brodie are valueless, in consequence of the very superficial manner in which the examination of the joints was conducted. The history of the condition of the joints in the aged, in which, when the carti- lage is gone, ebumation takes place, a change inducing little or no pain, is contradictory to the accuracy of Brodie's assignation of severe pain as a sign of cartilaginous disease. Osteitis induces the most dreadful suffering. Symptoms. While alluding to the gradual manner in which the disease may come on, M. Richet observes, that in the case of such superficial bones as the tibia and ulna, we may often detect early a little puffiness of the periosteum rounding off the edges of these bones that are naturally so sharp and distinct. The soft parts may be at first more considerably swollen than the articular extremity, the disease then seeming to have more tendency to attack the diaphysis, or even the opposite articular end, as, e.g., the pain and swelling of the knee in coxalgia. M. Richet, several years since, proffered the explanation of this circum- stance by the propagation of the inflammatory action along the medullary canal from one extremity of the bone to the other ; and all subsequent observation confirms him in its correctness. Such pains are important in diagnosis, showing that we have to do with an osteitis and not a synovitis. Diagnosis. In this section M. Richet chiefly occupies himself in pointing out the distinguishing marks between osteitis and chronic synovitis. The latter may be due to a local cause, although its progress is usually dominated by a general one : but osteitis is almost always referable to a general cause. Synovitis often suc- ceeds rheumatism. Osteitis is usually of scrofulous origin. In synovitis, the various symptoms may appear almost simultaneously; but in osteitis they are more gradual and progressive. In synovitis, there is hypertrophy of the synovial without swelling of the bone, and the softened ligaments allow of considerable and abnormal movements, while consecutive displacements occur frequentlv and rapidly, without deformity of the articular surfaces. In osteitis, there is appreciable enlargement of the bone, the limited motions are terribly painful, and the displacements, which take place slowly, are due to the flattening down of the deformed articulations. 42 On Wliite Swelling. [January, Treatment. Upon the general treatment of the diatheses upon which the disease depends, M. Richet has not much to say. He speaks highly of iodine and cod-liver oil in certain cases ; but he does not find that the former can be used as a substitute for the latter. He considers that the tonic effects of hydropathy are suffi- ciently shown to induce medical men to avail themselves of its aid. Sea air and mineral waters are useful in appropriate cases. Vege- table tonics are of little use ; and iron, to be even harmless, requires care in its administration. In the local treatment of synovitis, although leeches sometimes give great relief, they seem at others to do harm ; and when the relief obtained is not prompt, they should be discontinued, as they enfeeble. M. Richet attaches considerable importance to the prolonged use of local baths. He thinks the large flying-blisters, so much recommended by Velpeau, should not be employed until the subacute stage has been reached. The nitrate of silver ointment is very useful, and sometimes dissipates violent and obstinate pains. In pseudo-mernhranous synovitis, issues and the actual cautery, used transcurrently, may be resorted to when the ligaments are relaxed, and the bones, consecutively inflamed, are nigh luxation. In the fungoid form they are indicated early, and must be employed boldly. In this form, too, compression, combined with immovabil- ity, is useful. When the synovial membrane is much distended, it should be opened with a trocar. M. Richet has only sometimes derived benefit from iodine injections in fistulous openings ; but finds the fungosities that spring up are well treated by the tincture. Syphilitic Osteo- Synovitis. M. Richet remarks upon the silence of authors with respect to the influence of syphilis in relation to white swelling, their attention being confined to scrofula and rheu- matism. M. Ricord informs him, that although he has met with certain cases of white swelling, the cause of which has been influ- enced by syphilis, he has never seen any that seemed to have been directly determined by it. He believes, also, that this disease influences the compact rather than the spongy tissue of bone. Not- withstanding this opinion, M. Richet believes that syphilis may alone determine a synovitis or osteitis, and so constitute an import- ant variety of white swelling. Since his attention has been turned to the subject, he has met with sevei'al cases of syphilitic chronic synovitis of the knee-joint, and reports three of these in the present essay. The effusion takes place gradually, and is liable to inter- missions. The skin is never red or swollen, the tumefaction entirely arising from the amount of effusion, which is sometimes great, and the thickening of the membrane. This thickening may assume the form of indurated plates, which soften and rapidly disappear under the influence of iodide of potassium. The pain is not great, and is worst while at rest. Left to itself, it tends to pass slowly into the fibrous condition, producing partial anchylosis. M. Richet feels certain that several white swellings that resist all treatment are 1856.] Treatment of Pneumonia. 43 syphilitic, although the detection of this cause is often difficult. As the effused fluid has no tendency to become purulent, or the syno- vial membrane to become fungoid, the occurrence of consecutive osteitis is rare. It is rather the history of the case, than any pecu- liarity of local symptoms, that reveals its nature; the treatment often becoming the test of the accuracy of the diagnosis. Osteitis arising from syphilis is a far more serious affection than synovitis, and in M. Richet's opinion, it is as common. He furnishes the particulars of three cases. The pain is severe, deep-seated, lancinating, and especially nocturnal. It is propagated along the shaft of the bone, which is swollen and tender. On motion, it is very severe, and sometimes terrible. The articular tumefaction is partly due to enlargement of the bone, and partly to hypertrophy of the synovial membrane. The general symptoms are little marked, but the impoverishment of the blood by the syphilitic poison, and the terrible suffering sometimes induced, may produce emaciation and the straw-coloured skin. There is less tendency to suppurate than in simple osteitis. The pus is viscous, and the sinuses assume the syphilitic aspect The prognosis is much less serious than in simple or scrofulous osteitis, but more so than in syphilitic synovitis. The preliminary, erratic pains may be mistaken for rheumatism by the most skilful ; but in the latter there are febrile symptoms, while the joint is red and swollen from effusion. As compared with simple osteitis, the syphilitic form involves the articular structures earlier, but it does not give rise to local heat and oedema. The pain seems more concentrated in the deep-seated parts, and its nocturnal exacerbation is better marked. In simple osteitis, all the bones constituting the joint may become simultaneously affected ; but in the syphilitic form, one bone usually alone suffers, as the femur in the case of the knee-joint. The essay is illustrated by thirteen fully detailed cases, besides six of syphilitic white swelling, as well as by several good litho- graphs; and it must be regarded as a valuable contribution to articular pathology. [British and Foreign Med. Chir. Review. The Experience of Various Kinds of Treatment in Pneumonia. The author, after recapitulating the leading points of his former paper, considered, 1st, The question as to the influence of blood-letting in the treat- ment of pneumonia in regard to mortality. He denied that the normal mortality from that disease could be accurately given, showing, from a table he had collected, that it varied from 3 up to 31 per cent, out of some 7000 cases. He particularly alluded to age, sex, and complication as affecting mortality. At the extremes of life it was very fatal, but benignant at intermediate periods. It was more fatal among females ; and complications of other dis- eases, chiefly phthisis and Bright's disease, greatly increased it. 44 Treatment of Pneumonia. [January, Thus, a selection of favorable ages only, a diminution of the num- ber of females, in the number of complicated cases, would gener- ally diminish the mortality. 2d. The author then considered the treatment by blood-letting singly, instancing first two series of cases from Bouillaud, which he showed were not fairly selected according to age, sex and com- plication. Also, two series of cases from Grisolle, in one-third of whioh only had blood-letting succeeded in curing the disease ; in the remaining, it had failed, necessitating the conjunction of anti- monials; lastly, he alluded to cases similarly treated by Dietel, of Vienna; the mean mortality from the blood-letting treatment was 16'5 per cent. Dr. Kouth then considered the treatment by blood- letting, combined with tartar emetic, instancing the cases recorded by Dr. Hughes, of Guy's Hospital and others occurring in the practice of Drs. Walsh, Peacock, and Taylor. These cases appear- ed to be in no way selected ; indeed, as a rule, very unfavorable, the complicated cases amounting, in those of Dr. Hughes, to 51 per cent.; in the others, 53 per cent. He also alluded to some ca- ses similarly treated by Grisolle. The mortality obtained by these gentlemen was Simple AU Pneumonia Cases. Per Cent. Per Cent. Dr. Hughes 2-2 24 Drs. Taylor, Peacock, and Walsh .... 3 -2 30 Grisolle 254 Mean 26 3d. He then alluded to the treatment by tartar emetic singly, instancing cases from Louis, and Grisolle, and Dietel, giving a mortality, out of 170 cases, of 18 per cent. These cases were re- markable as generally recovering with very little loss of strength ; and in comparing this kind of treatment with that of tartar emetic and blood-letting, conjoined by blood-letting singly, the result proved that by blood-letting and tartar emetic conjoined was the most fatal, because the most depressing. 4th. Dr. Routh then dwelt on the treatment by chloroform, se- lecting Varentrapp's cases as the best recorded ; but even these were not fairly selected, because containing too small a number of females. The mortality he obtained was 4 per cent., or, including some other cases, which he ought not to have omitted, 11^ per ct. A large number of cases collected by Vacherer, Baumgartner, and Helbeing, (193) gave a mortality only of 4| per cent, but he could not speak as to their assertion, not having been able to find the original documents. 5th. The author then spoke of the results obtained by dietetic treatment only. These were of two classes, those obtained by homoeopaths, (i. e., in those cases where they had been also diag- nosed uud investigated by legitimate practitioners), and those ob- tained by experiments directly made by legitimate practitioners 1856.] Treatment of Pneumonia. 45 themselves. From Jessier's cases the mortality was 14 per cent. ; from Dietel's experiments, out of 189 cases so treated, the mortal- ity was 74 per cent.; Dr. Todd's treatment was also much less energetic. He discouraged blood-letting and tartar emetic, trusting chiefly to the liquor ammonia acetatis, and giving the patient support. 6th. Dr. Eouth then proceeded to speak of the treatment which he recommended. The indications were, first, to diminish the gen- eral fever, especially the increased cutaneous and pulmonary res- piration. The former was effected by the tincture of the root of the aconitum napellus, on the action of which, in small and poison- ous doses, he dwelt at length, and especially in reference to its certainty of action and utility as compared with the ordinary tincture of the Pharmacopoeia ; the latter indication was effected by oleacous inunctions, which cooled the skin very rapidly. The second class of indications was to relieve the local symp- toms, which was best effected by the employment of Junot's ex- hausting apparatus, which did all that blood-letting could do, but saved the patient's blood, and by dry cupping or counter-irritation largely, by turpentine, according to Dr. Todd's plan, or blisters followed by repeated dressings of cotton, so as to deprive the sys- tem of a large quantity of fluid ingredient. The last class of in- dications to be fulfilled was that which had reference to the support of the patient. He objected altogether to the 'diete absolue' of the French, recommending the ordinary middle diet of hospitals, or beef-tea from the first, to obviate tendency to death by depression. He occasionally gave small doses of tartar emetic during the first days of the disease, to promote expectoration, and perhaps an al- terative mercurial. Under this treatment, he had been generally very successful in pneumonia. Dr. Webster remarked that more men died of pneumonia than women, the proportion being 13 of the former to 10 of the latter. It was usually fatal among children ; but most fatal after the mid- dle period of life, the greatest mortality occurring in persons be- tween 50 and 60. He referred to the occasional termination of pneumonia in gangrene, and of its rarity in sane as compared with insane patients. Thus, in 3102 dissections of sane persons made in the Civil Hospital at Prague, 55 exhibited gangrene of lungs, or 1 in every 56 cases ; whereas in 123 dissections of lunatics, lately published by him in the Psychological Journal, 17 cases exhibited gangrene of lungs, or nearly 1 in every 7 autopsies, which makes the ratio eight times greater among insane than or- dinary patients. With respect to treatment, he observed that the experience of French, German, or Italian physicians, could not be compared with that of physicians in our own country, as the con- stitutions of the people were different, and consequently the same kind of treatment not applicable. In this country, though bleed- ing could not be resorted to to the same extent as formerly, it 46 New Treatment of Subclavian Aneurism. [January, might be still employed, according to circumstances, either locally or generally, followed by tartar emetic and the repeated application of blisters ; mercury afterwards, to the extent of slight salivation, was most serviceable. [Dr. Rouili London Lancet. Remarkable Case of Subclavian Aneurism ; New method of Treat- ment ; Recovery. Mr. Fergusson presented to his class on the 4th of August, a most interesting case one of a series, as we subsequently learned where a very remarkable cure has been effected in well-marked subclavian aneurism, by a new and specific method of manipulation which he has adopted. We may state here that we saw the case about a year and a half ago also, when the man was previously under treatment. Some short period before that time Mr. Fergus- son conceived the plan of stopping the circulation in the aneurism by pressing the sides of the aneurismal sac together, with their in- tervening fibrinous deposit; and in this case, from the phenomena attending the manipulation, there appear to us very little doubt that the object held in view by Mr. Fergusson had been attained viz : the clots of fibrin in layers in the aneurismal sac had been displaced, and, spreading from the subclavian into the auxiliary and brachial, a new sort of Brasdor's operation, at the distal side of the subclavian had been the result. In other words, we believe Mr. Fergusson here, without ligature, had attained all the advan- tages of the last-named operative proceeding ; for not only had a blocking-up of the axillary and brachial been followed by a par- tial stoppage of the current through the enlarged aneurism of the subclavian, but even with very marked, but not so satisfactory, results as regarded the pulse in the radial at the wrist, which be- came completely stopped for a time, with symptoms of paralysis in the arm, all resulting from the displacement of the fibrinous clots. The aneurism in the present case was situated in the subclavian, in the usual site of subclavian aneurism namely between the scaleni muscles, and to us seemed almost to invite some modifica- tion of the Dublin surgeons' plan by compression on the first rib. The plan by compression, we need hardly observe, is in general applied to the artery above the aneurism, between the latter and the heart. Crampton, however, in 1816, showed that the oblitera- tion of an artery can be effected without rupture or ligature of its coats, as generally conceived, simply by this blocking-up process. The early volumes of the Lancet contain cases also cured by Bras- dor's operation ; it seems, however more applicable to carotid than subclavian aneurism. Mr. Furgusson related to his class on the 11th, at some length, the details of a previous case of subclavian aneurism, of the same character as the present, in which his ideas on this subject were 1856.] New Treatment of Subclavian Aneurism. 47 first matured. In both cases the method of cure by deligation at the tracheal side of the scaleni, as well as Brasdor's operation at the distal end of the aneurism, were inadmissible ; yet it was gratifying to find the present plan, by firm pressure of the thumb on the aneurism, so as to displace some of the fibrinous clots, fol- lowed up by local pressure, succeeded in obtaining most striking and in many respects curious but satisfactory results. Intimately associated as the subclavian is at the right side with the vertebrals and carotid, the method of displacing fibrinous coagula is not with- out danger. A patient under such circumstances will fall down perhaps in a fit from want of circulation in one side of the " circle of Willis," formed by these arteries ; yet as the cause is so appa- rent, the danger may not be very alarming. Some instances of cure of aneurism of even the innominata have been given by American surgeons, in which recourse was had to ligature on Brasdor's plan of the subclavian ; the result here ought to be equally dangerous. Hodgson gives us cases also in which a plug of effused lymph had nearly obliterated the subclavian ; while Gendrin has imitated all the phenomena of arteritis and blocking up of aneurisms by injecting irritant substances into a portion of artery contained between two bgatures. In Mr. Fergusson's new mode of operation, we believe an entirely novel idea is acted on namely, the displacement of the lamcllated fibrin of the aneurism, on which no operation has been performed, and so directing the clots of fibrin that they shall block up the distal end of the artery so diseased. As Mr. Fergusson has expressed an intention of bringing the entire subject under the notice of the Medico-Chirur- gical Society, we purposely abstain from giving the cases in detail. The method of treating aneurism by compression, originating with Desault and Hunter, and recently revived with such excellent re- sults by the Dublin surgeons, will gain an immense accession of interest, if it should prove that the fibrinous deposit of the sac of the aneurism may be thus as it were utilized in bringing about the results hitherto gained in a different mode by Brasdor's operation at the distal end of the aneurism. Considerable caution will be at first necessary, as observed by Mr. Fergusson, in selecting cases which are fitted for the present method, as premature or ill-judged experiments in the shape of direct pressure or manipulation on the sac of aneurism not requiring it, one of which we mentioned re- cently as brought into Guy's where direct and prolonged pressure had been made in the popliteal space before the patient came into hospital would be certain to be followed by severe inflammation of the sac and other dangerous results. The spontaneous cure of aneurism is not unknown in practice ; it may take place, it must not be forgotten, by a coagulation of the contents or increase of the quantity of lamellated blood in the sac, the cavity becoming filled, and the circulation conveyed to the parts beyond the disease by the collateral vessels ; or, again in some rare cases the aneuris- 48 Dislocation of the Femur. [January, mal tumor may be doubled up and press upon the portion of artery leading directly to the aneurism ; or in a third fashion, as in a remarkable case given by Mr. Liston, where the patient had well- marked subclavian aneurism, which subsided and disappeared an aneurism of the innominata pressing on and obliterating the aneurism of the subclavian ! Whatever may prove to be the correct pathological explanation of the phenomena in Mr. Furgusson's present cases, we deem it our duty to state here briefly that the cure seems complete and unequi- vocal without any ligature of vessels, nor is there any reason to believe the case was one of spontaneous cure of subclavian aneu- rism, as in the case given by Mr. Liston. It is now two years since the man came first under observation ; he has been, on and off, under treatment all that time in King's College Hospital and at home in the country ; but happening to be in town within the last fortnight, Mr. Fergusson took advantage of the opportunity to exhibit the case to his class. [Lancet. Dislocation of the Femur into the Ischiatic Notch. Reduction by Manipulation. By Frank H. Hamilton, M. D., Professor of Principles and practice of Surgery in the Medical Department of the University of Buffalo. In my report on " Dislocations" made to the New York State Medical Society in February last, and just published, I have stated that in reference to the reduction of dislocations of the hip by "manipulation" alone, I did not feel authorized to speak authorita- tively, having as yet had no experience in this mode. I ventured, however, to express a hope, based upon the testimony before me, that it might hereafter prove, in a majority of cases, both safe and practicable. Since then an opportunity has been presented which has enabled me, in some measure, to determine, by personal ex- perience, the value of this procedure, and I hasten to lay the case before the profession. March 23, 1855. Charles McCormick, aged 21 years at work for the "State Line P. P. Co.," was caught between two freight cars, with his back resting against one and his right knee against the other ; his thigh being raised to a right angle with his body. As the cars came together he felt a " cracking " at his hip joint, and was immediately unable to walk or stand. Two hours after, I saw McCormick, and assisted by my son Theodore, and Austin Flint, Jr., I examined the limb and made arrangements for its reduction. The patient was lying upon his back and left side. His right thigh was flexed upon his body to nearly a right angle and adducted, the knee being carried across the opposite thigh. It was also rotated inward, but not forcibly. Turning the lad upon his back and rasing the left leg to a posi- 1856.] Dislocation of the Femur. 49 tiort corresponding to the right, both legs were carefully measured with a tape line from the anterior superior spinous process to the patella, and the right leg was found to be shortened one and a half inches. Measuring again from the ant. sup. spin. p. to the most prominent point of the trochanter major the distance on the dislocated limb was six inches, and on the sound limb five inches. The head of the bone could not be felt, but no doubt remained as to its position/ The limb was nearly immovable, except in one direction. It could neither be abducted, or rotated outward or carried downward. Procedure. The patient lying upon his back, I seized the right leg and thigh with my hands, the leg being moderately flexed upon the thigh, and carried the knee slowly up towards the belly until it had approached within twelve or fifteen inches, when, no- ticing a slight resistance to farther progress in this direction, I carried the knee across the body outward until I again encountered a slight resistance, and immediately I began to allow the limb to descend. At this moment a sudden slip or snap occurred near the joint, and I supposed reduction was accomplished; but on bringing the limb down completely I found it was in the same position as before. I think the head had slipped off from the lower lip of the acetabulum, after having been gradually lifted upon it. Without waiting, I commenced to repeat the manipulation, and in precisely the same manner. Again at the same point, when the limb was just beginning to descend, a much more distinct sen- sation of slipping was felt, and on dropping the limb it was found to be in place and in form, with all its mobility completely restored. No anaesthetic was employed, and no person supported the body or interfered in any way to assist in the reduction. No outcry was made by the patient, yet he informs me that moving of the limb hurt him considerably. The amount of force employed by myself was just sufficient to lift the limb, and the time occupied in the whole procedure was only a few seconds. After the reduction, he remained upon his back, in bed, eleven days, in pursuance of my instructions. At the end of this time he began to walk about, but was unable to resume work until after eight weeks or more. It is probable that he could have walked immediately after the reduction, without much if any inconve- nience, so slight was the inflammation which resulted from the accident. He never complained of pain, but upon interrogation he replied that there was a slight soreness back of the trochanter, near the head of the bone. This soreness continued several weeks and was especially present when he bent forward. Even at the pres- ent time, four months after the accident, be occasionally feels a pain at this point when he is stooping. The motions of the joint arer however, free, and he walks nimbly and without any halt. In short, if I may judge correctly from a single example, nothing 50 Seat and Varieties of Cataract. [January, could be more complete than the triumph of this process over a dislocation hitherto so formidable. Nothing could be more sim- ple and easy of execution, and nothing more gratifying both to the surgeon and to his patient. Unless, therefore, experience shall demonstrate in its practical working defects or dangers which I cannot now anticipate, I shall regard it hereafter as one of the most valuable contributions to our art, and its inventor as a true public benefactor. [Buffalo Med. Journal. On the Seat and Varieties of Cataract. By M. Malgaigne. Not only is M. Malgaine one of the ablest practical surgeons of the present time, but he has, by his patient research and great crit- ical sagacity, been the means of overturning more than one time- honored but erroneous doctrine. He thought he had succeeded in doing this as regards cataract, in his communication to the Acade- mie de Medecine, in 1841 ; but finding some persons still holding erroneous ideas upon the subject, he, in this paper, re-states the case at some length. The history of opinion upon the seat and nature of cataract may be divided into an ancient and a modern period. During the for- mer, extending from the school of Alexandria to the beginning of the eighteenth century, the site of cataract was placed in front of the crystalline. The modern period is divisible into certain epochs viz., 1. That of 1705, in which Brisseau demonstrated that the crystalline itself was the seat of cataract. 2. Between 1755 and 1763, Tenon and Hoin announced the existence of cap- sular cataract and cataract of the liquor Morgagni. 3. From 1790 to 1817, the German school multiplied the varieties of cataract beyond all measure. 4. M. Malgaigne published in 1841 the re- sult of his necroscopical researches upon the subject. Prior to 1840, he believed in the existence of lenticular and capsular cata- ract, as other people did, when accident led him to investigate the matter in a succession of persons dying with cataract, at the Bice- tre, and to his astonishment he never could discover any traces of a capsular cataract. In 1841, he communicated accounts of twenty- five autopsies, and since then, these have reached to more than sixty. In none of these did he ever find the capside opaque, or the opacity of the lens beginning at its centre the cataract inva- riably commencing in the soft layers of the lens lying nearest the capsule, the opacity, in the great majority of cases, being complete at its anterior and posterior surfaces, while the nucleus continued transparent. In some rare cases the nucleus was also opaque. In other rarer cases, the capsule was found thickened from the depo- sition of coagulable lymph attaching it to the iris ; but in no in- stance could he find an example of a simple capsular cataract. After a full consideration of the subject, and an examination of 1856.] Treatment of Yellow Fever. 51 the criticisms that have been advanced, he comes to the final con- clusions 1. That the existence of a cataract commencing in the centre of the lens is as yet purely hypothetical. 2. There is no example of a simple capsular cataract without opacity of the lens. 3. Complicated capsular cataract may form an exception to this rule ; only two instances of this, however, having been demon- strated. As to the cataract of the liquor Morgagni, the author's researches lead him to deny the existence of any such fluid. As a final resume, it may therefore be stated that, to the present time, two varieties of cataract only are known, lenticular and capsulo- lenticular the change in the crystalline always commencing in the layers adjoining the capsule, although this itself remains trans- parent. In a note, M. Malgaigne makes an observation respecting the mode of judging of the transparency of the sound crystalline, when removed. The light can be very well seen through it, but objects cannot be distinguished. The surface has lost the polish bestowed on it by its capsule, and it resembles a piece of broken crystal, which, although transparent, refracts the rays too much to allow of distinct vision. If however we attach the object to the lens, we then discern it wonderfully the smallest fibres, for ex- ample, of the tissue of a dissecting-room apron, upon which the lens has been laid, being distinctly visible. Applying this test to opacities, whether central or peripheric, slight or thick, yellow or brown, it becomes impossible to see the texture of the apron. [Rev. Med. Chir. Brit, and For. Rev. Professor W. Stone's Treatment of Yellow Fever. We extract from the New York Medical Times the following remarks of Prof. Stone, whose acknowledged ability and success in the treatment of Yellow fever entitle his testimony to great weight. The learned gentleman's views were delivered at a recent meeting of the New York Academy of Medicine. Treatment. Yellow fever is a self-limited disease ; it is not to be treated it is to be managed. All that is to be done is to keep the patient alive for a certain time, and he will get well. The disease is ushered in with a chill or slight rigor, often scarcely noticeable, followed by heat in the forehead, pain in head, limbs, and back. This is again followed by a hot fever, and if the patient be kept under cover, and carefully treated, these symptoms will quietly terminate in two or three days * but if left to them- selves to toss about and not remain under cover, the sweating stage passes on for five or six days, and collapse, black vomit, and death result. The only treatment found by Dr. S. to be useful, is to favor the efforts of nature in prolonged sweating, calm, and rest of the sys- N. S. VOL, XII. NO. I. 4 52 Treatment of Yellovj Fever. [January, tem, and the fever will generally be got rid of in the first two or three days. It terminates in favorable cases on or before the third day, leaving the skin natural. Those who treat it otherwise than expectantly do not understand the nature of the disease. Among those who may be said to understand the disease, there are two methods of treatment: the expectant cups to temples to relieve cephalalgia, slight laxatives to open the bowels, hot baths under the bedclothes. Others give quinine. Dr. S. was the first to do so, whoever has the credit, but no matter about that. The only difference is that they do not give it with any specific object. His method was a full dose at the beginning of the disease, but not afterward. Thus given, it promoted and prolonged the sweating stage, and while this was kept up, the patient was safe. It was remarked, that they would get well without quinine where it was generally prescribed. He was physician for many years to a hos- pital where there were 40 to 50 cases a day, and he noted that those in favor of this quinine treatment were about 10 per cent. Dr. S. remarked, that in 1847 he treated forty cases in sueceffi sion by quinine, among mechanics, who had no nursing except what was provided by friends, and did not lose a single patient. It was in a favorable epidemic, but considering their destitution of proper nursing, deaths would have been as likely to occur as in a worse epidemic. As to the use of calomel in this disease, there is no possible con- dition of the system where there could be any benefit derived from, its use there was no local disease. The liver has nothing to do with it. He knew this, for he had followed the patients of the Calomelites to the dead house in plenty.. While serving as sur- geon of the Charity Hospital, the medical side of the hospital was full, and there were several mechanics who applied for admittance, and wished to be treated by Dr. S. and as he had some empty beds; he received them. But one was sent to the medical wards, and he gave him foot-baths, kept him warm, regulated his drinks, &c, and gave quinine. The attending physician came in the morning ; he ordered a drachm of calomel, but Dr. S. put up magnesia. The next day he was better, and the doctor repeated the dose,- but he took the liberty to repeat the magnesia. He got Avell, and thence- forward was one of the attending physician's " brag cases." for he dared not tell him of his doings. Then eame new physicians from Paris, full of Broussais' theory, and they bled and boasted of their successes also for a while, and in truth they did succeed as well as the former. Then eame eclectics with fanciful theories; they gave a little calomel to disgorge the liver a little, cups a little, leeches a little, and with a result very little different from the others. In fact some will get well in spite of the treatment, and then again iome forms of the fever are fatal in the beginning. When, howe- ver, they are brought side by side, and we can observe them en masse, we can more properly judge of the relative value of the dif- 1856.] Treatment of Yelloiv Fever. 53 ferent modes of treatment, than in the isolated cases met with in ordinary practice. The difference is very manifest all perturba- ting treatment is alike bad. There are some peculiarities in the disease that might not at first strike one the disturbed nervous system, and especially de- lirium one of the worst symptoms. This may appear at first, but not usually. Its first evidence is restlessness and want of sleep ; objects are seen very much as in mania-a-potu. Narcotics produce stupor and death, for the patients with this disease are peculiarly susceptible to morphine : stimulants are much better. You must watch to give the stimulants as early as possible ; they then sweat off, and are relieved in 24 to 36 hours ; but even then they must not be disturbed if raised up, they faint away. Perfect and ab- solute rest, body and mind, are indispensable. If they are excited, i the heat returns, and they die. Watch for sleeplessness, and give minute anodynes and stimulants, such as they are able to bear. Of those cases that run on and approach the period of black vomit, if managed properly as to drinks, by avoiding bitter infusions, j &c, very many recover; and those that do not vomit would have i the black vomit if they vomit at all. Some have a preference for certain kinds of drink, as porter; others prefer brandy, &c. Give those agreeable to the palate. As they approach the black- vomit period with previous restlessness and acid secretions, give some alkali, with minute doses (say a 20th or a 30th of a grain) of mor- phine, with champagne, ale, beef-essence, &c. Impart to the pa- | tient a feeliug of safety and security. And yet I have thought, in proportion to the mildness of the disease was the danger ; for i quiet is absolutely necessary, and coercion does not answer. The patient is to be managed, not treated. Foot-baths under the clothes, will often produce favorable Bweats. When in a state of dry heat, forced perspiration is bad; sponging with tepid water is then better. The douche is but of temporary benefit, and the subsequent reaction leaves the patient worse. Sponging with lemon-juice, sweet oil, and salt is used by the Creoles and Spaniards, but pure water is better. All that is to be done is to ease them through, * * -x- * * * * * Dr. Gardner stated that Dr. Ashbel Smith laid great stress on covering, and said the patient should be enveloped in blankets and carefully excluded from the air. Was this correct, and what drinks are proper ? Dr. Stone.- Careful covering of the entire body and limbs is ab' solutely requisite, but not to swelter under too much covering. K the hands were but exposed, sometimes the heat would return and a relapse ensue. Some mild diaphoretics may be given ; such drinks as the patients desire ; one year all want brandy and water, other years malt liquors. Give that which is desired, and carefully avoid even the nervous shock caused by a bitter or disagreeable 54 Treatment of Sciatica. [January, medicine. Sponging the body under the clothes, ice water to head, generally were followed by reaction and more pain. Dr.. Cartwright had pursued the opposite plan of enveloping the head in warm fomentations. ******** Dr. Corson wished to know the doses of quinine which Dr. S. gave, and the vehicle. Dr. Stone replied that he usually gave a single dose of fifteen or twenty grains, according to circumstances, at the onset, per- haps ten grains more 12 hours after, but none unless on the first day ; and the second day it is entirely useless, and after that actually injurious, although they bear it better than any other remedy. It causes vomiting when given late, and is not necessa- ry, for its effects last several hours after its administration. Treatment of Sciatica. By Peyton Blakiston, F. R. S. Dr. Blakiston has pursued the following treatment for twenty- years with considerable success. He first saw it adopted in Paris in 1833 : A blister, about the size of a crown-piece, is placed over the chief seat of pain, which is usually the flattened part of the buttock. After it has risen well, and the cuticle has been thor- oughly removed, the raw surface is sprinkled with a powder, con- sisting of one grain of acetate of morphia on an average, and a little white sugar. This dressing is repeated for six successive days, the surface of the blister being kept in a raw state, if requi- site, by cantharides or savine cerate, or else by Albuspeyeres' plas- ter. This suffices for a very mild case ; but in severe cases of old standing, the pain will now be found to have left its original seat, and to have seized on the knee of the affected side. The same treatment is then applied to the ham; and after six dressings, the pain will have generally disappeared, and the patient will rapidly recover. By this mode of treatment, eighty-three eases of uncom- plicated sciatica have been cured, without a failure having come to the knowledge of the writer. This number might have been great- ly augmented had it included the results arrived at by such of his friends and former pupils as had employed it at his suggestion, and which have been no less successful than those which occurred in his practice; but he is desirous of recording such only as have come under his own immediate notice, and for the accuracy of which he consequently can hold himself responsible. In the great majority of these cases no other drug was administered ; but in a few some laxative medicine or injection was given to remove con- stipation. In two or three cases, there was a tendency to double sciatica, and then the pain passed from the sciatic region first treated to that of the opposite side, and from thence down to the knee of this last side, but never attacked the knee of the side first 1856.] Chlorate of Potash in Mercurial Stomatitis. 55 affected. It is right to mention, that in hospital practice three cases were placed under the writer's care, which he considered more than doubtful, and they were therefore treated under protest, so to speak. They all turned out cases of hip disease, and there- fore they are not included in those above enumerated. The difference in the sensations felt by the patients on the first appli- cation of the morphia was remarkable; and without any attempt to generalise, it may be stated that a close connexion was obser- ved between the sensations felt and the previous state of health. Thus the effect produced on three persons in robust health a blacksmith, a gamekeeper, and a lady was most intense; an ! extraordinary thrilling was felt over the whole body, particularly i at the extremities, with great nausea, and a tendency to faint. The lady vomited incessantly for twelve hours, so that it was found advisable to reduce the quantity of morphia in the powders to half a grain. On the the other hand, a gentleman, who had been much reduced by overwork and by long suffering, felt no effect j whatever from the application of the powders, and yet he recover- | ed in an equally short time with the others. A lady, also, who ! had been taking considerable doses of opium, hardly felt the appli- cation of morphia until it was increased to two grains ; but this . case has been excluded, because, although the sciatica was remov- ed by the treatment, there remained an incurable disease, which eventually destroyed her. One ladjr, aged 26, in whom the I disease was not of long standing, obstinately refused to have a j second powder applied ; but happily the one application sufficed ; to effect a cure. In six cases the disease recurred after an interval ; of from five to eighteen months ; and in two of these it recurred twice; but each attack was less severe than the one which prece- ded it, and yielded readily to the same treatment. It is possible however, that relapses might have more frequently taken place without having come under the notice of the writer ; but he thinks this cannot have happened very often. Some other forms of neu- ralgia were also benefited by this mode of treatment. Thus a very distressing case of neuralgia of the scalp yielded at once ; and shooting pains, which frequently accompany cancer of the stomach, were sometimes much relieved by it. [Med. Times and Gazette. On the Use of Chlorate of Potash in Mercurial Stomatitis. From the experiments of M. Herpin, of Geneva, from those of M. Blache(6raz. Bebdomadaire, vol. ii., No. 8, p. 147), as well as from some well-detailed facts that M. Demarquay has just reported, it would appear that chlorate of potash, given internally, arrests, with rapidity and certainty, the effects of mercurial stomatitis. This effect has been established in patients in whom the mercurial intoxication supervened on the exhibition of mercury for syphilis, puerperal peritonitis, and ophthalmia. 56 Treatment of Fistula in Ano. [January, The chlorate is administered in a mucilaginous mixture, the dose commencing with half a drachm, which is frequently suffi- cient to remove the symptoms. But it has been given to the extent of four scruples, two and a half drachms, half an ounce, and upwards. As this medicine, notwithstanding its remarkable efficacy, is by no means a specific, we must not neglect to combine with it local astringents and caustics, which, even alone, possess -so powerful an action in mercurial ptyalism. M. Grustin, intern in pharmacy, wishing, for the sake of experi- ment, to submit himself to the action of chlorate of potash, took two drachms at nine o'clock in the evening. On awaking, a sort of astriction, with slight nausea, was perceived in the mouth ; the gums were a little rough to the touch. Although the saliva was not sensibly lessened, it appeared to him to be more watery than usual, This observer has also proved that the chlorate of potash is, in great part, eliminated by the urinary secretion. [Bulletin General ale T herapeutiaue, and Gazette Hebdomadaire, N. Y. Jour, of Medicine. Treatment of Fistula In Ano. By T. K.Mitchell, M.D., F.B.C.S.I I am anxious to direct the notice of the profession to a modify cation of treatment in the cure of fistula in ano. It is, I believe, an established axiom that in all cases it is necessary to divide the sphincter ani muscle, the usual operation consisting of the intro- duction of a probe-pointed bistoury as far as the sinus extends. Others recommended the mere division of the sphincter in a lower situation. Whichever operation is performed, the result is very often a relaxed state of the sphincter for some time afterwards. In a case on which I operated twelve months ago, the gentle- man had considerable difficult}^ in retaining the bowel up, particu- larly after violent exercise or defecation. In this case I found that the fibres of the sphincter ani were much relaxed, so much so as to allow the rectum to protrude for several inches, so as very closely to resemble a prolapsed uterus. The constitution began to suffer from the constant discharges of muco-purulent matter, and he was quite incapacitated from following his employment. Hav- ing previously emptied the rectum by an aperient, I directed him to force down as much as possible, and then proceeded to touch the tumor with strong nitric acid ; this was done with a piece of thin wood, four stripes extending from the upper part of the tumor to the sphincter being made on the surface; the part was then smeared well over with oil, and returned. The operation requir. ed to be repeated at the end of ten days, when only about two inches of the rectum could be forced down, and he has since then been able to go about his employment without the slightest incon> yenience, 1856.] Sulphate of Bebeerine in Menorrhagia. 57 The profession are indebted to the late Dr. Houston, of Dublin, for the introduction of nitric acid in the treatment of vascular tumors of the rectum, many cases of its successful employment being given by him in the twenty-third volume of the Dublin Journal of Medical Science. Since the above case was treated, I have had several of a similar nature, and the result has been the same. It would, therefore, be unpardonable in me to enlarge further on the subject, particularly as a similar treatment has been adopted very extensively by other surgeons, and is well known to the profession. It, however, struck me that if, instead of the great relaxation of the sphincter which so frequently follows its division, we could cause a constriction as great or nearly so as before the operation, we should be doing good service. Now this I think may be accomplished hj a very simple method employing the nitric acid before the relaxation takes place, or prior to any protrusion; and the plan I adopt, and which I have hitherto found very successful, is to apply the strong nitric acid around the margins of the sphincter ani which have been divided, and this I do on the fourth day after the operation ; the pain of its application is quickly removed by smearing the parts over with oil, and it is only necessary to apply it twice. Before concluding these remarks, I wish to state that I have found patients laboring under diseases of the rectum particularly difficult to get under the influence of chloroform, and have found the pro- cess much facilitated by employing it locally as well as by inspi- ration, as I have found the parts excessively sensitive even when the patient has apparently been fully under its influence, and when pricking or pinching was unheeded. This, I think, may be easily explained by the fact of the patient's sufferings having been for some time directed to the part, and to the nerves being in a highly sensitive condition. [Lancet. On the Use of Sulphate of Bebeerine in Menorrhagia. By Prof. A. P. Merrill, M. D. A few weeks ago I was summoned, in haste, to a lady suffering from an attack of menorrhagia. She had been long subject to excessive menstrual discharges, and uterine haemorrhages, and had been treated for them by several physicians without succes. I administered five grains of the sulphate of bebeerine, which I happened to have in my pocket, and ordered twenty pills of four grains each, one of which she was directed to take every two hours, until relief should be obtained. On visitingher the succeed- ing day, she showed me the twenty pills, and said the dose I had given her suspended the discharge before they were brought from the druggist, and she deemed it unnecessary to take them. One other case, occurring about the same time, in all respects very 58 Editorial. [January, similar to the above, was relieved, also, by a single dose of five grains. I could relate more than a dozen cases besides the foregoing, more or less severe, in which the sulphate of bebeerine has been successful. Several women in this city are now in the habit of keeping the remedy always at hand, with perfect confidence, from the results of their own experience, of being able to restrain exces- sive menstruation, and uterine haemorrhage, whenever they may occur. In several cases, also, I have known it relieve leucorrheal discharges, and to give tone and vigor to the vagina, suffering relaxation from the effect of such discharges ; and it is the only internal remedy upon which I have been able to rely, for the re- lief of pruritus vulvae, et vaginae.. Whether this remedy will prove to be as valuable as the above experiments would seem to indicate, remains to be proved; and it is with a view to elicit such proof, that this publication is made. [Memphis Med. Recorder. EDITORIAL AND MISCELLANEOUS. Local Ancestkesia by cold. The efficacy of the frigorific mixture of ice and salt as a local anaesthetic, in surgical operations which do not in- volve the deep seated tissues, and the slowness of its adoption as a general rule of practice in such cases, will plead my apology for again directing at- tention to it. An instance of its successful application as late as yesterday, also prompts me to say another word upon the subject, in the hope that the same relief may he vouchsafed to other patients. Bob, a negro boy about 15 years of age, was sent to me from Barnwell District, S. C, with a tumor about the size of a woman's fist, situated on the leg, about the upper end of the fibula. This proved to be a lipoma of five or six j'ears' standing. The patient was brought before the Class of the Medical College and placed upon a table, when the freezing mixture was applied for four minutes. The surface being blanched by the cold, an incision six inches long was made and the tumor extirpated without the knowledge of the pa~ tient, who was lying in such a position that he could not see what was being done. The insensibility was so complete that when the operation was over, on being asked if it gave him any pain, he said that he had felt none what- ever, and that he did not know we had commenced cutting; he could not be made to believe the tumor was removed, until it was shown to him. There was no bleeding until reaction took place, when a slight oozing en- sued, which ceased upon bringing the edges of the wound together with adhesive strips. Although I have been now resorting to this mode of inducing local anaes- thesia for about a year, in all cases to which it was applicable, this is the first 1856.] Editorial. 59 instance in which total unconsciousness of the operation has been manifest. In most cases the patients feel the knife only as it reaches the deep tissues in passing behind the tumor, and then only slightly, inasmuch as the sensibility of the cellular structure is not great. When it is remembered that the greater number of surgical operations involve superficial parts alone, and that we may by the use of so simple and harmless an application as the freezing mixture, render them comparatively painless, it must be conceded that the discovery is one of great importance and that it should in all suitable cases take the place of the more hazard- ous expedient of chloroformization. Yet, if we are to judge from the paucity of recorded testimony, surgeons have been unaccountably dilatory in its adoption, in comparison with the alacrity exhibited in trying other anaesthetics. The freezing mixture maybe substituted for other anaesthetics in the amputation of the fingers, toes, and wrist, as well as the opening of furuncles, abscesses, and whitlows, the extirpation of superficial tumors, &c, thus reducing to a very small figure the number of operations in which chloroform or the ethers would be necessary or proper. Augusta, 20th Dec, 1855. L. A. DUGAS. BIBLIOGRAPHICAL. Clinical Lectures on the Diseases of Women and Children. By G. S. Bed- ford, A. M., M. D., Prof, of Obstetrics, &c, in the University of New York. 2d Edition. New York: S. S. & W.Wood. 1855. 8vo. pp. 568. (For sale by T. Richards & Son.) Whilst systematic treatises are necessary in the study of Medicine, much good may be accomplished by the publication of clinical lectures or remarks suggested by the presence of individual cases of sickness, and designed for the ear of Students. It is true that the printed lecture loses a part of its value to the reader, in not being accompanied by the presence of the pa- tient ; still, there are countless modifications and peculiarities met at the bed-side, which can find no place in a systematic treatise, and which may yet be made the subject of interesting observations to a class of novices, either orally or otherwise. In short, the relation of cases, with running comments upon them, constitutes one of the very best modes of conveying valuable information to the student of medicine. The work before us is one of this kind, written in an easy, lucid, and happy style, eminently practical, and therefore valuable as a contribution to med- ical knowledge. Prof. B's extensive opportunities have enabled him thus to bring together a large number of the most interesting specimens of female and infantile affections, and to indicate his views of their treat- ment. In the accomplishment of the task, the author has evinced a degree of discernment which will doubtless add materially to his already extended reputation. 60 Editorial. [January, A Treatise on Venereal Diseases By A. Vidai., (decassis) Surgeon to the Venereal Hospital of Paris, &c, &c. With colored plates. Translated, with annotations, bv Geo. C. Blackmax, M.D.,fec 2d Ed. New York: S. S. & W. AVood. 1855. 8vo.pp. 500. (For sale by T. Richards & Son.) Having already had occasion to notice this work, upon the appearance of its first edition, we can only reiterate our commendation of it, as one of the most complete and useful treatises on syphilitic diseases we know. History of Medicine, from its origin to the Idth Century, with an appendix containing a Philosophical and Historical Review of Medicine to the present time. By P. V. Renouard, M.D.. Translated from the French, by Cornelius G. Comegys, M. D., Prof, of the Institutes of Medicine in Miami Medical College. Cincinnati: Moore, AATilstach, Keys & Co. 1856. 8vo., pp. 719.' We are indebted to the publishers for this valuable work, the mechanical execution of which, reflects great credit upon the taste and ability of West- ern printers. It has long been a source of surprise to us that we had no History of Medicine in the English language, while the French and Germans are so well provided with them. We are happy to find the deficiency supplied by the industry of Prof. C. The translator has judiciously selected for pre- sentation to the American reader, the standard work of Renouard, in one volume, instead of the more extended and elaborate History of Sprengel, which would have been too voluminous for the mass of our practitioners, who will doubtless feel grateful to Prof. C. for the opportunity thus afforded of becoming acquainted with the history of their profession. M. Renouard divides the history of medicine into, 1st, the Age of Foun- dation, which comprehends the '"Primitive Period, or that of instinct," the " Sacred or Mystic Period" the " Philosophic Period" and the " An- atomic Period" and extends from the earliest ages to the death of Galen, A. D., 200. 2d, the Age of Transition, which includes the Greek and Arabic periods, ending A. D. 1400; and 3d, the Age of Renovation, em- bracing the "Erudite" and the "Reform" periods, from the 15th to the 19th centuries. We cheerfully commend this book to the patronage of the profession. The Anatomical Remembrancer, or Complete Pocket Anatomist : Contain- ing a concise description of the structure of the human body. 2d Amer- ican, from the 4th London Edition. AYith corrections and additions by C. E. Isaacs, M. D., &c. New York : S. S. t i< >n in tin1 pulmonary, not the cos- tal pleura; but, in the more advanced period of the disease, the internal aspect of the cavity of the pleura, -when presented to the notice of the pathologist, is, in gen- eral, so assimilated 1 > y the structural changes observed, that it is impossible to as- sign to either pleura a priority in morbid action. )- In this ease only, a loud splash was heard on succussing the patient. | Dublin Journal, vol. xvii. 1856.] Acidity of the Mouth in the Muguei of Infants. 95 On the part which Acidity of the Mouth plays in the Muguei of Infants. By Dr. Seux, Head Physician to the Hospice de la Charite of Marseilles. The mouth of the adult, which in health has an alkaline reac- tion, may in the morbid state become acid. Thus M. Donne has found the saliva to be acid in cases of gastritis, and it is known that in the muguet of the adult the mouth presents a very decided- ly acid condition. This acidity has also been found to exist in the muguet of infants ; in fact, M. (rubier, in a note on muguet insert- ed in the Gazette Medicate of the 26th of June, 1852, observes "I ascertained that children labouring under this singular affection have always extreme acidity of the mouth. The mucus covering the tongue, the cheeks, and every other part of the bucco-pharyn- geal cavity strongly reddens litmus paper even the moment after the child has suckled. This reaction exists before any trace of muguet is percepiible; but then there is already a very intense raspberry-like redness of the mucous membrane lining this first portion of the digestive tube ; so that from the coincidence of these two peculiar conditions we may anticipate the invasion of the cryp- togame." But it was especially important to ascertain if the mouth is alkaline in an infant in good 'health, as it is in the adult. In order to decide this point, I have made numerous researches, from which it appears that the mouth of children at the breast in good health is ordinarily acid. I have verified this fact repeatedly both in private and in hospital, and as well at the moment of birth as some days and even some months subsequently ; I have found it to be the case whatever was the strength of the child, or whatever were the hygienic conditions by which it was surrounded. My observations have been attended with the same result in children who have continued well, as in those who have, at a later period, suffered from illness. Not satisfied with having established the fact myself, I requested Dr. Magail, junior, assistant-surgeon to the Maternite, to under- take similar investigations, and the results obtained by him have agreed with mine. I did not commit to writing the results of all the observations I had the opportunity of making ; but the following are the details contained in the notes I possess on this subject: These notes refer to one hundred children in good health, aged from a few minutes to ten months. Of these one hundred sub- jects, eighty-seven were at the" Hospice de la Charite, and thirteen in private. In five only the mouth did not present a trace of acidity on the first examination, made some hours after birth ; but on a second examination instituted in three of them two hours subsequently, the mouth was acid ; in the ninety-five other chil- dren there was invariably proof of acidity from the first. I have arranged these children in three classes ; those who had 96 Acidity of the Mouth in the Muguet of Infants. [February, not yet suckled ; those who had suckled, and had always been well ; those who had suckled, and had had the muguet. The first class contained forty-nine; the second, thirty-eight; and the third, thirteen. In the forty-nine belonging to the first class, the mouth was ex- amined in eleven immediately after birth ; in eight, some hours later, and in thirty, from two to three days after birth. In the thirty- eight of the second category, the examination was made in thirty -four from two to fifteen days after birth ; in three, from a fortnight to a month; and in one, in a little more than a month after birth. In the thirteen belonging to the third class, I examined the mouth in nine, at the age of from a fortnight to a month ; in two, at two months; in one, at four months; and in another, at ten months. In testing the condition of the mouth, I made use of litmus pa- per rendered more sensitive by the addition of some drops of acid; this paper retained its blue colour when introduced into the mouth of an adult in good health. In the children of the three classes, it was more or less reddened. I did not observe any difference in the degree of reaction between the children who had and those who had not been suckled, nor between those who had just left the breast, and those who had not taken it for a long time. Neither was any difference perceptible between those who had not been ill, and those who had had the muguet. But a remarkable differ- ence always existed between children at different ages. Thus at the moment of birth the paper was feebly reddened, at the end of some days, and particularly after the first fortnight, it was strong- ly reddened, and at two months, or later, it assumed a still more decidedly red color. I had also frequent opportunities of examining contemporane- ously children of the same age, some of whom had the muguet, while some were free from it ; in all, the paper assumed the same red tint; in children of a month old especially, it was easy to ap- preciate this circumstance, because at that age the paper reacts strongly. From the foregoing I infer : 1, that the mouth of infants in good health is acid ; 2, that this normal acidity becomes more de- cided as the children grow older ; 3, that suckling is not without influence on this acidity. The fact of the normal acidity of the mouth of the infant being thus established, I am inclined to look xxpon this condition as a predisposing cause of muguet, for every one at the present day knows that the presence of acids is favourable to the development of the vegetable element of which this production is composed. .This normal acidity of the mouth in infancy may therefore explain the predilection of muguet for that age. Since, then, it is probable that acidity of the mouth in the adult 1856.] Seven Cases of Tetanus. tt7 affected with muguet precedes this affection, it may, perhaps, be its cause and not its effect. It will be easy to ascertain if, in the adult, in the chronic diseases which are sometimes followed by muguet, the mouth is acid before the development of the latter. The facts I have just pointed out call for new observations, and for my part I shall neglect no opportunities of completing the re- searches I have commenced on this subject. Thus it would be important to know at what period of childhood the mouth be- comes alkaline. Hitherto my object has been to ascertain the part played by the acidity of the mouth in the muguet of infancy ; I think I have attained it in proving that it ought to be considered as a cause, and not as an effect of that disease, as this acidity con- stitutes the normal state. [Gaz. Med. de Paris. Dublin Med. Press. Seven Cases of Tetanus. Communicated by C. Stilwell, of Long Island, New York. Case I. A strong, active woman, injured the sole of her foot by stepping upon a nail. A week after the injury, symptoms of locked jaw supervened. The spasms where regular and frequent. A consultation agreed in the diagnosis. Treatment I administer- ed half a drachm of tinct. opii. and one sixth of a grain of tart, antimony until one ounce was" taken of the former, without any symptom of narcotism. Emetics were used after the eighth close with a temporary relief of all the symptoms. I applied, to the entire length of the spine, a liniment of turpentine and laudanum, and administered half a drachm of sp. terebinth, by mouth, every two hours, until seven doses were taken. On the second day, the character of all the sj^mptoms assumed more the peculiarities of hysteria than true tetanus. The spasms were of every variety. Emprosthotonos, opisthotonos and pleurothotonos would succeed each other. Eecovery took place at the expiration of two weeks by a gradual subsidence of the spasms. Case II. A lad of 12 years of age received an injury in the bottom of the foot. When called to him I found slight rigidity of the jaws and muscles of the back. He complained of an aching sensation in the back and neck. The expression of his counten- ance was anxious, and the corners of his mouth were slightly drawn down closely approximating in expression the urisus sardoyiicus." Treatment. I covered the wound with a tobacco poultice. Applied to the spine a liniment of tinct. opii., aconite and turpentine, and administered internally tinct. opii. and spts. terebinthinse. There were no spasms, and recovery was imme- diate. Case III. A man aged 35, of intemperate habits, slightly in- jured the nail of his thumb. A week after the accident,, he com- plained of rigidity of the muscles of the neck. Complete trismus soon supervened, with regular spasms. He died on the third day. 98 Seven Cases of Tetanus. [February, Treatment. Dover's powders and quinine every four hours, tur- pentine in drachm doses, with liniment to spine of tinct. opii. and terebinthinaB. Case IV.' A youug mechanic, of sound health, received a slight contusion in the palm of the hand, A few days after the accident he was seized with a spasm. The jaws were locked for a few minutes. He complained of stiffness of the neck and back. The wound was opened, and a sedative poultice applied. A large to- bacco poultice was applied to the throat, and Dover's powder administered internally. No further treatment required. Case V. A lad, 12 years of age, was taken with idiopathic tetanus. I administered chloroform by inhalation, applied tur- pentine and laudanum to spine, gave turpentine and laudanum in large doses internally. He died. Case VI. This case, of a boy 13 years of age, presented several peculiar and interesting phenomena. For several days previous to any alarming symptoms manifesting themselves, his counten- ance would assume at times a peculiar and sardonic expression. His parents threatened to punish him for making faces not be- lieving anything to be the matter with him. There was complete trismus, with general spasms, during which his body would form a complete arch on the bed. There was strabismus of both eyes. Treatment. Quinine and Dover's powders. Turpentine liniment to back, combined with chloroform and laudanum, occasional doses of calomel to move the bowels, followed by enemata of turpea- tine and oil. He recovered in ten days by a gradual subsidence of spasms. For several weeks after convalescence he occasionally had a slight spasm. During his illness a splinter was discovered beneath the nail of the big toe. Case VII. This case was a child, 10 years of age, and admitted of more doubt than either of the preceding. A consultation de- cided that it was idiopathic tetanus. There was no trismus or stiffness of the muscles of the neck, but the spasms were confined to the back and lower extremities. I applied lint wet with chloro- form to the spine, until partial restoration occurred, and exhibited internally camph., tinct. opii. and chloroform every half hour. The spasms soon ceased. That the eastern end of Long Island predisposes to this disease from slight causes, I think no longer admits of doubt. Every do- mestic animal, excepting the clog and cat, are subject to it. The emasculating process produces more accidents from this cause alone than all others combined. The nature of this endemic in- fluence I fear will never be satisfactorily explained ; the fact that it exists, I think, is proved. Where no cure is known, prophy- lactic treatment deserves increased attention. A domestic remedy of almost universal application here, is salt pork worn upon the wound. As all the cases I have treated had availed themselves of this application, nothing further can be said in favor of the "por- 1856.] Opacity of the Cornea. 99 cine fomentation." It has also been the custom here to have every wound opened, and, frequently, irritating liquids injected. I have never believed any benefit was derived from this course. Of wounds (particularly punctured and contused) I have never known a single accident occur when treated with tobacco and opium. Of the pathology of tetanus we are entirely ignorant. I believe the traumatic form originates first locally in the wound, and the excito- motory nerves become deranged from this local cause. The chances of successful treatment, then, consist in powerful sedative applications to the wound. But if the wound exists, then make the applications to the spine. Chloroform by inhalation gives only temporary relief the frequent repetition soon exhausts the vital powers. Bleeding and warm baths I have never derived any benefit from. Active medication by mouth I think will disappoint expectations. Strychnine I have never used, but if any future cases present the opportunity for its trial I will give you the re- sults. [Boston Med. and Surg. Journal. Opacity of the Cornea treated by Operation. Dr. M. Davis reports the following cases of opacity of the cornea treated by operation under the care of Mr. Haynes Walton and Dr. Taylor. A man about 50 years of age, a patient of Dr. Tay- lor's, had a quantity of lime thrown into his eye four years ago. The eye was immediately washed out, and it was supposed that all the foreign matter had been removed, but a dense white opaci- ty remained, covering nearly two-thirds of the cornea, and com- pletely concealing the pupil when in a state of medium contrac- tion. Many ineffectual attempts had been made to remove or diminish the impediment to vision, by means of lotions and other local applications. On examining the eye minutely, it was seen that the opacity was smooth and uniformly covered by the epithe- lium ; its upper edge, where it did not extend to the margin of the I cornea, was shaded off gradually, and the surface generally ap- peared slightly more elevated than that of the clear part of the cor- nea. This elevation, taken in connection with the history of the case, led Dr. Taylor to suspect that the apparent cicatrix was formed by a portion of the lime which had not been removed at the time of the accident, and had become incorporated with the corneal tissues. He therefore with a fine iris knife, carefully raised the epithelium in front of the pupil, and found that, by careful manipulation, the opacity could be chipped off in small flakes, and that in no part, towards the centre of the cornea, did it appear to have penetrated the anterior elastic lamina. After clearing the pupil, the operation was suspended for the time, partly on account of the severe pain which it occasioned, and partly to avoid the risk of inflammation. On a subsequent occasion, the remainder was removed, with the exception of a few small spots towards the N. s. VOL. XII. NO. II. 7 100 Opacity of the Cornea. [February, margin of the cornea, which appeared to be due to interstitial in- flammatory deposit. The slight haziness which remained after the operation was speedily dissipated, and the man was dismissed with almost perfect vision. Chemical examination showed the opaque matter to con- sist of carbonate of lime. In another case, also under the care of Dr. Taylor, the opacity was removed, partly by operation, and partly by the process of absorption, excited by mechanical irritation. The patient, a female, 24 years of age, had been subject, till within the last six years, to attacks of ulceration of the cornea?. She now applied on account of a central milky opacity of the right cornea, shading the pupil and destroying useful vision in the eye. It had remained undiminished in size for six years, notwithstand- ing a great variety of local applications. Near the centre of the opacity were two small, dark-brown spots, situated apparently, in the substance of the cornea. These were, probably,, the effects of a former long-continued use of nitrate of silver solution, while the cornea was ulcerated. The surface of the opacity was readily peeled off in small flakes, by a cautious use of the iris knife, but the brown spots were found to be so deep-seated, that Dr. Taylor did not consider it prudent to interfere with them, especially as they would not impede vision. The result of this little operation, which has since been repeated, has been the rapid diminution of the opacity, and corresponding improvement in vision; and as absorption is still going on steadily, there is every prospect that the sight of the eye will be completely restored. It might be objected,, that the following ease ought not, in strict- ness, to be placed under the heading of this report, but it is given, not only on account of its great peculiarity, but because it is some- what allied to the above. T. P., aged 38, a meteorological instrument-maker, discovered, about four years ago, that the left eye was misty. The mistiness increased slowly, and attributing the failing of sight to the inju- rious effects of his trade, he disregarded professional advice, till the right eye had given evidence of the same kind of obscurity that had attacked its fellow, and now he applied to Mr. Walton. The eye first diseased, the left, is virtually blind, for nothing can be seen with it, as in the centre of the cornea there is a brown oval opacity, placed transversely, large enough to cover the pupil, and dense enough to intercept light. It is of a sepia colour, and shaded towards the extremities, not raised, and possessed of the same lustre as other parts of the surface of the cornea. The right eye is affected in a similar manner, but in a less , degree, and enough of the pupil is yet uncovered, that with a magnifying glass the coarser works of his trade can be executed. There have not been any subjective symptoms, and he himself is quite unaware that there are brown spots on his eyes. 1856.] Cancer in Children. 101 Mr. "Walton directed atropine to be used to the left eye, the effect of which was to dilate the pupil beyond the opacity, and thus to enable objects to be seen with that eye nearly as well as with the other. The right eye was then treated in the same manner, and the vision was improved. The patient now expressed himself quite satisfied with the benefit received, and desired to cease attendance, but yielded to the request of Mr. Walton to attend another day, that he might ascertain how far the opacities were capable of being removed by operation. An attempt was made to scrape a portion of one away ; but a clear surface beneath could not be obtained, as the disease had extended into the true texture of the cornea, and perhaps completely pervaded it. Dr. Taylor, who had taken his microscope to the hospital, to examine, in a fresh state, whatever might have been removed, found that the portion separated consisted of epithelium, some of which contained pigment granules. I must beg to observe that, so far as my personal experience goes, opacities resulting from loss of substance of the cornea ; in fact, cicatrices and interstitial deposits from inflammation axe not capable of being pared away, but depositions, for the most part consisting of earthy materials on the surface of the cornea, and the accidental impingement of a foreign substance, as in the first case, may be so removed. [Medical Times and Gazette. On the Occurrence of Cancer in Children. By M. GlJERSANT. The subject of cancer in children is nowhere treated of, proba- bly on account of the rarity of this affection during the early periods of life; however, there is not a year in which the author does not see some cases of it. For a very long time, cancer was met in children only in the orbital cavity, whether it took its origin from the globe of the eye or from the base of the orbit. It has since been proved to occur in the testicles. Dupuj'tren operated on several such cases ; M. Gruersant has also removed six or seven testicles effected with en- cephaloid cancer. Cancer has also been found in other parts, but less frequently, unless in the vulva. Ought we now to make a distinction between fibro-plastic and cancerous tumours? M. Ghiersant is strongly disposed to class them together, on account, he says, of the tendency the former possess, in common with the latter, to relapse. He admits, however, that their relapse occurs less frequently ; and in this point of view they have a character of relative benignity which should be borne in mind, but they are nevertheless, according to this surgeon, closely allied to cancer. The progress of a cancerous affection in a child is much more rapid than at a more advanced age. At the Salpetriere and Bice- tre, cancer is seen in old patients to remain stationary for from 102 Treatment of Chancre. [February, fifteen to twenty years. In children, on the contrary, trie progress of the disease is terrific. In a young boy, under M. Guersant's care for a cancerous tumour in the orbital cavity, the eye was driven out of the orbit in less than six weeks. The sufferings of this little patient were fearful ; the globe of the eye was extirpated, but the disease returned with extreme rapidity, and at the end of a month the ethmoid was destroyed. The prognosis in cancer in children is, therefore, very unfavora- ble; and because there is no chance of the disease remaining stationary, the indication is to operate with more rapidity and energy than in adults. But, on the other hand, relapse is so gen- eral and occurs so quickly, that we ought to resolve on operating only with the view of procuring temporary relief from intolerable sufferings ; nor should we fail to warn the friends of the patient of the likelihood of the disease returning. M. Guersant quotes, in support of these remarks, a case which terminated fatally; although on post-mortem examination, nothing but fibro-plastic tissue was found in the tumour, the destruction of which had been attempted. The patient had been a little girl, aged thirteen months, who had a tumor in the vulva. This tumor was tied by a surgeon on the 6th of November, and came away. The disease relapsed, and on the 18th December a secon d ligature was applied ; relapse occurred still more speedily than on the first occasion. In January, the second tumor was pretty large, and its presence gave rise to sympathetic vomiting. The child was pre- sented to the Surgical Society, the members of which body verified the existence of a multilobular tumour, with prolongation into the vagina. Although it was difficult to trace its limits, M. Hu- guier advised removal with the bistoury, and cauterization of its roots. M. M. Lenoir and Guersant were of opinion that the re- sults of such an operation would be incomplete. However the tumour mortified, and the child fell into a state of marasmus. M. Guersant thought it advisable once more to have recourse to liga- ture ; but the little patient was already exhausted, and sank in a few days from adynamia. Should excision have been more successful ? It is not probable.. Nevertheless, in another case, M. Guersant considering such an affection as a sort of polypus, would excise it early, and cauterize its base with liquid caustics ; and if the vagina was large enough to admit of these means, he would not despair of obtaining a more or less permanent cure. [Dublin Med. Press, from Jom,r. de Med., etde Chirurg. Treatment of Chancre. From observations conducted on a large scale at the Vienna Hospital, Dr. Sigmund concludes 1. Chancre can only be treated locally during the first four days, and the further we recede from 1856.] Mathyseii's Gypsum Bandage. 103 this, the greater the urgency of the general treatment. 2. The lo- cal treatment consists in cauterization, which effectually destroys all the chancrous exudation to the sound tissue. 3. The observa- tion of more than a thousand cases during eleven years, assures Dr. Sigmund that secondary symptoms never occur when the chancre has been completely destroyed within the first four days. He is only aware of two doubtful cases in which cauterization on the fifth day even has not prevented accidents. The best caustic is the Vienna, composed of quicklime and two or three parts of caustic potass. Cauterization should also be practised even after the fifth day, for although the chances of preservation from secon- dary syphilis are diminished, they are not totally abolished ; and we prevent the chancre being communicated to other parts of the same patient, or to other individuals. 4. The general treat- ment consists in the methodical employment of mercury, no other means curing so quickly and so surely. 5. In the exceptional cases in which secondary symptoms occur in spite of general treat- ment, they are not found in an aggravated form. 6. According to circumstances, the general treatment should be continued for six or twelve weeks. The levity with which the public and the pro- fession at the present time regard venereal symptoms, should be met by the strongest opposition. 7. Clinical observations shows that every chancre, well diagnosticated, and not carefully destroy- ed, leads to secondary symptoms, if general treatment has not been instituted. This will be admitted by all who establish a rig- orous diagnosis, and look for secondary symptoms soon enough where they are first to be found, viz : in the lymphatic glands. 8. Positive diagnosis is alone attainable by inoculation or the pro- duction of secondary symptoms. 9. Secondary symptoms are usually observed about the sixth week after infection, and very rarely later than the twelfth ; and we must not always depend upon the patient's assertion, but make ourselves a rigorous search for their early manifestation. If between the sixth and end of the twelfth week no secondary symptom has shown itself, and the local manifestation has disappeared, the patient maybe pronounced cured the few exceptions that occur notwithstanding. 10. The amount of mercury administered varies according to the indica- tions offered by differentjpatients. The dietetic and hygienic man- agement, both during and after taking the mercury, is too much neglected. [_V Union Medicate. American Jour, of Med. Sciences. Report on the Employment of MatliyserCs Gypsum Bandage. By Drs. Geimm and Jungken. Dr. Mathysen's bandage was employed in thirty-six cases of fractures of various kinds early in 1854. The bandage is pre- pared by stretching it upon a table, and well rubbing powdered gypsum into it on each side. It is then rolled up or otherwise ar- 104 Chloroform in Midwifery Practice. [February, ranged, according to the use to be made of it. Immediately before applying it, it is dipped in water or other fluid, the limb being protracted by a flannel or other bandage prior to its application. Any portion of the bandage that is found not to have become wet- ted is moistened by a wet sponge. Flannel will take up twice as much gypsum during the rubbing as linnen ; but it is more clumsy, and not so easily applied. If a very firm, immovable bandage is required, some of the gypsum, in the form of a thin paste, should be applied during the last turns of the bandage. Its appearance is much improved by passing a damp sponge several times along it while still wet, and at a later period it may be smoothly polished by means of glass. To remove the bandage, it only requires to be again well wetted. The Reporters pronounce this bandage to be the best of all hith- erto invented, including those that most resemble it, as the starch bandage, i\pon the following grounds: 1. The rapidity with which it hardens. 2. Its simplicity and easy application. 3. Its small cost. 4. The ease with which it may be removed the linen composing it being available, after twenty-four hours' soaking, for new bandages. 5. Its firmness and immovability render it suita- ble for the most oblique and difficult fractures. 6. From its rapid hardening and its firmness, it is well adapted for those cases which require extension and counter-extension to produce coaptation of the fractured parts. The position obtained remaining unchanged, apparatus of extension, so uncertain in operation, and so annoying to the patient, is not required. 7. The ease with which it is borne. 8. Its porosity. Cutaneous transpiration is not quite suppressed, and if the fracture be complicated by wounds, ulcers, &c, these are indicated by the discharges making their way through the bandage. 9. The gypsum bandage is a good conductor of heat, and a bladder of ice placed over some oil-skin, around the fractured part, takes effect in five minutes. 10. When the bandage is prop- erly applied, the form of the limb is so well displayed, that any irregularity of the fractured part may be judged of externally. 11. Its handsome appearance and regularity distinguish it from all analogous bandages. 12. Fractures seem to unite sooner under its employment. [Brit, and Foreign Med. Chiurg. Rev. from An- nul, des Charite-Krankenhauses. The strictest Caution requisite in Chloroformization in Midwifery Practice. Dr. M'Clintock briefly relates (June 6, 1855) to the College of Physicians in Ireland, the history of a case of chloroformization in midwifery practice, in order to show the great necessity that existed for always using the utmost caution and circumspection in the employment of chloroform inhalation in labour, as well as the great importance of intrusting its exhibition to none but a medi- 1856.] Chloroform in Midwifery Practice. 105 cal man. He did so because the writings and practice of some of the foremost advocates for anaesthesia bad led many persons to suppose that the administration of chloroform to parturient cases was almost, if not entirely, free from danger a most dangerous fallacy, and one that would inevitably lead to disasterous conse- quences is generally acted on. The leading circumstances of the case he brought forward were these : A healthy woman, aged 28, was admitted into the Lying- in Hospital, in labour of her first child, some days before. The first stage was very tedious, in consequence of an unyielding con- dition of the os uteri, and much general irritability. With a view to relieve this state, and to give her some rest, as she was much harrassed by frequent short pains, it was thought advisable to put her under the influence of chloroform. For about an hour she got it in small quantities in fact, merely chloroform d la reine but without experiencing any benefit, and without its producing any anaesthetic or soporific effect. The quantity put on the sponge a large cup-shaped one, was now increased, but still could hardly have exceeded one drachm, and was not more than is habitually given in the hospital to patients undergoing obstetric operations, to which cases its use is chiefly limited; and it was administered by the senior assistant, who has had ample experience of its use, having given it before in hundreds of instances. After the sponge was reapplied to her mouth, and she had taken three or four in- spirations, a change came over her countenance, the eyeballs turned up, the pulse left the wrist, respiration was suspended for a space of time that would have occupied about three or four in- spirations, and some froth collected at the angles of the mouth. On the first appeararance of these alarming symptoms, the sponge was instantly withdrawn, the free circulation of fresh air was pro- moted, the face and chest were aspersed with cold water, and ammonia was applied to the nostrils. It should, perhaps, be mentioned that during the entire of the above period she was in bed, and lying down. Under the influence of these restoratives, animation gradually returned. It was evident, however, to all around and many of the pupils were present that she was all but gone, and that her life was preserved by the early recognition of the poisonous effects of the medicine, and the prompt and judi- cious employment of appropriate restoratives. Hardly any one will venture to deny that had this woman been in non-professional hands , her life would have been lost. That she got a dose of chloroform which, to her, was an overdose, is sufficiently obvious ; and yet the quantity given, the quality of the chloroform used, the mode of exhibition, and even the administrator, were all the same as on hundreds of previous occasions, when everything went on favorably. Hence, then, the absolute necessity for invariably and uniformly observing the strictest caution, prudence, and circumspection in the employment of this powerful agent, and never intrusting its ex- 106 Dislocation of the Lower Jaw. [February, hibition to a non-medical person. A case that strikingly illustrates these remarks is recorded in the Medical Times and Gazette for April 14, 1855, where a lady died in the course of a natural labour, from the effects of chloroform administered to her by the nurse, on a handkerchief, without the sanction or knowledge of the doc- tor, who was in the house at the time. The quantity used in this case, with fatal effect, could not have exceeded five fluidrachms. [Dublin Quarterly Journal of Med. Science. Complete Dislocation of the Lower Jaw reduced by a new method. By W. Colles. Miss , aet. 25, whilst indulging in a protracted yawn, felt a jerk in the jaw, and found she could not close her mouth. She immediately applied to a medical man in her neighborhood, who recognized a dislocation, but failed in his efforts at reduction. She then applied to Mr. Colles. " The mouth was open, the symphy- sis of the jaw slightly projecting. On applying the fingers to the angle of the jaw, and tracing the ramus upwards, it led in a direc- tion much anterior to the position of the articulating surface. The posterior edge of the bone could be most distinctly felt, and a broad furrow or hollow existed between the bone and the ear. The heads of the bone were felt and perceived prominent in front of their natural position, so that the face appeared broader at this place than natural. " Before attempting reduction, I wished to ascertain the position in which I would have most command of the force to be used. Standing before her, I passed both thumbs into the mouth, but felt I would not have a position the most favorable for applying all my force, if necessary. " I then stood behind her, and it at once struck me this was the position which afforded most advantages. "Placing her head against my chest, I passed each thumb as far back on the corresponding side of the jaw as possible. By making a rotary motion from the wrist, I found the bone to yield; by now adding a motion of drawing the hand in towards the chest, the left side first, then the right, slipped into their positions, and the patient closed the mouth, the rows of teeth falling into their rela- tive positions, and she now could speak plainly. " I think there are many advantages to be derived from attempt- ing reduction in this posture, viz: the surgeon standing behind the patient, the head applied to his breast, and the thumbs turned inwards on the corresponding angles of the jaw, the fingers under the bone in front. " In the first place, the head is much more secure than in the original process, where it is applied against a wall, because in the latter the surgeon may press down the bone, and the patient gen- 1856.] Iodine Paint in Cutaneous Xcevi. 107 erally will draw the head in the same direction by moving the body forward in the chair. " By standing behind the patient, while depressing and pushing back the thumbs, he is pressing forwards with the chest, and thus fixes the head more steadily, and assists his manipulations; and even if the patient do move on the chair, a slight motion of his body will suffice to counteract this movement, and retain the head steadily fixed. "Another advantage is, that he can use much more force, be- cause when standing in front he can only use the museles that depress the hands ; whereas standing behind the patient he has the power of those muscles, and is assisted by the powerful class of muscles that rotate the thumbs inwardly ; and, besides, in the former case his pressure is away from his bod}*, whereas in the new position the pressure is more directly downwards and towards himself. The only disadvantage in this proceeding, if it can be considered one, is, that the mouth is stretched more than in the original plan." [Dublin Hospital Gazette. Cutaneous Nozvi cured by Application of Iodine Paint. S. Edwards, M. D., relates two examples of this. In the first case, the naevus was unfortunately situated on the side of the neck of a female infant. At birth it appeared simply as a small, red shining spot, which in three months increased to the size of a four- penny piece. The mother of the child at this time positively refusing to have any escharotics employed, fearing that it might give rise to a permanent and greater deformity, I recommended astringent and cold applications to be applied constantly, and this was kept up for some time, but with no good result. The na^vus at the end of ten months had acquired additional size, and was observed to become redder and a little more elevated, whenever the circulation was increased by awing, etc. The parents still refusing any of my former suggested remedies, or even of vaccin- nation, "until it got worse," I recommended the use of iodine paint, which was regularly employed by gently painting over the surface with a camel's hair pencil every alternate day, occasional- ly leaving it off for three or four days when the skin was very irritable and rough. Under this treatment I was pleased to find that the growth of the naevus was arrested, became smaller and mottled, and finally disappeared; a speck or two being alone visi- ble to mark its former site. The second case was very similar; occurred in a little boy nearly two years of age. The naevus was about the size of a shil- ling, but slightly elevated, and situated on the abdomen, and had gradually, but very slowly, increased since birth. No treatment had been employed, the physician who attended the mother of the child, having advised nothing to be done unless it increased. The 108 Contagiousness of Puerperal Fever. [February, tincture was commenced in September, 1854, and was continued more or less up to the last mouth, when the disease had disappear- ed, leaving scarce a trace of the mischief. [Med. Times and Gaz. Contagiousness of Puerperal Fever. M. Depaul believes that puerperal fever, especially when epidem- ic, is contagious. He relates the following examples. During an epidemic of puerperal fever at the Matcmite, a midwife was en- trusted with the case of a woman recently delivered, affected with a most severe metro-peritonitis. One morning this midwife, in giving the attention to the patient which her situation required, was powerfully impressed, and as if suffocated, by the emanations which escaped on raising the bed-clothes. The same evening a strong shivering fit occurred, her abdomen became very painful, pulse small and frequent, greenish vomiting, diarrhoea; at last all the symptoms most characteristic of puerperal fever. She died in forty-eight hours. At the autopsy the changes usually observed in cases of this nature were found, the tissues of the uterus being ulcerated. M. Depaul was enabled, moreover, to establish that this young woman was not only not in any form of puerperal state, but that she presented all the signs of virginity. A physician was engaged in making the post-mortem examina- tion of a woman who had died of puerperal fever, when he was summened to attend a labour. Precautions of every kind, change of clothes, washing, could not rid him of the smell that autopsies of this kind commonly leave on the hands. The labour took place in the usual way, but in the evening the patient was seized with a most severe puerperal fever, and died the next day. M. Depaul relates also another similar case in which the woman died in a few hours. \L' Union Medicale. American Jour. Med. Sci. Pathological Anatomy of Chronic Hydrocephalus. M. Blache, in a communication read before the Academy of Medicine, describes the details of the pathological alterations re- sulting from this disease. The following arehis conclusions: 1. In internal hydrocephalus, the serum accumulates in the cerebral ventricles, but not in the cerebellar or fourth ventricle ; it does not communicate with the cephalo-rachidean liquid. 2. Contrary to the opinion of some authors, the white and the gray substances are recognizable in the nervous laminae, into which the fluid pressure transforms the ventricular walls ; when the dis- tension has not been excessive, the circumvolutions are also to be found, and, in all cases, thickenings, which are the vestiges of them. i 3. The corpus callosum, fornix, and septum lucidum, are almost entirely destroyed and converted into fibrous laminae. 1856.] Experiments on the Smoke of Tobacco. 109 4. The tuberculum annulare, the cerebellum, and the origin of the cranial nerves, preserve their integrity, with the exception of more or less alteration always existing in the optic and olfactory nerves. 5. The ventricular membrane is thickened so much as to be capable of dissection throughout its whole extent, by which it has been established to be continuous with the choroid plexus, and prolonged across the aqueduct of Sylvius aud the foramen of Monro. 6. In the interval between the two laminae, which, by facing each other, form the septum lucidum, it is easy to demonstrate the existence of the fifth ventricle, and its communication with the third. 7. The pituitary body is canaliculated. 8. The anterior orifice of the aqueduct of Sylvius was found obliterated in the two cases where this wras examined ; the cere- bral cavities were thus completeby closed. 9. Regarding the nature of the malady, the absence of all soft- ening of the cerebral substance, and the very slightly plastic nature of the fluid effused, discountenance the idea of chronic hydroce- phalus being the result of inflammation. In our opinion, says M. Blanche, it is a pure and simple hydropsy .\_Edinburg Med. Jour. from E Union Mc.dicale. Some Experiments on the Smoke of Tobacco. In Froriep's Journal, of a recent date, an interesting article has been published on the habit of tobacco smoking, and on poison- ing by nicotine. Amongst the facts there mentioned, are the ex- periments instituted by M. Malapert, a pharmacien of Poitiers. His intention was to ascertain the exact quantity of nicotine absorbed by smokers, in proportion to the weight of tobacco con- sumed. The apparatus used consisted of a stone jar, in which the tobac- co was made to burn, connected with a series of bottles commu- nicating by tubes. The bottles were either empty, or contained some water mixed or not with a little sulphuric acid. From a few experiments, it was found that, in the smoke of tobacco extracted by inspiration there is ten per cent, of nicotine. Thus, a man who smokes a cigar of the weight of seventy grains, receives in his mouth seven grains of nicotine mixed with a little watery vapour, tar, empyreumatic oil, &c. Although a large proportion of this nicotine is rejected, both by the smoke puffed from the mouth, and by the saliva, a portion of it is nevertheless taken up by the ves- sels of the buccal and laryngeal mucus membrane, circulated with the blood, and acts upon the brain. With those unaccustomed to the use of tobacco, the nicotine, when in contact with the latter organ, produces vertigo, nausea, headache, and somnolence; 110 On the Minute Structure of the Liver, &c. [February, whilst habitual smokers are merely thrown into a state of excite- ment, similar to that produced by moderate quantities of wine or tea. From further investigations it is found that the drier the tobacco the less nicotine reaches the mouth. A very dry cigar, whilst burning, yields a very small amount of watery vapour; the smoke cools rapidiy, and allows the condensation of the nicotine before it reaches the mouth. Hence it comes that the first half of a cigar smokes more mildly than the second, in which a certain amount of condensed watery vapour and nicotine, freed by the first, half, are deposited. The same remark applies to smoking tobacco in pipes, and if smokers were prudent, they would never consume but half a cigar or pipe, and throw away the other. Smoking through water, or with long tubes and small bowls, is also a pre- caution which should not be neglected. {London Lancet. On the Minute Structure of the Liver, and on the Nature of the Change known as Fatty Liver. By M. A. Lereboullet. From this elaborate prize essay, which occupies many pages, we -can only extract the author's summary of his observations on fatty liver. "1. The fatty degeneration of the liver is due to the accumula- tion of fat in the biliary cells themselves. 2. Special fatty cells are not formed, as biliary cells would then be found amidst the fatty ones, which is not the case. 3. Nothing authorizes us to admit that fat becomes developed in the interstices external to the cells. 4. The biliary cells may, by the accumulation of fat, acquire double or triple their normal volume, this development of the cells explaining the increased size of the fatty liver. 5. These cells entirely lose their secretory character, and no longer contain biliary granules ; the biliary secretion is obstructed, and the con- tracted gall-bladder contains but little bile. 6. The fatty degener- ation induces a decolorized state of the liver, which progresses from the periphery towards the centre of a lobule, giving the organ a spotted and reticulated appearance. 7. The decoloration arises from the development of the fatty cells compressing the portal vesicles, and impeding the circulation in them. 8. In the artificial fattening of geese, the liver only becomes loaded with fat after the other organs of the body, and especially the abdominal viscera, have become saturated with it. 9. The cells of the liver of fattened geese differ from pathological fat cells, inasmuch as the fat that fills the former always retains the form of distinct droplets, accumulated in the cell, to which they give an irregular appear- ance on distension ; while in the pathological cells the fat becomes united into larger and larger drops, until the cell is at last distend- ed by a single one like a balloon. 10. The fatty cells in the goose resemble, as regards the disposition of the fat in the interior, 1856.] A Sign of Congenital Syphilis, &c. Ill the physiological fatty cells of the foetus and those of the lower animals. 11. The nuclei of the normal cells, as well as the biliary granules, disappear when the fatty degeneration commences. 12. The degeneration takes place simultaneously throughout the or- gan, but all the fatty cells do not present the same degree of development. 13. This change of biliary into fatty cells is ob- served in tuberculosis, cancer, cirrhosis of the liver, &c. 14. The deposition of fat in the cells appears to be closely connected with a diminution of the nutritive process, and consequently of organic combustion, which is the primary condition of that process. When the quantity of oxygen absorbed is less than in the normal state (as in tuberculosis, cancer, and probably all diseases of nutrition); or, when the respiratory elements (fecula, &c.) are taken in too large proportions, the combustion of these substances is incom- plete, and the chemical elements which enter into their composi- tion combine so as to form fat, which is deposited in the biliary cells. [British and Foreign Med. Chir. Review. A Sign of Congenital Syp>hilis derived from a Special Alteration in the Lungs. By M. Depaul. M. Depaul, in the introductory remarks with which he prefaces his account of this new sign, observes that a mother undoubtedly healthy may become infected by an embryo deriving its diseased condition from the father at the time of fecundation. He also re- gards constitutional syphilis as a much more frequent cause of sterility than it is usually supposed to- be, and perhaps more espe- cially when it exists in the man than the woman. When it does not prevent fecundation, it may prove fatal to the infant at vari- ous periods of intra-uterine life, or after birth. When death is caused at an early period of pregnancy, no anatomical lesion capa- ble of accounting for this effect can usually be found ; but when the disease arrests gestation later, it generally leaves evident traces of its existence. The skin, of all the other organs, is that in which its presence is most commonly manifested, pemphigus being the most characterissic form of disease,, as long since pointed out by P. Dubois. In all but two or three of more than forty cases of pemphigus in infants, collected by M. Depaul, constitu- tional syphilis has been detected in one or both parents. His own observations have not shown him much with regard to the- intra-peritoneal lesions described by Simpson as syphilitic ; but he has met with cases in which traces of peritonitis co-existed with undoubted syphilitic lesions. He has several times found the fibro plastic deposit in the liver, described by Gublerr the children not usually dying until some time after birth, although contract- ing the disease in utero. He has also seen several examples of abscess of the thymus, regarded by M. P. Dubois, sinee 1837, as a pathognomonic sign of congenital syphilis. 112 On the Etiology of Epilepsy, &c. [February, In 1837, M. Depaul directed the attention of tlie Academie de Medicine to a change observed in the lungs of children born of syphilitic parents, viz: the dissemination of multiple collections of pus through them ; and in the fifteen years that have since elapsed, he has observed at least twenty such cases, the particulars of two of which are here given. Microscopical examination shows that these collections are not tubercular deposits ; and M. Depaul believes that it is highly probable that the cases of tubercle in new-born infants given by Billard, Baron, and Husson, were real- ly examples of this affection. It sometimes exhibits itself under the form of simple indurations, consisting of infiltrated pus, and at others of true abscesses, surrounded by more or less thickened walls. Formerly M. Depaul regarded these as the only two forms of the affection, but he has now several times met with another, which may be regarded as its first stage, and which consists in a greyish induration without pus, but attended with a deposit of a considerable quantity of fibro-plastic tissue. Sometimes the lesion occupies very circumscribed spots, but in other cases it is more generalized, invading several lobes. The pulmonary tissue is im- permeable to air, even after repeated insufflation. These different degrees of the lesion are not unfrequently met with in the same subject. There are also usually other S3q>hilitic lesions present, as pemphigus, abscess of the thymus, &c. Various circumstances influence the prognosis in congenital syphilis. When the skin is affected, although the life of the child be seriously menaced, if the nature of the disease be recognise powerless. The conclusion of the author is, that this salt bears no therapeutical pretentions in the intermittents of hot countries, and that there is much doubt of its capability of rendering any service in those of our own climate. [Archives Generals. Brit, and For. Medico- Chir. Review. Notes on the Application of Statistics, to Questions in Medical Science, particularly as to the External Causes of Diseases. By W. P. Alison, M D., Edin., D. C. L. Oxon., Emeritus Professor of I Practice of Medicine, Edinburgh.* It has so frequently and so plausibly been urged, against all the . inquiries and studies which are termed Statistics, that the form of jsuch reasoning may be applied to the support of almost any propo- sition, that it becomes an object of very considerable importance, . in the view of any one who is truly convinced of the importance f and frequent practical application of such inquiries, to point out the circumstancss of any question, or departments of any science, :in which this kind of information is truly requisite, and the con- ditions under which it may be trusted. This is especially true of the science of Medicine, because there is one great department of that science, that which we term Etiology, or the doctrine of the external causes of diseases, in which our knowledge is acquired almost entirely in this way. It is in very few cases only, that our knowledge of the essential or intimate nature, either of diseases or J of the powers in Nature which excite them, enables us to form I any anticipation of the effects of those powers ; and it is simply by empirical observation, facts observed and recorded, and the fre- quency of their recurrence noted, although not explained, i.e., it is by the mere force of numbers, or by statistics, whether stated exactly in that form or not, that our information on that subject, and practical rules for the prevention or treatment of diseases, founded on that formation, are acquired, I have elsewhere stated, f what seems to me to be sufficient rea- sons,for the application of Statistics to inquiries of this kind beino- more frequently and obviously required, than in any of those which are made, either into the nature of diseased actions (or of vital actions in general), or the power and mode of action of reme- dies. The questions which we propose to ourselves in Etiology are truly simpler than either in Pathology or Therapeutics, they in- * Read to the Statistical Section of the British Association at Glasgow, Sept. 1855 (by Sir Archibald Alison.) f British and Foreign Review, etc., January and April, 1854. 166 Notes on the Application of Statistics, &c. [March, volve little or no exercise of judgment, simply the observing and recording of facts, according to directions which are made known, and the sufficiency of which can easily, at any subsequent timer be estimated ; the sources of fallacy connected with them are less numerous ; and, more especially, we can usually remark this, as to the observations by which we can fix on those antecedents of a disease, to which we ascribe the power of producing it, that the positive observation, of the alleged effect following the application of the cause, is supported by a large body of negative observations, often not stated in words, but truly essential to the validity of the inference; and, therefore, this class of observations is often more truly and efficiently statistical, the number of individual eases really contributing to the result obtained, is very much greater,, and the evidence afforded more decisive, than it can easily be made in the other departments of medical inquiries ; sometimes,, therefore, greater than those who have accustomed themselves only to physiological or pathological inquiries, or to watching the ef- fects of remedies, can easily perceive. The importance of this observation will not be denied, when we remember that this is the department of Medical science which is truly of the greatest practical importance. The knowledge of the external causes of diseases, is that which leads most directly to their prevention ; and to the preservation of those lives especially,, from which the greatest amount of labor of all kinds may be ob- tained, and which are, therefore, generally regarded as most valu- able to a state. In the course of the present century, improvements have been made in Medicine, which will bear comparison in their practically beneficial tendency, with those which have made this age and this quarter of the globe so illustrious, as regards the applications of any other Sciences to practical purposes. These have been almost exclusively in this department of medicine, and may be truly said to rest, as yet, almost exclusively on Statistics ; anticipating, pro- bably by several ages, any information within the power of the human race, as to the intimate nature of the phenomena which are thus recorded. It is simply by the force of numbers, attesting the simple fact of a disease, easily recognised, showing itself in many persons within narrow limits of time and space, and there only, that we have learnt how the poison of Small-pox maybe diffused; and that it may be disarmed of its power over the human body, by being first taken into, and modified by its passage through, the body of the cow, and then applied, in almost infinitesimally small quantity, to the human body itself, and there exciting a certain specific inflammatory process, absolutely devoid of danger, and incapable of communication through the medium of the air, and, what is still more inconsistent with the knowledge we have of other changes in nature; that this modifying and preserving effect on the human body, produced in infancy, continues equally per- 1856.] Notes on the Application of Statistics, &c. 167 feet, in a great majority of cases, after 60, 70, or 80 years, if life shall continue so long, i. e., after we are certain that the body on which it has been produced, has been repeatedly worn down and built up again, so that the poison introduced into the structure in advanced life, can no more be said to come in contact with living matter which has gone throgh the process of vaccination in infancy, than, according to the paradox of an ancient logician, a man can be said to have bathed twice in the same water, because he has bathed twice in the same river. So also it has been simply empirical observation, and, therefore, by reference to statistics, that we have acquired within these few years, information touching the extension of another epidemic, less frequent, indeed, but attended with peculiar interest, and often with extreme fatality, the Puerperal fever, which enables us, with almost absolute certainty, to predict that its propagation, after the manner of an epidemic, may hereafter always be prevented. For, I believe, I may safely assert, that the statistical observations of Dr. Semmelweiss, in the great Lying-in Hospital at Vienna, where upwards of 6000 births take place in a year, being in exact ac- cordance with what has been seen in this country, have unequivo- cally shown : 1. That this disease is, in fact, a case of the Diffuse inflammation or Erysipelas, attended with the same peculiarities in the exten- sion of the inflammation, and in the nature of the effusion, and the same variation as to the nature of the accompanying fever in dif- ferent epidemics. 2. That one immediate exciting cause of this form of inflamma- tion, which may always be suspected when it prevails epidemically, is the cadaveric poison, often evolved, duriug the decomposition of the human body, from whatever cause death may have taken place; but during one stage of that decomposition only, viz., that early stage during which the post-mortem inspections for the inves- tigation of the cause of death are most frequently made. 3. That when this form of inflammation assumes the form of epidemic puerperal fever, the mode of its transmission from one patient to another, is by accoucheurs or nurses, themselves in good health, but to whose persons or clothes minute portions either of the effluvia from others already affected, or of this cadaveric poison, have become attached ; and, 4. That when the obvious precautions are taken, to prevent any persons to whom, in either of these ways, the poison can have thus adhered, from acting as accoucheurs or nurses until effectually pu- rified, no " epidemic extension" of puerperal fever is seen. It is seldom, no doubt, that this last proposition can be submit- ted to a searching scrutiny, as in the year 1846, at the Vienna Hospital, under Dr. Semmelweiss, when the number of deaths after these precautions were adopted, was diminished by no less than 400 in that hospital alone, and in a single year ; but when it is 168 Notes on tlxe Application of Statistics, dec. [March, added, that each of the propositions above stated is quite in ac- cordance with observations made and recorded (although the bond of connection among them had unfortunately not been duly ob- served) in this country, whenever puerperal fever has been epi- demic, whether on a large or small scale, so that it would be easy to collect statistical evidence of the same kind from every such epidemic, wherever any record of the facts has been left, to estab- lish each of these propositions, the force of this statistical evi- dence becomes such as to justify the sanguine anticipation above announced. Our information as to the mode of extension of the malignant Cholera, is, unfortunately, as yet less certain or precise ; yet I think we may saj' it is so far advanced, that we may entertain a confident hope of its being very soon such as to disarm any epidemic cholera, in this climate, at least, of all its terrors. I allude to that subject here, chieffy because I think it affords an example worthy of notice, of what I have already stated, as to the frequent misapprehension of the strength of evidence, simply empirical, or founded on statistics, which may often be obtained in inquiries of this kind. I mentioned formerly in a paper on this subject, which I had the honour of laying before this Association at Birmingham, a single case which I saw in the year 1832, and which I have always maintained to have been sufficient, for any one who duly attended to the statistical evidence it afforded, to establish the proposition, that the disease is capable of propagation in this climate, by the intercourse of the sick with the healthy, without pledging us to any opinion as to the mode of communication, or as to the exist- ence of other modes. Now that it is generally admitted, that the assertion then made was correct, the question for discussion now being (as stated by the Editor of the British and Foreign Medical Beview) " not whether cholera is contagious or not, but how often it spreads by Hue agency of human bodies (i. e, by contagion), and h< >\\ often without that agency," (Journal for January, 1854, p, 298.) I think myself justified in drawing attention to the grounds on which it was made; and which, I still think, amply sufficient to establish that mode of communication, without, of course, exclud- ing others. The reason of this strong expression of opinion was, that the case furnished a remarkable example of the evidence which, ac- cording to what was formerly stated, a single positive fact may afford, quite of the nature of the instantia cruris, when supported by a large body of negative observations. The anxious expecta- tion of the disease in the town, in 1832, the careful division of the town into districts, and appointing of stations and medical men to each, and the number, zeal, and intelligence of these observers, were known to be such as to justify our sa}dng, that this was the very first case of the disease which ever originated in Edinburgh 1856.] Notes on ie Application of Statistics, &x. 169 or Leitli, in a person who had not left the town; and that for a time it was an isolated ease, no other appearing for ten days, in a population of above 140,000 persons, many of whom were in -cir- cumstances, in all other respects at least, equally favorable to the appearance of Cholera, as this woman was; as the subsequent appearance of the disease in many of them, during nearly a year that the disease afterwards existed in Edinburgh, proved. If the poison producing this " nova pestis" had no contagious property, this woman was not more exposed to it than any other of this large body of people ; but if it had that property in whatever other way it might be communicated, she was undeniably and peculiarly exposed, as she was engaged in nursing her son, in a close confined room, who was ill of the symptoms of cholera, du- ring the whole of the day preceding that in which she sickened and died ; and he had passed the next preceding night in a house j in Musselburgh, where patients in the malignant disease then were, and had been for weeks previously. Here, then, was a fair instan- i tia cruris, to determine whether the transmission of the disease, from place to place, known to be at that time a frequent event, was or was not dependent on intercourse of healthy persons, with those previously sick of it ; and the affection of this one person, i who had that intercourse, contrasted with the non-appearance of the disease inl-10,000 was, as I maintain, decisive evidence- Many cases, equally decisive, have since occurred, of which I have been informed, on the first appearance of a disease previously i unlcnoiun in a town or district, carefully observed ; e. g., at Ar- broath in 1853, where there was clear proof that the two first per- j sons of 15,000 inhabitants of that town, who took Cholera, "had . just returned from Dundee, where they had visited persons ill of cholera ;" their affection, therefore, proves nothing as to the effica- j cy of intercourse with the sick, in exciting the disease, rather than j merely visiting a particular locality; but the next six who took J it in Arbroath, the first six inhabitants of that town who took j cholera without leaving the town, had repeated and close inter- ;j course with those already affected before they took it ; and the j inference as to the contagious property is drawn, not from their n taking the disease, nor even from their taking it at that time, and in rapid succession, but from their being the only inhabitants of : Arbroath who took it, during the first week of its existence in that | town ; i. e., the positive evidence of the six who were known to ,' be exposed to that cause, is supported by the negative evidence of y the fifteen thousand who could not be shown to be, and the immense .! majority of whom certainly were not, so exposed. L I have great hopes that we shall soon have statistical evidence (i to establish a proposition which no other evidence known to us , could justify our admitting, but which, if established, would not jj only reconcile most of the conflicting statements on this subject, . but serve as a guide to almost complete security from any epidem- 170 Notes on the Application of Statistics, &c. [March, ics of this disease in future ; viz., that the poison of cholera, like oilier known animal poisons, is developed during the decomposition of the animal matter, the appearance of which is most characteris- tic of the disease, that which constitutes the " rice-water stools" but only in a particular stage of that decomposition, not immedi- ately after its formation in, or discharge from, the body; and again, not after the decomposition has gone to a certain length. All this can be proved only by Statistics, but is quite susceptible of proof in that way. The last proposition above stated that no poisonous property is attached to any part of a bod}r dead of cho- lera, after a certain stage of decomposition has been passed, seems nearly ascertained from the number of instances in which dissect- ing-rooms have been supplied with bodies of persons dead of cholera, for many weeks together, without any of the students at- tending them being affected. That the peculiar matter of the cholera evacuations, during its decomposition, perhaps especially in dry air, has a peculiarly poisonous quality, was, I believe, first suspected by Liebig, and partly by the analogy of the poison already mentioned, causing erysipelatous inflammation and puer- peral iever, and also of the sausage poison, repeatedly observed on a large scale in Germany, which is developed during a certain stage of the decomposition of the animal matter of those sausages, and disappears when their putrefaction has so far advanced. That the cholera can be communicated to animals by inoculation with this matter, of the peculiar rice-water stools, has been sufficiently proved by the experiments of Dr. Lindsay in this country ; and if a few more experiments shall give results similar to those of M. Thiersch, at Munich, I think we may assert that the proposition above stated, is statistically proved. "Dr. Thiersch collected the intestinal contents, or the evacuations, of cholera patients, and let them decompose under the influence of air and heat. From day to day he dipped into this matter pieces of filtering paper, which he dried, for subsequent experiments on white mice. Two of these animals at a time were exposed to infection for four days, by hav- ing a square inch of the filtering paper, thus prepared, moistened with water and mixed with their food. Each mouse took thus 1-2000 th gr. daily. The results were as follows: The prepara- tions from the matter during the first day of decomposition were innocuous. To this succeeded a period of from six to nine days, during which decomposition went on, and preparations from the matter in this second period of decomposition, caused disease in 30 out of 34 animals, and death in 12 of the 34. The symptoms were peculiar and characteristic. The hair fell off, the ears dropped, there was languor, then discharge from the bowels, first of white, then wateiw matter, the urine lost its smell, then was suppressed, 1he appetite became depraved, so that the animals would fill their stomachs with wool ; there was no apparent sickness, but such tonic muscular contractions that they seemed dead some time be- 1856.] Notes on the Application of Statistics, &c. 171 fore death. On dissection, accumulation of blood in the vessels of the small intestines was invariably found, their contents watery, with abundant epithelial flakes (just similar to those found in per- sons dead of cholera); the cortical substance of the kidneys passing into fatty degeneration, the bladder empty, the blood and the contents of the intestines answering to the test of ready mix- ture with amygdaliu, as in the cholera of man, which will not appear in the healthy animal. To this a third period of decom- position of the matter under trial succeeded, in which these poi- sonous effects were very slight, or not observed at all." (See Med. Times and Gazette, Nov. 25, 1854.) We have already a statement by Dr. Budd, of statistical obser- vations made on villages in England, where the entrance of Cholera appeared to be prevented by such expedients as these observations immediately suggest, for receiving the rice-water evacuations of cholera patients on linen or cotton, and burying or burning, or otherwise effectually destroying their substance, du- ring that period, thus indicated, after they have been passed, and before they have entered on the morbific decomposition ; and we have sufficient statistical evidence of the importance of another measure, which was first adopted, I believe, at Edinburgh, in 1832, and has since been recommended by the Board of Health in London, and adopted in different places, although not so generally or satisfactorily as could be wished, founded on the merely em- pirical statements I have made as to the communication of the disease from the sick to the healthy, and its apparent adhesion to particular, often very limited, localities, viz., the establishment of houses of refuge for the reception of all inhabitants of houses or rooms which might become infected with cholera in any town ; not themselves affected, nor required for the care of the first cases that might occur. Here such persons might be lodged in pure air, regularly fed, preserved from cold and from other (frequently concurrent) exciting causes of the disease, and treated with due attention to cleanliness, immediately on any symptoms of cholera showing themselves. The London Board of Health report, that they had information of 1691 persons taken into these houses of refuge, from rooms where there were patients in cholera, and of these, only 33 became affected with cholera, and only 10 died. In cases of which I was myself informed, in Edinburgh, at Glasgow, and at Oxford, during different epidemics, 1010 persons were ad- mitted from sick rooms into such houses of refuge, of whom 40 took the disease, and 15 died ; whereas the experience of Dr. Ham- ilton of Falkirk, of 251 cases of cholera appearing in 86 houses, where no such means of separation existed, gives only a fair idea of the extent to which successions of cases will often be observed, in confined air and dirty districts, possessing no such resource. I am happy to say, that so far back as November last, having written to Dr. A, Smith, at the head of the medical department of 172 Notes on the Application of Statistics, &c. [March, the army, on the subject of the decomposition of the rice-water stools, as the probable cause of the propagation of cholera, and of districts becoming tainted with the poison of that disease, I was informed by him that he had directed the attention of the medical officers in the Crimea to the facts now stated, so that if the disease shall appear in a malignant form in that army, we may hope for at least accurate and truly statistical information as to the reality of that opinion. Again, as to the Yellow fever, so frequently becoming epidemic in the hot climates, although we cannot boast of having acquired informatton either as to the nature of its cause, the essential char- acter of the morbid change it produces, or the power of any remedy over it^ yet by simply empirical observations, i. e., hy Statistics, we have information to the following effect, as stated in reports in Germany and France, on inquiries conducted by order of those governments, on a large scale, and considered by committees con- taining the names of Humboldt and Dupuytren, that it is a disease endemic, almost exclusively, "in districts nearly on the level of the sea, never appearing beyond 48 of north latitude, nor without a previous temperature of 72, only in certain circumstances pro- pagated by contagion," but when epidemic, always confined strictly to certain localities; so that the practical rule of immediately evacu- ating, i. e., removing all the inhabitants of places where it is de- clared to exist, and has formerly prevailed, is incontestable, and "of such proved utility, as will always justify its rigorous execu- tion." Without dwelling farther on the effects of Malaria, in this or any other climate, which we can only expect to be satisfactorily explained when pathology shall be considerably more advanced than at present, I may merely add, that such collections of facts have been made, and are now frequently repeated, as to the pla- ces and circumstances in which it arises from the earth, and the laws according to which it extends and multiplies, considered merely empirically or statistically, as we may confidently expect to be successful in disarming this cause of disease likewise of its terrors, long before the nature of the change produced by its ac- tion on the living body, or the rationale of any line of treatment of those who may be affected with it, shall become known. The cure of Epidemic Scurvy, resulting in different cases, as is now satisfactorily established, from different deficiencies in the Diet habitually taken, the efficacy, therefore, of different kinds of diet in counteracting this form of disease, still more remarka- bly, the power of small quantities of vegetable Acids in producing the same effect, and the extraordinary rapidity with which such changes of diet, and these acids, will produce their effect, may also be stated as examples, on a large scale, and of the most satis- factory kind, of what is generally called the power of Art over a most loathsome and virulent disease, but in reality must be re- 1856.] Discoveries of the Functions of the Spinal Marrow. 173 garded now, and probably long after our time, as results obtained by simply empirical observations of the course of Nature, statisti- cally arranged, fortunately facilitated by so many of the subjects being organised bodies of men ; and which have distinguished the present age to a degree, which those who are not familiar with the medical writings of the last century will hardly conceive. We have good reason to hope, that inquiries now on foot as to the external causes of Scrofulous, or what is now usually called Tubercular disease, including pulmonary Consumption, an in- quiry which we must perceive to be more complex, and in which the operation of various causes must be recognised, will be effect- ual in pointing out the means of counteracting that tendency in a very large proportion of cases of persons liable to it, simply on the principle of empirical observation, enlarged and arranged in the form of Statistics, long before we shall have information as to the essential nature of the vital process, or mode of operation of the causes in question. In illustration of this, I need only mention two facts, recently ascertained on so large a scale, that we have no doubt of their truth and importance, and which, even at present, may be said to be guides to successful practice in many cases only recently thought hopeless, although all that was previously known on the subject was certainly rather adverse than favorable to the supposition that they would ever be established. These are,' 1. The good effect of the Cod-liver oil if not of other animal Oils, on many cases of tubercular disease, in their early stage provided only that it can be retained on the stomach to the extent of an ounce and a half or two ounces daily; and, 2. The almost complete exemption of the inhabitants of the Faro Islands from tubercular disease, not- withstanding that their climate, as regards cold and damp, is ex- actly that which, in this country, has been thought most favorable to it. [Edinburgh Med. and Surg. Journal. M. Brown- Sequard,s Discoveries of the Functions of the Spinal Marrow. Seldom has the scientific world been taken more by surprise than when M. Brown-Sequard announced his recent discoveries relative to the functions of the spinal marrow. Whatever may be wanting to complete our knowledge of the action of this por- tion of the nervous system, the brilliant investigations of Sir Charles Bell seemed to have set at rest forever the question as to the particular fibres which communicate motion to the muscles, and sensation to the brain. The theory of Bell, in a few words, is as follows : " The spinal cord has two functions, relative to the two substances of which it is composed. It serves as an indepen- dent organ, detached from the brain, for the performance of reflex actions, a property which it owes to the grey matter contained in 171 Discoveries of the Functions of (lie Spinal Marrow. [March, its centre. By the white substance it acts as a medium of com- munication between the brain and the parts to which the nerves are distributed, the posterior columns conveying sensations upwards, and the anterior and lateral columns transmitting the power of motion in a downvjard direction. This theory was less the result of experiments upon living animals, than of a process of reason- ing, Sir Chaiiesliaving always manifested a strong repugnance to vivisections. M. Longet, however, demonstrated, by the applica- tion of galvanism to sections of the spinal marrow of animals, that irritation of the posterior columns caused no movement, while that of the anterior columns occasioned no pain. On the contrary the galvanic current caused extreme pain when applied to the posterior columns above the transverse section of the medulla, and excited movements when directed through the anterior col- umns of the lower segment. The grey matter was found to be insensible to the irritation of electricity. The theory of Bell, so remarkable for its simplicity and apparently so perfectly support- ed by the demonstrations of one of the most eminent experimental physiologists, could not fail of universal adoption, and although pathological facts were occasionally made known which appeared to contradict, to some extent, its conclusions, it seemed natural to believe that these were inaccurately reported. It will be observed, that in the experiments of M. Longet, the spinal cord was always completely cut across. We may not un- reasonably ask whether the organ thus divided is in the same con- dition for transmitting sensation and the power of motion, as when its continuity is in a great part preserved, and why this method of experimenting was employed, instead of cutting through each portion in succession, and observing the effect pro- duced upon the function attributed to that part? In reply to the latter inquiry, M. Longet states that the operation of laying bare the spinal marrow, and evacuating the fluid which is contained in the cavity of the arachnoid, is always followed by paralysis, both of sensation and motion, of the posterior extremities, thereby ren- dering further investigation impossible. Here was the great ob- stacle to researches in the functions of the spinal cord, and the removal of this obstacle was the first step taken by M. Brown- Sequard. He ascertained that the nervous disturbance following the opening of the spinal canal was caused by the loss of blood and by the pain and shock consequent upon the operation. By operating in such a manner as to prevent a great flow of blood, and by allowing the animal time to recover from the depressing effects of the operation, he found that both sensation and motion returned to the posterior extremities in almost, if not quite, their original degree. Thus enabled to experiment upon the cord in a normal state (as far as its functions were concerned), he proceeded to isolate va- rious portions of the different columns by sections made with ex- 1856.] On Chalk Metastases, 175 treme care, and demonstrated a series of laws relative to the spinal functions, the principal of which are the following: 1. The posterior columns may be divided without destruction either of sensation or motion. 2. Sensation and motion are destroyed when the grey substance is cut across. 3. Integrity of the antero-lateral columns docs not interfere with the loss of motion, nor does integrity of the posterior columns prevent loss of sensation. 4. Division of the posterior fibres of the cord., so far from abol- ishing sensation in the parts to which these fibres are distributed,, appears, on the contrary, greatly to increase it. 5. When the posterior columns are divided, sensation continues to be transmitted between the lower portion and the grey sub- stance, which transmits the impression to the sensorium by means of fibres descending from the upper portion, and joining obliquely the grey substance below the point where the section is made. Our limits forbid us to detail the experiments upon which the above conclusions are founded. They have been repeated over and over again with the same results, in the presence of a com- mittee appointed by the Societe de Biologie, consisting of MM. Claude Bernard, Bouley, Broca, Giraldes, Goubaux and Vulpian, to whom was referred M. Brown-Sequard's memoir, and who were entirely satisfied with his conclusions. The interesting report which they made to the Society is the most convincing evidence of M. Brown-Sequard's skill as an experimenter and his eminence as a physiologist. [Boston Medical and Surg. Journ. On Chalk Metastases (Kalk Meiastasen). By BuDOLPH VlRCHOwV (Virchow's Archiv fur Pathologische Anatomie, &c.) Some years ago Professor Virchow performed the post-mortem of a young lady whose case had thoroughly puzzled all the lead- ing physicians of Berlin. She had complained of pains throughout the body, but these, Avhich were attributed to rheumatism, had resisted all the means employed for its removal. After death nu- merous and large nodes of cancer were found in almost all the large bones, occupying cavities of a corresponding size in the osseous tissue, and no where rising above the level of the bone. A large quantity of white sandy deposit was found in the calyces and pelvis of the kidneys, and on dividing the lungs considerable deposits of a hard greyish white substance were found, and a simi- lar deposit occupied the mucous membrane of the stomach. The salts which had been absorbed in consequence of the caneerous deposits in the bone appeared to have found a fresh nidus in the kidneys, lungs, and stomach. Professor Virchow has recently met with four similar cases ; the following is a brief abstract of the 176 On ChaVn 3Ie(astases. [March, characteristic features found on cadaveric inspection. It may be premised that in all four there was evidence of recent degenera- tive nephritis, in the second or third stage of the disease, in that period at which the disturbance of the secretion is greatest ; a point upon which Professor Virchow lays great stress, as he attributes the chalky deposit to impeded secretion of the urine. In the first, a maid-servant, aged forty -threer the upper lobe of the left lung exhibited posteriorly a hard spot, the size of a nut, on section yel- lowish white, dry and friable, which proved to be chalky infiltra- tion. Similar smaller spots were disseminated through the lung. The second case occurred in a girl, aged fifteen, who presented a large mass of sarcoma, which had perforated the temporal bonus from without inwards. The right parietal bone was occupied by a similar growth ; the posterior part of the inferior lobe of the right lung presented several dense, dry, hard nodes of chalky infiltration. In the third case, a young man of nineteen years, who died of necrosis of the left femur, the mucous membrane of the stomach was found infiltrated with calcareous matter. The fourth case oc- curred in a man, aged seventy-three, who had labored imder a cancroid affection of the lip, of the clavicles, and several ribs, and died of gangrene of the lung. Here the lungS' exhibited, in addi- tion to spots of cancroid disease and gangrene, dense calcareous infiltration in a part that was very emphysematous, so that the septa of the tissue resembled hard spicule, and the inner surface of the pleura was invested with thick deposits. The last three cases resembled that of the young lady in Berlin in regard to the co-existence of extensive bone disease. In the first there was no apparent source from which the lime salts could be derived, but the bones were not especially examined. The chalky infiltration of the mucous membrane of the stomach, which is noted in two cases, deserves a little further attention. In both, the altered parts were altered in appearance and to the touch. They appeared opaque, whitish, more or less spotted, feeling dry and resistant; in the first case observed the tissues' crepitated on section. The microscope demonstrated a fine granular deposit (blackish by transmitted, white by reflected, light), external to the follicular structures, which would probably mean that a portion of the glandular tissue had been absorbed to make way for the deposit. Acids dissolved the granules, and caused an evolution of carbonic acid gas ; after the application of sulphuric acid, sulphate of lime crystals formed. The co-existence of extensive disease of the bones with extensive ossification of the vessels of the medullary portion of the brain, in the case of a young man aged twenty-six, is also quoted in illustration of the view advocated by Professor Virchow. Professor Virchow was of opinion that in these cases he had to deal with a direct cretification of the tissues, bearing, as he thinks, very materially upon the doctrine of metastases, on which account 1856.] Healing of Abscesses. 177 he has selected the title for his paper that we have placed at the head of this notice. [British and Foreign Med. Chir. Rev. On the Healing of Abscesses by the First Intention. By M. CHAS- SAIGNAC. M. Chassaignac has for some time past endeavoured to unite abscesses by the first intention, after their complete evacuation ; and he reports that his success has been very considerable. His method of procedure may be judged of by the narration of a case which recently occurred at the Lariboisiere Hospital and was observed by all who attend there. A healthy man, aged 19, was admitted February 17th, presenting all the symptoms of an acute abscess of the axilla, which had been about a week in forming. On the 19th, chloroform having been given, a considerable quan- tity of well-conditioned pus was discharged by the bistoury, pres- sure being exercised in all directions for the purpose of securing complete evacuation. The cavity of the abscess was next tho- roughly washed out with water introduced through the tube of an irrigator, in order to bring away any remaining pus, the injection being continued until the water returned completely limpid. Pressure was again employed to force out every drop of the water, and the orifice was strapped up. A large pad of charpie was in- troduced into the axilla in order to make pressure over that region, and the arm was confined in one of Mayor's bandages, as if for fracture of the clavicle. On the 21st cicatrization was complete, no discharge of pus whatever being visible. The bandage was continued as a matter of precaution for two or three days, and then the arm was allowed to hang down, no pain being reproduced. In the site of the abscess a little indurated spot could be felt. On the 27th he was discharged quite well. \_Oaz. des Hop., and lb. \ On the Removal of Articular Bodies by the Subcutaneous Section. By M. Chassaignac. The author prefers this designation to that of loose cartilages, as prejudging in nowise the nature of the bodies. In the present pa- per he relates two cases in which the operation devised by M. Goyraud of Aix was performed with success. This consists in opening the joint by the subcutaneous section, and forcing the articular body through the track of the incision into the cellular ,. tissue, and leaving it there for future removal. The following are the conclusions the observations of these and other cases have in- duced M. Chassaignac to arrive at :. 1. The pain, which is indu- i ced by the pinching exerted by the surfaces between which they j are compressed, is not felt when the bodies are voluminous. 2. ; The character of this sudden pain is not pathognomonic, pain quite : similar to it accompanying certain invasions of rheumatism or gout, 178 Hemostatic Agents. [March, and the dislocation of the semi-lunar cartilages. 8. Our diagnosis may be at fault from our mistaking the slipping of the fingers over the walls of the articular sac for the displacement of a mobile body a mistake that may far more easily occur than would be supposed. We have also to distinguish these bodies from partial indurations of the capsule, and from inequalities of the edges of the osseous articular extremities. 4. Among the concomitant af- fections that may be produced by the presence of these bodies are hydrarthrosis and anclrylosis. 5. Although when hydrarthrosis produces great tension it is an obstacle to our diagnostical exam- ination, a moderate repletion of the capsule favours the explora- tion. 6. The place of election for the operation on the knee-joint is the lower cul-de-sac of the synovial membrane on the inner side. 7. Before commencing any operation, small articular bodies must be previously fixed by acupuncture, as there is always great dan- ger of their escaping at the moment of operating. 8. When these bodies are multiple, we should collect them all at one point, so as to expel them by a single operation. Still, where one or two es- cape us, the operation does not always fail. 9. Articular bodies left under the skin for a considerable period, undergo a great diminution, so that a secondary operation for their removal is not always required. 10. So important is it to avoid suppurative in- flammation after the operation, that leeches should be freely appli- ed at the root of the limb, both as a preventive and curative measure. 11. Angioleucitis is- the species of inflammation mos-t to be dreaded after operation upon the knee. 12. In expelling the foreign body from the joint, we should endeavour that its course should be made as long as possible, experience showing that in such cases a portion of the track may stippurate with impunity, or at all events without the pus invading the cavity of the joint. [Revue Med. Chirurg., and Ih, Comparative Value of the Different Hemostatic Agents.- A correspondent sends us the following translation, which we publish as conveying valuable information upon an important sub- ject. [Boston Med. and Surg. Journal. The Gazette des Hopitaux of Sept. 29th, in an article on the comparative value of different substances as means of arresting haemoptysis, after remarking that bleeding for this purpose has deservedly fallen into general disfavor, alludes to the clinical re- searches of Dr. Aran, published in the Bulletin Gen. de Therapeu- tique, and gives a resume of the interesting and valuable results to which he had arrived. We translate passages which seem to us of considerable value. M. Aran has successively tried agents belonging to the class of haemostatics, properly so called, such as resinous substances, the ergot of rye and common salt ; then astringents acetate of lead, 1856.] Haemostatic Agents. 179 alum, eau de Babel, tannin, and gallic acid; nauseantsand emetics ipecac, tartar emetic, veratrine ; and sedatives of the circulation nitre and digitalis. Of the agents belonging to the first group, hemostatics proper, the essence of turpentine has seemed to M. Aran especially to de- serve the attention of physicians. He has prescribed it pure, in doses of from ten to thirty drops, in a glass of water, or made up into a bolus with magnesia, and taken enveloped in moistened wafer {pain d chanter). Generally within a few hours after the patient commences taking it, there is a very marked diminution in the amount of the hemorrhage, and in twenty-four or thirty-six hours at the most, it is reduced to a very small quantity or entire- ly ceases. On the other hand, M. Aran is convinced, as many English and German physicians have already proved, that the essence of turpentine is less suitable in hemoptysis, with a tenden- cy to inflammatory action within the chest, a febrile movement, or when it occurs in young or rather plethoric subjects, than when it happens in debilitated, cachectic subjects, with characters of pas- sivity or atony. Ergot of rye and the ergotine ofM. Bonjean, have shown much less efficacy against hemoptysis than essence of turpentine. The former, even, when given in a very large dose, has seemed to ex- ert only the most moderate influence upon the hemorrhage. The same is not the case with chloride of sodium or common salt, which has been proved to possess an undoubted efficacy in doses of from sixty to one hundred and fifty grains taken in the course of a few hours in solution, or in the form of powder. It is particularly deserving of recommendation in such cases, as it is constantly at hand. Among the astringents, M. Aran has found none worthy of confidence except tannin and gallic acid. Gallic acid seems to him preferable to tannin, as, with the same styptic properties, it has not the same drying action upon the tissues, and does not produce the obstinate constipation which occurs when the latter is employed. The medium close of gallic acid, as he administered it, was, from ten to twelve grains in twenty-four hours, in powders of two grains each, given at intervals of two hours. M. Aran acknowledges the power of nauseants and emetics to arrest hemoptysis, such as tartar emetic, ipecac and veratrine. With regard to the first two this property has been known for a long time. As for veratrine, in three cases in which it has been prescribed, the hemoptysis was arrested as if by enchantment as soon as nausea and vomiting took place. These agents would de- serve, then, to be placed in the first rank of hemostatics, if there were not others of equal efficacy, which do not produce nausea and vomiting, effects which are always painful or disagreeable to the patient. Nitre and digitalis have been equally, and with good reason, N. S. VOL. XII. NO. III. 12 180 Hcemostalic Agents. [March, extolled in this case by the name of sedatives to the circulatory system. Following the example ot Schmidtmann, who conceived the idea of combining sea salt with digitalis to combat haemopty- sis, M. Aran, for the same purpose, combined digitalis and nitre. This mixture, it appears, produced very remarkable results. In ordinary cases he gave in the course of twenty-four hours four grains and a half of digitalis and twenty-three grains of nitre in four powders. But when the hemorrhage was very profuse the quantity of nitre was carried as high as thirty-eight grains, and that of digitalis to eight or even twelve grains ; in some very grave cases the quantity of digitalis given was carried to twenty- three grains, and of nitre to sixty grains. A remarkable circum- stance noticed was, that when these remedies were given in this quantity the system was not affected in any unfavorable manner; the pulse did not suddenly abate in frequency, nor was there a very abundant diuresis. On the other hand, the effect upon the haemoptysis was most marked ; in a few hours the flow of blood was considerably reduced, and often after twenty-four or thirty -six hours there remained only a little bloody expectoration. The diminution of the hemorrhage was generally accompanied by a great calm. Nevertheless M. Aran observed that never, after the administration of essence of nitre and digitalis, was the arrest of hemorrhage so sudden as after the administration of turpentine or gallic acid. M. Aran sums up his opinion of the respective value of the dif- ferent agents in question, in the following words ; In profuse haemoptysis, but not immediately threatening life, the physician may take his choice of either of the precediug remedies. In very profuse haemoptysis, on the contrary, where it is necessary to ar- rest the bleeding as soon as possible, and by means the least likely to depress the system, the physician cannot trust the tardy reme- dies. Neither the ergot, nor sugar of lead,, nor eau de Rabel, nor alum, nor rhatany, &c, will be equal to the emergency. Only turpentine, gallic acid in a large dose, salt, nitre combined with digitalis, can be employed with success; but the necessity of pro- portioning the dose of the medicine to the intensity of the hemor- rhage, in administering the chloride of sodium, but particularly the nitre and digitalis, is productive of great inconvenience; the danger of too great a depression from too large a dose, or from too long a continuance of the remedy. " It is then to gallic acid and to turpentine that I give the pre- ference in these grave cases ; yet, under the apprehension of their insufficiency, I do not think the physician should limit himself to their use. It is under such circumstances that bandages applied to the limbs, which are very useful in other kinds of hemorrhage, and ice applied to the chest, have saved the life that was in dan- ger, by stopping the hemorrhage for the moment, and allowing the internal remedies to complete the work." A. 1856.] Methodical Cauterization. 181 On Methodical Cauterization of Abnormal Divisions of certain Or- gans. By M. Jules Cloquet. In two memoirs recently read at the Academie des Sciences, M. Cloquet furnishes some account of his mode of cauterizing fis- sures and fistulous openings, founded upon the observation of the powerful contractile effects exerted by cicatrical tissues acting at the angles of wounds caused by burns. He adopted it first in the case of fissure of the velum palati. The object was not to cauterize the entire extent of the edges of the division, and bring the granu- lating surfaces into contact by means of sutures and apparatus a plan long tried, sometimes succeeding, but oftener failing. The caustic is applied over a very limited surface, at the exact angle of the fissure; and, after the cicatrical tissue, which results has had time to produce its retractile effect, the caustic is again applied to the angle of the remainder of the division. The application is re- pealed again and again, at intervals, so that the fissured parts are thus brought towards each other bit by bit, and united by a series of cauterizations that may be regarded as so many points of suc- cessive suture. The operations for this infirmity, devised by Grafe and Roux, are difficult of execution, and not infrequently fail in success. M. Cloquet first put his plan into execution in a case in which the whole left side of the palate was fissured as a result of syphilitic ulceration. From eighteen to twenty cauterizations with the acid nitrate of mercury sufficed to effect a complete reunion. In another case of congenital fissure, the patient had already been operated upon by Roux's method, but violent coughing had caused the sutures to tear through. Successive cauterizations firmly uni- ted one-half of the fissure, with which the patient was satisfied, and refused to persevere. In a third case, M. Nelaton healed a traumatic division by a similar employment of the electric cautery. In 1851, a congenital fissure existing in a child eleven years old, was completely closed after twenty applications. In all these cases the pain was slight, no change had to be imposed in the regimen or mode of life, and no accidents resulted. Even unpractised sur- geons may perform so simple an operation without the aid of an assistant. It is slow in the production of its results, but this is one of the conditions of its success, and is of little consequence, as it does not interfere with the business of life. M. Cloquet thinks the actual cautery is the best means to employ, but for patients who dread this the electric cautry may be substituted. Another affection usually intractable is recto-vaginal fistula, and encouraged by the above success, M. Cloquet applied successive cauterization to its management. The index finger, guarded against the heated body, is introduced into the rectum, and, the external parts, being held open, the apex of the fissure is touched by a small cautery, the patient being able to at once get up and pursue her occupations as before. The pain and inconvenience of the 182 Synopsis of Thirty Cases of Ovariotomy. [March, application are so slight, that the women readily submit to it. A more considerable amount of union is produced by the early cau- terizations than by those made later, so that the complete cure becomes tedious a less inconvenience from the fact that the most serious consequences of the infirmity disappear after the early cau- terizations. [Gazette Medicate. [M. Cloquet refers to but six cases of cure of this fistula, and to six of fissured palate : and we cannot but feel surprised that a pro- cedure known by him since 1826 so easy of execution and so fertile in success as he states it to be, does not exhibit more abund- ant results.] Ed. Brit, and For. Med. Chir. Rev. Synopsis of Tlxirty Cases of Ovariotomy. Performed by Washing- ton L. Atlee, M.D., Philadelphia. Dr. Washington Atlee gives a summary of all the cases, thirty in number, in which he has performed the operation of ovariotomy. Such an assemblage of facts constitutes a valuable contribution to the history of this subject. We can only give a condensed view of the leading facts. Case. Died. Recovered. Tumour found. Operation completed. 1. Sixth day peritonitis .. Double ovarian . Yes. 2. .. Yes .. Fibrous extra-uterine, Yes. 8. .. Yes .. Ovarian, fibrous Yes. 4. Six months erysipelas .. Uterine No. 5. .. Yes .. Cystiform Yes. 6. In 3% years, from progress of disease .. Yes .. Uterine No. 7. Thrty-nine days after, of cholera, caused ) Vo i?^,,. . i.. v, w ;,. ,i,,\, I - *es Extra-uterine fibrous. les. by eating duck . j 8. Sixth day peritonitis .. Cystiform Yes. 9. Third day exhaustion .. Cystiform Partly 10. Third day exhaustion .. Cystiform Yes. 11. .. Yes .. Uterine No. 12. .. Yes .. Cystiform : .. Yes. 13. .. Yes .. Cystiform Yes. 14. Pregnant two months at time of opera- I _ B fe] tiform Yes. tion ; died in 30 days of exhaustion. ) J 15. Third day peritonitis .. Cystiform Yes. 16. Third day haemorrhage .. Extra uterine fibrous Yes. 17. Yes .. Extra-uterine fibrous No. 18. .. Yes .. Cystiform Yes. 19. Thirteen hours exhaustion .. Cystiform . Yes. 20. Nine hours exhaustion .. Ovarian Yes. 21. Third day peritonitis .. Three fibrous extra uterine Yes. 22. Cystiform Yes. 23. 22 days gangrene of jejunum .. Cystiform Yea. 24. .. Yes .. Cystiform Yes. 25. Fifth day exhaustion .. Cystiform Yes. 26. Cystiform Yes. 27. Fifth day-hamorrhage .. - .- { ^^*^.fo:** } Yes" 28. - Yes .. Cystiform Yes. 29. Sixth day haemorrhage .. Cystiform Ye8. 80. Yes ... Cystiform Yes. From the tabular statement we have thus constructed, it appears, that out of 30 cases in which the operation for ovariotomy was un- dertaken, ovarian tumours were found in 22 cases, and fibrous tumours of the uterus in 8 cases ; that in 4 cases the operation was abandoned, in as far as related to the object of the operation the removal of the tumour ; that 13 cases only recovered with life, in 2 of these the tumour being left behind ;, that in 17 cases the pa- 1856.] Epithelial and Villous Growths. 183 tient died, at intervals of from nine hours to thirty days after the operation, with the exception of one that survived six months. The causes of death were in 3 cases, haemorrhage; in 6, exhaus- tion; in 4, peritonitis ; in 1, gangrene of jejunum; in 1, cholera from indigestion ; in 1, erysipelas. It is right to state, that in some cases the author attributes the death to causes independent of the operation. In 7 cases the operation was undertaken under desperate circumstances, and with a view of arresting impending death; 5 of these died; 2 survived. [Amer. Journ. Med. Soc. On Epithelial and Villous Growths. Py Prof. Bruch, of Bale. The majority of pathologists are at present agreed that cancer- ous growths are primarily of local origin, and not the result of a cancerous dyscrasia; the proofs are also being multiplied that a transition from non-malignant to malignant growths may take place. Professor Bruch enters into an interesting disquisition on the nature of epithelial and villous growths, with a view to deter- mining their pathological classification. He admits, with Lebert, Schuh, and others, the occurrence of new growths, consisting of cylindrical epithelium, which have hitherto been observed only in parts normally presenting that variety of epithelium, viz., stom- ach, rectum, collum uteri, male urethra, eye, and fourth ventricle of the brain. Professor Bruch regards epithelial growths as the result of a morbid development of the epithelial investment and -epidermis, of the papillary body and of the cutis vera, which he considers to be non-malignant ; and he establishes a subcutaneous variety of epithelial growth, which he regards as malignant. "An essential characteristic," he observes, "of epithelioma, papillary, hypertrophy, and epithelial growths generally, is an intimate union and adhesion of the cells, which prevents their extrusion and causes their accumulation. The villi of the chorion of mammalia are regarded by Professor Bruch as the prototype of all normal and abnormal villous or pa- pillary formations; all being originally formed as simple eleva- tions of the integuments of the surface, and especially of the base- ment membrane. After reviewing the various forms of villi oc- curring in the body, he concludes that the growth of the papillary, villous, or fringed formations is an attribute of all the surfaces of the body, and that it is impossible to draw the exact line of demar- cation between that which is normal and that which is abnormal. Many warty excrescences, most condylomata, Clarke's cauliflower excrescence of the os uteri, the incipient condition of some villous cancers, are mere varieties of the same thing in different parts of the body. We cannot conclude this brief notice without advert- ing to an almost unique case observed by the author of the morbid formation of ciliary epithelium. It occurred in a woman aged 184 Vapour of Iodine in Ophthalmia. [March, forty, who died of phthisis, but had previously suffered from pain in the head, spasmodic action of the right arm, furred sensation of left hand, and burning of the soles of the feet. After death a rounded, well-defined tumour, of the size of a filbert, was found under the cerebellum, attached to the walls of the fourth ventri- cle. The microscope showed the tumour to be composed of villous prolongations, or pencils of vessels, closely aggregated in a dendri- tic or foliaceous arrangement. The surface was invested by a layer of cylindrical epithelium, many individual cells of which were recognized as ciliary epithelium. The form and size of the cells, the nature and seat of the nucleus, and the distinct, though naturally immovable, cilia, precluded all doubt as to their charac- ter. [Vierordt 's Archiv : Jahrgang : Brit, and For. Med. Cliir.Rev. Vapor of Iodine in the Treatment of Ophthalmia. Reported at a Meeting of the Society for Medical Observations, Oct. 15th, 1855. By Calvin G. Page, M. D. Case I. John "Williams. Married. Coal-heaver, aged 35 a dispensary patient. First applied to me in March, 1855, for treat- ment of his eyes. He had partial capsular cataract of one eye, with absence of the crystalline lens, caused by a wound with a pointed arrow, when he was a boy. The lids of both eyes were swollen and everted, and covered with exuberant granulations. There was great intolerance of light, pain and chemosis, with sclerotic and conjunctival injection, and constant lachrymation with some discharge of pus. I commenced using freely the sul- phate of copper with cooling applications, and in a fortnight he was able to work a little, which he had not done for four months previously. Dr. H. W. Williams saw him with me about this time. He has been under my care since that time, but the improvement would not progress beyond a certain point, though all means known to me to be used in such cases were applied. His constant exposure to coal dust probably prevented the usual action of remedies. I lost sight of him during the month of August and the early part of September. About the middle of September he again applied to me, when the condition of the eyes was as follows. The lids of both eyes were somewhat swollen, the inner surfaces were covered with granulations; there was some injection of both conjunctiva and sclerotica, intolerance of light, dimness of vision, and lachryma- tion with a small amount of pus. All other means having failed, I availed myself of the fact, that iodine, when dissolved in chloro- form, evaporates without leaving the stain of iodine, and I deter- mined to apply this vapor to his eyes. I commenced using it on the 20th of September and continued it daily until the 29th. After two applications the injection about the eyeball disappeared, leaving it in a perfectly normal condition, At the end of eight 1856.] Escape of Fluid from the Peritoneal Cavity. 185 days there was a spot near the inner eantbus, on the upper lid of eaeh eye, entirely tree from granulations. He has been seen seven times since the 28th of September, and the vapor has been applied. The granulations have nearly all disappeared from the upper lids, except at points near the outer angle. There is no intolerance of light, and the dimness of vision has disappeared. Case II. Annie Fowler, aged 11 years, No. 11 Friend St., a dispensary patient, was sent by a benevolent lady to Dr. Reynolds, Sen., who sent her to the Eye and Ear Infirmary, where she was somewhat benefited. She has scrofulous tarsal ophthalmia. Her mother, seeing the benefit to Williams (the patient first men- tioned,) requested me to take charge of her. I have applied the vapor eight times. One eye is nearly well, the other very much improved. Both these patients are still under treatment. The advantages of this method of applying iodine seem to me to be that the effect of the agent is obtained more rapidly and with- out the usual discoloration. The sensations to the patient are not disagreeable; the effect of smarting, &c, passes away in less than a minute. In applying it to the eyes, the lids should be closed. The vapor seems to penetrate through them. It appears to be ap- plicable wherever iodine is called for, as in scrofulous glands, hy- drops articuli, &c. The atmosphere should be excluded from the surface during the application of the vapor. [Boston Med. and Surg. Journal. Spontaneous Escape of Fluid from the Peritoneal Cavity. (From the American Medical Monthly.) Mr. Editor: The following case was recently communicated to me by Dr. Wm. Burns, of Littleton, 1ST. H., and I have thought it might prove interesting to the readers of the Monthly. Mrs. H., of Bethlehem, N. H., was married at the age of 32, having always enjoyed good health. Four years after, she became pregnant, and during pregnancy she became dropsical. It was believed that she had not less than fifty pounds of dropsical fluid in the peritoneal cavity at the end of pregnancy ; but all of this escaped spontaneously, per vaginam, during and immediately after delivery. This occurred in the year 1791. Two years after the birth of the child (1793,) the peritoneal cavit}'- has again become largely distended with the dropsical accumulation, and Dr. Moore, of Bath, N. H., performed the operation of paracentesis abdominis, removing sixty-four and three- fourths pound of fluid. During the following twenty-six years, up to 1819, Mrs. H. had filled with dropsical fluid nineteen times, for which she had been tapped six times, and had had thirteen spontaneous evacuations per vaginam. At neither of the six tappings had she lost less than sixty-three pounds of fluid ; and at each spontaneous evacuation 186 Luxation of the Knee. [March, the fluid had drained off in about forty-eight hours, flowing from the vagina once in two or three minutes. After the water had been removed, either by tapping or spontaneously, the sternum was so prominent relatively, on account of the collapsed state of the abdominal walls, that a common quarto family bible could stand on end in the hollow beneath its lower extremity. The ribs, also were correspondently prominent, and two of them had been broken by the distension. Dr. Burns tapped the patient, October 21st, 1819, removing twenty-two quarts of fluid, which weighed forty-nine pounds. She was then in the sixty-fifth year of her age, and had been blind four years. She had another spontaneous discharge of the fluid (the fifteenth in all) per vaginam ten months afterwards, August, 1820. At this time more than fifty pounds were supposed to be removed. Not long afterwards she died of some disease not con- nected with the dropsy. In this case there is reason to believe that the distension became bo great that the wall of the vagina gave way from the downward pressure, at the cul de sac, between this canal and the rectum; and thus the fluid was spontaneously discharged in the course of about forty-eight hours. Afterwards the rupture probably healed by the first intention, and everything remained in the natural state till the tension again produced the same result. And this state of things continued for more than thirty years, without much impair- ing the general health. The only thing worthy of remark was an occasional attack of vomiting during the last ten or eleven years. This case illustrates the method adopted by nature in perfor- ming the operation of paracentesis abdominis ; and I have for some time past been convinced that it is better to imitate the ex- ample she has given in this instance, and tap from the vagina, in all cases in which there is such a projection downwards of the cul de sac between it and the rectum as to indicate the presise point where the puncture should be made, and enable the operator thus to make it without risk to any vessel or any neighboring part. A report of a case under my direction, in which this operation had several times been performed, is contained in the American Journal of the Medical Sciences, for January, 1855. In every instance the puncture healed by the first intention, and no unpleasant symptom occurred. Yours truly, New York, Dec. 1855. E. E. Peaslee. Luxation of the Knee. M. Royer communicated to the Imperial Academy of Medicine, 18th Sept. 1855, a case of complete luxation of the knee forward, the tibia mounting many centimetres before and above the articu- lating surface of the femur, without tearing of the external parts. This luxation was easily reduced by forced flexion of the leg on 1856.] Editorial and Miscellaneous. 187 the thigh, and a prompt cure was effected. In a month the patient could walk, and in six weeks the cure was completed. [Revue de Therap. Med. Chiurg. Medical News and Library. EDITORIAL AND MISCELLANEOUS. A Manual of the Practice of Medicine. By George H. Barlow, A. M., M. D., Physician to Guy's Hospital, who see the same kind of lesion in simple and complicated cases, and em- ploy the same treatment in all. Having directed his studies with this view, M. Malgaigne had arrived at the conclusion that the uterine affections under discussion might be distributed in three principal divisions, viz : 1. Displacements, (prolapsus, anteversion, anteflexion, retroversion, re- troflexion.) The principal diagnostic sign is found in the effects of the vertical and horizontal positions of the body, which suddenly and com- pletely aggravate or relieve the patient's sufferings. 2. Chronic Metritis of every variety, (engorgement, catarrh, granula- tions, etc.) The cervix is painful when touched, and the recumbent posture (which is necessary for a cure) only moderates the pain, without relieving it altogether. 3. Neuroses, or neuralgia?, which are observed under two forms: neural- gia of the cervix, and neuralgia of the appendages of the uterus. JV1. Malgaigne considered M. Depaul's condemnation of the intrauterine pessary too absolute. It was proper, in the first place, to make a distinction between simple catheterization of the uterus, which was almost exempt from danger and the employment of an intra-uterine pessary. It was also neces- sary to take into account, the rare and exceptional cases in which mechan- ical treatment, by the pessary, redressor, or hypogastric girdle, have pro- duced sudden and instantaneous relief, and also those vet more remarkable examples, in which the simple contact (cittouehement) of an instrument with the cervix uteri has sufficed to dissipate the symptoms. M. Malgaigne's general conclusion is, that the intra-uterine pessary should not be condemned until it has been thoroughly tested, by being used * with prudence and precaution in those cases in which diagnosis clearly indicates the necessity of a redressing instrument. It is obvious that this is an incomplete view of the subject. In his three grand divisions, the orator makes no mention of constitu- tional causes or diathesis. Does he not admit, with us, that syphilitic, strumous, gouty, and dartrous diathesis are the sources of catarrhs, erosions, and engorgements, which cannot be considered mere local lesions of the uterus ? What value does he attach to the influence of the moral on the physical faculties, by which morbid symptoms are so readily engendered in women? What are we to understand by metritis, if congestions and fluxations, passive and in- flammatory engorgements, discharges, ulcerations, and divers speci- fic lesions are classed under this term. M. Depaul replied to M. Malgaigne; he did not, however, ap- proach the main question, but insisted on this fact, which, he maintained, was established by incontestible statistics, viz: That a great number of uterine displacements produce no symptom whatever ; and that, in many other cases, when concomitant lesions are cured, the symptoms erroneously attributed to displacement disappear of themselves. M. Huguier came next, and by a precise and logical argument attempted to prove, from anatomical, physiological, hygienic, and 222 Remarks on Uterine Affections. [April, pathological data, that some displacements (anteversion, retrover- sion, inflexion, anteflexion and retroflexion) were the direct causes of special disorders of the functions of the pelvic viscera, and that oftentimes they could be rational]}' treated and cured. He believed that latero-flexions and latero-versions usually depended on irremediable anatomical anomalies, but that they usually produced no in commodity ; the same tiling nearly was true of anteflexions, (the very deviation that M. Velpeau had pronounced, in the former discussion, the cause of the symptoms usually ascribed to so-called engorgement.) The retroflexions and retroversions, direct causes of sterility in some cases, involved difficulties, M. Huguier said, that it is not easy to remove. Often- times, however, he had succeeded with his fingers, aided by an uterine sound, and a bougie, or pledgets of lint in the rectum, in reducing or par- tially rectifying such deviations. Of all displacements, anteversion could be treated most advantageously, by an hypogastric bandage, by astringents, and appropriate decubitus. Not unfrequently an abnormal mobility of the uterus produced unpleasant symptoms, and in these cases the hypogas- tric belt was particularly efficacious. M. Hervez de Chegoin followed M. Huguier, and, in his turn, maintained the practical importance of displacement as an element of uterine disease, and discussed its treatment by mechanical means. M. Hervez established three principal classes of deviations : anteversion, retroversion, and prolapsus. He declared that he had often relieved dis- tressing general symptoms, unaccompanied by local symptoms,(which prac- titioners would consequently hesitate to refer to their true source,) by replacing the uterus by means of a special extra-uterine pessary. He for- merly denied that deviations were harmless, as has been maintained by some surgeons, who mistook the exceptions for the rule. He was positive that displacements produced sterility and a variety of serious symptoms, which could only be relieved by a mechanical treatment. He advocated his own pessary, which was innocuous, and pronounced the instrument of Simpson irrational and dangerous. In consequence of its communication with the peri- toneal cavity, he considered all irritation of the cavity of the uterus unsafe. M. Paul Dubois replied to M. Hervez, expressing his disbelief in the efficacy of the method of reduction employed by the letter. He though that replacing the uterus by acting on its internal walls was a rational proceeding in certain cases. The question was, could it be modified so as to avoid the dangers that now attend its use. In 1849, M. Dubois pronounced an extended discourse on the whole subject of uterine affections, in which, although he attached more importance to the etiology of chronic metritis than I do, yet, the distinctions he established and the reservations he made, approx- imated his views much nearer to mine than to those of any other of the speakers. It was at the meeting of the 10th of June that the judicious and eminent professor replied to M. Hervez de Chegoin. On June 27th, he resumed, and took up the subject of uterine dis- placements and their treatment. As in 1849, M. Dubois attributed primary importance to chronic metritis, 1856.] Remarks on Uterine Affections-. 223 and he ascribed to this complication, like the reporter, M. Depaul, the majority of those symptoms which other* made to depend on displacement.' He believed that most of the patients suffering from these symptoms, even those successfully treated by the Simpson Valleix method, were cured by the removal of the co-existing chronic uterine inflammation. By tempo- rarily replacing the womb, and keeping it in a state of immobility, time was afforded for the resolution of the concomitant metritis. The orator ad- mitted also, that an intra-uterine instrument might favorably modify a state of local nervous irritability which existed in many women. He believed that the intra-uterine instrument was applicable in the exceptional cases in which the gentler means in common use, antiphlogistics, sedatives, astrin- gents, cauterization, pessaries, etc., have failed. He observed that in con- sequence of disordered menstruation depending on. uterine lesions, a state of chloro-anaemia was often induced, which only yielded to general treat- ment. He had two grievous faults with which to reproach the intra- uterine redressor, regarded as a special method of treatment : 1. It caused pain and inflammation which might become fatal ; 2. It did not procure a durable reduction or replacement of the deviated or displaced womb. Operators were utterly deceived on this point. M. Cazeau objected to ascribing to an hypothetical metritis the symptoms observed in women palpably affected with displacements- or engorgements. He denied the existence of chronic metritis, as far as related to the par- enchyma of the womb, (imitating the scandalous incredulity ofM. Velpeau, who in 1849, denied engorgement, and substituted therefore, anteflexion.} M. Cazeaux admitted with MM. Huguier and Hervez de Chegoin, that pro- lapsus, retroversion, antevers-ion, and even anteflexion, were direct causes of symptoms remediable by mechanical means. He thought that the reporter, M. Depaul, had strikingly displayed the dangers of the intra- uterine pessary, but had not appreciated its advantages. M. Cazemi agreed with Professor Dubois in thinking that cures might be obtained, in excep- tional cases, by the prudent and careful application of this instrument,, which were not attainable by any other method. I avow that MM. Dubois and Cazeau appeared to me too lenient towards the intra-uterine instrument, restricted as are the advan- tages they attribute to it. M. Gillebert d'Hercourt, of Lyons, has- demonstrated in my opinion, by his experiments on the dead subject, the superority of pessaries of volcanized caoutchouc, which can be inflated after introduction, over all other mechanical means for the adjustment of uterine displacements.* At the meeting of July 4th, the discussion was continued by Professor Velpeau. He opposed the opinions of his colleague M. Dubois. He believed that the uterus could be replaced by the Simpson-Valleix instrument, or by any analogous intra-uterine bougie carefully applied and properly superin- tended ; and a radical cure was attained thereby, whereas pessaries and hypogastric belts are palliatives which must be habitually and indefinitelv employed. He had often used similar instruments, and had acted on the internal surface of the uterus by catheterism, injections, cauterizations, etc., * M. Gillebertr8 researches are published in a pamphlet {Etudes sur le mode'd ac- tion des pessaires, 8 vOi Lyons, 1854) which we have been unable to obtain. -*-0. 224 Remarks on Uterine Affections. [April, so frequently, that he was inclined to think the dangers of M. Vaileix's method were grossly exaggerated ; the method, moreover, could be modified and perfected. M. Vaileix's results were remarkable and deserved atten- tion. The three fatal cases which have been so bruited abroad should be compared with the very numerous cases in which intra-uterine redressement had been successfully em ployed. The orator regretted that M. Depaul had not discussed the fatal cases reported by MM. Broca and Cruveilbier, instead of making a condemnation of the method of M. Valleix the special object of his report. M. Velpeau entertained doubts in regard to the neuroses and phlegma- s-iae invoked by some of bis colleagues in explanation of the obscure points in this question. He referred to the frequent blunders to which Lisfrauc's engorgements had given rise, and insisted that the anteflexions and retro- flexions, to which he had first called attention, were the sources of charac- teristic, local symptoms. These displacements were not always curable ; but hypogastric bandages, pessaries of different forms, and intra-uterine sounds and redressors were resources of art that were sometimes employed with complete success, after the failure of all other remedies. This debate, like the one that preceded it, has proved that the greatest diversity of opinions may exist among the most eminent and enlightened men in regard to material lesions, which are acces- sible to vision and to the touch * Uterine displacements, which were barely mentioned in the dis- cussion of 1849, and which many surgeons at that epoch, contested or altogether denied, at least as a pathological species, with a char- acteristic array of symptoms; these uterine displacements we?e the turning point of the discussion of 1854. Now if we recall the predominant importance which surgeons have, in the last 30 years, successively assigned to chronic metritis, to ulcerations of the cervix, to engorgements of the neck, to granula- tions of the internal surface, and lastly, to deviations, we may safely predict that the latter lesions will not long enjoy their "bad emi- nence" in uterine pathology. If, on the other hand, we rellect on the serious and disasterous consequences which have resulted from the practical application of these wild etiological theories, we shall appreciate the value of words of caution promulgated by an esteem- ed and enlightened Academy. * It is curious to see how certain aristarchs, with the arrogance and imperturba- ble impudence engendered by the habit of being eloquent in the closet, have under- taken to lecture the orators of the Academy, and to assign subjects for their expres- sions of opinion. "No one [if we believe these gentry] has laid down Hie true basis of the discus- sion. . . To make displacements of the womb and their treatment by the intra- uterine pessary a simple practical question, is [in their judgment | the way to leave the Academy as much in the dark as before the discussion. 0 profound logicians, eminently positive philosophers! I think that you might learn a lesson of modesty in these various appreciations and interpretations of mate- rial and positive facts, elicited from the learned and skillful men who engaged in the discussion which you regard as so unphilosophical Note of M. Qibert. This indignant growl is intended for Dr. Auiedce Latour, editor of the VUuion Medicate. Translator. 1856.] Remarks on Uterine Affections. 225 When we see great surgeons so possessed by illusive hypotheses, as to propose and practice amputation of the uterine neck in women with no serious lesion, or no disease whatever of the uterus; when, in other instances, incipient pregnancy has been mistaken for grave uterine disease requiring the most energetic treatment ; when, over and over again, we observe patients subjected to cauterizations, pessaries, bandages, protracted decubitus, and the remedies of a. whole special therapeutical arsenal, who continue to suffer until they abandon their unfounded apprehensions, and abstain from all surgical treatment ; it is impossible to deny that flagrant abuses have been introduced in the treatment of diseases of women, abuses which it is the right and duty of academic bodies to signalize.* To caution the learned and skilful against their own delusions; to enlighten the ignorant who accept, with blind confidence, the theories promulgated by the former, and practice whatever is advi- sed by men of eminence ; lastly to admonish the public at large of the dangers to which too great credulity will expose it, these are the objects which may be accomplished by a decided expression of opinion by the Academy. This may be attained by a slight, but important modification of the conclusions of M. Depaul's report. I cannot now refer to all the facts in favour of the version which I advocate. But I may be permitted to advert briefly to the fact that the nervous, strumous, dartrous, syphilitic, rheumatismal, gouty, and hemorrhoidal diatheses, very frequently give rise to symptoms that are commonly ascribed to those uterine lesions which occupied the exclusive attention of Lisfranc and his pupils, lesions that are purely secondary when they really exist. I hasten to admit that local lesions not infrequently coexist witfe * "I have examined," Dr. Duparque writes, " portions of uterine tissue, in a per- fectly normal state, which had been removed in consequence of supposed schirrous induration of the cervix." "lean affirm," Dr. Deligny said to me, "that while Lisfranc was temporarily clinical surgeon at St. Come, I saw him amputate the cervix rn three cases in which only slight erosions existed." A woman in the commencement of pregnancy was on JLRoux's operating table,, at Hotel-Dieu, to undergo amputation of the cervix uteri. From some cause, the operation was postponed, when the patient's condition was happily discovered. An eminent surgeon examined a lady of twenty-six years bj the touch, and gave an alarming prognosis ; he thought that if she continued to neglect herself, in two months it would be necessary to have recourse to extreme measures. He had just amputated her elder sister's cervix. Subsequently this young lady attributed every uneasiness to her -ulcerated uterus. I had great difficult}- in eradicating these notions;, but after venisection, baths, rest, and mental discipline, her symptoms were amelio- rated, and her cervix was in the healthiest possible condition. [Quotations f rem i the work of Dr. Paidij.\ For my part, I hare attended two young women, in whom incipient pregnancy was mistaken for uterine disease. It was proposed to amputate the cervix in one case, and, in the other, to burn it off with the actual cautery. In both, pregnancy was normal and regular. I am also acquainted with two ladies of over srxty years, in whose cases a cele- brated surgeon advised removal of the oervix thirty years ago, who now enjoy per- fect health. Note of M. Gibert. 226 Hemarks on Uterine Affections. [April, the general diathesis. The most common is uterine catarrh, of which, redness, tumefaction, superficial ulceration, and passive con- gestion of the cervix, are incidental accompaniments, which occur particularly in women who have borne several children. But the degree of importance ascribable to these lesions is to be estimated from a multitude of local and general circumstances In many cases, it depends entirely on the amount of mental disorder excited by apprehension of uterine disease, which disorder re-acts on the physical organization. It is thus that we are able to account for cures obtained by the most dissimilar and singular methods. Some local phenomenon ceases, which has kept up what I call the uterine monomania, and presently all the nervous symptoms excited by this monomania cease likewise. I will adduce a single illustration of these strange recoveries, in which moral influences are chiefly effectual, although attention to the local condition is also requisite : A weak and nervous lady became alarmed by the reports of several friends, who were undergoing speculum treatment for womb-disease. She presented an anteversion of the womb, the organ being very moveable in a large pelvis; there was a decided anteflexion of the cervix, and uterine catarrh. In addition to these local signs, there existed the cortege of symptoms that Lisfranc attributed to engorgement: gastralgia, hysterical spasms, bearing-down pains in the loins, sense of weight in the perineum, and pain in locomotion. After divers ameliorations and relapses, a menorrhagic attack supervened, which was a finished stroke to the terrified lady, who took to her bed, and remained there for some months, the bleeding recurring from time to time. At last, I resolved to employ a kind of pessary recommended by old Dr. Dev* illiers, which is nothing else than an unripe orange. The soft and polished surface, and rounded form, of this fruit, allows it to remain in the vagina without causing discomfort, while its rind furnishes an astringent juice. The green orange was introduced during an intervel in the metrarha- gy ; the next day, the lady left her bed ; the pains ceased ; no more blood appeared except at the regular monthly period, when its quantity was moderate. Two years have elapsed, during which this lady has enjoyed uninterrupted health. The pessary escaped during an effort of defecation five days after it was applied. In this case as in many others, I attribute the cessation of the symptoms to the moral reaction which took place when the imagi- nation was calmed, and diverted from eternal contemplation of the uterus. It is useless to add, that in the case reported, the deviations of the womb continued notwithstandidg the restoration of the patient's health. We must not forget that, barely twenty years ago, the cervix uteri was amputated for simple ulcerations, and that if this opera- lion had not almost immediately produced several disasterous results some surgeons would still practice it. Now there are innu- 1856.] Etiology and Hygiene of Cancerous Tumours. 227 merable examples of women who refuse to submit to this operation, who are now in perfect health. I trust that the operation of intra-uterine redressement will be abandoned in its turn. Meanwhile, there is both utility and pro- priety in a salutary announcement to the medical public, of the abuses in surgical practice in uterine affections. It was on this account, that I proposed to amend the conclusions of M. Depaul's report, which apply only to displacements, so that they should em- brace diseases of the womb in general. Thus modified, the conclu- sions would read as follows : > 1. There has been great exaggeration of late years in regard to the influence of displacements of the womb, and other uterine lesions, such as ulcerations, engorgements, etc., on the health of women. 2. In many cases, the symptoms ascribed to these lesions, are produced by pathological causes of an entirely different nature. [ Virginia Med. and Surg. Journal. On the Etiology and Hygiene of Cancerous Tumours. By Professor Bouchardat, of the Faculty of Medicine of Paris. Having devoted a good deal of attention to some of the points involved in the great discussion on cancerous tumours which has lately agitated the academy of medicine, I had resolved to take part in the debate. But in preparing my remarks for that occa- sion, I found myself wandering so much from those subjects to which the discussion was limited, that I have determined to ar- range my ideas in this form, hoping that the facts which I am about to produce, may, one day, be of use in the investigation of those difficult and important questions which relate to the etiology, hygiene and prophylaxy of cancerous tumours. Before entering upon the matter before us, I cannot resist the temptation of expressing my opinions, with regard to one of the parties to the late academic debate. I mean that party who deni- ed the value of the microscope in clearing up the diagnosis of cancerous tumours. To some of these persons who have taken part in the debate, I am tempted to address a question, which I never fail to propose to those who talk with me about the alco- holic ferments, and who regard with doubt, the admirable discov- eries of M. Cagniard Latour. " Have you studied the ferments with the microscope ? No. Well, begin at once to study them conscientiously, and then we will discuss the subject." I well know that the subject of cancer presents many serious difficulties, but by ascertaining precisely the definition of the term, we can for the most part, explain away the difference of opinion. It is very evident that if we retain the old definition of cancer, the microscope will furnish information of great value without doubt but which will still not be pathognomonic. Cancer, they say, is an accidental production, capable of being N. S. VOL. XII. NO. IV. 15 228 Etiology and Hygiene of Cancerous Tumours. [April,. transmitted hereditarily r lmt produced more frequently from un- known causes. It generally increases rapidly, invading the sur- rounding tissues; ulcerates in process of time, producing great loss of substance, and sometimes large and repeated hemorrhages ; de- veloping in the neighbouring glands and ganglions engorgements of the same nature as the primary tumour; returning most gener- ally after ablation, either in the cicatrice or in the neighbouring glands, or in some other part of the economy; producing in its last stages a peculiar cachexia, and giving birth, in at least one-half the cases, to the production of many tumours either in the liver, lungs, or some other part of the system. We comprehend without difficulty, that some one of these symp- toms might be absent, and yet, that the existence of cancer would be not less certain. But does the manifestation of these various characters constitute a unique, fundamental disease, as for instance,, the various manifestations of the syphilitic poison constitute a malady identical in its origin? If we pursue this comparison carefully, it is plain that if from its causes, progress, and treatment, we should conclude that syphi- lis is a special disease, assuming various forms, we must conclude that the cancer of the old authors cannot be considered as a mor- bid unity. Diseases, certainly presenting many points of resem- blance, yet differing in many important features, have been group- ed together under the general name of cancer^ I doubt not that the time ia coming when these distinctions will be established, and I believe that we approximate the truth when we say, that cancer does not form a morbid species,, with distinct varieties, but should be rather considered as a class of diseases with many symptoms in common. Nevertheless, before determining this great question of the mor- bid unity of cancer, we should examine the objections to be urged against that large number of partizans who group cancerous' affections together,, just as they group syphilitic or tuberculous- affections. There is no doubt that from the point of view in which many authors- have placed themselves, this morbid unity seems very apparent, but when we regard this difficult question in its other aspects; when we consider the important facts which can be ob- tained from its etiology and therapeutics, our faith in this morbid unity diminishes; We can understand how an illustrious surgeon can say " I appeal to* my study of this affection at the bedside,, and I divide cancer into three classes those which always return, those- which frequently return, and those which rarely return," ( Velptfflt, session of l/he Academy, 9lh January.) The great surgical experience "which has led to this opinion, deserves our highest respect, particularly when it emanates from one who has so ably and patiently examined this difficult subject. But to the physi- cian, this problem, can receive another solution. To him, the dis- 1856.] Etiology and Hygiene of Cancerous Tumours. 229 tinction of the micrographer leads to useful results which cannot be appreciated by the surgeon who views the question in a different aspect. Before going farther with this discussion, I will reproduce vari- ous extracts from the Moniteur des Hopitaux, the work of M. Broca, a young surgeon, who at the same time is a micrographer and clinician. That he has studied the subject with great diligence is proved not only by the beautiful essay which was received with so much approbation by the academy of medicine, but also by many other remarkable articles which appeared in the journal edited by M. Caslelneau. We have the most profound conviction, that future investiga- tions will show the precise distinctions which exist between the j varieties of cancerous tumours. At this time, the majority of phy- ! sicians confound the simple glandular hypertrophies and cancerous tumours properly so called. But although the science is not suffi- ciently advanced, to determine accurately the lines of difference, yet we cannot doubt that some progress has been made. Let us now examine the etiology of cancerous tumours. We can take up successively the influence of hereditary causes and of age, before we discuss the important questions of diet, moral influence and external violence. We should sift to the bottom the chaos of malignity, and endeavour to shew by what rules we may either avoid cancers, or retard their progress when the evil has develop- ed itself. Hereditary influences play an important part in the pathogeny of cancer. M. Leroy d'Etiolles estimates that there is an hereditary transmission in one-tenth of the cases; M. Lebert in one-seventh. Without disputing these statistics, I will remark, that the heredit- ary influence in the genesis of diseases, comprises not only a native l predisposition, but also a group of habits formed by a similarity 'of education or even of organism, and that very often these hygi- enic habits lead many generations to the same end. Hereditary predisposition is not alone the fatal cause, but we can by rectifying the customs and bad habits of our predecessors, avoid the curse under which one or more generations have fallen. I am convinced ithat this view of the subject deserves serious attention. Functicnis of the skin in connexion tuiih age. We see cancers at all ages. It has been observed in children that the eye is usually 'the part affected, but it is a well established etiological fact that jthe relative frequency of cancer is much greater in the decline of adult life or in the beginning of old age. The appearance of the three principal species of cancer; cancer properly so called, cancroids and fibroids, coincide most generally with a degeneracy of the functions of the skin and especially in that important function (and yet one but little studied in its patho- genic effects), the production of the epidermis, with its appendaceS' "ithe nails and hair. 230 Etiology and Hygiene of Cancerous Tvmours. [ApriTr The important principles which are eliminated by the skin under the form of epidermic scales and hair, play an important part in the animal economy, and many diseases of the latter years of life appear at this period of giving way in the functions of the skin. External violences. We attribute in the etiology of cancer, much importance to the influence of external violence. I am far from denying this influence, but it is evidently indispensable that the other conditions of age and predisposition should be also present to give any value to this cause. Depressing moral influences and passions. The moral affections, and more especially grief, has a certain influence on the develop- ment and progress of cancerous affections. The effects of sorrow are depressing, they repress the energies. The skin is the first organ which feels the general languor. We can very well under- stand then, how these emotions lead to cancer, if the conditions of age and of nutrition are also present. We can also see how these depressing influences are involved in the word malignity, an ex- traordinary expression in scientific language, and which means something that we do not understand. However this may be, we have two principal interpretations of this word in connexion with cancer. Cancer is called malignant either when it leads rapidly to death, or when it extends quickly into the neighboring glands or into different organs than those originally attacked. That both of these results are greatly encouraged by the influence of the emo- tions of grief, we well know, and hence the influence which these passions have over the question of the maKgnity of cancerous tu- mours. We say that a cancer is malignant, when it extends very rapidly. This occurs when there is a change in the nutritive functions, in fact, when there is an anomalous action established in the organ- ism. It continues, indeed, because the movement advances in the direction it first assumed. Stahl has adopted this maxim of Plato, which expresses the idea: facilius est movere quieiumquam quietare motum* Without doubt, the skin does- not alone participate in this ab- normal direction of the vital movements, but it plays a part worthy f attention. It is very probable that the three principal species of cancer are caused by different modifications of nutrition. So we will say, though with great reserve, that the true cancer arises from a diminution of the epidermoid productions, and is influenced by age, or by some modifications of nutrition in the glands and lymphatic ganglions; that the development of fibroid coincides- with a diminution in the epidermoid production and a diminution or aberration in the production of fib re, and that cancroid owes its origin principally to a perturbation in the epidermoid functions. Diet. Deducting the many glandular hypertrophies which are often confounded with cancer,. I am convinced that diet has a great 1856.] On Urcemic Eclampsia. 231 influence in producing the three species of cancer. An exciting and largely predominating animal diet may do much in develop- ing this disease. The reasons I have for this opinion are drawn from the fact, that this affection is almost always met with in carnivorous ani- mals; the remarkable immunity of the Trappists who never eat meat, which is attested by M. Debreyne, and the mode of destruc- tion and elimination of the residue of animal matters. Prophylaxy. I will sum up, iu conclusion, the rules I believe most useful to follow, to prevent cancer, or to arrest its progress when the malady has displayed itself: 1st. To rouse the functions of the skin by cold baths, by daily frictions with coarse flannel or hair gloves. 2d. To stimulate the muscles by daily and regular exercise, and ! "by gymnastic exercises in proportion to the powers of the system. 3d. To prefer a vegetable diet, and to eat very moderately of i meats. 4th. To avoid moral emotions particularly of a depressing char- acter, and to keep the mind amused and agreeably occupied. 5th. To obtain either by regular habit or by some purgative, one \ or two regular operations from the bowels every day. [ Virginia Medical and Surgical Journal. On Uratmic Eclampsia. By F. WlEGER. Dr. Wieger proposes to defend that new view of eclampsia which regards it as a complication of uraemia, against the older views sustained by L'Huillier and Depaul. He divides his me- moir into six parts : 1. Critique of the Negative Observations. The author seeks to i show that the cases of eclampsia without albuminuria, recorded j by L'Huillier, Depaul, and Mascarel, must be eliminated, either j because the albumen was not searched for with sufficient care, i or because the absence of albumen does not prove the absence of ! uraemia. i 2. On tJie Condition of the Kidneys.- He seeks to invalidate the , assertion of Blot, that the kidneys in eclampsia are not always dis- i eased, by the collection of as many cases as possible. He main- tains that in albuminuria, fibrinous cylinder-casts are always found |i in the urine, and that these often increase after delivery, and are I found, ras Braun and Litzmann have shown, so long as there is albumen in the urine. He gives a table, which shows that up to the tenth day of the j puerperal state anatomical lesions in the kidneys are always found ; and that profound alterations of the kidneys are more frequent i than congestive conditions. He concludes this section with the following deductions : 232 On Urcemic Eclampsia. [April, a. The kidneys may be diseased without albumen being separ- ated in the urine in observable quantity. b. The absence of albumen at a given time is no sure proof of the absence either of disease of the kidney or of uraemia. The presence of albumen at a given time stands in no relation to the stage of the disease. c. The albuminuria increases at the approach of labor, during labor, and the fits of eclampsia. d. The kidneys cannot pour out albumen in any considerable quantity, or during a certain time, without becoming clogged up and diseased. e. The appearance of the kidney-disease is often complete, and effected in a short time ; often it persists in a slight degree, and be- comes aggravated in following pregnancies. /. When it persists during the puerperal state, the disease of the kidney induces other attacks, or causes complications, or aggra- vates existing ones. g. Albuminuria grows with the occurrence of complications. 3. Albuminuria and (Edema. a. On Albuminuria. Is there albuminuria without nephritis? The author cites instances from Simon, Schmidt, Henoch, and Canstatt, to prove the affirmative. As to the curability of the nephritis which attends pregnancy, he shows that as it depends upon transitory conditions, it is not like Bright's disease, which is commonly dependent upon persistent or recurrent external causes, as cold, &c. By adducing the statements of Blot and Litzmann, which ex- hibit the presence of albuminuria in fifty-six primipara? out of a hundred and seventy-eight, and in twenty-two multipara out of a hundred and fifty-nine, he confirms the opinion, that the first la- bor is a predisposing cause of albuminuria and eclampsia. b. Of GMema and Anasarca. The presence or absence of this symptom has no constant value in diagnosis. It is not always present in Bright's disease, 4. On Unemia and Uramiic Symptoms. a. On Uraemia. Uras- mia, the result of nephritis, is characterized in its chemical relations by the retention of water and excrementitial matter in the blood, which in its turn is impoverished by the loss of albumen and some- times of globules. The excrementitial matter is thus driven to the skin, stomach, or salivary glands, and even to the lungs, or accumulated in the serous cavities or cellular tissue, to be taken up again into the blood, to aggravate the uraemia. For this reason. a strong diuresis may often persist a long time without exercising a remarkable influence on the nervous system. The degree of intoxication can only be determined by simultaneous examination of the blood and of the urine. He cites two cases of Gegenbauer and Chaiari; in the latter, urea, and, by decomposition of this, ammonia, were found in considerable quantity in tha blood, and 1856.] On Urcemic Eclampsia. 233 the prophecy that eclampsia would break out was verified. The woman died. b. On Urcemic Convulsions. In seventy-eight cases of Bright, Barlow, and Frerichs, there was amaurosis and amblyopia tea times; syncope, nineteen times; singing in the ears and deafness, ten times; convulsions, fourteen times. The cerebro-spinal symp- toms which precede the attacks of eclampsia have the closest resemblance with those of Bright's disease. Out of a hundred and forty cases of eclampsia collected into a table, forty-three showed premonitory symptoms. Of the cases in which the eclampsia broke out before labor, there were forty per cent ; of those in which it began during labor, thirty per cent ; and of those in which it began after labor, twenty per cent., which were attended with premonito- ry symptoms. As premonitory symptoms, the author enumerates vomiting and diarrhoea, but principally headache, disturbance of intellect, and often delirium ; cramps and amblyopia, sometimes followed by blindness, not unfrequently precede. The changes of the pulse and pupils were too uncertain to be considered. As characteristic of the so-called ursemic eclampsia, the author mentions that no predisposition lies at the foundation of eclamp- tic convulsions; they cannot become habitual; as a rule, the fits are frequently repeated. The disease is never chronic; it makes ' no periodic relapses, and seldom returns in subsequent pregnan- l cies. The symptoms are those of epilepsy, without the cry at the I onset. The question as to the relation between epilepsy and eclampsia | the author regards as not settled, but inclines to the view that ' epileps}*- predisposes to eclampsia. Apoplexy of the brain and > membranes may cause fatal convulsions, and appears frequently | as a complication of Bright's disease, and makes the diagnosis more i serious. 5. Etiology aud Prognosis, External Predisposing Causes. The j bad method of living of the poor favors the disease, and is the rea- I son why it is more frequent in lying-in hospitals than in private i practice. Individual Predisposing Causes. First pregnancies, twin preg- i nancies, are mentioned. Dubois has pointed to distortion of the N pelvis and rachitis, duration of labor, and mal-position of child, 1 asphyxia, indigestion ; mental excitations, as fright, anger. The mortality is, according to Murphy, 24 per cent ; Blot, 354- ' per cent: Lever, 28 per cent; the author, 30 per cent The mor- tality among the children is given by Blot as 67 per cent, and by i the author as 45 per cent. Many children died shortly after ! birth, without inspection revealing any tangible cause of death. j Frerichs, Litzrnann, and Braun ascribe this death to intoxication of the blood. U 6. Treatment The author divides the prophylaxis into a remote (against the albuminuria), and a treatment against the ursemic pro- 234 Cesarean Operation. [April, dromata, shortly before the labor. The peculiar condition of the blood indicates the following fundamental rules of a rational treat- ment: a. The blood must be improved by good nourishment, tonics, and iron; Miquel recommends a vegetable diet, b. Exciting diaphoresis by baths, &c. c. Gentle purgatives, d. Maintenance of the urinary secretion by gentle diuretics. e. Direct action upon the renal obstruction, by abstraction of blood from the region of the kidneys. Treatment of the Uraimic Pre-current Symptoms before Labor. Tartar emetic, vapor baths, and scarification of the cedematous parts, are considered. Chailly recommends chloroform when there is great tenderness in the uterus. The author regards it only as a palliative against the convulsions, and not as against the funda- mental evil, the urgemia. General bleeding he regards as a precious means. The expectative method, the author regards as admissible when the convulsions are not strong, or first appear during the expulsion of the child. Opium, much praised by many authors, is, according to the author, chiefly useful after delivery. Cold affusions, are recommended by Recamier and Booth, Coma after cessation of the fits, the author treats with diaphoret- ics, salines, and diuretics, since the condition of the brain is caused, for the most part, not by hyperemia, but by serous infiltration. Of revidsive measures, the author rejects cantharides. Of anti- spasmodics, musk has been useful after too great depletion. The author then adduces several cases in which artificial delive- ry was resorted to, showing that often there is a rapid cessation of the attacks after the emptying of the uterus, and that the mortality is about the same. Abortion. Convulsions which appear before the period of via- bility of the foetus, end for the most part with its expulsion. In eclampsia before the beginning of labor, he enjoins excitation of the pains and hastening of delivery. He uses secale corimtum for this purpose, when the head cannot be reached by the for- ceps, [Schmidt's Jahrb. Med. Chir. Rev, On the Cesarean Operation, and its performance more than once on the same subject. By Prof. Stoltz, of Strasbourg. For upwards of fifty years, says M. Stoltz, this operation, al- though fretpaently resorted to in Paris, has not generally been followed by success, whilst towards the close of the last century it was, in numerous instances, attended with the best results, in the hands of the celebrated accoucheurs of that period, Lauversat, Deleurye, Coutouly, Millot, etc. This failure of the operation, in 1856.] Ccesarean Operation. 235 the practice of modern surgeons, he considers as having led to its being regarded as much more hazardous than it really is, and to its consequent restriction to those cases in which it is found impos- sible to effect delivery by any other method. Thus, the aceoxich- eurs of Paris have nearly all been induced to adopt the English practice, according to which, rather than risk the life of the mo- ther, they sacrifice that of the child, wherever the difficulty appears surmountable by so doing ; a proceeding which our author believes to be unjustifiable, on the grounds that one life is taken without any certainty of thus saving the other. M. Stoltz has performed the Gaesarean operation six times, with the result of saving both mother and infant in four of these instances, and the child in the remaining two. The latest of these cases is that which he commu- nicates to the Academy of Sciences, as possessing additional interest in the fact of its being the second occasion in which the operation had been performed, with complete success, on the same individual. The patient, AdeleFenninger, set. 39, was the subject of gener- al rachitic deformity, and had been operated on, three years pre- viously, by Dr. Bach, of Strasbourg, who published the case in the Gazette Medicate, of that city, in 1846. On that occasion the operation was successful, although performed under very unfa- vourable circumstances, the patient being "radicalement" rachitic, in very delicate health, ill nourished, and suffering from consider- able obliquity of the uterus. At the time of the operation, some- what too large an incision in the abdominal and uterine walls was attended with troublesome protrusion of the intestines ; and during the progress of the case, erysipelatous inflammation of the points of suture, and phlebitis, followed by oedema of the left inferior extremity, were circumstances which more than once threatened the life of the patient ; however, by careful attention, these dan- gers were averted, and a complete cure was obtained in the space of two and a half months. The second operation, which presents no features of much im- portance, is minutely described by M. Stoltz, who remarks, that from the ordinary course of the second pregnancy, three years af- ter the first operation, it may be concluded that the cicatrization of the uterus had been sufficiently perfect to resist with impunity a second dilatation of that organ; and that the second operation, like the first, had been complete in its success, mother and child being both saved. In conclusion, he refers to a number of other instances where the operation had been repeatedly performed on the same patient with successful results. The following published cases are enumerated by him, and the publication mentioned in which they are to be found : Dr. Mangold, of Bale, operated, first in 1797, and again in 1801, and M. Mautz, in 1807, upon the same patient, who died on the twenty-second day after the third operation. 236 On the Pathology of the Pancreas. [April, Dr. Bacqua, of Nantes, operated successfully on one patient, first in 1797, and again in 180(1 Dr. Dariste, of Martinique, operated successfully on one patient in 1805 and 1807. Dr. Lemaistre, d'Aix, operated three times on one patient, in 1805, 1807, and 1814. The patient died five days after the last operation. Dr. Charmed operated in 1813 (?,) and another surgeon in 1814, on one patient, each successfully. Chaussier communicates the successful performance of the oper- ation a second time. Merrem of Cologne, operated successfully on one patient, first in 1812, and again in 1826. Dr. Zwanck operated for the first time on a patient named Adametz; Dr. Weideman operated a second time ; Dr. Michaelis a third, and again a fourth time, with success. Dr. Kouvin communicates a case where the operation was re- peated with success. Dr. Bowen performed the operation twice on one patient, in 1833 and 1835, with success. Professor Kilian, of Bonn, operated successfully on one patient, first in 1832, and then in 1838. In another case, he operated in 1837, and the same patient recovered from a repetition of the operation in 1843. Dr. Mestenhaeuser operated successful^ on one patient in 1840 and 1844. Here then, adds M. Stoltz, are fourteen well authenticated in- stances of this operation having been successfully repeated on the same patients. In two of the cases mentioned, the operation was performed three different times, but, on the last occasions, followed by the death of the mother. In a third instance, however, it was performed no less than four times with complete success. This example would almost induce him to believe in those cases quoted by some authors, where women were said to have undergone the Caesarean section six or seven times. [Gazette Medicate. N. Y. Jour, of Medicine. On the Pathology of the Pancreas. By Dr. ElSENMANN. The interesting experiments of M. CI. Bernard upon the uses of the pancreatic juice, have led the author .of this article to consider whether or not the results obtained by that physiologist, are capa- ble of being applied to the diagnosis of disease in this organ. If the pancreatic juice assists the digestion, and consequently the absorption of fatty matters, the conclusion is, that when the func- tions of that gland are destroyed by disease, fat should pass with the dejections, and be found in them in an unaltered condition. It is interesting to observe how nearly science has anticipated what the observations at the bedside of patients laboring under such 1856.] On the Pathology of the Pancreas. 237 disease have confirmed. The author has united the facts observed by others with those presented in a case of his own. Of seven cases adduced, six terminated iu death ; there had been abundant fatty evacuations, and post mortem examination showed the existence of induration, or other alteration in the pancreas. In the seventh case^ quoted from Lussana, the patient recovered. The principal symptoms in this case were copious salivation, a sense of weight in the epigastrium not increased upon pressure, eructations, flatulence, coldness of the surface, and a small and slow pulse. The expression indicated abdominal disease. Consti- pation was present, but the faeces contained yellowish particles resembling fatty concretions, and which were in fact composed of fatty materials. These occurred in increased quantity after purga- tives. Mr. Eisenmann regards Lussana as the first who applied to pathology the discovery of Bernard. In the instance observed by himself the author had diagnosed pancreatic disease, but had not made out the presence of fat in the evacuations. This circum- stance induced him to suppose that the pancreatic juice did not exclusively produce the absorption of fatty matters, but was as- sisted in this action b}r the bile. Budge and Wistinghausen have made experiments which countenance this idea, and the author re- calls a case cited by Pearson, of a woman who evacuated daily 3 oz. of a fatty substance, and did not present, upon post mortem examination, any trace of pancreatic disease, but the liver was pale, large, and destitute of bile. One remarkable circumstance, is, that in many of the coses cited by M. Eisenmann, the oily eva- cuations had ceased, while the pancreas was so indurated as to render the performance of its functions impossible. The author also alludes to another circumstance, not less worthy of remark, viz, the large quantity of fat yielded, a quantity much greater, than that contained in the food, and which leads to the supposi- tion that part of the foecal matters is transformed into fat. How- ever that may be, the fact shows us that the presence of fat in the intestinal evacuations indicates with probability, but not with cer- tainty, derangement in the functions of the pancreas; while, on the other hand, the absence of fatty matters does not authorize us to conclude that there is no disease in this gland, if other symp- toms exist indicative of such an affection. The author has endeavored to employ the facts collected by him in establishing a more correct symptomatology of disease of the pancreas. He divides the symptoms into two classes, those ac- companying degeneration of the gland, and those arising from its acute and chronic inflammation. For the first of these, the symp- toms are too various to afford any certain signs of the affection; the presence of fat in the evacuations, and the examination of the abdomen by the hand, suggest, but cannot positively determine, its presence. It is otherwise, according to the author, with inflam- mation of the pancreas. This is distinguished by a sense of weight 238 Laryngotomy and Tracheotomy in Croup. [April, in the epigastrium, which is especially manifest about two hours after eating, extending towards the breast with a feeling of oppres- sion ; loss of appetite, inodorous eructations, malaise, retching or even vomiting, although the tongue may remain clean ; constipa- tion; small, diminished pulse; emaciation; expression of features indicative of an abdominal affection; melancholy and sometimes weariness of life. The author recommends as a mode of treatment, the waters of Friedricks-hall, in small doses. [Vierteljahrschrift fur die Praktis- clie Heilkunde. Buffalo Med. Jour. On die Comparative Value of Laryngotomy and Tracheotomy in the Treatment of Croup. By J. P. Bachelder, M. D. (Read before the New York Medical Association.) Among the remedial measures employed by surgeons for the cure of croup, that of making an opening into the trachea (tracheotomy) has been most frequently resorted to, while that of opening into the larynx through the crico-thyroid space, has been almost entire- ly overlooked and neglected. This preference of tracheotomy to laryngotomy, has never seemed to the writer to be predicated upon any sound reasoning; but, on the contrary, that the very nature of things was not only against it, but indicated most clearly that the other alternative should be preferred. With a view to a more correct appreciation of the comparative merits of the two operations, we have been induced to institute an examination into their respec- tive claims to be adopted by the profession. We shall consider I. The Objections to Tracheotomy. / These arise principally from the anatomical relations of important parts to that which is the immediate field of the operation : 1. The middle and inferior thyroidal veins, and the plexus or network which they form in front of the windpipe, some of which almost necessarily are wounded when tracheotomy is performed, give rise to a haemorrhage, which endangers and sometimes actually destroys life, either by draining the system, by blood getting into the trachea, or the delay occasioned by its flow. 2. The proximity of the carotids to the trachea, and the irregular distribution of blood vessels in this region.* 3. The thyroid gland is proportionally larger in the child than * The right carotid sometimes traverses the windpipe ; also now and then a middle thyroid artery mounts upwards directly in front of the trachea to the thyroid. Dr. C. E. Isaacs, the Demonstrator of Anatomy in the University of New York, who is one of the most indefatigable and accurate anatomists in the country, says " I have seen seven cases in which the middle thyroid artery arose from the innominata, and was distributed to the thyroid gland. In two subjects it was remarkably large, and its division in tracheotomy would have occasioned a very profuse haemorrhage." "In two instances, no innominata existed; but the arch of the aorta gave off, . 1. the right subclavian ; 2. the right carotid." 1856.] Laryngotomy and Tracheotomy in Croup. 239 in the adult, while other parts (particularly the trachea) are small- er; and the cervical portion of the thymus gland rising, in some cases in childhood, considerably above the sternum, shortens very much the tracheal space between it and the thyroid, 4. The depth and small size of the trachea, especially in children, render it difficult to open, and sometimes, it is said, even to find that organ, and greatly enhance the danger of wounding import- ant parts in close proximity. 5. The deficiency, at the posterior part of the trachea, of the fibro-cartilaginous rings, which therefore occupy only two-thirds of its circumference. These, when entire, by their elasticity, keep the windpipe fully distended; but when divided in front, as in tracheotomy, this re- sult no longer obtains, the divided extremities fall together, and not only close the opening made by the knife, but actually dimin- ish the calibre of the tracheal tube. This state of things is also aggravated by the action of the sternohyoid, and stern o-thyroid muscles, which lie on the sides and partly in front of the trachea, where their inner margins are nearly in contact, at the very place in which the opening is made when tracheotomy is performed. These ribbon-like muscles, when acting forcibly, swell into round- ed masses, in consequence of which, the sides of the trachea are compressed and forced together, and the opening,, made by the division of its rings, closed. These muscles, when they act, also draw the larynx downwards, which, by compressing the rings into a smaller space, and forcing them backwards, still further dimin- ishes the tracheal cavity. These circumstances, the action of the muscles and perhaps the flow of blood, render necessary the in- troduction of the metallic tube, through which respiration may be carried on, and matters which block up the air passages discharged. Objections, growing out of the danger, difficulty, and inexpedi- ency of this operation, will be noticed in another place. II. Objections raised against Laryngotomy.. The objections most frequently urged against laryngotomy, and of course regarded as arguments in favor of tracheotomy, are that in the former the wound is made in the inflamed part, and that the tube (the necessity for which, in this operation, is only assumed) could not be tolerated; therefore, the opening should be made be- low the seat of the disease. These, I am aware, have been consid- ered and adduced as the most cogent reasons against the opening being made in the crico-thyroid space. To the writer,, however, this reasoning has always seemed strangely inconsistent.- Let us examine its validity. 1. Cutting into the inflamed part. What is croup? Just what its technical name, tracheitis, implies, an inflammation of the trachea. Dr. Watson, whose authority in this matter will not be questioned, tells us that " the essence of this complaint is a violent 240 Laryngotomy and Tracheotomy in Crovp. [April, inflammation affecting the mucous membrane of that portion of the air passages which lies between the laryngeal cartilages and the primary bronchi ; in a word, of the trachea, or windpipe. That is the genuine seat of the disease, but the inflammation some^ times ascends into the larynx, and not unfrequentlv dives into the bronchi, and into their ramifications. Usually, the adventitious membrane commences just below the larynx, where it is thin and soft; about the middle of the windpipe" (the tracheotomic region) "it is more dense and firm ; lower down in the trachea, and in the bronchi, it is general^ looser again, pulpy, and broken."* With due deference, and in all candor, we would ask gentlemen who adopt the mode of argumentation alluded to, to consider to which place the reasoning most legitimately points? But with us, the idea of cutting into the inflamed part has little Weight, when we reflect how often it is done. What surgeon would hesitate to cut off an inflamed tonsil which endangered life? Or, who that has tried it, has failed to find that it is the most prompt and cer- tain method of curing that disease ? Who does not cut into car- buncles and inflamed parts to let out matter, and sometimes into parts affected with erysipelas for the same and perhaps other pur- poses? And who ever saw any injury result from the practice? 2. Intolerance of the tube. The other objection brought against laryngotomy is, that the tube cannot be borne when passed into the larynx. The fallacy of this objection will be presently pointed out, when it will be shown that the tube, should one be necessary, is equally well, and indeed better borne, than in tracheotomy, and is much more readily replaced after having been removed and cleansed, than when inserted into the trachea. After what has been said, we shall, of course, be free to admit the necessity of the tube when tracheotomy is resorted to ; but in that very necessity is to be found a serious objection to the operation itself, which is instituted for a double purpose, the admission of air, and the ejection of a superabundant morbid secretion. If, for the former only, the tube might not be so objectionable; but being made of inert materials, it cannot facilitate, but must necessarily impede and prevent, the discharge of matters, which thickened,, inspissa- ted, tenacious, and adhesive cling to its inner surface, and pro- duce obstructions which require its frequent removal. * To the remarks of Dr. Watson, we would add that the inflammation, which commences in the mucous membrane, not unfrequentlv, and in severe cases of croup generally, extends to all the other tissues and structures which enter into the con- stitution of the trachea. This involvement of the structures, somewhat peculiar in their organization, causes a contraction which not only diminishes the capacity of the trachea, hut interferes with Hie movements of that part as a whole, and also of its constituents among themselves. This diminution of calibre and mobility, with its morbid irritability, renders this organ much less tolerant of the metallic tuhe. Another objection to the tube in the trachea, grows out of the difficulty of adapting its size to the exigencies of the case: if too small, neither respiration nor the expul- sion of the morbid secretion can be carried on through it; if too large, it occasions great distress, by putting the trachea on the stretch/ 1856.] Laryngotomy and Tracheotomy in Cronp: 241 The rima glotticlis being the natural aperture through which matters within and below that orifice are discharged, the artificial opening, it would seem, should be as near it as circumstances will admit. If through the crico-thyroid space, and as large as that space will allow, the trachea entire and all its parts in possession of their vital properties, powers, and actions will contribute to- the expulsion of those matters; which it would, not do if crippled by the division of its rings in front, and also shackled and ob- structed by an inert tube within its cavity. This tube, if inserted through an opening in the crico-thyroid space, may be short, and therefore less likely to interfere with the functions of the trachea than it would if long and passed far into that organ, at or near its middle portion; in which case the patient, although he has the tube through which to breathe, gets on badly. Tracheotomy in comparison with Laryngotomy. Tracheotomy is a dangerous opera- tion, and under almost any circum- stances difficult to perform, especially in the child. It is sometimes follow- ed by or is the cause of immediate death, by haemorrhage, by the shock it gives to the system either by its violence or loss of blood, which the exhausted state of the patient cannot bear, or the delay occasioned by the bleeding or other circumstances. Tracheotomy requires a skillful,, practiced surgeon and anatomist, with divers instruments, for its per- formance. Laryngotomy is an operation easi- ly and quickly performed without hemorrhage or delay ; is attended with no danger, there being no parts of importance in the way of the op- erator's knife. It is, indeed, very lit- tle more difficult or hazardous than venesection in the arm of a tatchilcL Laryngotomy may be performed on the spur of the occasion, by almost any medical man, with the lancet only. The operator needs merely to pinch up a fold of integument -direct- ly over the thyroid cartilage, and an assistant to do the same over the cricoid, and then thrust a lancet, scalpel or bistoury, through, and di- vide the duplicative; this done, and the integuments being allowed to resume their natural condition, the operator, steadying the thyroid car- tilage between his thumb and fore- finger, pushes the lancet through the crico-thyroid membrane, close to the npper border of the cricoid cartilage, and makes a free opening into the' larynx ; which may, if required, be enlarged upward, two thirds the length of the thyroid, and downward, entirely through the cricoid cartil- 242 Laryngolomy and Tracheotomy in Croup. [April, Tracheotomy, in every instance, requires the insertion of a metallic tube, through which respiration may be carried on, and the morbid secre- tions discharged. age; and furthermore, through one or two of the tracheal rings, without trenching on the thyroid gland, and, besides, a portion of the cricoid in front may be removed. In laryngotoray the insertion of the tube is seldom necessary. The membrane occupying the crico-thy- roid space, being composed of the yellow elastic substance, contracts Tchem divided, and prevents the clo- sure of the opening ; the more cer- tainly if an incision be made upward so as to give the artificial opening the shape of an inverted J_. If ne- cessary, the angles with a portion of the thyroid cartilage, on each side of the perpendicular cut, may be clipped off; and also, as suggested, a portion of the cricoid cartilage in front may be removed. In this way, the artificial opening may be made considerably larger than the calibre of the trachea itself. Generally, we believe, it will be found that two strips of adhesive plaster applied, one on each side near the margin of the wound, (if longitudinally made,) and drawn backward and crossed behind the neck, wiO be all that is required to keep the wound patent. Tracheotomy is so difficult to per- In Jaryngotomy no anaesthetic is form, that the administration ofclilo- required; consequently, no risk from roform has been deemed necessary this cause need be incurred- to its best performance, and there is reason to believe that in more instan- ces than one, the influence of this agent, superadded to the exhaustion induced by the disease, the loss of blood, and the shock, notwithstand- ing the employment of this substance, has caused death or rendered it more speedy and certain. In favor of tracheotomy, it is urged that almost all authority is on its side. This is true, most strangely so; for the nature of things, anatomically considered, and common sense based on them, and also on sound reasoning, seem to be all in favor of laryn- gotomy. 1856.] Laryngotorny and Tracheotomy in Croup. 243 To this objection, as well as that already alluded to, the intoler- ance of the tube in the larynx, we beg leave to refer to the last June number of the London Lancet, in which will be found '"Some cases of Laryngotorny, by John Erichsen, Esq.," which seem to be exactly in point. They derive additional value and interest from the fact that they were all cases of laryngitis. In case first, he made an opening through the crico-thyroid membrane, and introduced a large silver tube. On the third day, the tube was finally withdrawn, and the wound gradually closed ; the patient recovered without a bad sjmiptom. Case 2. Mr. Erichsen says, "I lost not a moment in opening the crico-thyroid membrane, and inserting a large silver tube, which she has never been able to lay aside. It has been worn for between six and seven years, and in close proximity with the vocal cords f and, he continues, " the action of these has been in no tvay impaired.'1'' Pretty good evidence this, that the tube in the crico- thyroid space can be borne quite as well as in the trachea. Case 3. "A short, stout, thick-necked woman, about thirty years of age. There was not a moment to lose. I immediately proceeded to operate, but on making an incision through the integuments, the vessels of the neck, over-distended by asphyxial congestion, poured out so large a quantity of dark blood, that it was necessary to wait a few moments before opening the windpipe. During this delay the patient, who was seized with a severe spasm, ceased to breathe, and fell back to appearance dead. / immediately plunged the scal- pel through the crico-thyroid membrane, cut this freely across, and put in a large silver tube. She made a good recovery."* These were cases of laryngitis : of course the opening and insertion of the tube were in the inflamed part, yet not only no inconvenience resulted, but the most perfect success followed. They annihilate the objec- tions raised against cutting into the inflamed parts, and the intol- j erance of the tube in laryngotorny. A few short extracts from cases reported in the London Lancet, (December, 1855,) by Henry Thompson, F.K.C.S., M.D., will close this paper: Case 1. "A man about forty years of age," with "an attack of acufie laryngitis." "There was no time for delay. I proceeded at once to make an opening into the larynx, sufficient to admit a full-sized double-trachea tube. The relief was instan- taneous." This occurred on the 27th of September; and on the " 1st of October, the apparatus was removed, and the edges of the wound approximated;" which on the 8th "had entirely closed." "Case 2." "A little boy, three years of age, livid and almost insen- sible, struggling violently for breath. There was evidently no time to be lost. Opening first the crico-thyroid membrane, I found it necessary subsequently to divide the cricoid cartilage, and upper ring of the trachea, in order to introduce the tube. We had the satisfaction, however, of leaving him, in the course of half an * The italicizing is ours. N. S. VOL. XII. NO. IV. 16 244 Treatment of Pseudo-membranous Angina. [April, hour, completely relieved, and enjoying comfortable sleep." The next day, "June 3d," he was breathing comfortably, taking nour- ishment freely, and in all respects improving. Contrary to express orders, the tube was removed for a short time by the attendants of the child on the 5th instant, and he suddenly died of asphyxia, in less than ten minutes after taking, with considerable relish, a ba- sin of beef tea." Mr. Thompson very significantly and justly adds: "These cases are practically valuable, inasmuch as they present additional evidence in favor of an opinion, the accuracy of which is becoming more and more apparent, namely, that a tube may be introduced into the interior of the larynx, and be retained there for some time, without exciting irritation of the organ, even in the presence of acute laryngitis; and that it is therefore unneces- sary to resort to the severer method of tracheotomy, on the assumed ground that it is calculated to occasion less disturbance to an alrea- dy diseased larynx. [New York Medical Times. Treatment of Pseudo-membranous Angina* by the Alkaline Carbon- ates. (Translated from the "Gazette des Iiopitaux," April 7thr 1855, for the Boston Medical and Surgical Journal.) The solvent action attributed to the alkalies, upon the fluids of the body, and particularly upon certain abnormal products of se- cretion,, has already been taken advantage of in quite a large number of diseases. We are not sure whether pseudo membran- ous angina figures among the great variety of affections to winch this treatment has, of late years especiallv, been applied; our recollections on this point are not exact. Were this so, however,. the interest which attaches to the case recently communicated to the Academy of Sciences, by M. Marchal (de Calvi,) would be none the less real. Its clinical and practical bearing gives it na- turally a place in our pages. Starting with the idea that the principle which is the cause of the disease known under the name of pseudo-membranous angina [anrjine couenneuse\ is unknown to us, but manifests itself by a phenomenon, the formation of false membranes, indicating an excess of plasticity in the blood; and regarding this excess of plasticitv, if not the immediate cause, the most striking phenome- non of the pathology of the malady, at least the fact which nearest approaches it, and to which, consequently, we must address our- selves, in order to attack the evil as nearly as possible to its source, M. Marchal had for a long time, he sa}Ts, conceived the idea of resorting in such cases to the employment of alkalies, without, at * The French expression, angine eouemieuse, is one which it is difficult to render satisfactorily in English, but the literal translation, which we have adopted, will be sufficiently intelligible. The disease is also called pseudo-membranous inflamma- tion of the fauces, membranous angina, diphtheritis, blood. I prescribed twelve leeches to the submaxillary regions (six on each side,) and 12 grammes (3 drachms) of bicarbonate of soda, in twelve powders, one to be taken every half hour, in a -i spoonful of sweetened water. " This was at nine o'clock in the morning. At one o'clock, the 246 Pitt of the Iodide of Iron. [April, patient had taken 8 grammes (2 drachms) of the bicarbonate. The leeches had drawn a large quantity of blood, which still flowed abundantly, evidently less plastic than in the normal state. As to the throat, the appearance of things was astonishing, and afforded me as much surprise as pleasure. The false membranes on the tongue remained, surrounded by a pultaceous, dirty -grey layer, which also covered the gums, where it was white ; but the plastic infiltration of the posterior fauces had completely disappeared; not a trace of it was left. In the space of four hours, a most alarming state of things, capable of inspiring the deepest anxiety, had wholly subsided. Was this owing to the influence of the bicarbonate of soda ? Such is my opinion. " In the evening, red points appearing upon the skin, announced the scarlatinous eruption, which was general and intense, and which had hardly begun to fade before it was followed by a mili- ary eruption of white, serous vesicles, very close together, on the neck and arms, accompanied by short paroxyms, during which the heart beat violently, as in the suetie. "I return now to the essential point in this communication, the disappearance of the diphtheritis in the throat, under the probable influence of an alkaline salt. In the first place, no conclusion can be established in therapeutics from a single case. Moreover, this instance is not so demonstrative as we could wish, since in my patient the diphtheritic angina was connected with scarlatina, and the pseudo-membranous angina of scarlatina is much less grave than the idiopathic variety. But, as I have already observed, there was one circumstance, its hereditary character, which gave to the angina, although scarlatinous, a peculiar gravity. Besides,, when we reflect upon so sudden a disappearance of the diphtheritis,. after the administration of the bicarbonate of soda, we can hardly fail to see in it an effect and a cause; and we may ask whether the same effect would not take place in idiopathic diphtheritis. "I have said that the object of the alkaline salt was to counter- act the excess of plasticity in the blood ; it might also have another mode of action, a local or direct effect upon the diphtheritis. This did not escape the attention of M. Trousseau, to whom I commu- nicated the case, which so much interested him that he desired to try the alkaline carbonates in the treatment of pseudo- membran- ous angina. The local effect which I have mentioned is easily understood,, since a gramme (15 grains) of bicarbonate of soda, in a teaspoonful of water, is rather hard to swallow, and 'scrapes as it goes down/ according to the expression of the patient." Blancwdr$ Pitt of the Iodide of Imn. Five years ago, M. Blancard, a pharmacien of Paris, proposed an unchangeable pill of the iodide of iron, made directly from its elements, which was officially approved by the French Academy 1856.] Pill of the Iodide of Iron. 247 of Medicine. The excellence of this preparation was generally acknowledged, and it is already, in France, the most common form for the admininistration of iodide of iron. Our pharmaceutical authorities at Philadelphia, however, adhere to the saccharine so- lution which Dr. Jackson introduced many years ago, and Prof. Bache declares that the solid iodide "might well be dispensed with." Practitioners will differ sometimes from the chemists, and so it has proved in this case. It is found that, notwithstanding the assurances of the self-constituted authorities, the syrupy solu- tion of iodide of iron, does undergo change: that it often injures the teeth, disagrees with the stomach, and contains free iodine. Consequently, as our dispensatory-authors and colleges of pharm- acy simply advise us, if we must have a pill, to evaporate their syrup, or to use the antiquated and unreliable process of Callond, practitioners have found it of advantage to import M. Blancard's preparation, which is now very commonly prescribed, not only in New York and Boston, where there are agencies for the sale of it, but in many remote country towns. And here we may take the liberty of recommending to the gentlemen who have taken on themselves the direction of pharmaceutical matters in this country, that they should not be too dictatorial or dogmatic, if they expect to retain the authority which has been conceded to their talents and learning. With these preliminaries, we give at length the process for pre- paring Blancard's pills, which we take from the Bulletin de VAca- demie de Medecine. It is founded on the volubility of ether, and the insolubility of the iodide of iron in this vehicle: Take of iodine seventy-seven grains; Iron filings thirty-seven grains ; Distilled water two and a half drachms ; Honey one drachm : and thirty-four grains ; Absorbent powder (say powder of Althaea) i a sufficient quantity. Make 100 pills. Place the water, iodine, and iron in a Florence flask ; shake the | vessel as the reaction takes place ; filter the green liquor that re- i suits, into a small iron capsule, the weight of which is known. Wash the flask, and filter with two and a half additional drachms j of water, slightly sweetened with a portion of the honey to be ; used in making the pills. Pour both liquids into the capsule, and ' evaporate, at first rapidly, then at a gentler heat, until the weight of the mixture is equivalent to the combined weight of the iodine and the honey (171 grains, or 3iij. nearly). Add a sufficient quantity -< of powdered althaea root, or, still better, equal parts of althaea and liquorice powder, about 3ij. Divide the mass into four equal j parts ; roll each part in powdered iron. Make each mass into a cylinder on an iron slab; divide each cylinder into twenty-five .pills, and roll each pill in powdered iron, to cover the iodide ex- 1 posed by the spatula. Expose the pills to a gentle heat that they ' may contract no moisture, and proceed at once to the second part < of the process varnishing the pills. 248 Congenital Phymosis. [April, Make a solution of balsam of Tolu in three parts of ether. Place the pills in a porcelain capsule, pour on them a portion of the ethereal tincture, and impress a rapid motion of rotation, that the pills may be moistened on every side, and that the ether may evaporate rapidly. As soon as the pills begin to stick together, throw them on a dry surface, separating those that are agglutinat- ed and leave them exposed to the air for twenty -four hours ; then dry them over a stove at a gentle heat. It is well to give them a second coating of varnish. Blancard puts them in a bottle with a stopper covered with silver, which is at once tarnished by the vapor of free iodine. Each pill contains abont one grain of iodide of iron, and one- fifth of a grain of powdered iron on its surface. Two to four pills daily is the ordinary dose in chlorotic, scrofulous, tuberculous and syphilitic diseases. C. E. [Gazette Med. Sardin. Buffalo Med. Jour, and Month. Review. The Simplest Operation for Uncomplicated, Congenital Phymosis. By T. Fueneaux Jordan, Esq., M. B. C. S. Not only are Surgical authorities of opinion that circumcision is rarely, if ever, necessary ; but those truly frightful slits, exten- ding half-way up the penis, to be seen in the pretty engravings which adorn some (of our best, too) Surgical manuals are fast get- ting into chirurgical disfavor. The present mania, however, of attributing uncomplicated, congenital phymosis in every case to the unfortunate mucous lining of the prepuce alone, and the prac- tice of heroically slitting up the same to the very point of its reflection from the penis, has arisen rather from the hypothesis of theorists than from the enlightened experience of acute ob- servers. The non-dilatability of the con geni tally phymosed prepuce is confined to the margin of the preputial orifice and to the skin and mucous membrane in its immediate vicinity ; such non-dilatability undoubtedly extending to a greater distance on the inner than on the outer aspect of the foreskin. The received opinion, touching the non-elasticity of the prepu- tial lining in its entire extent, is so far from being correct, that ordinarily such lining, for some distance anterior to its point of reflexion, is arranged in rugous folds, like all other mucous mem- branes that are too large for the organ they line, save when the peculiar function of that organ is being exercised. The opinion that the skin is not implicated in phymosed stric- ture, is equally incorrect. In one patient, on whom I operated with complete success, by far the tightest portion of the prepuce, after recovery from the operation, was the skin for two lines behind the cicatrices. 1856.] Congenital Phymosis. 249 From the above remarks, it will be inferred that any incisions, which extend further than the parts forming the margin of the prepuce, and for a short additional distance on the mucous surface, are unnecessary, and hence cruel. A single incision, however, as described, would fail to secure the retraction of the prepuce, not because the incision is too limited, but because a single incision cannot possibly relieve the whole circumference of the congenital- ly contracted preputial orifice two, however, or at most three, of the small incisions in question would afford complete relief. The mode of operating which I have adopted, and with signal success in its results, is this: Having first induced local anaesthe- sia, by applying pounded ice to the penis for two minutes, I introduce one blade of a pair of scissors (blunt-pointed, yet cutting to the end) to the distance of an inch, between the glans penis and the prepuce, on one side of the penis, at a point midway be- tween the frenum posteriorly, and the mesial line anteriorly. Both layers of the prepuce being divided to the extent mentioned, a similar incision is made at a similar point on the other side of the penis. The prepuce is now retracted to the extent allowed by the incisions, which by this proceeding are brought quite external, enclosing between their lips an uncut layer of lining membrane. This is divided on each side, by introducing one blade of the scis- sors, to the extent of, and immediately under, the original wound. The entire prepuce may then be retracted, apiece of wet lint wrapped round the penis, and the whole supported by a proper suspensory bandage. The patient need not lie in bed. Where three incisions seem preferable, they should be equidistant from each other, the third being at the mesial point anteriorly, the two lateral incisions should be a little nearer the frenum, than when two only are made. The incisions may of course vary a line or two, one way or the other in extent, according as the constriction is more or less ag- gravated. The recapitulatory points to which I would draw attention, are: 1. That the skin is more, and 2. That the mucous membrane is less, involved, than is gener- j ally supposed. 3. That two, or at most three, comparatively small incisions will afford complete relief. 4. That no assistant is required, and 5. No instrument save a pair of scissors. 6. Two or three small incisions cause much less irritation, and heal much more quickly than one large one. 7. That the patient need not lie in bed. [lied. Times and Gaz. 250 Nitrate of Silver in Burns. [April, Nitrate of Silver as a Remedy for Burns. By John WlLTBANK, M. D., of Philadelphia. I wish to call the attention of the readers of the Examiner to the value of the nitrate of silver as an application to burns and scalds. I have used it frequently both in deep and superficial burns, and I have been equally surprised and gratified by the re- sults. The advantages of the caustic application are numerous. It furnishes a complete protection to the inflamed surface, subdues the pain, arrests the serous discharge, changes the character of the inflammation, promotes a speedy cure, and if I am not mista- ken, prevents the formation of those ugly cicatrices and the irregu- lar contractions of the skin which so often occur in the healing of burns. The mode of application is simple. In superficial burns a strong solution 20 to 40 grains of the nitrate to the ounce of water should be applied over the whole surface with a camel's hair pen- cil, vesications should be opened and the surface carefully wiped . dry before the solution is applied. If the burn is deep and the discharge of serum abundant, the entire surface of the ulcer should be touched lightly with the solid stick. [Medical Examiner. Formic Acid in the Blood of a Person, killed by the Inhalation of Chloroform. The following note, received from a source which entitles it to credit, will be read with interest. "In the Journal of January 17th, an account of a recent death from chloroform in this city, was given. A quantity of the blood, removed at the autopsy, was placed in the hands of Dr. C. T. Jackson for chemical examination. He has ascertained that the blood contained formic acid, and that it could readily be separa- ted by distillation in the heat of a chloride of calcium bath. " Chloroform consists of formyle and three equivalents of chlor- ine; formic acid of formyle and three equivalents of oxygen. The three atoms of chlorine leave the chloroform and unite with the blood, while three atoms of oxygen leave the blood and unite with the formyle of the chloroform, replacing the chlorine and producing formic acid. Thus the blood is not only deprived of its oxygen, but it is so altered as to be incapable of absorbing vital air and the patient dies from asphyxia. The production of formic acid under such circumstances has never before been known, and of course it is to be regarded as an important physiological fact of no small practical moment." [Boston Med. and Surg. Journal. Anaesthetics in the Austrian Army. A circular has recently been issued, ordering that in future, the army medical officers shall always employ, for the purpose of in- 1856.] Editorial and Miscellaneous. 251 ducing anaesthesia, a mixture consisting of one part chloroform and nine parts ether, this being the proportion long employed by Dr. Weiger, a Vienna dentist. [N. Y. Med. Times. Pathology of Diabetes. M. Andral stated at the meeting of the Academy of Sciences (Paris) in July last, that in five cases of diabetes which he had examined after death, since the publication of the researches of M. Bernard, he had uniformly met with one alteration. He had found in each instance all the anatomical characters of a very in- tense hyperaimia, and different in its aspect from ordinary hyper- semia of that organ. The tissue of the liver of the diabetic patient, is everywhere gorged with a large quantity of blood. M. Andral regards this as being at the same time, a change peculiar to diabe- tes, and a proof of the sugarforming function of the liver. \N. Y. Med. Times. EDITORIAL AND MISCELLANEOUS. Another Bearded Woman. Our city has been visited this month by another of those anomalous beings heralded as bearded women. The sub- ject of this notice is announced as the " Bear Woman," " a most extraor- dinary nondescript," "a half-human half-beast creature," "otherwise called Julia Pastrana, a hybrid root-digger Indian, from California" !! The pamph- let sold at the door contains, as usual in such cases, certificates from " Dr. Mott " and other " distinguished physicians." We do not envy the taste of the "distinguished" members of our profession who would lend their names to such purposes of humbuggery. We are happy to say, however, that the valued and respected name of Valentine Mott is not among the -certifiers. But, lest we might do injustice to the "distinguished" gentle- men, we beg leave to append their own language : " Dr. MotCs Certificate. "New York, December 3, 1854. "Sir : To naturalists alone we leave the task of solving the enigma con- cerning the origin of Julia Pastrana, the ' Semi-Human Indian,' which would have puzzled the Sphinx. From her uncouth gait, it may be conjectured that the mysterious animal moves as if an elongation of the Spinal column should have taken place, producing a tail, which in consequence of human- ity predominating, has been denied. " She is a perfect woman a rational creature, endowed with speech, which no monster has ever possessed. She is therefore a Hybrid, wherein the nature of woman predominates over the brute the Ourang Outang, Altogether she is one of the most extraordinary beings of the day. "I remain yours respectfully, ALEX. B. MOTT,"M.D." 252 Editorial and Miscellaneous. [April, " From Professor Brainerd. "Cleveland, August 5, 1855. "Sir: In compliance with your request, I will state that I examined the hair of the specimen of the Genus Homo which you have in charge, and compared it with the hair of the African, under a high magnifying power, and from this comparison, have no hesitation in saying that the individual in question possesses, by this test, no trace of negro blood. Her other peculiarities, the hair upon the body, its length and structure, the form of the mouth and nose, the size of her limbs, peculiarity of her breasts, &c, and various other features, entitle her, I think, to the rank of a distinct species. Yours, truly, "S. BRAINERD, M.D." We must leave it to others to say how " a perfect woman " can be " a Hybrid, wherein the nature of woman predominates over the brute the ourang outang," to say nothing about the sapient conjecture of "the elonga- tion of the spinal column " which "should have taken place, producing a tail." It is assuredly not surprising that whole communities should be duped, when men in high places, and therefore supposed to be well inform- ed, certify to such nonsense. AVe do not know the meaning attached by the certifiers to the word Hybrid, and will not stop to discuss the value of this term as applied to varieties of the human family, or to mixed races; yet, notwithstanding their opinion as based upon an inspection of the hair, we think this woman's flattened nose, thick lips, projecting jaws, and swarthy complexion, testify unmistakably to the infusion of negro blood in her veins. Her straight hair is like that of our savage, or other blanches of the red family, who probably furnished the other element of her origin. Be this as it may, Julia Pastrana is an exceedingly homely bearded woman, and nothing else. Her arms and shoulders are not more hairy than those of many men. The whole of her forhead, nose and face is covered with a downy beard about one-eighth of an inch in length, but which, beneath the chin, reaches two or three inches. There is nothing uncommon in her person nor in her gait. Medical College of Georgia. The Commencement exercises in this insti- tution took place on the 3d day of March. The Dean reported that "there were one hundred and seventy students in attendance upon the course of Lectures just concluded ; of whom 119 were from Georgia, 22 from Ala- bama, 18 from South Carolina, 5 from Mississippi, 2 from North Carolina, 2 from Florida, 1 from Texas, and 1 from Nova Scotia." The Degree of Doctor of Medicine was then conferred by Ex-Governor AVm. Schley, Pre- sident of the Board of Trustees, upon seventy-three gentlemen, and the Honorary Degree of Doctor of Medicine upon Dr. John Harwood Burt, of South Carolina. An able and appropriate Address to the Graduates was then delivered by the Rev. Mr. Ryerson, which was followed by a chaste 1856.] Editorial and Miscellaneous. 253 and eloquent Valedictory by Dr; W. L. M. Harris, of I he graduating class. These interesting proceedings were attended by a large and respectable concourse of ladies and gentlemen. The Graduates were : A. G. W. Stephens, J. G. Brown, G. F. Smith, T. A. Boddie, W. L. Selman, G. T. Clarke, William Goulding, Thomas Burdell, J. 0. Holloway, W. R. Murphey, T. M. C. Rice, H. N. Mitchell, G. W. Walker, J. C. Orr, A. W. Henley, Thomas Searls, T. W. Tison, Asahel Beach, M. C. Cox, J. L. Hughes, G. W. Wasson, J. J. Scott, W. C. Neal, J. T. Handley, M. A. Roach, FROM TEXAS 1 J. W. Veazey. from Georgia: R. T. Barton, Benjamin Garrett, J. L. Eshom, J. D. Young, J. G. McMath, J. T. Dismukes, Z. C. W. Davis, S. J. Robert, Joseph Wise, J. H. Wallace, J. R. Powell, J. M. Burns, D. A. Mathews, W. L. M. Harris, J. D. Moore, V. H. Shelton, 0. H. P. Slaten, FROM SOUTH CAROLINA \ B. W. Glover, T. E. Jennings, W. T. McFall, FROM ALABAMA ". G. W. D. Lawrence, Elias Davis, J. W. Smith, 0. S. Means, E. M. Newman, J. S. Beazley, A. C. Neal, W. M. Greene, C. L. Blair, J. J. Hardin, T. B. Ford, J. W. Cochran, J. M. Dent, J. W. Proctor, H. W. D. Ford, J. M. Matbis, John S. Bell, A. M. Parker, 1. J. M. Goss, A. C. Mathews. D. T. Riley, Charles Agar, A. J. Nagel, Job Thigpen, L. M. Underwood, J. F. Reynolds. FROM MISSISSIPPI ! D. S. Watts. Medical College of Savannah. The following gentlemen received their diplomas at the commencement, on the 6th March : E. L. Burton, J. S. Butts, Thomas Charlton, John Eckhard, James God- frey, D. O. C. Heery, G. P. Padelford, R. W. Skinner, R. E. Campbell, J. H. Hendry, J. S. Thomas, and A. A. Watts. Oglethorpe Medical College. The first annual commencement of the Oglethorpe Medical College of Savannah, took place on the 8th March. The following are the names of graduates : John W. Barber, S. D. M. Byrd, James A. George, J. J. Jones, W. J. Orr, Wm. M. Marsh, John A. Mayer, and John A. Owens. 254 Editorial and Miscellaneous. [April, Savannah Spring School of Medicine. An organization under the above name has been formed in our sister city. The term of Lectures is to be from the middle of March to the end of June. The lecturers are Holmes Steele, M. D., on Obstetrics, the Physiology of Generation, and Diseases of Women and Children ; John M. Johnson, M. D., on Medical Chemistry and Materia Medica ; Joseph J. West, M. D., on Anatomy, the Physiology of .the Viscera, &c; and Charles H. Colding, M. D., on Minor atud 'Operative Surgery. Fee $50, in advance. Medical Society rsv Bostwick, of New York city, Oliver, of Boston, Mass., Morton, of Nashville; Tenn., and Smith, of Vermont, are stationed at Odessa. Thirteen others have served in the Crimea, of whom five have died there; seven have re- turned, and one died at Berlin, on his way to America;. Dr. Draper, of New York, died of typhus fever at Sebastopol, on the 19th of March, 1855*. Dr. King, of Charleston, S. O, died of typhus fever at Kertch, on the 20th March, 1855. Dr. McMillan, of New Orleans, died of cholera at Sebasto- pol, in June, 1855. Dr. Jones, of Maryland, died of cholera at Simphero- pol, on the 24th of October, 1855, and Dr. Deninger, of Reeding, Pa., died of cholera at Simpheropol on the 25th of October, 1855. Dr. Stoddard, of Baltimore, Md., died at Berlin, on the 21st January, 1856. Over the- graves of Drs. Jones and Deninger, a very pretty monument has been erected by their comrades, and at the time of the taking of Kertch by the' allies, a monument to Dr. King was in process of construction, the monu- ment being erected by the city authorities. Drs. Harris, of New York, Turnipseed and Davega, of South Carolina, Henry, of Mobile, Ala., El- dridge, of Maryland, Read, of Norristown, Pa., and Holt, of Georgia, have retired from the Russian service. \Cor. N. Y. Herald. The March number of the New York Journal of Medicine, contains an able paper from the pen of Dr. John W. Corson, "On the Effects of Lead on the Heart," in which the author arrives at the following conclusions : 1. That allowing a due excess of force to carry on the embarrassed circulation in organic affections of the heart, it appears that certain symp- toms in slow poisoning from lead, as well as in cardiac disease proper, typhus fever, and apparent death from catalepsy or other causes, all tend to prove that, as a rule, the impulse may be termed the pulse of the heart ; and that, its more careful study than heretofore, may aid us in the general diagnosis and treatment" of disease. 2. That the symptoms of weakening of the heart in lead poisoning, are confined to cases of partial paralysis, or general muscular debility, j accompanied usually by the purple streak of the gams, indigestion, consti- | pation, pains in the head, muscles, or joints, and sometimes by lead jaun- i dice; and that commencing and emphasizing with the most frequent, these heart symptoms from lead are : weakened or soft tapping impulse ; faint- ness on unusual exertion ; feeble and generally slow pulse ; palpitation ; cardiac uneasiness ; and to these are occasionally added, great despondency 256 Editorial and Miscellaneous. [April, or morbid fear of death ; suspicions of organic disease of the heart, fainting fits, night-mare, or troubled dreams. 3. That these depressing heart symptoms are absent in the earlier and more acute stage of lead poisoning, known as " lead colic" when, on the contrary, the stimulus of pain generally renders the impulse of the heart and the pulse at the wrist more firm than natural. 4. That skill in the detection of minute variations in the impulse of the heart, naturally requires a little careful attention and practice. 5. That these debilitating effects of lead most commonly occur in hearts previously sound, hut they sometimes complicate existing organic cardiac disease from rheumatism or other causes. 6. That the agencies or causes of lead poisoning are very numerous, and often obscure ; and that slighter cases supposed to be ordinary dyspep- sia, constipation, debility, or bilious colic, are frequently undetected. 7. That the above tests of the immediate influence of lead on the heart in disease, are further corroborated by experiments upon animals; showing that, more mildly and slowly, lead, like digitalis, oil of tobacco, upas antiar, the woorara, and some other poisons, tends specially to paralyze the central organ of the circulation, and, like these, ultimately to produce what Bichat termed " Death by the heart." 8. That the remedies for the paralyzing influence of lead may be divided into two classes: Disinfectants, such as the iodide of potassium, and pre- parations of sulphur ; and Antiparalytics, such as strychnia and electricity ; that the best treatment combines these two elements; and that, on the whole, the most convenient and efficacious are free doses of the iodide of potassium, and minute proportions of strychnia or nux vomica. 9. That the above conclusions are founded mainly on the evidence of ten cases, principally among the badly-nourished and improvident poor finally resorting to public institutions; and they may possibly be some- what modified in future by more extended observation in private and more favorable practice. Vaccine Matter. As it may be interesting to physicians to know where fresh vaccine matter can be obtained, we insert the following: " Physicians wishing Vaccine virus, by addressing Dr. Win. Hutson Ford, City Vaccinator, Charleston, S. C, and enclosing one dollar, will receive, by return mail, ten points, or a set of glasses charged with fresh virus; or, by particular desire, a recent scab. Seventy -five points, or seven sets of glasses, will be sent for five dollars." Results of some Statistical and Physiological Researches on Twins. At a meeting of the French Academy of Sciences, Nov. 26, Mr. Baillarger read a paper containing the results of some statistical and physiological researches on twins. We have thought the subject presents some features which might interest the readers of the Examiner. "Numerical distribution and relative proportion of the sexes in twin births ; hereditary influence. "I. The facts group themselves into three categories: "The first, two boys at a birth. " The second, two girls at a birth. 1856.] Miscellaneous. 257 i " The third, a boy and a girl. "The result obtained in computing 256 double births- shows : Two boys in . . . . . 100 cases. Two girls in .... 5& "" One boy and one girl in 9"& "" " It would seem as if the presence of two boys in twin pregnancies is> almost twice as frequent as that of two girls. And also* that the third, class, that of the presence of the two sexes, is almost eqsal to the first. "II. The solution of the second question, viz: the- selative proportion follows from the above figures. In 512 twin children are found: Girls, 214; Boys, 298i "The number of boys exceeds that of girls, therefore, by more than one1 third. This result will certainly seem remarkable if we- bear in mind that the proportion of the sexes in the totality of ordinary birth. \ is of 16 girls for 17 boys. So that the difference is in the one case more- than a third, and in the other, only a sixteenth. The relative proportion of the two- sexes is governed then in twin pregnancies by special laws, quite distinct from those which govern normal births. This fact, interesting, in itself, becomes still more so when compared with the documents already collect- ed by M. Flourens on the proportion of the sexes in animals, in which the- predominance of males over females is one sixth instead of one sixteenths I would connect the great predominance of the male sex in twin births with another fact, which is deduced from the general statistics of births,, and which at first sight may seem strange. I refer to the far greater pro- portion of boys among still-born children. This amounts to IT boys to 12* girls. This singular predominance of boys among still-barn children canr in my opinion, be in part if not fully accounted for by the excess of the- male sex in twin births, which furnish, as is well known, a pretty consider- able contingent to the statistics of still-born children. " III. Twin births are hereditary in certain families, but in different de- grees and different conditions. A large number of facts show, that the- daughters of mothers who have had twin pregnancies, have often them- selves two children at a birth. This disposition occasionally passes over lone generation, when the grand-daughter instead of the daughter has one- 'or several double pregnancies. "The facts which I have collected would seem to prove that this heredi- tary disposition is transmitted also through the male. Seme- men would thus have the faculty of procreating two children at once-, althouo-h no such hereditary disposition existed in their wives. This fact would hare a great physiological importance, and I admit that it should be based on in- disputable proofs. I merely indicate it now, and will return to- ft in a future paper. "Before closing, it may not be improper to call attention to- the fact, that the hereditary disposition of which I have been treating, seems to have been taken advantage of to obtain among animals, species which procreate two young instead of one. Flocks of sheep have thus been formed, con- sisting of individuals which normally bear two lambs. Single birth among them become the exception instead of the rule. I have seen a flock com- posed of nearly one hundred head of sheep, of which each ewe annually brinsre forth two lambs." 258 Miscellaneous. Robert Collins, in his Practical Treatise on Midwifery, gives the result of 16,654 births, occurring in the Dublin Lying-in Hospital, during a period of seven years, from 1826 to 1833. Among these, as appears in a table, pages 164 and following, (Am. Ed.,) there were 240 twin births, in which the sex of the children is mentioned. By a computation of this table, we arrive at results relative to the numerical distribution and proportion of the sexes, materially different from those which Mr. Baillarger's facts would lead us to expect. Thus in 480 twin children, there were : Girls, 234 ; Boys, 246; distributed in the following manner: Two boys in . . . . 73 cases. Two girls in .... 67 " One boy and one girl in . . 100 " By these figures, the presence of two boys in twin pregnancies is only one- eleventh more frequent than that of two girls, and the presence of the two sexes is more than one-fourth more frequent than that of two boys. The number of boys exceeds that of girls by only one-fifteenth, a result but little larger than that obtained from the totality of ordinary births, viz : one-sixteenth. On the other hand, if we turn to the statistics of the same Hospital, as reported by Alfred H. McClintock and Samuel L. Hardy, for the three years of their connection with the Institution, from Jan. 1st, "1842, to Jan. 1st, 1845, (Practical Observations on Midwifery, p. 329,) we find that during that period, there were 6,634 births, of which 95 were twin births. In these there were: Girls, 79; Boys, 111; distributed thus: Two boys in .... 38 cases. Two irirls in .... 22 " One boy and one girl in 35 " Here we are struck with the similarity of the relations existing between the above figures and those which Mr. Baillarger found to exist between the facts collected by him. The presence of two boys is eight-elevenths more frequent than that of two girls, while in Mr. B.'s cases, it is twenty-one twenty-ninths, or the same thing. The presence of the two sexes is less than that of two boys, as with Mr. B., though not quite so near being equal. The number of boys exceeds that of girls more than one-third, as in Mr. B.'s cases, the ratio differing but a unit. [Medical Examiner. Albany Medical College. The donations to the Albany Medical College have amounted to $75,000. Of this sum, $50,000 have been expended in buildings, land, and for the support of the institution during the four years of its existence leaving a surplus of $25,000. Thirty gentlemen of Albany contributed to its permanent endowment $1,000 each. [N. Y.Med. Times. Asylum, for Inebriates. A petition is before the Massachusetts Legisla- ture, praying for the establishment of an Asylum for Inebriates, wherein they may receive such treatment as shall restore them to soundness of health and sanity of mind; and also to afford such facilities as shall render the asylum a self-supporting institution. [lb. SOUTHERN MEDICAL AND SURGICAL JOURNAL. (NEW SERIES.) Vol. XII.] AUGUSTA, GEORGIA, MAY, 1856. [No. L ORIGINAL AND ECLECTIC. ARTICLE XIV. IETTERS FROM SAUL. D. HOLT, M. D., UPON SOME POINTS OP GENERAL PATHOLOGY, LETTER NO, 11. Montgomery, Ala,, March 20th, 1856. Messrs. Editors In a few prefatory remarks in my first letter I j stated that I had no motive in offering my views upon certain l medical subjects to the profession, beyond a desire to add my tes- timony to the truth or falsity of the principles and the practice of medicine in the present day, which, of course, will be understood 1 as being confined within the limits of my own observation and experience, otherwise I should consider my testimony as worthless, I and would have spared myself the trouble of writing it out, and you of reading it ; and I may add, that this desire is strengthened ! by a sense of duty which I think is incumbent upon every man, who has devoted the greater portion of his life to the alleviation of ; the sufferings of his fellow beings, (especially if he is conscious of having been generally successful,) to let his views and plans (by ' which he has accomplished the greatest good) be known, whether they have resulted from his own unaided observation and experi- ence, or whether he has acted merely upon the suggestion of others and followed out plans which had already been laid down for his direction. Now, the testimony which I have to offer in favor of the value and efficacy of calomel in the treatment of most of the malignant N. S, VOL. XII. NO. V. 17 260 Holt's Letters upon General Pathology. [May, fevers, and other diseases of our climate, though by no means novel or original, is nevertheless the result of my own experience, and more particularly is it so with regard to the modes of its adminis- tration, and the peculiarity of its effects, according to the manner of its administration. I can not expect, however, that my testimo- ny will be received by the profession with much favor, when there are so few who have the boldness and independence to avow themselves the advocates of its use, or, are willing that the world should know, or believe, that they ever used it at all in their prac- tice. Some such / wot of, who boldly discard this, and other cardinal remedies, and endeavor to foist upon the profession, as their substitutes, such articles as phosphorus, bryonia, and aconite E Well, it is not for me to say who shall believe, and who not; it is only my business to testify, and all that I ask of the profession is to award to me the candor and honesty of purpose equal, at least, to my zeal and devotion to my profession, the honor and dignity of which I have so long endeavored to uphold. In -my last letter, I gave, in support of my views upon the uses of calomel, some testimony which was very good as far as it went, and upon high authorit}7. But Dr. Wood, upon some of the most important points, namely, the use of large doses of calomel, gave us only heresay evidence. I now introduce a witness, who is not only able to testify to all the points which I wish to establish, but he does it from his own knowledge,4which renders his testimony the more valuable. Doct. Jno. E. Cook, whose general principles I can not endorse, on account of his extravagant and ultra cathartic notions, which Avere at one time very popular in the western coun- try, has done more to bring calomel into disrepute, by combining it with drastric cathartics, than by the quantities used, which were often unnecessarily and extravagantly large, notwithstanding which, his observations with regard to its peculiar properties, its mode of action, its value, and efficacy in certain diseases and con- ditions, will be found to be correct, by any one who has the bold- ness to test them by practice ; and those who have not, are not competent to sit in judgment upon them. His general views, with regard to the cathartic action of calomel, are, that it draws directly from the biliary ducts, and relieves the vessels of the liver, and others connected with it, of engorgement or congestion; while ordinary cathartics draw upon the arterial capillaries, which open upon the internal surface of the intestinal canal. But I will let 1856.] Holt's Letters upon General Pathology. 261 him speak for himself. As a cathartic, he says: "Calomel is slow in operation, often requiring twelve hours ; it does not operate frequently, but the discharges are large ; it gripes little or none, in general, and is perhaps the most effectual medicine known in producing consistent discharges from the biliary ducts." Speaking of the difficulties often to be encountered in the treatment of au- tumnal fevers, Dr. Cook says: "These are a great disposition to serous discharges from the bowels, .... and extreme irritability of the stomach, in consequence of which almost every medicine is rejected as soon as swallowed." Now, these conditions I have seen presented by the opponents of calomel, as cases unsuited to the action of calomel, and they have argued that calomel, not only aggravated, but often produced them. But I have no doubt that in these cases, as in many others, calomel has been made to bear the sins of other remedies with which it has been coupled or combined. A notable instance may be found in Wood's Practice, which deals calomel a hard blow, on account of the quarter from which it comes. Under the treatment of Pernicious fever we find the following: "Not long since, under the notion that congestion was the evil to be encountered, copious bleedings and large doses of calomel were the remedies most relied on by many practitioners. Experience, however, has proved the frequent inefficiency and even danger of this practice, and the pro- fession generally are rapidly abandoning it." In this case, it is very certain that calomel has to suffer for being caught in bad company, as, on the next page, we find its character somewhat cleared up by the following sentence: "Another remedy which i3 decidedly called for, is calomel." But to return. My experience is most decidedly with Dr. Cook, who says, "The disposition to serous I discharges is readily overcome by the use of calomel ; and it is a i remedy that will not fail. There is almost no danger of exciting , ptyalism, while these serous discharges continue, and therefore there ought to be no hesitation in administering calomel, until dark and consistent discharges are obtained. If the case is urgent, from a j scruple to a drachm should be given at once, in order to obtain the desired effect as speedily as possible, and repeated, according to j the necessity of the case." Of irritability of stomach, Dr. Cook |says, "In some cases there are incessant and violent efforts to vomit for days together, or even until death. I have, in these cir- cumstances, given, with the best effect, a drachm of calomel. It 262 Holtts Letters upon General Pathology. pfay, produces a copious, tenacious, or viscid discbarge, of a deep green r nearly black color, and affords the roost marked relief. It very frequently happens that a physician will not venture, as he terms itr to give so large a dose, but will not hesitate to persist for days in repeating small doses, until they far exceed the quantity which, given at once, would have completely succeeded ; thus the risk of salivation is incurred, without obtaining the full benefit of the cathartic operation for it is to be remembered, that one or two large doses often so completely remove the irritable state of the stomach, that the case may be afterwards managed without calo- mel, , , It is exceedingly rare to find a patient require more than % dose or two, of the size above mentioned, to effect the object in view.'f For fear that I may be accused of having borrowed my views, with respect to calomel, from Dr. Cook, I will state that, until very recently, I had never read a page from that author in my life. A young professional friend, knowing that I was engaged in writing out my views, and knowing also that I entertained opinions, which, if not peculiar, were not entertained generally by the pro- fession, and supposing that I might find something corroborative or confirmatory of my views and opinions, placed his book in my hands, in which I find so much, which so perfectly coincides with my own experience, that I almost feel at a loss sometimes whether I am writing out Dr. Cook's notions or my own, so far as the ac- tion of calomel is concerned. This is my apology for drawing so largely upon Dr.. Cook's- book, with which I am not entirely done yet Dr. Cook, after giving the statement of a case, in which he gave a boy a little over an ounce and a half of calomel in seven- teen days, with good effect, says, "The risk of salivation in these extreme cases is less than is- supposed. I have never known a pa- tient in the circumstances, as above stated, absolutely requiring some- energetic mode of procedure, to be badly salivated after taking the I'avgest dseef ~&r. Cook further says, M I have even known salivation cured by purging with calomel alone,"' After giving the particulars of the case, and stating the condition of the patient, who, he says, was pale ; the pupils- were dilated; was restless and a little delirious; the stomach rejecting every thing, even watery the mouth sore, and saliva abundant he states that he gave his patient a drachm of calomel each, day, for six successive days -, a* 1856.] Holt's Letters upon General Pathology. 263 the end of which time the patient could sit up and eat, and every appearance of soreness had ceased in the mouth. One more draft upon Dr. Cook, and I will close with his evi- dence. "Many," says he, speaking of salivation, "consider a patient safe, as soon as this affection of the mouth appears. This opinion is, however, erroneous. The safety of the patient depends, not on producing ptyalism, but upon daily evacuations of consist- ent bilious matter. Without the latter, in cases of any violence, the patient will die, even in a state of salivation ; having tiiem, he will get well without it" I will now give a summary of the testimony, which I have ad- duced in support of the views which I have expressed in my last letter, respecting some of the peculiar properties of calomel, some of which are not recognized or acknowledged generally by the profession namely : That, as a catartic, calomel acts directly upon the vessels of the liver, and not, like most other remedies of that class, upon the mucous surfaces of the intestinal canal; that it is slow in its operation, and produces few, but large discharges ; that it is little or not at all irritating, and that it is the most certain and effectual medicine known for producing consistent bilious dis- charges. (I will add, that the sooner these effects are produced, in all cases which require its use, the better it will be for the pa- tient, and the less will generally be required ; hence the necessity of giving it in full doses, or in such quantity as will soonest effect the object.) That in those irritable conditions of the bowels, at- tended with frequent serous discharges, which are always trou- blesome and often dangerous, calomel is the best remedy, and will very certainly afford relief, if its use be persisted in until its action is impressed upon the liver ; that large quantities are sometimes required to accomplish this, and that while these serous discharges continue, or while the condition lasts, which gives rise to them, there is little or no danger of producing salivation. (The ease pre- sented in my last letter is very conclusive upon these points, and I have several others, to the same effect, though none which re- quired so large an amount of calomel.) That in cases of irritability of stomach and obstinate vomiting, calomel in a full dose will generally arrest it promptly, even before it has time to act upon the liver, and when arrested in this way, it is seldom apt to re- cur. (I have an innumerable quantity of cases demonstrative of this fact.) 264 Holt's Letters upon General Pathology. [May, With regard to the statement of Dr. Cook, that he had known salivation cured by purging with calomel, I must say that he has taken my thunder, as I have a case of the same kind to report, and thought I stood alone, never having heard of any other case of the same kind. As it is a practice, however, which should be resorted to only in extreme cases, I will give it notwithstanding. I con- cur with Dr. Cook, in opinion, that the risk of salivation in those extreme cases is not as great as is generally supposed ; and that the largest doses, seldom produce it. This is explained by the fact, that large doses will act soonest and most effectually upon the liver, whereby a repetition of large doses are generally rendered unnecessary, and that in cases requiring a repetition of the doses, such as have been mentioned, attended Avith an irritable condition of the bowels, and serous discharges, which generally depend upon plethora or congestion of the portal veins. Thus a double barrier is placed in the way of its action ; for while the plethoric state of the vessels retards absorption, the serous discharges from the arte- rial capillaries tend to hurry it away from the absorbents. It may be, too, that the same torpor, or insensibility, which would retard its jurompt action upon the liver, would pervade the whole system, and prevent its action upon the other organs ; but this is not pro- bable, as we sometimes see salivation produced from the repeated administration of small doses of calomel, while the liver remains insensible to its action, and the disease goes on unchecked, as be- fore, Such are the cases in which Dr. Cook says, he has known "salivation cured by purging with calomel alone." In such, I have seen both the salivation and disease removed by zfull cathar- tic dose of calomel. The safety of the patient does not depend upon salivation, but upon the prompt action upon, and the unload- ing of the vessels of the liver, While some physicians hail the appearance of salivation as the harbinger of safety to their patients, there are others who dread its appearance to such a degree that they will not venture to uso calomel at all, whether from a regard for the welfare of their pa- tients, or a greater regard for their own reputation, I will not de- cide. The popular sentiment, however, is unquestionably against it, under any circumstances, and so am I. Salivation is not what we want in the malignant and death-dealing diseases of the South; and if calomel is properly used, in these diseases, there is generally little or no risk of exciting it. Now, it is not always becoming 1856.] Holt's Letters upon General Pathology. 265 for one to speak of himself but professing to speak far myself, I may be allowed to say not, however, in an arrogant or boastful spirit that the success which I have had in the use of calomel, (for which, I am not too modest to acknowledge, the professional brethren, acquainted with my practice, have awarded to me a full share of credit,) has been, in a great measure, the result of the manner in which I have used it; and the few general rules which I have observed in the use of calomel have been after determin- ing the necessity of its use, then to use it in such a manner, and in such quantities, as will soonest accomplish the purposes for which it may be used ; and when this is done, then to discontinue its use. Now these rules, though few, and apparently very simple, to be reduced to successful practice, requires the exercise of judgment, prudence, and discretion; for if cannot be denied, that the evils re- sulting from the use of calomel have often been from a lack of these, and that it has often been used when it was not required; has been used under circumstances, and in such manner, and in such quantities, as to produce its worst, without its good effects, in cases in which it was required; and has often been continued after its use had ceased to be necessary. From observing these few rules, (the minute details of which I purpose giving hereafter, such as the circumstances which indicate the necessity of its use the time and manner of its administration, and the quantity necessary in each case ; the signs for its discontinuance, &c.,) which I have found little difficulty in reducing to practice, on account of popu- lar prejudice; having always been an open and avowed advocate of the use of calomel, I do not hesitate to declare that, with it, I have been the means of doing more good, and saving more lives, than with any, and I might say, all other remedies. Quinine, which may also be styled a life-preserving remedy, stands next to calomel, in value and importance, each having the highest claim upon the profession in their respective spheres of action ; for while calomel possesses the power of often rescuing or snatching a man from the jaws of death quinine has the power of keeping him out of them. Opium, too, has its claims ; and though high in the sphere of its action, which is more extensive than either of the others, it can be regarded only in the light of an auxiliary remedy. These, with the lancet, may be said to constitute the four cardinal remedies of the profession, with which, under proper management, the most malignant diseases may be successfully combatted. 266 Holt's Letters upon General Pathology. [May, Now, these remedies can aid each other in the work of preserv- ing life, but they cannot perform each others' work. Can quinine unload the liver and bowels? can it restore suspended secre- tion ? can it stop vomiting and purging ? can it eliminate poisons from the system ? Calomel can. Can calomel break up the peri- odicity of disease? can it prevent or remove depression, conges- tion and collapse ? can it give tone and energy to the nervou8 system? Yes, to a certain extent it can do all these things, though not so well as quinine. Can calomel and quinine subdue a burning fever, arrest a raging inflammation, or assuage a throb- bing or an aching pain ? Only to a limited extent, and in an indirect manner ; yet the lancet and opium will do it promptly. Is it not strange ! "passing strange!" that with all these things, full in view, there are physicians in our midst, whose opinions ought to be entitled to credit, who have openly denounced some of these remedies, (calomel and the lancet in particular,) as unsuit- ed, or unsuitable, in the treatment of some of our most formidable and dangerous diseases, and have offered us for their substitutes, phosphorus! aconite! and hryonia! Nor is it less strange, that large numbers of our southern physicians should have assumed, that the free use of quinine will enable them to dispense with the use of calomel in our dangerous diseases, and malignant epidemics. And, stranger than all, that there should be some old and long tried physicians, who advise that little or nothing should be done, alledging that one system, and set of remedies, work about as well as another, and all are of no avail. Now, to show all this matter up in its true light, I will give you an allegory: A poor fellow accidentally fell into a river, and in the act of drowning, called to some men on the shore for help. They had at hand a boat, and life-preserver, and a bundle of straws. One of them said to the other, I will throw him my life-preserver, it will hold him up better than the boat ; besides, I do not know much about boats, and I am told that they are dangerous things any way : so he threw him the life-preserver. Another one said, that's just what I think about boats ; they are dangerous and use- less things to my certain knowledge, for I have tried them often; let me throw him some of my straws. The third one said, I know the boat will not do under any circumstances, and I have no con- fidence in your straws, or your life-preservers either one is as good as the other ; let us watch him until he drifts ashore, and then 1856.] Dugas. Cases of Lithotomy. 267 we will help him. So the poor fellow drowned. And when the facts came to be known, how they had all refused to send him the boat, when they might just as easy have saved his life, the people all thought that it was very strange, that the men did not send him the boat, and give him a chance, at least, for his life. Some said they thought it a very cruel act, not to send him the boat ; others said they thought that it was a very foolish one ; but the men themselves did not seem to think or care much about it, and it all soon passed off and was forgotten. Finding that I shall not be able to make a statement of the cases, which I had purposed doing, illustrative of the more important points concerning the action of calomel, I will reserve them until I come to speak of the diseases to which they respectively belong. Having generalized to a sufficient extent, in my next letter I will make a summary review of the general principles which I have maintained, and afterwards will make a therapeutic applica- tion of them to some of our more formidable diseases. It is said that "drowning men catch at straws." For mercy's sake, let us offer them something better ; and if I can persuade one man only, that there is not so much danger in a boat, I shall consider myself well paid for my trouble. Respectfully yours, &c. Saml. D. Holt. ARTICLE XV. Cases of Lithotomy. By L. A. Dugas, M. D., &c. Case I. Henry S., the son of a highly respected professional brother of Coweta county, in this State, had experienced the usual effects of stone in the bladder from early infancy until the age of six years, when the bi-lateral operation of lithotomy was perform- ed in June, 1851. This operation was, however, productive of only partial relief, as he continued to suffer, although at first less severely than before it. In a short time his symptoms became as bad as ever; the wound, instead of healing as usual, was at the end of three months reduced to the size of a quill, and finally closed entirely about three months later. The little patient was brought here and placed under my charge in February, 1853. On endeavoring to sound him, I found that although the integuments cut in the previous operation had healed, 268 Dugas. Cases of Lithotomy. [May such was not the case with the urethra, for the sound would pass from this caual into a pouch in the perineum, and could be felt just within the thin skin which covered it. This circumstance rendered catheterism somewhat difficult, as it was not easy to carry the sound into the canal beyond after it had entered the pouch. I succeeded, however, in detecting a large calculus, and at once determined to operate. On the 22d February I performed the bi-lateral section, under the influence of anaesthesia, and seized the calculus, which crumbled into pieces on endeavoring to extract it. The scoop was then used, and about a table-spoonful of chalk}- -looking fragments removed. The bladder was carefully explored with the finger until every particle was brought away with instruments and re- peated injections of tepid water. On the seventh day the wound had entirely closed. The child returned home, with the injunction to use vegetable acids as freely as possible, so as to prevent a reproduction of the calculus, which was evidently ammoniaco-magnesian. How long these instructions were carried out I am unable to say. In a letter received from his father, I am informed that the child "for twelve months after the second operation enjoyed fine health, and was growing rapidly, without any symptoms of a return of the disease. After the expiration of this time he was attacked again, and suffer- ed as much as he had at any time previous, discharging quantities of pure pus, occasionally mixed with a little blood and small frag- ments of stone, which very much resembled those you extracted. He continued in this way some two or three months, suffering by paroxysms, when he was suddenly attacked with violent colic, ac- companied with vomiting and purging, which terminated fatally in two or three days." He died on the 27th September, 1854. Remarks. This case derives interest not only from the fact that the patient underwent at so early an age two operations of lithotomy, but also from the persistence, or rather recurrence, of .the calculous diathesis even after the second operation. I say recurrence, because there is no evidence of any reproduction of the disease for upwards of a }'ear after the second operation. From the little relief afforded by the first operation, the non-closure of the wound for many months, and the continually increasing severi- ty of the symptoms, it may be questioned whether some portions 1856.] Dugas. Cases of Lithotomy. 269 of the calculus had not been left in the bladder. Yet the opera- tion was performed by an experienced surgeon, who could hardly be presumed to have committed such an error. I am informed by the parent that the first stone was of the same character as that I removed, and that it was likewise crushed in the extraction. Case II. James F., of Dooly county, about twelve years of age, had suffered with symptoms of stone in the bladder from early childhood, but his general health was unusually good. Finding, upon examination, that the calculus was small, I determined to try to crush it with the lithotrite. Dilating bougies were accord- ingly used some days, but occasioned so much irritation in the urethra that they had to be discontinued, and I had to wait until this had subsided before making any further attempts. His ure- thral canal being very small, a correspondingly small lithotrite was passed into the bladder, and the stone seized ; but its hardness was such that it could not be crushed by any force that could be applied without danger of breaking the instrument. A few days later another attempt was made, with similar result. Lithotomy being now the only alternative, the bi-lateral opera- tion of Dupuytren was performed on the 29th July, 1855, under the influence of concentrated chloric ether, and a calculus of oxalate of lime removed. Its shape was a flattened ovoid, seven-eighths of an inch long, three-quarters of an inch wide, and half an inch thick. It weighed seventy grains. No unpleasant symptoms manifested themselves, and on the 9th August, being well, he returned home. Case III. Columbus A., of Columbia county, had experienced symptoms of stone from early childhood, and was very much emaciated and debilitated. Although in his eighteenth year, his physical development had been retarded by excessive suffering to such a degree that he did not appear to be more than ten years of age. For several years his urine was continually dripping, so that there was rarely any accumulation in the bladder. Sometimes he would pass off once in the course of twenty-four hours as much as two or three ounces of urine. It was remarkable that moderate walking, or riding in a carriage, did not aggravate the symptoms. Having been put under the anaesthetic influence of chloric ether, the bi-lateral operation was performed on the 13th November last, 270 Dugas. Cases of Lithotomy. [May, and an hour-glass shaped calculus was removed, of which the ac- companying wood-cut is a faithful delineation. It weighed about an ounce and a half, and was composed of ammonio-magnesian phosphate of lime. Upon making a longitudinal section of this calculus with a fine saw, a nucleus of darker and more dense material was found occu- pying the centre of the neck, and projecting about equally into the two enlarged portions of the stone. This nucleus presented more length than breadth, being about three-fourths of an inch long and half an inch wide. The shape and size of this nucleus will serve to account for the position occupied by the calculus, the large ex- tremity being found to be within the bladder, while its lesser end was in the urethra, and its neck consequently grasped by the orifice of the bladder. It would therefore seem that while small, as represented by the nucleus, it attempted to escape from the bladder, but was caught at the origin of the urethra, and remained there until by deposits upon its surface it reached its present dimensions. The deposit being more copious within the blad- der, this portion of the stone grew faster than that in the urethra. The abnormal position and form of the calculus rendered the introduction of instruments quite difficult, and much care was required not to break it in the extraction. On being removed, the pouch in the urethra was found lined with soft detritus, which had to be scooped out. The bladder was then carefully and re- peatedly washed out until no vestige of fragment remained. On the fourteenth day after the operation the patient began to pass his urine per urethram, and he went home on the 10th of December. 1856.] Placenta Prcevia. 271 The wound finally closed a few days after. He has continued to improve ever since, and is now in fine health. The position of the stone and its consequent immobility will explain the stillicidium urinas and the non-aggravation of symp- toms by walking and riding. Observations on Hcemorrhages arising from Imjjlantation of the Placenta upon the Cervix of the Uterus; with Pemarks on the Pathogeny and Therapeutics of this Accident. By M, Legroux,. Physician to Hotel-Dieu of Paris, Agrege Professor to the Facul- ty, etc. etc. Haemorrhage consequent upon the insertion of the placenta over the cervix of the womb, has, latterly, been the subject of much dis- cussion, both in learned societies and medical periodicals. The most complete and important document which has appeared among recent publications is Dr, Depaul's report* to the Academy of Medicine on a case of complicated labor, communicated by Dr.. Gerard. More recently, Professor Dubois has taken up this matter in his- clinical course ; and his lectures, which first appeared in the Jour- nal de Medecine et de Chirurgie Pratique, have been very generally republished. After such imposing authorities in obstetrical matters have given their opinions, I almost fear to enter on the question, or to give the results of my personal experience. For, if I have observed and appreciated facts aright, the generally admitted doctrine in respect to the pathogeny of placenta praavia must be laid aside. If I am not deceived, some of the precepts of the masters of obste- trical art must be modified or revised, and a new therapeutical element must find a place in their teachings. May the desire and hope of being useful to humanity justify the boldness of my un- dertaking f In the first place let me briefly recall the reigning doctrine ob the pathogeny of this haemorrhage. " It is generally admitted that the flooding becomes more profuse as labor advances, and the separation of the placenta, from which the haemorrhage- arises, becomes more considerable; that whatever increases the uterine- contractions necessarily augments the bleeding; that the means of arrest- ing this are precisely those which suspend the contractions, for the' haemorrhage lessens and ceases only in the intervals between the pains,'r (Gardien, 2nd ed. t. ii. p. 404.) And farther on, (p. 406,) it is stated that " the flooding produced by the- separation of the after-birth, at any other part of the internal surface of the * Bulletin de l'Academie, July 1852, 272 Placenta Prcevia. [May, womb, augments when the true labor pains are suspended, and ceases when the pains are active." The reason of this difference is that, in the latter case, the womb closes the orifices of the uterine vessels, as it contracts ; whereas, in the former, the contractions of the body and fundus dilate the cervix, and separate the placental attachments more and more, the distended vessels remaining open-mouthed. According to this theory, the haemorrhage is placental. A mul- titude of objections are at hand,, but I pass them hj for the present. With the opinion of Gardien, I collate those of Desor- lneaux and Professor Dubois. " Blood flows more abundantly during uterine contraction in haemorrhage from insertion of the placenta over the cervix, while, in other hemorrha- ges, the compression of the womb suspends the flooding. The blood in the former case, is forced out of the vessels of She cervix and of the placental parenchyma by the recession of the circumference of the uterine orifice, and by the pressure of the child on the placenta." (Diet, de Med. art. Me~ trorrhagie, t. xix. p. G60. This doctrine, attributed to Dupareque, admitted by Desor- meaux, M. Depaul, and Professor Dubois, and uncontradicted, so. for as I know, is very similar to that of Gardien ; only the latter attributes the haemorrhage to the gradual separation of the placenta, the vessels of which remain gaping ; whereas the other theory takes account of the pressure of the foetus, and assigns an utero-placen- tal origin to the haemorrhage. In both theories, however, the uterine contractions are considered the primary cause. The haemorrhage is in direct relation to the activity of the labor, and the haemostasis depends on its suspension. The practical deduction is this : to arrest the haemorrhage, moder- ate the uterine contractions. But inasmuch as parturition must go on, after all, we are advi- sed, in the face of theory, to hurry the labor by ergot, in order to hasten the delivery of the placenta. But we are necessarily placed between two perils. If we excite uterine contraction, as practical sense would seem to dictate, we incur the hazard of profuse and fatal flooding. If we moderate the pains, according to the indica- tions of theory, the blood does not flow so fast, but the patient almost invariably succumbs to the progressive anaemia. I hope to substitute for this theory one which subordinates the hozmostasis to uterine action and reciprocally, and which will permit uterine action to be augmented without danger. I shall state, in the first place, the facts on which this theory is based. My first cases* are designed to determine the source of the haemorrhage. * We have found it necessary to abridge the reports of cases, but have endeavored to omit no important fact. Otherwise, we could not have published M. Legroux's paper in a single number, as it occupies over thirty pages of the Archives, a greater space than we can afford. Translator's note. 1856.] Placenta Previa. 273 Case I. A woman set. 30, had been flowing, at intervals, for a fort- night, when she was brought to the Beaujon hospital in April 1852. She was near her term. She had lost much blood ; the fetal movements had ceased. She was still flowing moderately and though of robust habit, was pale and feeble. The os uteri admitted the end of a finger, and present- ed no abnormal appearance. (Rest in horizontal posture, astringent drinks and injections.) The haemorrhage ceased, but returned in a few days ; the patient be- came faint. I asked the advice of Dr. Robert, surgeon to the hospital. By digital and speculum examination, we made sure of a prominence of the posterior lip ; the finger, after passing the os, perceived a spongy substance. The woman bore the examination, in both the horizontal and vertical posi- tions, without discomfort. We decided to give ergot. The medication had not been commenced, however, when, towards the close of the day, the woman, without more flooding, died unexpectedly in a swoon. Autopsy. Central implantation of the placenta over the os uteri. Pla- centa soft, brown, decomposed, not foetid, however ; placenta easily de- tached. Foetus decomposed. No visceral lesion to explain the sudden death. The decomposition of the placenta, resulting from the death of the fcetus, forbids us to locate the haemorrhage in that organ. If the bleeding was utero-placental at the outset, it was assuredly purely uterine after the child's death. Notice also a fact, which is constantly observed in cases of pla- centa pra?via, that flooding occurred long before labor, and there- fore independently of uterine contraction, to which theory assigns the chief share in its production. The following is a succinct summary of a case observed in 18-44, at the hospital Saint- Antoine, and recorded with great care and detail by my friend Dr. Bernutz, who has kindly communicated it to me. Case IT. A woman, jet. 44, was in the eighth month of her thirteenth pregnancy. She menstruated the first four months, but had seen nothing since, until towards the end of the eighth month, when, after bad treat- ment from her husband, she began to flow, and Tost considerable blood at intervals for three days. The flooding ceased after a protracted syncope,, and the next day the woman was brought to the hospital. She was pale, but there was no haemorvhage. The os was dilated to the- size of a quarter of a dollar, and was filled with a substance which felt like- cup moss. In the night, copious haemorrhage, sighing respiration, epi'grastric pain,, feeble, frequent pulse, no uterine contraction, same state of os. (Cold va- ginal injections.) The haemorrhage ceased. The patient took a little wine, and felt better. The tampon was employd, but the patient complained of it, and of a great pain at the epigastrium; the stomach retained two scru- ples of ergot, which had been given in three doses. Soon after, the patient became delirious, the pulse failed, and a state of syncope ensued, which re- sisted every mode of stimulation.. 274 Placenta Previa. P^a7i Autopsy. Heart contains black and fibrinous coagula ; in the great ves- sels a quantity of blood analogous to what is usually found in examinations post-mortem. The uterus contains a foetus at term in a state of decomposi- tion. The placenta, implanted on the anterior surface of the cervix, completely closes the orifice, and rises a few lines beyond the posterior border. The os is dilated to nearly the size of an half dollar piece, and is filled by the tampon, which is hardly stained. No open vascular orifices. The anatomical conditions of the placenta are not mentioned in this case. Notwithstanding this omission, we may assume that the utero-placental circulation was more or less completely intercepted after the death of the foetus; for, according to Professor Moreau, when the foetal circulation ceases, the blood coagulates in the uterine vessels, and many of the latter are obliterated. Only enough blood goes to the womb as may suffice for its nutrition ; the stimulus which invited more is gone, and hence dilatation may occur without much haemorrhage, albeit the vessels which unite the placental borders are torn. This is Dr. Cazeaux's rational ex- planation of the dilatation of the cervix without haemorrhage. Death, in the two cases I have cited, was not the direct and immediate, but the secondary, effect of the haemorrhage. In the second case, indeed, the fatal termination was brought about by a series of accidents ; but in the first it occurred unexpectedly, and without extreme exhaustion. I think it useful to dwell on the dangers of the anaemic state in- duced by repeated floodings, dangers which continually menace the patient, even after a protracted cessation of the bleeding. I shall insist, also, on the danger of some of the obstetrical manoeu- vres which may be requisite under these circumstances. Case III. A year ago, a woman was brought, at the hour of my visit, to my lying-in ward at Hotel-Dieu, who had been several days in labor, and was exsanguined by repeated haemorrhages. A spongy substance, that was evidently the placenta, filled the orifice of the womb, which was detailed more than two inches, (6 centim.) The case was urgent. The extreme debility of the patient indicated that she could not withstand another haemorrhage. I attempted to deliver. Contrary to my anticipations, the cervix was so unyielding that I could not dilate it by introducing my fingers. I had scarcely commenced my manoeuvre when the woman swooned and seemed about to expire. I desisted, and ordered stimulants, broths, sinapisms, and left directions that the tampon should be used on the slightest recurrence of haemorrhage. Haemorrhage did not recur, but the patient sank gradually, and died in a few hours. Autopsy. Placenta over cervix, as had been recognized during life. No clot between the uterine and placental walls to explain the haemostasis. It was impossible to discover, at points where the placenta was separated, the orifices of any vessels. "What else could have been done for this poor woman, in her state of extreme exhaustion ? Artificial delivery would obviously 1856.] Placenta Prcevia. 275 have caused instant death, since even the introduction of the hand into the vagina induced syncope. Should the membranes and pla- centa have been perforated ? There were no uterine contractions, and the sudden removal of pressure from the abdominal contents, after the escape of the waters would have aggravated the syncope. I have since regretted that I did not use the tampon, which might have induced uterine contraction, and stimulated the vital powers. In this case, also, death took place many hours after haemorr- hage had ceased, and was a secondary result. I observe the same thing, lately, in the case of a lady of Cour- bevoie, whom I attended with two eminent colleagues. She was exhausted by repeated haemorrhages occurring in a lingering labor. When I saw her the flooding had stopped. The os was largely dilated; a large, spongy mass was behind it; the tissues were all relaxed. Extraction of the placenta, version and extraction of the child seemed easy. We decided that this operation was indica- ted. I practiced it. The whole manoeuvre required less than a minute. The lady complained, at the moment of extraction, of faintness and a sensation of anguish. No blood followed. Not- withstanding, and despite the devoted care and attention she received, this patient succumbed in a few hours, without reacting. In the last six months, two cases of artificial delivery in placen- ta praevia have been in my lying-in ward, under the care of Dr. Danyau,* specially charged with cases of dystocia. Both of them succumbed two or three days after the operation. The simple extraction of the placenta, after the child is born, produces the sensation of anguish I have alluded to, in a woman exhausted from haemorrhage. One morning during my visit, I found a young woman blanched by haemorrhage, which doubtless was due to inertia of the womb after expulsion of the child. The extraction of the after-birth seemed urgently requisite. I relied on the contractions which the introduction of the hand would excite; but this simple operation, as rapid as it was easy, produced, at the moment the placenta came away, a dying sensation, which was followed, in a few instants, by actual death. Death was certainly impending, and inevitable perhaps, in the exsanguined state in which I found this woman ; but I asked myself if I had not accel- erated the fatal event, by performing an operation. From these facts, the number of which I could readily increase, two conclusions may be drawn : 1. That anaemia due to repeated haemorrhages, an anaemia which I would term acute, in contradis- tinction to the chronic anaemia induced by unfavorable hygienic conditions, which may be extreme without endangering life that * Dr. A. C. Danyau, son of an accoucheur formerly in great vogue in Paris, and son in law of old Roux, is surgeon to the Maternite, He is one of the eight members of the section of accouchments at the academy, and is great authority at the Surgi- cal Society on matters pertaining to obstetrics. He has been in practice twenty- six years. N. S. VOL. XII. NO. V. 18 276 Placenta Previa. [May, acute anaemia, I say, exposes patients to sudden and unexpected death, and demands all the solicitude of the practitioner. 2. That the slightest obstetrical manoeuvre, during the debility of acute anaemia, may superinduce a fatal perturbation. After this digression, which 1 have thought might not be devoid of practical interest, I return to the facts which illustrate my views of haemorrhage in placenta praevia. Case IV. Mrs. Lemasson, *t. 28, rue St. Antoine, reached the eighth month other eighth pregnancy in May 1847, at which date she had an haemorrhage which seemed to threaten a premature labor. Moderate venesection, indicated by a somewhat plethoric habit, and cold applications to the abdomen and thighs checked the bleeding. It returned, however, on three occasions, before term, and was thrice controlled with the same facility ; but the third time, the bleeding was not restrained en- tirely, and it became abundant after three or four days, when labor began. The presumption of placenta prrevia was confirmed as soon as dilatation was sufficient to admit the ringer, which encountered a spongy mass, so thick as to conceal the prominences of the foetus. The dilatation reached about two inches and then ceased, notwithstanding the intensity and fre- quency of the pains. On exploring the orifice, carrying the ringer as high as possible, I passed, on th i left between the internal surface of the cervix and the placenta, and ascertained the following facts: During the uterine diastole, the finger passed readily between the separ- ated parts ; but then the blood streamed by it into the vagina. , During the systole, the finger was driven out by the tense membranes, which were pressed firmly against the uterine walls; the blood then ceased to flow, but that ichich had been poured into the vagina during the diastole was expelled by the downward jjressure of the womb. Having repeatedly satisfied myself of the correctness of these facts, I con- sidered it evident that the issue of blood from the vessels, the hcemorragie fact, was diastolic, though the appearance of the blood externally, the appa- rent haemorrhage, was systolic indeed, and coincided with the suspension of the real haemorrhage. The haemostasis was manifestly the consequence of the uterine contrac- tion, of the firm application of the membranes on the inner surface of the cervix. In order to arrest the haemorrhage, it was necessary to maintain this state of things during the repose of the womb ; to cause the combined mass of the waters and the foetus to press on the cervix in the intervals of the pains. The vertical posture fulfilled this indication. I boldly substituted it for the horizontal position hitherto adopted. The patient, too feeble to stand alone, was held by strong persons on either side, while I sat in front, supporting her feet and knees by mine, and sustaining her with one hand, while I manceuvered with the other. As soon as she was placed upright, there came a torrent of liquid blood and coagula well calculated to frighten me and cause me to repent of my experiment. But my fears were speedily dissipated ; the first gush over, the haimorrhagt ceased entirely ! I satisfied myself by the touch that, in the intervals between the pains, 1856.] Placenta Prcevia. 277 the womb remained on the floor of the pelvis, and that the weight of the waters and fetus maintained the separated vascular surfaces in apposition. The uterine contractions became at once stronger and more frequent. But the os did not dilate. What was the obstacle to dilatation ? Undoubtedly, the peripheric adhesions of the placenta, detached on a small part of the left side only. I attempted, passing my finger up on the left, to reach the membranes, but unsuccessfully. I presently detected, however, a fissure between the placental lobules which I separated, tearing with the finger nail the parts that offered resistance. I finally reached the membranes, and ruptured them during a contraction. A large rent was immediately torn in the pla- centa as the waters escaped. The placenta was thrust to the light by the head, which engaged at once, and after delivery was accomplished without any accident. The child was living and lusty. In a portion of its circumference, the placenta was torn for about two and a half inches. Near this rent was a smooth white surface, the cicatrix, probably, of an antecedent laceration. The woman had a good getting up. Case V. A few months after this confinement, Mrs. Lemasson became pregnant again. The abdomen increased rapidly in volume. By the eighth month it was enormous. During this month, she suffered from several haemorrhages, each of which lasted several days, and was treated by rest, refrigerants, astringents and injections. Before her confinement, the bleeding became continuous, and produced a state of anaemia. The pains were feeble ; they were not aroused by ergot ; the os did not dilate. The feebleness was such that I could not resort to the vertical posture. I plugged the vagina with bits of lint saturated with a solution of alum. When the tampon was removed, it was evident that it had suppressed the haemorrhage completely. The presence of the tampon excited contractions. In three hours, I cleared out the vagina, and found notable dilatation of the orifice, which wras occupied by a spongy mass. Following the periphery of the orifice, I found, on one side, a fluctuating membranous protrusion, which I ruptured. The head engaged and rapidly enlarged the opening. In a very few minutes two children were born. They had been dead for some days. The after-birth was delivered without difficulty. The subsequent history is less pleasing. The patient narrowly escaped death from metro-peritonitis. She had double phlegmasia dolens, followed by uncomplete anchylosis of the knees, which was not ultimately relieved, until she had passed two seasons at the Bourbonne springs. The menses have not returned since ; but at the supposed mouthly periods, the patient suffers from hypogastric pains and hysteriform symp- toms requiring anti-spasmodics, and occasionally, leeches to the anus. The general health is blooming, however, and these periodical indispositions are less severe at each return. This complete observation furnishes a demonstration of the propositions I have advanced, as will appear, I hope, from the following considerations : /Source of the hcemorrhage. When the child is dead, and the 278 Placenta Pravia. [May, placenta decomposed, it is obvious that the bleeding is purely uterine. This was the ease iu the first patieut whose history has beeu detailed. Admitting that after the death of the child, the placenta remains graited to the Avails of the womb, from which it receives materials for its nutrition through special vessels, it is evident that the vas- cular connections between these organs must be too restricted, the utero-fcetal circulation having stopped, to produce a notable haemor- rhage, such as caused death in case 2. In one case as in the other, the bleeding was exclusively, or almost exclusively, uterine. Is it so when the circulation between the mother and child is intact? A priori it might be argued that, nothing being changed in the progress of the accident, the blood comes from the same source. This rational deduction receives a practical confirmation from the case of Mrs. Lemasson. In her case, the bleeding was arrested by maintaining the placental and uterine surfaces in contact, while a portion of the placenta was exposed over an orifice two inches in diameter. If this organ had been the source of the haemorrhage, would it not have bled freely, while thus exposed, during the active pains excited by the vertical posture? Therefore, in all cases, the haemorrhage is almost exclusively uterine. The death of the child, which precedes deliver}- in the majority of cases, (in seven out of eight that have been under my care,) would allow us to suppose that the haemorrhage, at the onset, was placen- tal and fcetal. But there was no placental haemorrhage in Mrs. Lemasson's case, and her child was living and not anaemic by any means. The death of the foetus is due to the interruption of the utero-placental communications. It may be objected that Dr. Simpson's plan of extracting the placenta at once arrests the haemorrhage : Sublata causa, lollilur effectus. If this objection was valid, the decomposition of the placenta should have the same effect, which it has not. Why this difference? In the latter case, the placenta, although deprived of vitality, still retains its mechanical connections with the uterine walls. As these connections are broken up by the retraction of the walls of the womb, vascular orifices are exposed. Hence those intermittent haemorrhages, which occur during labor, although the child has ceased to live. In Dr. Simpson's operation, the portion of the uterine surfiice corresponding to the placenta is exposed at once; uterine contraction is excited by operative manoeuvres, and the vascular orifices are closed. Hence the cessation of the haemor- rhage. It is unquestionable that this operation would be injurious in cases of inertia of the womb. 1856.] Placenta Prcevia. 279 The practical deduction from this theory is: hasten, expedite Hie labor. The suspension of haemorrhage is commonly attributed to the formation of an obstructing coagulum. I have never been able to find this coagulum in any of my autopsies. If the haemostasis was due to such a salutary clot, the therapeutical deduction would be: let the clot alone, retard the labor, a most pernicious result. In the exposure of the uterine sinuses by the growth of the womb during pregnancy, and by the dilatation of theos during labor, id this mechanism, we find an explanation of the phases of apparition, suspension, and recurrence of haemorrhages from placenta praevia. Nature of the haemorrhage. Dr. W. Mackenzie's experiments on bitches near the full term of gestation, equally tend to prove that in partial separation of the placenta, bleeding occurs from the de- nuded uterus, and not from the separated placenta. From these same experiments, and from injections into the uterine vessels, through the hypogastric arteries, of defibrinated blood, this English author concludes that inter-utero-placental haemorrhage is arterial. With Dr. Jacquemier* I am unwilling to admit this con- ] elusion, when I consider the prodigious developement of the uterine venous apparatus during gestation, and the free communi- cation between all parts of it. This question, however, has more theoretical than practical importance. The capital point is to de- termine what organ furnishes the blood. Relation of the haimorrhages to uterine contractions. I repeat my remark that haemorrhage in placenta praevia occurs long before term oftentimes, and is consequently independent of uterine con- tractions. It has been asserted that the haemorrhage, in placenta praevia, takes place at each pain, and is arrested in the interval, and that the reverse obtains when the placenta is separated from its attach- ment to the fundus or body. In the first case, the observation is correct, but the interpretation ris erroneous. I have shown that the placenta is, at the most, only ' a very secondary source of haemorrhage. Common sense suggests the improbability of much effusion of blood between the surfaces of the ovum and uterus, when these surfaces are strongly pressed ;' together; and what common sense indicates, experience corrobor- ates. It is, indeed, a matter of ordinary observation that, in the .horizontal posture, the flooding ceases in the interval, and returns [with the pains; but the interpretation of this fact is that the real 'haemorrhage occurs in the interval, and that the apparent haimor- 'rhage is only the elimination of blood already effused. In the second case, observation has certainly been defective, but the conclusion is correct. The haemorrhage does occur during the repose of the womb, but it is impossible to believe that the flooding Gazette hebdomadaii'e de Med. et de Chir. March 24tb, 1S54. 280 Placenta Prcevia. [May, is manifested externally at this period ; it is only when the womb contracts that the blood that has filled the vagina during the dias- tole is expelled. It is incorrect, therefore, to institute any distinction between the different insertions of the placenta, in respect to the time at which the haemorrhage takes place. Vertical position in labor. In the horizontal position, in which the parturient woman is commonly placed, the uterine contractions force the womb towards the vulva and the foetal extremity towards the cervix. When the pain is over, the womb reascends in the pelvis, and the child falls back in the uterine cavity. The weight of the ovum is supported by the posterior wall of the uterus ; a part of the force of each contraction is expended in raising the fcetal mass, and depressing the womb to the pointatwhich the preceding pain left it ; this force is lost as far as expulsion is concerned. In ordinary labor the womb is equal to its double task ; but when the pains languish, the force of the contractions is barely suf- ficient to raise the fcetal mass and imperfectly depress the womb. The labor becomes stationary, and may remain so for hours or days, unless art intervenes. Ergot may render good service in such cases, or it may be insuf- ficient, and the forceps may be resorted to. Now, under these circumstances, the vertical posture alone, or aided by a dose of ergot, will almost invariably induce sufficiently active labor to bring a- bout a natural delivery. In this position the fcetal mass presses constantly on the cervix, and is a permanent cause of dilatation. However feeble the con- tractions may be, they are exclusive^ employed in expulsion, for the womb ascends but little in the intervals. Moreover, this position almost always excites more frequent and energetic pains. By this means, the use of the forceps maybe avoided* in a great majority of cases, a desirable result, inasmuch as many per- sons who practice obstetrics are not familiar with the application of these instruments. I have already treated of the haemostatic effects of this position. It assuredly does not always succeed, however, and may often be prohibited by the exhaustion of the patient. What resource have we then? The Tampon. Methodical plugging of the vagina, advocated in 1776, by Leroux of Dijon, is now generally admitted to be an invaluable remedy. f *I was present, a short time since, when ii distinguished obstetrician delivered a robust lady by means of tin- forceps. She had been in labor three days in the hor- izontal posture. While the operator was preparing the bed, the patient experienced a desire logo to Btool, and was placed for a moment on a chair ad hoc; such violent pains came on, thai if the operation had been delayed for a few minutes, the child would inevitably have been precipitated into the vessel. Author snote. \ Dr. Legroux introduces here a long extract from a lecture of Prof. Dubois on the tampon, which we omit, as we intend to publish that lecture entire. Translator. 1856.] Placenta Prarvia. 281 I usually introduced the speculum, and filled the vagina with little balls oflinen or charpie by means of a long pair of dressing forceps, and when the tampon nement is complete, I apply a T bandage. Many accoucheurs employ the simple pessary of vulcan- ized india-rubber, invented by Gariel, and recommended particu- larly by Dr. Chailly. This is inflated after its introduction; the facility with which it is applied permits frequent examinations during the labor, without discomfort to the patient. Perforation of the membranes. To evacuate the waters, and al- low the uterus to contract and close the vascular orifices laid bare by the separation of the placenta, is a practice advised by the majority of authorities, in all cases of profuse flooding towards the end of gestation.* Nearly all, however, require that the com- mencement of labour should be clearly indicated by unmistakable pains. The author of the excellent treatise from which I learn these facts, considers rupture of the membranes preferable to the tampon. Professor Dubois is so convinced of the utility of rupturing the membranes, that he lays it down as a maxim that this manoeuvre should be employed in preference to forced delivery by the podalic version ; but he makes it necessary that there should be strong and frequent pains, a certain degree of dilatation and dilatability of the cervix, and a favorable presentation. This is something more than a " commencement of labor," certainly. It reduces us to the or- dinary indications for the operation almost. Dr. Cazeaux (loc. cit.) observes that, after haemorrhage, the pains are generally feeble, and that labor may advance considera- bly without any noticeable pains; that the pains may be suspend- ed after having been strong and frequent, although the cervix is dilated and soft. In these two cases, the condition of the cervix i will determine the accoucheur's conduct. If this is favorable, the j best way to excite or renew the contractions will be to rupture the ! membranes. But, notwithstanding the authority of Dr. Cazeaux, I cannot be- ;, lieve it prudent to perforate "when the end of the finger can be I introduced, and feels the membranes growing tense at intervals." I am more struck by the dangers than by the advantages of per- foration at this stage. It is not certain that this operation will arrest haemorrhage. If delivery is not rapidly accomplished, the contractions will separate other parts of the placenta, and the haemorrhage will return. A premature evacuation of the waters . retards the labor, and far from being favorable to the child, sub- jects it to the dangers of uterine compression. When the tampon affords this security, why not wait until the os is sufficiently dila- ted and soft? Moreover, if haemorrhage returns after premature \ evacuation of the waters, we cannot have recourse to the tampon with the same confidence ; the blood may accumulate in the uterus. * Cazeaux, Trait6 des Accouchemeuts, p. 775. Paris, 1S50. 282 Placenta Prcevia. [May, When the placenta is partially implanted on the cervix, a period always arrives when a portion of the membranes protrudes at the os. It is at this point, obviously, that they should be ruptured at the opportune moment. But when the placenta is centrically implanted, should it be directly perforated? Dr. Gendrin adopted this procedure in two cases. He traversed the centre of the pla- centa with a female catheter ; the Avaters escaped, and the haemor- rhage ceased. Notwithstanding his success, I should not dare to imitate him. If such a perforation is converted into a laceration, and the foetal head passes through it, the placenta may be caught upon the shoulders, and constitute a grave obstacle to delivery* I deem it safer to wait for dilitation, and to rupture as near the edge of the placenta as possible. The escape of waters will make a rent, through which the foetal extremity will pass, pushing the placenta to one side. The proposal to rupture the membranes early is attributed to Prezos. But it is to be observed that this accoucheur, by dilita- ting the os with his fingers, in the first place, excited contractions, and that active pains being induced, the membranes could be rup- tured with less hazard. It is admitted that, when the waters are evacuated, the contrac- tion of the womb brings the foetus in contact with the vascular orifices, whence a salutary compression. Now it is not certain that contraction will ensue ; neither is it certain that some prominence of the foetal ellipse will be pressed against the part at which the placenta is separated. Do we not deprive ourselves of the most efficacious compressor, of an upper tampon or bladder pessary, by evacuating the waters prematurely? Before disgorging the ovum, is it not rational to wait until the foetus, closely compressed on all sides, will suffice for a tampon ? To sum up what I have said, the conduct of the accoucheur in the fioodings towards the end of gestation, due to separation of the placenta, is as follows : 1. To use the tampon, in the form, if possible, of the bladder pessary, which allows the condition of the parts to be examined, Avithout discommoding the patient. 2. To place the patient in a vertical position, having her held if necessary. This position completes the tamponnement. It suffices alone, if the labor is active. 3. Induce and promote pains by ergot, if requisite. 4. Perforate the membranes when the pains are strong and re- gular, Avhcn the cervix is soft and dilated, Avhen the presentation is good. 5. If the tampon and vertical posture fail, the membranes must be ruptured prematurely, which will temporarily restrain the haemorrhage. G. Lastly, if the haemorrhage still persists, and menaces life, the placenta must be extracted. 1856.] Placenta Prcevia. 283 Extraction of the placenta. Complete separation and extraction of the placenta, advised by Dr. Simpson of Edinburgh, will arrest the haemorrhage immediately, at least in the majority of cases. This operation is indicated when the means I have described are unavailing. It is an extreme resource. It is inadmissible unless the child is dead or not viable, and delivery by version or the for- ceps is impossible. (Dubois.) Case. A woman, at term, was seized with an haunorrhasce, which was attributed to insertion of the placenta on the inferior segment of the uterus. Unsuccessful efforts were made to peforate the placenta ; but, even after tearing away a portion of the placental parenchyma, the operator failed to reach the amniotic cavity. The tampon did not arrest the bleeding. The woman was carried to the hospital des Cliniques. The membranes were ruptured, and ergot was administered. The uterus contracted incom- pletely ; the haemorrhage moderated, but was still alarming. Professor Dubois presently arrived, and found the vagina filled with blood. The os was dilated to the size of a silver dollar; the placenta was implant- ed over it centrically. The pulsations of the foetal heart could not be per- ceived. As the want of dilatation forbad an attempt to deliver by version or the forceps, M. Dubois observed that it was legitimate to separate and extract the placenta. He introduced his hand, secured an edge of the placenta, separated, twisted, and extracted it. The haemorrhage ceased. Tn an half hour, active pains came on, and the child was delivered in five hours.* This case proves that I was correct in supposing the rupture of the membranes was not a certain haemostatic. Inertia of the womb might allow the haemorrhage to continue after the placenta was extracted, also. There cannot be complete security, therefore, after that operation. Artificial and forced delivery. If the means that have been de- scribed did not arrest haemorrhage, rather than standby helplessly while life was ebbing, it would be right to resort to an hazardous operation, to deliver forcibly, making an incision in the cervix if necessary. Such an operation will be very rarely indicated. But when there is good dilatation, and a soft and yielding cer- vix, ought we to deliver immediately by version or the forceps? I may be wrong ; but in such a case, I should wish to wait for natural delivery, if I was master of the haemorrhage. I should be still more inclined to this course if the waters were intact, and I could count on the amniotic bladder as an upper tampon to aid my vaginal or lower tampon. If the waters have escaped and the woman is exhausted, artificial delivery is the onty resource. But, I repeat, I have a dread of the perturbation produced by obstetri- cal manoeuvres at such a moment. If the woman is so feeble that artificial delivery is deemed too hazardous, she should be placed with her head low, her limbs raised by pillows; a bandage should be placed around the abdomen ; hot wine, broth, and other resto- * Journal de Medicine et de Chirurgie Pratique, June 1S55. 284 Cataleptic Hysteria. [^a7, ratives should be administered ; sinapisms should be placed on various portions of the skin. Perhaps these means will revive the powers, and the labor may be accomplished. I will not dwell long on these great obstetrical difficulties. My experience does not warrant me in saying more. Let me in conclusion, adduce a single etiological remark. All the cases of placenta prasvia of which I have learned the his- tory, occurred in women Avho had borne several children, in whom the uterine cavity was necessarily larger than in primiparaj, a con- dition favorable to the descent of the fecundated ovum into the lower part of that cavity. Prophylaxis is at fault in such circum- stances, unless it might be prudent for a woman predisposed by an antecedent placenta pnevia, to pass the early part of a subsequent pregnancy in an horizontal posture. [Archives Generals de Med. Virginia Medical Journal. Cataleptic Hysteria. Dr. Eingland communicated to the College of Physicians, in Ireland, April 4th, 1855, the following very curious case of cata- leptic hysteria: Mrs. , an English lady, of literary tastes and sedentary hab- its, about thirty years of age, and married eight years, had been very delicate from her earliest infancy. During the six years antecedent, and the year immediately subsequent to her marriage, she suffered from most intense headache. Two years prior to her marriage she was under treatment for spinal irritation, as she was informed by her then medical attendant. About this period, too, she voided several portions of tapeworm, and had frequently, both before and after her marriage, passed large quantities of ascarides. She was at all times subject to palpitation of the heart, and had on one or two occasions a slight hysterical fit. She suffers intense pain on touching the last dorsal vertebra, which for some years has projected to about the size of a nut. A sound as loud as the snapping of the fingers is frequently heard proceeding from this locality whenever she is much fatigued, or has been standing for a considerable time ; and this sound Dr. Eingland has more than once heard. She also experiences, since her first confinement, great pain on the least pressure being made against the coccyx, which has been slightly dislocated downwards and backwards, and has become anchylosed in that direction. On the second night after she was married, whilst engaged at prayers, she was suddenly, and without the least premonitory indication, seized with the first of the series of fits about to be described; and this was shortly followed by a second, of a like character. An interval of six months then elapsed without their recurrence; when, however, being much about that length of time pregnant, she was again attacked, and, as on the former occasion, 1856.] Cataleptic Hysteria. 285 without any premonitory symptom, and whilst in a state of com- plete mental quiescence, having been previously engaged in calm, unexciting conversation with her husband. The headache from which she had previously suffered was greatly aggravated from this period until after her confinement, and sue has described it as though a tight iron cap was violently pressed on the upper half of her head, to which the headache was strictly limited. The fits now returned with but very short intervals, and it was with con- siderable difficulty her medical attendant prevented a premature confinement. Some little time after the fits became completely established, she observed that, if she was engaged in conversation immediately an- tecedent to the access of one, she could not command the words she uttered, although fully aware of what she ought to say, and thus she frequently appeared to give expression to the most absurd ideas, and to opinions which were quite opposed to what she had intended to convey. Often, too, having spoken a portion of a sentence, she terminated it on a subject quite different from that upon which she had commenced her observations, or came to an abrupt close, finding herself totally deprived of further utterance. Up to, and during her confinement, she had frequent attacks, sometimes so many as thirty in the twenty-four hours, and seldom less than fifteen or twenty. After her confinement, which was easy and natural, they were reduced to two or three in the da}', and on very rare occasions one whole day has elapsed without their recurrence. Within the last eighteen months her health in this respect has considerably improved, as, repeatedly, days, fre- quently weeks, and sometimes even a month, has elapsed without a fit. The origin of this affection she attributes to excessive fright, produced by witnessing very violent paroxysms of hysteria, almost amounting to insanity, in a female relative, with whom she was on a visit shortly before her marriage. Fatigue, excitement whether pleasurable or the reverse or even music if loud or prolonged noise the slightest start the least pressure against the painful part of the spine, or against the coccyx, instantly induces a fit; they frequently, however, come on without any apparent exciting cause. The duration of each fit is very variable; sometimes it lasts only three or four minutes, and sometimes it is prolonged to an hour and a half. Dr. Ringland has witnessed several which lasted from twenty minutes to half an hour each. She has never had less than two fits when attacked, the second being of much shorter duration than the first, and invariably suc- ceeding it after but a short interval. She appears to have been obnoxious to the attacks at all times and seasons, in all postures, and under every circumstance. She has been liable to them in summer as well as in winter; has been 286 Cataleptic Hysteria. [May, attacked whilst in bed or at her meals ; whilst engaged in read- ing, writing, or in conversation; whilst standing, walking, or sitting ; whilst alone or in the midst of strangers ; frequently with a word half uttered, or a piece of food partially masticated ; and more than once has her life been placed in jeopard}' by the fit oc- curring when she was near a fire, or whilst she was engaged in the act of deglutition. The presence or absence of menstruation has no apparent connection with the attacks, nor has that secretion ever been in the least affected by them; neither does the existence of pregnancy or lactation seem in any respect to influence this strange affection, excepting that the fits have been much more fre- quent from the moment of impregnation up to the period of quick- ening, than at any other time. Instantly, on the access of a fit, she falls backwards and forwards, according to the direction in which her head has been at the mo- ment. iShould she, however, have her baby in her arms at the time, she holds it firmly clutched in her hands, which cannot, without considerable violence, be opened; although, when the fit ensues at any other time, her hands, though closed, can be easily opened. The particulars of this lady's case Dr. Ringland. learned from herself some months prior to her then approaching confinement her fourth and which took place early in December, 1854. Im- mediately after the birth of the chiid, which was mature and healthy, she had one of her customary fits, which was followed by a second, immediately after the expulsion of the placenta. The following is a brief description of the first fit witnessed by Dr. Kingland. Without any previous indication whatever, she suddenly seem- ed to faint, and lay in a state of apparently total unconsciousness. ,She, however, was quite aware of every circumstance that occurred .around her, and could afterwards detail the conversation which had taken place in the room. Her limbs remained in whatever position they were in at the time of the attack, or in any other to which they were subsequently changed. There was no alteration in the color of her lips, in her complexion, or in the appearance of her skin, which remained of the natural temperature. Her eye- lids were closed, but when raised, continued open until closed again. The pupils contracted well on exposure to light. Her pulse was about 100, but very feeble. There were no apparent Leavings of the chest nor movements of the nostrils. Repeatedly during the existence of the fit, but more violently towards its close, there were convulsive twitchings of the muscles of the face, /spasmodic clenching of the fingers, and forcible supination of the hands on the forearm. There were no convulsive movements of tin' lower extremities, although such occasionally occurred, as she informed Dr. Kingland, and were always present during the first few months of the existence of the fits. 1856.] Pharyngeal Abscess. 287 No restoratives were applied during the fit, as she bad previous- ly intimated to Dr. Eingland that the employment of the most simple of these had always produced violent and prolonged hys- teric paroxysms, which never presented themselves when inter- ference was not had recourse to. After the lapse of about five minutes she gave a deep sigh, then opened her eyes, looked about her, and feebly held out her hands. On this signal, which is well understood by her attendants, she was without delay raised into a sitting posture, and after a brief interval of quiet she was perfectly restored. Had not her attendants, as she informed Dr. Eingland, at once placed her in the erect position, she would have relapsed again and again into the fit. She, too, is so concious of this necessity, that instantly ou the subsidence of the fit she holds out her hands,, as described, thereby indicating her desire for the requisite assistance. Should she at this time be handled roughly, or should the tender part of the spine or the coccyx be touched, she at once relapses into the fit. She is not able until after the relapse of considerable time, and not even then without the greatest effort, to utter a single syllable, the peculiar condition excited throughout the system appearing in her case to attach itself more firmly to the tongue than elsewhere. After the subsidence of the attack she is greatly distressed with tremors of the whole body, which last sometimes for only a few minutes, but at times continue for several hours. Dr. Ringland, before concluding, made a brief summary of this singular case, directing attention to its leading characteristics and points of interest; especially to the previous existence of spinal irritation ; the occurrence of the attacks in summer as well as in winter; the existence of consciousness during the fits; the erect position being necessary at the close of the fit, and neglect in this respect causing relapse; the loss of speech being prolonged after the subsidence of the other symptoms ; and finally, to the fact that restoratives induced hysteria, [Dublin Quarterly Jour. Med. Sci. Cases of Pharyngeal Abscess. Dr. "VVm. Lochhead, of Glasgow, records (Glasgow MedicalJour- nal, October, 1855) the two following interesting cases of pharyngeal abscess : "Case I. On 1st April, 1855, I was called to an infant, aged six months, that was very much reduced by the discharge from abscesses, which had formed on various parts of the body, but which had now dried up. It was breathing with some difficulty, every inspiration being accompanied with a sound, as if the nasal passages were obstructed. On examining the nose, nothing could be found sufficient to account for the symptoms; neither was there &88 Pharyngeal Abscess. [^ay, any enlargement of the tonsils, nor indeed any morbid appear- ances, so tar as I could observe, except that the mucous membrane was redder than natural, this being the only evidence of the pre- sence of inflammation. The dyspnoea appeared to me to depend ou some obstruction connected with the posterior naresr and not upon auj" inflammatory action going on in the organs of respira- tion, as the sounds of the chest were quite normal. I ordered the child to be placed in an easy posture, allowing it perfect liberty to move its head in whatever direction it seemed to be most at ease. while it was made to inhale the vapor from warm water, and had a blister applied to the nape of the neck. Next day, and indeed for several days afterwards, the breathing got very little worse. But on the 8th of April the symptoms were much aggravated, the breathing being accomplished with difficulty, and attended with a loud noise, the head thrown back, the face pale and anxious, and the mouth wide open, with great restlessuess. Ou examining the throat minutely, there was observed the rounded form of an ab- scess, deep in thepharvnx, situated in front of the fourth cervical vertebra. Its real position, however, could not be accurately ascertained, as retching was induced whenever the tongue was touched. I was satisfied that it was an abscess, from ite having so suddenly assumed its present prominent position, nothing having been observed the day previously. Deeming the ease now of suf- ficient interest and danger to justify a consultation,. Dr. Lawrie was called in, who at once confirmed my views, both as regarded the nature of the ease, and the immediate treatment to be adopted. The swelling being very deeply situated, and not easily brought into view, was with some difficulty reached; but by pressing dow n the tongue with the index finger of the left hand, a bistoury, guarded to within a short distance of its point, -was thrust into the swelling, when there issued a copious discharge of pus, with in- stant relief to the little sufferer. " On the 9th the dyspnoea had again partially returned, from the sac of the abscess having again filled. I did not, however, inter- fere until the symptoms were more urgent, thinking that the mat- ter would soon find its way through the old opening. Early ou the 10th I was summoned in great haste, as the child was said to be dying. I found all the appearances of impending suffocation more marked than ever they had been. So hastily, having guard- ed my abscess lancet, I proceeded to make a free incision into the tumour, as far down as I could reach, when a large quantity of fetid pus was discharged, and complete and permanent relief fol- lowed. For a lew days I emptied the sac occasionally, by pressing upon it with the finger; but from that time up to the 3d May the child has done well, and is at present in vigorous health. "I ought, perhaps, to state that the patient had been put upon syrup of the iodide of iron, quinine, port wine, and every other means that could be thought of to improve the general health ; but 1856.] Pharyngeal Abscess. 289 these means having nothing to do with the abscess under consid- eration, need not be enlarged upon. ''Case II. On the 2d of August, I was requested by my friend Mr. R. Renfew to see a child, aged eleven months, with an in- flamed submaxillary gland, which had been gradually subsiding under appropriate remedial measures. But as the dyspnoea seem- ed to increase, although the swelling was not so great, he thought there might be some inflammatory action going on in the larynx. On accurate examination, however, it was found to be a case of abscess in the pharynx. As the danger was not imminent, we agreed to defer interference until the swelling became more point- ed. On the succeeding morning there was still no urgent necessi- ty for interference, and as the breathing was not worse, we thought it better still to wait. In the evening the symptoms became more alarming, the dyspnoea very great, and the abscess more enlarged and prominent. As I found great difficulty in reaching the ab- scess, guided, as in the former case, by the index finger, I pressed down the tongue by means of a spoon, bent to nearly a right an- gle, which enabled me to see the tumour, and to open it exactly in the mesial line, and at its most dependent part, which had the sub- sequent advantage of allowing the sac to empty itself completely, without further interference, which certainly happened, as the case gave no further trouble. "Remarks. These cases of abscess do not differ essentially in their nature from abscesses in general, but derive their peculiar interest from their situation alone; and as, according to the adage, to be 'forewarned is to be forearmed,' I may save some of my pro- fessional brethren much anxiety by having given them a hint regarding the formation and means of diagnosis ofabsceses in this region of the body, I have presented the details at what some may think a greater length than their importance demands. When, however, we consider the comparative frequency of inflammation in the air-passages and surrounding structures, more especially in 'children and infants, practitioners cannot be too well acquainted with every concomitant circumstance that may assist the diagnosis in each particular case. Indeed, no one who had not really seen such cases as those described could believe the dificulty in the diagnosis in the earlier stages of the disease. For my own part, although watching my little patient carefully for some days, it was only when the case reached its height that I was sure of its real nature. Many might think they had to treat a case of ordina- | ry laryngitis, when the violence of the dyspnoea suggests a particu- i lar examination of the air-passages, and an abscess is discovered. "As to the exact situation of the abscess, I believe in both cases, that it was about the fourth cervical vertebra, or between the fourth and fifth ; but it is difficult to fix its real position, as the movable pharynx ascends when the tongue is pressed down. But from the 290 Minute Anatomy of the Liver. [May, great obstruction which it causes to the respiration, it appears to be immediately behind the larynx. " The treatment when the real nature of the case is made out, is simple enough, viz : to open the abscess in the mesial line, and at the most favorable point for the free exit of the pus. In order to avoid the loss of blood, which is of importance when the child is weak, and to prevent the necessity for a second operation, I would not recommend the use of the lancet until the abscess became well defined. "The causes of pharyngeal abscess may be found in that of ab- scesses in general, and, consequently, the prophylactic as well as remedial measures must be adapted to the exigency of each parti- cular case. But as my object in this paper has been merely to call attention to the termination of the inflammatory process, and to put upon record these two cases, it is not necessary to go into the origin and history of this very rare and highly interesting af- fection." \_A mer. Jour, of Med. Science. Minute Anatomy of the Liver. The minute anatomy of the liver has been lately examined by Beale,* who, from his dissections and injections, comes to the fol- lowing results : 1. That the essential constitution of the liver is that of a double network of minute vessels, one of capillary bloodvessels, and ano- ther of cell-containing tubes, naturally adapted to each other. Both of these sets of tubes in each lobule appear to communicate with those of the neighboring lobules in all livers excepting that of the pig ; and this circumstance is connected with the fact, that in all other animals but the pig, the hepatic lobules are not isolated by intervening and limiting fibrous tissues or capsules. As to the latter position, Beale agrees with Weber. 2. That the cell-containing tubes are in all vertebrata continu- ous with the ultimate fine ducts of the viscus; in some cases directly so, whilst in others, as in the rabbit, and slightly in man and the dog, a fine network of the ducts themselves intervenes. The base- ment membrane of those tubes being, after foetal life, incorporated with those of the capillaries, so that the secreting hepatic cells are only separated from the stream of blood by a single intervening membrane. The cell tubules contain the hepatic cells, as also granular and coloring matter and cell debris; the cells observing no order of arrangement, as some have thought, and contrasting in size, &c, greatly with the epithelium lining the ducts, from which they are strictly separated. 3. That the fine ducts are many times narrower at the point where they are continuous with the cell tubes, than those tubes * Proceedings of the Royal Society, June, 1855. 1856.] Gypsum or Stucco Bandages. 291 themselves; and that the larger ducts and larger interlobular ducts freely anastomose with each other. 4. That whilst the finest biliary ducts are only composed of basement membrane, that of the larger ones is more complex, con- taining numerous cavities; especially in the pig, which, although generally considered to be glands, are in fact reservoirs for the bile, retaining it, and bringing it into intimate relation with the abundant surrounding bloodvessels, so that it may undergo requi- site changes. This the author also considers to be the function of the vasa aberrantia, so named by Weber. In this view, it will be seen that Beale considers the structure of the liver to be strikingly different from that described by Kolliker and Hanfield Jones, and assigns a different office to the secreting and epithelium cells ; for, whilst the latter looks upon the cells of the ducts as chiefly forming the bile, Beale considers that they stand in relation to the hepatic cells as the columnar epithelium (lining the stomach tubes) does to the secreting cells at the bottom of them. Beale prepared his specimens by injecting the portal vein with lukewarm water until the bile was washed out of the ducts by it, and then injecting the ducts ; after which the portal vein was in- jected with size. The ducts were also examined in specimens hardened in alcohol, to which a solution of soda had been added, in order to render the sections transparent. Dusch* finds that the hepatic cells are dissolved in bile and in solutions of glycochlorate of soda. They also enlarge on the addi- tion of chloroform, according to Lereboullet, their contents be- coming very clear. [Brit, and For. Med. Ghir. Rev. We find in the " American Medical Monthly" a report of some exceedingly interesting " Practical Lectures on Military Surgery," delivered at the New York Medical College, by Isidor Gluck, M.D., Chief Surgeon to the Hungarian Hussars, and to various Hospitals during the late war in Hungarjr, &c, &c. His description of the mode of using Gypsum or Stucco bandages in the treatment of frac- tures on the field of battle, will suggest to the ingenious surgeon the use of such dressings in civil practice. Western Lancet. Gypsum or Stucco Bandages. "Although even in compound fractures, where the wounded place has to be left uncovered, the application of Scutin's starch bandage answers this purpose best, still there are some objections to its being used in the field, or even in the hospital. 1. It dries too slowly, and cannot replace therefore immediately manual extension, that is required in order to retain the ends of * See Caustatt. N. S. VOL. 511. NO. V. 19 292 Gypsum or Stucco Bandages. [May, the broken bone in mutual contact. It is, therefore, necessary to use machines or apparatus till the bandage becomes dry for 24^8 hours. 2. The thickness of the walls of the bandage diminishes, while the bandage becomes dry, and thus receding somewhat from the liinb, cannotserve instead of the manual extension. 8. The application of the starch bandage costs on the field much time and trouble. The limb must first of all be surrounded by a roller, then covered with compresses, and rollers; pasteboard and splints are then applied, and the whole again surrounded by a roller. The application of openings (windows) in Scutin's band- age is combined with difficulties. If the windows are made at the time when the bandage is applied, the same keeps badly together, the fractured ends and wood or tin splints must be used; if the windows have to be made when the bandage is dry, the wounded portion remains covered for a day or longer, and the excision or formation of the openings is in the hardened starch bandage yet more troublesome. 4. However dexterously we may apply the bandage, it will be pretty difficult to make so large openings as required, in order to expose the injured portion without loosening at the same time the whole bandage, while small openings or windows expose but a por- tion of the injured part. 5. In suppurating wounds, the pus discharged, as well as the fluid applied for cleansing the wound, and the moisture of the cataplasms, will run under the bandage and destroy the epidermis. 6. The hardening and unequally contracting starch bandage, (i. e. quickly hardening at its thin portions and slower in its thick- er ones); exerts an unequal pressure and therefore an injurious effect on the swollen parts. 7. The starch bandage cannot be applied for transporting the wounded soldier, who receives on the battle-field a compound fracture, because it requires warm water, (not always ready in the field) for preparing it; then again it dries slowly, the formation of windows causes loss of time and trouble, requiring the application of splints, and because the parts being covered for a day or two, are injured as suppuration may follow, and the pus stagnates and runs into the bandage : in damp weather it becomes moist and soft in the rain; it is, therefore, necessary to have ready made capsules of starch bandage, and the so-called movo-amov ible bandage, which often do not appose sufficiently, and cannot therefore replace man- ual extension. Recently gypsum bandages have been suggested in Belgium, but their application, according to Dr. Mathieson and Van De Loo, is troublesome, and takes much time, so precious on the battle- field. This bandage is not lasting, its preparation and preservation still more difficult than that of Scutin's starch bandage, much more preferable and practical is the preparation and application otgyp- 1856.] Gypsum or Stucco Bandages. 293 sum bandages, as made by Pirogoff,* and used by him to the great- est extent with the best results. The gysum bandage is, on the battle-field, in many respects pre- ferable to the starch bandage. The gysum solution requires but cold water, and turns hard as soon as applied, and replaces therefore immediately manual exten- sion, and neither machines nor apparatus are required for that purpose. The dry gypsum bandage becomes so hard, that no splints are required, even if large windows are made, and trans- porting of the wounded soldier is, immediately after the application of the bandage, possible without injury. The gypsum bandage is simple and cheap, as it consists of old coarse linen and gypsum ; its application is simple and quickly made. The gypsum bandage replaces manual extension perfectly, the assist- ants need only for a few minutes keep the limb extended after the bandage has been applied, then the gypsum bandage is stiff and hard enough to retain the ends of the broken bone in the position given to them. Their displacement is impossible as long as the swelling does not diminish, and a considerable interspace is not formed between the limb and the bandage. Thus the gypsum bandage renders superfluous all machines for extension, as required, while the starch bandage becomes dry. Only by the application of the gypsum bandage in oblique fractures of the thigh it is necessary to fix the pelvis, and to retain the limb extended by means of a bed-table, and by weights attached to the extremity. More apparent yet are the advantages of the gypsum bandage in oblique fractures, where the ends of the broken bone are distant from each other, in compound fractures and generally everywhere where it is necessary to keep open a wounded spot. In Pirogoff's mode of applying the gypsum bandage, the open- ings (windows) may be made at once, through them it is possible to view the position of the broken ends, the excoriations and wounds, and the curative process may be watched in its course. The gypsum bandage does not contract like the starch bandage, interspaces form slower between it and the leg, as in the gypsum bandage the interspaces depend upon the decrease only of the swell- ing, and not like in starch bandages also, from unequal hardening of the bandage, and then again it does not become moist and soft in rainy weather. In complicated fractures the pus may be discharged, and find exit through the large windows made, and does not burrow itself under the bandage as is common in the starch one. Wet dressings are applied immediately on the wound itself. The gypsum bandage becomes hard immediately after having been ap- plied ; wounded soldiers may therefore be safely transported im- mediately after application of the gypsum bandage, from one place to another, even in the rain, without the bandage being dis- *Pro of Surgery in St. Petersburg (Russia.) 294 Gypsum or Stucco Bandages. V^&Ji turbed, although the gypsum bandage may appear wet externally, which sometimes lasts for a few hours. The gypsum bandage may therefore be cut through immediate- ly after the application in the interspace of the splints, if that should be required, in consequence of too great a pressure or pains, &c. In the battle-field, as well as in the hospitals, for transportation of the wounded soldier in the treatment of complicated fractures, with great dislocation of the ends of the fractured bones, the gyp- sum bandage is preferable to every other kind of bandages. Requisites necessary for the application of Gypsum Bandages in the battle-field as well as in the liospitals. 1. Long, old hospital stockings made of linen, cut in front along the seam, (if the seam is behind the stocking it must be turned and cut); old drawers also cut along the seam, and divided for one or the other limb ; sleeves of old shirts, (or instead of those, long linen flaps cut in the form of stockings); drawers or sleeves; jackets or old vests, abdominal bandages covering the body once and a half; for fractures of the bones of the rump, pelvis, and of the neck of the thigh bone. These pieces of linen used for surrounding the limb must be equal, soft and dense. All seams must be removed. 2. Cotton or cleaned soft flax, pads filled with soft material, lint or flax for filling up, (for instance, around the trochanters, around the malleoli in the popliteal region, and around the achilles tendons) simple and graduated compresses. 3. Splints of different dimensions in regard to length, width and thickness, made of old coarse sack linen, as used for instance in hospitals for mattrasses or straw mattrasscs. The old sack linen is folded twice, thrice, or four times, to the width of two fingers to one-third of a yard. The splints must in fractures of the leg, the upper and forearm, exceed at least one- third of a yard the fractured bone, and in fractures of the thigh, and that of the neck of thigh it must be one-third of a yard longer than the whole extremity. 4. Strips (compresses) of the same linen from two inches wide, and of such a length as to surround the limb once or twice; they are calculated to fasten the splints, and are called transversal stripes. (Pirogoff.) These transversal stripes may be made also of fine linen, if the bandage should be a light one. 5. Plaster of Paris (gypsum) in form of fine powder and well dried. For the application of a bandage, never less than 2 lb. have to be used, (as for fracture of the forearm,) nor more than 7 lb., as for fracture of the neck of the thigh bone. 6. A vessel with cold water. The gypsum solution should not harden sooner than in five or eight minutes, in order to allow the application of the bandage. Although hardened, it still looks wet 1856.] Gypsum or Stucco Bandages. 295 from the evaporation of the water, out of the bandage painted. over with gypsum solution, and the patient may safely be carried with it. 7. Large brushes as used by house painters. Besides those necessary requisites in hospitals, may be used finer linen rollers for simple fractures and splints made out of paste- board, and for complicated fractures, with large wounds, splints of wood, of different dimensions, together with pads attached to them on both ends, and also a few pieces of sheet iron or tin may be held ready. The Application of Gypsum Bandages, is made in the following ivay: The injured limb is first surrounded with dry linen, a sleeve, a linen stocking, or with half a drawer. Bony prominences must be wadded, and hollows filled out with cotton. The linen surrounding it must not be too thin, nor have holes in it, in which case the linen must be doubled, or the limb first covered by cotton. If this is not done the moisture passes to the skin, and the patient complains of a cold or burning sensa- tion. 2. The broken limb is put in the required position, the extension is then made, and the fractured ends then approximated. Some- times it is necessary to begin with the reduction, and subsequently follows the surrounding of the limb. 3. The splints and the transverse strips of sack linen, each three or four times folded, are put near the patient in that order as re- quired to be later applied to the limb. An assistant prepares the solution of gypsum, and paints with it the splints and strips, or rather dips them into the solution and brushes them with it. 4. The proper application of the bandage depends now upon the gypsum solution. If the solution be too thick it dries quick, the splints and transverse strips are not united firmly together: nor are the splints firmly fixed if the solution be too thin. When the solution becomes denser, water must not be added to it, as the so- lution becomes through it creamy, is not imbibed by the linen, cannot be smoothed, does not adhere, and takes a long time to become dry. 5. The splints and strips of linen must be dipped in the solu- tion, which I now prepare by adding to two pounds of water the equal weight of gypsum. They must be extended and swinging free, and must thus be brushed over on both sides with the gypsum solution. 6. The splints must be applied longitudinally to the limb, and must be fixed by the transverse strips, carried around both the limb and splint. The transverse strips are applied in pairs, so that the one should cover the other partially. The splints may be applied in such a manner that the one should 296 Dislocation of the Femur. [May, cover the other partially, or, what is preferable, in such a way that between the splints should remain a free ojDen space on the side in front of or behind the limb. The assistants producing extension must continue to do so until the bandage is hardened i.e., about eight minutes after the gypsum bandage has been applied. Du- ring its application the limb must be kept extended free, in order to be accessible from all sides. The splints must be pressed firmly to the limb by the hand. The transverse strips must be drawn firmly and tightened around the limb, and by the hand or brush well covered with gypsum solution, in order that all prominences and hollows should be equalized. In oblique fractures and dislo- cations of the fractured ends, at least two layers of transverse strips are necessary. But if the bandage has yet to be removed, it is necessary 1st. To apply the splints so as to leave a space between them. 2d. The transverse strips are covered from the middle (where about the extent of two inches remains uncovered) towards their ends with gypsum solution. 3d. The transverse strips are applied so that the uncovered part should correspond- in its situation to the longitudinal interspace between the splints. In the field it is necessary to have arranged, before the applica- tion of a bandage, all requisites in one package for each fracture separate. Thus, for fracture of the forearm the bandages should be separate from those for fracture of the leg." Report of Three Cases of Dislocation of the Femur Reduced by Manip- ulation. New Method of Reducing Dislocations of the Femur on the Pubes. By E. J. Fountain, M.D., of Davenport, Iowa. Recently I sent to Dr. Reid, of Rochester, New York, a brief report of three cases of dislocation of the thigh, one of dislocation upon the dorsum ilii, and two upon the pubis all reduced by manipulation. At his suggestion, I send a full report of these cases for publication. The case of dislocation upon the dorsum was reduced very quickly and easily by following exactly the di- rections given by Dr. Reid, with whom this vastly improved method originated. The two dislocations upon the pubis, I reduced by manipulations based upon the same principles; but by a mode of manipulating quite different from that required for the reduction of a dislocation upon the dorsum ilii. The report of these two cases will be the first of the kind upon record. A concise summa- ry of the rules for the operation will be appended to the report. Dislocation upon the dorsum ilii. Oct. 7th. I was called in the night to go in haste to the relief of a lady, Mrs. S , who had re- ceived, as stated, some serious injury of the hip, or thigh, by being thrown from a wagon. I was accompanied by my partner, Dr. Adler. We found the patient in bed, complaining of pain in the 1856.] Dislocation of the Femur. 297 left hip. The examination revealed at once the nature of the in- jury, which was a dislocation of the left femur upon the dorsum ilii. On placing the patient erect, the characteristic appearance was presented. The knee resting upon the lower third of the thigh, the great toe of the foot upon the instep of the opposite limb, and the trochanter major approximated to the crest of the ilium. The diagnosis was confirmed by an attempt to rotate and abduct the limb. A mattress was thrown upon the floor, and upon this the patient was placed upon her back. A towel was carried around the sound thigh and hip, and held down by Dr. Adler ; but this assistance 1 found to be quite unnecessary. I then grasped the knee with my right hand, and the foot with my left; flexed the leg on the thigh, and carried the knee and thigh over and upon the sound one, and then upwards as high as the umbilicus, keep- ing it constantly pressed down upon the body. I then carried the knee outward, bringing the heel inward and the foot over the op- posite limb, at the same time making gentle oscillations of the thigh, when the head of the bone slipped suddenly into its socket. The force required was quite moderate, and the pain almost no- thing. The time occupied by the manipulation, from the instant I took hold of the knee and foot, until tin: operation was completed, did not exceed ten seconds. The manipulations were made by one continuous uninterrupted motion. The knee was caused to make a " semi-circular sweep " over the sound limb and across the body, then a few quick oscillations, and it dropped down into its natural position. I held the thigh up firmly and steadily, while making the oscillations; and in this position, at right angles with the axis of the body, and abducted, and the foot over the opposite thigh, the head of the bone entered socket. Dislocations on the Pubes. Case 1. In June, 1854, I was called to see a man who had fallen from the second story of a house to the ground, upon some pieces of timber. His lower jaw was frac- tured, and his left hip dislocated. The limb was a trifle shortened and the foot strongly everted. The prominence of the trochanter major was lessened, and the head of the bone could be felt upon the pubes. While waiting for the appearance of Dr. Arnold, who had also been sent for, I was reflecting upon the necessary arrange- ments to be made for the application of the putties. While thus meditating upon the subject, I began to think of the possibility of reducing the dislocation by manipulation. Considering the posi- tion of the head of the bone and its relation to adjacent parts, it occurred to me that by rotating the limb still more strongly out- ward, I might elevate the head of the bone from its resting-place the trochanter major acting as a fulcrum. Then, by carrying the leg and foot, and after it the knee and thigh, over the opposite thi<2'h, while the limb was still strongly rotated outwards, the head of the bone would be made to move upwards and outwards in the arc of a circle of which the trochanter major would be the centre, and 298 Dislocation of the Femur. [May, the neck the radius. After being thus brought over and upon the edge of the acetabulum, a motion of the limb directly upwards would, in the same way, throw the head of the bone into its sock- et, the muscles attached to the trochanter major holding that point comparatively fixed. Before the arrival of Dr. Arnold, I had determined to test the theory; and on explaining my views to him, he at once expressed his willingness to have the attempt made as I suggested. At worst, it could only fail without much, if any, harm, and then we had the pullies ready for application after the " classical method." The patient was placed upon the floor on a quilt. Being a man of strong muscular development, I thought there would be more certainty of success if relaxation was first produced by the inhala- tion of chloroform. He readily came under its influence. When quite unconscious, the limb was taken by the foot and knee and rotated outwards, the leg flexed and carried over the opposite knee and thigh, the heel kept well up, and the knee pressed down. This motion was continued by carrying the thigh over the sound one, as high as the upper part of the middle third, the foot kept firmly elevated. Then the limb was carried directly upwards by eleva- ting the knee, while the foot was held firm and steady, at the same time making gentle oscillations by the knee, when the head of the bone suddenly dropped into its socket. Time required in the operation, from twenty to thirty seconds. The force used was slight ; I believe it could have been reduced about as well without the chloroform. Case 2. Oct. 31st, 1855. John McCarthy, an Irishman, had his hip dislocated by falling with a horse he was riding. The horse slipped and fell, rolling over upon him. I found the limb about the same in length, as the sound one ; but greatly everted, the toes pointing directly outward. On attempting to rotate and flex the limb, pain was produced, and a comparative immobility manifested by resistance. The head of the bone was felt forward upon the pubes. As soon as I discovered it was a dislocation, my first thought was to send for Dr. Adler to witness the operation. But the temptation to take hold and reduce it immediately, was too strong. The patient was resting upon a low couch. I imme- diately took hold of his knee and foot, rotated outwards and flexed the leg by carrying the foot over the sound thigh, keeping the heel well up, and pressing the knee down. After I had brought the thigh in this way over the upper part of the sound one, I car- ried it directly upwards, holding the foot firmly up and making oscillations by the knee, when the head of the bone slipped into its socket, and the limb at once assumed its natural appearance and mobility. A little more force was required in this, than in the other case; but it was still quite moderate, and the pain very slight. In this case I had no assistance whatever. Time occupied in ope- rating, about twenty seconds. 1856.] Prize Essay on Placenta Prcevia. 299 The history of these cases fully demonstrates, to my mind, the immense value of this new method of reducing dislocations of the hip. Notwithstanding the unsatisfactory results of the trials at the New York Hospital, I have perfect confidence in the correct- ness of Dr. Eeid's method of manipulation. It is certainly one of the greatest improvements of modern surgery, the value of which may be understood when contrasting an operation requiring but ten or twenty seconds and without pain, with the instructions of Sir Astley Cooper, viz : Venesection to syncope, hot bath, tart, antimony to nausea, and then the application of the pullies from four to six hours, if necessary ! To Dr. Beid is due the credit of this splendid improvement, in which the whole profession must participate, as a most valuable contribution of scientific surgery to the relief of suffering humanity. It remains to be seen how far the test of future operations will confirm the value and correct- ness of the method of reducing dislocations on the pubes, as illus trated by the two preceding cases. It is my opinion that dislocations into the thyroid foramen may be reduced by the same method as the last. In conclusion, I will recapitulate the method of operating for dislocations on the pubes. Taking the knee in one hand, and the foot in the other, rotate the whole limb outwards, and flex the leg on the thigh by carrying the foot over the opposite knee. Then carry the limb, foot for- wards, over the opposite thigh, at the same time twisting the heel upwards, and pressing the knee down. Carry the thigh in this way over the sound one as high as the upper part of its middle third, then elevate the limb by raising the knee while the foot is held firm, at the same time making gentle oscillations, when the head of the bone will slip suddenly into its socket. [iV. Y. Jour, of Medicine. Dr. J. D. Trash's Prize Essay on Placenta Prcevia. The following are the corollaries deduced by the author of this interesting paper : (published in the Transactions of the American Medical Association.) 1. " We have shown that, as a general rule, cases in which de- livery takes place prematurely, are attended with greater risk to the mother than those occurring at the full time, with the exception of those before the seventh month, which rarely prove fatal, in consequence of the undeveloped condition of the blood-vessels of the womb at that early period. The probabilities of the child being saved are probably better at full term, though this is not so dis- tinctly shown by our statistics. Hence, if it be possible, cases in which premature delivery is threatened ought to be conducted to the full period. ay, 300 Prize Essay on Placenta Prarvia. [M; "This was the advice of Mr. Kinder Wood, a successful obste- trical teacher, who was in the habit of detaching the placenta in cases of dangerous haemorrhage from its presentation. When haemorrhage comes on before the completion of the term of preg- nancy, absolute rest and cold, with, in some cases, opium, should be resorted to for the purpose of restraining haemorrhage, avoiding the use of the tampon until the progress of the case indicates that extreme measures must be resorted to; for the introduction of the tampon, in the cases in which it is noted, was, in certain instances, soon followed by labor pains more or less effective. But, when its use is determined upon, a suppression of the haemorrhage ma}' be confidently relied upon for a time, at least, provided its introduc- tion be skillfully effected. In many instances, however, at kthis early period, the haemorrhage continues, and artificial delivery is the only resource. 2. " Most cases of partial placental presentation require only rupture of the membranes. By this simple expedient, the uterus is brought into active contractions, and haemorrhage restrained within, moderate limits, or entirely suppressed, until delivery takes place spontaneously, as occurs in a large proportion of cases, or is accomplished by art. But haemorrhage, in cases of partial presen- tation, is not always thus controlled, and our first table furnishes not a few which were attended by most alarming loss of blood.* 3. "In cases of complete presentation, if haemorrhage does not yield to simple measures, and in dangerous cases of partial presen- tation, early delivery is of the first importance. To select the most favorable opportunity, for this is often one of the most criti- cal tests of the physician's skill. To do this before the os has be- come dilatable is to incur the risk of inflicting serious lesions upon the uterine neck, and a difficult and protracted withdrawal of the child; while, to wait unnecessarily long, is to expose the patient to great hazard from unnecessary loss of blood. The rule should be to wait not i~or a dilated, but a dilatable condition of the os. The great source of danger in the conduct of cases of placenta praevia is the delay required to permit the necessary dilatation of the mouth of the womb ; while waiting for this necessary prerequi- site to delivery, exhausting haemorrhage has often taken place, from the eifects of which the patient has never recovered. "With the hope of keeping the bleeding in check during this necessary delay, the membranes may be advantageously ruptured; for we need not, in these cases, fear any embarrassment to deliv- ery from this cause, inasmuch as the uterus is almost invariably relaxed after severe haemorrhage. The administration of ergot, under such circumstances, in the manner already described, with the view of keeping up a pressure upon the mouths of the bleed- ing vessels until the os should dilate, is sanctioned by the results * Of the eight cases lost among Dr. Lever's eases, foub were eowplete, and koub partial presentations. 1856.] Prize Essay on Placenta Pravia. 301 in some of our cases in which it was employed; and although not often given, as we judge, with this particular view, it promises to be, in many cases, a valuable resource. In Dr. Fountain's two cases of complete presentation, rapid dilatation took place under its repeated administration ; a compression of the placenta was kept up until the os permitted the introduction of the hand for turning, and both mothers and children were saved. In this way we imi- tate, to a certain extent, the course pursued by nature in sponta- neous expulsion of the child. "The inhalation of ether , in one instance, quickened labor, and chloroform, in another, seemed to favor relaxation of the uterus. How far these agents, especially the latter, may prove subservient to this important object, experience has not yet determined. 4. ' But whatever means may be resorted to for keeping in check the flow of blood while the os is undergoing dilatation, the physician should not leave his patient after that process has begun. Dangerous, and even fatal, flooding sometimes takes place even when the os is yet undilated, as happened in a case recorded by Smellie. Dr. Bigby laid down the rule, that the patient should not be left by her physician after the placenta was discovered to be presenting. This rule he afterwards modified, as the interval, in such cases, is too long to justify the sacrifice of time. But the physician should remain beside his patient until active haemor- rhagehas ceased; and if dilatation is in progress, it is imprudent to leave the bedside until delivery has been effected. It has occurred in the experience of every physician to be surprised by the unex- pectedly sudden dilatation of the os in some cases of ordinary labor. On reading several of our cases, it is very apparent that from a neglect of the precaution here urged, the physician failed to be at hand when sudden and fearful haemorrhage took place, followed by perilous and even fatal exhaustion. Such sudden losses of blood are not uncommonly accompanied by a degree of dilatation of the os uteri that would render immediate delivery in- admissible, as in Case 69, from Rigby. " It corresponds with the experience of those who have had the largest opportunities for observation, and is an inference certainly warranted by a general survey of our cases, that of patients who enjoy intelligent and active medical assistance from the commence- ment of haemorrhage until the termination of labor, a very large proportion are conducted through their perils in safety, and no inconsiderable proportion of the children are saved. An early delivery by turning has been sanctioned by long experience, as the best general mode of treatment for securing safety to mother and child. 5. "But in some instances, haemorrhage will not yield to the means thus far recommended, and the os continues unprepared for artificial delivery. In these cases we may separate the placenta, with the confidence of almost certainly putting an end to the 302 Fistula in Ano. [May, hemorrhage, and with an almost equal certainty of destroying the child; unless the os should permit artificial delivery within a short time after the separation is effected. The urgency of the symp- toms in such instances, is sometimes very great, and it must be left to the judgment of the practitioner, in each individual instance, to determine whether to separate the placenta or to wait still longer. 6. "The os may be dilated or dilatable, and the patient in a state of extreme exhaustion. Here, turning could be performed with facility, but delivery would be hazardous. In these cases, the placenta may be detached with much less disturbance to the mother than would occur in turing under such circumstances, and an opportunity afforded for the patient to rally before she should be delivered. Table III. affords several instances in which spon- taneous delivery took place after such separation, and the patient recovered. Yet even in these cases, we must bear in mind that children are by no means necessarily destroyed by excessive loss of blood by the mother; and a resort to the stethoscope would doubtless often prove of great assistance, where in doubt as to the propriety of detaching the placenta. When we have satisfactory evidence that the child is dead, there can be no objection to an early resort to the separation of the placenta." \_N. Y. Jour. Med. On certain forms of Fistula in Ano, with reference chiefly to their Treatment without dividing the Sphincter Muscles. Mr. Hird read, Oct. 20th, before the Medical Society of London, a paper on this subject, and also gave his opinion in favor of the treatment of many special cases of complete fistula by means of the ligature. After alluding to the painful and hazardous opera- tions practised by surgeons for the cure of fistula until a more correct view was taken of the disease by Percevall Pott, by whose influence and example the barbarous treatment at that time had recourse to was renounced by the profession in this country, the author gave a minute description of the anatomical structure of the lower part of the rectum, and of the tissues which fill up the ischio-rectal fossae, and observed that many obscure collections of matter can only be diagnosed by those who are familiar with the complicated fascial and muscular boundaries of the space surround- ing the extremity of the gut. Mr. Hird then described the varie- ties of spontaneous abscess which affect this region, and gave the result of several cases of fistula which had not entered the rectum, or laid bare its walls, in which no operation was performed; and strongly opposed the assertion made by Mr. Syme, and many other surgeons who have written on this disease, " that all remedial measures, except the knife, are ineffectual." As a preventive treatment against the formation of fistula, he urged the necessity of freely laying open all abscesses in the neighborhood of the rec- tum before the walls of the bowel are laid bare. The incision 1856.] Tracheotomy in Croup. 303 should be directed from before backwards, and not transversely, so that the discharge may have no mechanical difficulties to over- come in its exit. When the abscess does not close by the ordina- ry process of granulation, Mr. Hird advises the use of mild injec- tions of nitrate of silver (four grs. to the ounce), and the application of well-adjusted pressure on the part. In two cases of eight and ten years' standing in which this treatment was not successful, he effected a cure by means of a platinum wire heated by electricity, and connected with the poles of a galvanic battery, similar to the one used by Mr. Marshall for applying electric cautery to fistulous openings in the cheek, and advises the use of this agent before re- sorting to division of the septum. In cases of complete fistula, the author has no confidence in any treatment except that of laying the cavity of the abscess and of the rectum into one by dividing the sphincters. This, he said, might be accomplished either by means of the*knife, the ligature, or electric heat. Although the knife is the favorite instrument of the majority of surgeons, he prefers the use of the ligature in all cases where the hemorrhoidal veins are unusually large, or when the patient has a dread of the knife. He considers, also, that this method of operating possesses advantages over the knife in many special cases, and, if judiciously applied, and only tightened by means of the fistula- tourniquet to a degree of tension sufficient to accomplish the division of the sep- tum, is not so painful as the operation with the knife, less so in the after-treatment, and frequently accomplishes a cure in a shorter space of time. Hemorrhage and the dread of a cutting operation are avoided by this plan. Mr. Hird's experience does not confirm the opinion of Sir. B. Brodie, that all fistulas have an internal ori- fice leading into the rectum ; neither do his observations verify the opinion of many writers, that fistulas are most frequently found in phthisical patients; but, on the contrary, are in harmony with the views of Andral and Louis, both of whom demonstrate, by statisti- cal inquiries, that these affections, occurring simultaneously in the same individual, are merely the result of accident, and that they do not stand to each other in the relation of cause and effect. [Med. Times and Gazette. Tracheotomy in Croup. By Dr. TROUSSEAU. I am firmly decided, for my part, not to be discouraged, but to advocate tracheotomy with so much the more conviction, as the proportion of successful cases increase ; and if that proportion re- mained, even as it was ten years ago, I will still proclaim the necessity of tracheotomy, and I would not cease to uphold it as a duty a duty as imperious for a surgeon as the ligature of the carotid artery, after a wound of that vessel, even if death followed the operation as often as the cure. Here are the results of my operations for tracheotomy, during the year 185i : I operated on 30-i Excision of Joints. {^-^Ji nine children. Of these, two died, while seven were cured, and are now living in perfect health. Certainly, the proportion of cured is not always so great ; still, if I make the sum total of the operations I have performed in the last four years, I find twenty- four operations, and fourteen cures, equivalent to more than half. At the Hopital des Enfans Malades, in the last five years, the proportion of cures has been nearly a quarter. Here are the offi- cial numbers viz : 1850 . 20 operations . 6 cures, about l-3rd. 1851 . 31 " .12 " more than l-3rd. 1852 . 59 " .11 " less than l-5th. 1853 .61 " . 7 " onlv l-9th. 1854 .44 " . 11 " only l-4th. 215 " 47 " about l-4th. This result is considerable, if we remember the social condition of the children who are brought to the Hospital, the deplorable treatment they are subjected to, by "sagefemmes," quacks, etc., in a word, those persons the poor generally consult in preference to doctors. We should bear in mind, too, the unfavorable condi- tion of the Hospital, where the children operated upon are placed in the midst of the most varied and fatal contagion; so much so, that often, when the operation for tracheotomy is succeeding as well as could be desired, the scarlet fever, measles, small-pox, or whooping-cough, cause the most fearful complications. I do not doubt that half the operations performed out of Hos- pital are successful, always provided tracheotomy takes place when the chances of cure are possible. This restriction is important* for, if the diphtheritic infection is thoroughly rooted in the system,, if the skin, and particularly the cavities of the nose, are invaded by this special phlegmasia; if the quickness of the pulse, delirium, prostration, indicate a profound poison, and if the danger is rather in the general state, than in the local lesion of the larynx or of the trachea, certainly the operation should not be tried, for it is inva- riably fatal ; when, however, the local lesion constitutes the prin- cipal danger of the disease, no matter at what degree asphyxia has arrived, even if the child has but a few moments to live, tracheoto- my succeeds invariabl}'-, as well as though it had been tried three or four hours sooner. [Ibid. Excisions of Joints. On a recent occasion, Mr. Fergusson submitted to the inspection of the pupils of King's College Hospital, a number of patients on whom excision of the various joints had been performed from time to time, and took the opportunity of making some valuable remarks upon the improvements which had been made in this de- partment of surgery, and upon the individual cases now submitted 1856.] Excision of Joints. 305 to notice. He first made some observations upon the introduction of excision of the elbow joint, in the place of amputation through the arm. Passing a eulogium upon Professor Syme for the part he had taken in introducing and recommending this operation, he observed that it was not followed out even yet, as it ought to be, notwithstanding its acknowledged superiority over all other modes of treating incurable disease of that joint. As illustrative of these remarks, two patients were introduced in whom excision of the elbow-joint had been performed, in one of which it had not been done more than ten weeks, and yet the patient (a woman) had already got an excellenl arm. Mr. Fergusson stated that, in reference to this proceeding (in the elbow), there was now no question in the mind of any surgeon; but in the instance of some other joints, there had been much controversy, and he would now draw their attention to a case where he had performed the operation of excision of the head of the thigh bone several years ago with the most complete success. [The individual on whom this operation had been done, was brought into the theatre ; he was a fine healthy young man, and walked with the greatest facility, and stated that he sometimes walked sixteen miles in the day], lie was particularly glad at being able to show them this patient, inasmuch as some very erro- neous remarks had been made in reference to the propriety of this operation. Mr. Syme had, in his lectures in the Lancet, recently published, stated that, if the head of the thigh bone had been taken away with success, the limb could not be of any use for the sup- port of the body ; but those who now had the case before their eyes could see for themselves how gratuitous such an assertion was. Three patients were next brought forward, upon whom excision of the knee-joint had been successfully performed. The first was a fine healthy woman, who had undergone the operation about two years since; a perfect anchylosis had taken place, and by the help of a high boot, well fitted to the limb, she walked with the utmost facility. The second was a little boy who had undergone the operation twelve months since, and could also walk, even without artificial assistance, with great facility ; and the third case was also a lad upon whom his friend, Mr.Henry Smith, had opera- ted nine months since, under the greatest disadvantages; but here also, as the pupils could see, the patient had made an excellent recovery, and could walk about with the same facility. Mr. Fergusson made some lengthened remarks upon the opera- tion in question, and stated that although, to his regret, most unjustifiable and unhandsome remarks had been directed by Mr. Syme against the promoters and pursuers of this mode of treat- ment, the proceeding had been followed out by several surgeons, and the success was so admirable that, notwithstanding the veto of the Edinburgh Professor, the operation was now fairly estab- 306 Structure of the Spinal Cord and Spinal Nerves. [May, lished ; taking the opportunity of eulogising Mr. Jones, of Jersey, and the late Dr. Mackenzie, for their efforts in this direction, he concluded his remarks by stating that he hoped his pupils would endeavor, in fitting instances, to follow out the same line of prac- tice, for which they had ample authority in the cases he had just had the pleasure of bringing before them that day. [Med. Times and Gazette. Structure of the Spinal Cord and Spinal Nerves. In an inaugural dissertation before the University of Dorpat, by Philip Owsjanuikow, the author has entered at great length on the structure of the spinal cord and spinal nerves. The conclusions drawn from the observations were as follows : 1. That all the fibres of the spinal nerves which enter into the spinal cord are united to gangliated cells. 2. That one filament extends to each gangliated cell from the anterior spinal root, and one from the posterior root; a third, a commissural one, from the other part of the spinal marrow ; and in many fishes a fourth, passing from the brain. The presence of this single fibre passing to the brain, may, as the author throws out, be of moment in reference to the question of the possibility of the same fibre being both afferent and efferent in function, a posi- tion which Du Bois-Raymond thinks tenable, as judging from his experiments, though, as a rule, this power is not put into action, in his opinion. The author of the paper now considered, thinks, on the contrary, this aforesaid power is always put into use. 3. That from each cell of the spinal marrow, a filament extends to the brain, forming the white substance. 4. That the chief mass of the spinal marrow, containining fibre and cells, is a united areolar web, which being arranged in great abundance about the central canal, and furnished with numerous bloodvessels, produces the ruddy gray color of the substance which is generally supposed to be owing to pigment cells. 5. That the gelatinous substance of Rolandi is connective tissue. 6. That the cells found as well in the posterior horns as in the surrounding substance of Rolandi, are corpuscles of the united web. 7. That the cylindrical axes are of a round form, and are com- posed of the same substance as the nervous cells. 8. That the cylindrical axes in the grey substance are formed of a membrane peculiar to themselves, which surrounding also the nerve cells, may be separated from the fundamental mass composed of the united web. 9. That in some fishes, the cylindrical axes of the spinal cord are exposed, the cellular web in which they arc placed forming no especial investment. 10. That in those fishes which have anterior and posterior spinal roots, round gangliated cells are found, sending out in various directions divided branches. [Brit, and For. Med. Chir. Rev. 1856.] Premonitory Diarrhoea. 307 Premonitory Diarrhma. The New York Journal of Medicine, for January, 1856, con- tains an article by Dr. Macloughlin, of London, upon the Pre- monitory Diarrhoea of Cholera, from which we extract the following important conclusions: 1. That cholera that is, vomiting, spasms, etc., is always preceded by a diarrhoea, for a few hours, or for a few days, or for a few weeks. 2. That there is, as yet, no well-authenticated case of cholera without an attack of spasms. 3. That a painless diarrhoea may drain away almost the whole serum from the blood, until the blood has ceased to circulate, and until the heart has ceased to beat, before the patient is attacked with vomiting, spasms, etc., that is with the second stage of cholera. 4. That if the disease is scientifically attended to in its diar- rhceal stage, it can be cured, and, consequently, the developed stage prevented, and life saved. 5. That these two pathological facts are now acquired to medical science, viz : 1. That every case of cholera is preceded by a diarrhoea, for a few hours, a few days, or a few weeks. 2. That the disease, scientifically treated in the diarrhceal stage, is easily cured. 6. That it is in the power of human foresight to prevent an attack of developed cholera. In a letter dated 2d July, 1855, inserted in the Association Med. Journal, it was attempted to point out what diarrhoea, if left to itself, will run into cholera in a few hours ; and what diarrhoea, if left to it- self, will not run into cholera for a few days, or for a few weeks. " I am fully aware that this pathological point requires to be further studied. I, therefore, submit it to the profession, in the hope that more careful and more attentive observers will be ena- bled to give us valuable information on this important subject, so that the medical attendant, on arriving at the bed-side, may be enabled to pronounce whether his patient will be attacked in a few hours, or in a few days, or in a few weeks, with cholera, if the diarrhoea is not scientifically attended to, or whether the diarrhoea will be cured by the efforts of nature ; and so that the medical attendant may not be left, as he now is left, to establish his progno- sis on conjectures. There is, also, another point to which I beg leave to call the attention of the profession. I have now seen five severe outbreaks of epidemic cholera, and I have reason to believe that a great and an important change takes place in the constitution of every individual, where epidemic cholera is about to break out, which change in the constitution of every individual, persists while the disease rages, and after the disease has passed away for some time. N. S. VOL. XII. NO. V 20 S08 tSIcm Diseases. [^av> That tins change in the constitution of individuals is manifest by the facts, that those of a costive habit, who have a passage from their bowels only every twor three, four, or five days, of hard fecal matter, have now a passage from their bowels daily, of soft fiecal matter. That those who are jn the habit of having a passage daily, of solid fyecal matter, have now two or three passages daily, from their bowels, of soft fa?eal matter. That those who usually require laxatives to keep their bowels free, now do not require laxatives; or if they take any, they find that one-half, one-third, or one-quarter, the usual dose has the same effect as a full dose had formerly. And further, that it is now dangerous to give a full dose of pur- gative medicine, lest this dose should induce diarrhoea, followed, too often, by fatal cholera. The Medical Times, of September, 1854, page 272, contains the report of four cases of cholera, which were induced in St. George's Hospital here, by the administration of the full dose of purgative medicine, and of which, one died. That, further, every individual in the locality is troubled with more flatus than usual, especially between one and five in the mor- ning, and that every one about to be attacked with diarrhoea has a pressure, and a weight on the sphincter of the anus, and a feeling of insecurity, as if at any moment, he would lose command over it. If in consequence of the observations and of the researches of the profession in every country, it is ascertained that this change in the constitution of all the individuals in a locality where cholera is about to break out, does take place, and that this change per- sists while cholera rages, and after it has passed away some time, it may throw some light on the etiology of the disease, and prove that cholera is not a contagious disease." Skin Diseases. The following notes from Professor Uebra's Annual Report of Diseases of the Skin, treated at the Vienna Hospital, is from the Assoc. Med. Journal: I. Acne. 17 cases (13 males-, 4 females). Vapour bath and washing with soap and alcohol, sufficed to cure all these cases. There were 4 cases of the allied affection sycosis, all of which were successfully treated by inunction with iodide of sulphur ointment, and the application of strong nitric aeid as a canstic. II. Ecthyma. 13 cases (11 males, 2 females), generally associ- ated with scabies or pediculi, and induced by tl>e scratching. Warm fomentations sufficed for the cure. III. Eczema.- 150 cases (96 males, 54 females). Hebra includes under this term the various forms of impetigo, tinea, and porrigo; there being, as he believes, no difference between them and eczema impetiginosum; for, on destroying the efflorescences, or removing 1856.] Skin Diseases. 309 the crusts and scabs, we then perceive the characteristic phenomena of eczema red, moist places, with more or less infiltration of the cuticle. With regard to the cause of the disorder, it was traced with certainty to an elevated temperature (either exposure to the sun or working at the oven) in 22 cases; to irritation of the skin by ointments, plasters, etc., in 21 cases; to the repeated action of water in washing clothes, to fomentations, etc., in 9 cases ; to scratching the skin, in consequence of the irritation caused by pediculi, in 20 cases ; to varicosity of the veins in 19 cases ; and in eight cases it was associated with anomalies of menstruation. The modes of treatment were very various, but in each patient the system commenced with was adhered to. 1. In 46 cases, cold water alone was used, in the form of fomenta- tions, baths, douches, etc. 2. In 6 cases, a wash of sulphate of zinc ( 3 j to the pint of wa- ter) was used. 3. One case was treated with corrosive sublimate baths. 4. In 2 cases, the parts were kept moist with a dilute solution of potash ( 3 j to the pint of water). 5. In 3 cases, the caustic action of a concentrated solution of potash ( 3 j 3 ij of water) was tried. 6. In 70 cases, soft soap was used. It was usually applied night and morning for three consecutive days, to the diseased places, which were then covered with flannel, and left untouched for four consecutive clays. This process was repeated till the moisture and itching disappeared, and there was merely a red, dry, squamous surface remaining, (pityriasis rubra,) which was treated with tar. 7. In 19 cases, tar was used; the best being that obtained from the wood of the beech or of the juniperus oxycedrus (the product in this case being the oil of cade). The action of both these agents is nearly the same, but the latter is the least disfiguring, and, there- fore, most applicable for diseases of the face. We have already indicated the proper period for commencing this form of treat- ment. The affected parts are smeared over once or twice a day, till an unbroken blackish brown investment is formed, which usu- ally happens after about half a dozen applications. During this time, the parts must not be touched with water. The longer the tarry covering remains, the more certain is the result of its action. If it soon falls off, this is a sign that moisture is still exuding, and we must return to the preceding treatment (merely with soft soap). 8. In 3 cases, the expectant method was trusted to. Whatever was the external treatment, internal remedies were at the same time used, to improve the general health : as, for instance, cod-liver oil in the scrofulous cases, aloes and iron in the chlorotic cases, etc. IV. Elephantiasis Arabum. 6 cases (4 males and 2 females). In 5 cases, the leg was affected ; and in one, the penis and scrotum. One patient recovered in consequence of prolonged pressure by 310 Apoplexy in Relation to Chronic Renal Disease. [May, bandaging; and in 4 others, an improvement was manifested. One woman died from phlebitis, but compression had not been used. V. Favus. 13 cases (7 males, 6 females). In all these cases the scalp was the seat of the disorder; and in this position the dis- ease is especially persistent, from the fact that the peculiar micro- scopic fungi of favus occur within the hairs, which thus form a reservoir of spores, from which a new development of favus masses springs up when the older masses have either fallen off or been removed. [When favus occurs in any other part, it always runs an acute course, and disappears spontaneously in a few weeks.] The treatment consisted in keeping the affected spots as clear as possible, and extracting the diseased hair with the fingers. YI. Herpes. 28 cases, (21 males, 7 females). One was a case of herpes circinatus, 2 of herpes iris, and the remaining 25 of her- pes zoster. The treatment in all the cases was expectant. VII. Herpes Tonsurans (occurring in 5 men), and Pityriasis Versicolor (in 13 men) were always cured in the course of a week or two by active inunction with soft soap, and then covering the part with flannel. The soap should be rubbed in for the space of ten minutes daily for from four to six days, and a layer of about a line thick left, before flannel is laid. [N. Y. Jour, of Med. Apoplexy in Relation to Chronic Renal Disease. The following extract is from an interesting paper, by "W. Sen- house Kirkes, M. D., in the Med. Times and Gazette. The intimate connection thus apparently subsisting between sanguineous apoplexy on the one hand, and diseased cerebral vessels, enlarged heart, and renal disorganization, on the other, as deduced from the foregoing analysis, will, perhaps, be best appre- hended by viewing the result of this analysis in a kind of tabular form. The 22 cases of sanguineous apoplexy may then stand thus: Cerebral Vessels. Heart. Ki chronic disease, obey diuretics well, and that no inconveniences are produced." The prescription which the patient, in this case, had been taking was as follows: R. Potass* tartrat. fas., spirit, aether, nitr. ss., aqua? piment, 3j. Ft. haust. ter die. The case was, of course, one of chronic dropsy, and the diagnosis as to its renal cause, had depended upon the absence of cardiac disease, and the presence of a large quantity of albumen in the urine. [Med. Times and Gazette. Bromo-Ioduretted Preparations: translated from the French, by M. Morton Dowler, M. D., New Orleans. The following is a summary of the conclusions arrived at by Dr. Lunier, in a long memoir contributed by him to L1 Union Medicate: Part First. 1. The cod-liver oil acts at one and the same time by its oily matter, and by the iodine and bromine of potassium which enter into its composition. 2. These two haloid salts, favor the digestion of the oily matter, by increasing the activity of the pancreatic secretion. 3. This fatty substance, and highly combustible aliment, play an important part in the act of respiration, and in the development of animal heat. 4. The iodine and bromine associated together, act with much more energy than when separately administered. 5. That we can supply the place of the cod-liver oil, by the bromo-ioduretted preparation, associated with any hydro-carbona- ceous substances, as chocolate for example. 6. The bromo-ioduretted medicine augments the secretion of the digestive juices, gives activity to the organic functions, and espe- cially favors the development of the adipose tissue. 7. This agent sometimes determines on the skin and mucous membranes, a light inflammation, which has not, however, any tendency to suppuration. 8. It excites also, some cerebral affections, which take on the form of nervous fever, and more generally it puts on the form of general progressive paralysis. 9. The oily matter enters the digestive apparatus, or provides for the transformation of the immediate non-azotic principles. 10. The oily matter is deposited in the tissues when the oxygen introduced into the system is insufficient to consume it. {La bruler!) Part Second. 1. Leanness, which has not its origin in any serious organic lesion, is successfully treated by the cod-liver oil, or the bromo-ioduretted agent, mixed with oily matter. 2. Opium, more than any other medicine neutralizes the effects of this medicine ; (the cod-liver oil) employed with precaution is capable of being useful in the treatment of obesity. 3. The bromo-ioduretted treatment would appear to modify, ad- vantageously, certain diseases of the pancreas. 1856.] Bromo-Iodurelied Preparations. 315 4. In phthisis pulmonalis, the cod-liver oil acts in a special manner, in furnishing an aliment to the pulmonary combustion ; (iin aliment a la combustion pulrnonaire /) 5. It is therefore contra-indicated in the acute stage of the dis- ease, when there is an urgent necessity of leaving the affected organ in a state of repose. 6. The mineral waters, the fucus, the lichens, and sea-salt, owe their virtues, in the treatment of pulmonary consumption, to the iodine and bromine which enter into their composition. 7. In tuberculous chloro-anoemia, and in certain inveterate cases of chlorosis, the bromo-iodine treatment should be associated with the use of ferruginous preparations. 8. In scrofulous and syphilitic affections, in goitre and glandu- lar enlargements, the bromo-iodine treatment succeeds by im- pressing on the capillary circulation, and the secretions, an ex- cess of activity which eliminates the morbific elements from the organism. 9. It is especially to the fatty substance that we most attribute the good effects of cod-liver oil in rickets. 10. In chronic coryza and ulcerated ozcena, bromo-iodine treat- ment modifies rapidly the state of the mucus of the nasal fossae. 11. This treatment, owing to its direct action on the uterus, and the active impulse which it gives to the capillary circulation, will often be employed with success to re-establish or excite menstrua- tion. 1. Bromo-ioduretted cod-liver oil: ft. Iodide of Potassium or of Iron, Bromide of Potassium or of Iron, of each, gr. iv. ; Cod-liver Oil (brown) gxvj. Ft. Mist, secund. art., of which take from one to five spoonfuls daily. 2. Bromo-ioduretted oil : ft. Iodide of Potassium or of Iron, Bromide of Potassium or of Iron, of each, gr. viij ; Neat's Foot Oil, or Sweet Almond Oil, fxvj. Ft. Mist, secund. art., and take from one to five tablespoonfuls daily. 3. Bromo-ioduretted Chocolate: ft. Iod. of Potas. or of Iron, Bromide of Potas. or of Iron, of each, gr. iij. ; Cake Chocolate, Powdered White Sugar, of each q. s. M. ft. secund. art. a mass of gviij, to be divided into troches, (tablettes,) of gj. each, of which from one to five are to be taken daily. 4. Bromo-ioduretted Biscuits : ft. Iod. of Potas. or of Iron, Bromide of Potas. or of Iron, of each, gr. iv. ; Bread Biscote q. s. M. ft. secund. art., ten biscuits, and take four or five daily. 5. Bromo-ioduretted Salt : ft. Iod. of Potas. or of Iron, Bromide of Potas. or of Iron, of each gr. iv. ; Gray Table Salt iij. Mix carefully, and preserve in a close vessel. Take from 3ij. to 3 v. daily by salting. No. 1. No. 2. gr. xix. gr. xij ss. gr. xij ss. gr. xix. : S"j.; 1 xx. 516 Presentation of Dead Children [May, 6. Bromo-ioduretted Butter : R. Bromo-ioduretted Salt 3 v. ; Fresh Butter Jxvj.; to be consumed in two or three days. I. Bromo-ioduretted Solution : R. Iodide of rotas, or of Iron, Bromide of Potas. or of Iron, Extract of Gentian, Water, II. ft. secund. art., a solution of which take from one to three tablespoon- fuls daily at meals. The extract of Gentian ought to be left out when a nearly tasteless mixture is desired. 8. Bromo-ioduretted Pills : No.l. No. 2. R. Iodide of Potas. or of Iron, gr. xix. gr. xij ss. ; Bromide of Potas. or of Iron, gr. xij ss. gr. xix. ; Powder and Syrup of Gentian, q. s. M. ft. secund. art. pil. xl., of which take from one to three daily at meals. 9. Emmenagogtie Potion : R. Iod. of Potas. or of Iron, Bromide of Potas. or of Iron, of each, gr. iv. ; Syrup of Artimesia 3 v. ; Distilled Water of Artimesia; Distilled Mint Water, of each, 3x. M. ft. secund. art., a portion of which take one or two tablespoonfuls every morning on an empty stomach. [New Orleans Med. and Surg. Jour. On ilie mode of Presentation of Dead Children in Labour. The Association Medical Journal for Aug. 31, contains an inter- esting paper on this subject by Dr. J. Mathews Duncan. The following are the author's conclusions drawn from the observations he has made : 1. The healthy foetus floats obliquely, with its head lowest, in a fluid of its own specific gravhy a position corresponding to that it has in utero. 2. The foetus has a specific gravity of about 1050, while that of the liquor amnii, at the full time, is nearly 1010. 3. Soon after the death of the foetus in utero, changes take place in it (probably chiefly in the brain) which alter its position of equilibrium in a fluid of its own specific gravity, so as to be gen- erally the reverse of that of the healthy foetus; that is, so as to be oblique, with its head highest. 4. It may happen that an advanced stage of decomposition of the foetus, with collapse of the cranium, may make its position of equilibrium, when floating, again oblique, with the head lowest. 5. These circumstances have probably considerable influence in determining the frequent malprescntations of dead children. [Am. Jour, of Med. /Sciences. 1856.] Miscellaneous. 317 EDITORIAL AND MISCELLANEOUS. The Action of Medicines in the System ; or, "on the mode in which Thera- peutic Agents introduced into the Stomach produce their peculiar effects on the animal economy P Being the Prize Essay to which the Medical Society of London awarded the Fothergillian Gold Medal for mdccclii. By Frederick William Headland, M.B., B.A., F.L.S., M.R.C.S.. etc. Second American, from the second revised and enlarged London edition. Philadelphia: Lindsay and Blakiston. 1856. We took occasion to speak favorably of this work on the appearance of the first edition, and the correctness of our estimate of its value has been demonstrated by the early demand for another supply. It is certainly an excellent book for students as well as practitioners who may not have kept pace with the improved views of therapeutics. The action of medicinal agents introduced into the stomach is treated of under the heads of the following Propositions : Prop. I. That the great majority of medicines must obtain entry into the blood, or internal fluids of the body, before their action can be mani- fested. Prop. II. That the great majority of medicines are capable of solution in the gastric or intestinal secretions, and pass without material change, by a process of absorption, through the coats of the stomach and intestines, to enter the capillaries of the portal system of veins. Prop. III. That those medicines which are completely insoluble in wa- ter, and in the gastric and intestinal juices, cannot gain entrance into the circulation. Prop. IV. That some few remedial agents act locally on the mucous surface, either before absorption, or without being absorbed at all. That they are chiefly as follows : a. Irritant Emetics. b. Stomach Anaesthetics. c. Irritant Cathartics. Prop. V. That the medicine, when in the blood, must permeate the mass of the circulation, so far as may be required to reach the parts on which it tends to act. That there are two possible exceptions to this rule : a. The production of sensation or pain at a distant point. b. The production of muscular contraction at a distant point. Prop. VI. That while in the blood the medicine may undergo changes, which in some cases may, in others may not, affect its influence. That these changes may be a. Of Combination. b. Of Reconstruction. c. Of Decomposition. Prop. VII. That a first class of medicines, called Haematics, act while in the blood, which they influence. That their action is permanent. 1. That of these some, called Restoratives, act by supplying, or causing to be supplied, a material wanting ; and may remain in the blood. 318 Miscellaneous. [May, 2. That others, called Catalytics, act so as to counteract a morbid mate- rial or process ; and must pass out of the body. Prop. VIII. That a second class of medicines, called Neurotics, act by passing from the blood to ihe nerves or nerve centres, which they influence. That they are transitory in action. 1. That of these some, called Stimulants, act so as to exalt nervous force, in general or in particular. 2. That others, called Narcotics, act so as first to exalt nervous force, and then to depress it, and have also a special influence on the intellectual part of the brain. 3. That others again, called Sedatives, act so as to depress nervous force, in general or in particular. Prop. IX. That a third class of medicines, called Astringents, act by passing from the blood to muscular fibre, which they excite to contraction. Prop. X. That a fourth class of medicines, called Elimi natives, act by passing out of the blood through the glands, which they excite to the per- formance of their functions. The work is then concluded by considering the action of some of the more important medicines in particular. It is for sale by T. Richards & Son, of this city. Minutes of the Seventh Annual Meeting of the Medical Societg of the State of Georgia, held in the City of Macon, April 9th, 1856. The Society assembled in Temperance Hall at 10 o'clock A.M., and was called to order by the President, Dr. L. A. Dugas. The Recording Secre- tary, Dr. O'Keefe, being absent, Dr. Ellison was requested to act pro tern. On calling the roll, the following members answered to their names: Dr. R. D. Arnold, of Savannah, " J. R. Boon, of Macon, " S. W. Burney, of Forsyth, " H. F. Campbell, of Augusta, " G. F. Cooper, of Americus, ' L. A. Dugas, of Augusta, " 1. E. Dupree, of Twiggs county, " W. W. Flewellen, of Columbus, " J. C. Ellison, Dr. J. M. Green, of Macon, " M. A. Franklin, " " " D. W. Hammond, " ' " G. Harrison, " " " P. M. Kolloek, of Savannah, " R. H. Nesbit, of Macon, " Thomas Lamar, " " " E. S. Way, of Pulaski county. " J. G. Westmoreland, of Atlanta. The minutes of the last meeting were read and approved. On motion, the rules were suspended, and the following gentlemen, on written application, were duly elected members of the Society: Drs. C. E. Bellamy, of Columbus; B. S. Carswell, of Twiggs Co.; A. A. Trammel, of Forsyth; 0. S. Promt, of Jasper Co.; Ebon Hillyer, \Y. II. Oliver, J. 11. Ethridge, of Atlanta; J. Harris, of Crawford Co.; J. R. Janes, of Slarksville ; W. E. Vason, of Albany ; C. B. Sutton, of Lee Co. The election of officers being next in order, a ballot was ordered, and the following gentlemen duly elected : 1856.] Miscellaneous. 319 President Ira E. Dupree, M. D., of Twiggs county, 1st Vice-President Thomas Lamar, M. D., of Macon, 2d Vice-President S. W. Burney, M.D., of Forsyth, Cor. Secretary F. C. Ellison, M. D., of Columbus, Rec. Secretary D. C. O'Keefe, M. D., of Greensboro', Treasurer C. B. Nottingham, M. D., of Macon, Drs. Flewellen, Arnold and Burney, were appointed a committee to nom- inate delegates to the next meetinsj of the American Medical Association. At 12 o'clock M., the hour appointed for the purpose, an interesting oration was delivered by Dr. W. W. Flewellen, of Columbus, upon " The Rise and Progress of Experimental Sciences. After which, on motion, the Society adjourned, to meet again at three o'clock P. M. Afternoon Session. The Society was called to order by the President, and business was re- sumed. Reports from auxiliary societies being called for, Dr. Ebon Hillyer pre- sented a report of the organization, officers and members of the auxiliary society in the city of Atlanta which, on motion, was received. Written communications being next in order, Dr. Arnold presented an instructive and interesting paper upon the Relations between the Remittent and Yellow Fevers, showing conclusively that they were distinct diseases, and that they need never be confounded with each other. He also pre- sented, for the inspection of the Society, representations in oil colors of the liver in Yellow fever, and in Bilious fever; that of the former being of a bright box-wood color, and the latter a decided brown. The discussion of this subject was continued for some time by Drs. Dugas, Campbell, Kollock, Hillyer, and others all sustaining the views advanced by Dr. Arnold. Dr. Arnold also presented for the inspection of the Society, a new and simple method of preserving specimens of morbid Anatomy. Dr. Kollock next presented an interesting paper upon the Health of the City of Savannah, during the winter and spring of 185G Epidemic Mea- sles, and its complications with Pneumonia, Laryngitis and Varicella. After which, the Society adjourned, to meet again at 8 o'clock P.M. Evening Session. The Society re-assembled, the President in the Chair. Dr. G. F. Cooper, who had just reached the city, appeared, and read a practicable and interesting paper upon the Influence of Diet in the Manage- ment of Diseases. The Committee on Business, consisting of Drs. Dugas, Green, Kollock, Flewellen and Way, reported the following subjects and essayist, for the next annual meeting: 320 Miscellaneous. P^fay, 1st. Dr. P. M. Kollock on the Treatment of Vesico-vaginal Fistula. 2d. Dr. J. G. Westmoreland What is the difference between the "Coun- try fever" of the sea-board, and the Remittent fevers of the middle counties of Georgia ? 3d. Dr. H. F. Campbell Are there any means by which the extension of Yellow fever into the interior may be prevented ? 4th. Dr. Joseph A. Eve On the Diseases of the Cervix Uteri. 5th. Dr. L. D. Ford On the connexion of Pneumonia with Remittent fever. 6th. Dr. C. B. Nottingham On the Diseases of the Spinal Marrow. 7th. Dr. F. C. Ellison On the relation of Epidemic Dysentery to Malarial fevers. 8th. Dr. W. M. Chartres On the relation of Acute Meningitis to Malarial fevers. 9th. Dr. E. F. Way On the Pathological difference between acute, articu- lar and chronic Rheumatism. 10th. Dr. Ira E. Dupree On the Treatment of Prolapsus Uteri. 11th. Dr. Ebon Hillyer Under what circumstances is Trepanning justi- fiable? 12th. Dr. J. M. Green On the value of Escharotics in the treatment of Cancer. 13th. Dr. R. D. Arnold The Pathology and Treatment of Erysipelas. On motion of Dr. Dugas, the Essays read by Drs. Arnold, Kollock, and Cooper, together with the Address of Dr. Flewellen, were ordered to be published. On motion of Dr. Arnold, the thanks of the Society were tendered Dr. Flewellen for his appropriate and erudite oration. The selection of orator for the next annual meeting being next in order, Dr. G. F. Cooper was unanimously elected, and Dr. R. C. Mackall his alter- nate. The city of Augusta was selected as the next place of meeting. The Committee of arrangement are Drs. Campbell, Harris, Doughty, AValton, and Phinizy. At a late hour, on motion, the Society adjourned, to meet again at 10 o'clock A. M., on the second Wednesday in April, 1857, in the city of Au- gusta. F. C. ELLISON, Recording Secretary, pro tern. Mode of Testing the Translucency of Hydrocele. Dr. W. Frazcr directs attention (Dublin Hospital Gazette, Nov. 1, 1855) to what he believes to be one of the best methods of employing the valuable test of translucency in hydrocele, a test which is practically so important as a differential diag- nostic in discriminating between mere serous effusions in the cavity of the tunica vaginalis and various affections of the testicle, or scrotal hernias. Of course, every one is aware that the test is not free from objection ; thus 1856.] Miscellaneous. 321 it is almost or entirely useless in those instances in which the effused fluid is of very dark color, or is mixed with blood, &c, and also whenever the tissues of the tunica vaginalis are of unusual thickness, or are the seat of cartilaginous or osseous deposit, or when they are coated internally by the products of previous inflammatory action. Independent of these excep- tional cases, there are a number to be met with in practice, in which the test is of value. As ordinarily employed, by placing a candle at one side of the tu- mour, and excluding the passage of the light laterally by means of the hand, it is, at best, a clumsy proceeding, and liable to errors. I have found the stethoscope much more useful, as a means of excluding the diffused light, and by applying the eye to its expanded bell-shaped portion the ear-piece being firmly placed upon the scrotum, held in a tense condition we can even map out the state of the parts with tolerable accuracy, if the contained fluid be of ordinary character, and detect the position of the testicle by the opacity it produces, especially when it occupies any unusual locality, as the front or sides of the scrotum, or is adherent from inflamma- tion after previous tappings. We can employ either a lighted candle or bright sunlight, as our best means of obtaining the requisite illumination ; but even in diffused daylight I have succeeded very well in the manner I mention. [Am. Jour. Med. Sciences. New Form of Astringent Application. By Dr. William Bayes, Brigh- ton. Pure glycerine dissolves nearly its own weight of tannin, affording a very powerful local astringent application. The solution of tannin in pure glycerine appears to me to supply a desi- deratum long felt, and capable of a great variety of useful applications. The solvent property of glycerine over tannin allows us to form a lotion of any desirable strength, as the solution is readily miscible with water. The solution of tannin in glycerine, in one or other of its strengths, is peculiarly applicable to many disorders of the mucous membrane, readily combining with mucous, and forming a non-evaporizable coating over dry membranes ; hence it may with benefit be applied to the mucous mem- branes of the eye and ear in many of its diseased conditions. It forms a most convenient application to the vaginal, uterine, urethral, or rectal membranes, where a strong and non-irritant astringent lotion is desired. In local haemorrhages, where the bleeding surface can easily be reached, it will prove very convenient, and may be applied either with a sponge or small brush. The solution must be kept in the dark, and should not be prepared for any great length of time before used, or decomposition will occur. It 13 singular that glycerine does not possess the same property towards gallic acid. [Association Med. Jour. On Forcible Feeding. Dr. Szigmondy describes a simple and effectual means of administering fluid nourishment to persons who are unconscious, suffer from trismus, or obstinately refuse food. The patient is laid horizon- tally on a bed, with the head somewhat raised, and the food is poured by teaspoonfuls through the nostrils. Reaching the pharynx, the movement of deglutition is provoked ; and as soon as this is perceived, another small portion is poured in. In this way too, physic can be given to children who resist. He relates a case of severe alcoholic coma, with spasmodic 322 Miscellaneous. closure of the jaws, which was speedily relieved by the introduction of a solution of tartar emetic. This means is far easier to practise, and causes less irritation, than the introduction of the stomach-pump. Dr. Beer states that by the magnetico-electrical induction apparatus, the mouth can be sufficiently opened to admit of portions of solid food being introduced. [ Wien Wochen. Med. Times and Gaz. Ergot of Wheat. Dr. Jobert makes the following statement, as the results of his observations : 1. The medical and obstetrical properties of this ergot are as incontestable as those of the ergot of rye, and its effects are as prompt, as direct, and as great. 2. Its hemostatic action appears certain. Dr. Jobert has administered it several times, against abundant discharges of blood, and immediately after labour it has almost constantly and fully succeeded. 3. In the dose of from one to two grammes, (fiteen to thirty grains,) according to urgency, in cases of uterine hemorrhage during any period of pregnancy, it has frequently succeeded in lessening, if not in completely arresting, the haemorrhage, and this without appearing to produce any stimulant action on the uterus. [Gaz. des Hop. Asso. Med. Journal. St. John Long's Celebrated Liniment. The yolk of an egg; oil of tur- pentine fgiss.; strong acetic acid f|i.; pure water fiii.; first rub the yolk of the egg, the water, and the acetic acid together, then add the oil of tur- pentine, and agitate the whole until they are well mixed. This counter- irritant liniment is applied by means of a sponge; its effects vary with the force which is used in rubbing, and the length of time the application is continued. [Edinburg Med. Journal. Formula for the Internal use of Chloroform. M. Dannecy, pharmacien, at Bordeaux, recommends the following formula : Pure chloroform, half a drachm; oil of sweet almonds, two drachms; gum arabic, one drachm ; syrup of orange flowers, one ounce ; distilled water, two ounces ; mix the chloroform with the oil, and make an ordinary oily draught. The author also gives a very ready mode of testing the purity of chloroform. Mix the latter with some oil ; if the chloroform be quite pure, the limpidity of the oil will not be destroyed ; whereas, any chemical impurity, however small, will give rise to a cloud. [Lancet. New Treatment for Itch. MM. Dussard and Tillon assert that itch may be often cured immediately by painting the body over with chloruret of sulphur dissolved in sulphuret of carbon. The application kills the acari and their eggs. Sometimes it is necessary to repeat the application, as some of the acari, or some of their eggs, may not have been killed by the first. [Gax. Ilebdom. Am. Jour. Med. Sciences. Spender's Chalk Ointment in Ulcers of the Leg. Dr. Patterson has col- lected 125 cases of chronic non-specific ulcers of the leg, in which, under this mode of treatment, the cure has been rapid and complete. The fol- lowing formula he prefers : R Crete preparate, ftiv.; adipis suilli, Ibi.; olei olive, Jiii. Having heated the oil and lard, add gradually the (balk, finely powdered. The ointment and a bandage being once applied, it is left until the cica- trix forms and becomes firm. [Edingburg Med. Jour. SOUTHERN MEDICAL AND SUEGICAL JOURIAL. (NEW SERIES.) Vol. III.] AUGUSTA, GEORGIA, JUNE, 1856. [No. 6. ORIGINAL AND ECLECTIC. ARTICLE XVI. The Value of Diet in Disease. By G. F. Cooper, M. D., of Ameri- cus, Ga* Although much has been -written upon the value of diet, and the function of digestion, comparatively nothing has been done to direct attention to its value in disease, and to the importance of that function though altered in a morbid condition of the body. Among the many elaborate treatises upon these subjects especial- ly digestion we know of none of any practical worth to the pro- fession in the management of disease. In this respect we think we are, to some extent at least, at fault ; and while we would dis- like to see any abatement of the interest in the investigations on the one hand, it is very desirable, on the other, to awaken an interest not hitherto manifested. We propose, in this paper, to speak of the value of diet in disease, under two propositions: 1st. Its use in supplying the wastes of the tissues; and, 2d. In the maintenance of the function of animal heat. And if these two uses of diet have justly deserved, and received, so much attention, physiologically, we feel assured their import- ance is in no sense inferior, nor should they receive less consid- eration in a pathological point of view. It would be supererogation to dwell upon the part that diet * This paper was read at the recent meeting of the State Medical Society, and ordered to be printed. N. S. VOL. XII. NO. VI. 21 324 Cooper, on the Value of Diet in Disease. [June, takes in supplying those wastes, constantly in progress, in a nor- mal condition of the animal economy ; this is more ably and elaborately discussed in our standard works, than it can possibly be done here. All recognize the necessity of these wastes being replenished, and look alone to the introduction of food, for the accomplishment of this end ; yet, in disease, we can look indiffer- ently upon the rapid destruction moving apace before our eyes without regarding it as a matter of much moment, and never dreaming how this devastation is to be stayed, or the wastes to be supplied. In the treatment of much the largest proportion of diseases, one of the greatest desiderata is to husband the strength of the patient; ordinarily, however, we conclude, in view of the anorexia and impaired function of digestion, we can by no means look to diet to aid us; but by avoiding the imprudent use of depletents, to keep in store the requisite amount of strength, to enable the pa- tient to endure, at least, the early period of his attack, though it have considerable duration. Emaciation, and consequent loss of strength, in abstinence, make much more rapid progress, in disease than in health, because there are other conditions present, which aggravate and expedite the work of destruction. It is true, there are no expenditures or wastes, from exercise, which are ever going on in health ; but, whatever the advantage gained in this respect, it is far more than outweighed by the abnormal conditions inti- mated above ; and however much this fact may be overlooked, in disease, it is one of no mean import, and should not be lightly regarded, but every effort should be made to counteract those morbid influences which wear down the energies of the subject, and which we, not unfrequently, though unwittingly, aid, by what is believed to be the only practicable and admissible plan of treat- ment. In health, the processes of decay and replenishing are constant- ly active, but the supply is more than adequate to the demands of nutrition ; for nature deposits in the adipose substance, a reserve, which is always furiously attacked in disease. The question is not to prevent waste which is really depurative but to provide material from without, and thereby preclude the drafts which would, otherwise, be made upon these resources which are provi- ded, not only for a respectable embonpoint, but for our endurance both in health and disease. 1856.] Cooper, on the Value of Diet in Disease. 325 The blood is the great medium through which all these import- ant operations are effected ; and while it conveys those nutritious substances which build and keep up the human fabric, it is no less the temporary receptacle of the noxious and effete matters, which it gathers in the remote points of its circulation, for the purpose of transmitting them to their proper places of exit. This being the office of the blood, we readily perceive how important that it be kept pure, and prepared to supply the various tissues and organs with such material as is required for their proper nutrition and functions. Now, one of the principal means of preserving the blood pure, is by proper supplies from without, and whenever they are cut off, every circuit the blood makes, of course only serves to augment its impurities; but when it is frequently re- ceiving these accessions from external sources, whatever be the nature of its impurities, they are to a greater or less extent, as the case may be, constantly undergoing dilution, and the result is, not only the wastes are supplied, but all the organs are kept in a state of preservation, whereby they are enabled to perform their several functions better, and the laws of the economy, if not perfectly maintained, continue with, comparatively, little interruption. The blood, when deprived of its supplies, through the ordinary channel, would naturally invite them from the tissues, with which it is everywhere in contact; and here a remarkable difference oc- curs for, while in health it receives its nutritious materials at or very near the centre of circulation, and the debris at its remote points, now, indeed, that is when external supplies are suspended, it takes in both at the same point, and the same instant, which must insure the more intimate mixture of the two qualities, there- by deteriorating the blood much more certainly than if its supplies had been received through (as they are mainly) the thoracic duct. In this state of things, a double, and, to some extent, unnatural action is forced upon the capillaries whereas, normally, they are required only to receive the debris of the tissues ; now, they must also receive the nutritious elements, because of their failure from without; and how far this action may go to engender irritation, and excite and aggravate disease, cannot, in this connection, be determined. Second Proposition : the maintenance of the function of animal heat. Whatever may be the contrariety of opinion of the exact 326 Cooper, on the Value of Diet in Disease. [June, nature and source of animal heat, its existence and importance in the animal economy are known to all, and it is of equal moment that we elevate an abnormally low degree, as we must reduce an abnormally high one ; for while the powers of the system sink ra- pidly in the former case, they are no less exhausted in the latter. In disease, we most frequently meet with an exalted degree of this function; and it would appear, from a cursory view of this subject, that the continued introduction of food would not only add heat to the flame, but serve to perpetuate the trouble. We think, however, this cannot be shown ; but, on the contrary, as has alrea- dy been intimated, the absence of food, necessarily, begets this very condition of the system, and the use of diet, instead of ex- citing, it seems reasonable to believe that its effects would be soothing, and would rather allay than provoke excitement. If we arrest the supply of water to the engine, the heat is not diminish- ed, but increased; and as cold is often used to arouse the function of innervation, and thereby restore lost heat, as well as to reduce it when raised above the normal degree so, in the body, the pru- dent introduction of food may both excite and diminish, augment and lessen the temperature. To say the least of it, we cannot hope to subdue an abnormal degree of heat, by studiously withholding food, when it is excited and kept up by other causes operating upon the fluids of the body, and changing their nature and unfit- ting them for their accustomed actions; but simultaneous with other treatment, we must essay, by the use of proper diet, to dilute and weaken, and, possibly, entirely overcome those causes, which, in the absence of food, would likely become intensified and great* ly promote disease. The wrecked seaman, when the short supply of provision is exhausted, which, in haste, he snatched from the sinking ship, will prey upon his own flesh; and so of the body, when its external supplies fail, it turns upon itself, until its inward resources are consumed every round of the blood less ning the store on hand, as well as adding to its own impurity, andsoon the operations of nature cease. In discussing the other phase of this preposition, thai is, wfa p the temperature is abnormally low, our way is apparently more clear, though we are not sure that stronger reasons can be adduced in its support; however, cone will question the necessity of the rapid introduction, not only of food, hut the most powerful stimuli, to excite and bring up the degree of heat, especially where its 1856.] Cooper, on the Value of Diet in Disease. 327 failure is obviously owing to the want of adequate nourishment. When the animal heat falls suddenly below a healthy degree, we may reasonably suspect the nervous system, with which this func- tion is intimately aasociated, and over which it exerts a manifest influence and control, to be involved; in this case, the use of food may, perhaps, be regarded of secondary importance, but by no means to be neglected. As before stated, the blood being the medium through which this important vital action is effected, it can only do so when its character affords the requisite elements. It is apparent when the blood is deprived of its food from without, from which it derives those elements, required to meet and combine with the oxygen of the air, received through the lungs, it must be not only materially, but injuriously modified: nor can its drafts upon the supplies in store be responded to with that promptness, nor will they yield those qualities or elements, which the blood requires for a proper maintenance of this function, or which food, from without, affords. The capacity of the blood for the reception of oxygen, must be- come constantly less, and while this may be, in one sense, conser- vative, yet in the end it will tell upon the energies of the general system, and hastens the patients dissolution. Respiration is ordinarily, in disease, accelerated, and while the capacity for oxygen may be diminished, the quantity of oxygen is, perhaps, in the main, increased. Now here, on the one hand, we have one element probably augmented while on the other, when food is not taken, those elements with which it is to combine for the production of animal heat, will be found wanting; in which case the body, which has to furnish them, essentially provides the means of its own destruction. The errors of the profession in the premises, to our mind, are two : 1st. In regarding the appetite as the index to the wants of the system; and, 2d. That the function of digestion is, in disease, suspended ; or incapable of preparing food for absorption and nutrition. . In disease, although anorexia may be present, the wants of the economy are imperious; and yet, because these wants are not in- dicated by any rational manifestations, we are' ready to conclude there can be none a great error: for we are not to suppose, from anorexia, that the system is free from want, but that it is evidence 328 Cooper, on the Value of Diet in Disease. [June, of an impure state of the blood, and vitiation of the secretions ; for this state of the secretions, even of the mouth, does, unques- tionably, have much influence upon the appetite. Abstractly considered, I cannot understand why these wants do not exist, and why we do not proceed to their supply as readily as if the appetite were present to indicate them. As a sentinel, who sleeps at his post, would fail to give the alarm upon the approach of the enemy, so the appetite does not, in dis- ease, make known the necessities of the system, and the work of devastation, in case of abstinence, may progress covertty, while the physician is patiently waiting the return of the lost appetite, which we always hail with exultation, and regard as the harbinger of convalescence ; it should never be considered, primarily, as evi- dence of want, or the re-appearance of the powers of digestion, but the resumption of the normal actions or functions of the body, which have been to a greater or less degree impaired : in this case, the il vis medicatrix natural" is entitled to the credit, rather than the doctor. Now, we ask, what would be more likely to provoke appetite, restore a healthy state of the secernent functions, and aid in sub- duing disease, than the prudent allowance or introduction of food? In all cases, this would not be practicable, owing, mainly, to de- lirium ; but, where there is sufficient mental clearness, the necessity and object of taking food may be, without difficulty, made obvious to the patient. 2d. We feel assured that it is erroneous to conclude that diges- tion, in disease, is suspended, or even measurably so, and inca- pable of exerting its peculiar actions upon food, and fit it for assimilation. Although the various organs of the body may be, more or less, impaired in their functions, yet we know they are not, ordinarily, suspended; and there is no just reason why diges- tion should be considered more at fault than the other functions indeed, there is every reason to believe, from its position and , importance to all the operations of the economy, it would be the last to succumb, or even become impaired. "We have so often observed food disposed of, comparatively, easy, and producing desirable results, that we are constrained to i believe that digestion usually stands ready to do more, and better, | than we are willing to allow ; and unless there are indications i which absolutely preclude it, we should presume upon the power i 1856.] Cooper, on the Value of Diet in Disease. 329 and readiness of the digestive organs to perform their part, at least, adequate to the wants, though unexpressed, of nature. As we would superintend and exercise control over a stubborn and capri- cious child, knowing better what he needs and what to provide for him, than he does for himself: so, in disease, we should become the guardians of our patients, knowing that the perversion under which the several functions may be laboring, prevent nature from exhibiting her usual mien, or making known her accustomed wants. If we investigate the symptoms present in cases of starvation, or long abstinence, we cannot fail to recognize many features strikingly simulating those observed late in disease ; nor would it be rash to conclude that, not unfrequently, they may be ascribed to the same cause in both instances, to wit: want of food. We mention these facts, more particularly, to show how absurd would be the attempt to restore persons in this starving condition, except by introducing food as rapidly as the nature of the case, and pru- dence, would permit. Because there are no local lesions, in the beginning, in one case, this fact does not abate the necessity of food in the other; nor could we be warranted in withholding it on this account, but guard against such improprieties as might lead to injury, or aggravation of disease. A year or two since, the report of a number of cases of Con- tinued fever appeared in the London Lancet, the treatment of which consisted, mainly, in the use of brandy, and the result was most satisfactory. This success may be explained upon the prin- ciple that the brandy afforded food, it being rich in those elements needed to combine with the oxygen received through the lungs, as well as giving tone to the general system. It has also been proposed to treat delirium tremens by the free, discrete use of diet ; it being alleged that the delirium and vigilance are the result of abstinence which is almost alwaj7s the case in that disease rather than the effects of alcohol, or loss of accustomed stimulus. We believe the suggestion one of practical importance, and merit- ing trial at the hands of the profession. The state of the blood has never received that attention in dis- ease that it truly deserves perhaps the long reign of Solidism prevented it ; but of late years, humoral pathology is so univer- sally acknowledged, it seems that accurate observation, with ex- periments, should no longer be delayed. So far as can be known, 330 Cooper, on the Value of Diet in Disease. [June, and is practicable, there should be an adaptation of food to the wants of the blood that is, when the blood is defective in any of its normal qualities, we should have recourse to those articles of diet, simple in their nature, but abounding in those elements, of which the blood has been deprived, and vice versa, in case of ex- cess. It is upon this principle we proceed in the dietetic manage- ment of diabetes, and with more success than by any other method. Dr. Charles Hooker, in a late paper, entitled, "Report on the Diet of the Sick,"* a synopsis only of which we have seen, the following statements occur: "The appetite is regarded as nature's proper guide, and the general principle is maintained, that, with the sus- pension of the gastric secretions, the stomach loses its digestive powers, and food can only prove a cause of irritation. This rea- soning has led to most erroneous dietetic management." He might have added, and by consequence, to most ruinous results. Again : " In diseases, generally, a return of appetite is regarded as a favorable symptom, indicating a returning healthy action and condition of the stomach." Would it not have been more rational, and better in keeping with facts, to have said "indicating a re- turning healthy action and condition " of the several functions, instead of simply that of the "stomach?" We are happy to find that we agree so nearly with sentiments from so distinguished a source, though we are compelled to dissent from some positions, or rather rules, which he prescribes for the dietetic management of the sick. In his first rule, he says : " The food should be com- pletely masticated and insalivated before passing into the stomach." The objection is not to the rule, but to the nature of the food im- plied. It seems to us, that when the secretion, and thereby the action of the stomach, are impaired, those substances should be ingested, which would require the least effort of that organ, and that would be easiest absorbed. Our chief reliance should be upon nutritious fluids, and looking to that other important action of the stomach, viz., venous absorption, for the ready conveyance of nu- trient material to the general system ; at the same time, let solid food be used as much as the nature of the case will allow. Dr. Hooker, in his second rule, says: "Food should be admin- istered at regular times, corresponding with the previous habits of the patient." In disease, generally, we must bear in mind, there is no appe- *Made to the American Medical Association, Session for 1855. 1856.] COOPER, on the Value of Diet in Disease. 331 tite, and so far as previous habits, in regard to eating, are concerned, we say they are measurably broken up ; the patient would not, likely, relish food at one hour more than another; besides, the regular meal hours would not be sufficiently often, for the patient rather loathing food, and digestion more or less impaired, we can only give small quantities, and have these digested; they should, therefore, be repeated at rather frequent intervals, and thus we may introduce, in twenty -four hours, a considerable amount of nutrient material, without its proving nauseous to the patient, or taxing his stomach beyond its powers. We cannot do better than insert his 4th rule entire. " Medica- tion should be directed with a view to aid, and not impair, the appetite and digestive action. Without regard to this precaution, the purpose of restoring the appetite, and sustaining it during the progress of disease, will often fail. Medicines, nauseous to the taste, given just before eating, will sometimes effectually destroy the appetite for food. Thus, medicines, appropriate to a case, may do more harm than good, if given at improper times. Quinine, and other bitter tonics, judiciously employed, invigorate the diges- tive organs and improve the appetite ; but for this purpose, they are best administered with the food. Their action, and the stimu- lus of food then coincide ; but given between meals, or even half an hour or an hour before the food, they often spoil the appetite." We must hot forget that, in disease, most usually, we have no appetite to sustain no appetite to spoil ; and it is to this point we have endeavored, in this paper, to direct the attention of the pro- fession the necessity and practicability of using food or diet, without appetite because it is just here, we think, most fault at- taches. From what has been said, it follows : 1st. That, in disease, the want of food is obvious, although there is no appetite present to indicate it; and, 2d. That the use of diet is entirely feasible, and that the diges- tive organs are capable of preparing the requisite amount of food; and, 3d. The prudent and discriminate use of food tends to allay, rather than to aggravate disease. 332 Kollock, on the Health of the City of Savannah. [June, ARTICLE XVII. Health of the City of Savannah during the Winter and Spring of 1856. (Read before the Medical Society of the State of Georgia, at its Annual Meeting, April, 1856, and ordered to be printed.) By P. M. Kollock, M. D. The winter which has just closed, has been the most intensely cold that I have ever experienced in Savannah, during a residence of thirty years. The mercury has been depressed to an extremely low point, and continued at that low point for a greater length of time, than has ever occurred before, within my remembrance. This hyperborean condition of the atmosphere, however, has not, as a general rule, exerted any deleterious influence upon the health of the inhabitants the city having been entirely exempt from the prevalence of any epidemic during the winter months. Contrary to precedent the succession of an early spring to a cold winter all Nature seems to have been exceedingly averse to donning its vernal garb, and April finds us nothing loth to the occupancy of the seat in the chimney corner. About the beginning of February, we began to be made aware that the healthful state of existence which had been so long en- joyed by our city, was about to be interrupted, cases of measles presented themselves, and we very soon found ourselves in the midst of an epidemic. I saw nothing of the disease until the 20th of the month. On that day, I was called to see Amos Henderson's son, Polk, and Win. Black's son, Phineas ; the former 5 years old, the other sev- eral years older. The rational signs in these two cases were indicative of the ap- proach of typhoid pneumonia. There were present, fever, with a very frequent, small pulse (120 in the minute) in Polk's case the respiration labored and hurried (52 in the minute), cough, without much expectoration or pain chest resonant on percussion respi- ration bronchial, without rales. He was treated with cathartics of ol. ricin., alterative doses of cal. and pulv. Dover., sol. tart. ant. and nit. pot. and small doses tr. aconit. On the 24th, the diagnosis of this case was decided by the ap- pearance of the rubeolous eruption on the face. Immersion of the whole body in a warm bath brought out the eruption on the rest of the body. After this, the rubeolous disease pursued a very 1856.] Kollock, on the Health of the City of Savannah. 333 regular course, the eruption disappearing, with some desquamation, at the usual time; but an obstinate and troublesome cough re- mained, normal resonance of the chest existing on both sides, with loud, mucous rales all over the right lung, unattended with fever. This condition has been gradually ameliorated by the revulsive action of blistering with cantharides, and pustulation by means of croton oil and tart, antim. applied, alternately, to the right inter- scapular space, posteriorly, and the subclavicular, anteriorly ; also, by the administration of 10 grs. of alum, three times a day, and a cough mixture composed of syr. senek., syr. scill., syr. tolu., ol. Jecur. asel. and acid hydrocyan. The symptoms in the case of Mr. Black's son, were very similar to those of the case which has just been detailed. To them, was superadded muttering delirium, dry and brown tongue, sordes on the teeth and lips. The rubeolous eruption did not manifest itself until the eighth day, and its appearance was followed by an alle- viation of all the preceding alarming symptoms. The treatment of this case was similar to that in the preceding, a blister having been superadded, applied to the nucha, on account of the delirium. The tr. aconit. was used in these two cases, in con- sequence of the favourable influence on the pulse, which has been lately claimed for it; but it failed to exhibit any such influence. Desquamation occurred in this last case on the 28th, the attack having commenced on the 15th, and convalescence was not attend- ed by any unpleasant sequelae. As is usual with rubeola, the stage of incubation occupied three or four days ; the eruption arrived at its climax about the third or fourth day, and declined from this time, not disappearing entirely, in some instances, until the eighth or tenth day from its com- mencement. The epidemic disease was developed among the younger mem- bers of my own family, attacking first a boy of seven years. The eruption showed itself on his body first, on the fourth day. It did not disappear entirely from the anus and legs until the eighth or tenth day. He became convalescent, and began to go about, as usual, and take his regular meals, when symptoms of indisposition re-appeared, accompanied with fever, anorexia, &c, and in a few hours after, a vesicular eruption exhibited itself on his face, ex- tending rapidly to all parts of his body, and in great profusion. The vesicles were in some places conical, and in others umbilica- 334 Kollock, on the Health of the City of Savannah. [June, ted, surrounded by a very slight areola without any elevation of base. Those which first appeared, dried in the course of forty-eight hours others succeeding them in different places, generally dis- tinct, but sometimes confluent ; they were filled with a whey-like serum, not becoming purulent. While this boy was confined to bed with measles, his elder bro- ther, about nine years old, who occupied the same room, com- plained of feeling unwell, having headache, loss of appetite, &c. In a few hours, an eruption of vesicles occurred on his face, and extended soon to the rest of his body. These vesicles were dis- tinct, somewhat umbilicated, with an areola, and supported on an elevated base. They somewhat resembled varioloid ; but I did not consider thern worthy of that title. This vesicular eruption was very much of the same nature as that of the boy first named, which was doubtless varicella. At this same time, two young negroes who attended in the house, and three others in an out- house on the same premises, showed the same eruption, unattended by fever. The boy of nine years old (whose eruption was vesicular) was kept in bed two or three days, and purged with citrate of magne- sia, and dieted. He then became convalescent, left his bed, and returned to his usual habits. In a day or two, however, he began to lose his appetite, to flush in the face, feel pain in the head, with a dry and hot skin. He was treated to another dose of citrate of magnesia and put to bed, and a warm bath administered at bed- time. On the following morning, the rubeolous eruption made its appearance, accompanied with cough, inflamed eyes, fever, &c. This disease ran its course regularly, and without any unusual symptoms, terminating in rapid convalescence. Two other still younger children, a boy and girl, occupying the same room with the other cases which have just been detailed, were attacked in the same way, with the rubeolous disease first, followed by the vesicular or varicellous. The rubeolous disease in the little girl's case was unusually se- vere, being attended with a very profuse eruption ; on the second day of which her pulse rose to 160 in the minute respiration 48, accompanied with alarming convulsive jerkings of the head and extremities, and harrassing cough. She was subjected to hot mustard pediluvia, mustard poultices to extremities and chest, dry cupping to interscapular region, alterative doses of calomel and ipecac, flaxseed enemata. She recovered perfectly. 1856.] KOLLOCK, on the Health of the City of Savannah. 335 The treatment which I have employed in this disease, has con- sisted of mild purging with castor oil or citrate of magnesia, diluent drinks of flaxseed infusion, arrow-root, gum-water, mustard pediluvia, mustard or pepper poultices to extremities, chest, abdo- men and throat; hot general baths, when the eruption is back- ward in making its appearance ; occasionally spts. minder., to allay febrile symptoms. After the decline of fever, and during the de- cline of the eruption, pulv. Dover, to check diarrhoea (to which thercis a very great tendency) and to procure rest; flaxseed ene- mata, to allay tenesmus. For the purpose of removing cough and bronchitis, which is apt to continue after the disappearance of the fever and eruption, I prescribe mixtures composed of syr. senek., syr. scill., syr. ipecac, syr. tolu, and sometimes, gum amnion, and aq. laur. ceras., or acid hydrocyan., elix. paregor. and Dover, pulv. Where there is exhibited any tendency to pneumonia, or cere- bral disease, alterative doses of calomel, combined with ipecac, or pulv. Dover, sometimes vin. antim. and blisters. I have used mur. ammon. where the bronchial affection proves obstinate, but I do not consider it as efficacious as alum. Usually, measles is an exceedingly mild and manageable disease with us ; so much so, that very many persons consider it entirely unnecessary to send for a physician. The popular notion is, that it is only necessary to keep the patient warm, and give saffron tea to bring out the eruption. Some, who are more economically inclined, give sheep or goat dung tea, instead of saffron, for the same purpose. I am inclined to consider one quite as good as the other. The eruption is much more speedily and effectually brought out by giving cool, demulcent drinks internally, combined with revulsive stimulating poultices, and warm baths to the surface. The epidemic of which we are speaking, has proved the most serious and severe disease, of this character, which I have ever encountered. It has been attended with unusual mortality, in consequence, mainly, of the grave complications which it has in- volved. The most frequent of these are pneumonia and laryngitis ; in some casjs, tendency to cerebral diseases. I attended the son of a South Carolina planter, who came to Savannah to put his children to school. His eldest son, 15 years of age, had ridden on horse-back from home about a day's jour- ney. He sickened on the day of his arrival in Savannah, having 336 Kollock, on the Health of the City of Savannah. [June, fever and cough. His father, without the advice of a physician, gave him calomel, in broken doses, to the amount of 12 grains, following it with a dose of castor oil. The rubeolous- eruption showed itself on his face, full and confluent, but sparingly on the extremities and trunk. The larynx became, rapidly, deeply in- volved, cough and respiration croupy, with pain and sense of suffocation. The eruption assumed a livid tint, typhoid symptoms supervened, and he died on the fourth day from the commence- ment of the eruptive stage. The result of this case might have been different had my direc- tions been followed in the application of revulsives to the surface. A general warm bath was not administered, for the want of the proper conveniences; and although mustard poultices were, subse- quently, freely applied, the eruption continued scant, and pale or livid on the surface. An attempt to vomit him with ipecac, failed (the drug passing off by the bowels); a blister was applied to top of sternum ; alterative doses of calomel and ipecac, were exhibit- ed ; and he was stimulated with turpentine, wine, brandy, and carb. ammonia, without avail. My friend, Dr. Bulloch, saw the case with me. He considered it the worst case of measles which he had ever seen, and expressed the belief, that in cases of this description, proper aeration of the blood is prevented, and a state of asphyxia is induced by the ex- tension of the inflammatory irritation throughout the mucous membrane lining the bronchial tubes and vesicles. I attended a child of Mr. A. A. Solomons, druggist, aged two years. There is a strong predisposition in the children of this family to cerebral disease. This child was attacked with fever, cough, anorexia, and great irritability of temper. It was purged with calomel and castor oil, and leeched behind the ears. The febrile symptoms being thus moderated, and believing that they were the prodromes of measles, an active and persevering revul- sive treatment by warm bathing and mustard poultices, was insti- tuted, and followed by the rubeolous eruption on the third or fourth day. The eruptive stage passed off with regularity slight cough and frequency of respiration continuing but conjoined with ex- cessive irritability of temper, a dull and sleepy appearance of the eye and perfect aversion to food and nourishment of every de- scription. In consideration of the family predisposition to cerebral affec- I 1856.] Kollock, on the Health of the City of Savannah. 337 tions, these last mentioned symptoms were calculated to create uneasiness. My friend, Dr. J. B. Eeacl, was called in consultation, and we determined to watch the case very closely, and pursue a semi-expectant and alterative course of treatment. Although there remained cough and some abnormal frequency of respira- tion, there were presented no physical signs of pneumonia or other thoracic disease. The most prominent symptoms indicated cere- bral irritation. But as the child had been considerably reduced by the rubeolous attack, it was possible that its present condition might be only hydrocephaloid, the effect of debility, and not hy- perexcitement. It was enjoined, therefore, upon its nurses, to persevere in endeavoring to introduce as much nutriment into its stomach as possible. A pursuance of this course for a few days was productive of good effects, and the hydrocephaloid symptoms disappeared entirely. The simple uncomplicated cases of the epi- demic, as is usual, terminated favorably, with very few exceptions, requiring very little medical treatment. The various complica- tions which have been spoken of, required to be met with the same remedial means as are found effectual in their treatment, when uncombined with measles or other morbid conditions. The co-existence of measles with some of the other exanthemata, is alluded to by authors. Measles and scarlatina have been observ- ed mixed up together in the same case. Small-pox has been seen to succeed measles, and measles small-pox. The same with the vaccine disease: and Gregory states, that "one of the most fami- liar modifications is, an abundant crop of miliary vesicles on the anus and trunk, filled with transparent lymph, and of such size and distinctness as to create the suspicion of the disease being small-pox." But I do not find in any author, exactly such a com- plication alluded to, as that which I have described as occurring in my family. In one of my children, and in several little Negroes, the vesi- cular eruption, resembling most nearly varicella, made its appear- ance first, and was succeeded, several days after its cessation, by measles. In three other cases, (whites occupying the same room) measles appeared first, ran its course, convalescence succeeded, and then a re-development of morbid phenomena, terminating in the vesicular affection. Desquamation occurred in some of the 3ases of measles; but these were the exceptions the majority ex- hibiting no desquamation. 338 Diseases of the Female Urethra. [June, I have heard it suggested that in cases where desquamation oc- curs, the protection against a second attack may be made more perfect. I am not disposed to admit this, inasmuch as second at- tacks are rare, and the cases of desquamation are almost equally- rare. The epidemic still lingers in our city, and will probably contin- ue until the subjects are exhausted. It is gradually extending to the country and plantations. That it is propagated by contagion in many instances cannot be doubted. It made its first appear- ance on Ossabaw island, which is on the sea coast, 20 or 30 miles from Savannah, on a plantation at the south end of the island, immediately after the return of a negro boy from Savannah, in whom the disease was developed. After the disease had run its course with him, nine other cases broke out simultaneously on the same plantation there being no case on any other part of the island at that time, nor had there been previously. Diseases of the Female Urethra, (Read before the Suffolk District Medical Society, Feb. 23, 1856.) By Walter Channing, M. D. These diseases are of the meatus, or are just within it, or occupy more or less of its lining tissue. Those which are at or nearest the meatus may arise by a narrow foot-stalk, or may have a broad base. They have, sometimes, many origins, or proceed as vegetations of various length, from a single base, or may have independent origins. At times they are acuminated, at others rounded, with narrow, or almost filiform foot-stalks. When of broader origin they may be oblong, or circular. They may not be much elevated, but lie broad and flattish upon, or within, the meatus. In one case. the tumor, if such it may be called, arose thin and broad, and pro- truded, fan shaped, beyond the external labia. In structure these growths are very delicate, seeming to be a mere mass of vessels enclosed within the finest, tissue. This it. is which accounts for their color. This is the brightest ruby red. We rarely meet with any structure of which the color is more dis- tinctive than it is in this disease. It explains the hemorrhage which has been met with after their excision. In some cases this is as unmanageable as in any surgical operation which has hemorrhage as a result. We are not always aware of the amount, as the flow may be towards, and into, the bladder. Subsequent micturition shows the amount. Another sign is the sensibility of these growths. It is emphati- cally exquisite. The slightest touch produces intense suffering. 1856.] Diseases of the Female Urethra. 339 Micturition is dreaded. Walking or sitting brings with it severe pain, so that the patient is obliged to keep, as much as possible, at rest. This has been especially annoying to women who live by work. At times they must abandon all active employment. It seems hardly possible that so small a disease should produce so much annoyance. In those instances in which the disease extends much, especially to, or beyond the labia, there may be a fetid acrid discharge, which irritates and inflames the surfaces to which it is applied, or upon which it accumulates. In some cases the meatus is thickened ; sometimes half round, at others in two opposite parts of its circumference, forming distinct lips, with a linear opening. In such the meatus may be patulous, or easily opened, showing a morbidly red surface of the urethra within. In these instances there is less suffering than the prece- ding form of the disease has accompanying it, but it is quite enough to trouble the patient and to act as a fret upon the mind, producing depression of spirits, and if it have existed a long time without being diagnosed, and has been treated as is common dysuria, there is a hopelessness of recovery which does not promote convales- cence. This last is marked by paroxysmal attacks of suffering, the intervals of which may become longer and longer until they disap- pear. Another form of structural urethral disease is found in the urethra itself. The meatus is well, but patulous. There is no outgrowth. There is nothing unusual in it except its being very open, or easily opened. Within is the ruby red color. There is one lesion in it which has rarely been met with by me. This con- sists of cracks or fissures, appearing as lines only, and often only attended with pain during micturition. Of the subjects of these diseases, as to age, it has been met with from 12 or 13, to between 40 and 50. Sedentary persons, as dress makers, shop tenders and domestics have furnished most cases. The most healthful in appearance, and in fact, have been its sub- jects, and the suffering has been equal in all its subjects. One fact in the history of these diseases deserves special notice, and which has been adverted to. This is the accompayning con- dition of the bladder. It gets to be very irritable. It bears but little urine without distinct complaint. The patient's occupation or situation may prevent a prompt attention to the call. The suf- fering is great ; but worse, the bladder becomes seriously impaired in its functions, and may always trouble the patient. In this form of the disease the diagnosis is made with much difficulty, so that the effect of a disease becomes the leading object of regard, while the disease itself lies unnoticed and unknown. Symptoms of grave renal trouble may be developed at length, and a condition of help- less invalidism may be the result. Diagnosis. This is not difficult if its means are used. These are mainly inspection of the part. This may be made sometimes n. s. vol. xn. no. vi. 22 340 Diseases of the Female Urethra. [June, with the speculum with a fenestra or window in its tube. If the disease be beyond vision, then the catheter very slowly introduced, or a bougie, may point it out. Chemical examination of the urine will separate urethral from vesical and renal maladies. Symptoms, and appearances, as above given, will of course form an important part of the means of diagnosis. Case I. This occurred many years ago, in a domestic apparent- ly in perfect health, about 18 years of age. I saw her with my friend, Dr. Putnam. The local symptoms, so grave in this case as to make it absolutely necessary for the patient to leave her place, led Dr. P. to ask for an examination, when vaginal explorations were rare. He discovered a tumor, projecting from the urethra, small in size, with a broad base, ruby red color, and of exquisite sensibility. Dr. Putnam removed the tumor by excision, immedi- ately afterwards applying the nitrate of silver. The recovery was speedy and perfect. Case II. This case was seen by me with my friend, Dr. Bow- ditch, some years ago. A domestic, aged about 15 years. No cause was assigned for the disease. It had existed for some time, and was the smallest in size of any met with. It was little more than filiform. The suffering was out of all proportion to the size. This case was treated with the nitrate only, and permanent recove- ry followed. Case III. Miss , aged about 30, dress maker, applied to me on account of very severe, or distressing dysuria. She had great pain Irom walking, or any exertion, referred to fore part of the front passage. She had suffered from it for a long time without being able to make up her mind to apply for relief. She was asked if in her occupation she had not felt obliged to retain her water when the calls to pass it were very urgent. She said yes. This question is always asked by me in like complaints, and it is almost always an- swered in the affirmative. The largest class of patients who con- sult me for these complaints, complicated as they often are with obstinate costiveness, and various uterine maladies, the largest number of these are folders, and stitchers of books, milliners, dress makers, shop tenders, slop-shop sewers the most sedentary of employments, and which to be made at all remunerative must be steadily pursued for many hours in succession. So true is this that the noon meal is carried to the rooms in which they have employ- ment, so that from 12 to 15 hours may be passed without the least exercise. It is in these that the calls of nature are unheeded and the surest foundations are laid for incurable invalidism. Dr. Franklin, I think, died of stone, and traced his disease to his con- finement to the printing press in early life, and his neglect of the functional means of health. Upon examination of Miss 's case, a tumor was found project- ing from the urethra of a larger size than had been met with by me before in this situation, and having the characters above described. 1856.] Diseases of the Female Urethra. 341 She consented to have it removed, and this was done next day, Dr. Putnam assisting me. The base was broad, and it was impos- sible to remove the whole of it without a hazard of hemorrhage which it might be found difficult to check. The nitrate was applied to the wound. Next day the patient was found very comfortable. As a portion of the disease remained, the nitrate was applied once or twice a week, until it was entirely removed. Between one and two years after, the disease returned. This was after case IV., which follows. The tumor was about the size of the first, and the same symptoms accompanied it. Before re- moving it, ice was applied until sensibility was entirely removed, and with the best result. There was no feeling of the excision of the tumor, nor from the application of the caustic. After a few subsequent applications of the nitrate no appearance of the disease remained. Case IV. This was a school girl of about 13. Menstruation had not occurred. She was unusually tall and large for her age. Health perfect, robust. There was the developement of more years. Her mother, an intelligent woman, was uncertain of the time of the occurrence of the disease. There had been, for some time, smarting and difficulty in micturition, with much chafing of the external labia and a fetid discharge. At length a thin, bright, flat substance, with a scalloped edge, was seen projecting between the labia, which was followed by increased difficulty, and walking be- came very painful. She was taken from school. Dr. Putnam saw this case with me. It was as described by Mrs. . The slight- est touch produced intolerable pain and a sudden spring of the patient, which stopped the examination at once. It was soon found that nothing could be done without etherization, and next day this was tried. Great difficulty was met with in overcoming the power of the patient, and when the fullest effects of ether were apparent in the general system, the local sensibility remained so perfect as to I make the child wholly unmanageable. Chloroform was next used and freely, but with no effect. It occurred to me, in the failure of these means of quiet, to try ice. The trial was made and was per- fectly successful. Not the least uneasiness was betrayed when the ) diseased mass was freely handled, when it was embraced by the i hooked forceps, nor when it was cut off by the scissors, nor after- II wards when the nitrate was freely applied to the cut base, which ; was deep within the meatus. Next day patient was found comfortable. Inquiry was made if hemorrhage had occurred. There had been no external bleeding, 1 but with urine which had recently passed, a large quantity of co- agulated and liquid blood had come away. There was no return of this, and recovery was rapid. This is the only case within my observation of these diseases in which hemorrhage has followed the excision of these outgrowths. It is worth remembering. If the symptoms of this accident occur, and there be no external flowing, 342 Diseases of the Female Urethra. [June, an examination of the urethra, and the use of the catheter, might discover the cause, and plugging might prevent farther trouble. As for the most part the disease has its seat near the meatus, it could not be difficult to apply here the means to check it, and direct or mechanical ones must be more sure of the effect than are che- mical ones. Case V. Mrs. , a widow, about 40, called on me on account of long-continued pain in the back and hips, sense of weight and dragging, leucorrhaea, and disturbed menstruation. She had also dysuria, internal hemorrhoids, which much embarrassed defecation, and had almost cartilaginous and numerous vegetations surround- ing the anus. Her general health was wretched. Emaciation great, and upon the whole she was as severe a sufferer as is often met with. Examined by the speculum, a tumor was seen pro- jecting beyond the os uteri, of the size of a small walnut. It was soft, easily bleeding, and insensible. Quite a large vegetation was found at the meatus urinarius. It had the usual color of such growths, but was the least tender of any before seen by me. Treatment was first directed to the uterine outgrowth. This was too soft for the ligature or foreceps. Caustic was freely and frequently applied. The good effects were soon obvious in the entire disappearance of the disease. The os uteri closed and pre- sented the linear diameter and size of health. The same means were successfully used for the disease of the meatus. The caustic gave pain, but the free use of cold water soon removed it. Much more time passed before the cure, than was required for the remo- val of the uterine disease. The hemorrhoids were removed by ligature, the tumors being forced out of the bowel by the patient for the use of the ligature. After those had been removed which were pendulous enough to be tried, a tumor with a broad base re- mained, and kept up the old irritation. To this caustic was applied by the rectal speculum having a lateral opening. The ex- ternal vegetations were removed by the scissors, to the bases of which caustic was applied immediately after the excisions. Alter several months' treatment Mrs. recovered, and is now in good health. She has regained flesh, and uses exercise freely without any of its former accompaniments. This case was complicated with heart disease. On ascending heights, distressing palpitation with dyspnoea were experienced, accompanied by rigors in which the teeth would chatter as in severe paroxysms of intermittent fever. The skin became cold and livid. There were no signs discovered of organic cardiac trouble, and its imitations have gradually diminished as remote local diseases have disappeared. Case VI. Mrs. , aged about 30. In this case the whole urinary apparatus was diseased, and had been so in various degrees] for a long time. There was an outgrowth from the urethra involv- ing the meatus. This was exquisitely tender, hardly tolerating the touch constant dysuria, with frequent calls to pass water. Is con- 1856.] Diseases of the Female Urethra. 343 stantly in bed, the least movement producing increased suffering. Constant uneasiness in the part diseased, with paroxysmal exagger- ations which it was not easy to remove or diminish. The catheter was used and the whole extent of the urethra was found as tender as was its meatus. The urine was rendered in various conditions. At times it was bloody. Liquid and coagulated blood was so freely passed that at times it seemed to make the principal amount of what came from the bladder. Sometimes it was purulent, and in no case have I seen so much pus in the urine as in this. At other times the precipitate was flocculent, branny, reddish, or quite pale. At others albuminous. Along the back and in the renal places there was much tenderness. The treatment of this case was designed to meet obvious indica- tions. The constitutional symptoms were febrile, or such as very grave local disorder commonly induces. There was heat, quick pulse, no appetite, prostration. Local bleeding, counter-irritation, alteratives, narcotics and subnarcotics, diosma, tinct. fer. mur., demulcents, external applications in their endless variety these were among the means employed. She was etherized and the urethral outgrowth removed by excision. The nitrate was after- wards used to check hemorrhage. At times were signs of improvement and recovery. The vesical hemorrhage, if it were vesical, would cease. And so would it be with pus, which replaced hemorrhage, and with other deposits. The urethra would seem to be recovering, and then without known cause, the patient not having left her bed, all the symptoms would in various order show themselves. At length, when much relieved, Mrs. determined to go home. This she did, her husband com- ing to go with her. Her travel was more than one hundred miles j and was without accident, at least I have not heard that it produced I any. I could not learn what had been the precise relation of symp- j toms in this case. It had lasted so long that the order of their i occurrence was forgotten, if it had ever been observed. Thus, was !' the urethral difficulty the first in the order of symptoms, and the \ vesical and renal, effects of this, either by contigunous or continuous k sympathy ? Or were these last first in the order of diseases or ' symptoms ? The outgrowth was cut away because it was a source c of exquisite suffering during micturition, and during the premonito- ry actions of the bladder which make up the call to pass urine. 1 Sulphuric ether was used before operating. Its effects were un- i like any I have observed during or after inhaling ether. The respi- '] ration ceased, the pulse continuing. There was the same appear- ance of entire repose, pallor and insensibility, as has been observed 1 in fatal cases from chloroform. Respiration was at length produ- ' ced, and with gradually shortened intervals was re-established. She was cautioned not to use ether again. But in the night, during a paroxysm of intense agony, she insisted on breathing it again. Her attendant yielded. The same result followed as before, and 344 Diseases of the Female Urethra. [June, from which she recovered after the use of the same means. This is the only case in which trouble has followed the use of ether in a very large observation of its agencies by myself and by many others. It was doubtless owing to conditions produced by long- continued suffering, and though apparently alarming, was perfectly recovered from. Case VII. Mrs. , about 30. This, with other cases, was complicated with uterine functional disease with displacement. The dysuria was of long standing, and was independent of any disease of the meatus. This last was patulous and soft. Within the urethral tissue was redder than natural, and presented a distinct oblique fissure. This is the only case in which I have met with this affection in this organ. It was treated with a solution of nit. argent, applied with a brush. It is under treatment. Case VIII. Mrs. has one child ; called on me on account of displacement of long standing, the os uteri being turned strongly towards, and resting against, the hollow of the sacrum. With the symptoms of such dislocation was very troublesome dysuria. As this last might be owing to the pressure of the fundus upon the bladder, attention was directed to the womb. It was replaced and Hodge's lever pessary introduced. The relief of symptoms of dis- placement was perfect. After a time they returned. Examination showed the pessary out of place. It was adjusted and worn for some weeks, but gettingagain displaced, it was removed, and Meigs's ring pessary substituted. This answered perfectly well. It was worn four or five months, and as all the symptoms for which it was used had disappeared, it was removed. It had not at all been in- jured by this long use. Dysuria continued, and became a very troublesome disease. The urethra was examined. The lips, or edge, were found much swollen, but not at all reddened. Upon opening the meatus, a swelling with a broad base was detected, bright red, and very tender, and beyond, the lining membrane had tire same color. At first the solid nitrate was applied. Its good effects were manifested after a few applications. The solution was now substituted, with entire relief of the dysuria. There was an opaque mucous discharge from the urethra, which has been met with in other cases, but this has nearly disappeared. Mrs. can now take long walks without inconvenience, and considers herself well. Cases enough have been given to illustrate the general his- tory of the diseases under consideration. Remarks. It may be asked if there were not a specific cause of these urethral lesions. The answer is distinctly in the negative. The ages of some of the patients and the social position of others, and direct inquiries wherever suspicions arose of causes, have satis- fied me that there was no reason for suspecting or believing in the action of such a cause. The treatment was in no case specific. Strictly local remedies were relied on. In one case only am I sure 1856.] Diseases of the Female. Urethra. 345 that the disease re-appeared, and since its second removal it has not returned. Few diseases would seem to present greater difficulties in their diagnosis, and few are more painful and persistent where a correct diagnosis is not made. The difficulty lies wholly in not using the only sure means of diagnosis ; for when an examination of the dis- eased part is made, the discovery of the nature of the malady is at once made. The sight and the touch should be both employed. Of the treatment there is but little to be added, and that caution- ary. Hemorrhage has been alluded to. If my memory serve, one case is reported which was disastrous in its results from this cause. There has been but one case in my practice, in which there was bleeding after the application of caustic, and that was internal into the bladder. This should be borne in mind, as we may have the symptoms of large haemorrhage without external flow. Should hae- morrhage be excessive or continue, then caustic, pressure by a bougie, or other means, may be employed. Grave peritonitis, we are told, has followed slight operations on the vagina There is a case is mind, in my own practice, in which very severe pain and soreness in the abdomen followed the injection of the cervix uteri with a solution of nit. argent. No case is remembered in which operations in the meatus, or urethra, have led to such results. The first case in which ice was used to destroy sensibility ocur- red some years since, and I am not aware that such an employment of it had been made before, or that I had met with the suggestion, or the authority of its actual use. Quite early in my professional life, an aged physician, now long dead, said to me that he had used ice, in the form of icicles, in cases of sore throat in which the ton- sils were much swollen, and the pain was great, and that relief had followed, and so nearly to the application, that he could not but regard it as its consequence. This conversation may have uncon- sciously suggested the use of ice in the cases reported. It was perfectly successful. Dr. Arnott, of England, and physicians and surgeons in America, have more recently recommended and em- ployed ice previous to surgical operations to prevent pain, and I think by Dr. Arnott to make other anaesthetics unnecessary. In my cases the effect was excellent. Under ether or chloroform the patient will sometimes start at the first touch of the knife, though apparently under their fullest operation. This has been met with by me too often to doubt it. In Case IV. it made the operation ut- terly impossible. Ice at once removed all pain. In a recent case, in which an abscess of the abdomen was to be opened, ether was used until its fullest effects were manifest. The first touch of the knife caused so much starting that it was only by use of force to restrain the patient that the operation could be completed. When Mr. recovered his consciousness, he had not the least memory of having resisted what had been attempted. After this paper was read, a request was made that the fellows 346 Whooping Cough. [June, present would communicate such cases of female urethral disease as might have fallen under their observation. From one, three cases were reported, and two from another. In one of the last, no structural disease had been discovered, though carefully looked for. The pain was confined to the urethra, and was represented as very severe. Many methods of treatment had been used. Some months of relief were experienced, but some threatenings of return of the symptoms had been recently manifested. Another fellow reported very interesting cases without discovered urethral lesion, though most carefully searched for, in which the symptoms reported in the cases in this paper were present in severe form, and in which injections of narcotics and sedatives into the urethra had been remedial. [Boston Med. and Surg. Journal. Wliooping Cough, its History, Nature, and Successful Treatment, By Laurence Ttjrnbull, M.D., &c. This disease has been to me one of much thought and con- siderable personal interest, from having had four of my children attacked with it in its most aggravated form. My attention was also particularly called to it during the months of May and June, 1854, when the malady prevailed to a considerable extent in our city ; cases of it have also continued to occur up to the present month, July, 1855. In referring to the works of Hippocrates, (Sydenham Society's Edit, in two vols., London, 1849,) I find no description of whoop- ing cough, neither is there any account of it in the Seven Books of Paulus iEgineta,* so that I would infer that the Greeks, Bo- mans and Arabians were not acquainted with it as a distinct disease. Dr. Willis was the first medical writer who accurately described whooping or chin cough, his work being published in 1682, (in two vols.)f It was not until the present century, however, that this disease was fully investigated and made known to the medi- cal public, which was chiefly done by the labors of Bosen, Cullen, Schaifer, Hufeland, Mathai, John, Authenrieth, Watt of Glasgow, and Albers of Bremen. It is stated by Bosen, that it passed from the East Indies and Africa into Europe. First stage. The first stage of whooping cough has no distinct and prominent symptoms by which it can be distinguished from ordinary catarrh, or bronchitis, except, perhaps, a slight difference in the voice and cough which sounds louder and shriller; the ex- * The Seven Books of Paulus yEgineta, translated from the Greek, by Francis Adams, LL. D., in three vols., Loudon, printed for the Sydenham Society, 1844. \ " Tussis puerorum couvulsiva, sue suffocativa et nostro idiomate chin-cough vulgo dicta." (Opera Omnia, Amst. 1682, vol. ii. p. 169.) 1856.] Whooping Cough. 347 pectoration is usually limpid, but in some instances I have noticed it opaque, yellow, and even greenish. This period may last from five days to as many weeks. Lom- bard states that in an epidemic which occurred at Geneva, it lasted from one month to six weeks; when the whoop is going to occur, it is usually noticed in the second or third week, but I have had several cases where the cough was present without the whoop. This absence of the whoop is often very unfortunate, for chil- dren may in this way propagate the disease, and cause whole families and even schools to be attacked. This fact was proven in the case of my son, aged seven years ; he sat in school by the side of a little boy who had a cough, which was very sonorous and painful to listen to, but the anxiety of the teacher was much relieved by being informed that his physician did not consider it whooping cough ; subsequently the youngest child of this family was attacked by the disease and whooped, and the boy was then kept from school, but too late to save the other members of his class, ten of whom took the disease, so that the school was nearly broken up; my son communicated it to his three sisters, who all suffered more severely from it than he did. I therefore think that children should not be allowed to mix with their companions when suffering from a cough of this char- acter, if the disease prevail in the locality. Second stage. The second or spasmodic state of this malady, is easily known, by the peculiar sound and suffocating character of the cough. In this stage, almost every organ is irritated, and it even produces discharges of blood from the nose and mouth. The expression of the countenance is most distressing. When this stage is at its height, the child seems to know by some inward sensation that the attack is coming on, and it either cries or lays hold of some object by which it can support itself until the parox- ysm is over. The face and neck become swollen, and in some in- stances remain so, and the child, at the termination of a fit of coughing, either discharges some thick tenacious ropy mucous, or evacuates the entire contents of the stomach. The least mental excitement, either of joy or sorrow, will pro- duce an attack, and the number varies with the severity of the disease. The paroxysms last from one-fourth to three-fourths of a minute. The average duration of whooping cough is from six to eight weeks if not checked, but in many instances it lasts as many months; second attacks are rare, and yet they do occur. Whoop- ing cough prevailed in this city with measles, in May and June, 1854, followed in October and November by chicken pox, and in January, 1855, by scarlet fever, with sporadic cases of catarrh and croup, showing a connection or relation one with another, so that the same causes may give rise during an epidemic to simple catarrh, croup, whooping cough, or even measles. 348 Whooping Cough. [June, The complications of whooping cough I cannot enter into, but the chief of them are croup, bronchitis, pneumonia, pleurisy and dis- eases of the brain and cavity of the abdomen, which are to be recognized by their characteristic s}Tmptoms. According to Billard, post-mortem examinations have not re- vealed anything uniform in this disease, except bronchial catarrh in its various stages. Sydenham imputed the disease to a subtile and irritating vapor in the blood. Hufeland considers that the eighth pair of nerves is diseased, and is the cause of the double irritation of the bronchia and stomach. According to M. Guersent (Diet, de Med.) whoop- ing cough is a catarrhal affection, seated in the trachea and bronchi, consisting of a specific inflammation, accompanied with spasm of the trachea and glottis. Dr. Watt, of Glasgow, considers the dis- ease to be inflammatory and seated in the bronchi. Albers, of Bremen, considers whooping cough to be an affection of the nerves of the thorax, with which bronchitis is frequently complicated. Laennec regards it as a variety of pulmonary catarrh, and from the convulsive character of the cough he calls it convulsive catarrh. Dr. Webster (Med. and Phys. Jour.) is of opinion that the symp- toms, when closely viewed, suggest the impression that whooping cough depends upon inflammatory irritation of the brain or its membranes. This is the opinion held by Dr. Copland, and very many distinguished men of the present day, but to my mind it is not satisfactory. The whooping cough, in its first stage, is certain- ly of an inflammatory character, chiefly affecting the lining membrane of the air passages, but this is of a specific nature. In the second stage there is no evidence of inflammation indicated either by the pulse, skin, or any other organ, but there is a power- ful irritation of the laryngeal constrictor, and bronchial muscles and nerves, producing a cough which occurs rapidly many times so that a single inspiration is followed by five or six successive expirations constituting paroxyms of coughing (tussis accessus,) accompanied with redness of the face, watery eyes, headache, tin- nitus aurium, fulness of the cervical veins, retching and sometimes vomiting. By some writers it has been considered that ihis disease was produced by a peculiar miasma, acting chiefly on the nerves, and is also ascribed to the presenceof minute insects in the air(Boehme Linnaeus,) or, according to Prof. J. K. Mitchell, its epidemic origin may be a peculiar fungus; "the spores of these plants are not only numerous, minute, and indefinitely diffused, but, like the animal, all have the power of penetrating into and growing upon the most interior tissues of the human body," passing into the .systems of those exposed to its influence by the respiratory organs or stomach, producing the irritation of the mucous membrane of the air passages. " Introduced into the body through the stomach, or by the skin or lungs, cryptogamous poisons are known to pro- 1856.] Whooping Cough. 349 duce diseases of a febrile character, intermittent, remittent and continued and even the disease of the mucous membrane, termed aphtha?, arises from the presence of minute fungi."* Dr. M. has not made this application of his doctrine to this par- ticular disease, yet I do not see any good reason why it should not be so applied. According to Dr. Spengler, of Ellville, epidemic diseases depend on the presence or absence of ozone. He states that in the village of Roggendorf, in Mecklenburgh, towards the close of 1846, when slight catarrhal affections became prevalent, but slight traces of ozone were to be detected in the air. With the opening of the following year, however, these catarrhal affections assumed the severest forms of tracheal and bronchial disease, and whooping cough became common both among children and adults ; then reagents detected a great increase of ozone in the atmosphere."! Prognosis. The prognosis in uncomplicated whooping cough is very favorable, and is unfavorable only in proportion to the dangerous nature of its complications and the age of the child; the best season for a favorable termination is spring or summer. The modes of Propagation. The disease may occur epidemically or sporadically, and it possesses infectious properties. It is propa- gated through a family from one to another; they are not all apt to be attacked at the same time, and by removal to a distance a child may escape. Dr. Cullen believed that it disappeared in from four to six weeks, but this has not been proved by subsequent observa- tion. Children who have suffered from this disease, should not be sent to school or play with their companions for at least two months. Treatment. There are but two classes of symptoms to be com- bated in this disease when no complication exists. The inflamma- tion must be reduced by depletion, expectorants and refrigerants. In the second class of symptoms, the chief object is to diminish the abundant secretion and allay the great irritability of the laryngeal constrictor, and bronchial muscles and nerves. The means to accomplish this, in my hands, have been the ab- straction of blood ; the application of a few cups or leeches to the nape of the neck or under the clavicle, with counter irritation, by means of sinapisms and blisters, which will soon allay the conges- tion of the brain or lungs. To diminish the febrile action small doses of tartar emetic, combined with Dover's powder or prepared chalk, with the free use of syrup of ipecacuanha as an emetic may be given ; these will lessen the bronchial inflammation, and reme- dy the often disordered state of the stomach and bowels. During the whole stage of the disease, demulcent drinks should be freely administered, such as flax seed tea, barley or rice water. When fully satisfied that the inflammation has been subdued, * Lond. Med. Gaz. Henlie's Zeitsehrift, vol. vii. p. 1. \ On the Cryptogamous Origin of Malaria and Epidemic Fevers. J. K. Mitchell, M.D. Philada, 1849. 350 Whooping Cough. [June, indicated by a slower pulse, less heat of skin and no active conges- tion of the brain or lungs, I have then followed the treatment with belladonna, and my success with this remedy has been most grat- ifying. Before administering it I tried, in vain, the free use of cochineal in combination with alkalies, assafcetida, opium, alum, hydrocyanic acid, &c. In every instance in which the system was fully brought under the influence of the belladonna, indicated by dilatation of the pupil with confused vision and reddened skin, I was enabled to check the annoying cough and whoop of thirteen children duringthe month of May and June, 1854, and seven cases since that time, making twenty cases in all, eight males and twelve females; the youngest was nine months and the eldest ten years. The following was the method followed : The system being pre- pared by reducing the inflammation by the means before spoken of, obtain, if possible, English extract of belladonna, fresh and good ; let the extract be triturated with water or simple syrup ; if it is to be kept for some time, add a small quantity of alcohol. The dose for a child three months old is the sixteenth of a grain every three hours, to a child one year one-eighth of a grain, and so to other ages in proportion. Inform the parent or nurse of the change it will produce upon the eye, also that it may redden the skin. When full dilatation of the pupil is brought about, the medicine is to be intermitted until it has gone off again ; the belladonna is to be administered in slightly increasing doses, so as to keep the child under its influ- ence for several da}?s or until the paroxysms are checked, which will usully occur towards the sixth or eighth day of the second stage. In the twenty cases cured by the use of the belladonna the cough and whoop returned in a few cases on exposure to cold, or ita disagreeable, windy weather; but by combining the extract with syrup of ipecacuanha a few doses soon checked the cough and whoop-; in only one case out of this number was it complicated with inflammation of the lungs and this case recovered. The average duration of my twenty cases was ten days after the whoop had commemced, when the case was free from complications, which shows the great advantage of this treatment. The ordinary duration of the disease, when treated in the usual manner, is from 1| to 3| months; even by prussic acid, or the application of nitrate of silver, the average given is from two to three weeks. It is stated by Dr. Gibb that with the use of nitric acid, the average duration was only six or seven days. Several physicians who have used this remedy, however, do not find such favorable re- sults from its use. I have added to my communication some extracts from the experience of a few distinguished medical men on the use of this important agent, belladonna. This remedy was used in whooping cough about the yenr 1783, 1856.] Whooping Cough. 351 by Dr. Buckhaave, of Copenhagen, who gave the powdered root in doses of two grains, morning and evening, to a child of five or six years of age. The cure, it is stated, was generally accomplish- ed in from seven to fourteen days.* Dr. Miquel. (of Neuerhaus,) says the belladonna is a remedy upon which he can always depend in this disease. In the course of many epidemics which he has observed during fifteen years, he has constantly cured the cough in eight days.f Dr. Samuel Jackson, of this city, late of Northumberland, who although he was not the first to employ the belladonna, yet by his valuable publication in 1834 brought its virtues prominently be- fore the medical public, has continued its use for twenty years, and his confidence in its powers to arrest the paroxysm and cure the second stage of whooping cough in the great majority of cases is undiminished. Dr. Hiram Corson, formerly President of the Medical Society of the State of Pennsylvania, a distinguished practitioner of Mont- gomery county, Pa., in a paper on the efficacy of belladonna as a remedy in Pertussis, published in the Amer. Jour, of Med. Science, for Oct. 1852, makes the following observations: u My experience in purtussis had satisfied me that of all the remedies in common use, those recommended by writers upon diseases of children are almost useless. Children affected in the winter continued to cough and strangle and suffer for many weeks with scarcely a percepti- ble amendment. It was painful to visit and mortifying to prescribe for those afflicted with this malady." He commenced the use of belladonna in four easos, and in one week they were all well. His method of using it was to begin with the sixteenth of a grain to children under one year every two hours, and increasing a little every day until full dilatation of the pupil occurred, the skin became flushed and vision confus- ed ; this he accomplished by dissolving eight grains of the extract in an ounce of water, nine drops of which contained the eighth of a grain. In an epidemic in 1810, he used the belladonna in hundreds of cases with great relief in nearly all. By giving it in small doses at first, the fears of the patients were allayed. In 1817-8, he also prescribecHt in numerous cases with much success. He concludes his paper in these words: "During the last seventeen years, I have given the extract of belladonna to hundreds of patients from two months to fifty years of age, and am firmly convinced that it has a greater control over whooping cough, than any other remedy in common use. That while, in a few cases, the system did not seem susceptible to its action in the doses I have prescribed, yet *Dr. Duncan's Commentaries for 1793, and Dr. Gibb on Pertussis, p. 282, 1854. f Vol. vii. Amer. Jour. Med. Sciences, p. 524, from Archives Generales, August, 1830. 352 Whooping Cough. [June, in nearly all the disease yielded quickly. It is a safe and efficient remedy for pertussis in children of any age. Dr. Eberle, in his Treatise on the Diseases of Children, second edition, remarks "that the belladonna has been highly celebrated, and is without doubt, b}^ far, the best article of the kind we pos- sess. My own experience leads me to testify confidently on this point. I have prescribed it within the last six years, (1834), in perhaps twenty cases, and in the majority of them with evident advantage." Professor Borda, he remarks, was the first he be- lieved who used it as a remedy, and his belief in its efficacy is al- most unlimited. Hufeland and Alibert are almost equally decided in their praise of the virtues of this article. The mortality from this disease in our city in 1850 was 114; 1852, 168 ; and for 1853, was 64. In 1853, in the district of Rich- mond, it occurred as an epidemic. In severe cases, Dr. Janvier used the belladonna with the best results. "It mitigates the par- oxysms better than any other sedative."* Dr. Condie remarks in his work on diseases of children, that the narcotic from which the greatest amount of benefit is to be antici- pated in this disease, is unquestionably the belladonna ; it has been very extensively employed, and the evidence in its favor is strong and conclusive, (by Kahleiss, Janin, Hufeland, Wideman, Raisin, Guibert, Alibert, Shafer, Laennec, Muller, Blache, Maunsell and Lombard). He further remarks that he had given the belladonna a very fair trial, and has, in many cases, been pleased with the prompt and decided relief produced by it, "while in other instances it ap- peared to exert no influence whatever." I think that this last remark may be often accounted for by the bad character of the belladonna, which is even found in some of the drug stores in this city, for it is an uncertain preparation un- less'when procured by evaporation in vacuo, for some samples from some of the Parisian shops were found by Orfila to be quite inert. Dr. Williams, of London, has used belladonna with great ad- vantage in his practice. He gives it in quarter-grain doses to a child of two years, increasing the dose to double that quantity or more, where it fails to relieve. He remarks that these doses, in general, cause some dilatation of the pupil, and conceives that the remedial agency of the drug depends on the same power to diminish irritability of the bronchial and laryngeal muscles which is here evinced with regard to the iris." f Dr. G. A. Rees has found belladonna one of the most efficacious remedies in Pertussis.:}; -. * Report I'hila. Co. Med. Society for 1853. f Gibb on hooping cough, p. 284, from Medical Gazette, Feb. 1838. \ Diseases of Children, 2d edition, 1844. 1856.] Wfiooping Cough. 353 Dr. Waller cured two cases with the twelfth of a grain of ex- tract, three times a day; prussic acid and conium had failed in affording any permanent relief.* Eberle assigns the highest place among narcotics to belladonna in whooping cough. Dr. Churchill says that this is perhaps the most influential nar- cotic and sedative we possess (in pertussis); it has been very ex- tensively employed, and the evidence in its favor is very strong, f Belladonna has been eminently useful in the epidemic of whoop- ing cough which M. Debreyne has observed, but recourse should not be had to it until the inflammatory element has been over- come by leeches, emetics, &c. Dr. A. T. Thompson says, I have ordered the extract of bella- donna in doses of one-eighth of a grain to a child of eight years, and gradually increased the dose to a quarter of a grain. Its power over the cough is extraordinary.^: I might bring forward the testimony of many other writers, and a mass of evidence from medical practitioners, to establish still more firmly the fact of the efficacy of belladonna in this peculiar malady, but it will not, I trust, be necessary. I will now endeavor to give an epitome of the experience of the best writers in the treatment of whooping cough by means of other agents. The first of these which I will notice is alum, which has been very highly recommended by Dr. Golding Bird ; it has been em- ployed with success by Dr. John F. Meigs, of this city, who speaks of it as follows, in his useful work on diseases of children : " From reading Dr. Bird's remarks on alum, and prompted by my know- ledge of its admirable qualities in the treatment of croup, I was led to make trial of it in the disease under consideration, and I belive I may say that it has exerted a more decided influence in moderating the violence of the disorder, than any remedy that I have ever made use of. I have administered it in fifteen eases, beginning in the course of the second stage. In all, it was beneficial, and in some the effects were strikingly useful, the improvement being more rapid than I had ever seen to residt from other remedies." Dr. Bird gives from two to six grains every four hours. His formula is as follows : $. Aluminis, gr. xxiv; Ext. Conii, gr. xii; Syrup Bhoeados, 3ii; Aquae Aneth. f. ?iij. M. Give a medium- sized spoonful every six hours. Dr. Meigs gives it in smaller doses, and without the Ext. Conii. To children under one year, half a grain to a grain three or four times a day ; and to those over that age, two grains every six hours. * Lancet, vol. 1, 1845, p. 137. f Elements of Materia Medica. X London Jour, of Medicine, April, 1850. This is considered by Dr. Butter as the remedy, namely conium, for whooping cough, and he eulogises its use. 354 Whooping Cough. [June, Dr. Crossly Hall, an English physician, employs the alum in powder, prescribed in a little water eight times a dajr, and he con- siders it a very useful remedy. Mr. Davis highly extols the efficacy of alum in pertussis. In the last edition of Underwood's Treatise, edited by him, he says: "After a long trial, I am disposed to attach more importance to alwn, as a remedy in whooping cough, than to any other form of tonic or anti-spasmodic. I have often been surprised at the speed with which it arrests the severe spasmodic fits of coughing; it seems equally applicable to all ages, and almost to all conditions of the patient. The dose for an infant is two grains three times a day; and to older children four, five and up to ten grains may be given mixed with syrup and water." I have employed alum both in the case of my patients and my own children, and gave it freely ; it moderated the intensity of the disease, but it did not in my hands make a cure, so that, after its use, for ten days, I had to resort to the belladonna, which, in a week, completely checked the whoop. Another agent which has been very highly lauded is the hydro- cyanic acid, which is considered by Dr. Thompson, of London, to possess a "specific power" over the disease. Dr. West, of London, author of a valuable treatise on the dis- eases of childhood, says, "that the acid sometimes exerts an almost magical influence on the cough, diminishing the frequency and severity of its paroxysms almost immediately, while, in other cases, it seems perfectly inert ; and again in others, without at all dimin- ishing the severity of the cough, it exerts its peculiar poisonous action on the system so as to render its discontinuance advisable." He recommends it to be given by itself, diffused in a little dis- tilled water, sweetened with simple syrup, and the dose he begins with is half a minim every six hours for a child nine months old. He has never but once, however, seen really alarming symptoms follow its use, though he has employed it in many hundred cases; still he remarks that although the severity of the cough may be relieved by the acid, it does not enable the practitioner to dispense with other remedies. Dr. Hamilton Roe, in his treatise on whooping cough, gives to an infant three quarters of a minim of hydrocyanic acid, Scheele's strength, gradually increasing it to a minim, which is administered every four hours ; for a child three years of age one minim, gradu- ally increasing, if necessary, to a minim and a half every four hours. Dr. Roe says he is convinced, from the result of all the trials he has made, that this drug will cure almost any case of simple whooping cough in a short time. Dr. Edwin Atlee first used it in 1824, and from that year until March, 1832, he says he has treated more than two hundred patients, and never failed to cure in from four to ten days.* * American Jour. Med. Sciences, voL vii. and vol. x. 1856.] Whooping Cough. 355 This medicine is highly recommended by Muhrbeck, Kahleiss, Yolk, Heller, Granville, Lombard, &c. I have tried this acid, but it did not at all please me in its effects. Another remedy which demands our notice is the precipitated subcarbonate of iron, (ferri sesquioxidum). The following obser- vations on its use are by Dr. H. C. Lombard, of Geneva, who, after praising the virtues of assafoetida, flowers of zinc, opium, prussic acid and belladonna, says, "I come now to my specific, or rather to the remedy advised by Dr. Steyman, as the best anti- spasmodic in whooping cough. Dr. Steyman had advised to give from four to ten grains of subcarbonate of iron in the twenty-four hours ; he gave as a rule to increase one grain for each year, so that a child six years old was to take six grains in a day, but from the beginning I found the dose quite inadequate, and I increased it to twenty-four and thirty-six grains in young children. I have given it either with water and syrup, or mixed with a cough mix- ture. It has never produced any inconvenience. On the contra- ry, I have found that all the children treated after this method were much less weakened, and recovered faster than with all other remedies. The proofs of the advantageous effects of it have been so numerous that I can scarcely enter into the detail ; however, I may give a few facts to corroborate my assertion. In a child four years old I gave the subcarbonate of iron, and the fits, which in the preceeding week, had been 101 in number, were reduced to 66 in the following week. In a weak and debilitated boy, aged seven years, the powder of belladonna had proved quite useless ; when I tried the powder of iron, so prompt was the effect that in a few days the boy was quite cured ; the sister of this boy was also cured with great rapidity. The last case of whooping cough which I have treated lately was of four months duration, and every thing had proved useless, when I gave the iron powder, which in the space of a few days succeeded in making the cough less and less. In fact, I think I may assert with security, that the subcarbonate of iron enjoys a remarkable property to make the fits less violent, to diminish the number, and after a certain number of days to cure entirely the whooping cough. It enjoys, besides, the advantage of strengthening the little fiatients, and gives them force to resist a complaint which sometimes asts some weeks, and generally leaves the patients weak, low and exhausted. In some of those who have taken it, I have often seen, during the first days, a temporary increase of the cough, but it always subsided after two or three days, and did not prevent the good effects of the medicine. The beneficial results obtained by the use of the iron powder are easily explained by its anti-periodic and anti-neuralgic properties, and it shows a posteriori how much the whooping cough resembles a true neuralgia, or, at all events, a true nervous disease." N. S. VOL. XII. NO. VI. 23 356 Whooping Cough. [June, I have not tried this remedy, arid can, therefore, give no opinion of its efficacy; but should judge from its tonic and blood-restoring properties, that it would prove a iiseful agent in low anaemic or debilitated cases. Garlic is a remedy very highly recommended by Dr. Dewees; indeed he states in his work on Diseases of Children, " that he has never employed any remedy of equal efficacy." A child of six or seven years may begin by taking a third of a common sized clove, morning, noon and evening, in the absence of all febrile excitement, gradually increasing the dose. Mr. Sutcliff combined the Peruvian bark with cantharides, and administered it with great success in whooping cough during twenty years. The following is his formula : 3 Tin ct. Cort. Peru v. f. 5vi. Elix. Paregor. 3ss. Tinct. Canthar. 3i M. Of this mixture, small doses were given three or four times- a day, gradually increasing until a slight strangury was excited, then the dose was to be diminished. When the active symptoms have subsided, Dr. Beatty, of Dub- lin, used the same remedy, and it is also recommended by Dr. Graves. The following is his formula. $. Tinct. Cinch. Comp. 3 v. " Lyttse, " Camphorse, act. 3ss. M. S. A teaspoonful three times a day in flaxseed tea or barley water. Professor Trousseau recommends the following solution of ni- trate of silver in whooping cough ; one-fifth of a grain in solution with simple syrup daily. Cauterization by nitrate of silver has also been employed as a remedy in pertussis by Dr. Eben Watson, of Glasgow. The strength of the solution is gr. xv. to the ounce of water, applied every second day, by means of whalebone tipped with sponge, at first to the pharynx, and then to the glottis and larynx. The whole number of cases treated by M. Joubert and Dr. Watson, in 1854, were 167. Cured in two weeks, 96 cases, or 57.4 percent. " in three or four weeks, 61 " 36.5 " Eesisted the treatment, 9 " 5.3 Died, 1 " or nearly 0.6 " To prevent the irritability of the stomach, he gives frequent small doses of of heavy magnesia, combined with a few grains of the trisnitrate of bismuth. He also employes the index finger or teaspoon to make the application to the throat of children. Nitric Acid was was first recommended by Dr. Arnoldi, of Montreal, as a remedy in pertussis with much success, and it has 1856.] Whooping Cough. 357 been adopted by Dr. Gibb, of London, late of Canada, who has published a work on whooping cough, in which he has given the opinion of ninety-three physicians, in relation to its pathology, with its history, mortality, complications and causes. He has also entered into a consideration of forty-three remedies, viz.: venesection, leeches, emetics, antimonials, external applications, change of air, warm bath, hydrocyanic acid, laurel water, belladon- na, opium, hemlock, henbane, digitalis, tobacco, arsenic, silver, iron, zinc, lead, copper, cauterization by nitrate of silver, inhala- tions, coffee, Peruvian bark, quinine, hydrochloric acid, sulphuric acid, nitric acid, cochineal, alum, tannin, vegetable acids, alkalies, vaccination, cantharides, musk, assafcetida, meadow narcissus, cup moss, castor, nux vomica, and miscellaneous remedies. He re- marks that the nitric acid has succeeded over and over again when other means have failed, and it is not such a hazardous remedy, when administered with ordinary precaution, as many described by him in his work. Dr. Arnoldi's method of prescri- bing the acid is as follows : " To a tumbler full of very sweet water (almost syrup,) add as much acid as will bring the water to the strength of pure lemon juice, when it is ready for use ; an adult may consume this quan- tity in three or four hours, a child one year old may take a desert spoonful every hour." "He has remarked that the efficacy depends on the amount taken, and that especially by the frequency of repetition, to save the teeth, he advises a solution of carbonate of soda, two drachms to eight ounces gf water, to be used as a gargle immediately after taking the acid." "The object entertained by Dr. Arnoldi, in using this acid as a remedy, was to introduce the elements of the atmosphere into the blood by the process of gastric digestion, so as to enable the lungs to outstand the stage of tempory asphyxia. Whether the theory be correct or not, the result, he says, of his practice has been almost universally successful." He then goes on to give the out- lines of twelve cases which were treated by Dr. A. with success. The doctor met with a few cases where the disease seemed to re- sist the action of the acid, owing, he remarks, to " spinal torpor at the track of the eighth pair and phrenic. In these the application of an ointment of the biniodide of mercury, so as to produce the specific eruption, and this produced a second and a third time, completely restored the efficacy of the acid." " Dr. Gibb's own cases were sixty-four in number, which are re- ported as cured ; he combines the acid with honey or syrup, and compound tincture of cardamom, &c." Chloroform has been enployed by Dr. Fleetwood Churchill, as a specific remedy in whooping cough in four cases which he re- ports ; in two of these the whoop ceased in two days ; in the third case it required its use for three weeks ; in his fourth case 358 Vicarious Menstruation. [June, the patient had to resort to the use of Prussic acid to complete the cure. "In the case of young children he drops thirty drops on the palm of the hand, the mother to hold this before the mouth and nose of the child, sufficiently near to inhale it fully, but not so close as to exclude a portion of atmospheric air. The best time to begin is just as the patient feels the irritation in the chest increased to a cough. Still he considers it more suitable for young persons of twelve or fourteen years old and upward. Two successful cases have come under my notice ; the method was by placing a small por- tion of chloroform in a vial, and when feeling the inclination to cough, to inhale by removing the cork, the small bottle being carried in the pocket." Before concluding my remarks upon the treatment of this dis- ease, I must not neglect to state the great importance attached by some authorities to a change of air in the last stage, or the debility which results from it. Dr. Lombard remarks, that " in many cases which had baffled all attempts to stop the cough, a change of air has accomplished the cure. I have found it equally indiffer- ent to go out of town, or to come into town, provided there be a change ; and even in the short distance of half a mile, I have seen the good effects of this plan of treatment." Dr. West, of London, says that change of air with the use of alum during the last stage, generally expedites the cure." According to Dr. Gregory, change of air after severe and protracted eases is the only thing that will give the patient a chance of recovery. Billard states "that goat's milk, pure or diluted, a good nurse, a residence in the country, particularly in the spring and summer, will materially conduce to the recovery of infants at the breast." But nothing can be more pernicious than the exposure of child- ren suffering from whooping eough, to cold or inclement weather for it will bring back the cough and cause inflammation of the lungs. [Medical Examiner Vicarious Menstruation. "We find the following cases, reported by Prof. Boring, in an interesting article contained in the Atlanta Medical Journal: " The first is, that of a married lady, Mrs. , twenty -two or three years of age, of rather feeble constitution, sensitive, nervous habit, poor digestion, and generally feeble health. She menstru- ated first at the usual age and continued healthy in this respect for the space of three or four years, when. the catamenial flow was suddenly arrested by falling into a stream of water, the discharge being present at the time. Since then she has been the subject of irregular menstruation, the secretion coming on sometimes too 1856.] Vicarious Menstruation. 359 soon, then too late; at times insufficient in quantity, and at other periods profuse and exhausting. She has been married about two years, but without issue. When I first saw her, she was laboring under what was supposed a dangerous attack of hemorrhage from the stomach and bowels. I found her vomiting and purging what seemed to be decomposed blood, with great exhaustion, and the pulse ranging from 120 to 125 in the minute. It did not occur to my mind at first, that this was an instance of Vicarious Menstrua- tion, but the physician who had been in charge of the case, having blistered over the region of the stomach, and administered the usual remedies, I determined to wait and extend my observations before instituting treatment. In the mean time, developments went far to impress me with the ojDmion, that the disease, was not one of real hemorrhage, but of menstrual character. Upon insti- tuting thorough inquiry into the history of the patient, I became satisfied of the nature of the case, and treated it accordingly. The attack soon passed off, and the patient recovered a pretty good state of health. My efforts were then directed to the correc- tion of the uterine system and the establishment of healthy men- struation. In this, I have been partially, and only partially, successful. The catamenial secretion has become almost uniform in regard to the time of its recurrence, but is sometimes protract- ed and profuse, and not unfrequently attended with severe head- ache and distressing nausea. I have also observed a strong tendency on the part of the stomach, at each monthly period, to become nauseated, and, as I believe, to take on this remarka- ble action. "Before concluding this case, I ought to state, that it not un- frequently happens with this patient, that at her menstrual periods the breasts become more or less tumefied and painful, and at the same time similar appearances occur on other parts of the body, particularly on the chest. "The second case alluded to, is that of a negro woman, belong- ing to Mrs. , about thirty-five years of age, of apparently good constitution, and, with the exception about to be mentioned, gen- eral good health. "She began menstruating at the age of fifteen, and continued regular in this respect until about three years since. Eight years ago, when about twenty-seven years of age, she was attacked with violent pain in the foot, which was succeeded by an abscess, which was lanced, but did not heal. Ulceration succeeded, which con- tinued to move upwards until the leg was involved and became the seat of its permanent location. About three years since, the catamenial discharge began manifestly to decline, and so continued until it ceased altogether, when she was seized with severe shoot- ing pains, passing from the sacro lumbar, to the uterine region, and to the ovaries. At the approach of her next menstrual period, she noticed a slow oozing of blood from the ulcer on the leg, (I 360 Suggestions upon Animal Odor. [June, give her own account of the matter,) which continued about the usual time of that discharge and ceased. At subsequent periods, the same discharge sometimes occurred, while at others, instead, small sacks of blood were formed contiguous to the ulcer, which were obliged to be opened and the blood discharged, before relief could be obtained. " In June last, the ulceration of the leg had become so extensive and threatening, as to require, in the judgment of Dr. , (whose patient she then was,) amputation. " Since the operation, the ulcer being removed, there has been no regular monthly periodic discharge of blood, but, at each monthly period, sacks, such as were above described, form around the stump of the amputated limb, and require to be lanced for the relief of the patient. I have seen these sacks, and in fact opened them, and can entertain no doubt as to their true nature. So uniform are these singular occurrences in their periodic character, as to have induced this woman to keep a lancet for the purpose, and thus surgically to perform the work of menstruation. It should be ob- served that she continues without any vaginal discharge, and that the determination of blood to the stump of the amputated limb, together with the formation of these sacks of blood, occur periodi- cally, and observe strictly the menstrual periods, as to the time of their recurrence and duration." Suggestions upon Animal Odor. By Charles Van Alen, M. D. Each genus, species, and perhaps individual, of the whole world of animal life, is probably distinguished by its peculiar odor. We will not discuss with the metaphysician the question, whether odor exists independently of the sense of smell ; we take it for granted that it is a property of certain forms of matter, independent of this sense. This fact, so apparent in animals that come within the ordinary scope of observation, justifies the conclusion by analogy, that the whole animal kingdom is similarly endowed. Some of the more prominent examples will naturally suggest themselves to the student of Natural History. The musk odor, with its numberless varieties, belong to the musk deer (moschus moschiferus) to several of the ape kind, and to the different varieties of the musk rat : the peculiar smell of the civet, that of the castor (castor fiber) and the strong offensive odor of the pole cat and of our native skunk ; and among insects, the delicate musk perfume of the cerambix nmschfr tus, the apis fragrans, and the tipula mosclri/era, and the odor of the cerambix saveolens, nearly allied to, though more delicate than, the rich perfume of the otto of roses, offer readily illustrations of the extent and variety of animal odor. In man, as in other animals, there exisis a peculiar distinctive odor, not impressing itself in a (state of health with much intensity upon our duller sensation, but 1856.] Suggestions upon Animal Odor. 361 always clearly perceptible to the more acute sensibility of some of the lower animals. It is contended with some degree of plausibili- ty, that each race of mankind has its distinguishing odor. "The Peruvians," says Humboldt, " who in the middle of the night, distinguish the different races, by their quick sense of smell, have lormed three words to express the odor of the European, the American Indian, and the Negro." The following observation is quoted by Blumenbach from Thibault de Chambollon, in refer- ence to the Caribbeans. " They have all a strong and disagreeable smell. I cannot," says Chambollon, "give the remotest idea, by description, of its peculiarity. Whenever a similar odor is obser- ved, is called at the Antilles, the Caribbean smell, which proves the difficulty of defining it." It is generally conceded, and most of us have daily opportunity for obtaining olfactory evidence of the fact, that the negro emits a peculiar odor, distinguishing him from the white race. Dr. Carpenter denies this. He allows that the negro, in common with the Hindoo, secretes a more abundant perspiration than the white, but asserts emphatically that it is not more odorife- rous. Dr. Prichard, on the other hand, though an earnest advocate for the utiity of origin of the whole human family, remarks in speaking of the perspiration of the dark colored races, that it has a peculiar odor, which is well known in negroes and the Caribbee Indians. On the score of sniell, no obstacle exists to the most inti- mate relations between the white man and the negro, which will not easily yield to a due application of soap and water. That each individual as well as race, of the human family, is endowed with a peculiar odor, seems evident, from the ease with which the dog scents his master, The interesting history of Julia Brace, an inmate of the Hartford Asylum, affords further evidence of the fact. This unfortunate girl, burn blind, deaf and dumb, having no other mode of communication with the external world than by the sense of smell, taste, and touch, by the increased power of which nature strove to compensate her for her severe affliction, was enabled to distinguish persons, by the exercise of the first sense alone. The eloquent author of the " Religio Medici," and the '' Urn Burial," has some observations pertinent to this subject. " We acknowledge," he says, that " certain odors attend on animals, no less than certain colors ; that pleasant smells are not confined to vegetables, but found in divers animals, and some more richly than in plants; and though the problem of Aristotle inquires, why no animal smell sweet beside the pard, yet later discoveris add divers sorts of monkeys, the civet cat and jazelon, from which our musk proceedeth. We confess that beside the smell of the species, there may be individual odors, and every man may have a proper and peculiar savor, which although not perceptible unto man, who hath this sense but weak, is vet sensible unto dogs, who thereby can single out their master in the dark. We do not deny that particu- lar men have sent forth a pleasant savor, as Theophrastus and Plu- 862 Suggestions upon Animal Odor. [June, tarch report of Alexander the Great, and Tzetzes and Cardon do justify of themselves." In that charming specimen of self-portrai- ture, the autobiography of Lord Herbert of Cherbury, the brave knight, the courteous gentleman, and the learned scholar, present- ing in his character the rare union of a complete knowledge of the world and the deepest wisdom of the closet, we read, " It is well known to those who wait in my chamber, that the shirts, waistcoats, and other garments I wear next my body, are sweet beyond what easily can be believed or hath been observed in any else ; which sweetness also was found to be in my breath above others, before I used to take tobacco, which toward my latter days, I was forced to take against certain rheumes and catarres that troubled me, which yet did not taint my breath, for any length of time." In a quaint old work entitled " The life of the learned and pious Dr. Henry More, late fellow of Christ College in Cambridge, by Rich- ard Ward, A. M.," the author remarks, "I was mentioning some- what but just now of his body, and this reminds me of some things that were peculiar in that also as well as in his mind; he has told us occasionally, in a discourse concerning the famous Greatrakes and what was extraordinary in that person," " that not only his own urine had naturally the flavor of violets in it, but that his breast and body, especially when very young, would of themselves in like manner send forth flowery and aromatic odors from them, and such as he daily almost was sensible of, when he came to put off his clothes and go to bed ; and even afterwards, when he was older, about the end of winter or beginning of spring, he did frequently perceive certain sweet and hebaceous smells about him, when yet there was no such external objects near, from whence they could proceed."* These reports of sweet smells must be taken " cum grano salis," to give them the savor of truth. They probably take their origin in an exaggerated egotism, which envelops in its in- cense every thing that pertains to self. In considering the physiology of animal odor, and endeavoring to trace out its cause, considerable difficulty is encountered from the unsubstantial nature of the object of investigation, from the impos- sibility of discriminating with exactness its varieties, and from the various degrees of sensibility of different observers. Attempts have been made to classify systematically the various odors. The most plausible one divides them into Acidulous, Spirituous, Camjrfiorous, Fragrant, Somniferous, Fetid, and Alkaline; but these terms do not admit of a strictly philosophical application. All odors are compo- site, and all individuals are possessed more or less of an idiosyn- * In a late work, called theTable Talk of Samuel Rogers, we find the following: "Sir Henry Englefield bad a fancy (which some greater men have had) that there was about his person a natural odor of roses and violets. Lady Grenville heariog of this and loving a joke, exclaimed one day when Sir Henry was present, "Bless me, what a smell of violets 1" "Yes, said he, with great simplicity, "it comes from me." 1856.] Suggestions upon Animal Odor, 363 cracy of sense. These facts present themselves as insuperable ob- stacles to an exact definition. The physician, in this as in every other department of the science of medicine, must not confide too trustingly in fixed rules, but endeavor to sustain his uncertain steps by individual experience and observation. Various animals (of which mention has already been made) more prominently distinguished by their odor, such as the musk deer, the civet, and the castor, have peculiar organs, generally situated in the neighborhood of the genitals, devoted to the particular function of generating odor. In others, as the pole cat and the skunk, the stench is due to the ordinary secretions. The odor of these various animals is not of the same intensity at all times and seasons. With some it is voluntary, and thrown out as a protection against attack ; and with others it is generated independently of the will in the rut- ting season, as a source of attraction between the sexes. Animal odor in its natural condition, of whatever kind, is unquestionably a source of pleasure to its possessor, and to those of the same order, and of repugnance to most others, which contribute towards preserv- ing the integrity and individuality of the races, thus administering to a wise purpose in the economy of nature. The principal sources of odor in man, are the breath, and the different secretions. The air expired gives out the odor, in dimin- ished intensity, of the ordinary articles of diet consumed. The perspiration has naturally an acid odor, differing in degrees in vari- ous parts of the body, being more sensible in the groin, in the neigh- borhood of the genitals, and the feet. The other secretions and excretions have peculiar smells of their own, each of which contri- butes towards producing in man his distinctive odor. This is affect- ed in a remarkable manner, and very variously, by habits of life, the atmosphere, diet, and more especially disease. Persons engaged in certain employments, whatever may be their attention to personal cleanliness, are observed to become so impregnated with the pecu- liar odor of the objects by which they are constantly surrounded, as to give it out long after a change of occupation. Chomel states that he had a hostler under his charge at the hospital, who during the course of a bilious fever, exhaled a strong smell of the stable, although all his clothes had been removed, and he had been repeat- edly washed. All who approached him felt assured that the odor proceeded directly from the patient himself. The effect of diet and of various articles used as remedies, in altering the animal odor, is a familiar fact. Those in the habit of eating garlic and onions, habitually smell of the peculiar odor of these plants; and the Greenlander, whose constant vegetable food is of the pea kind, is reported bv travellers to emit a leguminous smell ; the noisome stench which infects the urine, after eating as- paragus, cannot have escaped the dullest sense of smell; and the violet odor from the administration of the oil of turpentine, the pecu- liar flavor given to the breath and urine and the perspiration by otj-l Suggestions upon Animal Odor. [June, copaiba, sulphur, and various other remedies, are the results of everyday observation. It is doubtless the vapor of the essential oil belonging to the articles taken into the system, which is thus ex- haled, and which, though not sensible to chemical tests, becomes evident to the sense of smell. The varieties of odovamong individu- al races are attributable probably to their various modes of life. The effect of disease is increasing and varying the animal odor of the human body, more especially recommends itself to the regard of the medical observer, from its direct bearing upon diagnosis. It is believed that much useful information would be the result of directing inquiry and observation upon this subject. Its investiga- tion is urged upon the physician as promising to result in a fair return of profit, available for practical purposes. Certain diseased conditions of the system affect in a remarkable manner the odor of the breath, and thus afford a valuable symptom of their existence. In some febrile diseases the breath acquires a sweetish, and in vari- ous affections of the stomach a strong pungent, acid odor. This acidity is occasionally of such intensity, as to impregnate every thing which surrounds the patient, his clothes, bedding, and the whole fur- niture of the room: and is indicative of a severe form ot gastric disease, which most frequently results in death. In gangrene of the lungs, the breath emits an odor of putrified flesh, a most unvarying and important distinctive system of this disease. In several forms of dyspepsia, in bilious fever, in scurvy, and in the latter stage of consumption and typhus fever, it assumes a fetid character. Mer- curial salivation, and various affections of the mouth and throat are easily discernible by the peculiar and offensive odors they give to the breath. A fit of drunkenness is invariably detected by the spir- ituous odor exhaled from the lungs, when otherwise there might be danger of confounding it with severe disease. The perspiration in a variety of different affections undergoes sensible changes in odor, worthy of the physician's regard. In prolonged constipation, a very marked odor of sulphureted hydrogen is observed, especially in females, who are more apt to neglect the state of their bowels, and whose false modesty disposes them to conceal their condition from their physician. This odor will be found a useful, and often the only attainable indication in such cases. In various diseases of the skin, a peculiar smell of the transpira- tion is an unvarying symptom. In all syphilitic eruptions, the odor is marked and peculiar. In small-pox it is equally distinctive and prominent, and is by many compared to the smell of mouldiness ; in porrigo favosa also, it resembles the stench of cat's urine, and in miliary fevers, by some it is likened to ihe smell of lime, by others, to that of decayed straw. A peculiar fetid smell of the perspiration of the feet is frequently observed, and presents a troublesome and obstinate disorder. The writers upon the sweating sickness, the terrible plague which devastated Europe in the 15th and 16th cen- turies, have exhausted their powers of language, in endeavoring to 1856.] Suggestions upon Animal Odor. 365 describe the rankness of the odor of the perspiration which was the prominent symptom in that disease. They speak of the horrible stench of the sick, the odor teterminus, of the afflicted being sur- rounded by a thick stinking mist of their lying, as it were, in a stinking swamp of sweat, and overwhelmed with disgust of them- selves, in consequence of their loathsome and ill-odored condition. In rheumatic diseases, most of the secretions and excretions are per- ceptibly changed in odor, and more especially the sweat, which assumes a nauseous. acid smell. Fevers of alow typhoid character are easily indicated by an odor like that of mice; and in the latter stages of typhus, the smrll is decidedly cadaverous. The insane are observed to emit a peculiar odor from the skin. The urine also acquires various odors in different diseases. In Bright's disease it sometimes exhales the smell of boiled beef; and in diseases of the bladder and some typhoid affections, that of shell fish ; in acute in- flammatory disease, and in various disorders of the kidneys, an am- moniacal odor. The smell peculiar to the faeces varies frequently in disease. It is of a cadaverous nature in typhoid fever and chronic diarrhoea; and resembles that of macerated flesh in certain malig- nant dysenteries. In many of the diseases of the digestive organs in children, its condition supplies important indications. The stools are offensive in the early stages of cholera infantum, and again in- odorous in its more advanced periods, and in the severe forms of dysentery. The odor of what is thrown up in vomiting aids in forming a just notion of the nature of the disease in which it exists. The sense of smell is necessarily applied to for a right appreciation of the condition of certain ulcers, putrescent wounds, gangrene, and purulent deposits. The odor is the most reliable means for the de- tection of poisons by prussic acid, and aids in discovering the pre- sence of the metallic, narcotic, and other poisons. The septic con- dition generally reveals itself by a smell indicative of the process of decomposition. It is to this state that may be attributed the various changes in the animal odor, produced by disease. Whether this disorganization originates in the solids or fluids, or, as is more pro- probable, occasionally in both, it becomes no one in the present state of pathological science dogmatically to decide. That the composi- tion of the humors of the body, is at least secondarily affected, there need be no hesitation in asserting. It is no longer heresy to speak of the corruption of the fluids, the decomposition, or, in other words, the new chemical combinations set up in them, uncontrolled by the vis vitas. To what else can be attributed the loathsome putrid sweats in the sweating sickness, the cadaverous odor in the last stages of typhus, and the putrescent ex- halations in scurvy and other analogous affections? Much pro- gress in pathology has been hindered by the excessive reaction of opinion against the exclusive doctrines of the Humoralists of a past age. Liebig, Prout, Bright, and others, have established a firm foundation of well-ascertained facts, upon which it is hoped 366 Treatment of Scarlatina Anginosa. [June, the superstructure of a new and rational system of humeral patholo- gy will arise, fact by fact, cemented fast by experiment and logical deduction. [New York Medical Times. Treatment of Scarlatina Anginosa. Mr. Pye H. Chavassee, F.R.C.S., read before the Medico-Chir- urgical Society of Birmingham, March 4th, 1856, the following paper on this disease: As I have been very fortunate in my cases of scarlet fever, I consider it a duty to bring my treatment before the notice of the members of this Society. My plan, of late years, has been so uniformly successful (not having lost a case of scarlet fever for upwards of seven years,) that I have not deemed it necessary to keep a record of cases. The system I adopt, in a case of scarlet fever, is to keep the bed-room cool I may say cold and to have a thorough ventilation through it : I, therefore, throw open the windows, be it winter or summer, and have the curtains and valances of the bed removed. If it be winter time, 1 allow the patient to have one blanket and a sheet ; if it be summer time, a sheet only to cover him. If the throat be not seriously affected, I merely order a narrow strip of flannel once round the throat. If the tonsils be much enlarged, I apply a barm and oatmeal poultice to the throat, changing it night and morning. I prescribe an acidulated infusion of roses mixture, that is to say, infusion of roses, with an excess of acid, made palatable with an additional quantity of syrup, to be taken every three or four hours. This is the only medicine I give. When the child is old enough, I find roasted apples, mixed with raw sugar, very grateful to the patient. Here let me pause, to advise my medical brethren always to make medicines for children pleasant. The administration of nau- seous medicine to children oftentimes causes sickness, disgust and irritation, which irequently do more harm than the medicine does good. But to return to our subject : I avoid purgatives in scarlet fever. I never, on any account, give a particle of opening medicine for the first ten days at least. It is my firm conviction, that the adminis- tration of purgatives in scarlet fever is a fruitful source of dropsy, disease and death. When we take into consideration the sympathy that there is between the skin and mucous membranes, I think that we should pause before giving irritating medicines. The irritation of purgatives on the mucous membrane may cause the poison of the skin disease to be driven internally, to the kidneys, throat, peri- cardium or brain. You may say, do you not purge if the bowels be not open for a week? I say emphatically, No! Now with regard to food. If the infant be at the breast, keep him entirely to it. If he be weaned, and under two years old, give 1856.] Treatment of Scarlatina Anginosa. 367 him milk and water, and cold water to drink. If he be older, give him toast and water, and plain water from the pump, as much as he choses ; let it be quite cold the colder the better. Weak black tea, or thin gruel, may be given, but caring nothing if he take no- thing but cold water, unless he be an infant at the breast. Avoid broths and stimulants of every kind. Now, you must warily watch for a change of temperature of the skin. As long as the skin is hot, the above plan I steadily follow ; but the moment the skin of the patient becomes cool, which it will do, probably, in five or seven days, instantly close the window, and immediately put more clothes on the bed. But still do not purge. You will find the acidulated infusion of roses most grateful to the little patient ; it will abate the fever, it will cleanse his tongue, it will clear his throat of mucous, it will, as soon as the fever is abated, give him an appetite. I believe, too, the acid treatment has some peculiar properties of neutralising the scarlatina poison. I do not pretend to explain how, or why, or wherefore. When the appetite returns, you may consider the patient to be safe. The diet must now be gradually improved. Bread and but- ter, milk and water, and arrow-root, made with equal parts of milk and water, may be given for the first two or three days. Then a light batter or rice pudding may be added ; and, in a few days af- terwards, a little chicken or a mutton-chop. Within the last few years, I have had some fearful cases of scar- let fever; but, relying on this plan of treatment, I have given, even in very bad cases, a very favorable diagnosis. I have had cases where there have been violent headache and delirium ; where there have been immense swellings of the parotid and submaxillary glands ; where there has been enormous enlargement and ulceration of the tonsils ; where a great portion of the fluid that has been taken by the mouth has escaped down the nostrils ; where there has been a purulent discharge down the nose, which discharge has in many instances quite excoriated the skin over which it has travelled ; and yet in such cases the patients have invariably recovered. There is another important regulation I lay great stress upon. I never allow a scarlet-fever patient, even if the attack be mild, to leave the house under the month in the summer, and then not if the wind be in the East or Northeast; nor under six weeks in the win- ter. During the last seven years, I have never had anasarca from the scarlatina ; and I attribute it entirely to the plan I have just re- commended, and in not allowing my patients to leave the house under the month until, in fact, the skin that has peeled off has been renewed. Dr. Watson, in his valuable lecture?, gives some advice on this subject. From the sixteenth to the thirtieth day, I watch the case assiduously, to assure myself that there be no drop- sical approach, carefully examining the urine, ascertaining that there be plenty of it, and that it be not albuminous. Let me now sum up the plan I adopt : 368 Treatment of Scarlatina Anginosa. [June, 1. Thorough ventilation, a cool room, and scant clothes on bed, for the first five or seven days. 2. A change of temperature of skin to be carefully regarded. As soon as the skin is cool, closing the windows, and putting additional clothing on bed. 3. Infusion of roses with an excess of acid, sweetened, the only medicine to be given. 4. Purgatives to be religiously avoided for the first ten days at least, and even afterwards, unless there be absolute necessity. 5. Leeches, blisters, emetics, and cold and tepid spongings, inad- missible in scarlet fever. 6. A strict antiphlogistic diet for the first week, during which time cold water to be given ad libitum. 7. The patient not to leave the house in the summer under the month ; in the winter, under six weeks. My firm conviction is, that purgatives, emetics, and blisters, by depressing the patient, sometimes cause scarlatina anginosa to de- generate into scarlatina maligna; for although I have had numerous cases of scarlatina anginosa (my practice being much among chil- dren,) and some of the cases very severe ones, I have never had, since I have adopted my present plan of treatment, one single case of scarlatina maligna. I have such faith in my present plan of treatment, that if it be duly followed out, I should seldom despair of even the worst of cases recovering. I am aware that some of our first authorities advocate a different plan to mine. They recommend purgatives, which I may say, in scarlet fever, are my dread and abhorrence. They advise cold and tepid spongings a plan which I think dangerous, by driving the disease internally. Blisters, too, have been prescribed ; these I consider weakening, injurious, and barbarous, and likely to irritate the already inflamed skin. They recommend leeches to the throat, which, I am convinced, by depressing the patient, lessen the chance of battling against the disease, and increase the ulceration of the tonsils. Again, the patient has not too much blood ; the blood only is poisoned. I look upon scarlet fever as a specific poison of the blood, and which will be eliminated from the system, not by bleed- ing, not by purgatives, not by emetics, but by a constant supply of fresh and cool air, by the acid treatment, by cold water as a bever- age, and for the first few days by a strict antiphlogistic diet. Sydenham says, that scarlet fever is oftentimes " fatal through the officiousness of the doctor." I conscientiously believe that a truer remark was never made; and that, under a different system to the usual one adopted, scarlet fever would not be so much dreaded. Let me urge my medical brethren to give my treatment a fair trial, and I am convinced that they will then add their testimony to mine, that the plan is a good one. I have spoken out fearlessly and boldly ; but I feel so satisfied of the truth of my sentiments, and of 1856.] Varioloid and Varicella. 369'1 the immense importance of the subject, that I could not be less em- phatic. [Ass. Med. Jour. Varioloid and Varicella. By Prof. Trousseau. Many practitioners of high scientific repute believe that the same relationship prevails between varicella and varioloid as between this last and variola. This it is impossible to admit. If we bring am individual having genuine vaccine scars in contact with a small- pox patient, he may take a varioloid, and, while suffering from this,. he may communicate a true variola to a. subject who has neither been vaccinated nor had the smallpox. If we take the pus from a varioloid patient, and inoculate the healthy person, as has been done in epidemics when vaccine lymph has run short, we produce the legitimate smallpox. These are so many proofs of the identity of the two affections. It is not thus with varicella. It neither arise* from contact with varioloid, or is capable of communicating true variola. We see it arise just as easily in persons who have had that disease, as in those who have been exempt from it ; in the un- vaccinated, and in those who have been vaccinated. M. Trousseau has seen an epidemic of varicella at the Neckar Hospital which attacked all the children, a short time after vaccination had been quite successful. This is an important question in hygiene; inas- much as varicella, of itself, is an affection destitute of danger; and we may leave the subject of it in communication with surrounding persons, without the fear of finding a serious malady developed. The same practice, pursued in varioloid, might give rise to a mis- chievous development of variola. Varioloid. Thirty-five years ago, an authentic example of small- pox after vaccination was unknown, although Jenner had seen ex- amples of this, and had indicated them ; but, as there are always to be found persons more royal than the king, so there were practi- tioners who accorded to vaccine more than he who had discovered and propagated it had claimed for it. In 1825, a very violent epi- demic of small pox prevailed in Paris, during which individuals who had been vaccinated were attacked. M. Husson, who was one of the Vaccine Committee in 1800, and one of the most ardent pro- moters of vaccination, contested the validity of these cases ; and so extraordinary was the circumstance thought to be, that whenever a varioloid patient arrived at the hospital, the bells were loudly rung, in order to call as great a number of practioners together as possible for the verification of the fact. An epidemic at Edinburg, and two at Marseilles, multiplied examples. The attention of gov- ernments became aroused, and especially in Germany, where re- vaccination has been rendered obligatory. At the present day, there is no hospital in which we may not see persons having the vaccine scars the subject of variola, and even dying of it. It may occur even as early as the second or third year after vaccination ; 380 Varioloid and Varicella. [June, and M. Trousseau has seen an infant at the Necker Hospital take a genuine variola six weeks after a successful vaccination. A mo- ther and her three children also took it soon after vaccination, and in the woman, who died, it was confluent. At its onset varioloid differs in nowise from variola. Fever arises and continues until the eruption appears. We see, however, more frequently supervene a scarlatiniform or petechial eruption, but it does not influence the prognosis unfavorably, as in variola. The eruption does not differ from that of variola, until the eighth day ; but at the eighth day from the commencement, or the fourth from the eruption, in place of tumefaction and inflamed areola superven- ing, we find the integuments become pale and flaccid. The pus- tules do not become larger, remain accuminated, and umbilicate but little. They dry without bursting, become rugous, and pass into the " horny" condition. Those of the limbs, in place of acquir- ing a size three or four times as large as those of the face, do not increase, and cornify in the same manner. By the tenth day the eruption is dry. In more serious forms, when the varioloid, as some times happens, is confluent, there is sometimes secondary fever ; but at the tenth day, the tumefaction stops short, without any acci- dent supervening, while in variola its doing so would be of falal au- gury. The whole terminates with a rapid desquamation, although marks may remain, especially in persons with delicate skins. Varicella. When a child is brought to the Necker with varicel- la, the date of its admission is noted, and sixteen or seventeen d. later, other children always exhibit the same disease. If, on the contrary, it had been a small-pox case, other cases would have been observed from nine to eleven days afterwards showing that the period of incubation is very different in the two affections. A child, in good health, whether vaccinated or not, whether having had variola or not, becomes suddenly the subject of a sharp attack of fever, there being present neither vomiting nor lumbar pain. The next day, or sometimes even the same day, fifteen or twenty red points are observed upon the skin, and some hours later the epidermis is raised. Twenty-four hours after the appearance of the red points we observe bullae or phlyctaenae, quite rounded in form, and transparent, as if they contained water. They resemble sudamina, magnified from ten to fifteen times. In variola and va- rioloid the eruption never assumes this bullar form. In those dis- eases, too, the fever and the eruption continue until the latter is completed. In varicella the phenomena take place successively. There is a day of complete apyrexia, the fever comes on during the night, and the next day we find from thirty to forty points of erup- tion. The same takes place during the next twenty-four hours, and so on for four or five days, so that we have four or five successive eruptions. Twelve hours after the appearance of the eruption, there is a limpid bulla formed, and forty-eight hours after the liquid has become lactescent, which is never observed in any form of va- 1856.] Case of Varicocele. 371 riola. In variola discreta the eruption is of a very regular, rounded form, like wax dried upon the skin ; but after two or three days the bullae of varicella become unequal, irregular and puckered, but never offer any appearance of umbilication. When pus begins to form in the phlycteenae, a livid red, inflammatory areola is produced, larger in size than the variolous areola. When the pustule bursts it leaves a dark brown scab, having nothing in common appearance with the yellow scab in variola, but much resembling that of echthyma. From twelve to fifteen days are required for the complete evolution of a variolous pustule, while four, or at most five, days suffice in varicella. So little dangerous is this affection, that M. Trousseau knows of no example of its having terminated fatally. Still, in some children, who manifest the purulent diathesis, it is followed by suc- cessive eruptions of pemphigus, which terminate by exhausting the patient and causing death. But these deaths cannot be imputed to the varicella itself. Thus then, variola and varioloid are identical; while varicella is distinguished from these by the differences in its period of incuba- tion and febrile paroxysms, by the form and duration of its eruption, and by the absence of danger. [Ranking's Abstract. Case of Varicocele cured by Retrenchment of the Scrotum. By Sam'l B. Richardson, M. D. The well-known chagrin and mental despondency, resulting sometimes in mono-mania and suicide, which constitute a part of the history of this distressing and not unfrequent malady ; not to mention the uncertainties, danger and sometimes fatal results of operations for its radical cure heretofore, impart more or less of in- terest to every well attested case of successful treatment. With these views, the following observations are placed before the pro- fession, s Case. B H , Esq., of Southern Kentucky, aged 29 years, unmarried, of respectable family, possessing a good constitu- tion, the only disease from which he has ever suffered being inter- mittent ague and fever, which occurred during his adolescence and early manhood. In the midst of health and cheerfulness, on the 27th of October, 1838, an amicable rencounter took place between himself and a companion, in a tussle or wrestle, resulting in his friend falling be- neath him. Just at the moment of greatest effort, he felt a sharp cutting pain, of short duration, in his left spermatic cord near the external ring. The day succeeding, a tumor was discovered in the cord near the testes, which gradually increased in size up to the time of operation. A month succeeding the accident, pain, with a sense of languor and aching, was felt in the right groin, hip, and loins, attended with no inconsiderable mental despondency, which symptoms afterward frequently exascerbated and remitted. In the N. S. VOL. XII. NO. VI. 24 372 Sulphur in Itch. [June, month of May, 1839, he came to Louisville to consult me respec- ting his case, when I discovered a marked varicocele of the left spermatic veins, with an increase of the constitutional and mental symptoms, and the digestive organs not acting healthfullv. I informed him that nothing short of a surgical operation prom- ised permanent benefit ; but to this he objected ; and, preferring a trial of other remedies firs-t, and promising if they proved unsuc- cessful, he would return in the autumn, and submit himself to any treatment I might consider best. The remedies then prescribed were designed to correct the disordered state of the stomach and bowels, and to compress the enlarged veins ; but they only succeed- ed in ameliorating the general and local distress, without lessening the original malady. On the 13th of October, this patient arrived in Louisville a second time ; and three days thereafter I operated upon him by removing quite a large section of the entire scrotum and sub-jacent cellular tissue, in the presence of and aided by Drs. Donne and T. L. Caldwell. The part removed, which laid bare the testes, measured, when moderately stretched, 5| by 3^ inches in extent. The wound was closed by five interrupted sutures, and interposed adhesive strips, over which was placed a light dressing of lint spread with simple cerate, and the parts placed in an elastic silk suspensory bandage, firmly drawn up. Adhesion took place througlwut, with slight exception, and but little constitutional reac- tion occurred. The fourteenth day succeeding the operation, Mr. H. visited my office, when I could discover no evidence of varico- cele. He left for home the eighteenth day after the operation. The evening before, I was happy to find, upon a careful examina- tion of the cord, that no enlarged veins existed while he was in the erect posture, and after continuous exercise about the city ; nor was he able to enlarge them by the most forcible expulsory efforts of the diaphragm and other abdominal muscles. All his previous pains, and the uneasiness of the right groin, hip, and loins, had ceased, and there remained but a slight fulness of the cord at the external abdominal ring. [Louisville Kentucky Review. Cure of Itch in half an hour by SuTpJiur in a liquid form.- Dr. E. Smith called attention to an article in the Gazette Heb- domadaire, by Dr. Bourgignon, in which is a confirmation of the value of the treatment of itch, in Belgium, by sulphur, combined with lime, in a liquid form. The remedy is prepared by boiling one part of quick lime with two parts of sublimed sulphur, in ten parts of water, until the two parts are perfectly united. During the boiling it must be constantly stirred with a piece of wood, and when the sulphur and lime have combined, the fluid is to be de- canted and kept in a well stopped bottle. A pint of the liquid is sufficient for the cure of several cases. It is sufficient to wash the body well with warm water, and then to rub the liquid into the skin for 1856.] Editorial. 373 half an hour. As the fluid evaporates, a layer of sulphur is left upon the skin. During the half hour the acarus is killed, and the patient is cured. It is only needful then to wash the body well, and to use clean clothes. In Belgium the treatment is introduced by first rubbing the body for half an hour with black soap ; but this does not appear to be necessary. The only essential act is that of the careful application of the fluid sulphur. The lime is of no im- portance in the treatment, except to render the sulphur soluble, and such would probably be the case if potass or soda were employed. The chief point in the plan thus employed, which is an improve- ment upon the mode of application of sulphur in substance with lard, is the more ready absorption of the remedy, and consequently the more certain and quick destruction of the insect, by using sul- phur in a fluid form. In so disgusting a disease, it must be of great moment to be able to cure it in an half hour. [Asso. Med. Jour. EDITORIAL AND MISCELLANEOUS. BIBLIOGRAPHICAL. Physical Exploration and Diagnosis of Diseases affecting the Respiratory Organs. By Austin Flint, M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c, &c. Philadelphia : Blanchard & Lea. 1850. 8vo., pp. 636. (For sale by T. Richards & Son.) Prof. Flint's contributions to practical medicine have already established a high reputation which will be found fully sustained by the valuable trea- tise before us. It is high time that the profession in our country should place themselves above the reproach of ignorance on so important a branch of their studies as Diagnosis and we need not add that this can only be done by a careful application of the physical means so elaborately and lu- cidly developed in this work. No man in this country has done more than Prof. Flint to incite our countrymen to a proper appreciation of their value. On some Diseases of Women admitting of Surgical Treatment. By Isaac B. Brown, F.R.C.S., Surgeon Accoucheur to St. Mary's Hospital, &c, &c. Illustrated by 24 wood cuts. Philadelphia: Blanchard & Lea. 1856. 8vo., pp. 276. (For sale by T. Richards & Son.) This work fills an important gap in English medical literature, and cannot fail to be well received in this country. The author treats of Ruptured Perineum, Prolapse of the Vagina, Prolapse of the Uterus, Vesico-vaginal Fistula, Lacerated Vagina, Polypus of the Uterus, Stone in the female bladder, Vascular tumor of the meatus urinarius, Imperforate hymen, En- cysted tumor of the labia, Diseases of the Rectum resulting from certain conditions of the uterus, and ovarian dropsy. We cheerfully commend it to our readers. 874 Editorial. [June, The Principles of Surgery. By James Miller, F.R.S.E., &c, heat, and other causes, which tend to produce nervous depression, and to derange the functions of the liver and other organs, which stand in immediate or intimate relation to it, these diseases will assume very different characters and present very different aspects in Montgomery or New Orleans, from the same diseases in Phila- delphia or Boston, and will require a corresponding modification of treatment; and so of all other diseases. Dr. Wood, of Philadelphia, has stated that he never saw a case of malignant, or pernicious intermittent, or remittent fever, except in the hospital, among sailors recently from the southern coast, or among medical students from the South or south-western states ; yet he has, no doubt, seen many cases of simple intermittent and re- mittent fever. And the reason is, that in Philadelphia, though sufficient cause may exist to produce a simple intermittent, there is an absence or want of the causes necessary to create a predispo- sition to malignancy in them; and our southern students and sailors having been long subjected to the influence of causes which tend to impair the general vigour of the system, and create a pre- disposition to the condition of depression and congestion, when exposed to the influence of the causes which, in Philadelphia, pro- duce only simple intermittents, have developed in them the most malignant and complicated forms of the disease. The causes of malignancy in these diseases are little less observa- ble in the influence of seasons, than in climate and latitude, as the milder and more simple forms of the spring season may be per- ceived gradually to change, as the season advances, to those of a more violent and complex character, until the fall season, when they reach their greatest malignancy. Such is the course of these malarious affections, in our southern latitudes, when uninfluenced by the prevalence of epidemic causes, to which they are at all times liable. Now, I will not attempt to deeide the question, whether the greater malignancy of these affections depend upon the gaeater de- gree of concentration and virulence of the malarial poison, which is supposed to produce them, or upon the causes, wihch are neces- sary to generate the poison, acting directly upon the animal system, "in conjunction with the poison,, impairing its tone and vigor,, thus laying the foundation for, or creating a predisposition to,, the con- dition of depression and congestion, which, with the functional derangement of the Ever, consequent upon the same causes, deter- 1856.] Holt's Letters upon General Pathology. 389 mine their greater malignancy. Eeason and observation incline to the latter conclusion ; for if we take the case of the sailors and med- ical students, coming from the South, in Philadelphia, we see the ma- lignant forms of disease excited in them by causes, which in others (where no such predisposition existed) could excite only the milder form of the disease. Now, if it should be contended that these cases, and similar ones, such as our pneumonias, dysenteries, and other like diseases, which occur in the fall, winter and spring, de- rive their malignancy from the presence of malarial poison in the system, I would reply, that it is not reasonable to suppose that a poison capable of producing such terrible results, could lie dormant in the system for weeks, and even months, without manifesting some signs of its presence, and then, under the influence of some slight exciting cause, develope all its pent-up fury. The laws of physiological chemistry would forbid such a thing, as the poison would, ere long, be eliminated from the system, or shorn of its virulence-. The more reasonable hypothesis is, that the character of all these affections is determined by the predisposing and not the exciting causes, but that they acquire force from each other, in the manner which has already been explained. To place this matter in a stronger light, I will suppose two men, equal in gen- eral respects, one taken from the hills of New Hampshire, and the other from the bayous of Louisiana, to be inocculated with small-pox virus, taken from the same subject at the same time; it would be but reasonable to suppose, (believing that all diseases, in a malarial region, are subject to the influence of the causes which produce malaria,) that whatever differences might exist in the character of the two cases would depend upon the influence of climate, and not upon any difference in the nature of the exciting- cause. In both cases, small-pox, in its suigeneric character, would be the result ; but the probabilities are, that the New Hampshire man would have a highly inflammatory form of the disease, with- out complications, and would require antiphlogistic and sedative treatment while the Louisiana man would have a low congestive form, attended with biliary and other complications, and require the use of stimuli and tonics. Apply the same argument to the cause, whatever it may be, which produces yellow fever. We hear it asserted, and it is generally believed, that the character of yellow fever is mild or malignant, according to the virulence of the cause which produces it. Is this proposition true? I am 390 Holt's Letters upon General Pathology. [Jutyi willing to admit, that the cause which produces yellow fever may- be generated in much greater abundance, and affect a mucb great- er number of persons at some times, and under some circumstances, than it does at others; and though it is a malignant and fatal dis- ease in its tendencies, at all times, it sometimes becomes much more so. But I am not prepared to admit that these results de- pend upon the more concentrated and virulent character of the poison, whatever it may be, which produces it, but my position is this; that yellow fever possesses an essential typical and stiigen- eric character, having for its production the operation of a specific cause, which, like the causes which produce small-pox, measles, or scarlatina, can only produce them in their simple, essential or suigeneric character, in which, if divested of all adventitious or extrinsic causes and influences, they would universally be the same. But as such a thing would be impossible with respect to yellow fever, and not much less with the others, I am compelled to believe that the different forms and modifications which yellow fever assumes, depends upon the adventitious influences which surround it, and not upon the cause which produces it. The most common and universal of these are such as relate to the person, and which modifies the disease to some extent in each individual case, independently of the influences which determine the general character of the disease. All diseases are subject to the influence of these individual pre- disposing causes, and none exhibit their influence in a more marked degree, or show so clearly their modifying influence, independently of the action of the specific or exciting cause, as does scarlatina, it being not unfrequently the case that we observe in the same fami- ly, and even in the same room, and at the same time, almost all grades of the disease, from the mildest and most simple, to the gravest and most malignant forms. Now, it cannot be contended, even upon the slender foundation of a probability, that the great- er malignancy of these cases depends upon the greater virulence of the exciting cause ; and even if they should all be of that charac- ter, it would furnish no conclusive evidence that the exciting cause was more virulent, but that the extrinsic and modifying influences were more potent and active. However interesting and important, in a practical point of view, may be the enquiry into the nature of the specific causes of disease, and the individual predisposing causes which modify them, I am 1856.] Holt's Letters upon General Pathology. 391 admonished, that to avoid the charge of indulging too freely in etiological speculations, abstractions and subtleties, it is proper that I should follow out my original design of endeavoring to point out the peculiar modifications and complications of our southern dis- eases, which result from the operation and influence of general pre- disposing causes, and of urging upon southern practitioners, the absolute necessity of watching carefully the changes which from time to time they undergo, and of conforming their practice to the general pathological condition which exists, modifying it to suit the exigencies of each case. In describing these diseases, I shall not follow the plan which has usually been adopted by systematic writers, of giving in regu- lar detail, all the causes, symptoms, and distinctive features the modes of treatment and prevention their terminations, &c, &c, which make up their complete history in their simple elementary or typical character, presuming that every physician is familiar with them in that character, which, as I have before stated, is universally the same, when not modified by adventitious influ- ences; but shall describe them only in their modified and compli- cated forms, according to their general pathological character, and the classification which I have adopted, observing, however, ac- cording to the relation of these diseases, the order of arrangement adopted by the systematic writers generally. The first which come up in that order, are Intermittent and Remittent Fevers. My reason for coupling these : two diseases, is, that they possess no appreciable pathological dis- i tinctions which entitle them to a separate consideration : they i result from the operation of the same causes, though perhaps from different degrees of intensity are subject to the same modifica- - tions and complications, and in many instances assimilate each other so closely that it is a difficult matter to draw a distinction i between them ; especially is it so with respect to those of the quo- tidian and the double tertian types, which may be said to include : all their malignant forms and varieties, whether it be their original i tyPe) or whether they may have changed to one or the other of those types during their progress. It will not be amiss to include, with these the double quotidian; but this type is of comparatively :' rare occurrence, except in the diseases of children; and so far as any modification of treatment would depend upon the distinction, 392 Holt's Letters upon General Pathology. [Jutyf whether in a child or an adult, it would matter little whether it be classed as intermittent or remittent. When the intervals extend beyond* the types, the similitude between intermittent and remit- tent fever in a great measure ceases, and I doubt very much whether there is such a thing as a remittent fever of the tertian, much less of the quartan types ; and when these fevers, with long intervals, assume a malignant cast, (which is not often the case,) it is generally the result of individual predispositions, or of some controlling epidemic influence. Now, with respect to the type of these diseases, and the periodic character of all malarial diseases, it is necessary that I should say something, for the reason, that a knowledge of this peculiar phe- nomenon, not only enables us to understand them better in their true, essential character, as well as in their modified and complex forms, and also the source from which they spring, but also enables us to treat them with a certainty of success which could never be attained without such knowledge ; and I feel very certain that success often depends as much upon the timely application or ad- ministration of a remedy, as it does upon the nature and the thera- peutic property of the remedy itself. Hence I would insist that no practitioner in the South, however skilled he may be in the treatment of malarial diseases, can be too well versed in a know- ledge of the laws of their periodicity, which is the key to success, whether in the treatment of the milder and more simple, or in warding off and combating the more malignant and complex grades. In noticing this phenomenon of periodicity, I shall not presume to attempt, what so many wiser heads have failed in, to give a satisfactory explanation of its cause. Having, however, an idea with regard to its nature, it cannot be regarded an act of temerity in me to express it, which is this: that while the general system is known to be governed by the laws of periodicity in the perform- ance of many of the vital functions, as observed in gestation, men- struation, &c, which periods arc but the multiplication of a certain number of shorter, or diurnal periods, the brain, and animal portion of the nervous system, under the influence of diurnal revolutions, and of sleeping and waking, is seen to alternate be- tween a state of activity and repose, whereby it becomes reinvig- orated while the organic portion of the nervous system, though often excited, never acquires less than a passive state of activity, 1856.] Holt's Letters upon General Pathology. 393 -.as the laws of vital action forbid a state of perfect rest. Hence it is, that in non-malarial regions all diseases may show certain signs of periodicity, during the twenty-four hours of a paroxysm, mark- ed usually by an increase of excitement, while in malarial regions the periodicity will be marked by the signs of depression : hence, I infer that the cause of such periodicity as belongs to non-malarial diseases, should be ascribed, in most part, to the influence of diur- nal revolution, with, perhaps, some degree of reinvigoration of the animal nervous system, while the periodicity of malarial diseases should be ascribed to the depressing influences of malaria upon the organic nervous system, and the influence of diurnal revolutions combined. Now, if this explanation is not more satisfactory than the hundred others which have been given, it is at least in con- formity with what I have said on a former occasion, namely, that malaria, the supposed product of heat, moisture, and decomposing vegetable matter, acted chiefly upon the oaganie nervous system, jprodueisag diseases whose most prominent characteristic is periodi- city; and that the non-malarial, or those which were produced from epidemic influences, animal effluvia, and other causes, which act manifestly with more force upon the brain and animal nervous system, exhibited none of the signs of periodicity, unless they were combined with strong malarial influences, under which they sometimes lose their essential suigeneric character. To pursue the subject of the particular types of intermittent and remittent fevers, of which there are three single, three double, and a number of complex, which are not necessary for me here to enumerate. The single types are the quotidian, the tertian, and the quartan having, respectively, intervals of twenty- four, forty- eight, and seventy-two hours, from the commencement of one attack or paroxysm, to the commencement of another, according to the type; the quotidian occurring every day, about the same hour; the tertian occurring every other day, about the same hour, and the quartan occurring every fourth day, or at intervals of every seventy-two hours. The double quotidian has two par- oxysms in twenty-four hours, occurring each day abou|; the same hour. The double tertian has a paroxysm each day, occurring one day in the morning, and the next day in the evening, and so on, the paroxysms on alternate days corresponding with each other. The double quartan has a paroxysm on two successive days, none on the the third, and one again on the fourth, and so 394 Holt's Letters upon General Pathology. [July? on, every seventy-two hoars. A feature in these types worthy of note, is, that the longer the interval, the shorter is the paroxysm; and, inversely, the shorter the interval, the longer the paroxysm. Thus, the paroxysm of a quotidian will often occupy eighteen out of the twenty-four hours a tertian will occupy from ten to twelve, and a quartan from six to eight hours. Another feature worthy of observation, is, that each paroxysm, of whatever type it may be, if intermittent, will terminate within twenty-four hours; but if remittent, it may go on to twenty-four, thirty-six, forty-eight, sixty, and seventy-two hours, corresponding in its exacerbations and remissions to its intermittent prototype. As these types, however, are subject to change, and are more often obscured by extrinsic or adventitious influences, without being really changed, and as it is sometimes a matter of the utmost importance to obtain aud pre- serve a knowledge of the true type, much advantage may be gained by ascertaining the time of day when the attack commenced, and watching carefully the duration of the first paroxysm. If, therefore, an attack commences in the morning, and continues for fifteen or eighteen hours, we may safely conclude that it is a quo- tidian; if the parox}'sm commences in the morning or forenoon, and lasts ten or twelve hours, we may infer that it is a tertian, or a double tertian ; and if it occurs in the evening, and lasts about the same time, say eight, ten, or twelve hours, we may rely very confidently on its being a double tertian ; and if it occurs in the forenoon, and continues only for six or eight hours, we may as certainly depend upon its being a quartan, or other type of long interval. With regard to the triple, quadruple, and other complex types, not being familiar with them in practice, I know of no gen- eral rules by which they could be recognized, when masked or obscured. A knowledge, however, of the prevailing type, will aid in arriving at a knowledge of the true type of these obscured or masked intermittents. A curious, and not unimportant fact connected with intermit- and remittent fevers, is, that an attack seldom or never comes on during the hours of the night. This fact may serve to show that the organic nervous system, which is always more active and busy, in proportion, while the animal nervous system is at rest, is better able to resist the depressing influences of malaria at such time, but succumbs more readily to its influence when the animal pow- ers resume their accustomed sway. It may serve to show, also, 1856.] Holt's Letters upon General Pathology. 395 that the animal powers are less impressible by the influences of malaria, otherwise they would fall an easy prey to its influence during the hours of their repose, but such, we see, is not the case ; and we may safely infer that fevers, which have their accession during the hours of the night, are not of malarial origin. But how stands the case, with respect to the action of epidemic influences, animal effluvia, and such other causes as are known to act more de- cidedly upon the animal nervous system, and whose power it may be able to resist, while in a state of activity, during the day time, but to which it falls an easy prey at night, when in a state of rest. Take yellow fever, for example, which we suppose to be the pro- duct of a specific animal effluvium, and we see that the attacks of a large proportion, if not a majority of those cases which are more clearly defined in their essential typical or typhoid character, take place during the hours of night, while those which occur during the day, often afford unequivocal evidences of a malarial influence from their manifest tendency to assume the character of periodici- ty. These facts, if such they are admitted to be, lend support to my ideas with regard to the periodicity of disease, and leads us to the inference, at least, that malaria, though it may modify, has no positive agency in the production of yellow fever, in its essential typical or typhoid character. But, finding myself digressing, and handling a subject which perhaps should have been reserved for a more appropriate occa- sion, I will conclude my remarks upon the periodicity of disease, by relating the particulars of a case, which will tell, in stronger terms than words could express it, the importance and necessity of a proper knowledge of the types of periodic diseases, and the danger which often results from a want of such knowledge, as oc- curred in the case which I am about to relate. Miss , a young lady about 17 or 18 years of age, of prepossessing manners, possessed of intelligence and a remarkably fine flow of spirits, and in the full enjoyment of health, beauty and loveliness, was attacked on the 10th January last with a slight chill and fever, for which her parents gave her a little blue mass and quinine, and she had no return of it. But from that day, to the time when I was called to see her, which was on the 25th of February, her health gradually, but very perceptibly, declined ; the rose left her cheeks and the coral her lips, and she now presented a perfect specimen of anaemia, or leucocythemia, having rather the appearance of bleached wax, than of flesh and blood. At this time I obtained the parti-. cularsofher first attack, up to which time she had been perfectly healthy, without disturbance or interruption in any important function, as might 396 Holt's Letters upon Gerieral Pathology. [July, have been presumed from her condition ; but after this time, her strength gradually declined, and though she continued her ordinary pursuits, slight exercise produced fatigue ; her appetite became impaired, and her sleep less quiet and refreshing. She suffered no pain or soreness, but at times felt an uneasiness at the stomach, and sometimes an inclination to vomit. The tongue was clean and natural in appearance; the bowels were consti- pated; the urine limpid and abundant; the catamenia regular, but pale and almost colorless ; the liver and spleen free from soreness or enlarge- ment ; the spirits cheerful, the mind sprightly, and the pulse generally regular and natural, though rather feeble. Upon the best view which I was able to take of the case, finding no par- ticular organ to whose account I could lay the charge of the mischief, though I suspected it to be the result of the cause which produced the chill in the first instance, there being no discoverable signs of periodicity about the case, and not suspecting the cause to be still at work, I directed my treatment to a restoration of the tone and vigour of the general nervous system, by enriching the blood, and restoring its healthy constitution at the same time. So, after the action of pills of blue mass and colocynth, to relieve the constipation, (which they failed to do,) I put her upon a gener- ous diet, with porter, and moderate quantities of Champagne wine, or brandy, and pills of quinine, ext. of gent, and iron. Under this treatment, which seemed to me to be rational, she perceptibly grew worse from day today, until Sunday, the 2d of March, when she took her bed for the first time, except for the purposes of rest. At this time the symptoms became more violent ; the stomach was irritable, with frequent vomiting of thin, bilious matter, with flatulence, and pain at the pit of the stomach; consti- pation continues, with some pain in the course of the colon; considerable thirst; some slight evidences of nervous disorder, or rather of desponden- cy, and the pulse frequent and somewhat irritable. These symptoms con- tinued to recur, with more or less violence, for which I prescribed various remedies, and devices such as, sinapisms and enemata, and salts, senna and manna, to act on the bowels ; lime water, soda, creasote, morphine, &c, for the relief of the stomach, pains and flatulence; but all, with little or no good effect, with the exception, perhaps, of the morphine. On the 4th, finding her condition worse, with an evident downward ten- dency, and the inefficiency of the remedies which I had used to restrain the vomiting, or move the bowels, which had not been done for several days, notwithstanding her enfeebled and ansematous condition, I determined to resort to calomel, and accordingly gave her 30 grains, which had the effect of stopping the vomiting, and producing two evacuations from the bowels. But, notwithstanding the favorable action of the calomel, on the morning of the 5th she had a chill, which so completely prostrated her, that she could not be moved without endangering her from syncope, and I feel confident she could not have survived another ; but this one, dan- gerous as it was, proved to be the means of her safety, for I saw at once, from what had transpired in the last few days, that she was laboring under the baneful influence of a double tertian intermittent, a paroxysm of which could be distinctly traced from Sunday evening, up to Wednesday morn- ing; and upon her own review of the case, she could confidently refer to her better and worse feelings, in the forenoon and afternoon, of alternate days, from the very beginning. 1856.] Holt's Letters upon General Pathology. 397 With the new lights now before me, I proceeded accordingly. I had 30 grs. of calomel and 30 grs. of quinine made into twelve pills, and di- rected one pill to be given every three hours ; and in addition, as soon as the violence of the paroxysm had passed, I ordered some chicken soup, which she relished, and retained well. At night I gave | gr. morphine, and 10 grs. quinine. On the morning of the 6th, her condition was improved ; but as the battle was to be fought in the evening, by way of preparing her for it, I ordered 5 grs. quinine to be given at 6 o'clock, 5 grs. at 9 o'clock, and 5 grs. at 12 M. At 2 o'clock P. M., I had her enveloped in blankets, and surrounded completely with bottles of hot water, and so kept her until about 5 o'clock, when she was completely drenched with perspiration ; I then had them gradually removed, her clothing changed ; ordered her a cup of tea, and a gr. of morphine, and directed 5 grs. quinine to be given at 12 o'clock, 5 grs. at 3 o'clock, and 5 grs. at 6 o'clock, and the bottles to be re-applied, as before. By 8 o'clock, on the 7th, she was in a full per- spiration ; at 9 o'clock, I commenced having the bottles removed, with the extra covering; by 12 o'clock, she was comfortable; and from this time, when I considered her danger and disease, alike^ at an end, she continued to improve. Having taken all the calomel and quinine pills, and had two or three proper evacuations, there was no further need for their continu- ance. I apprehended that, in her anaemic state salivation might take place, but there were no signs of such an occurrence. As a measure of safety, I di- rected 10 grs. of quinine, to be given on the septenary days, or at night, preceding the morning paroxysm of the septenary days, until the fourth, or twenty-eighth days had passed. I also put her again upon the course of medicine and regimen which I had at first chalked out, but with better success, as under it she has gone on steadily to improve, and she now enjoys rather more than her usual health, as there is somewhat more of her to enjoy it, having gained considerable upon her former weight, and lost nothing in other respects, being one of the most lovely girls that Mont- gomery can boast. I have related this case, with the hope that it may be the means of helping some junior, or even senior brother, who may become similarly involved, out of the dilemma and state of perplexity in which I found myself involved in this case, for I do not hold to the truth of the aphorism, that "all is well which ends well." The subject of " Intermittent and Eemittent fevers," will be continued in my next. As ever, yours, Saml. D. Holt. 398 Billingslea's Appeal. [July, ARTICLE XIX. An Appeal on behalf of Southern Medical Colleges and Southern Medical Literature. By Jas. C. BlLLINGSLEA, M. D., of Foster's, Tuscaloosa Co., Alabama. Most , persons might think that this communication should be made through the medium of a popular newspaper, but as phy- sicians are more nearly interested, than any others, on this import- ant subject, I have chosen your journal, through which I desire to call the attention of southern physicians to the necessity of patronizing our southern institutions, and our southern medical journals. The necessity of this patronage is demanded, not only by the political aspects, which are now presented in these United States, but also by humanity. First, let every southern ph}^sician ask himself, how much of patronage is bestowed on our southern literature by our northern brethren; and also, what views they as Northern men entertain towards us as Southerners. There is scarcely any article emanat- ing from a southern pen, which is republished in the Norih, it matters not how much of merit it may possess. But on the other hand, see how they are treated by us in return. Our south- ern journals republish every thing, which they think would ad- vance the science of medicine, without any regard to the geogra- phical location of the author. All they seem to care for, is our patronage, and don't extend to us the same in return. If we were so poor in medical literature, and so wanting in great minds, whose thoughts are reflected by their writings if we were destitute of these, and of colleges wherein our young men could be trained, and instructed iu all that would make them use- ful in life, then I would say, of course patronize northern institu- tions and journals, for it is the best you can do. But on the contrary, we have medical colleges, which in point of mental endowments can compare favorably with any in the world. We also have medical journals, which, to the southern physician, are always filled with matter of interest and profit. And as our northern brethren seem to ignore everything southern, simply because we are slaveholders: and as scientific men North, can so far forget their duty, as to lend their aid substantial aid and their voices, to the getting up and sustaining of colonization 1856.] Billingslea's Appeal. 399 societies, for the avowed purpose of prohibiting the extension of our domestic institutions, we, as southern physicians, should with- hold our patronage (which is not small), both from their colleges and their literature. They would then feel, very sensibly, the extent of our influence. For hundreds of our young men are sent North, annually, to be taught in their colleges, who spend their money most lavishly among them, and return to hear themselves and their institutions traduced, and to see their literature slighted. But, as I said at the outset, there is another weighty (and I may say more important) reason, aside from politics. I said humanity demanded the support of home institutions. (Now I want none of my professional brethren, who claim anorthern college as their alma mater, to take offence at what I shall say.) I say, humanity demands it for the simple reason, that those young men who ex- pect to practice South, with any degree of success, should be taught in our Southern colleges; because our practice here, in the most of out malignant diseases, is entirely different from that taught in northern institutions, and by northern writers. I con- stantly meet with physicians of eminence, who graduated North, who have long since abandoned the most of the fundamental principles of practice, as taught them in the lecture roomr because they have learned, by experience by observation at the bedside, and by communing with southern writers, that they were unsuit- ed to the diseases as they met them in this climate. It is in vain, to appeal to the young men, or their parents, not to send them North to study medicine, for they are almost invariably governed in their choice of a school by their preceptors. And it is a la- mentable fact, that these same preceptors generally advise them to attend lectures where they happened to graduate; and so this institution is handed clown to the student's student, and so on, as a sort of heir-loom. At the same time, these physicians, not want- ing in medical attainments or practical skill, which they have acquired by long study of the diseases common to our climate, at the bedside, will acknowledge, when you appeal to their candor and to their patriotism, that we have equally as good schools (or even better), for conveying practical information, as they have North. Some of these brethren will, however, only admit, that as our diseases are so different from those at the North, and requiring such different treatment from those, that the student at least should attend one course of lectures South. NowT this admission, of itself, 400 Billingslea's Appeal [July, should be enough to convince the student, that if one course South is important, both are more so. For why send your student North, when he will have to commence the study of practice when he gets back, after finding out, by experience, (bitter and morti- fying as it sometimes is,) that it will not do to put in practice the theories taught him in his alma mater? You are doing him a great piece of injustice when you do so. It will be borne in mind that a large number of our physicians live in the country, or in country towns, in the midst of large plantations, and where, of course, the slave population preponderates largely ; and that owing to the exposure of this class of people to the vicissitudes of the weather, the southern physician is called more frequently to visit negroes than whites. And as it has been contended, most ably, by Dr. Cartwright, and others, (and not without reason,) that the distinctive peculiarities of the negro race call for a different mode of treatment than that best adapted to the whites, I would ask, where are our students to learn this peculiar practice ? Cer- tainly not in northern institutions! certainly not from northern journals! As to the study of the rudiments of the science of medi- cine, (Anatomy, Physiology, and Chemistry,) they can be learned North, as well as South, for they are the same everywhere. Again, there is no material difference in the practice of Surgery or Mid- wifery, North or South ; but the great difference is in the treatment of our malignant diseases, which, when treated even on the most approved plans, kill thousands; and this approximation to the suc- cessful can only be attained readily by attending southern lectures, and reading southern authors. Then, where is the necessity of deserting our home institutions, or our home literature, and swell- ing the catalogues of those northern schools with the names of your pupils, and the pockets of those who conduct them with their money, when you have medical colleges at your door, where Anatomy, Physiology, Chemistry, Surgery, Midwifery and Thera- peutics are taught as well, and where practice is taught better? For a man had better never be taught than to be taught wrong. To the southern student we would say, you can have the satis- faction of spending your means in supporting southern institutions, *and southern talent, and at the same time get value received. We do not pretend to say that the fault is in northern Professors, for teaching you such practice, as not adapted to this climate; for they teach such theories as they think best to be practiced 1856.] Billingslea's Appeal. 401 in their climate, and the fault lies in you for going there to be taught. To prove what I say in regard to our southern institutions being equal to any as to facilities, I have only to point you to the alumni of the Louisville, Charleston, Augusta, Nashville, Memphis, New- Orleans, and of other colleges, who are now enjoying in our citiesr in our towns, and throughout the country, most enviable reputa- tions as practitioners, as writers, and as lecturers. The South should awake to the necessity of favoring home institutions, which are springing up so rapidly, and are generally self-supporting* The founders of, and instructors in, these institutions call loudly for your support. Georgia has now one old and well-established medical college, and several others in their infancy; and though it has been said that the medical college located at Augusta was defunct, its list of graduates for the present year numbers more than we have ever seen before ; and I rejoice to learn bat it was never in a more flourishing condition, and never better prepared to impart a thorough and practical knowledge of the science of medi- cine than at present. This institution still lives to see her gradu- ates occupying the Professor's chair in other colleges. Charleston, Nashville, Louisville, and New Orleans, all offer rare inducements to the southern student. New Orleans excels any in the U. States, and I might say, equals any in the world, in hospital and clinique facilities. There the Charity hospital is open at all hour&during the' whole course of lectures, where the student may see hundreds of patients daily, suffering from all the ills that u flesh is- heir to." He can see the practice of the professor or physician whose ward he may visit : he can take notes watch the patient see the re- sult; and if the disease proves fatal, he can follow the body to the dead house, with scalpel in hand, and there examine for himself to see if the diagnosis was correct. In this respect, New Orleans outstrips all her sisters. But in the majority of our southern col- leges, the instructions are very thorough, and a young man even of medium talent and application will most always come out of them a good practitioner. As to Literature,, we have most excellent periodicals, conducted by the most accomplished and scientific members of the profession, and contributed to by the best southern talent, which will com- pare favorably with any in the United States, both in style and matter. Indeed, each number of them is full of matter of vital 402 Remedial and Anaesthetic uses of Intense Cold. [July, interest to the southern practitioner. There is the New Orleans Medical and Surgical Journal, published bi-monthly, and edited by B. Dowler, M. D., which is always full of interesting and sci- entific matter, and each number is worth the subscription price for one year. There is the Southern Medical and Surgical Journal, published at Augusta, Ga, and edited by Prof. Dugas and H. Ros- signol, M. D., which is one of the most interesting monthlies extant, supported mostly by southern patronage. There are also the Charleston, Atlanta, Memphis, and other southern journals, which deserve greater credit and better patronage than they receive. So we can't say we have no literature worth supporting. This article is already more length}' than at first designed. In conclusion, let me say to my brethren, let us not patronize those northern schools and northern works, simply because "distance lends enchantment" to them, to the neglect of our own. Besides medical colleges and medical literature, the arguments here used will apply equally to literary institutions, periodicals and journals, which are also largely patronized by the South ; but I do not pro- pose to notice these more fully, but will leave it to others. My object is to get the profession to change their misguided system of patronizing /o/'eu^i establishments, when we have as good, yea, better at home. My task is done, but imperfectly so ; but if I can,: by these few desultory thoughts, hurriedly thrown together, set the profession to thinking seriously upon this subject, and per- haps elicit something on my side from more able pens, then we may look soon for a reform, and then my object will be achieved. In this, I disclaim all intention of wounding the feelings of any one, or of drawing any invidious distinctions between southern institutions or journals. All I want, is to impress upon my south- ern brethren the necessity of educating their students South, if they intend practicing their profession South. But if they design loca~ ting North, I also say send them North to study. Remedial and Anxst/ietic uses of Intense Cold. By James Arnott, M. D., London. Although the subjects of the remedial efficacy of congelation and local anaesthesia from cold have been for some years before the public, they are as yet but little understood and appreciated. This has resulted partly from their having been imperfectly ex- 1856.] JRemedial and Anaesthetic uses of Intense Cold. 403 plained, in consequence of the publications respecting them being severally incomplete, and partly from the strength of the preju- dice against extreme cold. Dr. Rowley, Avho in his attack on cowpox, declared that the accounts which he had heard of the ter* rible effects of communicating the " cruel and beastly" disease Were enough to " freeze the soul," was probably not more horror- striken than some have been by the proposal to freeze the body ; and the introducer of vaccination was hardly more abused than the proposer of congelation has been. It is in the hope that this prejudice may be thereby abated, and the subject rendered better understood, that the following brief statement is published. Even in France, where both the remedial and anaesthetic uses of in- tense cold have been turned to account for some time by M. Vel- peau and other leading practitioners, there is still much doubt about the best mode of applying the agent. In a paper in the Bulletin de Therapeutique of the 15th ultimo, M. Richet, Surgeon of the Hospital Saint Antoine, in Paris, reports thirteen operations in which local anaesthesia had been produced by the very imper* feet means of the quick evaporation of ether. As no remedy has been longer in use, and few are more valued than the local application of moderate degrees of cold, or a tem- perature ranging from that of dissolving ice to about 70 of Fah- renheit, it may at first appear singular that a greater or more pow erful remedial effect should not have been sought by increasing the dose of the agent, or employing a lower temperature, in the same manner as we have sought and found much greater remedial benefit in many cases by using mercury, antimony, quinine, and other drugs, in larger doses than had been customary. The reason is, that medical men were under a most erroneous impress sion respecting the effects of very low temperatures on the body. Because a temperature of zero stops the circulation, and because the vitality of a part has been lost by its long -continued congelation, whether caused by exposure to severe cold in winter or by the in- cautious use of ice in hernia and other diseases, it was hastily and erroneously inferred that there was danger of loss of vitality from short continued congelation. The mistake would not be greater to infer from the fact, because a long-continued stoppage of the cir- culation through a limb from an improper application of a band- age has occasioned gangrener that it would be dangerous to use the tourniquet in operations. The correction of this error will be deemed of no little import- ance when it is considered that in short-continued congelation, judiciously applied, we have an unfailing means of immediately arresting inflammation wherever it can be reached by the remedy ; of not only giving speedy relief from pain in many diseases, but in consequence of the organic changes produced by it, of obviating the return of pain ; and in malignant disease of producing an amount of benefit much exceeding that yet accomplished by other N. S. VOL. III. NO. VII. 26 40-i Remedial and Anaesthetic uses of Intense Cold. [July, means. Although much inferior in importance to these results, it is jet another great benefit conferred by intense cold, that the pain which would be otherwise caused by the greater number of surgical operations can be prevented by it with perfect safety ; and not only can pain be prevented, but the inflammation proceeding from the surgeon's knife, that so often proves fatal, may also be obviated by the same means, and with almost equal certainty. It will be proper to consider the remedial and anaesthetic effects of intense cold separately; but before doing so, it is necessary to men- tion how this degree of cold is produced and applied, as well as to attempt an explanation of its mode of operation. That degree of cold may be called intense which immediately benumbs the part to which it is applied, speedily stops the circu- lation through it, and congeals the adipose matter. 1 have usual- ly produced these effects by placing, what are termed frigorific mixtures either immediately in contact with the skin or mucous membrane, by means of a net of thin gauze containing them, or by allowing them to act through thin bladders or metallic vessels of appropriate form ; but there are various other ways of effecting the same object, some of which are preferable fbrcertain purposes. Substances passing rapidly from the solid to the fluid, or from the fluid, to the aeriform state, strongly abstract caloric from other bodies in contact with them ; and substances, either solid, fluid, or aariform, already sufficiently cooled by artificial means, may be placed in contact with the part; the first, as solid metallic balls of appropriate shape ; the latter two, when forming strong currents. When cold is produced by the common frigorific mixture of ice and salt, aud applied by means of a gauze bag or net, the follow- ing is a convenient mode of proceeding : If the congelation is not to be extensive or long-continued, a piece of ice of the size of a lara;e orange will be sufficient. This is well pounded in a coarse cloth or bag, and the powder being placed upon a large sheet of paper, is thoroughly mixed by means of a paper-folder, with about half its weight of common salt. The mixture is then put into a net of about four inches in diameter, and as soon as it begins to dis- solve it is ready to be applied. The net is not kept motionless on the part, but is frequently raised in order that fresh particles of the mixture may be brought in contact with the skin ; and the water that escapes from it may be absorbed by a sponge, or al- lowed to fall into a basin placed underneath. If the surface to be acted upon is of small extent, a very thin and large copper spoon containing the mixture, or a solid brass ball of about a pound weight which has been immersed in ice and salt, will often an- swer, and be a neater mode than the net. The moment a gauze net or a thin metallic vessel containing ice and salt is applied to the skin it is benumbed. There is hardly a sensation of cold produced, and no tingling or smarting. If the contact of the frigorific be continued a few seconds longer, the sur- 1856.] Remedial and Anaesthetic uses of Intense Cold. 405 face becomes suddenly white in consequence, doubtless of the arrest of the circulation ; and this change of color is attended with a slight smarting like that produced by mustard. There is now complete anesthesia, which, if the frigorific were removed, would remain complete for several minutes. But if the frigorific be allowed to act, another change is produced the adipose matter under the skin is congealed, and the part becomes hard as well as white. The depth to which the benumbing influence of cold will extend depends upon a variety of circumstances, as the degree of cold, the duration of the application, the vascularity of the part, whether pressure is used or the circulation is suspended, &c. After the usual application of cold for anaesthesia, the circulation soon returns to the part, and the skin assumes a red color, which lasts for several hours. If the congelation has been considerable, there is now some smarting felt, unless the natural heat be more gradually restored by pouring cold water on the part, or by placing on it a little pounded ice, or a bladder containing iced wa- ter. If the application has not exceeded the first stages, there is no smarting, and no necessity, therefore, for such precaution. The redness produced does not, as might at first sight be sup- posed, indicate an inflammatory condition, but the very reverse. The tonicity of the small arteries appears to be lessened or suspend- ed for a time, and, instead of being inflamed, the part is render- ed unsusceptible of inflammation. Parts cut after congelation healed by adhesion or the first intention more quickly than they otherwise would ; and, as has already been said, we possess in this expedient a certain and prompt remedy for every inflammation accessible to its complete influence. I. Remedial Uses of Intense Cold. The remedial qualities of in- tense cold may be described as antiphlogistic, anodyne or sedative and specific ; and it is useful in the diseases for which other reme- dies possessing these qualities have been employed, viz : in inflam- matory, painful or irritative, and malignant diseases. The circumstances which limits its application in these is the impossi- | bility of extending its influence beyond a certain extent or depth, although it is certain, from its effects in deep-seated disease, that this influence, whether it be direct or sympathetic, is more exten- I sive than would at first be supposed. It may be laid down as a rule that in every case in which the local application of moderate ' degrees of cold has been found of service, the use of well regulated congelation would prove much more useful ; and in those diseases of similar character, in which moderate cold has not been employ - ed from the idea that their seat was beyond its reach, congelation might be tried with reasonable hope of success. Intense could has this immense advantage over other powerful remedies of the same class, that it may be used with impunity if it does no good it will 3j do no harm. Who will venture to affirm this of bleeding, mercu- | ry, antimony, opium, chloroform, arsenic ? Neither in my own 406 Remedial and Anaesthetic uses of Intense Cold. [July, practice nor (as far as I can learn) in the practice of others has there been any untoward result from the use of congelation. Its action being confined to the diseased part, and not uselessly ex- pended on the rest of the system, affords the explanation. Other topical remedies have much the same character for safety, but what other expedient of this class has a tenth part of the power of intense cold? Instead of enumerating the diseases in which this agent has been employed according to the above classification, I shall mention, first, those in which it has been more or less successful; and, second,, those in which it might, reasoning from analogy, be tried with hope of advantage. In administering intense cold as a remedyr the common or a more powerful frigorific has been generally ap- plied directly to the part, o"r with the intervention only of the thin gauze containing it ; and the duration of the congelation has been from one to ten minutes. In the spring of the year 1850, I requested the house surgeon of the Brighton dispensary to apprise me of every case f acute lumbago that came under his notice, and in all of these, amounting to nine, I employed congelation with perfect and permanent suc- cess. The net containing the ice and salt was passed to and fro for five rrhnutesr over a surface, of about 8 by -I inches, the skin being blanched during the whole of this period. In only two or three cases was it necessary to apply the remedy twice. Several of the patients rose immediately afterwards from their bedsr to which they had long been confined. In most cases of chronic rheumatism the remedy has been equally successful ; and this, on account of the frequency of the disease,, is one of its most valuable applications. Sciatica has generally yielded to it, but by no means so easily. In acute rheumatism the local inflammation of the joints is, by this means,, invariably and completely relieved, and that portion of the accompanying fever thence arising is consequently removed. The disease,, thus treated, will run a painless course of about a week's duration. In no case, of about a dozen in which congela- tion was almost exclusively employed, was these extension of in- flammation to the heart ; and I am persuaded that the best plan of preventing this is to subdue the inflammation of the joints from which it generally originates. I did not use the remedy in cases where the heart was already affected, though I have since learned that congelation is employed in the hospital at Vienna (where it was introduced some years ago by Dr. Waters of Chester,) as an application to the chest of rheumatic carditis. That this affection of the heart would occasionally occur during the treatment of acute rheumatism by congelation is very probable, because it often arises, as the same affection of the joint does, from a morbid con- dition of the blood, over which the remedy can have no control ; and that such an occurrence, in the present feeling on the subject, would be called metastasis from cold is very certain ; but I am 1856.] Remedial and Anaisthetic uses of Intense Cold. 407 convinced that it will yet be acknowledged, though probably after many years, that this affection would be much decreased in fre- quency by the adoption of any means capable of quickly subduing the accompanying arthritis. When it is considered what an immense amount of eventual mischief arises from the organic disease of the heart that occurs under the common modes of treat- ing rheumatic fever, to say nothing of the patient's present sufferings and tedious confinement, it is to be lamented that pre- judice should oppose any measure of greater promise. In the rheumatic gout the relief has been as marked from congelation as in lumbago. In ordinary inflammation of the joints it has also been exceedingly useful. Ophthalmia has been immediately cured by keeping the frigorinc in contact with the gently-closed eyelid for three or four minutes. Glandular inflammation in the neck and groin yield to a high degree of cold with equal facility. I have been told that in orchitis its beneficial operation is imme- diate ; and I have little doubt that, from its closeness to the surface, the urethral iuflammation causing orchitis would be quickly suppressed. Congelation has often at once converted an irritable into a healing ulcer, though sometimes the patient has complained of the pain of the operation. It is probable that had the salt in the mixture been prevented from coming in contact with the irritable surface, this would have been in a great degree prevented. Certain acute inflammatory affections of the skin are equally under its influence, as erysipelas, eczema, impetigo. It has not often failed in prurigo, but in only one case of psoriasis has it appeared to be of service. Painful nodes are at once re- lieved by this means and the inflammation subdued. I have only used congelation in carbuncle as an anaesthetic previously to cutting it, but it is probable (judging from its effects in severe boils,) that the incision might have been dispensed with. It has been mentioned to me that severe cold has been employed with | . the same view in whitlow, of which it is certainly a sufficient cure. The inflammation following sprains, contusions, and other similar injuries is perfectly under its influence ; and the same may be said of burns. In one of my publications on the subject I have related the excellent and speedy effects of congelation in a case of meningitis, and also in a case of peritonitis. I have not had the opportunity of trying it in other affections of this description. Headache of various kinds has at once yielded to the application, for a minute, of a frigorific over the painful part; and in neural- gia affecting the side it has generally proved efficacious. In neu- ralgia attacking the face and other parts it has often succeeded and often failed. If the seat of the disease be deep in the brain, little can be hoped from this remedy, although there are a few obstinate cases of neuralgia in which it does not deserve a trial. Toothache is generally at once relieved by it if properly applied ; and there is no remedy for the painful affection of the mouth caused by 408 Remedial and Ancesthetic uses of Intense Cold. [July, mercury comparable to congelation. A spoonful of dissolving ice and salt is repeatedly put into the mouth, until it becomes benumb- ed. In one case of severe scurvy of the gums, where I feared a loss of the teeth, extensive congelation of the gums immediately arrested the disease. In many of the diseases just enumerated the promptness of the cure is as remarkable as its certainty. In military and hospital practice this advantage is very prominent. In cancer the effects of congelation have been various. From my own experience and that of others, I think that in its early stages, and when from its size the tumor can be thoroughly brought under the influence of the remed}T, it will be cured by it. In all stages the progress of cancer will be arrested or retarded, and the pain accompanying it assuaged. The difficulty in ad- vanced cases is to cause a sufficient degree of cold to pervade the tumor. The French translator of a recent paper of mine on the subject, (l'Union Medicale for May,) thinks that the frequent occurrence of cysts in cancerous tumors may facilitate this. But if layer after layer is acted upon it may be enough. In cancer of the womb the frigorific is applied by means of a speculum, and one stronger than ice and common salt will generally be required. The opinions of Dr. Hughes Bennett respecting the nature of can- cer have much influenced the mode in which I have used conge- lation in its treatment, M. Velpeau states, in his recent elaborate work on the diseases of the breast, that he has employed long- continued congelation as a substitute for caustic in cancer ; but of this effect of the agent I have no knowledge. There are other diseases in the treatment of which severe cold would probably be very useful. It might be applied with such a hope to the spine in tetanus, or to the scalp in certain varieties of mania. After gunshot and other severe wounds it would prove a powerful preventive and cure of inflammation. Even in pleuritis and other deep-seated inflammation of the chest, as well as in va- rious uterine affections, beneiit might rationally be expected from it. In two cases of epidemic cholera I administered a succession of draughts of a temperature of about 25 of Fahrenheit, with ap- parently excellent effect; and I cannot doubt that the application of cold to the interior of the stomach which, as appears by the recently published report of the College of Physicians, is the only treatment of cholera which has been unanimously approved of has not been carried far enough. If the irritation of the mucous membrane be considerable, (as it must be to account for the ex- hausting and fatal discharges) the temperature of ice merely is not sufficient to subdue it. II. Ancesthetic Uses of Severe Cold. As patients now expect to have ever}7 operation performed without pain, both they and their surgeons will be glad to have an easy and agreeable meaDs of accomplishing this, in all the common operations, unaccompa- 1856.] On Laceration of the Perinmum. 409 mied with the dangers of chloroform. What can be less trouble- some in opening an abscess, for instance, or making a cutaneous incision, than touching the skin for a moment with a small brass ball that has been immersed for a few minutes in ice and salt, or .a thin spoon filled with such a mixture? It is true that in deep- -seated operations such a means can only suspend the sensibility of the skin ; but it is the incision of the skin which constitutes the most painful part of every operation, and if this be benumbed, a .smaller, and consequently less hazardous, dose of ether or chloro- form than has usually been administered would be enough to remove the sensibility of the other tissues. These deep-seated operations, however, constitute a small minority, and if the list of jrecorded deaths from etherization be referred to (now amounting to more than fifty) it will be found that in three-fourths of the number complete anaesthesia might have been produced with per- fect safety by cold. M. Velpeau, who introduced anaesthesia from cold into France, has, in a lecture on the subject recently reported in the Gazette des Hopitaux, expressed the doubt whether in some operations the hardening of the tissues by this means might not prevent their being cut with ease. I have not found this to be the case, nor does he himself allude to this supposed disadvantage, when, in his work on diseases of the breast, he mentions that he has excised tumors after anaesthesia from cold. The fear of reaction I have already adverted to in the prefatory observations. Instead of reaction being produced, the anaesthetic | is a preventive of inflammation from the wound ; and were it 1 used for this purpose alone it would be invaluable. Local anaesthesia from cold may, as has already been observed, I be produced in a great variety of ways. Some of these may be I applied so as to cause immediate congelation, but it is questiona- i ble whether the anaesthesia is not more extensive and lasting 1 when more slowly caused. Such details, however, are unsuited ; to the general view of the subject intended by the present com- i munication, which, I fear, has already exceeded its proper i bounds. [Edinburgh Monthly Jour, of Med. Science. On Laceration of .the Perinaium in Primiparce. By T. Snow Beck, M. D. j I have before me the notes of one hundred and twelve cases of I primiparae, observed within the last five years, of which seventy-five, or two-thirds, had laceration of the perinaeum through the whole extent ; while in thirty-seven, or just one-third, no laceration took place. Unless this result had been fortified by notes made as soon [ as I returned home, and bv the examination of the parts by the eye, as well as by the touch, I might have considered that some error i had crept into these observations ; but, with the precautions taken, 410 On Laceration of the Perinceum. [July, I feel assured of the accuracy of the result, however contrary it may be to previous opinions. The laceration apparently took place just as the head was ex- truded. The perinaeum was perfect immediately before the head was expelled, and was lacerated after the birth of the child. In a few instances, by keeping the finger on the centre of the perinaeum, it was felt to give way, to allow the head to pass ; but in the great majority no indication of laceration was perceived until after the completion of parturition. In the interval between the extrusion of the head and the expulsion of the body, the parts were so much on the stretch, that it was impossible to determine with certainty whether laceration had occurred or not; but, as the shoulders pass- ed without the least difficulty through an opening of sufficient size, it appears most probable that the laceration did not take place at this period, but had occurred previously. Of the seventy-five cases in which laceration occurred, fifteen of these, or twenty per cent., healed by the first intention, and the pe- rinaeum was as perfect as before the confinement ; while fifty-three, or seventy-five per cent., healed by granulation, and produced a more or less perfect perinaeum; In not one instance has any in- convenience followed,' such as prolapsus of the uterus, bearing- down pains, etc., and in only one case was there any trouble at- tending the accident. This case was among the first observed, and while my mind was still imbued with the serious consequences which followed laceration of the perinaeum. It did not heal by the first intention, and the granulations were small, and showed little inclination to unite into those of the opposite side. I became anxious, applied different remedies, and, finally, the quilted suture. Nothing which was applied appeared to produce any effect, and the operation of the sutures was decidedly injurious. In the first in- stance, it frightened the patient ; was a source of constant annoy- ance ; produced irritation of the part; and, from the pressure of the silk inducing ulceration of the deeper structures, became loose, and was obliged to be removed. The laceration, however, gradually healed, leaving not more than a quarter of an inch of the rupture unclosed. In this case, the effects of the ligatures were such as to deter me from applying them on any subsequent occasion. In all the cases I have observed, neither the patient nor the nurse was aware that anything had occurred more than usual. The patient said she felt very sore, could not sit up in bed for some few days in .consequence, and when she began to sit up out of bed, required a pillow, or some soft substance to sit upon. But these were consid- ered as "nothing more than usual on such occasions." Little need be said of the thirty-seven cases wherein laceration did not occur, except that some, at least, were such as might dpriori, have been supposed likely to suffer from this accident. The patients were spare, and rather above the average size; the perinaeum small in extent, firm, and somewhat unyielding. But in women with 1856.] On Laceration of the Perinaeum. 411 this conformation, scarcely one suffered from laceration, and then only when the size of the child was disproportionate to that of the pelvis of the mother ; but when the perinaeum was broad, thick, and soft, scarcely one escaped being torn through. It, of course, will remain for further observation to determine whether these cases, taken indiscriminately from the practice of one physician, fairly represent the average occurrence of this accident in women confined with their first child. If it does, then laceration of the perinaeum becomes the rule in such cases, instead of the ex- ception ; but, even if it does not, it yet shows that this accident is of much more frequent occurrence than has been supposed. These cases further show that when laceration does occur, this will heal perfectly by ordinary attention, rest, and cleanliness. Such, at least, must be admitted from the result of the seventy-five cases, every one of which has healed with little trouble, and none have been followed by any annoying consequences. From these facts we may, I think, advance a step further and conclude that, in cases where the laceration has extended through the sphincter ani, there is great probability that the laceration will heal, in many cases, by the natural process ; and that time should be given for this purpose, before any operative procedure is had recourse to. The majority of those females who form the subject of these ob- servations, have been confined with the second, and several with the third, child ; but in no instance has laceration again taken place, and in only one was there a slight tearing, during the birth of a large child, which soon healed. It would then appear that the cica- trix which follows a lacerated perinaeum is less liable to give way during parturition than the natural structure of the part. It is an acknowledged fact that severe laceration of the perinae- um, involving the sphincter ani, has not unfrequently occurred without the accident having been discovered until some time sub- sequently, by the inability of the patient to retain the motions, and other distressing consequences. And it is also known that tearing of the perinasum, up to the sphincter, has taken place, and has not subsequently healed. But we have no information as to the cir- cumstances which have interfered with the healing process, which, these present cases appear to show, usually takes place. My own experience would lead me to conclude, that many cases may, and do, occur, without the medical attendant being aware of the acci- dent. For, although my attention was specially directed to this point, yet several occurred wherein the laceration was not per- ceived until a careful examination of the parts had been made after the labor was completed. Had this examination, which is unusual, not been instituted, the accident might not have been discovered, either at the time, or subsequently, by reason of the strong tendency which appears to exist for the healing of any tearing or other injury to the generative organs of the female, when the process of parturi* tion has been completed. [Med. Times mid Gazette, 412 Congenital Pliymosis. [Juty? Tlie Simplest Operation for Uncomplicated, Congenital Pliymosis. By T. Fukneaux Jordan, Esq., M. R. C. S. < Not only are Surgical authorities of opinion that circumcision is rareJy, if ever necessary; but those truly frightful slits, extending halt-way up the penis, to be seen in the pretty engravings which adorn some (of our best too) Surgical manuals, are fast getting into chirargical disfavor. The present mania, however, of attributing uncomplicated, congenital phymosis in every case to the unfortu- nate mucous lining of the prepuce alone, and the practice of heroi- cally slitting up the same to the very point of its reflexion from the penis, has arisen rather from the hypothesis of theorists than from the enlightened experience of acute observers. The non-dilatability of the congenitally phymosed prepuce is con- fined to the margin of the preputial orifice and to the skin and mucous membrane in its immediate vicinity ; such nondilatability undoubtedly extending to a greater distance on the inner than on the outer aspect of the foreskin. The received opinion, touching the non-elasticity of the prepu- tial lkaing in its entire extent, is so far from being correct, that ordinarily such lining, for some distance anterior to its point of reflexion, is arranged in rugous folds, like all other mucous mem- branes that are too large for the organ they line, save when the peculiar function of that organ is being exercised. The opinion that the skin is not implicated in phymosed stricture, is equally incorrect. In one patient, on whom 1 operated with complete success, by far the tightest portion of the prepuce, after recovery from the operation, was the skin for two lines behind the cicatrices. Fnom the above remarks, it will be inferred that any incisions, which extend further than the parts forming the margin of the pre- puce, and for a short additional distance on the mucous surface, are unnecessary, and hence cruel. A single incision, however, as des- cribed, would fail to secure the retraction of the prepuce, not beeause the incision is too limited, but because a single incision can- not possibly relieve the whole circumference of the congenitally contracted preputial orifice; two. however, or at most three, of the snaall incisions in question would afford complete relief. The mode of operating which I have adopted, and with signal success in its results, is this: Having first induced local anaesthe- sia, by applying pounded ice to the penis for two minutes, I intro- duced one blade of a pair of scissors (blunt-pointed, yet cutting to the end) to the distance of \ an inch, between the glans penis and the prepuce, on one side of the penis, at a point midway between the frenum posteriorly, and the mesial line anteriorly. Both layers of the prepuce being divided to the extent mentioned, a similar incision is made at a similar point on the other side of the penis. The prepuce is now retracted to the extent allowed by the incisions, 1856.] Congenital Absence of the Nose. 413 which by this proceeding are brought quite external, enclosing between their lips an uncut layer of lining membrane. This is divided on each side, by introducing one blade of the scissors, to the extent of, and immediately under, the original wound. The entire prepuce may then be retracted, a piece of wet lint wrapped round the penis, and the whole supported by a proper suspensory bandage. The patient need not lie in bed. Where three incisions seem preferable, they should be equidistant from each other, the third being at the mesial point anteriorly, the two lateral incisions should be a little nearer the frenum, than when two only are made. The incisions may of course vary a line or two, one way or the other in extent, according as the constriction is more or less aggra- vated. The recapitulary points to which I would draw attention, are : 1. That the skin is more, and 2. That the mucous membrane is less involved, than is generally supposed. 8. That two, or at most three, comparatively small incisions will afford complete relief. 4. That no assistant is required, and 5. No instrument save a pair of scissors. 6. Two or three small incisions cause much less irritation, and heal much more quickly than one large one. 7- That the patient need not lie in bed. [Med. Times and Gaz* Congenital Absence of the Nose: New Rhinoplastic Operation. By M. Maisonneuve. Among the defects of conformation of which the human face may be the seat, there is one which must be of extreme rarity, as I have been unable to discover any record of its occurrence; I allude to congenital absence of the nose. A case of this kind having recent- ly come under my notice, I have thought it would be useful to publish it, and at the same time to make known the novel proceed- ing by means of which I succeeded in remedying the deformity. Eugenie Marotte, aged seven months, was born strong and well formed, except that her face was completely devoid of any nasal prominence, and that in place of this natural projection there existed only a plain surface pierced with two little round openings scarcely one millimetre (0-03937 inch) in diameter, and three cen- timetres (1-1811 inches) distant from each other. In addition to giving the child a most grotesque appearance, this deformity occa- sioned her much inconvenience in the act of respiration, and therefore in that of sucking. In these two points of view, conse- quently, it was important to remedy this faulty conformation, and for this purpose her parents came to Paris to consult me. No similar instance having been known to science, the ordinary 414 On Necracmia. [Juty) rhinoplastic processes were, of course, inapplicable to the case. I therefore, devised the operation I shall now describe. On the 18th of May, 1855, the child having been previously placed under the influence of chloroform. I carried inwards, from each of the nasal orifices, a transverse incision one centrimetre (0.393708 inch in length. Two vertical incisions, commencing from the inner extremity of the preceding, were now directed towards the free edge of the lower (sic) lip, near which they were brought together so as to form a V. From these latter incisions resulted a narrow flap comprising the entire thickness of the lip: it was dissected and horizontally raised to form the inferior septum of the nose. There then resulted a true artificial hare-lip, the edges of which I united by means of the twisted suture. But to obtain this union, it was necessary that the space comprised between the nasal openings should be shortened by the entire width of the flap detached to form the septum, and that consequently a projecting fold should be formed at the expense of intermediate skin. This fold, supported by the artificial sub-septum, constituted a perfectly regular nasal prominence. In order to understand completely the mechanism of the operation it is sufficient to repeat it on a piece of paper, when it will be im- mediately seen how satisfactory the result is. The final issue was not, however, obtained without some trouble. The infant, irritated with pain, did not cease during the first twenty- four hours crying, so to speak, and struggling : the consequence was a partial disunion of the points of the upper suture. This, however, was attended with the incidental advantage of suggesting to me an improvement in the operation for hare-lip. This improvement consists in the subcutaneous division of the orbicular muscle at each side of the wound, in order to prevent its contractions from tearing open the cicatrix. Thanks to this improvement, union took place without difficulty, notwithstanding the uneasiness of the little patient ; and at the time of her departure from Paris, the cure was complete. The nose was of a very regular shape, and the openings of the nostrils being ample, admitted of easy respiration. [Gazette Medical de Paris, and Dublin Medical Press. On Necrcemia. By Dr. C. H. Jones, F. R. S. This term is applied by Dr. Williams to that condition of the blood, in which it appears to be itself primarily and specially affect- ed, and to lose its vital properties. It is, in fact, death beginning with the blood. The appearance of petechia? and vibices on the external surface, the occurrence of more extensive hemorrhages in the internal parts, the general fluidity of the blood, and frequently its 1856.] On Necrcemia. 415 unusually dark or otherwise altered aspect, its poisonous properties, as exhibited in its deleterious operations on other animals, and its proneness to pass into decomposition, point out the blood as the first seat of disorder ; and by the failure of its natural properties and function, as the vivifier of all structure and function, it is plainly the medium by which death begins in the body. The blood, the natu- ral source of life to the whole body, is itself dead, and spreads death instead of life. The heart's action is faltering and feeble; the atonic vessles become the seat of congestions, and readily permit extravasations. The brain, insufficiently stimulated, after slight delirium, lapses into stupor; the medulla no longer regularly res- ponds to the besoin de respirer / and the respiratory movements become irregular. Muscular strength is utterly lost ; offensive colliquative diarrhoea, or passive intestinal hemorrhage often occurs ; sloughing sores, or actual gangrene of various parts are easily pro- duced ; and putrefaction commences almost as soon as life is extinct. The track of the superficial veins is marked by bloody stains ; hypostatic congestion takes place to a great extent ; the blood remains fluid, and stains the lining membranes of the vessels. Ro- kitansky describes the blood as often foamy, from the development of gas, and of a dirty red rasberry -jelly color; its serum dark fern exuded haematine ; and its globules swollen up by endosmosis. Coagula are either totally absent, or are very soft and small. The exudations are of a dirty red turbid, thin. There is scarcely any rigor mortis; the tissue of the heart and of other organs is flaccid and softened, and stained by imbibition of the serum. Gas is quick- ly formed in the vessels and in the areolar tissue, in giving rise to a kind of emphysema. It is verv remarkable that this necraemic condition, or one closely resembling it, may be brought on by vio- lent shocks inflicted on the nervous system, as well as by the intro- duction of miasmatic or animal poisons into the circulation. Vio- lent convulsions, overwhelming emotions, the shock of an amputa- tion, a stroke of lightning, even a severe exhausting labor, are mentioned by the German pathologist as having produced this effect. More common causes are, however, malignant scarlatina and typhus, yellow fever, the plague, and the disease called glanders. It may be said, generally, that the early appearance of sinking and prostration in any fever, indicates that the blood is thus seriously affected. We are ignorant what is the exact nature of the changes which takes place in this condition of the blood. Probably they are more of a vital than merely chemical kind that is, they affect the properties of the blood more than its composition. The blood globules do not appear to be destroyed ; but they circulate probably some time before death, as so many dead particles prove to be en- larged and to stagnate in the capillaries, and to part with their contained haematine. The fibrine is in great part destroyed ; but how this comes to pass we are ignorant. We can perceive, on the whole, scarce anything more than that the powers of vital chemis- 416 Iodine, as an Antidote to Poison of Rabid Animals. [July, try rapidly decay, and those of ordinary chemical affinity supply their place. [Braitliwaite 's Retros. Iodine, as an Antidote to the Poison of Rabid Animals. By Wm- H. Mussey, M.D., of Cincinnati. Prof. Brainard, of Chicago, has demonstrated the value of Iodine as an application to snake bites. Early in 1853, I determined to treat wounds by rabid animals with Iodine, in the belief that it would decompose the animal poison; and I now present the follow- ing cases as the initiative of the treatment, without claiming that the question is settled, as I know that cases of Hydrophobia are ex- ceedingly rare not bearing a proportion greater than 1 to 20 of those wounded by animals supposed to be rabid : Case I. April, 1853. Mr. B., aged 25, painter. When three miles from the city, was bitten by a dog supposed to be rabid, and I believe, was so, though there was no opportunity for the proof, as the animal was killed. The patient came immediately to my office. On his right hand were several wounds, to which I applied the Tincture of Iodine every five minutes for an hour, and then applied an emollient poultice, with directions to apply the Iodine every hour for the next ten hours, and every four hours for the twenty- four hours succeeding, with a change of poultice every twelve hours, till the wounds should heal. I saw the patient daily for a week, and occasionally for six months after. No symptoms of Hy- drophobia had appeared. Case II. April 29, 1853. IT. S., aged twelve years. Was bit- ten by a furious watch-dog, in the side and arm, through clothing. There was no evidence that the dog was rabid, but I instituted the same treatment as in the former case. Case III. June 24. G. H., aged twenty-five. Was bitten in the hand by a large pup, three months old. Ordered the applica- tion of Tincture of Iodine. Case IV. July 4. W. M., aged nine years. Was bitten (through his clothing) by a dog running the streets. There were five wounds in the leg and two in the side. I saw the patient twenty minutes after, and applied Iodine and poultices, as iu Case I. The patient is well at this date. The same dog bit an Italian in the leg, and the surgeon in attendance cut out a large piece of the integument, and the patient recovered from the operation, and was not attacked with Hydrophobia. I believe the dog was mad, but as he suffered the death penalty, there was no opportunity for proof. Case V. September 16. Mrs. S. Bitten in the hand. I could not determine if the dog was rabid or only worried by its pursuers. Ordered Iodine. There was no subsequent trouble. Case VI. December G. W. A., aged twelve. Bitten several times in the hand. Treated as Case I. 1856.] Favus, successfully treated. 417 Case VII. H. K., aged ten. Bitten by same dog. Ordered like treatment. No subsequent difficulty. Case VIII. June 2G, 1854. Miss H., aged nineteen. Was bit- ten in joint of great toe by a cat. Four days after, I was called, and found joint inflamed, and slight tetanic spasms about the larynx and inferior maxilla. Applied Iodine and poultices, and adminis- tered antispasmodics. Patient recovered. On a review of the foregoing, it will be noticed: 1. That in all cases I apply the Tincture of Iodine, as there is some uncertainty as to the character of the wound. 2. That in cases 1, 4, 6 and 7, the animals inflicting the wounds were probably rabid ; whilst in cases 2, 3, 5 and 8, the animals were probably not rabid. 3. That in cases 1, 3, 5, 6. 7 and 8, the parts wounded were not protected by clothing. 4. That dogs show no respect for the calendar, or summer ordi- nances, but have their day whenever it suits their taste. [Cincinnati Med. Observer. Favus, successfully treated by Phytolacca Radix, or Poke Moot. By H. Gatch Carey, M. D., Dayton, Ohio. The phytolacca decandra, or poke, is indigenous to almost all parts of North America. Its medicinal qualities have received but little attention. Taken internally, it is an emetic, tardy in operation; cathartic and slightly narcotic. " In over doses it produces exces- sive vomiting and purging, attended with great prostration of strength, and sometimes- with convulsions. In small doses it is an alterative, and has been recommended in rheumatism. Externally it has proved beneficial in piles, psora, and tiena capitis." (U. S. ]).) I have cured three cases one severe and obstinate, of sycosis with a decoction of the poke root. The action of the remedy was* prompt and highly gratifying. The pathological resemblance' which subsists between this disease and' favus, induced me to test the virtues of the agent in the latter. The case was one of six months standing, and had been under treatment during that time by a regular, scientific physician. The disease had only been tem- porarily benifited by the course of medication. The general health of the child ait. eight months, was good'. No hereditary elemenfs of disease could be traced. The eruption occupied the parietal protuberances, extending forwards to the middle of the sagital suture,, back as far as the centre of the occipital bone, and all the interme- diate space. A dense light brown crust covered the above defined region. Characteristic yellow points imbedded in the derma, could be detected along the' line of the disease, rendering the diagnosis clear. 418 Microscopy of the Kidney. [Juty) I directed thorough ablution with soap and water three times per day, and the crust to be kept constantly saturated with, $. Carb. Potass. 3iv. Glycerine 5ij. m. The head to be covered with an oil silk cap. At the end of the third day, under the use of this treatment, the scale was entirely removed. The scalp was ulcerated in several places, and the re- mainder which was originally covered by the crust, furnished unmistakable evidence in a multitude of yellow points offawus dispersus. Pruritia was almost intolerable. The glycerine and potash only had the effect of softening t'he crust, thereby rendering its removal easy by soap and water. The exuberant cryptogami were not in the least, repressed by the appli- cation. A single night was sufficient to give a coating to the diseased surface. After removing the hair as far as possible with scissors, I ordered the ablutions to be continued, and the affected parts to be kept con- stantly moist with a decoction of poke root. This was effected by means of clothes saturated in the decoction and applied to the diseased scalp, with the oil silk cap superimposed. The crust ceased to be reproduced immediately upon the application of the wash. In four days the yellow points in the scalps had disappeared, and the ulcerations soon healed under the use of the decoction. In a fortnight, after the first use of the poke root, the disease had vanished, and hair in limited quantities now covers the affected parts. [Western Lancet. Microscopy of the Kidney. At the April session of the Academy, Dr. Isaacs read a continua- tion of his paper on the Microscopy of the Kidney, in which he proved still more decidedly than at the previous meeting, the fallacy of some of the physiological views of Bowman and other European authorities, and demonstrated to perfection the true anatomical and physiological relations of some important parts, especially the con- nection between the Malpighian tufts and the uriniferous tubes. His investigations have settled this vexed question, so that there can no longer exist any doubt of their being an anatomical connec- tion and a direct functional relation between these two parts. He tied the renal artery of a cat, after putting the animal under the influence of chloroform, and was then enabled to see the passages of blood directly from the capilliary turft in the tube ; and he has proved to exist, what others have denied, because they failed to see, the presence of nucleated cells upon the surface of the tuft, as well as upon the inner surface of the capsule of the tube, which embra- ces and covers the tuft. The cells of the capsule he discovered to be of a different chemical character from those of the tuft as nitric 1856.] Placenta Prcevia. 419 acid, while it destroyed the former, had no effect upon the latter. Upon his inability to discover any cells upon the tuft, Bowman based his theory that the office of this congeries of capillaries was to separate water only from the blood ; a theory which is subverted by Dr. Isaacs' discovery of a cellular formation upon them. He furthermore demonstrated the presence of various substances in the tube, such as bile in a jaundiced person, and various salts which could only have got there through the Malpighian tuft. In this, as in his former paper, Dr. Isaacs was eminently satisfac- tory to his audience, who received his communication with fre- quent demonstrations of their gratification. [Med. and Surg. Rep. Placenta Prcevia. By John P. Mattaeuk, M. D., LL.D., of Prince Edward, C. H., Virginia. Implantation of the placenta over the os uteri may be central or marginal, and in either case will pretty uniformly be the cause of haemorrhage, as the uterus expands during the advancing periods of utero-gestation. Where central implantation exists, the safety both of mother and child will be seriously jeopardized, while a marginal attachment chiefly endangers the life of the foetus, and not necessarily that of the mother, though by neglect and impro- per treatment, she too may be placed in imminent peril by it. It is generally at or about the seventh month of gestation that placenta praevia begins to endanger from haemorrhage ; and this is due to the more rapid and extensive expansion of the cervix uteri, from this period, in enlarging the uterine cavity, to accom- modate the increasing size of the contained ovum. In some instances, however, no serious danger threatens until labor com- mences at the full term. In central implantation the placenta is attached more or less centrally over the os uteri, and is decidedly the most important and dangerous deviation, while the danger diminishes as the at- tachment varies from this to the marginal. The haemorrhage attendant on placenta praevia from the seventh month, and before labor commences at the full term, is due chiefly to the separation of the placenta around its circumference, and the consequent rupture of its vessels there, caused by the increasing dilitation of the cervix uteri at this period, while that occurring with the commencement of labor is caused by the separation of i the placenta, and rupture of the utero-placental vessels around the , os, as this opening dilates to give exit to the uterine contents. In the first, the haemorrhage is less violent and menacing than that connected with separation of the placenta from the os uteri, because the separation is gradual in the former, and the vessels, that are ruptured from time to time, smaller and more delicate. Here the vessels are ruptured only as the cervix expands; and N. s. VOL. XII. NO. VII. 27 420 Placenta Prcevia. [July, as this dilatation is slow and gradual also, and the consequent haemorrhage comparatively moderate. When, however, labor commences, the os uteri dilates more or less suddenly, and the separation of the placenta, if the case be one of central implantation, will be propotionally sudden also, and the consequent haemorrhage must necessarily be sudden and im- petuous in greater or less degrees. If the haemorrhage appears near about the seventh month, it will in all probability result from the separation of the placenta at its circumference, as no other portion would be likely to be detached at this period of utero-gestation ; and it would be moder- ate, because, as already stated, the placenta must be more or less gradually separated, then, from the uterine surface, by reason of the comparatively slow expansion of the corresponding wall. But should it set in with the accession of labor, if the views already expressed are correct, it would be both sudden and im- petuous, from the sudden separation of the placenta, and rupture of the utero-placental vessels at or near the os, chiefly if not ex- clusively the result of sudden dilatation of the os uteri, as prepar- atory to the expulsion of the foetus. And such will be the case, also, should a border of the placenta only be connected with the os uteri. These divisions of placenta praevia implantation, if carefully studied in practice, will enable us to determine at once the char- acter of the haemorrhage, both as respects the seat of the vessels yielding the blood, and its danger to the mother and foetus. In many instances, uterine haemorrhage occurs during pregnan- cy, at or after the seventh month, that causes not a little alarm with females, and much perplexity with practitioners in determin- ing as to its precise nature. The discharge of blood often, in some of these examples, will be quite free and menacing for a few moments, but will very soon greatly abate, or cease for some hours entirely, leading the physi- cian to believe that there will probably be no return of it. After a while, however, and without any known cause, it recurs, and pursues the course of the first attack ; and again abates, or ceases entirely; and in this manner it may return and abate after intervals until labor sets in at full term; or it will cease altogether before that time. This description of uterine haemorrhage must either be due to central implantation of the placenta over the os uteri, or a margin- al attachment may exist, with the border of the placenta extend- ing beyond the os uteri sufficient^ to occlude it. It may also be due to detachment of a portion of the chorion from the correspond- ing uterine mucous lining, by an accidental blow on theabdomen, or by a fall or severe jolt. If it result from placenta praevia, the probabilities are against the complete arrest of the haemorrhage until the attendant preg- 1856.] Placenta Previa. 421 nancy terminates, and in favor of the return of it in an aggravated and menacing form when labor sets in. But should it depend on partial separation of the ovum, in a majority of cases spontaneous arrest of it would follow, and a cure be effected by proper treat- ment, with little danger of recurrence, unless brought on by expo- sure of the woman to causes similar to those that induced it at first. A sudden and profuse discharge of blood from the vagina, as labor commences, or as the os uteri begins to dilate, could not fail to lead to the belief that there was implantation of the placenta over the os uteri, and that the haemorrhage resulted from the rup- ture of the utero-placental vessels, caused by the sudden detach- ment of the placenta from the os as it is forced open by the uterine contractions, constituting labor in its first or preparatory stage. In these cases it will invariably be the duty of the obstetrical attendant to examine carefully into the condition of the os uteri, per vaginam, in reference to implantation'of the placenta over it. If the haemorrhage is profuse, little difficulty will attend the in- troduction of the index finger of either hand into the os uteri to a sufficient depth to ascertain if the placenta is situated upon it or not, as that opening is always more or less dilated by the escaping blood. The examination, however, should be conducted with gentleness, taking care, as the finger is introduced, not to force open the os violently, nor to employ undue force with it against the placenta. If the case is ascertained to be placenta praevia, the cause and nature of the haemorrhage will be satisfactorily declared, and a course of treatment must be adopted accordingly. But if no pla- centa can be found to occlude the os uteri, and instead of that structure the delicate and thin membranous envelope of the foetus presents, it will be fair to presume that the haemorrhage is due to accidental separation of the ovum from the uterine surface, which we know is generally harmless and easily corrected nay, most frequently, it subsides spontaneously, if the woman is still and quiet in bed for a few days. In the treatment of pregnancy and labor, complicated with im- plantation of the placenta over the os uteri, great difficulty has always been experienced, whether the attendant haemorrhage commences early or at full term ; and perhaps no question in obstetrical therapeutics has given rise to greater contrariety of opinion or of medication. It is not the writer's intention to notice these discrepancies, as he could not examine them fully in a paper like this, designed chiefly to explain his individual methods of treating placenta praevia, and through the pages of a monthly medical journal. Having had considerable experience in the management of this menacing and formidable obstetrical hydra, 1 he proposes merely to present a condensed transcript of that ex- perience. 422 Placenta Prcevia. [Jutyj In haemorrhage connected with placenta praevia, from the seventh month to the close of the eighth, it will not generally be necessary to do more than maintain the bowels in a soluble state by gentle cathartics, such as the bitart. potass., Seidlitz powders, and the like; to detract blood if the habit is plethoric, or the pulse strong and excited ; to enjoin absolute rest in the recumbent pos- ture; to restrict the diet; to guard against nervous excitement; to allow free ventilation of the woman's apartment, and cold drinks or ice; to require the person to be loosely dressed, and to be kept cool; to use narcotics in conbination with astringents if there is much nervousness, as internal remedies, or astringents alone if narcotics are not demanded, especially acetis plumbi, snip, alum or tannin ; and cold, wet cloths over the hypogastrium and vulva. Sometimes it will be necessary to have recourse to the tampon, especially if the woman is delicate and the haemorrhage very pro- fuse; and when employed, it should be carefully applied to the os tineas, and steadily and firmly pressed against it until the hae- morrhage ceases. Even after the external appearance of blood is no longer visible, it will be safest to continue the pressure upon the tampon for some hours ; and when the pressure isto be discontinued, it must inva- riably be gradually done, and the instrument suffered to remain. The writer has often witnessed the return of the flooding by too suddenly removing the pressure from the tampon, and from the premature withdrawal of the tampon also. The best tam- pon can be made of raw cotton enveloped in fine linen or ken- ting, so as to forma firm ball ; and the surface to be applied to the os tincae, before the envelope is put on, should be well satur- ated with a powder of equal parts of sulphur, alum and tannin. By using a square piece of soft old linen of proper size for the envelope, it can be put over the medicated cotton so as to form a handle beyond the ball, that will be found convenient in the in- troduction or removal of the tampon ; and to render the ball firm, the gathers of the envelope should be tied firmly close up to the corresponding surface of the cotton with a strong thread. In numerous instances, the writer has succeeded in restraining uterine haemorrhage, in cases of placenta praevia, by the energe- tic employment of the plan of treatmnnt that has been briefly sketched, and women have been conducted thereby, in compara- tive safety, to the close of pregnancy. It is true, haemorrhage, connected with malposition of the placenta, is not generally attended with very great danger in the 7th and 8th months of pregnancy, especially the 7th, as already slated, but it should always be regarded with solicitude, because it is sometimes fatal. When it complicates labor, however, it is indeed a formidable accident, demanding decision and the most exalted skill, in many cases, on the part of the obstetrical attendant, to advert the dan- gers that peril the life'ofboth mother and infant; audit is the 1856.] Placenta Proevia. 423 form that this paper is designed chiefly to consider. A labor thus complicated is distinguished by the discharge of blood from the vagina, more or less profusely, with the commencement of uterine pain ; but the haemorrhage is most free and impetuous as the os uteri becomes dilated, and particularly so, if the dilatation is sud- den ; and it is the sudden separation of the placenta from the os and cervix uteri, and the consequent rupture of the connecting vessels, that cause the haemorrhage, as has already been stated. In many cases, these pregnancies are attended with occasional discharges of blood from the 7th month down to the commence- ment of labor, that are restrained by appropriate treatment ; but although they are menacing in a high degree now and then, the haemorrhage is far less impetuous than that ushered in by the accession of labor. In treating this complication of labor, the aim should be to save both mother and child, if possible. But if this is impracticable, and one must be sacrificed, every consideration of duty and hu- manity demands that the foetus should be the victim. When haemorrhage sets in with labor, whether impetuous or not, the saftest and most reliable means of restraining it is the tampon; and it should be resorted to without a moment's delay; and formed and applied as already suggested, only that the ex- tract of belladonna must be used with the astringents in medica- ting it, and in quantities varying from twenty-five to forty grains. This instrument, as already stated, should be carefully and firmly applied to the os uteri, so as to prevent the further escape of blood from the uterus, and to cause a coagulum to form in the os and over the separated portions of the placenta. By the addition of the belladonna to the alum and tannin, two important ends may be simultaneously attained; that is, the coagulation of the blood around and in the orifices of the ruptured vessels, and the prompt and free dilatation of the os uteri. Iu many cases the haemorrhage will be promptly and complete- ly arrested by these measures; but if not completely staunched, it will often be greatly moderated, so as to allow time for the safe and full dilatation of the os, and spontaneous delivery of the foetus. If, however, the haemorrhage proves obstinate, and from the blood already lost, seriously endangers the life of the woman, it will not be safe and proper to trust farther to the tampon alone, but the immediate resort must be had either to delivery by intro- ducing the hand into the uterine cavity and turning, or to forcible separation of the placenta from the uterus with the index finger passed between them. If the haemorrhage has been very profuse and exhausting in its effects, whether of long or short continuance, attempts to de- liver would not be justifiable or safe. But should the obstetrical attendant see the case before such prostrating loss of blood had taken place, and the os uteri could 424 Placenta Praivia. [July, be entered without the employment of undue force, delivery by turning or with the forceps might be promptly resorted to. But to attempt delivery after the woman has become greatly enfeebled by the lioodings, would seriously endanger her life. Indeed it would be murderous, in a majority of instances, as the process requires more time for its completion, even when executed in the most dexterous manner, than could be safely consumed while the flooding continues. In numerous instances, attempts to deliver, or even its accom- plishment, have proved fatal under these circumstances, when life might have been perpetuated by a different procedure. True it is, some few women of uncommon vigor of constitution have escaped with life ; but such examples are remarkable exceptions, and do not in the least weigh against the plan here advocated. If the case forbid all attempts to deliver, the second expedient that has been suggested must be adopted, and without a moment's delay ; that is, the separation of the placenta from the os and cer- vix, by forcibly and quickly passing the index finger between them, so as completely to detach the placenta from the uterine surface. This operation causes considerable but temporary increase of the haemorrhage, and should be executed with the utmost des- patch, or the woman may sink from the loss of blood before it is accomplished. As soon as the placenta is detached, the medicated tampon, without the belladonna, must be applied. And to save time, that instrument should invariably be previously gotten ready. By carefully pressing the entering surface of the tampon against and partially mto the os uteri, and firmly holding it there with the fingers, the haemorrhage will instantly cease; and after a short time thus restrained, there will be very little danger of its recurrence, even if the tampon should be removed, which howe- ver, must not be attempted ; it must invariably be forced away by the uterine contractions upon the renewal of labor. When the ease is a marginal implantation of the placenta over the os and cervix, and delivery is forbidden, by reason of the pre- vious loss of blood, and great prostration of the woman's strength it will be necessary also to resort to the expedients just described. In some of these cases, however, when the placenta barely or im- perfectly occludes the os uteri, it will only be necessary to detach it partially ; and the writer's experience has led him to adopt and to advise the practice of separating that organ on its occluding border to a line a little beyond ihe opposite half of the os uteri. This separation very often, aided by the medicated tampon, will completely or greatly restrain the haemorrhage, and at the same time afford a chance for the preservation of the foetus. After the haemorrhage is restrained by the means which have been suggested, a question arises as to the propriety of speedy delivery by artificial means. Should there be very great prostra- 1856-] Placenta Previa. 425 tion of the system from the flooding, artificial delivery must not be attempted until the energies recuperate, as manifested by a well developed and equable reaction. In numerous melancholy instances, women have perished by being delivered too soon after the arrest of profuse haemorrhage from placenta praevia', especially before the powers of the system had reacted sufficiently to restore a well balanced circulation. As long as there is no haemorrhage and absence of uterine contraction, attempts at artificial delivery should never be made. There will be infinitely less danger in delaying delivery in such cases several days, if reaction is no lon- ger deferred, than from an early resort to it. Inflammation might supervene from the detention of a dead foetus 24 or 36 hours after the arrest of the haemorrhage, causing its death; but this possible contingency would not bear a comparison with the almost certain danger of death to the mother, should she be delivered before reaction takes place to a sustaining extent. The writer has known women to die, in several instances, al- most at the moment of delivery, who had previously flooded most profusely from placenta praevia, but had ceased to do so as soon as the placenta was detached. In these cases there was great prostration of the system, manifested by difficult respiration; absence or alarming depression of the radial pulse ; tinnitus aurium ; moaning; restlessness; and a tendency to swoon from the slightest change in the posture of the body ; and though delive- ry was not attempted or accomplished for more than ten hours after haemorrhage had been arrested, there was not the slightest tendency in the system to react; and the woman died the instant the stimulus of distention was removed from the uterus and abdo- men. In such examples of placenta praevia, the safest and most rational mode ol procedure is, to employ such restoratives and incitants as may be demanded to re-excite the flagging operations of the system, and to wait patiently until reaction is fully restored, or until spontaneous delivery takes place, which often occurs with the re-establishment of a well-balanced circulation, and is seldom fraught with danger, unless improperly managed or officiously interferred with. Should utero peritonitis threaten, even before delivery is ac- complished, purging the bowels impressively once or twice will effectually avert it, and not only without increasing the depression of the vital actions, but actually re-exciting them. In some most menacing and exceedingly perplexing cases of this kind, the writer has resorted to purging with the happiest results in prompt- ly exciting the uterus into vigorous and effective contractions, speedily resulting in delivery, and in the removal of the symptoms threatening inflammation also. It is important after every delivery to have the abdomen sup- portingly bandaged; but in the case now under examination it should be done with compressing force, and continued until every 426 Pneumonia. [Julj> menacing symptom subsides, unless contraindieated by increasing abdominal tenderness, and when to be discontinued, it must inva- riably be gradually done. The views advocated in this paper, in regard to the treatment of labor and haemorrhage, in cases of implantation of the placenta over the cervix and os uteri, have been long entertained by the writer, and their correctness and safety often verified in his inter- course with cases complicated with such malpositions, or, as usual- ly denominated, placenta praevia. In more than thirty-five cases that have been treated by him, only two unfortunate results fol- lowed ; and the treatment now pursued by him, and commended through this paper to his brethren, was suggested by those two unfortunate cases more than twenty -five years ago, while he was a young practitioner of medicine. These views, however, are not peculiar to the writer, although original with him; and it is gratifying to find that they are enter- tained, in the main, also by some of the ablest and most successful as well as prominent obstetrical practitioners both of this country and of Europe, with Professor Simpson generally conceded to be the highest authority at the present time in midwifery at the head of them. [ Virginia Med. Jour. Pneumonia discussed in thirty-three Aphorisms. By M. BOUCHUT. Our readers will be interested in the perusal of the admirably condensed series of aphorisms taken from the excellent work on Diseases of Nursing Children, by M, Bouchut. This mode of im- pressing a subject on the memory is very effective and one often employed by the eminent author of this treatise. We are pleased to see that a translation of the work is announced by Dr. Bird of New York, from the publishing house of the Messrs. Wood. Primary pneumonia, which is also called pneumonia d'emblee, is rare in children at the breast. Pneumonia usually follows simple bronchitis, or bronchitis complicating fevers, or acute febrile diseases. Primary pneumonia is usually lobar. Consecutive pneumonia is always lobular. Lobular pneumonia is sometimes discrete, sometimes confluent. The pneumonia of children at the breast is almost always double, and usually attacks both lungs. Lobar or lobular pneumonia is observed under two anatomical forms, slightly differing as to structure; these are intra-vesicnlar and extra-vesicu- lar pneumonia. Intra-vesicnlar pneumonia, usually primary, leads to congestion and thickening of the walls of the cells of the lung, with the formation of an internal plastic deposit, which constitutes the character of red and gray hepatization. 1856.] Pneumonia. 4:27 Extra-vesicular pneumonia, always consecutive, only produces conges- tion and thickening of the walls of the pulmonary vesicles, without fibrinous plastic secretion in the interior of these vesicles. Chronic pneumonia, more common in the infant at the hreast than in the adult, is always lobar. Pneumonia often engenders the formation of fibro-plastic miliary granu- lations in the interior of the cells of the lung, in lymphatic and scrofulous children, or in the issue of parents tainted with scrofula. The developement of lobular pneumonia is favored by the crowding of children in the wards of a hospital. Ordinary and frequent cough, accompanied by fever and anhelation, should make us fearful of an invasion of pneumonia. Expiratory, groaning and jerking respiration is a certain sign of the ex- istence of confluent lobar or lobular pneumonia. Panting respiration, accompanied by a continual movement of the nos- trils, is a sign of pneumonia. Dullness of the chest is generally but slightly defined in the pneumonia of children at the breast. When dullness of the chest exists in a young child with a very bad cold, pneumonia should be feared. Dullness confined to one side of the chest in a young child rather indi- cates pleurisy than pneumonia. The subcrepitant rale which accompanies the cough, the fever, and an- helation, confirm the diagnosis of confluent lobular pneumonia. Bronchial respiration, which is rare in children at the breast, always belongs to lobar pneumonia, and sometimes to confluent lobular pneumo- nia, Bronchophony, that is to say, the resounding of the cry, indicates that pneumonia has arrived at its last stage. The exaggerated vibration of the thoracic walls at the time of the cries, indicates pneumonia, whilst their absence, on the contrary, points out the existence of pleurisy with considerable effusion. The acute or moderate fever at first continued, presents numerous exacer- bations in the course of pneumonia. Primary pneumonia, or d'emblee, is less severe than consecutive pneu- monia. Pneumonia consecutive to simple pulmonary catarrh is often cured. Pneumonia consecutive to measles, scarlet fever, small-pox, is a very serious disease. The pneumonia of children at the breast is, especially, a serious disease, in consequence of the complications which precede or follow its develope- ment. The pneumonia of children at the breast has a great tendency to pass into the chronic state. The pneumonia which is consecutive to the developement of fibroplastic miliary granulations, or to tubercular granulation, is usually fatal. Expiratory, groaning and jerking respiration, accompanied by move- ments of the nostrils, announces that the life of the child is in great danger. The swelling and oedema of the hands, or of the feet, which comes on in the course of pneumonia, indicates an approaching death. (Trousseau.) The return of the secretion of tears, which has been suspended in the 428 Necrosis of the Inferior Maxilary Bone, dr. [Jul}-, attack of pneumonia, is a good augury for its favorable termination. (Trousseau.) One or two leeches at short intervals, several blisters in front of the chest and doses of ipecacuanha, are sufficient for the cure of simple acute pneumonia. [ Virginia Med. Journal. Necrosis of the Inferior Maxillary Bone from the Vapor of Phospho- rus. Removal of the entire Lower Jaw, and Recovery. By Dr. James E. Wood, of New York. The very brilliant operation described in this paper, which we find in the New York Journal of Medicine, May 1856, has many points of interest to the reader. The victim to the deleterious fumes of phosphorus was a " dipper" in a lucifer match factory in New York, an occupation she had followed for two years and a half. The first signs of mischief appeared in the form of tooth- ache, and one tooth was extracted, but swelling" of the jaw-bone supervened, followed by discharge of pus, and she entered Belle- vue hospital, and came under the charge of Dr. Wood. Necrosis of the inferior maxillary bone existed both on the right and left side, and Dr. Wood performed his first operation on the right and most diseased side. Finding the bone necrosed to its articulation, he removed the whole of the right lateral half of the inferior maxillary, and twenty-eight days afterwards he was com- pelled to perform a like operation on the left lateral half. The patient was discharged on the 20th of March 1856, with remarka- ble preservation of the contour and comeliness of the face. Necrosis, the result of the fumes of phosphorus, although a subject of but recent investigation, is not a very rare affection, as in tne paper before us, we find seven other instances of like charac- ter reported by Dr. Van Buren. They have all resulted from the exposure to tne fumes of phosphorus in "match factories," and the vast consumption of this modern convenience has undoubt- edly developed this sad disease. Dr. Wood remarks : Phosphorus disease, or necrosis from exposure to the fumes of phospho- rus in the manufacture of lucifer matches was first noticed in Germany. Lorinscr of Vienna, published the first account of this disease in 1845, and reported a number of of cases. Soon after, Heyfelder of Erlangen, and Strohl of Strasburg, published cases ; and in 1847, Drs. Von Bibra and Geist, published a separate work. In the following year, accounts of the disease were published in England ; and in noticing a case, in the surgical reports of Guy's hospital (1846-47) of separation an,d exfoliation or the lower jaw, from exposure to phosphorus, in the manufacture of lucifer matches, it is stated, that the disease was previously noticed to be not un- commom in those working in phosphorus. Mr. Stanley alludes to this disease in his treatise on Diseases of Bones. Cases have been occasionally reported in English periodicals; and in the Lancet for 1850, (vol. i. p. 41,) there is an interesting clinical lecture by Mr. Simon, on this subject, with 1856.] On the Treatment of Haemoptysis. 429 the full details of a case. Phosphorus disease does not seem to have been frequently noticed in this country, if we may judge by reported cases ; yet the causes exist among us in all their intensity. I am aware, indeed, of but a single case which has been placed on record, and that was observed by Dr. Bigelovv of Boston. That this disease is more prevalent in this country, than might be inferred from this single case, is evident from the several cases appended to this paper, which I have been able to collect, and the case kindly communicated by Dr. Van Buren. That phosphorus is the destructive agent in this disease, has been proved by experiments upon animals. Rabbits exposed to the fumes of phospho- rus, under circumstances similar to those which determine the disease in man, are similarly affected. Another fact seems clearly established, viz : the vapor of phosphorus must come into immediate contact with the per- iosteum or bone, in order to excite the morbid process. This explains, in the first place, why but few, comparatively, are affected who work in these manufactories ; and in the second place, why the lower jaw is more fre- quently the seat of the disease than any other bone. For it appears that those only sutler who have decayed teeth the defect in the teeth allowing the fumes of phosphorus to penetrate to the periosteum. So important is this latter fact, that the government of Erfurt has passed a decree, that no person having decayed teeth shall be allowed to work in lucifer match factories. In a factory in this city, no workmen is allowed to return to his work for a week after the extraction of a tooth. The prognosis in these cases is very unfavorable. "When the disease first comes .under notice, the peiiosteal inflammation has generally long existed, and new formations already separate the bone from its covering. More frequently the suppuration is established, exfoliations of bone are taking place, and the whole morbid process is in active progress. The sys- tem now hueaks down under the exhausting discharges and poisonous ema- nations from the jaw; and the miserable subject of this destructive disease falls a victim to its inroads upon its strength long before the completion of the process of exfoliation. [Ibid. On the Treatment of Haemoptysis. By M. ARAN. M. Aran agrees with those who entirely condemn the employ- ment of blood-letting in the treatment of haemoptysis, as it only temporarily arrests the bleeding, while it is dangerous, owing to the debility, and increased susceptibility, to the intercurrent affec- tions it gives rise to. He has, for some time past, been engaged in testing the efficacy of the various haemostatic agents employed in haemoptysis; and in this paper he gives the results of his ob- servations. He considers the essence of turpentine a most valua- ble remedy, given in doses of from 10 to 80 drops every hour, either in a spoonful of water, or mixed up with magnesia as a bolus. Marked amendment usually occurs in a few hours, and in from twenty-four to thirty-six hours the bleeding ceases. It is less suitable for young or plethoric subjects with febrile action, than in weak cachectic individuals, exhibiting atonic characteristics. Ergot of rye and ergotine are far less efficacious ; but chloride of 430 Croup and Method of its Treatment. [July, sodium, given in doses of 1 to 2^ drachms, proves very efficacious in some cases, and has the advantage of being always at hand. Among the astringents, tannin, and especially gallic acid, are to be recommended; the latter while quite as efficacious, does not exert the same desiccating effect upon the tissues, or induce the obstinate constipation produced by tannin. As a mean dose, M. Aran gives 15 centigrammes (a centigramme is \ grain) every hour or alternative hour. He has had little experience in the use of emetic and nauseating remedies; but in three cases in which veratriae was employed, the bleeding ceased as if by enchantment. This class of remedies, indeed, would deserve to stand in the first class of haemostatic agents, were there not others possessing like efficacy, and yet not giving rise to the painful nausea these pro- duce. M. Aran has derived great advantage from the combined use of digitalis and nitre. In ordinary cases, he gives in the twenty-four hours, 30 centigrammes of digitalis, and \\ gramme (a gramme is 15 grains) of nitre, divided into lour doses; but in very severe cases, these doses may be very much increased, so that the digitalis has been given to the extent of 1^ gramme, and the nitrate to 4 grammes, without injuriously affecting the action of the heart, while the effect produced upon the hemorrhage has been remarkable. Its arrest, never, however, takes place so sud- denly under the use of these medicines, as when turpentine or gallic acid is employed. In abundant, but not immediately dangerous hemorrhage we can choose among any of the above-mentioned means. In ex- tremely abundant hemorrhage, we must arrest the flow as speedily as possible, by agents which do not depress the powers of the economy too much, and which are not too slow in their operation. Neither ergot, acetate of lead, nor alum is sufficient to meet the danger. Turpentine, gallic acid, chloride of sodium, or nitre with digitalis, can alone be trusted; but the necessity of increasing the dose with the intensity of the hemorrhage may, perhaps, render the chloride of sodium, and especially the nitre and digitalis, dan- gerous, through the possibility of the production of a too great depression of the heart's action. It is, therefore to gallic acid or turpentine that we must chiefly trust in these severe cases ; and we must not limit ourselves to their employment, but also endea- vor to procure a temporary arrest of the hemorrhage by ligatures to the limbs and the application of ice to the chest, allowing the means employed internally to consolidate this temporary Cure. [Med. Tunes and Gaz. from Gaz. Hop. Croup and Method of its Treatment. Dr. Hftnerkopff has recently published a paper, in which he extols the administration of the sulphate of copper in this disease. He has used this substance in 99 cases of croup, 77 of which 1856.] Croup and Method of its Treatment. 481 recovered; and the total quantity administered by him to these patients was 2846 grains, or, on an average, 31^ grains each. He has never seen any poisonous effects result from its use, al- though one child got 27 grains daily for a week, or in all 216 grains; and another, 4| years old, took 150 grains in seven days, and a third, aged 21, 120 grains in three days. No inflammation, gangrene, or other bad symptoms took place. In 8 out of 13 cases which proved fatal, there were either other diseases coexisting, or the author was called to see them too late, so that he considers that his remedy failed in only 5 out of the remaining 82 cases. The mode in which he administered the salt was to dissolve from 6 to 8 grains in I j of water ; and, according to the age of the pa- tient, and the severity of the vomiting induced, to administer, more or less frequently, from a teaspoonful to a tablespoonful of this solution, until vomiting occurred. The nature of the vomit- ing should always regulate its administration; for the induction of vomiting is absolutely essential for the therapeutic action of the remedy, as it has a kind of specific influence on the disease. Dr. J. Samter, of Posen, has also written a paper in praise of the sulphate of copper in this disease. His remarks on its advan- tages and mode of administration so closely resemble those of Hon- erkopff which we have given, that it is unnecessary to quote them here at length. He uses a solution of from 4 to 8 grains,, (and in severe cases, 10 to 12 grains,) in ?ij of water; of this he gives 3ij repeatedly, till vomiting is induced, and thereafter 3j every two hours. In additin to the use of sulphate of copper, this author, at the beginning of the disease, applies four, eight, or twelve leeches to the larynx, and especially if there be any pain felt there,, and he afterwards applies stimulating epithenes. He also uses the inha- lation of powdered alum and sugar, employs warm baths, and envelopes the feet in hot sand, etc. Gunsburg Zeitschrift, vj.r 1855. Dr. Luzsinsky considers that there are four therapeutical indi- cations in the treatment of croup, which must be attended to by the physician. 1st. To change the peculiar blood crasis which exists. 2d. To prevent the localization of the inflammatory pro- cess in the larynx. 3d. To treat the spasm of the larynx. And, 4th. To encounter and destroy the false membranes whieh have been formed. For the fulfilment of the first indication, most men have recom- mended the use of mercurials, but Luzsinsky depends more upon alkalies, and especially on the carbonate of potass, which exercis- es a solvent action on all the albuminous products of the organism. Its use retards the developement of the constituents of the blood, and greatly impairs the vital coagulability and inherent plas- ticity of that fluid. This is the theory of the action of this salt, which Eggert recommended as a specific in croup, after an expe- 432 Experimental Researches, &c. [J aly , rience of it in about 250 cases. It may be given advantageously in doses of from 3ss to 3ij daily. Carbonate of soda may do in mild cases, but the other alkali is alone to be relied on in more severe ones. The second indication may be answered by the application of a blister, the size of a crown-piece, to the upper part of the manu- brium of the sternum. Spasm of the larynx is most surely treated by opium, applied externally, in conjunction with vesicants (15 grains to 3ss of ojjium, to 3ss of lard,) and also given in small doses internally. To arrest the formation of the pseudo-membranes, nitrate of silver, in a concentrated solution, may be applied to the fauces and enterance of the larynx. Emetics may thereafter be given, and they are only necessary in the exudative stage. Luzsinsky gives decided preference to the use of sulphate of copper, which he- administers by giving, every 15 minutes, a teaspoonful of a solu- tion of two or four grains (or even more,) of the salt in 3 iiss of some fluid. He does not look upon tracheotomy, in croupr iau a favorable lighht. Out of 30 cases treated thus by Dr. L. only seven died. Oester Zeitschrift, i, 6, 8, 10, 1855 ; also Schmidts Jahrb. xi, p. 207, 1855.- Dr. Menschel relates a case of croup in which, despite the timely and assiduous use of all the ordinary remedies for this disease,, difficulty of respiration and danger of suffocation increased. He then painted the whole of the front of the neck very darkly with a strong tincture of iodine, ( 3j of spirit,) and covered the part with flannel, smeared with digitalis ointment. After an hour the urgent symptoms had abated, the patient slept quietly during the- night, and next day was convalescent. [Preuss. Verein. Zeitungr 10, 1855. Edinburgh Med. Journal. Experimental Researches on the Production of a Convulsive Epilep- tiform Affection, after Lesions of the Spinal Chord. By M. Brown-Sequard. The author by numerous investigations, has assured himself that this convulsive affection may be produced after the following le- sions : 1st. Complete, or nearly complete, transverse section of one lateral half of the spinal chord. 2d. Simultaneous transverse section of the posterior columns of the posterior grey cornua, and of apart of the lateral columns. 3d. Transverse section of the posterior columns alone. 4th. Transverse section of the lateral columns. 5th. Transverse section of the anterior columns. 6th. Transverse sections of the entire spinal chord, in the dorsal and lumbar regions. 7th. Puncture of the spinal chord. Lesion of the chord would appear to be less and less capable of producing the epileptiform affection, in proportion as they are made 1856. j Relative Value of Disarticulation of the Knee, &c. 433 nearer the cliordal extremity. The time of the appearance of this affection is almost always in the third week after the operation. Convulsions occur sometimes without external excitement, but in general they can be very easily provoked, either by irritating one side of the face in those cases where the lesion exists only in a lateral half of the chord or the two sides indifferently, when both halves of the chord have been injured ; or again, by preventing the animal from breathing for a very short time. This convulsive affection much resembles epilepsy. It appears to differ from it only in this, that the animal cries during the attack, if be is pinched. The author has shown that the number of attacks increase consider- ably in animals which he shut up in a narrow space, and to which he gave much food. On examining animals having this convulsive affection, M. Brown Sequard found decidedly artificial lesion of the chord, a state of congestion of the base of the brain, and of the gasterion ganglion on both sides, when the lesion was on both sides of the spinal chord, and only on the side of the lesion, when it was on but one lateral half of the chord. From the facts reported in this work, the author draws the follow- ing conclusion?: : 1st. Various lesions of the spinal chord may produce in mammi- ferae a convulsive affection, having much analogy to epilepsy. It seems, consequently, that in man it is not by mere coincidence that we find alterations of the spinal chord in epileptics. 2d. Lesions of the spinal chord may produce such a change in the vitality of the trigeminal nerve, or of that part of the brain where this nerve rises, that the irritation of the branches of this nerve in the face, produces convulsions. Farther the right half of the spinal chord has this influence on the trigeminal nerve, or the encephalon of the right side, and the left half of the chord on one or other of these parts on the left side. [Gaz. Heb. from Amer. Med. Monthly. The Relative Value of Disarticulation of the Knee, and of Amputa- tion of the Thigh. M. Baudens, in a paper on this subject, referred by the Academy of Sciences, of Paris, to the section on medicine and surgery, says that the opinion of all the chiefs of the ambulances, confirmed by all that he saw from Marseilles and Toulon to Constantinople and the Crimea, is that disarticulation of the knee should be preferred to amputation of the thigh, whenever it is not possible to amputate the leg below the patella. Disarticulation should be performed imme- diately, that is as early as possible after the wound is received. Consecutively, amputation of the thigh should be preferred. The difference of success in immediate or consecutive disarticulations is due to the fact that even in the condition of health, the size of the bone is not in perfect harmony with the quantity of soft parts; and 434 Gallic Acid. [July, the disproportion becomes still greater when the patient has lost his flesh bv prolonged suffering and profuse supuration. [Gaz. Hebdom. Ibid. Gallic Acid. A London Physician reports several cases in which this remedy was successfully used as a haemostatic. The first was a case of vesicle haemorrhage, from a polypoid growth in the bladder. Six grains invariably checked the hemorrhage. The second a case of scarlatinal dropsy. Urine at first albuminous and afterwards bloody. Five grain doses three times a day greatly reduced the amount of blood; but it was not until a drachm a day had been continued for some time, that albumen and blood both disappeared from the urine. If the acid was omitted for a single day, the urine became as bloody as ever. He took more than eight ounces of the acid, and was cured. The third was a case of ha?matemesis, from chronic gastric ulcer. Ten grains were given every hour, and the patient finally relieved. The fourth, a case of albuminu- ria, in which the acid was given in doses often grains thrice a day. Decided relief was obtained ; but the patient was not cured. Case fifth, excessive menorrhagia, always checked by the acid in five- grain doses. Case sixth, menorrhagia, Avith ovarian irritation, simulating pregnancy. Every occurrence of hemorrhage effectu- ally controlled by the acid. Case seventh, hemorrhage from the bowels of a new-born infant, The acid given too late. The child sank after the first dose, exsanguine. Case eighth, cerebral he- morrhage from atheromatous deposit in the vessels of the brain. Relieved, but not cured, by the galic acid. Case ninth, intercra- nial hemorrhage from a fall ; relieved, but not cured, by the acid, in ten-grain doses. Case tenth, profuse epistaxis in typhoid fever. Two five-grain doses, and the application of the remedy to the schneiderian membrane readily stopped the discharge. Case eleventh, acute tonsillitis. Relieved by the following gargle: 3. Gallic acid, 9 ij ; distilled water, hot, 3 viij. Mix. Cases twelfth and thirteenth, tonsillitis, relieved by same gargle. Cases four- teenth and fifteenth, polypus uteri. Hemorrhage relieved by the acid in full doses. Case sxteenth, hemorrhage from injury to the vagina. Relieved by two-grain doses of the acid every half hour and cold applications. Case seventeenth, in- ternal piles, with unusually severe hemorrhage, checked by live- grain doses every three hours. Case eighteenth, haemoptisis, re- lieved by three five-grain doses, and a second attack by the same. Case nineteenth, erysipelas of the face, relieved by the application of a lotion, 3ij of the acid dissolved in a pint of warm water. Case twentieth, a profuse haemorrhage from a deep cut, arrested by powdered gallic acid placed in the wound, and without pain. 1856.] Treatment of Fistula Lachrymalis. 435 He suggests that the garlic mentioned in case eleventh might be used, in conj auction with the nitric acid treatment, in scarla- tina. In cases of yellow fever, we have succeeded in restraining he- morrhages from the stomach and bowels, and other outlets of the body, by the use of this remedy in doses of five to eight grains ; and we have found it scarcely less effectual in restraining watery dejec- tions from the bowels. A case of pyrosis was promptly relieved by the same remedy, as were also, to a marked extent, the dyspep- tic symptoms with which the disease was complicated. [New Hampshire Jour, of Medicine. On the Treatment of Fistula Lachrymalis. By M. TAVIGNOT. M. Tavignot is of opinion that fistula lachrymalis is the result of an organic disaccord between the chemical properties of the tears and the physiological properties of the nasolachrymal mucous membrane. This explains both the obstinacy of the disease and the relative efficacy of that treatment which most protects the mucous membrane from the contact of the tears. We find the tears will not flow through the canal, even when it has been dilated by surgical means ; while the presence of a for- eign body in the canal causes the cessation of the accidents ; this being better tolerated than the tears, the access of which it prevents. These various modes of treatment only succeed after long perse- verance has modified and transformed the characters of the mucous membrane. In place of occupying so long a time in obtaining this alteration in the sac and the duct, the author recommends that the gland itself should engage our attention. Where the affection does not arise from scrofulous disease, when it is ameanable to appropriate remedies, he is unaware of any means of restoring harmony to the parts, although in the 'early stages antiphlogistics and topical remedies do much to remove complications and procure tempora- ry relief. The contact of the tears can only, by the various means usually employed, be tempo rarity prevented, while obliteration of the passages is difficult to obtain, and is attended with stillici- dium. The lachrymal gland itself may, however, be removed without inconvenience. It is, in fact, the orbital portion that is alone to be removed; and the palpebral granules that remain suffice, with the mucus of the membranes, to lubrify the surface of the eye. The operation is inoffensive. Very soon great ame- lioration ensues, after the immediate effects of the operation have passed away, and this may go on to a definitive cure. When this ; is delayed, owing to the still disordered state of the passages, iodine injections should be employed. [Moniteur des Hopitaux. Brit, and For. Medico* Chir. Rev. N. S. VOL. XII. NO. VII. 28 436 Editorial and Miscellaneous. [July, The Seton before the Academy of Medicine of Paris. A very hot discussion has just been closed before the Academy of Medicine of Paris, on the use of the seton; and a great many instructive facts, both in ancient and modern medicine, connected with that powerful derivative, were brought to light, both by M. Bouvier, the author of the paper and advocate of the practice, and M. Malgaigne, the caustic and epigrammatic decrier of the seton. There can be hardly any doubt but that the latter eminent sur- geon went too far with his condemnation, and that the timely use of the seton, especially in chronic ophthalmic cases, will continue in favor with the great majority of practitioners. M. Bouvier employs little cords of No. 1 bougies, and covered with a water- proof composition, instead of the skein or tape. [London Lancet. EDITORIAL AND MISCELLANEOUS. Sulphur to arrest Vomiting. We are informed by Dr. J. F. Reynolds, of Newborn, Ala., that he lias recently succeeded in arresting two cases of vomiting, which had resisted the usual remedies, by the administration of a tea-spoonful of the Sublimed Sulphur. The dose is to be repeated imme- diately, if rejected. Never having used sulphur for this purpose, we can say nothing of its efficacy ourselves, but think it worthy of trial. Dr. II. A. Ramsay. We take from the Augusta Chronicle and Sentinel the following notice relating to the late notorious Editor of the "Georgia Blister and Critic," who for some years past seemed to take peculiar plea- sure in traducing honest men anonymously and otherwise. " Bonn t y Land and Pension Fraud. The Pension Office at Washington baring had suspicion of fraud being practised on account of the number of claims for homily land and pensions for revolutionary service sent from Col- umbia county, in this State, despatched Mr. Stephen C.Dodge, Special Agent, toinvestigate the matter. After some interviews with Mr. Stewart, the U.S. Marshal in Savannah, and Mr. Ross, of Macon, the Deputy U. S. Marshal, whom he met, in this city, he returned to Savannah and obtained warrants for the arrest of Dr. Eenry A. Ramsay and Richard W. Jones, of Columbia county, on the charge of having fabricated testimony in support of false pension claims. The arrests were made in this city hist Sunday, and the prisoners W( re forwauded to Savannah. On Wednesday they were examined before the U. S. Commissioner. Judge Henry required the pris- oners to enter into bonds for their attendance during the examination of $5,000, which bond was given by Ramsay, hut in default of which Jones was lodged in jail. The examination is said to have revealed the grossest 1856.] Editorial and Miscellaneous. 437 fraud and deception which had been practiced on persons whose affidavits had been obtained in support of false claims. Dr. Ramsay, who is thought to have been the chief instigator of the scheme, absconded during Wednes- day night, forfeiting his bail, and has not since been heard of. Vigilant efforts are being made for his re-capture. Jones is still in Savannah jail." Teeth extracted without pain. Instruments for the production of local insensibility to pain in Dental and Surgical Operations, secured under the Patent Laws, are now ready and for sale, with full instructions for use, at $25, and can be had by addressing Messrs. Jones, White & McCurdy, at their Philadelphia, New-York, or Boston Depots; or by addressing I. B. Branch at Galena, 111. American Dental Convention. The second annual meeting of this body will be held in New-York, on the 6th of August next. 7 O Death of James McCaffcrty. It is with profound regret we have to an- nounce the death of our worthy and highly esteemed Publisher. Mr. James McCafferty has been the printer and publisher of this Journal for nearly twelve years, and has always discharged the duties assigned him with punctuality and distinguished ability. The publication will be hereafter issued by Jeremiah Morris, for the benefit of the estate. Ninth Annual Session of the American Medical Association, at Detroit, Michigan. The Association met at Fireman's Hall, at 11 o'clock, A. M., and was called to order by the President, Dr. G. B. Wood, of Pennsylvania. Dr. Pitcher, of Michigan, in behalf of the Committee of Arrangements, welcomed the assemblage in handsome style. The roll was then called by Dr. Wistar, of Pennsylvania. On motion of Dr. Thompson, of Delaware, a recess of fifteen minutes was taken to allow the delegates from the respective States to report one member from each State represented, as a Committee to nominate officers for the ensuing year. After the Nominating Committee had retired, Dr. Pitcher, of Michigan, from the Committee of Arrangements, reported the order of proceeding for the session. The President announced the death of the eminent Dr. John C. Warren, of Boston, Mass., whereupon, Drs. Childs, of Massachusetts, and Gross, of Kentucky, having made some remarks; a committee of five was appointed to draft resolutions expressive of the feelings of this Association at the loss of their late associate. AFTERNOON SESSION. The Secretary read a letter from Dr. Grafton Tyler, of the District of Columbia, one of the Vice-Presidents, excusing his absence. He also read letters from the State Medical Society of Tennessee, and from the University of Nashville, inviting the Association to hold its next 438 Miscellaneous. [July* annual session at Nashville, Tennessee. Also, one tendering the use of the Hall of Representatives of that State for the purposes of said session. The following report was accepted and the nominations unanimously confirmed : President Dr. Zina Pitcher, of Detroit. Vice-Presidents Drs. Thomas W. Blatchford, of New- York; "Wm. K. Bowling, of Tennessee ; E. Geddings, of South-Carolina ; W. H. Brisbane, of Wisconsin. Secretaries Drs. W. Brodie, of Michigan ; R. C. Foster, of Tennessee. Treasurer Dr. Caspar Wister, of Pennsylvania. On motion, the President was requested to deliver his annual address. At the close of the address, on motion of Dr. Atlee, of Pa., Resolved, That the thanks ol'the Association be presented lo our late President for the able and interesting parting address he has just delivered, and that he be request- ed to present to the Committee of Publication a copy, for preservation in our trans- actions. On motion of Dr. Atlee, of Pa., Resolved, That a Committee of three be appointed to inform tie President and Vice-Presidents elect of their election, and conduct them to their seats. The President appointed as such Committee, Drs. Atles, of Pa., Reeves, of Ohio, and Sutton, of Ky. Upon taking the chair, Dr. Pitcher returned thanks for the- honor conferred. Dr. Frost, of Charleston, S. O, offered the following resolution, which was adopted : Resolved, That the thanks of this Association are due to the retiring officers for the zealous and efficient manner in which their duties have been performed ptn our late President, for the courtesy and ability with which he has presided over our de- liberations ; to all the officers, for their attention to the laborious duties of their sta- tions not excepting our Committee on Publication, to whom we must feel indebted for the satisfactory form in which the volume of the transactions appears. On motion of Dr. Gunn, of Michigan, Resolved, That the resolution passed at St. Louis, requiring a majority of the Committee on Publication to be appointed from residents of the place where the meeting is held, be repealed. Dr. Palmer, of Illinois, from the Committee on Prize Essays and Volun- teer Communications, submitted the following: "The Committee on Prize- Essays and Volunteer Communications, report, that some months since thy issued a card, which was extensively publish- ed in the medical journals, setting forth the terms upon which essays in- tended for prizes would be received ; but that the number of papers presented has been but four. " By referring to the past records of the Association, it is found that the numbers received by preceding Committees have been, in 1852, sixteen ; ' in 1853', fifteen; in 1854, nine; in 1855, six ; and in 1856, four. Your Committee beg leave to call attention to this almost rtgular and quite ra- T>id decrease in the number of essays presented, for the purpose of having the Association consider whether there be not danger that the number which may hereafter be furnished, will be so small as to afford insufficient rarr^e of comparison and* choice as to cause the preference shown to be much valued, if, indeed, presentations do not cease altogether, and whether any means should be dvised for preventing such a result. 1856.] Miscellaneous. 439 " The essays received by your Committee have been subjected to a care- ful examination ; and while admitting that they all possess a degree of merit, which would render them suggestive and useful, if given to the pro- fession, still, in their opinion, but one manifests that evidence of careful and laborious investigation, that wide scope and rigid accuracy of logical reasoning, that chasteness of expression and artistic skill in the presenta- tion -of the subject, as to furnish sufficient claim for awarding a prize by this body. " Bat one prize is therefore awarded. The essay selected for this honor, bears the title ' An Essay on the Arterial Circulation.' "It is regarded by the Committee as possessing the merits just alluded to, and while not wishing to give an unqualified endorsement of all the views which it contains, they regard it as possessing, not only interest in its physiological and scientific relations, but also real value in its patholo- gical and practical bearings. " The production has considerable length, and by the fulness with which the views advanced are discussed, it partakes as much of the nature of a treatise as an essay. It has, at least, one quality which Lord ]3acon con- sidered necessary to a treatise, as distinguished from an essay, it required a degree of leisure on the part of the writer, and will require the same on the part of the reader for him fully to appreciate its value. " The essay bears the motto ' Una est Veritas? (Signed) A. B. Palmer, Chairman. Samuel Denton, Silas H. Douglass, Ab'm Sager, E. Andrews. " On breaking the seal of the accompanying packet, Dr. Henry Harts- horn, of Philadelphia, Pa., was found to be th successful essayist." The report was accepted. Dr. Blatchford, of New York, from the Committee on " Hydrophobia, and the connection of the season of the year with its prevalence," read a report thereon. The Committee, in conclusion, submitted the following resolution, which was adopted : Resolved, That the Secretary transmit to the Governor of each State a copy of the statistical part ot this report, with :the respectful request that he would bring the sub- ject before the Legislature of the State over which he presides, that in iheir wisdom they may devise and unite upon a plan by which the evil may be mitigated, if not removed. The Committee on Nominations reported in favor of holding the next annual meeting of the Association at Nashville, Tenn., and the report was adopted. Dr. Wister, of Pa., from the Committee on Publication, made the annual report. It states that the first copies of the transactions of the last session of the Association were issued on the 10th of November, 1855 ; that 1000 copies were printed ; that the aggregate expense of printing, illustrating and binding was $1,922.70 ; that the distribution of the volume was effect- ed, in every possible instance, by express; that Drs. C. Hooker of Ct., Al- den March of Albany, J. L. Atlee of Pa., W. Brodie of Mich., C. B. Gibson of Richmond, E. L. Beadle of N. Y., H. W. DeSaussure of S. C, C. A. Pope of Mo., D. H. Storer of Mass., T. G. Richardson of Ky., J. Moran of 440 Miscellaneous. [July* B. I., T. Miller of D. C, F. E. B. Hintzc of Md., L. P. Bush of Del., Z. Pitcher of Mich., and J. B. Lindsley of Tenn., have rendered essential ser- vice to the Association some in procuring subscriptions to the volume, and all by cordial co-operation in its distribution ; that it is important to 6ecure efficient co-operation in every State by the appointment of gentle- men whose duty it shall be to aid in procuring subscriptions for, and cir- culating the transactions; that Connecticut is especially to be commended for her services in this particular ; that not a little embarrassment was ex- perienced by the committee in restoring to the list of permanent members the names of those who had been left off by order of the Association for non-payment of assessments ; that they had endeavored, however, by care- ful comparison of the various lists, to supply all omissions ; that the com- mittee had been reluctantly obliged to omit from the transactions two valuable reports on epidemic diseases by Dr. L. H. Anderson, of Ala., and Dr. E. D. Fenner, of New Orleans, but, as they had not been presented to the Association, and acted on by that body, there was no other alterna- tive ; that the following resolution, passed at the last session, should be strictly enforced : Resolved, That, hereafter, beginning with the session of 1S5G, no report, or other paper, shall be entitled to publication in the volume for the year in which it shall be presented to the Association, unless it be placed in the hands of the Committee of Publication on or before June first. The report further states that the number of volumes of transactions now remainino- on hand is as follows: of Vol. I. 41, of Vol. II. 9, of Vol. III. 32, of Vol. IV. 7, of Vol. V. 316, of Vol. VI. 66, of Vol. VII. 120, of Vol. VIII. 351 ; that some of the leading journals abroad have expressed a strong desire to complete their sets, and it rests with the Association to determine whether the missing numbers shall be supplied ; that, as only seven complete sets of the transactions are now in the possession of the Association, the committee recommend that no copy of either of the eight volumes which is necessary to the complete sets now remaining shall bo disposed of separately, or with any number of volumes short of a com- plete set. Dr. "Wood, of Philadelphia, moved to refer the nominations of standing committees to the Committee on Nominations. Carried. The same gentleman made a request in behalf of Dr. Hamilton, that the committee of which Dr. II. is chairman, may be continued for another year, it not being prepared to report at present. Granted. Dr. Pomeroy, of N. V., moved to reconsider the resolution requiring a member, when speaking, to stand upon the platform, and not to occupy more (ban ten minutes in his remarks. Lost. Dr. Smith, of N. J., moved that that portion of the resolution requiring members, when speaking, to take the stand, be rescinded. Carried. Dr. Atlee, of Pa., moved to refer the prize essay of Dr. Hartshorn on Arterial Circulation, and the report of Dr. Blatchford on Hydrophobia, to the Committee on Publication. Carried. Dr. Wist or, of Pa., the Treasurer, read his annual report. It recom- mends that the Treasurer be requested, at an early date after the adjourn- ment of the present meeting, to address a circular to each permanent member, announcing the abrogation of the resolution of 1854 making a yearly subscription to the transactions obligatory and the consequent 1856.] Miscellaneous. 441 restoration to membership of all those dropped from the published list of that year, advertising, also, the practicability of procuring back numbers of the transactions, with information as to the cost at which the series of volumes may be rendered complete, or an entire set furnished by the Association. Dr. Gross, of Ky., stated that Dr. "Wood, of New York, who was then in the meeting, had lately performed an operation in an extraordinary case removing a jaw-bone and moved that a time be appointed for the Asso- ciation to examine the part extirpated. Dr. Wood said he had not with him the article spoken of by the preced- ing speaker, but would lay it on the desk of the President in the morning. The President read a communication from Dr. Stille, Chairman of the Committee appointed last year to consider the subject of extending the lectures of each chair in medical schools over a period of two years, stating that the views of medical institutions had as yet been imperfectly ascer- tained, and asking a continuance of the committee. Granted. The President read an invitation to the Association to attend the ses- sion of the American Association for the Advancement of Science, at Alba- ny, in August next, at which time, also, the Dudley Observatory will be inaugurated, and an address delivered by Hon. Edward Everett. The in- vitation was accepted. SECOND DAT. The Secretary read communications from the following gentlemen ask- ing an extension of time in which to report upon the subjects named : Dr. A. J. Semmes, of N. Y. " Coroners' Inquests." Dr. J. Taylor Bradford, of Ky." Treatment of Cholera:' Dr. J. M."Reese, of N. Y " Infant Mortality." Dr. E. R. Peaslee, of Me. " Inflammation, &c." Dr. J. W. Corson, of N. Y. " The Causes of the Impulse of the Heart, and the Agencies which Influence it in Health and Disease." Dr. Mark Stephenson, of N. Y. " The Treatment best adapted to each Variety of Cataract, with the Method of Operation, Place of Election, Time, Age, &c." Dr. Beech, of Mich. "Medical Topography and Epidemics." Dr. J. C. Hutchinson, of N. Y. " The Anatomy and Histology of the Cervix Uteri." Referred to the Committee on Nominations. The Secretary announced that he had received the following resolution adopted at the last meeting of the New York State Medical Society : Resolved, That ihe members of the American Medical Association be invited to attend the semi-ceniennial celebration of this Society, which will occur on the first Tuesday of February, 1857. The invitation was accepted. The Secretary read a communication from Dr. Hamilton, of Buffalo, N. Y., transmitting the second part of a report upon Deformities after Frac- ture and Dislocations, and asking for a correction of the minutes of last .session in regard thereto. Dr. Hamilton also asked that he be permitted to incorporate, in a volume upon the subject he is preparing for publica- tion, that portion of the report already published by the Association. On motion of Dr. Brodie, of Michigan, the minutes were amended. 442 Miscellaneous. [July* Dr. Atlee, of Pa., offered a resolution that the request of Dr. H., in re- gard to the publication of the report, be granted. Dr. Lindsley, of Tenn., opposed the resolution. A similar request was denied at the session of the Association held at St. Louis. Dr. Palmer, of 111., moved to refer the matter to a special committee. Carried. Dr. Sutton, of Ky., offered a resolution that 1,000 copies of the address of the late President, Dr. Wood, be published. Adopted. On motion of Dr. J. B. Lindsley, of Tennessee, Resolved, That a committee of three be appointed by the Chair, to prepare a suita- ble minute in reference to the death of our lale Secretary, Dr. P. C. Gooch, of Rich- mond, Va., who fell a martyr while contending with the pestilence in Norfolk, in 1855. Dr. Gross, of Ky., from Committee appointed the day previous, reported the following preamble and resolutions relative to the death of Dr. J. C. Warren, of Boston ; Whereas, It has pleased Almighty God to remove from the scene of his earthly la- bors our late fellow-member, Dr. John C. Warren, of Boston, formerly President of this Association, and for many years Professor of Anatomy and Surgery in Har- vard University; And whereas, It is just and proper that, when a great and good man dies, his mem- ory should be cherished by his fellow-citizens, and transmitted unimpaired to poste- rity for the encouragement of future ages; therefore, Resolved, That this Association has learned with profound regret the news of an event which has deprived the American medical profession of one of its oldest, most useful, and most illustrious members American surgery one of its greatest orna- mentsscience one of its best iriends and humanity one of its noblest benefactors. Resolved, That the lile of Dr. John C. Warren, affords an example of a man who, notwithstanding the possession of ample riches, devoted himself, heart and soul, for upwards of half a century, to the cultivation and advancement of his profession, and lo the good of the human race. Resolved, That this Association deeply sympathises with the family of Dr. Warren in their bereavement, and the Secretary be requested to transmit lo them a copy of these proceedings. The preamble and resolutions were adopted, and referred to the Com- mittee on Publication. Dr. Gross, of Ky., read a report on " The causes which impede the progress of American Medical Literature." In conclusion, he submitted the following resolutions : Resolved, That this Association earnestly and respectfully recommends: 1st. The universal adoption, whenever practicable, by our schools, of American works, as text-books for their pupils. 3d. The discontinuance of the practice of editing foreign writings. 3d. A more independent course of the medical periodical press towards foreign productions, and a more liberal one towards American j and 4th- A better and more efficient employment of the facts which are continually furnished by our public institutions, for the elucidation of the nature of diseases and accidents, and, indirectly, for the formation of an original, a vigorous, and an independent national medical literature. Resolved, That we venerate the writings of the great medical men, past and pre- sent, of our country, and that we consider them as an important element of onr national medical literature. Resolved, That we shall always hail with pleasure any useful or valuable work, emanating from the European press, and that we shall always extend to tfiem a cordial welcome, as books of relerence, to acquaint us with the progress of legiti- mate medicine abroad, and to enlighten us in regard to any new facts of which they may be the repositories. Dr. Phelps of New York, moved that the report and resolutions, as a whole, be adopted, 1856.] Miscellaneous. 443 At the suggestion of a menber, the question was divided. The report was adopted. Upon the reading of the first resolution, a member proposed to substi- tute "just" for "liberal" in line 5. Dr. Gross accepted the amendment. Dr. Cobb, of N. Y., was opposed to the resolutions. If adopted and sent out to the world, they savor too much of know-nothingism to make them palatable. [Sensation.] Dr. Leid, of Pa., was in favor of leaving to teachers of medicine the selec- tion of their own text books. Dr. Davis understood there was another report touching upon the subject that upon "American Medical Literature," by Dr. Brecken ridge, ofKy. He moved to lay the resolutions upon the table until that report was read. Carried. The Secretary read a communication from Dr. P. A. Jewett, of Conn., Chairman of the Committee to Procure Memoirs of the Eminent and Wor- thy Dead. Referred to Committee on Nominations. Dr. Breckenridge, of Ky., read a report upon American Medical Litera- ture. It was accepted and referred to the Committee on Publication. THIRD HAY MORNING SESSION. On motion of Dr. Atlee, of Pa., Resolved, That the President shall be authorized annually to appoint delegates to represent this Association, at the meetings ot the British Association, the American Medical Society of Paris, and such other scientific bodies in Europe as maybe affiliated with us. Adopted. On motion of Dr. Mendenhall of Ohio, Resolved, That the Secretary be instructed to strike the name of G. H. Cleveland from the list of permanent members of this Association. On motion of Dr. Atlee, of Pa., Resolved, That the name of James R. McClintock be striken from the list of per- manent members. These expelled members were accused by the movers of the resolutions of having retrograded into quackery. On motion of Dr. Bissell, of New York, Resolved, That this Association has learned with deep regret of the death of one of its members, Dr. Theodore Rotneyn Beck, of Albany, N. Y., whose whole life has been devoted to the attainment and promotion of medicine and general science, and that we do hereby express our high appreciation of ihe excellencies of his character, distinguished by its simplicity, integrity, and firmness of purpose, and by the extent and variety of his acquirements in medical as well as in almost every department of science. Resolved, That the above resolution be referred to the Committee to procure memorials of the eminent and worthy dead, and that they be requested to procure a memoir of the late Dr. Beck, to be published in the transactions of the Association. Dr, Bloodgood, of III, offered the following : Resolved, That the constitution of this Association be so amended as that hereaf- ter the President shall be elected by ballot, and shall not be a resident of the State in which he is elected. On motion of Dr. Watson, of N. Y., laid on the table. Dr. AVister, of Pa., offered the following, which was adopted : Resolved, That the invitation to gentlemen of the medical professiou of Canada, extended to them by the American Medical Association at its session in Philadel- phia, be renewed for the meeting at Nashville, Tenn ; and that this Association may be safe from the introduction of unsuitable persons, it is recommended that gentle- men presenting themselves from the Province of Canada should be provided with a letter of introduction to this Association from one of the following gentlemen : Drs, 444 Miscellaneous. [Juljt Tarquand A Scott, Woodstock, Canada ; Drs. Hodder, Bethune, Richardson, Bon- nell, Haswell, Widmer, Beaumont, Herrick, of Toronto; Drs. O'Reilly, Craiggie, Dugnan, of Hamilton; Dr. Sampson, of Kingston. Dr. Phelps, of New York, offered the following : Wlvereas, It has pleased an All Wise, but Inscrutable Providence, to visit the city of Norfolk, Va., and vicinity, with a desolating pestilence, equal, or surpassing, any record in ancient or modern limes, and by which, in a few weeks, forty physicians, either residents or those from abroad, who had promptly rushed to the rescue, among the the number ol whom was our late Secretary and associate, Dr. Gooch. of Rich- mond had been swept away ; therefore, Resolved, That such an instance of signal and unflinching devotion to the cause of science and of humanity demands at the hands of this national Association a passing expression of their high admiration of this, another memorable instance of the unparallelled sacrifices of the profession to the interests of the healing art and of the race. Resolved, That this minute be incorporated in our transactions. Dr. Stocker, of Perm., offered the following amendments to the constitu- tion : Amend article 3 so that it shall read: " Article 3. The regular meetings of the Association shall be held annually, and commence on the first Tuesday of May. The Association shall meet biennially in the city ol . The place of meeting lor the immediate year shall be determined by a vote of the Association." Amend article 4 by providing for or.e permanent and two assistant secretaries, and also specifying the duties, &c. of each. Laid on the tahle under the rule. Dr. Dorsey, of Ohio, offered the following : Resolved, That in May, 185S, and every third year thereafter, this Association meet at Washington City, and that the present officers be requested to correspond with the Board of Managers of the Smithsonian Institute, in regard to furnishing necessary rooms for the keeping of the archives of the Association. Laid on the table under the rule. On motion of Dr. Atlec, of Pa., the report and resolutions of Dr. Gross, and the report of Dr. Breckenridge, upon "American Medical Literature," were referred to the Committee on Publication. Dr. Palmer, of 111., from Special Committee to which was referred the communication of Dr. Hamilton, reported the following resolution, which was adopted : Resolved, That leave be granted to Dr. F. H. Hamilton to make use of the materi- als of his report on " Deformities alter Fractures," which is in course of publication by this Association, in his anticipated work upon "Fractures and Dislocations." Dr. A. B. Palmer, Professor in the Michigan University, from the Com- mittee on Plans of Organization for State and County Medical Societies, presented a lengthened and able report, containing numerous useful sug- gestions, with outlines for the proper organization of local societies, and a series of resolutions in accordance with the views enforced in the report. Accepted, and referred to the Committee on Publication. On motion, the resolutions were temporarily laid on the table for further action by the Convention. Dr. Davis, of Illinois, chairman of Special Committee, reported on "The Changes in the Composition and Properties of the Milk of the Human Female, Produced by Menstruation and Pregnancy," in a paper containing numerous valuable details of much interest to the profession and the public, obtained by careful examination and comparison, and showing conclusively the ill effects of lactation, especially during the latter of the periods referred to. Accepted, and referred to the Committee on Publication. 1856.] Miscellaneous. 445 Dr. Chas. Q. Chandler, of Missouri, who was to report on "Malignant Periodic Fevers," submitted, as a substitute, through the Secretary, a pa- per on " Sulphate of Cinchona," which was received as a " voluntary con- tribution," and referred to a special committee. Dr. Johnson, of Chicago, asked further time to report on "Excretions, &c. Referred to Committee on Nominations. Dr. J. M. Newman, of Buffalo, from Committee on the Sanitary Police of Cities, presented an elaborate report, embracing details of the various estimated causes of disease in cities, as compared with rural localities, together with nemerous valuable statistics of mortality in the larger cities of Europe and the Union, of which the Doctor, at the request of the Asso- ciation, gave a brief, verbal abstract. The report evidently embodies a vast mass of useful information, with deductions from it that city life is inimical to health and longevity, and arguments enforcing the urgent necessity for ameliorating the senitary condition of the populous localities of cities and large towns. Of diseases arising from impure air and insufficient ventila- tion, classed under the term "zimotic," the report stated that, in 1850, 40 per cent, of all the deaths in the various cities were of that nature. The report also embodied details of the loss of life from cholera, small pox, &c, giving startling expositions of clanger from these sources, and recommends the enactment of laws for compulsory ventilation and cleanliness, as well as for vaccination, &c. Accepted, and referred to Committee on Publica- tion. AFTERNOON SESSION. Dr. A. J. Fuller, of Me., chairman of the Committee on the Best Treat- ment of Cholera Infantum, read a report thereon, in which he stated that the pathology of the disease was little understood, and that physicians should interchange views on the subject. The report was accepted and referred to the Committee on Publication. Dr. Green, of N. Y., chairman of the Committee on the Use and Effects of Application of Nitrate of Silver to the Throat, read a report thereon. He asserted that great benefits had been derived from topical medication in thoracic diseases, tuberculosis, bronchitis, &c. The report was accept- ed and referred to the Committee on Publication. Dr. Flint, of Louisville, chairman of the Committee on the Best Mode of Rendering the Medical Patronage of the National Government Tributary to the Honor and Improvement of the Profession, read a report thereon. He denounced the granting of patents by the United States government to " quack medicines," stating, however, that it appears, from a letter writ- ten by the present Commissioner of Patents, that the practice of the office has been to discourage such abuse of its functions, and that, during the past fifteen years, but four or five such patents have been granted, although from twenty to thirty applications therefor have been made per year. The credit of sanitary improvements, Dr. Flint said, were not due to individu- als, but to medical science. Such improvements are never discoveries or revelations, but inductions. The United States government should aid the great cause of medical science by making appropriations for the publica- tion of the transactions of the National Association, and by paying prizes I for the best essays on subjects selected by that Association. The report was accepted and referred to the Committee on Publication. The Committee on Nominations made the following report : 446 Miscellaneous. [July, The Nominating Committee beg leave to make the following report : For Chairmen of Special Committees for 1857 : Dr. E. R. Peaslee, of Brunswick, Me., on Inflammation, its Pathology and its Relation to the Recuperative Process. Dr. J. C. Hutchinson, of Brooklyn, N. Y., and Charles E. Isaacs, of New York city, on the Anatomy and Histology of the Cervix Uteri. Dr. J. Taylor Bradford, of Augusta, Ky., on the Treatment of Cholera. Dr. Mark Stephenson, of N. Y., on the Treatment Best Adapted to Each Variety of Cataract, with the Method of Operation, Place of Election, Time, Age, &c. Dr. J. W. Corson, of N. Y., on the Causes of the Impulse of the Heart, and the Agencies which Influence it in Health and Disease. Dr. D. Meredith Reese, of N. Y., on the Causes of Infant Mortality in Large Cities, the Source of its Increase, and the Means for its Diminution. Dr. J. Foster Jenkins, of Yonkers, N. Y., on Spontaneous Umbilical Hemorrhage of the Newly Born. Dr. Henry Carpenter, of Lancaster, Pa., on the Use of Instruments in Obstetrical Practice. Dr. Alex. J. Semmes, of Washington, D. O, on the Measures to be Adopted to Remedy the Evils Existing in the Present Mode of Holding Coroners' Inquest. Dr. J. Marion Sims, of New York city, on the Treatment of the Results of Obstructed Labor. Dr. J. B. Flint, of Louisville, Ky., on the True Position and Value of Operative Surgery as a Therapeutic Agent. Dr. G. Volney Dorsey, of Piqua, Ohio, on the Causes and Cure of Indi- gestion, especially in relation to the Therapeutic Indications to be derived from the Chemical Composition of the Deposits in the Urine. Dr. C. B. Coventry, of Utica, N. Y., on the Medical Jurisprudence of In- sanity, and the Testimony of Skilled Witnesses in Courts of Justice. Dr. Jos. Leidy, of Philadelphia, Pa., on Human, Animal, and Vegetable Parasities. Dr. M. D. Darnall, of Bainbridge, Ind., on the value of a Strict Atten- tion to Position in the Treatment of Diseases of the Abdomen. Dr. George Sutton, of Aurora, Ind., on Milk Sickness. Dr. Clark J. Pease, of Janesville, Wis., on the Blending and Conversion of the Types of Fever. Dr. B. S. Woodsworth, of Fort Wayne. Ind., on the Best Substitute for Cinchona and its Preparations in the Treatment of Intermittent Fever and Malarious Neuralgia. Dr. Franklin Ilinkle, of Marietta, Pa., on the Use of Cinchona in Mala- rious Diseases. Dr. Henry F. Campbell, of Augusta, Ga. on the Nervous System in Feb- , rile Diseases. Dr. John Neill, of Philadelphia, Penn., on the Laws, Governing the De- posit of Bone. Dr. John W. Green, of N. Y. City, on the Intimate Effects of Certain Toxicological Agents in the Animal Tissues and Fluids. Dr. George Suckley, U. S. A., on the Medical Topography and Fauna of Washington Territory. Dr. Jas. Cooper, of Hoboken, N. J., on the Flora of Washington and Oregon Territories. 1856.J Miscellaneous. 447 Dr. Ohas. E. Isaacs, of N. Y., on the Intimate Structure and the Patholo- gy of the Kidney. Dr. Israel Moses, of New York City, on the Diseases Incidental to Euro- peans from Temperate Climates in their Transition through Central Ameri- ca. Dr. T. W. Gordon, of Georgetown, Brown County, 0., on the Etiology and Pathology of Epidemic Cholera, to be continued three years, and with power to add any other members. Dr. H. A. Johnson, of Chicago, on the Excretions as an Index to the Organic Changes going on in the System. Dr. D. D. Thomson, of Louisville, on the Remedial Effects of Chloroform. Standing Committees. Committee on Publications. Drs. Francis G. Sroilh, of Pa.r Chairman ; Caspard Wister, of Pa. ; Samuel L. Hollingsworth, of Pa. ; Samsel Lewis, of Pa. ; H. F. Askew, of Del. ; Wm. Brodie, of Mich. ; R. C. Foster, of Tenn. Committee on Prize Essays. Drs. Wm. K. Bowling, of Tenn., Chairman ; E. B. Haskins, of Tenn. ; Thomas Lipscomb, of Term. ; A. H. Buchanan, of Tenn. ; B. W. Avent, of Tenn. ; W. A. Cheatham, of Tenn. ; Paul F. Eve,, of Tenn. Committee of Arrangements. Drs. C. K. Winston, of Tenn., Chairman; Ira Conwell. of Tenn. ; William D. Haggard, o>f Tenn. ; J. L. C. Johnson, of Tenn.; F. A. Ramsay, of Tenn. ; Geo. Grant, of Tenn. ; J. B. Lindsley, of Tenn. To fill vacancies in the Committee on Medical Topography and Epidem- ics. New Hampshire. Dr. V. P. Fitch, of Amherst. Colifornia. Dr. Robert Murray, of Fort Miller. To fill vacancies in the Committee upon a Uniform System of Registra- tion of Marriages, Births and Deaths : Vermont. Dr. Adrian T. Woodward, of Castleton. Connecticut. Dr. Wm. B. Casey, of Middletown. Virginia. Dr. R. W. Haxall, of Richmond. California. Dr. Arthur R. Stout, of San Francisco. They recommend the continuance of the " Committee to Procure Memo- rials of the Eminent and Worthy Dead," and that the report, as far as prepared, be referred to the Committee on Publication. Standing Committees. On Medical Education. Drs. E. Geddings, of S. C, Chairman ; C. W. Le' Boutillier, of Minnesota; G. F. Mitchell, of Ohio; S. W. Clanton, of Ala.; S. W. Butler, of N. J. On Medical Literature. Drs. R. Hills, of Ohio, Chairman ; D. W. Yan-- dell, of Ky. ; R. R. Porter, of Del. ; H. A, Johnson, of 111. ; Charles E. Swan, of Maine. The President stated that Dr. Anderson, of Ala., chairman of Committee' on Medical Education, had sent in his report. It was accepted and referred to the Committee on Publication. A report from Dr. Wroth, of Md., on the- Medical Topography and Epi- demics of the Eastern Shore of Maryland, was accepted and referred to the Committee on Publication. A Report from Dr. Cain, of S. O, on the Epidemic of Yellow Fever in 448 Miscellaneous. [July* Charleston in 1854, was accepted and referred to the Committee on Publi- cation. A report from Dr. Fenner, of La., on the Medical Topography and Epidem- ics of Louisiana, was accepted and referred to the Committee on Publica- tion. Dr. Palmer, of 111., offered the following, which was adopted. Resolved, That the volunteer communications in the hands of the Committee of Arrangements be referred, with all other such communications, to a special com- mittee to be appointed by ihe Chair, residing at the place of publication of the transactions; and if in their judgment, the papers are worthy, they be referred by them to the Committee on Publication, to go into the transactions of the Asso- ciation. The President appointed as such a committee, Drs. A. Stille, S.Jackson, and F. J. B. Biddle. The authors and titles of the volunteer communications were announced by Secretary Brodie as follows : By Dr. C.J. Chandler, ofBoeheport, Mo., on Sulph. Cinchona in Period- ic Diseases. By Dr. Isidor Gluck, of New York, on Formation of Gun Shot Wounds, &c. By Dr. G. P. Hachenberg, on an Improved Method of Applying Com- pression to the Scrotum. The Committee on Medical Literature, for 1855, was continued for . another year. Dr. Neill of Philadelphia, offered a resolution that no medical prepara- tion, account of surgical operation, or anything else designed or calculated to give notoriety to an individual, be laid before the Association, until re- ported upon by a special committee. Dr. Wood of N. Y., presumed that this resolution was aimed at him. He had come here with the description of a disease never before described by surgeons phosphorus disease of the jaw-bone. He had felt great de- licacy in inviting the attention of the Association to the subject, and it was not until after consultation with many of the most prominent members of the body, that he had permitted a friend to do so. As for the charge of seeking notoriety, he denied it in toto. He had aimed at no such purpose, and he felt wounded at the tone of the resolution. Much applause followed the conclusion of Dr. Wood's remarks. Dr. Neill disclamed the intention of personal allusion in the resolution he had offered. That resolution embodied a principle which never should be violated. Dr. Wood's reputation, or notoriety, might not be enhanced by the action tinder reference, but the privilege of similarly proceeding might be abused by other persons hereafter. Dr. Neill's remarks were received with applause. Dr. Wood said he had heard beforehand that such a resolution was to , be offered ; and it was not the resolution itself that he cared so much about, as the outside talk. He expressed a desire that the motion of Dr. Gross, of Ky., inviting the Association to examine his (Dr. Wood's) surgical spe- cimen, would be striken from the minutes. Dr. Thompson, of DeL made some humerous remarks. He hoped that New York would hold Iter jaw, and Philadelphia not stick in hers. He trusted that Dr. Neill would withdraw his resolution, and that Dr. Grossr motion would be striken from the minutes. If these were done, he would 1856.] Miscellaneous. 449 see that all was made right between the opposing gentlemen before they reached home. Dr. Gross moved to strike his motion referred to from the minutes, for the purpose, he said, of removing the bone of contention. Dr. Neill withdrew his resolution, and Dr. Gross' motion was striken from the minutes. Dr. Dorsey, of Ohio, offered the following resolution, which was adopted : Resolved, by the American Medical Association, That the Committee of the Etio- logy and Pathology ot Cholera be instructed to memorialize the Cor.gTess of the United States, requesting that Honorable body to grant every necessary assistance which can or will promote the objects for which the Committee has been appointed. Dr. Wister, of Pa., offered the following which was adopted : Resolved, That a committee of three be appointed by the President to correspond with the proper officer of the Smithsonian Institute, inquiring into the possibility of procuring a chamber in that institution for the uses of this Association. The President appointed as such committee, Drs. Wister, of Pa., Hale, of Washington, and J. Neill, of Pa. Dr. Phelps of N. Y., offered the following, which were adopted : Resolved, That the thanks of this Association are due, and are hereby tendered, to the Fire Department of the city of Detroit, for the use of their large and commodious hall, so amply furnishing to us accommodation for the convenient transaction of business. Resolved, That the urbane deportment and elegant hospitalities of the profession and of private individuals, as well as the polite attention of citizens generally, de- mand of this Association a high appreciation of the cultivated manners of this city of the West, and which has tended greatly to enhance the pleasure of the session here of the delegates from abroad. Dr. Atlee, of Pa., offered the following, which was adopted : Resolved, That all voluntary communications hereafter presented to the Associ- ation shall be referred to a Special Committee, to be appointed by the President on the first day of each annual meeting, whose duty it shall be to examine such com- munications and report upon the propriety of their presentation and reference to the Committee of Publication. Dr. R. K. Smith, offered the following : Resolved, That a special committee be appointed to report to the next meeting of the American Medical Association a classification of those diseases which involve a derangement of the mental manifestations. Adopted, and Dr. Smith appointed chairman of said committee, with power to choose his associates. Dr. McGugin offered the following: Resolved, That a special committee be appointed to report on the subject of "Stomatitis Materna." Adopted, and Dr. McGugin appointed chairman of such committee. On motion of Dr. Bailey, of 111., Dr. Davis, of Chicago, was requested to continue his observations on the changes produced in the composition and qualities of milk by pregnancy and menstruation ; also the best substitute for the mother's milk when weaning becomes necessary ; and report at the : next meeting of the Association. The Association then adjourned to meet in Nashville, Tenn., in \Qb*I. A Uterus in a Man sixty-three years old. By Prof. Langer. The case of Professor Langer is a physiological curiosity. Professor Aramij has recently found, at the necropsy of a man sixty-three years old, a struc- ture resembling a uterus, between the rectum and bladder. The man had 450 Miscellaneous. had a " capon's voice," beard well grown ; he had lived thirty years in childless wedlock. The uterus was two-horned, ending in two large open tubes. The mesometrum (ligamentum uteri latum of the female) ended on either side in a fine doubling of peritoneum; a true ala vespertilionis, which embraced the testicles and epididymi ; and, at the upper border, the end of the tube. On the left side, the uterine horn, with its tube, was dragged over by a scrotal hernia. The distance between the two testicles in the preparation is sixteen inches. A round ligament (uterine) is marked by a bundle of vessels on the right side. The uterus is connected with the upper part of the prostate. The arteries of this uterus arise, with those of the bladder, from a common arteria vesico-uterina. The organ could be easily inflated through the abdominal end of the tube. There were no strong folds in the interior, even at the isthmus. Above the isthmus, the walls of the two-horned uterus were soft, the muscular tissue loose, its mucous membrane was easily separated as a distinct layer. On a section, there were detected tubular crypts opening on the free surface. In fine, there were distinguished three parts of this nterus ; An orificial part a gland less, thickeded portion, terminating at the isthmus ; and a part provided with the ordinary uterine glands, which end in two short horns, which again end in tubes. The testicles were of the normal size. The vasa deferentia ran in an obliqne direction to the isthmus uteri, to pen- etrate the prostate. True vesiculie seminales were absent. [Med. Chir. Review. Quick Process for Mercurial Ointment. M. Bernier, Pharmaceutist of Reuwez (Ardennes,) recommends the following process. Take one-third of the lard to be used for the ointment, heat it in a skillet of copper till it com- mences to disengage vapors and burn, and then pour it into an earthen vessel, and place it in the cellar for ten or fifteen days. Use this lard to extinguish the mercury, employing an iron mortar, and observing to add the mercury gradually as each addition disappears. The mercury is soon perfectly extinguished when the rest of the lard is incorporated thoroughly, the whole operation requiring but an hour. [Eeportoire de PKarmacie and Ametican Jour, of Pharmacy. Muriate of Opium. We have met with, in looking over old files of the Medical Times and Gazette, a new preparation of opium ; and as it is al- ways desirable to have as many modifications as possible of a drag which so frequently requires to be used, and which acts so differently on peculiar idiosyncracies, we give it a place in our pages. Take of the best powdered opium, 3i; muriatic acid, 3i ; distilled water, 3xix. Shake this mixture frequently for fourteen days, and strain. The dose is from twenty to forty drops. [Philadelphia Med. and Surg. Jour. Chloride of Zinc Collyrium. Mr. Critchett of the Royal ophthalmic hospital (Moorfields) has been in the habit of using frequency a lotion of the chloride of zinc as a lotion in thickened and vascular conditions of the conjunctive. He regards them as in an analogous condition to the gleets of the urethra, and calls this condition a "gleet of the eye." Its strength is one grain to the ounce. [lb. SOUTHERN MEDICAL AND SURGICAL JOURNAL. (NEW SERIES.) Vol. XII.] AUGUSTA, GEORGIA, AUGUST, 1856. [No. 8. ORIGINAL AND ECLECTIC. ARTICLE XX. LETTERS FROM SAML. D. HOLT, M. D., UPON SOME POINTS OF GENERAL PATHOLOGY. LETTER NO. 13. Montgomery, Ala., June 25th, 1856. Messrs. Editors Having spoken of the periodic character of these fevers, (intermittent and remittent,) and insisted upon the necessi- ty of attention to that which constitutes their most important characteristic feature' important, at least, so far as their proper treatment is concerned, I will next examine them with reference to the nature of their special pathology ; but before I do so, it is necessary that I should make some general remarks respecting the nature of that condition of the system called "fever." Heretofore, in my remarks respecting the general pathological conditions of excitement and depression, I have designedly neg- lected to draw any distinctions between the febrile affections with which they were associated, whether they were regarded as idiopa- thic or symptomatic, for the reason, that I desired to keep the attention fixed upon the conditions, and not upon the diseases, with which they were associated ; and for this purpose, selected pneu- monia, or inflammation of the lung, as the disease, and the fever as the consequential condition, varying in character and degree according to the nature of the individual, and general predisposing causes, epidemic influences, &c, which I have already pointed out. N. S. VOL. XII. NO. VIII. 29 452 Holt's Letters upon General Pathology. [August, I come now to consider "fever" in the light of a disease, and not a condition, symptomatic of, or depending upon, the pre-existence of some other disease ; and the first question which presents itself is What is fever? If we define it to be a state of general ner- vous excitement, with increased vascular action to such a degree or extent as to derange, interrupt, or suspend, the healthy per- formance of the vital functions, with the characteristic signs of such a condition, as heat and dryness of skin, with increased strength and frequency of pulse, it may serve to convey a general idea of fever, but does not let us into the secret of its first cause, or the true pathology of the disease. A better definition of fever, in my opinion, is, that it is an effort of the system to relieve some laboring organ or impeded function, to restore some suspended secretion, or to rid itself of the presence of some noxious and of- fending cause. That fever, though it consists in a concatenation of morbid actions which involve the whole system, often producing the most dangerous and fatal results, is nevertheless a recupera- tive process, or a sanative effort of the system to overcome some pre-existing morbid impression under which it labors, as the result of the operation of one or more of the thousand causes, apprecia- ble and non-appreciable, moral, physical and chemical, which are perpetually at war with the vital powers, and interfering with the healthy operations of the animal econom}7. That the concatena- tion of morbid actions constituting fever has its origin or starting point in some part, organ, system, or function, all being subject to the influence of the morbific agents, and capable, under circum- stances, of originating the febrile movement. That the pre existing morbid impression which calls the sanative effort of the system into action, is a change in the innervation of the part, which im- plies a departure from the line of healthy excitement, by such an accumulation or exaltation of nervous power above, or such a loss, destruction, or depression of nervous power below that line, as to interrupt, suspend or destroy the healthy action of the part, organ, system, or function involved, and consists of debility or nervous depression the first link, irritation the second, and in- flammation the third, in the chain of all morbid actions; upon these depending all the changes which take place in the fluids and solid tissues consequent upon the febrile movement. This view of the subject assigns to all fevers a local origin, but it does not explain how the existence of a local morbid impression, 1856.] Holt's Letters upon General Pathology. 453 either of depression, irritation or inflammation, brings about the febrile movement. This may not be so difficult to explain, or understand, with reference to those fevers which are recognized as symptomatic, having inflammation or irritation as their osten- sible cause, if we call to our aid the physiological relations which are known to exist between all parts of the system through the great nervous centres, and the facility and rapidity with which, by direct and reflex nervous action, impressions are transmitted and communicated from one part of the organ or system to another. But it is somewhat different with those fevers which have no such ostensible cause, and which have, in consequence, been recognized as idiopathic fevers. Such are the fevers under consideration (intermittents and remittents) in their essential typical character. To explain the origin of these fevers, we must suppose, what has generally been conceded, that the causes, which are very numer- ous, act with a greater degree of force upon some organs than upon others that some are directly depressing in their influence, and others indirectly so; but that they all tend to the same result, namely, debility and depression. Pathologists have endeavored to assign for the seat and origin of these fevers a special location ; some have taken the brain, others the spinal or ganglionic cen- tres, while others have taken particular organs, as the stomach, liver, spleen, &c. But the truth, I think is, that though some organs are more uniformly implicated in their origin, none can be said to be invariably or essentially concerned ; but that those or- gans which have been most strongly impressed, or which yield most readily to depressing influences, -will have to bear the brunt and burden of the disease. Hence the great variety of these dis- eases which have been described by the systematic writers, both in this country and Europe varieties founded, not upon an}' dif- ference in their essential pathology, but upon the organs involved. When, then, any important organ, from the operation of the de- pressing causes, falls into such a state of debility or depression as to render it incapable of performing its accustomed functions, the recuperative powers of the system are called into requisition in aid of the laboring organ ; the sanative effort commences, and a rally of the vital forces takes place in the organs where it accu- mulates, at the expense of a proportional loss to other organs and parts of the system. This process will usually be attended with a sort of oscillatory motion in the nervous and circulatory systems 454 Holt's Letters upon General Pathology. [August, constituting the forming stage of these fevers. At this time, the genera], remote or systemic capillaries, sharing in the general loss of nervous power, become relaxed, allowing the free flovvof blood out of the arteries, while its flow is retarded in the lungs, from a similar loss of power in the muscles of respiration. Thus, the bal- ance between the arterial and venous portions of the circulation becomes broken, and the blood accumulating upon the right side of the heart, in the large venous trunks and cavities, constitutes the congestive or cold stage or chill. Now, though an analysis of the symptoms and phenomena which belong to, and distin- guish this condition, shows not a single one which is character- istic of fever, but indicates, on the contrary, a diametrically oppo- site condition, we are bound to consider it an essential condition in the pathology of these fevers, being generally found to appear in the first and the last act, and frequently throughout the drama. When this condition has reached the lowest point of depression, and continued for a somewhat indefinite time, the recuperative powers of the system are again called into operation, the sanative effort and the reactionary movement commences. The accumula- ted excitability, the nervous power, which had been rallied in support of the laboring organ, being now no longer necessary for its support, is redistributed to the organs whence it was taken. The organs of respiration thus acquiring their accustomed power of action, allow a free flow of blood through the lungs, while the remote or systemic capillaries, having regained their lost tone and power of action, and the blood retarded in its flow through them, accumulates upon the left side of the heart, producing a general arterial plethora, giving rise to the characteristic phenome- na of, and constituting the true febrile condition. When this reactionary movement commences, which is at first slow, import- ant changes take place with respect both to the nervous and cir- culatory systems. The blood which had been pent up, and become somewhat depraved, acquires, in its passage through the lungs, new life, which it imparts to the heart and arteries, to the brain and other nervous centres, increasing their activity, and thus creating a state of general nervous excitement and increased vas- cular action, giving rise to heat and dryness of skin, and strength and frequency of the pulse, the characteristic symptoms of fever. This state of excitement, after continuing for a somewhat indefi- nite period, gradually subsides, the capillaries gradually relax, the 1856.] Holt's Letters upon General Pathology. 455 balance in the circulation becomes restored, the secretions become, re-established, and an end is put to the paroxysm. This hasty and imperfect sketch of an intermittent, serves to show us the existence of two distinct pathological conditions, one consisting in a state of general nervous depression, attended as a consequence with a broken balance in the circulation, and an un- due accumulation of blood in the venous system ; the other con- sisting in a state of general nervous excitement, with a consequent broken balance in the circulation, and an accumulation of blood in excess in the arterial system. That one, or the other, of these conditions constitutes the essential pathology in all fevers, there can be but little doubt; and that both are necessary and essential to the formation and progress of intermittent fever, I think there can be none; and I might say that there is little with respect to remittent fever. It is true, that a paroxysm of these fevers may be ushered in with such slight evidences of the existence of de- pression and congestion, as to escape the attention of the patient, and the observation of attentive and skilful observers ; but such cases cannot be taken as exceptions to the general rule, as I have before shown that these conditions may exist in various degrees of development, from the lowest grades of depression below, to the highest grades of excitement above the line of a healthy excite- ment; and I think it would be much more fair and reasonable to suppose that the depression really existed in such cases, though not observable, than to suppose that it did not, because the signs of its existence could not be observed. My impression, therefore, with respect to these fevers, is, that the first essential element in their pathology is nervous depression, with more or less of general venous congestion ; and that the se- cond essential element in their pathology is, nervous excitement, with increased vascular action, with more or less general arterial plethora. Whether this be the case with respect to other fevers, must remain for further discussion, while we go back a little, and examine into the laboring organ which has given rise to all this mischief and disturbance. Well, in the absence of positive proof to sustain the position, I would assume, as the most pro- bable state of the case, that the accumulated excitability or ex- altation of nervous power in the weak and laboring organ would serve to relieve it from its condition for the time being, but upon its re-distribution, and the subsidence of the general excitement, 456 Holt's Letters upon General Pathology. [August, it would be left in near about tbe same state of debility and de- pression as at first, and would be tbe subject for renewed or repeated efforts of tbe system, tbrougb a succession of paroxysms, until tbe condition was removed or overcome by tbe efforts of nature, or art ; sucli being the character of our simple intermittents. Or, to take another step in the morbid concatenation, we may sup- pose that the weak and laboring organ being, in consequence, unable to resist the force of an increased column of arterial blood, which would accumulate iu undue quantity, and thus give rise to irritation in the organ, would in turn Lave the effect of keeping up for a longer time, and in a higher degree, the febrile movement as observed in our simple remittent fevers ; or, from the oft re- curring state of irritation of the organ from repeated paroxysms, or a protracted state of general excitement, the local excitement or irritation might eventually spring up into a state of inflammation, the highest and last link in the chain of morbid actions, which we see occurring sometimes in intermittent and remittent, and in va- rious other forms and grades of fevers. Such being the usual progress in the degrees of morbid action in the organs involved in our fevers, we are not required to recognise local inflammation as essential, either for their production or for their continuance. Local inflammation often exists without fever : it often occurs as the the consequence of fever; and we often have fever in which there is no evidence of the existence of inflammation, either as cause or effect. Besides, inflammation is not a primary but an ultimate degree of morbid action, and even when considered as the cause of fever, it might not be found an easy matter to estab- lish tbe fact, that the febrile movement had been incited by the ultimate, and not the primary morbid action. Now, I wish it to be understood that the examples of the degrees of morbid action, which I have stated, are not confined to the organ which created the disturbance ; nor docs it necessarily pass through these degrees during the progress of the fever, but that through the intimate anatomical and physiological relations which exists among the different organs, many of them become involved and assume one or other of these degrees of morbid action, having had no direct agency in the production of the fever. Ilence they should be re- garded as non-essential, and as the result of adventitious influ- ences. At. the character of all these fevers is determined by the teral predisposing causes which I have elsewhere shown, so it 1856.] Holt's Letters upon General Pathology. 457 is with the different organs involved, being the result of individu- al and general predispositions, and often of prevailing epidemic influences. To enable us to trace the phenomena of these fevers as near as possible, through the order in which they arise, and to preserve as accurately as possible their relations, one to another, we will commence with those which result directly from the broken bal- ance of the circulation, and the undue accumulation of the blood in the large venous trunks and cavities, which we recognise as General Congestion from General Nervous Depression, Having de- signated the lungs, heart and liver, as the points for the forma- tion and the chief seats of congestion, we are bound to suppose that under the operation of general causes it would commence simultaneously at all those points, and consequently all the organs anatomically related which become involved, do so, at the same time. Passing by the general outward signs of the condition of nervous depression and congestion, the first organ which claims attention is the brain. Though this organ shares alike with other organs in the general loss of nervous power, and is often the seat of irritation and inflammation, it is never, as I have before shewn, the seat of congestion, except as the consequence of congestion in the lungs or the 'heart; consequently, whatever importance may be attached to that condition of the brain, (and I am not disposed .to attach a great deal, from the fact that it is rather a mechanical than a pathological effect,) for its removal, we must look to the organs which gave rise to it. Congestion of the brain is not in itself a very dangerous affair, for occupying a closed cavity, it is subject neither to a very great increase or diminution of its proper quantity of blood, either of which would be apt to produce sud- den fatal results, in cases of great general depression. This cir- cumstance, which I have endeavored to explain elsewhere, enables the brain to continue in the exercise of its functions, often in a wonderful degree, amidst the general wreck and prostration of all other vital functions. Cases, however, often occur in these fevers, in which the action of the heart is sufficiently strong to throw an undue quantity of blood upon the brain, giving rise to more or less pain or uneasiness in the head, dullness of intellect, drowsi- ness, and not un frequently to stupor and insensibility, which usually occurs suddenly as by an impulse. Now, these evidences of cerebral disorder, though not devoid of danger, are generally 458 Holt's Letters upon General Pathology. [August, more alarming than dangerous, for the reason that they imply no seated morbid action in the brain, and generally subside and pass away with the paroxysm. They cannot, however, be regarded with indifference, or without apprehensions of subsequent danger, as upon the establishment of the febrile stage of the disease, the brain would be more apt to become a seat of morbid action, and a state of irritation kindled up in the previously distended vessels, which might continue, in that character, through a succession of paroxysms, producing in each, headache, delirium, convulsions, and other signs of cerebral irritation, and, as has been explained, ultimately to spring up into a state of inflammation with all its direful consequences. I feel inclined to pause here, for the pur- pose of making some practical comments upon these different morbid conditions or states of action in the brain, knowing as I do, that they are too often mingled up and confounded, and that cases have been heroically treated (to the great detriment of other or- gans, and the system, generally,) as inflammation of the brain, which were but slight congestion or irritation, which would have yielded, and which did yield at once upon the arrest of the parox- ysm. As this subject, however, must claim attention hereafter, I will proceed to enquire into the effects produced upon other or- gans from congestion of the liver. "Whether the liver is the prime seat of these fevers, (which I am inclined to believe, but which is not for us now to determine,) one thing I think is very certain, that it is more uniformly involved or complicated with them, than any other organ. Though it has been maintained upon high authority, that these fevers are of gastric origin, to which doctrine I cannot assent, much less that inflammation is essential to their production I cannot deny that gastric disorder is a very common (though not an invariable) at- tendant upon them. Nor is it strange that it should be so, when we look at the character of the organ, its size, the extent of its mucous surfaces, the number of its bloodvessels, its extensive ner- vous sympathies, and the readiness with which it sympathises with other organs"; yet it is strange what it can endure without evident disturbance, when we see it receiving large quantities of crude, heterogeneous, and apparently indigestible substances ; be- sides, other strong and irritating substances, such as salt, vinegar, pepper, mustard, wine, brandy, hot tea and coffee, or ice-water, and sometimes physic all with apparently the same degree of 1856.] Holt's Letters upon General Pathology. 459 impunity. Now, these things I will not attempt to explain, but there is one thing which I think their existence serves to show, namely, that the stomach is not so sensitive to first impressions, or ready to take on morbid action from the influence of general causes, as it is through sympathy, or direct communication with other organs. The liver, which may become congested from congestion in the lungs and heart, being itself a point for the formation of conges- tion, especially in the portal circulation, when that organ and system is in that condition, has the effect of throwing the blood back, or darning it back to the organs whence it came, thus ob- structing the flow of blood through the capillaries of those organs producing such a state of plethora, or mechanical congestion in them as occurs in congestion of the brain. The effect of conges- tion of the liver is, therefore, felt in all the abdominal viscera, (it- self included,) and most of these being secreting organs, besides the effects or consequences which are likely to result from the ob- struction, and the accumulation and retention of an excess of blood in their capillaries, in the establishment of irritation and in- flammation in the manner already described, they have their func- tions thus mechanically interrupted, without having necessarily labored previously under any morbid action. The consequence of this stagnation and accumulation of blood in the vessels of the stomach, from both forward and backward pressure, is to create a sense of fulness and distress in that organ, sometimes pain, and often nausea and vomiting; indeed, so common are these things to our fevers, as to have lent support to the doctrine that they are of gastric origin. But observation has taught me that they sel- dom occur in fevers where there is no hepatic obstruction, and seldom or never fail to disappear when the obstruction is removed. As a consequence of the accumulation and stagnation of blood in the mesenteric vessels, from congestion in the liver, we frequently have, as a concomitant of these fevers, a serous diarrhoea from the percolation of the thinner constituents of the blood into the intes- tines, and sometimes when these vessels are in an unusual degree or state of atonicy, blood itself is poured out in such quantities as to be both alarming and dangerous. Besides the spleen, which we may suppose to suffer in the ratio with other organs, the liver only remains to be considered among those which furnish the chief pathological and characteristic phenomena of these fevers, and as 460 Holt's Letters upon General Pathology. [August, I shall have occasion more than once to refer to it, I will next examine into the effects of general congestion upon the constitution of the blood, and the consequences resulting from the changes thereby induced. Whatever changes may take place in the con- stitution of the blood from excessive or defective secretions, and the agency which such changes have in the production of these fevers, (which we suppose to be no little.) belongs to another branch of the subject; but, there can be no doubt that as cause or effect, the stagnation of the blood in these organs (whereby its elaboration and its depuration are both arrested or suspended,) acts injuriously upon the constitution of the blood, rendering it less fit for per- forming its offices, and sustaining the great vital functions de- pending upon it, and thus favoring the continuance or increase of general nervous depression. This change in the constitution of the blood consists chiefly in its defective and imperfect oxygeni- zation, consequent upon the feeble respiratory movement, and pulmonary congestion, and in an increase of the carbonaceous products from the same causes, together with the suspended func- tions of the livei', which products are known to possess powerfully depressing influences upon the nervous centres. Having thus examined into the pathological condition of the principal organs and systems, as they may be supposed to exist in the first stage, and at the commencement of intermittent and remittent fevers, the next step will be to examine them in connexion with the second or febrile stage, which must necessarily be deferred until my next letter. Before I close, however, it may not be amiss to say, that any cause which is capable of producing great and sudden depression in the nervous centres, can bring about a condition similar to that which I have described, such for instance as heavy blows upon the head, violent injuries, strong or violent passions and emotions of the mind, the action of deadly poisons, &c. But the depression and congestion thus produced will generally be sudden, evanes- cent and transitory, leaving no traces behind ; while the depression and congestion of these fevers is generally the work of their pre- disposing causes, which have operated for a length of time, and though they may not be so perfect and complete, are always more permanent e, is as well known as the vapor-bath, and needs no comment. The symptoms of coup-de-soliel, in its ordinary form, are precisely similar to prolonged syncope. The exhausting in- fluence of a sultry day, or of a hot sun directly after a shower, are familiar instances of the effect of high humidity upon the system. But the proposition remains to be proven by hygrometrical obser- vation, and not by the uncertain perceptions of the senses. I purposely omitted to mention the hygrometrical condition of New York and St. Louis in the epidemics cited, because it was desired that the relation of heat in their causation should be tested by itself. We may now, however return to it. Mr. Blodget(then of the Smithsonian Institution) said of it (New York Journal of Medicine, Oct., 1853,) that "the temperature of evaporation at New York, at the time of greatest mortality in August, was from 80 to 84, being higher than the maximum temperature of evaporation at New Orleans at any time in 1852, by 2. Commenting on this point on another occasion, we made the following remarks: " This implies, necessarily, a high fraction of saturation, and placing all the evidence together the fact that the temperature 1856.] Sun Stroke. 487 at 2 P. M., was only 90 to 92 (not an unusual heat for the season,) that the cases were mostly among foreigners, that Dr. Swift des- cribes the symptoms as indicative of ' nervous debility,' and not of 'cerebral congestion,' that the dew-point reached a tropical maximum, and the conclusion is irresistable that, not dry heat, but along-continued bath of aqueous vapor was the true cause of this unparalleled mortality. But, as if to make the evidence irre- fragable, we are told that ' eleven patients were attacked one morning in the laundry of one of our principal . hotels ;' and ' several were brought to us from a sugar refinery, where, after working several hours in a close and over-heated apartment, they fell down suddenly in a state of insensibility.' I regard these last mentioned facts as of the last importance. Here, in a laundry, or in a sugar-refinery, unaffected by solar rays, filled with vapor artificially produced, having an excessive humidity, unventilated (for on these fatal days there was no wind.) men fell by dozens in sudden death. The experience of all time contradicts the idea that dry heat can produce these effects, and I regard them as con- clusive upon the question, whether or no the combination of high heat and humidity is of itself a cause of disease.'' Turning again to St. Louis, we ascertain from Dr. Engleman's tables, that during the period of nine days before alluded to, the mean temperature of evaporation was 78, against a dry bulb tem- perature of 86. The fraction of saturation is high enough to prove the presence of an immense amount of aqueous vapor, nearly as much, in fact, as could be forced into the air without having it in the form of steam. Without multiplying statistics, I may state that the examinations of such weather records, corresponding with periods of mortality from sun-stroke, as have fallen under my notice, has uni ormly resulted in fixing a high temperature of evaporation as the efficient condition of the cause of the disease, and that without dtfinite relations to the dry bulb temperature. A question of much interest connected with this theorv of cau- sation, is as to what power a humid atmosphere exerts on the absorption of the solar rays. I made last summer, some experi- ments, with a view to ascertain this point. So far as thev went they seemed to prove that the difference between a thermometer in the sun and one in the shade, is greater on days of least humid- ity. The observations were, however, made without sufficient precaution against reflected heat, and will be repeated during the present summer with care. The method of making them is to use four thermometers : 1st, one with a dry bulb: 2d, one with a wet bulb these two to be in the open air. shaded. A third thermometer should be exposed with a naked bulb to the sun's rays, while a fourth should be similarly exposed and wrapped around with black wool. Only clear days should be noted. In this way we hope to establish some relation between humidity and 488 Carbonic Acid in Premature Labor. [August, radiation, corresponding with that which is evident to the senses in the chill produced on going into the shade on a humid day. Buffalo Medical Journal. Carbonic Acid as a means of artificially producing Premature Labor. By M. Scanzoni, Professor to the Faculty of Wiirzburg. Two years since M. Scanzoni proposed to provoke premature labor artificially by exciting the breasts by means of cupping glasses, and by reflex action to produce contractions of the muscu- lar fibres of the uterus. This process, made use of on several occasions, often promptly induced labor, at other times it succeed- ed better as an adjuvant, while in many cases its effect was incom- plete, or failed almost entirely. The application of the glasses frequently produced excoriation of the mamella?, inflammation, abscesses, and more or less severe pain. Generally, the result of the mammary excitation was particularly evident, when the irrita- tion of the nerves of the mamellae was accompanied with local excitation of the womb, and when besides the cups, the uterine douche, the colpeurynta of Brown, the tampon, &c, were used. Desirous of finding a certain means of provoking uterine contrac- tions without inconvenience to the mother, and without danger to the infant, and persuaded that artificial premature labor is one of the most useful and valuable resources of obstetrics, the professor of Wiirzburg continued his researches, and in the interesting prac- tice which the maternity of Wiirzburg furnished, occasion soon offered upon which to experiment. Taking the observation of M. Brovvn-Sequard as a starting point, which shows that carbonic acid provokes the contractions of the muscles of organic life; that the genital organs for a long time exposed to the action of this acid become the seat of very severe congestion ; and that it is even a sure means of curing amenorrhcea, M. Scanzoni resolved to em- ploy this acid to arouse the contractile power of the uterus, and to excite it so as to bring about labor. The apparatus employed was as follows : A flask holding about a. quart, hermetically sealed, with a stopper having two openings, by one of which a tube penetrated to the bottom of the flask, to the other orifice was fitted a horn pipe which connected with a caoutchouc tube about a foot long, ending in acaniilaof an ordin- ary injecting syringe. Bicarbonate of soda, and then some acetic acid is introduced by the first tube, a conical glass speculum is placed in the vagina. The caoutchouc tube inserted in a cork is introduced into the speculum, which it exactly fits. The carboniG acid is increased or diminished at will by the addition or not of acetic acid. The following is the report of the case in which it was first em' ployed : 1856.] Carbonic Acid in Premature Labor. 489 D. S , 26 years old, primapara, menstruated for the last time May 26, 1855; entered the Maternite of Wiirzburg Jan. 29, 1856. Pelvis low and narrow. The antero-posterior diameter, ordinarily from 4 to 4 inches, is only 3 to 3 inches. The vaginal portion of the neck is from five to six lines in length, and the external orifice firmly closed. The head of the foetus was felt above the anterior portion of the vaginal arch, the beatings of the heart were heard to the left, and the extremities of the foetus were felt to the right and high up, near to the bottom of the womb. The mother thought she was in the thirty-second or thirty-fourth week of ges- tation, and the examination of the genital organs confirmed this opinion. The narrowness of the pelvis preventing natural labor from taking place, and furnishing the indication for the induction of premature labor, M. Sea nzoni resolved to try carbonic acid. Feb. 2. At eight o'clock in the evening, the apparatus was ap- plied for twenty minutes for the first time, without provoking any notable modifications. Feb. 3. At eight A. M., application for twenty minutes, and at eight P. M. for half an hour. The mother felt while the gas pene- trated into the vagina adisagreeable sensation of painful prickings, and during the day darting pains about the umbilicus. Evening The vaginal portion of the neck was slightly softened. After a good and tranquil night the pains about the umbilicus recurred. Feb. 4. The apparatus was used half an hour morning and night. The same pricking sensations during the application. The neck became dilated during the day so as to permit the finger to feel the inferior segment of the membranes. During the night, severe and darting pains in the groins and back; towards evening the hand placed upon the abdomen followed the evident contractions of the uterus, which, to tell the truth, soon after ceased. Feb. 5. In the morning another application for half an hour, followed by the ordinary pricking sensations. The orifice was of the size of a two franc piece, yielded easily, and was readily dila- ted by the finger. The vaginal secretion is very much increased. In the afternoon the painful contractions of the uterus appeared, which increased in intensity by degrees. At half-past six in the evening the membrane broke, and an hour after a living child was expelled, which weighed 1350 grammes. During delivery a slight hemorrhage appeared, which necessitated the removal of the placenta a quarter of an hour after the birth of the child. The sequelae of labor were not at all troublesome. Mefteotions. With the exception of the vaginal prickings, which seemed to continue only during the application of the cur- rent of gas, the employment of carbonic acid is followed by no serious inconveniences, and acts with sufficient energy, since its application during 3^ hours was sufficient to provoke the expulsion f the foetus. Unfortunately there is but one case, and it may be that this process may have some unpleasant results in nervous 490 Amputation in Sjyhacelus. [August, women, and cause uterine spasms rather than normal contractions. The vagina may hecome irritated, and it is not clearly proved that the increased vaginal secretion was not caused by a com- mencement of vaginitis. To decide upon the value of this me- thod, the author himself calls for further experiments, and it is desirable that the demand of the distinguished physician of Wiirz- burg should meet with some replies. [ Weiner Medicinishe Wochen- schrift, from Amer. Med. Monthly. Is it always necessary to resort to Amputation when a Limb is at- tacked with Sp)hacelus f Prof. Bardinet, of Limoges, has brought this important question before the Academy of Medicine of la Haute Vienne, and has an- swered it in the negative. We are too ardent partisans of conservative surgery, having ourselves sufficiently often protested against the excessive tenden- cy to operate everywhere and at all times, not to hasten to sub- mit to our readers the reasons adduced by M. Bardinet in support of his opinion. The following is the resume of his memoir: 1st. In this memoir I report eight new cases of sphacelus (two of the fmger, three of the forearm, and three of the leg,) in none of which amputation was performed. The task of eliminating the dead parts was intrusted to nature, except that her operations have been actively aided by the employment of the ordinary dis- infectants, and especially by the early resection of the dead parts near the eliminatory circle. In these eight cases recovery took place. Had amputation been performed, it is, on the one hand, ex- tremely probable that a certain number of patients would have died; on the other, several of them would have been deprived, in consequence of the necessity of amputating above the eliminatory circle, of a portion of their limbs (the knee, for example, or the upper part of the forearm,) which they are fortunate in having been able to preserve. It is, therefore, not alwaj^s necessary to amputate in cases of sphacelus. * 2d. We should, above all, be extremely cautious in having re- course to amputation in cases of spontaneous gangrene first, because in such coses, whatever we do, and even after the estab- lishment of the eliminatory circle, we can never be sure that the gangrene will not reappear, and that we shall not thus needlessly add the pain and dangers of a serious operation to those of the original disease. 3d. Because the fear of amputating in parts whose vessels are diseased, obliges us to carry the section up to a considerable 1856.] On Liquidambar Styracifiua. 491 height, and thus involves, sometimes very uselessly, the sacrifices of parts which might have been preserved, and the loss of which is to be lamented. 4th. Because the gangrene may attack several limbs in succes- sion, and even all the limbs, of which I have quoted two exam- ples, and we should then find ourselves compelled to perform a series of sad mutilations. 5th. Because, on the contrary, in confining ourselves to cutting away the dead parts near the circle of elimination, we perform an operation which is always practicable and always useful, as it lib- erates the patient from a focus of infection. 6th. Because we avoid the risk of performing an amputation, all the benefits of which will be lost if the gangrene makes fresh advances. 7th. Because, in adopting the new mode, we do not unnecessa- rily remove parts which the patient is much interested in pre- serving. 8th. Because we have still the power of performing amputation, if it should become necessary. [Dublin Medical Press from Presse Medicale Beige. On Liquidambar Styracifiua. By Charles W. Wright, M. D., Professor of Chemistry in the Kentucky School of Medicine. Liquidambar Styracifiua, commonly called sweet-gum, is indige- nous to nearly every part of the United States, and constitutes one of our largest forest trees. When an incision is made through the bark of this tree, a resinous juice exudes, which possesses an agree- able balsamic odour. When this substance first exudes, it is of the consistence of turpentine, and possesses a stronger smell in that condition than it does after it has become resinified. Contrary to the statements made by Wood and Bache, in their Dispensatory, this tree furnishes a considerable quantity of resin in the Middle States, particularly in the States of Ohio, Indiana, and Kentucky, bordering on the Ohio River. It is annually collected in those States, and sold under the name of gum-wax. It is a much more agreeable masticatory than the spruce-gum, and is chewed in the West by nearly all classes. By proper incisions, one tree will yield annually about, three pounds of the resin. The chemical composition of the specimens collected in this lat- itude correspond with that given by M. Bonastre, of specimens gathered elsewhere, viz : benzoic acid, a volatile oil, a semiconcrete substance separated by distillation and ether, an oleo resin, a prin- ciple insoluble in water and cold alcohol, termed styracine. The bark of the tree contains tannic and gallic acids, to which its as- tringency is due. What I wish more particularly to call attention to is the employ- ment of a syrup of the bark, of this tree, in diarrhoea and dysentery, 492 Quinated Cod-liver Oil. [August, and more especially the diarrhoea which is so prevalent among children during the summer months in the Middle States, and which frequently terminates in cholera infantum. The best formula for the preparation of this svrup is that given in the United /States Pharmacopoeia, for the preparation of the syrup of wild-cherry bark, of which the following is a copy, the sweet- gum bark being substituted for the. wild-cherry bark. "Take of sweet gum bark, in coarse powder. Jive ounces; sugar (refined) two pounds ; water a sufficient quantity. Moisten the bark thoroughly with water, let it stand for twenty-four hours in a close vessel, then transfer it to a percolator, and pour water upon it gra- dually until a pint of filtered liquor is obtained. To this add the sugar in a bottle, and agitate occasionally until it is dissolved." The dose of this syrup for an adult is about one fluidounce, to be given at every operation, as long as the operations continue to re- cur too frequently. One advantage which this medicine possesses over most astrin- gent preparations is that of having an exceeding pleasant taste, and of being retained by an irritable stomach when almost every other substance is rejected. Children never object to it on the score of bad taste. The resinous and volatile bodies which it contains, no doubt enhances its value. My brother. Dr. J. F. Wright, ol" Co- lumbus, Indiana, has employed this preparation for the last three years in a great number of cases, with the most satisfactory results. He prefers it to any other article where there is an indication for astringent medication in the class of diseases before referred to. In the bowel complaints of children it has a decided advantage over all preparations containing opium, and I am always pleased with the happv results which follow its employment in that class of patients. \_Amer. Jour, of Med. Sciences. Quinated Cod-Liver Oil. By M. Donovan. A preparation of cod-liver oil, called oleum aselli cum quina, has been lately introduced into medical practice, and is favorably no- ticed by some practitioners. It is probable that the tonic effects of quinine, conjoined with the restorative powers of the oil, may afford a combination of greater efficacy than is possessed by either sepa- rately. To many persons, the mawkish taste of the oil modified into the decided bitter of the quinine is an improvement. I have been informed that the combination of sulphate of quinine with cod-liver oil is effected by exposing them in a state of mixture to a certain temperature: if the heat be too high or too low, the combi- nation, it is said, will either not take place or it will be subverted. I have made some trials with very unsatisfactory results, the quan- tity of sulphate which dissolved being very small, as might be ex- pected from the character of sulphates in general. Aware that the alkaline basis of sulphate of quinine possesses 1856.] New Method of Treating Phagedena. 493 some of the properties of a resin, it seemed probable that it might dissolve in oil ; and, on making the experiment, I found that this is actually the case. The alkaloid quinine is known to possess little efficacy as a me- dicine on account of its insolubility in aqueous liquids ; hence, it is always administered in the state of acidulated disulphate, or, in other words, in the state of sulphate. Oil, by rendering quinine soluble, develops the medicinal virtues of that alkaloid, and thus, for every useful purpose, acts the part of sulphuric acid. A few trials convinced me that quinine may be dissolved in cold cod-liver oil in even greater ratio than it is ever necessary for the purposes of the physician A solution of eight grains to the ounce is intensely and persistently bitter. When the mixture is first made, a very disagreeable and peculiar smell is developed; but by exposure to the air for an hour or two, or better by filtering, the smell exhales and is dissipated. The colour of the oil is deepened by the combination. This compound, which may be briefly named oleum aselli quina- turn, has this advantage, that two active medicines, of coinciding effects, may thus be administered at one dose. To some, it is a severe trial to swallow either of them; and to such persons it would be a relief, instead of taking two separate disagreeable doses at dif- ferent times, to swallow both at once, and have done with them. There are constitutions which will not tolerate the free exhibi- tion of cod-liver oil, and patients of this class are precluded from availing themselves of advantages which might have been of the utmost value to them. Perhaps the quinated od would agree bet- ter with such stomachs. [Dublin Med. Press. New Method of Treating Phagedena. Mr. Cock has recently been trying, in Guy's Hospital, a plan of treating phagedenic ulcers by constant irrigation. The method is, to have the sore well exposed, and the affected limb placed on some water-proof material ; a reservoir above the bed is then fill- ed with lukewarm water, and, by means of an elastic tube, a stream is kept continually flowing over the surface of the sore. By this means all particles of discharge, etc., are washed away as soon as formed, and the ulcer assumes the clean, pale appearance of a piece of meat which has been long soaked. In all the cases in which it has been practicable to employ the irrigation efficient- ly, a speedy arrest of morbid action has been secured, and the number has included several in which the disease was extensive and severe. The theory cf the treatment is, that phagedenic action is a process of local contagion the materies morhi by which the ulcer spreads being its own pus. Admitting this supposition which there is every reason for doing to be true, the object to be kept in view in curative measures is either to decompose or to re- 494 Chloroform in Cynanche Trachealis. [August, move the local virus. This end is accomplished somewhat clum- sily by such remedies as the nitric acid, which, unless so freely used as not only to char up all the fluid matters, but to destroy the whole surface of the ulcer to some depth, fails to prevent a recurrence. Mr. Cock's plan of subjecting the ulcer to a perpetu- al washing attempts the accomplishment of the same end by a more simple and direct method. It involves no pain to the pa- tient, and does not destroy any healthy tissues. Its one advan- tage seems to be. that, excepting on the extremities, its use would be attended with some inconvenience, from the difficulty of pre- venting the water from running into the patient's bed. Should, however, further trials confirm the very favorable opinion which has been formed at Guy's as to its value, these difficulties might, no doubt, be surmounted by the contrivance of suitable apparatus. The directions as to temperature of the water are that it should be as warm as comfortable to the feelings of the patient : and, as preventive of smell, Mr. Cock advises the addition of a small quantity of the chloride of lime or of soda. [Med. Times and Gaz. Chloroform in Cynanche Trachealis. By J. JEFFERY, M. D., of Southfield. As much has been written on the disease called Cynanche Trachealis, or Croup, and a variety of favorite remedies presented to the medical profession, which have excited the most ardent hopes for a short time, that something reliable had been discover- ed, which would not only inspire confidence in the physician, but remove the anguish of the sufferer, and dispel the terror and dis- may that weighs down many an anxious parent; which hopes have mostly perished in embryo, it is with some diffidence that I present any thing on the subject fearing it may not sustain the confidence it has excited in my mind. I wish to report a recent case that came under my care, the treatment of which was entirely new to me, (but perhaps, not to others,) and so perfectly agreeable to the patient and satisfactory to myself, that the merits of the remedy may be duly tested by the medical profession. The pa- tient, a lad between four and five years of age, had what the parents called whooping-cough, (but from their account rather a peculiar type or form, as also many cases that I have witnessed during the past winter.) while they lived in Redford. The family came here about the first of April, two of the children exhibiting some symptoms of the remaining disease. On the evening of the 23d ult., the patient came in from play, with a severe cough which alarmed the parents. I was absent from here. They got at my office a composition, prepared with Lobelia Sem., Ant. Tart., Lard and Licorice, administered it through the night with no benefit. On the A. M. of the 24th, I saw him and found him 1856.] Chloroform in Cynanche Trachealis. 495 with all the symptoms of severe croup, could only speak in a par- tial whisper; nervous system very irritable. Skin dry, consider- able thirst, no cough of importance. The patient suppressing the effort to cough as much as possible. The shrill whistling sound of breathing could be heard for two or three rods from the house. Bowels had not moved for twenty-four hours ; tongue with brown- ish coating. Gave him about 15 or 20 grs. of Ilyd. Sub. Mur., followed with a teaspoonful of Sal Epsom. In the evening, bow- els moved freely, and he appeared some better for a short time. Advised inhalation of vinegar and water, with the ordinary rem- edies. 25th, at 3 o'clock, A. M., was called to see the patient, as they thought he was dying. Found him unconscious, with the eyes half open and turned upwards, head thrown back, respira- tion feeble and exceedingly difficult, trachea apparently nearly closed up, pulse scarcely perceptible at the wrist, heart violently agitated, as if making its last struggle, extremities cold, &c. Un- der these discouraging circumstances, I concluded to try the effect of chloroform, in order to palliate the distressing symptoms and ease the patient through the portal of death. I put it on a hand- kerchief and placed myself by his side, allowing access to the air, holding it under the chin. In about ten minutes, the breathing was much relieved, the pulse became moderate and of fair strength at the wrist. The heart quite calm. I continued this about two hours, regulating the strength of the chloroform to the urgency of the symptoms. The patient seemed to fall into an easy slumber, the eyes closed ; still the breathing was not natural, but so much improved that I began to feel some hopes of recovery. I left the chloroform in the care of the nurse, with instructions to use it suf- ficent to keep the patient quiet. Saw him again in the afternoon, found him with skin moist, and very much improved in strength, and all the urgent symptoms relieved, but coughing and raising his mouth full of tough phlegm, quite often, having the appear- ance of a pseudo-membranous substance, which continued for about twenty-four hours. The patient walking about the room part of the time. At the end of about thirty-six hours from the time of the commencement of the chloroform, he was able to eat nearly a full meal, and play around the house ; a slight wheezing continued for about three days, since which he has been well. All the medicine I gave after the evening of the 25tb, was a solution of Muriate Ammonia, half 3 to half pint of water and molasses, dose one to two teaspoon sful every two or three hours. If you deem this of any importance, you can publish such part of it as you choose in your worthy journal, or dispose of it as you see fit. My only object is to aid the profession in their endeavors to benefit suffering humanity, and secure the confidence of com- munity in medical science. [Peninsular Jour, of Med. 496 On Detection of Strychnia. [August On Detection of Strychnia. By Marshall Hall, M. D. The detection of strychnia as a poison is, at this moment, of deep public interest. When the chemical test fails, there remains, I think, another the physiological. Having long studied the effects of strychnia on the animal economy, (I have sent two papers on this subject to the Institute of France,*) I am persuaded that these effects on the most excitable of the-animal species are at once the most deli- cate and specific tests of this poison. I have just performed two experiments, and only two, for want of materials for more. I requested Mr. Lloyd Bullock, of Hanover street, to dissolve one part of the acetate of strychnia in one thousand parts of distilled water, adding a drop or two of acetic acid. I then took a frog, and having added to one ounce of water l-100th part of a grain of the acetate of strychnia, placed the frog in this dilute solution. No effect having been produced, 1- 100th of a grain of the acetate was carefully added. This having produ- ced no effect, in another hour 1-I00th of a grain of the acetate- was again added, making the 3-100th, or about the thirty-third part of a grain. In a few minutes, the frog became violently te- tanic, and though taken out and washed, died in the course of the night. I thus detected, in the most indubitable manner, one thirty-third part of a grain of the acetate of strychnia. It appeared to me that, had more time been given to the experiment, a much minuter quantity would be detectable. I placed the second frogf in one ounce of distilled water, to which I had added the l-200th part of a grain of the acetate of strychnia. At the end of the first, the second and the third hours, other similar additions were made, no symptoms of strychnism having appeared. At the "end of the fifth hour, the frog having been exposed to the action of l-50th part of a grain of the acetate of strychnia, tetanus came on, and under the same circumstances of removal and washing, as in the former experiment proved fatal in its turn. I thus detected l-50th part of a grain of the poisonous salt by phenomena too vivid to admit of a moment's doubt; the animal, on the slightest touch, became seized with the most rigid general spasmodic, or, rather, tetanoid rigidity. And this phenomenon, alternating with perfect relaxation, was repeated again and again. As the nerve and muscles of the frog's leg, properly prepared, have been very aptly designated as galvanoscopic, so the whole frog, properly employed, becomes strychnoscopic. * See the Comptes Rendu* for June 1847, and February 1853. f These frogs were not fresh from the pools. 1856.] Astringent Application. 497 In cases of suspected poison from strychnia, the contents of the stomach and intestines, and the contents of the heart, blood-ves- sels, &c., must be severally and carefully evaporoted, and made to act on lively frogs just taken from the ponds or mud. I need scarcely say that, taken in winter, the frog will prove more strychnoscopic than in summer, in the early morning than in the evening. The best mode of performing the experiment also remains to be discovered, with all its details and .precautions, an inquiry into which I propose to enter shortly. Meantime, this note may not be without its utility. P. S.. I have repeated my experiment. I placed one frog, fresh from the pools, in an ounce of water, containing the l-50th part of a grain of the acetate of strychnia ; a second in the same quanti- ty of water containing the l-66th, a third containing l-100th, and a fourth containing l-200th. All became tetanic in two or three hours, except the third which was a female, (the other being males,) which required a longer time. The 1 -200th part of a grain of the acetate of strychnia is, there- fore, detectable by means of this test conferred by physiology. We now placed a male frog in l-400th part of a grain of the acetate of strychnia, dissolved in six drachms of water. In three hours and a half it became violently tetanic. The fresh frog is, therefore, at this season, strychnoscopic of l-400th part of a grain of the acetate of strychnia, and probably to a much minuter quantity, which ulterior experiment must show. In two other experiments the l-500th and the l-1000th of a grain of the acetate of strychnia were detected. [Lancet. Neiv Form of Astringent Application. By Dr. William Bayes, Brighton. Pure glycerine dissolves nearly its own weight of tannin, afford- ing a very powerful local astringent application. The solution of tannin in pure glycerine appears to me to sup- ply a desideratum long felt, and capable of a great variety of useful applications. The solvent property of glycerine over tannin, allows us to form a lotion of any desirable strength, as the solution is readily misci- ble with water. The solution of tannin in glycerine, in one or other of its strengths, is peculiarly applicable to many disorders of the mu- cus membrane, readily combining with mucus, and forming a non-evaporizable coating over dry membranes ; hence it may with benefit be applied to the mucus membranes of the eye and ear in many of its diseased conditions. It forms a most conveniet appli- cation to the vaginal, uterine, urethral, or rectal membranes, where a strong and non -irritant astringent lotion is desired. H)S Radical Cure of Hydrocele. [August, In local haemorrhage?, where the bleeding surface can easily be reached, it will prove very convenient, and may be applied either with a sponge or small brush. The solution must be kept in the dark, and should not be pre- pared for any great length of time before used, or decomposition will occur. It is singular that glycerine does not possess the same property towards gallic acid. [Association Med. Jour. Radical Cure of Hydrocele. A man, aged 31, has recently been under Mr. Lloyd's care, in St. Bartholomew's, on account of a hydrocele, which had been several times tapped, and on one occasion treated by the injection of iodine, with the hope of permanent cure. The latter expedi- ent, however, had failed, the sac having re-filled. Mr. Lloyd adopted a plan which has long been a favorite with him, of intro- ducing a little of the red precipitate into the sac. The fluid hav- ing been drawn off by a canula, large enough to allow a director to enter it, the latter instrument, oiled, and then dipped in the powder so a to carry a few grains adhering to it, was introduced and moved about in the cavity. The introduction was repeated two or three times ; some inflammation followed, and a perfect cure ensued. The practice has the advantage over that by injec- tion of not requiring any special apparatus. Mr. Lloyd believes it also to be more uniformly successful. [Med. Times and Gazette. Observations and Remarks on Diseases of the Brain. By H. Bam- berger. Verhandlungender Physicalisch-Medicinischen Ges- ellschaft in Wurzburg. Although we are not informed with regard to the number of the cases upon which Dr. Bamberger's remarks are founded, it is manifest that his experience is extensive, and his opinions there- fore carry considerable weight. The cases which he does record are of much interest, and embrace almost the whole field of cere- bral pathology. The following arc the prominent points of his investigations to which we would draw the reader's attention. Apoplexia Nervosa. Pathological anatomy has so much narrow- ed the limits within which it is possible to apply the term nervous apoplexy, that we now rarely meet with cases to which it may be fairly given viz., those in which sudden death occurs with cere- bral symptoms, and in which no palpable lesion is discoverable after death. It is probable that the microscope and pathological chemistry may reveal minute changes that have hitherto escaped detection, and that the term, in its present sense, may have to be entirely eliminated from nosology. Dr. Bamberger is of opinion that sudden death resulting from violent emotions, electricity, and 1856.] Diseases of the Brain. 499 concussion, must be classed in this category. He quotes one case that fell under his observation. A girl, aged twenty, previously in perfect health, was admitted into the Prague Hospital in Janua- ry, 1850, having the evening before been seized with vomiting, followed by universal convulsions and unconsciousness, brought on by the information received in the morning of the same day that her lover had proved faithless. The temperature of the sur- face was elevated, the pupils unaltered, the eyes closed, the face pale, respiration stertorous, and the pulse intermittent. There was occasional spasm of the extensors of the upper and lower extremi- ties, and also of the abdominal muscles. The extremities, when raised and allowed to fall, descended as if lifeless, though not actually paralytic. There was no return of consciousness, and she died twenty-eight hours after the seizure. Necropsy. The brain was pale and anasmic, the walls of the left ventricle of the heart were slightly hypetrophied, the aorta very narrow and its coats thin, the heart and large vessels were full of loose coagula. All other organs were perfectly healthy. There was no suspicion nor any evidence of poisoning. Apoplexia Serosa. We are still on debatable ground; for although the occurrence of sudden death, with symptoms of apo- I plexy, and exhibiting serous effusion into the ventricles, the sub- ; stance of the brain, or the meninges, is undoubted, the majority of observers (as Abercrombie, Dietl, Wunderlich, Leubuscher) are * of opinion that these cases are rarely, if ever, idiopathic. Dr. Bamberger has frequently met with the varieties of acute serous j effusion alluded to, but is of opinion that they are always the i secondary result either of cerebral diseases and abnormal state of } the cerebral circulation, or of an altered state of the blood induced I by some other acute or chronic disease, as granular kidney, typhus, i acute exanthemata, tubercular, cardiac, and other maladies. Meningitis. Dr. Bamberger adverts briefly to a few points con- nected with this subject, one of which is the occurrence of inflam- mation limited to the ventricular lining membrane; he is of opin- ion that where the post-mortem appearances indicate such a condi- tion, a previous inflammatory exudation on the surface has been reabsorbed, or overlooked as an unessential concomitant. Cerebral Hemorrhage. -The author refers all cases of haemor- rhage to increased pressure in the vascular system, or to an altered condition of the blood, but from the alterations previously induced in the coats of the vessels. He admits that the latter lesion has not yet been demonstrated. As but few authentic cases of passive ; haemorrhage within the cranium are on record, he relates some that have fallen under his own observation in typhus (typhus pe- 1 techialis,) scurvy, and chlorosis. The rarity of the occurrence in typus is shown by the fact that Dr. Bamberger has only met with it once in above a thousand cases of the disease. In that case, after death, which had ensued on the thirteenth day of the typhus, N. S. VOL. XII. NO. VIII. 32 500 Diseases of the Brain. [August, in a boy, aged fifteen, a cavity of the size of an egg, containing blood that was slightly coagulated, was found in the right corpus striatum.. This was also the site of the apoplectic spot found in a girl, aged twenty-five, who died suddenly while under treatment for intense chlorosis. In scurvy, which the author has repeatedly found almost epidemic, he has also met with apoplexy in a girl, aged twenty-three, in whom numerous small apoplectic spots were found closely aggregated in the right anterior cerebral lobe, be- sides another large extravasation on the convexity of the left posterior lobe. "We must pass.over the author's observations on the uniform occurrence of the crucial paralysis shown with reference to the facial, fifth, oculomotor, optic, and acoustic nerves; on the rapid return of sensibility, compared with that of motility, in the para- lysed half of the body; on haemorrhage into the pons, the sac of the arachnoid, into the tissue of the pia mater, and the grey matter of the brain. Red softening occurs in three forms; it may be latent and ac- companied with such trifling symptoms as not to induce a suspi- cion of a cerebral affection; it may be accompanied by symptoms of apoplexy ; or it may manifest a very chronic form, in which we meet with the most varied symptoms of cerebral irritation and compression. It is only in the last variety that a diagnosis is pos- sible, though even here there are numerous sources of error. A very peculiar case is detailed, in which the author assumes the con- versionof the ordinary products of normal inflammation into tuber- cle a view which iscertainly at variance with the prevailing opin- ions on tubercle and the tubercular diathesis. The case is briefly this. A female, aged thirty-five, wasseized in the fifth month of her seventh pregnancy with pneumonia, which lasted three weeks; about three weeks later severe headache was followed by sadden rigidity of the left extremities, the fore-arm and leg being flexed ; se- vere convulsive movements of the same extremities ensued lasting a few minutes. There was no unconsciousness, though she was slight- ly giddy during the attacks. The rigidity and the temporary spasms continued for a week, when she was admitted into the hospital (November, 1851.) She was able to answer questions, but her memory was somewhat impaired. There was occipital headache, paralysis of the left side of the face, violent contraction of the right trapezius, of the left arm and leg; attempts to overcome the flexion caused severe pain. Sensibility of the parts unimpared, total loss of motility ; some improvement took place in the paraly- tic condition, but in December an epileptic seizure supervened; delivery followed in the same month; further epileptic attacks ensued, with pleurisy in the right side, and advancing tubercular disease of the lungs. Death on the 27th January. The state of the brain was as follows: On the inner and upper surface of the right hemisphere, a portion of the size of a desert plate exhibited 1856.] Diseases of the Brain. 501 intimate adhesion between the membrane to the brain by means of a greyish-red cellular tissue, and a yellow cheesy friable mass; the subjacent gyrr were converted into a similar substance to an extent of 9 to 10 lines, not circumscribed as cerebral tubercle gen- erally is; the cerebral tissue in the immediate vicinity was redden-' ed and softened, the more distant portions almost pulpy. Old and recent tubercles were found in the apices of both lungs; the liver and spleen also showed tubercular deposit. Dr. Bamberger argues that the symptoms showed that the cerebral disease commen- ced with inflammation, and that therefore the deposit in the brain was the result of a conversion of plastic exudation into tubercle; but it necessarily suggests itself that the tubercular deposit may have been lon; dormant in the brain, and that the inflammation was a secondary affection. Until such cases are multiplied, it ap- pears illogical to adopt a theory which is opposed to the common experience of pathologists. Two interesting cases are given of encephalitis, resulting from plugging of the arteries by fibrine carried from other portions of the circulating apparatus. With regard to cerebral abscesses, Dr. Bamberger only confirms the known fact of their remarkable latency. The details of three cases are introduced in evidence. Paralysis Agitans. In one necrospy of a female, aged forty-five who had been subject to constant tremors of both upper extremi- ties and the head from her childhood, the meninges were found opaque, and infiltrated with serum of which two ounces were found in the ventricles; the brain was otherwise normal. The characteristic feature was found in the spinal cord, which was white and moist, and exhibited throughout the white matter numerous grey, gelatinous spots; from the middle of the cervical to the middle of the dorsal portion there was a central canal, admitting of the passage of a probe. Dr. Bamberger regards the gelatinous spots as the residue of previous inflammation, and the formation of the canal as the result of atrophy of the cord. Encephalic Tumours. The diagnosis of encephalic tumours still remains, to a great extent, a matter of guesswork, the symptoms being mainly those of compression, which they share equally with other affections. Of 17 cases observed by Dr. Bamberger, 11 occurred in men, 6 in females ratio established by Lebert and Friderich. They were distributed over the different periods of life as follows: Under ten years, 1; ten to twenty, 3 ; twenty to thirty, 4 ; thirty to forty, 4 ; forty to fifty, 2 ; fifty to sixty, 2 ; sixty to seventy, 1. Six were large tubercular or tuberculoid masses; 2, cancerous; 2, fibrous tumours; 2, simple cysts (not appoplectic ;) 1, echinococcus; 1, extended hard masses, of an un- defined character; 2, osseous tumors in the cerebral tissue; and 1, cholesteatoma. In 10 cases the cerebrum, in 5 the cerebellum, and in 2, both were affected. The most uniform symptom was cephalalgia: this was absent 502 Obliteration of the Thoracic Aorta. [August, only in two cases; it was severe and paroxysmal in 6. Paralytic affections occurred next in order of frequency viz., 10 times; in 5 gradually, in 5 suddenly. Convulsive attacks were met with 8 times ; 7 in the form of epilepsy (6 of these with cerebral, 1 with cerebellar, tumours;) 1 in the form of convtilsive affections of one side of the face. Derangement of the intellectual functions occur- red in 8 cases. The details of 3 cases of encephalic tumours, for which, howev- er, we cannot make room, conclude Dr. Bamberger's interesting communication. [Brit, and For. Med. Chir. Review. Obliteration of the Thoracic Aorta. Wochenblatt der Zeitschrift der k. k. Gesellshaft der Aerzte zu Wien. At a meeting of the Medical Society of VienDa, held on the 19th October, 1855, Professor Skoda introduced a man affected with obliteration of the thoracic aorta. In illustration of the lesion, the Professor exhibited preparations of a five-months' foetus and of a new born child, in which he indicated the point at which alone this anomaly can take place or has hitherto been observed. It is the point at which the ductus botalli communicates with the aorta and the short space intervening between this point and the origin of the left subclavian artery. During foetal life, this por- tion is commonly narrower than the remainder of the aorta, and only acquires the same calibre after birth. The individual in question was a man, aged forty -seven ; a jeweller; of normal complexion, and throughout well nourished. On the whole, he enjoys good health, and has only come under clinical observation owing to his having, for three years past, suffered from some dyspnoea in making violent exertion. This is due to an insufficiency of the tricuspid valve, which has only been established for three years. The following are the grounds upon which Professor Skoda has diagnosed a co-existing obliteration of the aorta: In addition to the blowing murmer coincident with the impulse, and which in- dicates the above-mentioned insufficiency, a "peculiar vibration or whirring (schwirren) is to be..perceived over the greater part of the thorax, partly by palpation, partly, as in the course of the intercostal arteries, by auscultation ; it follows the impulse, and for that reason has its seat in the arteries. The vibration of the arteries of the thorax is due to their dilatation, as may be shown by touching the superficial epigastric arteries, which are much di- lated and very tortuous. The beat of the crural arteries at the groin is very feeble, and no pulsation can be felt in the abdominal aorta." These are the indications characteristic of obliteration of the thoracic aorta ; the collateral circulation is carried on by the bran- ches of the subclavian arteries, which must therefore be dilated. 1856.] Punctured Fracture of the Cranium, &c. 503 A large volume of blood passes from the anterior intercostals to the posterior intercostal, and by centripetal movement reaches the descending aorta, which is thus filled with blood sufficient to sup- ply the arteries of the intestines, but not sufficient to produce distinct pulsations. The inferior extremities probably also receive a supply by the the anastomosis of the superior and inferior epigastric arteries. No cyanosis is observed, because nowhere venous blood is introduced into the arterial system. In connection with this case, Professor Skoda made the follow- ing remarks : 1. That in examining the heart, we occasionally perceive murmurs which give rise to the assumption of valvular disease, while the heart is afterwards found healthy ; and that the murmur was produced in the coronary arteries or in other arteries, in the vicinity of the heart. Such errors can only be avoided by carefully attending as in the case detailed, to the coincidence or non-coincidence of the murmur with the movements of the heart. 2. The circumstance that the nutrition of the individual was un- impaired, although the circulation in most of the organs must be, doubtless, slackened, proves that the deranged nutrition, so fre- quently coinciding with impediments in the circulation, does not depend solely upon the latter. Professor Skoda was of opinion that the obliteration of the aorta was due either to a complete obliteration or absence of the corres- ponding portion of aorta in the foetus, or to the contraction of the latter ccineidently with the ductus botalli, owing to the exception- al extension of the tissue of this channel into the coats of the aorta. Porfessor Skoda maintained that the obliteration could not be set down to inflammation, as arteritis led, not to obliteration, but to aneurism. He referred to an analogous case which had occurred in his wards some years previously, where no disturbance of func- tion was manifested until, accidentally, endocarditis supervened. Death occurred later from pneumonia; and the obliterated aorta has been preserved in the anatomical museum of Vienna. [Ibid. Case of Punctured Fracture of the Cranium, and Wound of the Brain, with loss of Cerebral Matter, without the occurrence of corresponding serious symptoms. By M. Morton Dowler, M. D., of New Orleans. Instances of recovery after the most formidable injuries of the brain are not frequently recorded, and hive, in some cases, not a little contributed to overthrow the theories of physiologists and psychologists, demolishing, at once, as with a "knock-down argument," the skullbump psychology. The crowning case of Gage, related in the July, 1850, numberofthe " American Journal of the Medical Sciences,1'1 affords an exemplification, which coming from a less reliable source, would be regarded as almost incredible. 504 Punctured Fracture of the Cranium, dec. [August, It has been seen in this case that a tapering iron bar, of the length of three feet seven inches, and of the diameter of one inch and a quarter, ma}7 enter beneath the zygoma, and pass out at the junc- tion of the sagittal with the corona! suture, passing through the anterior lobe of the left cerebral hemisphere, and that the subse- quent report may be, as in this case, that "the patient has qu'te recovered his faculties of body and mind, with the loss only of the sight of the injured eye." Nevertheless, whatever may be the deductions afforded by exceptional and extraordinary cases such as this, all surgery gives us emphatic warning that in cases attend- ed with any manner of lesion of the brain, its blood-vessels, its meninges, or its bony protection, the gravest and most serious results should always be apprehended and guarded against, on the part of the attendant. A patient whose brain has been laid open, and the proper substance of the same wounded, should be considered as being in both immediate and ultimate peril, and should no urgent or alarming symptoms whatever occur during the treatment of such case, it may be considered as a remarkable exception, and the more especially where the patient -is of tender age, and has received a severe punctured wound. Of such excep- tional kind is the following case, which is not like the case of Gage, given as an extraordinary case of mere recovery, but as ex- emplifying recovery without any symptom corresponding to the gravity of the injury sustained, being in this respect the most re- markable I have ever witnessed. On the 8d day of September last, a little boy, Louis, son of Mr. R. D. Maclin, of the Fourth District of this city, received a punc- tured fracture of the skull, and penetrating wound of the brain, under the following circumstances: a negro servant girl ascended a shed, about 12 feet from the ground, for the purpose of driving a nail, using, in place of a hammer, a large male hinge, weighing nearly two pounds, which had been drawn from the post of a wide gateway ; and after effecting her object, without taking the pre- caution to look downwards, she threw forcibly from her hand the hinge, which descending, struck the child on the parietal bone of the left side, an inch and three- fourths from the coronal, and one inch from the sagittal suture, the post-spike of the hinge present- ing, and entering the brain. The child was at the time sitting with the head erect, and the iron entered in nearly a perpendicu- lar direction. The spike of this formidable iron is a four-sided body, six inches long, gradually tapering on all sides, but so flat- tened latterally as to tripple the width of the horizontal surfaces, thus terminating in a wedge, the edge of which is half an inch long, and which is dull and battered. The iron penetrated about an inch, passing into the medullary matter of the brain, making by the tapering spike, an external opening three-fourths of an inch long, and one-fourth of an inch wide. The great weight of the butt end of the hinge, and its slight deviation from the perpendicu- 1856.] Punctured Fracture of the Cranium, &c. 505 lar direction of the spike, caused it to be swayed over across the sagittal suture, the thin parietal bone affording no other resistance than as a fulcrum on which the whole iron became a lever of the first kind, to injure the brain in the direction of the parietal pro- tuberance, and the child's body was thereby drawn over to the right, and- he was found with the right side of his head on the ground. Mrs. Maclin ran to the child's relief, and drew out the huge spike from his head, and she saw particles of cerebral matter adhering to the rough, rusty iron, and also escape from the wound. The blood at first escaped pretty freely, but soon ceased to flow. The force and weight of the iron was such, that it produced a sim- ple oblong opening the exact shape of the spike, without there occurring any surrounding depression, or radiating fracture, the displaced bone being comminuted into small particles, as is believ- ed. But few of these latter were ever found, and must have cleared the wound during suppuration, otherwise they involve a mystery. After the transient primary shock had subsided, none of the symptoms of concussion or compression of the brain mani- fested themselves; nor did they subsequently, the child relating to his father, in an hour afterwards, how the accident happened, and inquiring "if he must die" from the injury. Dr. W. P. Sunderland, the family physician, was sent for, and was soon in attendance. Very reasonably regarding the case as one likely to be attended with the gravest consequences, it resulted that I met him in consultation, and was fully impressed with the justice of his apprehensions. He had sponged the wound, and made the only topical application subsequently resorted to a simple compress saturated with cold water. We engaged to meet twice a day and watch the progress of the case. The patient never at any time labored under any apparent urgent symptoms, excepting during the second and third days; nor was any medical treatment found neeessary, or resorted to, excepting the adminis- tration of an occasional saline aperient. Excepting during these two days, there was but little febrile irritation or pain : there was freedom from delirium, from coma, and the intellectual mani- festations were unchanged, the wound soon beginning to suppur- ate, and to rapidly heal. During the second and third days there was considerable nausea and uneasiness of the stomach. The patient was kept for many days strictly in the recumbent position. I discontinued visiting him at the end often days, and he was subsequently under the care of Dr. Sunderland. Towards the close of December the wound completely healed, and a firm membranous cicatrix now shows the seat of the injury. The patient is a child of great intelli- gence, and his faculties have in no way suffered from a wound in which there has been a loss of cerebral matter amounting, as Dr. Sunderland and myself both estimate, to at least a drachm in weight. 506 Simple Ulcer of the /Stomach. [August, In neither the effects of injuries nor from the effects of remedies can we calculate on uniform results. The most inexplicable pe- culiarities and individualities interpose themselves, so as to render an ordinarily salutary remedy pernicious and an ordinarily fatal injury a thing of ready cure. Much here remains to be elucida- ted before the depths of pathology and therapeutics can be con- sidered as explored. [iV. 0. Med. and Surg. Journal. On Simple Ulcer of the Stomach. By M. Cruveilhier. M. Cruveilhier has recently presented two papers to the Aca- demie des Sciences upon this subject, and the following are the general conclusions : 1. There exists a disease of the stomach that may be anatomically characterised as simple ulcer of the sto- mach, usually chronic. 2. This lesion, which is far more common than is usually supposed, differs from cancerous ulcer, with which it is generally confounded, in its curability. 3. It is susceptible of complete cicatrization, this being accomplished by means of very firm fibrous tissue, differing essentially from scirrhus, with which it has been confounded. 4. When the ulcer penetrates through the whole of the coats of the stomach, the loss of sub- stance is repaired by surrounding organs, which also sometimes participate in the ulceration. 5. Danger may continue even after the cure of the ulcer, as the cicatrix often becomes the seat of consecutive ulceration, with all its attendant accidents. 6. It is one of the most frequent causes of blackish vomiting and dejec- tions, and the most frequent one of haemorrhage of the stomach whether accompanied by hsematemesis or not. 7. Simple ulcer is the most frequent cause of perforation of the stomach. 8. The two principal accidents are haemorrhage and perforation, which take place more commonly consecutively, i. e., by the erosion of the cicatrix, than primarily, or during the period of formation of the ulcer. 9. This ulcer, or ulcerative gastritis, may be always suspected, and almost always positively diagnosed. 10. It is distinguished from idiopathic gastralgia by the permanence of the symptoms it gives rise to, although these have alternations of ex- asperation and remission. Gastralgia is only temporary, comes and goes sudden^, leaving no traces of its presence, and may be suddenly relieved by opiates. 11. It is distinguished from non- ulcerative gastritis and gastralgia by black vomit and stools. It is very probable, however, that simple ulcer may exist without these discharges, and then its diagnosis from gastritis would be difficult. These black discharges are not characteristic of cancer; and, to some extent, are more inherent to simple ulcer than to it, for they belong to all periods of simple ulcer, of which they con- stitute the first symptom, while cancerous ulcer is not attended with them until the last stage, and sometimes not at all. 12. The 1856.] Treatment of Typhoid Fever with Tar Water. 507 distinctions between simple and cancerous ulcer are founded on, first, the physical signs, there being no tumor in the former; and, next, on the pain which is often absent in cancer but never in ulcer. The pain in the latter is like that of an open wound or burn, opposite the xyphoid appendix, striking through to the spine. In cancer there are cramps or spasmodic contractions, with induration of the stomach. 13. The true touchstone is the effect of alimentary regimen, which completely fails in cancer, but succeeds surprisingly in ulcer. 14. The great object in treat- ing the disease is to find an aliment that is tolerated by the sto- mach without pain, for then the cure may soon be effected. In the immense majority of cases, milk diet induces improvement from the very first day, and sometimes operates like magic ; but when it ceases to be agreeable to the patient, or fatigues the sto- mach, we must unite it with other substances, in the choice of which the instincts of the stomach must be consulted. Alimenta- ry regimen, in fact, constitutes the entire treatment, but nothing can be more difficult than the direction of this, according to quan- tity, quality, repetition, preparation, and temperature. 15. Medi- cinal substances^ whether general or topical, are quite secondary in importance. Iron and bitters are quite contra-indicated; and opium only succeeds when gastralgiais associated with the inflam- matory action. Gaseous waters, ice, alkalis, and especially phos- phate of lime prepared by the calcination of bone, alkaline and gelatinous baths, cold ablution of the entire surface, (in some cases very hot ablutions,) cold baths, and, in some cases, very hot sit- ting baths, stimulant frictions, with shampooing of the entire surface, derivatives or revulsives applied to the epigastrium are the means which have seemed to exert most influence on the pro- gress of the disease. 16. It must never be forgotten, that this ulcer is very liable to relapse, such relapse sometimes going on to haemorrhage or perforation. Such relapse may be certainly pre- vented by a good alimentary hygeine, and avoiding medicinal 6timuli. [Comjptes Hendus. Med. Times and Gazette. Treatment of Typhoid Fever with Tar Water. By Dr. Chapelle, of Angouleme. (Translated for the Charleston Medical Journal and Review.) Having observed the favorable effect of tar in a certain case of Typhoid fever, Dr. C. was induced to pay particular attention to this remedy, in a series of cases occurring during the typhoid epi- demic of 1854, 1855. His conclusion is, that liquid tar, if not an absolute specific, is yet incontestable the most efficacious agent yet discovered for the treatment of the above mentioned disease. The tar should be administered internally, as a drink, and in the form of an injection. 508 Fungus Hvematodes aired by Chloride of Zinc. [August, The drink is prepared in the following manner: About Sij. of liquid tar are put into a vessel, containing nearly a quart of hot water; after it has stood a few hours, the patient commences to drink it, filling up with ordinary water after each draught, so that the same dose of tar will last during the whole treatment. The injection is prepared by rubbing up the yellow of one or two eggs with a table-spoonful of liquid tar, and diluting with a little more than a pint of warm water; this serves for two injections. The patient should drink as much of the draught as he can ; as to the injection, that should be insisted on in proportion as the drink disgusts, for the intestines should be always kept supplied with a certain quantity. Sometimes six, eight, and even ten ene- mata should be administered in twenty-four hours. Should the patient be taken with diarrhoea, these injections check it promptly. This treatment, if continued for two or three days, generally triumphs over the typhoid state. Typhoid fever of ordinary in- tensity, called usually mucous fever, needs double that time; but typhoid fever, property so-ca41ed, of whatever form, is vanquished in its essential phenomena in eight to ten days. Each day the skin loses its dryness and heat, the tongue becomes clearer, the abdomen presents less tension and susceptibility, the sleep is calm- er, the fecal matter acquires a more normal odor, and the digestive functions recover strength. When there exists only a simple ty- phoid state, the tar draught alone is. commonly sufficient; but when the general perturbation augments, the febrile re-action in- creases, and the functional disorder is excessive, a much stronger dose of the tar is required, and the injections are then indispensa- ble. In all cases where the breast or the head has been affected with violent perturbation, the disappearance of the ordinary ty- phoid phenomena does not immediately produce a cessation of these complications. These functional disorders either disappear gradually of themselves, or need the application of treatment ap- propriate to the morbid state. [Rev. Med. Chirurg. Fungus Ilaimatodes, cured by Chloride of Zinc. By F. J. CoGLEY, Madison, Indiana. In February, 1856, I excised from Mr. P. M., aged twenty-four, an enormously enlarged testicle, wdiich on examination proved to be, unequivocally, medullary sarcoma. There is not a larger, or purer specimen, of medullary cancer in the British or French mu- seums. About the middle of January, the wound being nearly healed, he returned to his home; but soon found it would not en- tirely close. lie returned to me the first of March, with a bleed- ing fungus, the size of a hen's egg, protruding from the small portion of the wound, which had refused to heal. It was, beyond doubt, fungus hcematodes. 1 transfixed the base of the tumor, with two sharp pointed 1856.] Detection of Phosjihorus in Poisoning. 509 probes, crossing each other at right angles, and involving consid- erable sound tissue: then applied a strong ligature below the probes, in order to prevent haemorrhage; afterwords I protected tlie scrotum from the zinc, by muslin strips passed round under the probes. After removing a portion of the fungus with the scissors, I applied the chloride of zinc in its p,urity, and continued its application until the fungus was entirely destroyed. In a few days, a very deep eschar came away, and the ulcer healed very rapidly, so that in twenty days, he again went home with the wound entirely closed. It is my decided opinion, that if I had excised this fungus, it would have been rapidly reproduced ; nor do I believe that any "combination" of u chlorides"* could have enhanced the value of the application. This patient has had a slight cough, with bloody expectoration for more than a year; his general appearance cachectic; and it seems more than probable he has fungi in his lungs, but is enjoy- ing tolerable health. [Lancet. Chloric Ether in Diarrhoea. Diarrhoea of a painful character, and attended by spasmodic action, has been relieved in England by the use of chloric ether, after having resisted opium and a multitude of other remedies. "The effect of ether in every case was marvelous. The spasms and pains were relieved as by a charm; the diarrhoea ceased; warmth returned to the extremities; the pulse, before perhaps flagging, increased in force and volume. The relapses were un- frequent, and were generally checked at once by a single dose.", The same treatment was found efficacious in an epidemic diarrh,cea, which was supposed to be premonitory of cholera. "Hundreds of cases in which alarming cramps existed, were cured like mag- ic. [New Hampshire Jour. Antidote to Strychnia. M. Guiboust lately stated to the Academy of Medicine that, having observed a dog in violent convulsions, in consequence of eating one of the compound balls containing strychnia, he forci- bly made it swallow powdered gall-nuts, when the convulsions ceased immediately. Ipecacuana was then given to the animal, but the latter could not vomit. The next day milk was given to it and manna, after which the dog recovered. M. Caventon said that the infusion of gall was a very effectual opponent to vomiting, and that he had observed it destroy the power of Tartar Emetic. M. Orrila had already advised the administration of this infusion in cases of poisoning by opium and salts of morphia. [Bulletin Universe. Boston Med. and Surg. Journal. * Lancet, June, 1855. 510 Editorial, [August, EDITORIAL AND MISCELLANEOUS. A Practical Treatise on the Diseases of the Testis, and of the Spermatic Cord and Scrotum. With numerous wood engravings. By T. B. Cur- ling, F.R.S., &c, " Nulius addict us jurare in verba magistri." If Yellow fever were only a higher grade of Bilious fever, we ought to see it " cropping out," whenever there was any unusual intensity, or any greater prevalence of the latter. I have witnessed every epidemic in the city of Savannah, from the year 1830 up to the present time; I have often known and 2 seen Bilious fever of a malignant congestive type ; for fifteen consecutive summers I was the attending physician of the city hospital, whither the worst cases of our ordinary climate fever are conveyed. When year after year, I met with malignant and fatal cases of Bilious fever, and yet with not a single one of Yellow fever, I began to doubt whether or not I was right in my opinion. Occa- sional]}'' a few cases of Yellow fever would occur, at intervals of years; these I studied with intense interest. From 1830 up to 1839, I never saw a case of Yellow fever in the city. Its charac- ters were indelibly imprinted on mj* memory from the experience of 1827. In 1839, the city of Augusta was ravaged by this scourge : it was denied at the time that Yellow fever prevailed there. In the last of August, a patient, fresh from Augusta, en- tered the city hospital, and died in a couple of days. My then colleague, Dr. P. M. Kollock, and myself examined the body, and found the unmistakable post-mortem appearances of genuine Yel- low fever. A short time afterwards, a patient from Charleston entered, and died, and after death presented the same appearances. It is worthy of recollection, that although these cases were placed in the wards of a hospital filled with Bilious fever patients, there 518 Arnold. Essay vpon (he delation of [September, was no propagation of the disease. I still look back upon the year 1839, as the sickliest season I have ever experienced in Savannah, with the exception of our terrible epidemic of 1854. Old inhab- itants will recollect it as the driest summer on record, when turnips were planted in the bed of the Savannah river opposite Augusta. It was also a hot summer. Bilious fever prevailed over the whole country, and in a malignant form. Contrary to what would seem the fact at first view, such a season was peculiarly calculated to generate the malaria which is the generally acknowledged cause of Bilious fever. It is conceded that mere moisture will not pro- duce malaria; but mix vegetable matter with water, and subject it to heat, and the most malignant malaria will be generated. That year, swamps and ponds which had been covered with water since they had been known to the white man, were dried up, and the vegetable debris which had been precipitating to their bottom for years and years, were exposed to the action of the sun and air, and consequently were decomposed, and generated malaria. Now, Bilious fever prevailed with great violence in our city from early in July. I cannot imagine more favorable circumstances for the spread of Yellow fever than accompanied the introduction of those two cases in our city. Later in the season, I did meet with seve- ral cases of Yellow fever, but they were so few in number that I did not consider them as entitled to be considered epidemic. They were isolated, occurred in different parts of the cityr and had not the slightest connection with the cases of the hospital. I consid- ered them sporadic, and they most undoubtedly originated on the spot. I met with one solitary case of Yellow fever, with black vomit, in the fall of 1840. She was an unacclimated foreign lady, who had not stirred out of the city during the whole summer, nor had she even peeled a banana from Havana. In March, 1841, a case was brought to the hospital from Deme- rara, and in October of the same year a case occurred in my private practice, both of which were reported by me in the American Journal of the Medical Sciences for October, 1842. A few cases occurred at the hospital late in the fall of that year. I found the post-mortem appearances so similar in all the cases I had examined, from 1827 up to this time, that I was convinced that Yellow fever must be a disease sui generis. It was with in- creased interest, that during the summers of 1843, 4, 5, 6, 7, 8, 9, 1856.] Bilious and Yellow Fever. 519 I examined every case of fever which died at the hospital. Neither during life, while attending them, nor after death, did I find any signs to make me ever suspect that Yellow fever had existed. With the exception of a sporadic case in June, 1852, I met with no Yellow fever until the fall of 1852. Late in September, an utiacclimated painter was attacked with it in the north-eastern portion of the city: he had been working here all summer, and had had no connection with Charleston or Havana. He was removed to the hospital after he had thrown up black vomit, and he died. I had resigned my post as physician there in 1850. and ,i was not attending. An autopsy was made, at which I was pre- sent. Before it was done, I stated to the attendants what morbid appearances I expected to see; and they turned out exactly as described beforehand. The fever began to show itself in several places about the middle of October; but, fortunately, a frost early in November cut it short. I examined several subjects who died of it, and found the same peculiar morbid appearances. In 1854, it was my lot again, as in 1852, to have the first Yellow fever pa- ,] tient. I was called in on the night of the 3d August, and he died on the morning of the 5th, after having discharged quarts of genu- ine black vomit. My last case of Yellow fever, with black vomit, died on the 27th November. In the intermediate time, I had seen J hundreds of cases of genuine Yellow fever. I had made post-mortem examinations in the beginning, the middle, and the end of our epidemic, under the broiling sun of August, the more temperate atmosphere of the latter end of Sep- tember and October, and the almost cool temperature of Novem- ber, and I found nothhig new. From the beginning to the end, ,j I found the same morbid appearances. Of course I do not mean that each case was an exact copy of the other; but just as all cases of genuine Typhoid fever present the same morbid appearances, \\ although the patches of Peyer may be more ulcerated in one case j than in the other, or in some cases they may be enlarged without being ulcerated. Now, the morbid appearances after Bilious fever have never, in my experience, approximated those after Yellow fever; and the symptoms during life have presented wide and marked differences. Let us devote a little attention to these two conditions. It is well known that all fevers have many symptoms in com- mon in their beginning, such as headache, lassitude, pain in the 520 Arnold. Essay upon the Relation of [September, limbs, &c. ; and that merely from such symptoms it would be im- possible for the most experienced and skilful practitioner to diag- nosticate the particular kind of fever presented to him. He must wait the progress of the case, and the development of the charac- teristic S3rmptoms, before he can decide. Of course I speak of the inception of the disease. Certain fevers come on, as a general rule, more suddenly than others; bnt the rule is not invariable, and we would be at a loss to make a correct decision if we depended merely on the first phenomena of febrile disturbance. Moreover, some cases of well-known specific exanthematous dis- eases are developed so imperfectly that we are at a loss to decide, positively, whether or not the patient has had the genuine disease. Every practitioner of any experience must have met with such cases of Scarlet fever and Measles. Yet no one has ever, in latter days, denied that they are distinct and peculiar diseases, although a little more than a century ago Measles was confounded with Small-pox. I do not deny that, when no suspicion is aroused, sometimes the first notice the physician has that he is treating a case of Yellow fever, is the appearance of the fatal black vomit. But even in epidemics of Yellow fever, black vomit often supervenes when the patient has apparently passed the point of danger and offered no untoward symptoms. Nor must it be supposed that all cases of genuine Yellow fever appeared in one stereotyped edition. There was every variety of grade and intensity, from the ephemeral attack of twelve hours of fever, followed by speedy convalescence, to the more prolonged paroxysm of seventy-two hours, ushering in a malignant or a fatal case. Yellow fever is essentially a fever of one paroxysm; but that paroxysm is of very unequal duration, as just intimated. Now, if the access of fever should not be very marked, it could not be distinguished at first. Again: there are some cases which are ushered in with such marked symptoms that }rour suspicions would be at once aroused. The first case with which I met, in 1854, was one of this nature. There had been no unusual severi- ty in the fevers which had occurred up to that time. The summer had been the very hottest I had ever experienced, and what is very rare many fatal cases of coup desoleil had occurred. I was called to see my patient at night (3d of August) ; he had taken comp. blue pill : he offered the usual symptoms of fever pain in the 1856.] Bilious and Yellow Fever. 521 head, in the loins, over the upper part of the sacrum, down the thighs ; a hot, dry skin, and accelerated pulse. I directed a de- mulcent drink, and that a dose of castor oil should be administered the next morning early. On my visit the next morning, I found him with a raging fever; intense headache; blood-shot, shining, watery, smoke affected eyes; a full, bounding, but not very fre- quent pulse; a constant retching, and quite delirious. The land- lady said to me, "Doctor, what kind of a fever is this ?" I replied, " It is first-cousin to Yellow fever." I bled him, and applied a blister to the epigastrium, and directed cold demulcent drinks. The fever continued unabated all that day and the ensuing night. On the morning of the 5th of August, on my visit, they showed me a large wash-hand basin filled with matter, which I pronounced black vomit. He continued to eject large quantities of it, and at noon he died. This man was a carpenter by trade, a northerner; it was his first summer south ; he had been working on the roof of a house which was just finishing, and before he had moved to the place where he was then boarding, had lived in Curry town, the extreme south-western portion of the city, and had walked nearly a mile two or three times daily to and from his work, which was in the north-eastern portion of the city, through the broiling sun. It is again to be noticed that not a single other death occurred in that house during the season. After the epidemic became a fixed fact, and cases had occurred all over that section of the city, two of the inmates had the fever, but it was in a mild form. There was not any loop-hole whereon to hang even a suspicion that this man's disease had been contracted any where out of the limits of the city no "low, long, black-hulled schooner" had just arrived from the West Indies to afford an easy solution of how Yellow fever had attacked a denizen of Savannah. The house was a mechanics' boarding-house. A great panic ensued ; but I am yet to learn that any boarder contracted the disease from this case. The next afternoon, the 6th August, I was called by Dr. Jas. B. Read to see a case on the extreme eastern edge of the city, many squares distant from the first case. The patient was a young German girl, entirely unacclimated; the house where she lay was on the eastern bluff of the city, overlooking the low swampy grounds in that direction; it was amply ventilated, standing isolated in a large lot. She had been engaged sewing- decorations at the theatre, distant about three-quarters of a mile 522 Arnold. Essay upon the Relation of [September, and had walked to and from it in the hot sun, during the whole season. Unfortunately there was no doubt about the case ; she was moribund, with black vomit thrown up all about her. On the afternoon of the 5th, 1 was called to see a patient in Congress-street, about a hundred yards to the north-east of my first patient, but in a different street. His fever did not attract my attention particularly. He was of a lymphatic temperament, a northerner who had resided several years in the city, and whom I had attended some summers before in a very severe attack of bilious fever. His fever was not very high ; he complained of pain and languor. I gave a dose of blue pill, and directed oil the ensuing morning. On the 6th his medicine purged him and he was better. On the 7th, when I called to see him, he had left the house and gone to his business. On the evening of the 8th I was called to him: I found him with a slow pulse, a cool skin, and a constant retching, ejecting glairy matter, and no bile. For ths first time, I suspected Yellow fever, and that the cessa- tion of the fever had been the calm which follows the single paroxysm of that fever. I ordered a blister to epigastrium, ice to suck, and iced gum water for a drink, and my alterative pow- ders, (two grains of calomel, and one sixth of a grain of opium,) every two hours. On the 9th, he was much the same, except that the prostration was greater, so as to seem to threaten death from sheer exhaustion. Towards night, I discovered flocculi of black vomit in his vomit. He continued to throw up the black vomit mixed with a good deal of mucus, all that night, and all the next day, and died on the night of the eleventh. The quantity eject- ed was not very great, and it was thrown up with a great deal of straining and mixed .with mucus. He sank away gradually and gently, like one yielding to the effects of a depressing poison, without the power of reaction. Let us contrast the first case and this: The first case occurred in an unacclimated subject it was violent from beginning to end. The last occurred in an acclimated subject it was slow in its progress, ^e?s maiked in the first stage, but running its stage of calm and secondary fever as is most generally seen where death does not occur during or just after the paroxysm of the fever. Now no fact is more notorious than that acclimation to a warm latitude diminishes the susceptibility to yellow fever, and that it is far milder in those who have constantly resided south, summer 1856.] Bilious and Yellow Fever. 523 and winter, than in those who have not; and who are consequent- ly unacclimated. By this time, the eleventh of August, I had been called to many cases, all in the north-eastern part of the city, but in separate houses and different streets not in any ways con- nected with each other, and I could not doubt that we had a different fever to contend with than a bilious remittent fever, and I will now proceed to state the symptoms which brought me to that conclusion. Of course I will state what was the gen- eral type. The invasion of fever was more sudden than in ordinary Bilious fever, and although all fevers will be found to have a cold stage of some kind, it was not well marked in these. There was intense pain in the back, over the last lumbar vertebra and upper part of the sacrum and extending down the thighs along the sciatic nerve. The pain over the eyes, in the frontal region, was excru- ciating; the eyes were watery, shining, sometimes injected, some- times not, with the upper lid partially drooping, like one whose eyes were watering from a quantity of smoke. The skin was in- tensely hot and very dry; the stomach was very irritable; the ejecta were either a serous fluid, bluish green, as if blue vitriol had been dissolved in water; or a glairy, viscid, tenacious mucus. But the pulse was not disturbed in accordance with the general perturbation, it seldom being over a hundred beats to the minute, and very often not more than eighty or ninety. This 6ymptom I have been disposed to look upon as very characteristic. This febrile state lasted from twelve to seventy-two hours, on an average about thirty-six hours, and was succeeded by a cessation of these symptoms, and an apyrexia, but without any critical eva- cuation whatsoever. After this, in fatal cases, black vomit came on immediately, or it was ushered in by increased irritability of the stomach, it becoming intolerant of the mildest ingesta, by a constant empty straining, and by the most acute sensibility of the epigastrium to any pressure. With this, in most cases, there was the most remarkable depression of strength ; in some cases, several hours of a most perfect calm succeeded the paroxj^sm, and there was nothing to rouse suspicion of danger but a slow pulse, it gen- erally sinking to forty or sixty beats in the minute. When black vomit supervened, a few hours terminated the case. With all this manifest affection of the stomach, the brain, as a general rule, did not sympathise. The intellect was not affected, untd the last 524 Arnold. Essay ujjon the Relation of [September, closing scenes of life, when the brain gave away in common with the rest of the organism. This, considering the violence of the febrile paroxysm, must be considered one of the characteristics of Yellow fever. The thirst was great, but the tongue was not generally parched. At this period of the epidemic, the fatal cases terminated quickly ; black vomit came on within three or four days, and the patient seldom survived beyond the fifth day. When he did so, the chances were greatly in his favor. I have sketched only the prominent symptoms. Do they differ from those presented in a case of Bilious fever? Let us take a well developed, well marked case, with which to make our com- parison. A Bilious fever is almost always ushered in with a pretty dis- tinctly marked chill. There are certain symptoms, as stated before, which are common to the various forms of fever, such as weari- ness, head ache, back ache, &c; but the invasion of these pains is not so sudden in a Bilious fever. After the cold stage, there is an evident reaction of the system, and a hot stage ensues. This, again, is followed by a third stage, viz., one of sweating; the fever then abates, with a distinct critical evacuation, either by urine or by perspiration ; and in a few hours it again begins to increase, and having attained its height a sweating stage again follows; and so the fever goes on, the remissions becoming shorter, the stages less marked, until the system sinks under it; or the paroxysms becomes lighter, the remissions so marked and distinct that they slide into intermissions, and the patient recovers. Marked Periodicity is the distinctive characteristic of Bilious fever, as far as it has come under my observation. But there are certain symptoms attending the paroxysms which are quite distinctive. The pulse becomes more accelerated in Bil- ious fever, ranging far above one hundred, increasing as the fever increases, becoming slower as it abates, presenting, as verified by me, in scores of cases, a variation of forty beats to the minute be- tween my morning and evening visit. There is headache in Bilious fever, but is not of that intense supra-orbital character as in Yellow fever, and is more diffused over the anterior portions of the brain. There is very frequently great irritability of the stomach in Bilious fevers, and the stomach ejects great quantities of bile. Sometimes the bile may assume a 1856,] Bilious and Yellow Fever. 525 greenish color. Very often, a severe attack of Bilious fever may present its paroxysms so marked, and the remissions so distinct, that you could with propriety class it in the intermittent variety ; still the three stages, of cold, heat, and sweating, can be easily traced and marked in the form of Bilious fever. Now, if Yellow fever was but the highest grade of Bilious or Climate fever, we ought to find the worst cases of the latter closely approximating, if not running into the former. But what are the facts? The congestive type of Bilious fever (as witnessed by me in hundreds of cases) is unquestionably the very worst type of that fever. Every year, however healthy, affords cases of it in those individu- als who have been exposed to swamp miasma in their avocations. Watchmen are required at the wharves under the bluff of the city. Savannah lies on a high bluff, forty feet above the level of the tide, and fronts to the north. Northward is a low alluvium extending in a direct line due north, for fully four miles before the high ground of South-Carolina is reached. Hutchinson's Isl- and, immediately opposite to, and north of the city, is under the dry culture contract, which prohibits the planting of rice within a mile of the Exchange ; but beyond the back river and on the Ca- rolina side, are vast bodies of land, fully from two to four miles through in a northward direction, and extending east and west for about twelve miles, which are cultivated in rice with all its concomitant moisture. To the northeast of the city, these lands extend to the limit where the water becomes brackish and unfit for the culture of rice. To the direct east of the city, and beyond the limits of the dry culture contract, and on the Georgia mainland are many hundreds of acres of land cultivated in rice. To the north-west of the city, the alluvium takes a bend to the north, affording in that quarter some of the finest rice plantations in South-Carolina. What constitutes the defence of Savannah against the malaria of these low grounds? I answer; that, fortunately, almost the whole northern front of the city is defended by a high row of brick storehouses rising some twenty or thirty feet above the level of the plain on which Savannah stands ; which store- houses are not inhabited, and thus afford a material bulwark against the introduction of malaria into the city. To the north- east of the city, this protection is not afforded, because the store- houses have not been built up in compact mass above the level of the plain of the city, as they have been at the portion of the front 526 Arnold. Essay upon the Relation of [September, more westwardly. In this portion of the city there are many dwelling houses on Bay-street which are not protected; whenever the winds prevail from the north or north-east, those houses have invariably, and I speak advisedly from many years' experience, afforded the first cases of Bilious fever, and the most malignant types of it every year. I have a patient who lives in this locality. About six years since he moved into his house, and he and his whole family (a wife and three children,) were desperately ill of Bilious fever. I advised him, nay, insisted upon it, giving my reasons, that in the sickly season, when malaria was generated, (say from the first of June until a frost in the fall,) he should keep all the windows on the north side of his house closely shut by the sashes, from early in the evening until the sun was high up in the morning. He has done so, to the exemption of his family from fever, and the great curtailment of my professional fees. Such has been my advice to all persons inhabiting houses exposed in a similar manner, and I distinctly aver, that where the advice has been followed, the same result has obtained. Those individuals whose liberty is the practical one so much sighed after by the pseudo-philanthropists of the North, of work- ing or starving, are the ones who take the perilous occupation of watching at night under the bluff, and who are thus exposed to the malaria which may be blown from the north-east, the north, or the north-west, just as the wind may set. The summer of 1855, was the healthiest I have ever known in the city. Fevers did not rise above the grade of intermittent, as a general rule, yet I met with two cases of congestive fever, both of which were fatal within four days from my first visit, and each individual had contracted his fever, from exposure at night and early in the morning, in the very locality 1 have pointed out. They were the fac simile of cases occurring more or less frequent- ly every year; they were malignant, and they were fatal ; but they offered not the slightest resemblance to Yellow fever. The fever was high, the pulse was accelerated up to 120 to 140 iu the min- ute ; while the skin was hot to the touch, it was covered at times with moisture, standing out in great beads of sweat. The brain %was affected with stupor from the very commencement. When the fever remitted, which it did in the morning, and notably on the morning of the alternate day, the brain would become relieved in a measure, but as the fever exacerbated it would again become op- 1856.] Bilious and Yellow Fever. 527 pressed. These cases terminated in a stupor many hours before death. Perspiration in the very heighth of the fever, I consider as a very common symptom of the congestive form of Bilious fever, and I always consider those cases most dangerous which show this symptom, while there are stupor, an accelerated pulse, and an in- tensely hot skin. Whilst the cases which terminated favorably have the paroxysm of fever resolved by a critical sweat, with an abatement or cessation of the other febrile symptoms; I have time and again seen a man in articulo mortis, with a pulse so accelera- ted that it could not well be timed ; in a profound stupor, and with the sweat standing out on his skin in great drops ; and this condi- tion of affairs had not supervened just before the patient became in extremis, but had gradually come on in the last exacerbation of fever. There are other cases which come under the category of pernicious or malignant intermittents, or congestive chills. I have known a patient in a state of perfect apyrexia in the morn- ing, to die in the afternoon. These are the most malignant forms of climate fever met with in this city. I may fail to convey an idea of their real character, but it is from want of power in my pen, not from want of their total dissimilarity to Yellow fever. Late last fall, but before a frost, a watchman on the Charleston wharf, at the northwestern portion of the city, was found early in the morning lying in a state of complete insensibility. The night had been a stormy one; he had had intermittent fever, but had persisted in going to his work in spite of the remonstrances of his wife. He was carried to his house on the brow of the bluff, and I was sent for. I found him in a complete stupor, with his pulse nearly gone, his extremities icy 6old, his whole periphery cool, skin mottled, purplish, or rather in some parts bluish, with a clam- my sweat, hurried respiration, and in short, in what I considered a dying condition. I had him stripped and rubbed dry, had dry heat applied to the surface, sinapisms to every available point, and a large blister to the epigastrium and one to each leg. Friction was applied continuously for some hours; after awhile he was en- abled to swallow: I gave him hot brandy toddy every half hourr and calomel two grains, and opium one-sixth every two hours. Eeaction gradually took place and the next day, about twenty- four hours after he had been brought home, he spoke. From that time he began to mend, and is now at this present writing "earn- ing his bread by the sweat of his brow." 528 Arnold. Essay upon the Relation of [September, The rationale of this case is simple. The exposure to cold and moisture in an undue degree, converted what would have been, without such exposure, a mild paroxysm of simple intermittent into a malignant congestive chill, oppressing and depressing all the vital powers so as to prevent proper reaction, thus giving a fair representation of the congestive form of Bilious fever. If it were not so, I am at a loss to comprehend what that type of fever is, and must come down from the witness stand as never having seen a genuine case of it. One more prominent symptom remains to be noticed. While a jaundiced hue often follows an attack of bilious fever, another colour is its most frequent concomitant. There is in the worst types of it, a peculiar pallid anemic hue. This hue can be seen in those cases which have not fully recovered from attacks of intermittent fever, or where, as is often the case, a severe attack of bilious remittent fever has been succeeded by attacks of irregular intermittent fever prolonged late in the fall or even after a frost. In my clinical lectures at the Savannah Hospital, I have frequently diagnosticated malarial fever subjects from merely seeing them, before, I had asked a single question of the patient. In enumerating the peculiar signs of Yellow fever, I did not speak of the yellow colour of the skin because I wished to reserve that point up to this period. Now, as a general rule, fatal cases of that disease presented that discoloration ; and an unfavorable prognosis was almost always to be formed when the skin began to assume that colour; yet in the commencement of the epidemic, during our intensely hot and dry weather, when the cases were more acute and terminated more rapidly, I saw many dead bodies whose skin could not have afforded any index to the disease of which they had died, although black vomit had been freely thrown up before death. Of the cases which did recover, although many had been very severe, very few presented airy morbid discoloration of the skin, and it was a subject of frequent remark by those who returned to us after the pestilence had left us, that they were astonished to see the survivors looking so well and free from any marks of previous diseases. A gentleman, his wife and child, had all had very severe attacks of the fever in September 1854. He Visited the north late in October for a change. He has often told me that persons there would hardly believe that they had just come from what was then an infected city, and that they had been 1856.] Bilious and Yellow Fever. 529 sufferers from the scourge, so little did they bear any traces of it with them. Let me then sum up what are the prominent symp- toms during life of each disease, before I go into the signs presen- ted after death. I speak of the average of symptoms without noticing the varieties which occur in this, as in every other disease. In Yellow fever, the access of the disease is generally sudden ; a person may be about in the morning and quite ill in the evening, or may be well in the evening and attending to business and be prostrated in the morning following. The sympathetic pains are much greater ; the pain is over frontal region, over sacrum and down the thighs ; the skin is hot and dry, and does not pour out perspiration as in Bilious fever ; the pulse, never mind how high the febrile symptoms, seldom ranges over a hundred ; the tongue is not coated, on the contrary offers no index of the state of the stomach. The paroxysm of fever subsides without any critical evacuation and a state of calm succeeds which lasts from a few hours to forty eight hours. The pulse at this stage generally falls as low as fifty or sixty. In bad cases, the stomach invariably shows great tenderness upon pressure, or there is an uneasy sensa- tion in the epigastrium, and an intolerance of food. With this, there is also a remarkable prostration of strength. Many cases seem to be threatened with death from sheer exhaustion; nor is this at all dependent on any previous evacuations from the system, nor is it always in a direct ratio to the severity of the febrile parox- ysm, for it would occur where there had been no evacuation, and would follow a very slight paroxysm. If the case continued to grow worse, the retching is followed by the vomiting of the black vomit, the occurrence of which at the season of the year when alone Yellow fever prevails in this climate, leaves no doubt as to the nature of the disease or the fate of the case; or hemorrhage would occur from the mouth, the lips, the tougue, the gums, a scorbutic oozing. In an epidemic of Bilious fever, many of the cases have their periodicity so well marked that no one could doubt as to their true nature. Other cases have their remissions more ob- scurely marked, and without close watching, would seem to be continued fever, but a close observation will generally detect marked remissions, and decided exacerbations. The remissions almost always occur in the forenoon, the exacerbation in the latter part of the day and at night. Bilious fever seldom attains its height at one bound as does Yellow fever. Questioning will frequently 530 Arnold. Essay upon the Relation of [September, reveal the fact that there has been a distinct intermission between the first and second paroxysm. The pulse is most certainly more accelerated in Bilious fever, reaching often in a parox}Tsm up to 120 to 140. It will also vary many beats in the course of the day. A paroxysm seldom lasts longer than twenty-four hours when it either terminates, or there is a marked remission accompanied by sweats more or less profuse, and a sensible abatement of all the febrile symptoms. After this the fever again rises, again runs the same round. If the case is to terminate favorably, the paroxysms become lighter and lighter, the remissions more marked; very fre- quently they may be considered perfect intermissions, and you will see that the great peculiarity of Bilious fever is its periodicity. In the paroxysms there are headache, and backache, and pain down the sciatic nerve, but they are not so marked, as a general rule ; not of such a neuralgic character as is so often seen in Yellow fever. There are nausea and vomiting, but bile continues to be thrown up to the last stage of Bilious fever, should it be a case marked by great irritability of the stomach. Now when a person is attacked by Yellow fever, of course there is some bile in the system, and it may sometimes be thrown up at the very commence- ment of the attack, but certainly it is never seen in the advanced stages of the disease. In October 1842, I published the article on Black Vomit in the American Journal of the Medical Sciences alluded to before. My experience was then limited, but I adhere without qualification to the opinion then announced by me, viz: "Perhaps there may be bile in the incipiency of the attack, before a physician is called, but in every case that has ever come under my notice, that has terminated in black vomit, the absence of bile in the excretions has been the distinctive characteristic of the disease." The head is decided- ly more affected in Bilious fever, than in Yellow fever. It is a common thing for patients to remain in their senses long after they have reached the stage of black vomit. Just before death, the brain gives way as the other organs do. But in a bad case of Bilious fever there is almost always oppression of the brain, and cases lie in a stupor for two or three days before death. I think the anatomical lesions discovered in Bilious fever after death, which, I will detail further on, sufficiently ac- count for this. I think I have furnished sufficient points of contrast for the 1856.] Bilious and Yellow Fever. 531 symptoms during life. Let us follow out the diseases, and see what anatomical lesions are left on the dead body by them. In Bilious fever we find marks of disease on the mucous coat of the stomach, the upper part of the duodenum and the liver. These I may state as invariable. In a large number of cases, and particularly in the worst types of Bilious fever, there are traces of the disease on and under the meninges of the brain. In Yellow fever we find the same organs affected, except that, as the brain is involved during life in but comparatively few cases, it does not exhibit the same uniform alteration as do the stomach and liver. Now here is a point of relation, and to what does it amount?' to no more than does the relation of scarlet fever to measles, in each of which the skin and air passages are affected. In Bilious fever we find what I consider undoubted marks of an inflamed stomach. The mucous membrane is often red and injected, either puncta- ted or arborescent, it is often softened, so as it can be easily scraped off with the handle of the scalpel ; it is very often of a slate colour in protracted cases, but invariably traces of bile can be detected in the stomach or in the intestines. In Yellow fever, we also find the mucous membrane injected, but certainly much more generally and much more intensely than in Bilious fever. You do not always find black vomit in the stomach, because it may have been ejected just before death, but most generally you will. I have opened, in my day, several subjects dead from Yellow fever, in whose stomach black vomit was found, although not a particle had been thrown up. The patient, from Augusta, who entered the hospital in 1839, alluded to before, was one of these cases. Without a post-mortem examination, it might have remained in doubt as to what his fever was. Another case, amongst the very last of 1854, was examined after death by Dr. J. B. Read and myself, and black vomit was found in the stomach, although none had been ejected during life. Black vomit is however generally found in the stomach ; but it is found free in almost all instances, lying on the surface of the mucous membrane ; but there are cases in which the peculiar flocculi of black vomit can be detected in the very mouths of the patulous vessels of the mucous membrane ; and in some cases, I have seen a dark black arborescent injection running under or in the mucous membrane, exactly like the red arborescent injection so N. S. VOL. XII. NO. IX. 34 532 Arnold. Essay upon the Relation of [September, frequently met with. Now black vomit is a Hemorrhage. I express- ed in 1842, (loc. cit.) my belief, that it was blood altered ; in 1852r I detected blood corpuscles existing in it; I exhibited them under the microscope to Dr. Wragg, Dr. West, Dr. Read, Dr. Bulloch, and the late Dr. Ladd. Here is proof positive that the mucous mem- brane is the seat of a peculiar hemorrhage. Dr. Copland has some grounds in wishing to designate Yellow fever as the hasma- gastric pestilence. Whatever may be the real poison, it undoubt- edly has a peculiar tendency to produce hemorrhage from the stomach ; but there is a great deal of acid in the stomach, and it produces a peculiar effect on the blood, coagulating it into the flocculi of black vomit. The ejecta in Yellow fever, tested by litmus paper, always show strong acidity ; it is the acid which turns the blood, and prevents the haemorrhage from being a mere hematemesis. Occasionally the hemorrhagic tendency of the disease is shown by its action on the bowels, and blood is passed downwards. Such cases, as far as my experience goes, are always fatal, are genuine Yellow fever ; but must be distinguished from those in which the black vomit is passed per anum ; in the latter case, recovery is more apt to follow than when the unaltered blood is passed. Now, if Yellow fever were but the highest grade of Bilious fever, we ought every season to meet with occasional cases in which black vomit would be found in the stomach after death, even if it were not ejected during life. Such cases have never occurred in my experience. But it is when we examine the liver that we find unmistakable evidences of the peculiar nature of Yellow fever. In Bilious fever we find the liver of various shades, dark brown, umber, bronze, but always gorged with blood. In Yellow fever it is always altered in colour, being pale and destitute of blood. The best colour to which I can compare it is boxwood. Some boxwood is of a dirty yellow, some of a brighter yellow ; so of the liver, some arc of a light pale boxwood, almost a dirty ash white, some of a more pronounced yellow color. In a Bilious fcver liver, by pressing a piece of white paper on the cut acini, you will stain it yellow, showing the secretion of bile still having existed up to the time of death ; but this cannot be done with a Yellow fever liver. It sometimes contains a thin bloody serum, most generally it is almost dry. In 1827, Dr. Waring pointed out to me this state of the liver as the exact state present- ed in our fatal epidemic of 1820. In every case that I have had 1856.] Bilious and Yellow Fever. 533 the opportunity of examining from that time to the present, I have found the identical appearances. I examined cases at all times of our epidemic of 1854, and I found no variation of any account. I consider this conclusive proof of the identity of the disease, from 1820 to 1854. One case early in the season, presented a mottled liver, that is, there were spots in it which had undergone the peculiar change incident to Yellow fever, and there were other spots in which the liver presented the natural Spanish brown color. I attribute this to the patient having died before the change in the circulating fluids had been sufficiently great to effect the alteration of the en- tire parenchyma. In some cases of Yellow fever, I have seen the gall bladder contain only a dirty, thick, viscid bile. In Bilious fever, it is always filled with bile. In Yellow fever, the absence of bile is not confined to the sto- mach : you may search from the cardiac orifice to the anus with- out finding a trace of it ; often have I done so, and never have I succeeded. I do not say, that a person who has the opportunity of examining every fatal case which may occur in a large hospital may not succeed better, but when a man is harrassed with constant demands on his time, as a physician in full private practice will be in great epidemics, he cannot examine every case. It was my object in 1854, to procure a record of the post-mortem appear- ances during the various periods of the epidemic, and I examined cases which died in August, September, October, and November, and I found a great uniformity in all of them the discolored liver and the total absence of biliary secretion in the prima? vise. I was the attending physician of the Savannah Hospital for ev- ery summer, from that of 1835 to that of 1849, inclusive. I rarely allowed a fatal case of Bilious fever to escape without an autopsy. I state most distinctly, that in every case I found an abundance of bile in the intestines, if I did not find it in the stomach. My examinations of the head in Yellow fever have been very few. In the great majority of cases, the cerebral symptoms did not induce me to do so. I have seen cases in which the head was involved from the commencement, and, doubtless, those cases would have furnished evidences of cerebral engorgement ; but, as a, general rule, the local manifestations of Yellow fever are in the stomach and liver. The existence of long continued stupor in Bilious fever made me examine the brain very frequently ; indeed, 534 Arnold. Essay upon the Relation of [September, in the great majority of cases, and as I stated before, enough was found to account satisfactorily for the stupor; serum was gene- rally effused under the coverings of the brain, in the ventricles, and under the arachnoid, and the latter membrane was frequently opalescent. I have always considered the brain as a special organ for the local manifestation of Bilious fever, both from the decided symptoms presented during life, and from the post-mortem ap- pearances. I present for the inspection of the Society, drawings in oil colors taken from nature, of the appearances of the liver in the two dis- eases. An inspection will be better than any description. The Society cannot fail to see, at a glance, the vast difference from the brown and bronze of the four copies of the Bilious fever livers, and the light yellow boxwood color of the Yellow fever liver. It has been my object to sketch the prominent characteristics of the two diseases, presented during life and after death. If they be so widely and so uniformly different, how can we class them as the same disease, modified only by intensity? The second opinion entertained, that Yellow fever is a disease, sui generis, special, distinct, has been sufficiently discussed in the consideration devoted to the opinion, whether it is only a higher grade of Bilious fever. It will be seen that I entertain this belief. The question of its origin and propagation would, itself, afford scope for an essay ; and mine has already occupied so much time, that I could not go into it now. I can bear my decided testimony that in no instance has there ever been the shadow of the shade of proof, that it ever was imported into Savannah from abroad. On the contrary, the proof is positive that its first victims had had no communication, direct or indirect, with any source of infection. Moreover, when the British steamer Conway, which ran to the West-Indies, touched at this port, I attended two cases of Yellow fever from her, both of which died in the city, and yet no disease was propagated from them. In March, 1841, (as will be seen by my article quoted before,) I brought a case from a ship from De- merara, and placed it in the hospital where the patient died. It is said that it can be propagated from abroad in a city, although most give up the point as to its contagion in the country. The whole experience of 1820 and 1854, when our citizens fled by nundreds into the country, and into neighboring villages, towns, and cities, does not afford a single instance where the disease was 1856.] Bilious and Yellow Fever. 535 spread by the fugitives. If then, it is not propagated into the country, and into other cities by land routes, why is it supposed to be so fatal when it comes by sea? If one case can originate in a place, why not ten or twenty ? Case upon case occurred in 1854, in which the patients had not been near a deceased subject. Isolation was no protection. The poison, whatever it may be, spread like a pall over the whole city, and covered in its embrace all who staid, or entered its precincts ; but a quarter of a mile be- yond its limits the poison became innocuous. Such is fact. Let those who appeal to fancy, disprove it, or theorise upon it. Again : facts prove that Yellow fever is a city disease. Expo- sure to swamp malaria, staying on a rice plantation in the summer, and in the fall before a frost, will produce a malignant and most fatal Congestive-bilious fever ; but never, no never Yellow fever. Such cases of Bilious fever, as I stated before, I meet with every year; but, thank God, very seldom have I encountered cases of Yellow fever. Yellow fever, in this locality, has this in common with Bilious fever, it never prevails except in the summer and fall months, and is most effectually cut short by a frost. As a general epidemic, it ceased to prevail in Savannah about the second week in October in 1854 ; yet the poison continued in the atmosphere until a frost, ! and attacked those strangers who imprudently returned into the j city. The last resident whom I attended was attacked on the 1 25th of October. The cases which occurred afterwards were, with- out exception, strangers and unacclimated. ,- Since my connexion with the Savannah Medical College, I again :i attend "the hospital, and it was there, and amongst seamen that I : met with my last cases. They lay promiscuously amongst patients i with other diseases, but in no single instance did any body catch i the disease. I stated towards the close of that ever memorable ;i season, that I would expect to meet with Yellow fever for a fort- ' night after a frost. I had taken up the belief that ten days, or a fortnight, was the period of incubation of the poison. My last case died at the hospital on the 27th of November ; frost had oc- 1 curred on the 13th of that month. The unfortunate subject had reached our city before the mighty destroyer of the poison had withered and destroyed its noxious powers. Such, gentlemen, is my experience of the relation of Yellow and Bilious fever. Savannah, April, 1856. 536 Holt's Letters upon General Pathology. [September, ARTICLE XXIV. LETTERS FROU SAUL. D. HOLT, M. D., UPON SOKE POINTS OF GENERAL PATHOLOGY. LETTER NO. 14. Montgomery, Ala., July 22nd, 1856. Messrs. Editors Having expressed the belief, that the liver is primarily affected, and largely concerned in the production of these fevers, (intermittents and remittents,) it is but proper that I should give some of the reasons which induce that belief. The liver is a large central organ, having more intimate and extensive anatomical relations with other important organs and systems, and a greater number of offices and functions to per- form, than any other organ in the body. It receives the blood from other organs, which is distributed through its substance, from which the bile is secreted ; it receives and elaborates a large por- tion of nutritious matter furnished by the process of digestion, to which the bile largely contributes ; it prepares the carbonaceous products for more easy and rapid combustion in the lungs, and thus aids in the production and evolution of animal heat ; it elimi- nates the impure and effete matters from the blood which it re- ceives, and thus acts the part of one of the principal depurating organs of the system. The liver, being an excitable organ, is liable to frequent interruptions in the performance of its functions, by causes which tend to increase or diminish its activity, either of which results must be felt in a greater or less degree throughout the system, but more particularly by those organs in immediate connection with, and dependent upon it. To say nothing of other causes, the stimulant effects of atmospheric heat (which, by-the-by, is essential to the production of these fevers) upon the liver, which it highly excites, often causes an increased, and sometimes very excessive, secretion of bile ; and the bile thus secreted is generally imperfectly formed and depraved in its character, and in place of subserving its natural purposes, it acts as an irritant to the stom- ach and intestines, giving rise to bilious vomiting and purging, (than which nothing more rapidly prostrates the nervous or vital powers,) suspends the function of digestion, interrupts the process of elimination, and depuration, and, in a word, suspends or de- ranges all its functions, as well as those of dependent organs. But if these effects follow excessive action, from over excitement, let 1856.] Holt's Letters upon General Pathology. 537 us see some of those which result from, deficient action, from de- pression. The non-secretion of bile, which is essential to the digestive process the non-elaboration of the materials of nutri- tion the non-elimination of the impure and noxious substances from the blood, and all the consequences which grow out of these suspended functions, to say nothing of the effects resulting from bilious and sanguineous congestion of the organ, are the legitimate and natural results of torpor and acidity of the liver. The question then arises what cause is most likely to produce this condition of the liver ? Without calling in the aid of other causes, which no doubt exert an influence in the production of these fevers malaria, for instance which may have the effect of increasing the bile matter in the blood, and thus increasing work for the liver, or which may have the effect of impairing the pro- cess of digestion and nutrition, thus impoverishing the blood and rendering it more difficult of depuration, we can find a cause (and the true one in my opinion) for this condition of the liver, in the loss of excitabilitg from over action, consequent upon long continued and high ranges of atmospheric heat. While atmospheric heat is thus employed in the production of these fevers, at least so far as the liver is concerned, it exerts a large influence in determining their general character, with respect to the degrees of excitement, as it tends in the same manner to impair the tone and vigour of the ! whole nervous system, as it does the liver. When the febrile or i reactionary movement commences in these fevers, in the manner which has been indicated, by the redistribution of the accumulated ( excitability to the organs whence it was derived in the formation i1! -of the cold stage, or stage of nervous depression, it will proceed Li with a rapidity, and progress, to an extent or degree of excitement a proportioned ahvays to the condition of the general system, in re- & spect to the amount of vigour and excitability which it possesses, I as determined by the operation of the individual and general pre- | disposing causes, and by the presence, or not, of epidemic influ- - ences thus giving rise to the modifications which these fevers assume with respect to the degrees of excitement, which I have attempted, accordingly, to classify. So far, then, as the febrile movement, and the essential type and character of these fevers are concerned, it matters not whether the excitability of the system is plus, or minus, or whether the excitement rises above, or falls below the fine of a healthy excitement. If the system possess vigour 538 Holt's Letters upon General Pathology. [September, and tonicity, the depression will generally be slight and of short duration, and the reaction will be prompt, rapid and complete. If the system possess less vigour, and more elasticity and mobility, the reaction may be rapid, but will be less certain, complete, or permanent ; and if the system is enfeebled and depressed, the re- action will be proportionately slow, feeble and imperfect, or incom- plete thus furnishing us 'with the inflammatory, the irritant, and the congestive forms or grades of these fevers, with such intermedi- ate grades or degrees as have already been noticed. Before I attempt an explanation of the pathological condition of the principal organs, as they exist in the second or febrile stage of these fevers, it is proper that I should first notice the condition of the skin, and the remote systematic capillaries, as they not only play an important part in the production of these opposite condi- tions of the system, but furnish the most prominent signs of the actual condition Avith respect to the degrees of excitement or de- pression. I have stated that in the formation of the cold stage, these vessels became deprived of their accustomed or proportionate share of excitability, and in consequence became relaxed, allowing of the free escape of the blood sent to them by the heart, which continues its action to some extent independent of the general loss of excitability; and the flow of blood being retarded in the pulmo- nary extremity, from a feeble respiratory movement, necessarily accumulates upon the right side of the heart, including the pulmo- nary artery and its ramifications. While this state of congestion gives rise to plethora, or engorgement in the organic capillaries, in the manner which has been described, the remote capillaries re- main free from such engorgement, except in very extreme cases of depression, as in collapse and asphyxia, and this is owing to the valvular structure of the veins, and the remoteness of their radi- cles in the extremities from the seat of congestion, which has been shown to be in the lungs and heart, (congestion of the liver hav- ing no agency, so far as the remote capillaries are concerned). The cold, flaccid and shrunken condition of the skin and extremities, and the feeble action of the heart, indicate the feebleness of the respiratory movement, and the sluggishness of the pulmonary circulation, which is sometimes so great, that not only do the ex- tremities become cold, but the whole surface of the body, and even the tongue and breath become so. This condition may exist in various degrees, from the slightest chill perceptible, to a complete 1856.] Holt's Letters upon General Pathology. 539 collapse, depending of course upon the degrees of nervous depres- sion ; and so may the febrile or hot stage vary in degrees of excite- ment, from a simple flush to the most intense febrile action. Now, as it is our duty to enquire what takes place in these conditions, it is equally our duty to enquire into their why and wherefore. It would seem, then, that the two extremities of the circulation were mainly employed in the formation of the cold and hot stages of intermittent and remittent fevers; that while nervous depression retards the flow of blood through the pulmonary extremity, the same cause, by relaxing, allows it to flow readily and freely through the remote capillaries, and the natural consequence must be an accumulation of blood on the right side of the circulation, as it exists in the cold, or congestive stage, and which must continue to exist, with the attendant phenomena, as long as the depression continues; and that, while excitement accelerates the flow of blood through the pulmonary extremity, it retards it in the remote ca- pillaries, and the accumulation necessarily takes place on the left side of the circulation, as it exists in the hot or febrile stage. It is true, that the circulation of the blood depends upon the action of the heart, but the heart has not as much agency in the produc- tion of these conditions as we might be disposed to believe from first sight. The retardation of the blood in the lungs cannot be charged to a want of action in the heart, for in fact, the blood is thrown in excess upon the pulmonary capillaries by the heart's action : nor is the emptiness of the remote capillaries, in the cold stage, to be laid to the feeble action of the heart, as we see that the , action of the heart is always sufficient to empty the arteries. With this explanation of the manner in which the cold stage of an intermittent is formed, from a want of nervous power and action in the two capillary extremities of the circulation, in consequence of its accumulation in the liver, or other weak and laboring organ, which I have shown to be the first step or link, in the chain of morbid actions which follows, with the blood accumulated upon the right side of the circulation, with its attendant consequences and its phenomena, I will proceed to examine the consequences of a return or restoration of nervous power to the capillaries of the two extremities, being the commencement of the reactionary or febrile movement. Upon an increase of the respiratory movement, and a freer flow of blood through the pulmonary extremity, the heart, in conse- 54:0 Holt's Letters upon General Pathology. [September, quence of an increased supply of blood, which has been revivified in its passage through the lungs, becomes increased in action and sends the blood out to all parts, as fast as it is received from the lungs. If the heart failed in this, and was not responsive to the stimulus of the fresh arterial blood, an increased flow of blood through the pulmonary capillaries would necessarily produce con- gestion in the pulmonary veins a thing, I dare say, which rarely occurs. So far, the action of the heart is instrumental in carrying on the febrile movement, though not instrumental in starting it. The next event in the regular sequence is an increase of the gen- eral excitement, from the stimulus of the blood upon the nervous centres, and an increase in the activity or power of action, in all parts which share in the general excitement. If the remote or systematic capillaries receive their full share of excitement, and regain their contractile power, they will be enabled to retain their blood sufficiently long for the arteries to become refilled, which will be the sooner, in proportion to the flow of blood through the pulmonary extremity of the circulation. In this condition of things, we have a full development of the febrile stage, with all the phenomena dependent upon it, such as a hot, dry skin full, strong pulse, &c, &c. But this prompt reaction, and high excite- ment, presupposes or indicates a full share of vigour and excita- bility in the system, which does not always exist in our latitude. From the influence of causes, which have been sufficiently pointed out, it is generally the case in our climate that owing to less vigour, and greater elasticity and mobility of the system, independ- ent of the immediate depressing influences which would retard . reaction, notwithstanding there may be a free flow of blood through the pulmonary extremity, duly exciting the heart to ac- tion, and* the nervous centres respond to the stimulant influence of the blood, promising a full and uniform, or perfect, reaction, the unequal distribution of nervous excitement is almost always certain to prevent it. Thus, if the remote capillaries fail to receive their due share of the nervous power, or excitability in its re-dis- tribution, or of the new excitement kindled up by the reaction, through the nervous centres, the consequence will be that they will allow the blood to pass so rapidly out of them as to prevent the perfect filling up of the arteries, which is the case in the irri- tant forms of these fevers, and which are characterized by a hot, but generally moist skin, and a frequent pulse the action of the 1856.] Holt's Letters upon General Pathology. 541 heart being spent in frequency of action on account of a dimin- ished column of arterial blood, the nervous centres, in such cases, being often the seat of accumulated excitement, giving rise to de- lirium, convulsions, &c. A greater degree of depression, or less of reactionary power, with loss of tone and contractility in the Systemic or remote capillaries, generally determines the grade of these fevors, which will be known by *the feebleness of and fre- quency of the pulse, and the coldness and fiaccidity of the skin, during the reactionary or febrile stage of the disease, or paroxysm. In all the grades of these fevers below the irritant, the febrile ex- citement, though generally manifest, never rises so high as to create or establish a general arterial plethora, or a preponderance of the blood upon the left side of the circulation, except in organs which have been engorged by previous congestion, as the brain, stomach, liver, &c, in the manner which has been described, or in such parts as may become the point of accumulated excitability, giving rise to irritation or inflammation, which conditions are usu- ally manifested by increased heat of the head and body, while the extremities remain cold, or pre tern aturally cool during the parox- ysm, indicating a want of tone or power of action in the remote capillaries. Having given what I conceive to be the "rationale," or the physiological and pathological process by which the cold and hot stages of intermittent and remittent fevers are produced, which, so far as the two extremities of the general circulation are concerned, is applicable to the production of every other form, grade, or type . of fever, whether the attack be preceded by depression and congestion, or whether (if such a thing be possible,) the sys- tem rise into a state of general febrile excitement without it, I feel it due to myself in order to prevent misunderstanding, to re- peat, that the capillaries of the pulmonary extremity of the general circulation, under the influeuce of general nervous depression, fails to transmit the blood through them as fast as it is sent to them by the heart, and consequently the blood accumulates behind them ; and that the remote capillaries, under the same influence, transmit the blood faster through them (except where it is opposed by phy- sical obstruction,) than it is sent to them by the heart ; and that a reversed condition and result occurs when these vessels are under the influence of general nervous excitement, the heart in the mean- time performing its part in the circulation of the blood, but not 542 Holt's Letters upon General Pathology. [September, controling the action of the capillaries* It may be asked, why re- sort to a local origin, and to the doctrine of accumulated excita- bility for the production of the cold stage, and its diffusion or redistribution for the production of the hot stage of these fevers, when an easier and shorter way would have been to assign their production at once, to the direct influence of the causes of depres- sion and excitement upon these vessels ? In my opinion, I have given the true method of their production. In my last letter, I stated that a condition of general depression and congestion could be produced from a sudden and violent shock to the great nervous centres ; and so may a high state of general excitement be pro- duced from some powerful cause, but in each case they would be but ephemeral and transitory, while in these fevers these conditions are permanent, or of frequent occurrence according to their type, form, or modification. The importance of these points of pathology, respecting the degrees of nervous excitement, and the consequent unequal and irregular dis- tribution of the blood, involving, as they do, the most serious conse- quences, attendant upon these and, indeed, all other fevers, is my apology for dwelling upon them with so much earnestness and per- tinacity ; for I candidly believe, that if they were looked to more * I would not, question the fact that the circulation in the capillaries is assisted, as has been maintained by the influence of affinities, that is, that the arterial blood in exchanging oxygen for carbon in the remote or systemic capillaries produces a forward movement, and that a deficiency of oxygen in the blood, has the effect to retard its movement in the remote capillaries, while in the pulmonary extremity the affinity of venous or carbonized blood for oxygen produces the same result, and that an excess of carbon retards it in the pulmonary capillaries. But this doctrine does not serve to account for the broken balance which sometimes suddenly takes place in the formation of the cold and hot, stages of the fevers in question, and cer- tainly does not serve to explain the causes of their production, if we leave out of view the condition of the capillaries, with respect to the degrees of nervous excite- ment and depression, upon which I maintain these disturbances in the circulation mainly depend. And if we attempt to explain the production of these phenomena, According to the doctrine of affinity, we will find that the condition of the capilla- ries have no agency in their production, but that they depend upon the condition of the blood with respect to its amount of carbon and oxygen ; and, we will be com- pelled to look further for the causes which produce that condition, which will be found as I have maintained, in defective and imperfect ecration from an enfeebled res- piratory movement, whereby the quantity of oxygen is diminished; or from defec- tive and imperfect depuration from suspended functions of the liver, whereby the quantity of carbon is increased in the blood, which after all are but the effects or results of deficient nervous excitability. H. 1856.] Holt's Letters upon General Pathology. 548 closely by the profession at large, our cardinal remedies would receive the credit of their true " behest," and these diseases would be treat- ed with more uniformity and success than they generally have been. It is not in the spirit of arrogance, but of self-gratulation, (which, by-the-by, is about my only reward) that I say, that the principles which I am endeavoring to advocate have carried me through a practice of nearly thirty years, with, perhaps, as few disappoint- ments, or causes of regret, as the most favoured of my cotempora- ries. It is not very delicate, I know, for a professional man to blazon his success, even in the ears of his colleagues ; but, as an argument in support of this principle which I advocate, I will state that, in the management of certain formidable diseases, scarlet fever, for instance, though I have encountered it in all its forms and varieties, through several epidemics, besides many individual or sporadic cases, I have had the good fortune never to lose a case. It is but justice, however, to myself and the profession, to say, that I have pursued no plan, and used no remedies, which are not recog- nized and prescribed by the best authors, with this exception, that viewing the disease as self-limiting, having a definite course to run, according to its essential and specific nature, I have generally avoid- ed as much medication as the books prescribe, but have left it to its course, watching, however, for such symptoms as did not belong to it in its essential character, and treating such upon the general prin- ciples which I am now advocating, to which, next to peculiar good fortune, I must ascribe my success. In the management of yellow fever my success has been little less than in scarlet fever; and so of typhoid fever, and various forms of congestive diseases, the details of which will hereafter be given among others, a severe epidemic congestive pneumonia, over sixty cases of which I treated one season, without the loss of a patient. It is not my privilege to say as much of some other epidemics which I have encountered, such as cholera, and cerebrospinal meningitis. But in these, the want of equal success depended rather upon the want of a timely and proper application of the principles of which I speak, than from error or defect in the principles themselves, as, after all, I have not been able to ascertain that any other plan of treatment was more successful. I am not so vain and arrogant as to suppose that all case3 of those malignant diseases which I have named are amenable to treatment, and that a great many of them would not terminate fatally under any known plan or system of 544 Holt's Letters upon General Pathology. [September, treatment ; but I do say, that hundreds and thousands of cases ter- minate fatally, which under a timely and proper course of treatment would recover ; and that in all such cases, where the physician has been called in time, the responsibility is upon him, and he cannot, upon the plea of their malignancy, or the impotency of the remedies at his command, evade, or shrink from it. Nor should he be too ready to claim the honor of success, as there are hundreds and thousands of cases which would recover without his aid or assist- ance. Such, no doubt, was the case with the largest number of the cases of scarlatina and typhoid fever which have fallen into my hands, which (" an honest confession being good for the soul") I am willing to confess, though I could not say so much with respect to the other diseases named. Upon a redistribution of nervous power, or excitability, those organs will receive the largest share, whose capillary vessels have been the seat of engorgement from venous congestion. These have been shown to be, the brain, stomach and intestines the liver and spleen; and these, in consequence of irritation thus kindled up in them, become the points of determination and accumulation of blood, as it finds its way, more or less rapidly, through the pulmonary ex- ' tremity of the circulation. From the direct action of the causes of irritation, the capillaries of these and other organs may become the seat of engorgement, (which may or may not excite a febrile move- ment in the system.) which is the antecedent condition to inflamma- tion in these organs. Thus, we see that the capillaries of these organs are doubly liable to engorgement, and, liable to double en- gorgement ; for, if the reactionary powers of the system are insuffi- cient to effect a full and complete reaction, and entirely remove the congestion, which is generally the case in our worse forms of fever, these organs, especially those which are connected with, and are dependent upon, the liver, (which often remains in a state of con- gestion after the lungs have been set free,) must necessarily remain to a greater or less extent, in a state of engorgement, to be increased from an increase of blood thrown upon them in consequence of the febrile reaction; and whether the reaction be partial or complete, these organs will always claim, and will generally receive, more than their full share of the circulating fluid. Hence it is that so many of these fevers are characterised during the febrile stage or exacerbation, by heat of the body and head, but preternatural, cool extremities, with a variable, but generally a feeble or frequent 1856.] Holt's Letters upon General Pathology. 545 pulse ; and this is the class of fevers which I have designated as congesto-infiarnmatory and congesto-irritant. Should there exist a greater amount of excitability in the system, with an active pulmo- nary circulation, the degrees of animal heat will be proportionably exalted, and the action of the heart increased, giving great celerity to the blood which is in active circulation, and diffusing heat throughout the system. In this form of fever, which we recognize as the irritant, and by far the most common in young subjects notwithstanding the reaction is often violent, as evinced by the in- creased action of the heart, and the great increase of heat which extends to the whole surface and the extremities the reaction is never complete or permanent, for the reason that the enfeebled and relaxed condition of the remote capillaries permits such a free escape of the blood, that the arteries fail to be filled up, in consequence of which the pulse never requires much strength, but is always fre- quent, and the skin, though hot, is generally moist, a state of things peculiarly characteristic of this form of fever. Now, while the re- mote capillaries participate for a short time, and to a limited extent, in the general febrile excitement, the organic capillaries always come in for their full share, if not more, as evinced by the delirium and convulsions, and the copious bilious vomiting and purging which are almost the constant attendants upon the exacerbations of this form of fever, abundant secretion being one of the diagnostics between this and the inflammatory form. The irritation excited in the brain by the stimulus of highly oxygenized blood, consequent upon the active pulmonary circulation, constitutes a new and altogether different morbid action from that which existed in consequence of mere physical obstruction and engorgement of its capillaries from congestion in the lungs, manifested by a change of the dull, inactive and comatose state of the brain into a state of delirium, or phrenzy, and convulsions. This condition is sometimes the result of sympa- thetic action, in which case, though the manifestation may be nearly the same, the irritation will be more transitory and evanescent, and seldom passes into a higher or inflammatory grade of action, which a long-continued or frequent renewal of the condition, from the re- currence of paroxysms, is apt to do. Another source of disturbance in the functions of the brain, and other nervous centres, is to be found in the changed character and depraved condition of the blood ; but cerebral disturbance from this cause seldom takes place in the early stages, or in the milder forms 546 Holt's Letters upon General Pathology. [September, of these fevers, and is only found in the protracted and violent case?, in which the excitement has been so high as to suspend for a length of time the functions of secretion and excretion, allowing of the ac- cumulation of poisonous matters in the blood, which should have been thrown out by the liver and other depurating organs ; and the blood thus depraved, being thrown upon the brain and other nervous centres, unlike the freshly oxygenized blood, instead of excitement, produces depression, with low delirium and coma, the characteris- tics of the typhoid condition. It seems to be scarcely necessary to say that the inflammatory form of these fevers is distinguished from the irritant, by the more equally diffused and permanent character of the excitement by the greater strength and less frequency of the pulse by the more uniform and often less intense heat by the dryness of the skin, and the suspension of the secretion generally by the more protracted febrile exacerbation, and generally by less cerebral disturbance in the earlier stages of the disease. Notwithstanding the frequent occurrence, and the important con" sequences of disturbance in the functions of the brain and other nervous centres in these fevers, there are other organs not less fre- quently involved the derangement of whose functions are no less important and serious in their consequences than those of the brain these are the liver, stomach and intestines. The condition of the latter, in connection with congestion of the former, in the cold stage of these fevers, I have already considered, and as these organs are all subject to the same states of morbid action, and the same consequences and results, from exalted excitement, it will be unne- cessary to notice them separately, and I shall therefore confine my remarks, chiefly, to the functional derangements of the liver. These fevers have generally been called bilious, but whether they are en- titled to the appellation from an excess, or deficient secretion of bile would be a difficult matter to determine. A certain degree of ex- citement is necessary for the performance of the functions of secre- tion, and whether it is too high, or too low, it becomes alike suspend- ed ; hence we notice that in the cold stage of these fevers, and particularly in those more decidedly congestive in their character, the vomiting and purging, which is a common occurrence, consists in the discharge of a glareous, mucus, or serous matter, having more or less acrimony, without any of the properties of bile. But upon the return of excitement, and the establishment of a febrile reaction, large quantities of bile are often poured out, giving rise to 1856.] Holt's Letters upon General Pathology. 647 violent and obstinate bilious vomiting and purging. This excited, and active secretory function of the liver, often occurs as an idio- pathic affection, but when it occurs as one of the phenomena, or as a concomitant of these fevers, it is usually in connection with the milder and more simple forms of intermittents, attended with a lively reaction, or with the earlier stages of remittents having the irritant form or character, of which it may almost be said to consti- tute a characteristic feature. But in the more advanced stages of these fevers, and in those of higher grades of excitement, as well as those of a lower, the suspension of the biliary secretion is one of the most common occurrences, and constitutes one of the most serious difficulties with which we have to contend. It is important, there- fore, to enquire into the causes, and then into the consequences, of the suppression or suspension of the secretion. We have stated that over action from excessive stimulus, induced debility and ex- haustion in the nervous tissues and have ascribed to this condition of the liver, (a state of depression from excessive action from the stimulus of atmospheric heat,) the origin of these fevers, and have shown the consequences which resulted, not merely in the suspension of the biliary secretion, but the formation of a portal congestion, and the consequent obstruction and interruption of the functions of other organs, and the changes thereby effected in the constitution of the blood. Now it must be borne in mind that the liver is lia- ble to congestion and engorgement from several different causes one from congestion of the lungs, from local debility or depression in its vessels from excessive excitementor arterial and capillary engorgement and engorgement of the biliary ducts. The first, re- sults from the general causes of depression ; the second, from general or local causes of depression in the capillaries of the portal veins ; the third, from excitement and the stimulus of freshly oxygenized blood accumulated in the hepatic artery and its capillaries mani- festing the signs of irritation, and perchance, the signs of inflamma- tion but I must say, that in my whole practice, I never met with a case which I could recognize as inflammation of the liver; the fourth, engorgement of the biliary ducts and gall bladder, from the accumulation of bile consequent upon its previously abundant or excessive secretion, which, from its retention in these vessels, and having parted with its thinner portions, it often becomes black and inspissated. Hence, it is, that we often see harrassing vomiting, and purging of thin bilious matter of various color and consistence, N. S. VOL. XII. NO. IX. 35 548 On Scarlatina. [September, followed by the discharge of large quantities of black or deep green and consistent bilious matter, which is always hailed as the harbin- ger of safety to the patient, especially, if it has been the work of a substantial dose of calomel. Being admonished that I am transcending the usual limits allot- ted to my letters, I must close for the present, and resume the sub- ject in my next letter. Hoping that you will not tire from reading, before I do from writing about these things, I remain, as usual, Your friend, &c. Saml. D. Holt. On Scarlatina, audits Relations to Rheumatism, Carditis, and Al- buminuria. By Dr. W. Hughes Willshire, Assistant Physician to the Charing-Cross Hospital. [The complications of scarlet fever are very numerous, and will be found amply treated of in works on the subject ; but rheumatism is one of those which, though common, has been but very cursorily noticed, excepting within the last few years. In 1851, Betz, of Heilbronn, drew particular attention to it, and went so far as to hint at an essential relation between acute rheumatism in the child and scarlet fever.] He implies, at least, that an arthritic affection in young children often could not be told from the exanthem in question. That he had seen albuminuria and desquamation of the skin in acute rheu- matism in children who had shown no exanthematous eruption ; and, on the other hand, that the eruption was not an essential symptom of scarlet fever, leaving it, therefore, a very difficult, if not impossi- ble, case in which to arrive at a differential diagnosis. In 1853, M. Trousseau stated that he had very frequently met with the com- plication we are speaking of; that the arthritic disorder sometimes, though but rarely, became generalised, and attained a high degree of intensity, accompanied by delirium and other nervous symptoms terminating in death. In 1854, I myself read a paper before the Medical Society in London on Rheumatism in Children, in which I adverted to its union with scarlatina (reported in 'The Lancet,' 1854, vol. i., p. 138) ; and a few months afterwards, Mr. Haydon.of Bovey Tracy, communicated some very interesting facts in ' The Lancet," in reply to a commentary, as it were, upon my paper. You "will find Mr. Haydon's communication in the first volume of that journal for last year. This gentleman has had some very corrobo- rative experience, and states, that although he cannot coincide in the views I have detailed of Betz, he admits there is a remarkable analogy between the phenomena, especially the secondary ones of the two diseases; and that so closely does he consider the two rela- ted that he makes it a rule, on the decline of the rash in scarlet 1856.] On Scarlatina. 549 fever, to administer lemon juice. I strongly advise you to read Mr. Haydon's remarks, and then to turn to Betz's paper, which you will find in the eighteenth volume of the 'Journal fur Kinderkrank- heiten.' In both essays you will find how easily certain cases of the two affections I say certain cases, mind might be confound- ed together. If we were to take extreme forms of the two diseases viz., on the one hand, an almost universally bright-red child, with sore throat, strawberry tongue, who had been known to have been with other children similarly affected, and on the other hand, a pallid, scrofulous child, without any cynanche, with a white-coated, moist tongue, and swollen and painful joints, there would certainly arise, I should say, no difficulty about the matter. But you must recol- lect scarlet fever is not always of this characteristic appearance ; the sore-throat may be next to nothing, or absent; the rash only evident about the joints, which may be a little puffy and painful ; the tongue but moderately and simply coated, and the child not known to have been directly exposed to the zymotic virus. On the other hand, if what is stated be true, albuminuria may be tempora- rilv present in rheumatism, as also, according to Betz, desquamation of the cuticle. Now, in a case presenting such equivocal signs as I have hinted at as possible, I do not know that from these signs alone, and from these only, the differential diagnosis could be per- fected. But this I must believe, from my own experience up to the present, that the further course of the malady, together with the commemorative history of the patient, would not fully help me out of the difficulty. The difficulty, in truth, has not yet occurred to me; but let me tell you that in India and in America a somewhat analogous one has happened to others, and from this, and what you will glean from Dr. Betz and Mr. Haydon, it is not impossible we might hereafter have a case occur amongst us, or an epidemic dis- order, which should have such a mixture of the symptoms of rheu- matism and scarlatina that we should be much puzzled to give it a satisfactory name. A late patient of mine had been surrounded by the scarlatinal poison; she had sore-throat, diffused red efflorescence ; the tongue and even breath were those of scarlet fever. The rash subsided, desquamation just began around the neck, when pains of the ankle and wrist joints came on ; the parts were swollen and shining, and a kind of secondary fever was lighted up. Now, whatever might be thought of this latter affection, the former was clearly not rheu- matism. That there is some obscurity about the exact nature of a disease occasionally attacking not only children, but adults, and marked by arthritic pain and tension often of a severe character, accompanied by a scarlet rash, is plain from the accounts given by some American and East and West India practitioners. For in- stance, in 1824, 1825, and 1847, outbreaks of a disease like the one I have just mentioned occurred in the East Indies. In the summer 550 On Scarlatina. [September, of 1828, the malady appeared epidemically in some of the southern cities of the American Union, after having previously prevailed in some of the islands of the Gulf of Mexico. In Charleston it spread with great rapidity, ultimately attacking almost the entire popula- tion. In this latter city the last occurrence of it that I have found recorded was in 1850, and is alluded to by Dr. Dickson, of South Carolina. In Calcutta, again, during the hot and rainy season of 1853, a variety of the same affection prevailed, and has been well discussed by Dr. Goodeve in the first volume of the ' Indian Annals of Medical Science' for that year, and to which I must refer you. Now, this disease has been called scarlatina rheumatica by Cocke and Copland, exanfhesis o.rthrosia by Nicholson, and the strange cog- nomen of dengue has been popularly bestowed upon it. I have said that the first account of this disease goes not further back than 1824 ; but it is proper I should mention that Dr. Dickson, of Charles- ton, writes as follows: "I recognize Rush's "break-bone fever' of 1780 in Philadelphia as the first notice of a malady such as I have called dengue ;" and Dr. Waring, of Savannah, alludes also to dengue under the title of " eruptive breakbone." I cannot go into the details of this peculiar disorder : indeed, I have only alluded to it to show you that there occurs a fever, ac- companied by arthritic pains and a red exanthem, whose true rela- tions to scarlet fever yet require clearing up. However, I may just remark, that Dr. Dickson regards dengue as a distinct contagious- disease, giving immunity from second attacks, and that it is not scarlatina ; whilst Mr. Goodeve states that most of the symptoms characteristic of the latter affection found expression in some of the cases occurring in Calcutta. He says, "the fever eruption, red- dened mucous membrane and tonsils, desquamation of cuticle, swell- ing of hands and feet, state of the tongue, albuminous urine, and all such as go to make up scarlatina ; but it would be premature to as- sert that the cause is identical with that of scarlatina. I should say that it would require a longer series of observations of several epi- demics, with careful examination of all the attendant circumstances,, before we could pronounce the diseases to be identical." Again. Dr. Copland affirms, that the disease called dengue "Was not a form of scarlatina is shown by the severity of the rheumatic or neuralgic symptoms," &c. ; and "that it was not a rheumatic fever was shown by the undoubted propagation of it by infection," &c. I see that in some later observations by Dr. Mackinnon, in the third number of the 'Indian Annals,' he doubts whether any of the epidemics of India described as attended by red efflorescence of the skin can be identified with any of the varieties of the scarlatina of Europe, denies the disease we have referred to to be contagious, and for which, he says, the name of " the red fever " is as good a name as any other. On reviewing the different accounts given by Indian and Ameri- can writers of this puzzling affection, the disease appears in certain 1856.] On Scarlatina. 551 places, and epidemics, to have had more the characters of rheuma- tism ; whilst in others it has had more those of scarlatina. The case mentioned may be said to illustrate, so far as my own experi- ence extends in respect to the relations between scarlatina and rheumatism, one form of the arthritic complication namely, that occurring early in the course of the exanthematous disease. When it so occurs, the specific inflammation about the joints terminates, like primary or idiopathic rheumatism, in resolution or delitescence. But it may take place at a later period of the disease, when all has been thought to be over. It occurs after desquamation has made some progress, and then may terminate in the suppurative crisis. Now, this is peculiar about the rheumatic inflammation generally of young children ; unlike in adults or older children, it may lead to purulent effusions into joints, and also about them. I have known this to occur in several instances, and it is more liable, I believe, to ensue in the secondary rheumatism of scarlatina. This is a fact well known to authors. If I recollect aright, Dr. Kennedy, of Dublin, has published something upon it, and Trousseau, I know, states that scarlatinal rheumatism is often more dangerous when localized to a single joint, than when attacking several articulations at one time, as it is then more inclined to terminate in suppuration, and even eventually to result in caries of the articulating surfaces. This cir- cumstance, however, of the arthritic inflammations of infants and young children, not unfrequently terminating in the formation of matter, has led some pathologists to deny the true rheumatic nature of the disease in question. I must confess, too, it does seem to me not improbable that the results of pyohaemia, or purulent infection, of phlebitis, umbilical or otherwise, may, along with other forms of abnormal action, have been occasionally placed to the credit of ordi- nary rheumatic inflammation. But Mr. Henry Lee, who has paid great attention to the subject of purulent infection, states that he has seen, as the result of the absorption of sero-purulent fluid from an ill-conditioned abscess, very severe rheumatism, affecting, in some instances, the pericardium and dura mater. In these cases there was occasionally more fluid secreted than in ordinary rheu- matism, but in milder examples there was no such distinctive mark; they are said to have been " in every sign and symptom apparently identical." I have undoubtedly seen cases in children, which I should not have known from rheumatism, terminate in the suppurative crisis. If it be said, then such cases therefore could not have been rheuma- tism, the argument is of course settled ; but it appears to me only so by apetitio principii. In adults, again, rheumatism does occa- sionally, however rarely, terminate in the formation of matter. In this case of mine some mischief ensued certainly to the mitral, if not also to the aortic valves. It may be but slight, still there it is, and may lay the foundation for changes in after years connected with the walls of the heart's chambers. The abnormal sound (which 552 On Scarlatina. [September, some of you have listened to) at the apex is very loud, but this is not proof of the amount of structural mischief at the mitral, for there may be much noise and slight change, and but little noise and great alterations. The former, I hope, is the case here ; but from the pulse being so small at the wrists, my hope is not to be too much trusted too. A German pathologist affirms it to be a general thing in scarlatina for the first sound of the heart to be aspirated or blow- ing, which is a result of the altered state of the blood, and not of the valves, and is a proof that scarlatina and all its complications arise from one common blood disorder. I presume he must mean to re- fer only to the sound at the base, and not at the apex (where our worst one is), of the cardiac region. Sounds at the base may be of haemic origin, but at the apex they are, I believe, always of struc- tural derivation. The liability of the heart to become affected during scarlatina has been known for some time. Roux in 1819, and Krukenbergius in 1820, are said by Rilliet and Barthez to have referred to the occur- rence of pericarditis in connection with scarlatina and measles. Trousseau says Bouillaud pointed it out ; but certain it is Mr. O'Fer- rall, in 1835, detailed to Dr. Graves, of Dublin, how he was obliged to have recourse to leeching, calomel, and James' powder, to over- come acute pericarditis in connexion with scarlatina. Several later writers, as Burrows, Willis, Joy, &c, have noticed this com- plication ; and not long ago, M. Trousseau stated it as his belief, that " many cases of organic disease of the heart, which only become evident at an after period, have had their origin in scarlet fever." But, so far as I know, we are most indebted to Dr. Scott Alison for prominently bringing this matter before our notice, though it has been said that the frequency of the complication has Deen somewhat exaggerated. You will find Dr. Allison's original paper in the 'Medical Gazette' for 1845. The case I have mentioned makes the third one of heart complication during scarlatina that I have seen, and here it has occurred in connexion with an arthritic affection. One might d priori, suppose the sequences of the phe- nomena would always thus present themselves, but it seems that it is not so, as the involvement of the cardiac organ is alluded to by writers, as well as seen by myself, without the arthritic affection having preceded or accompanied it. I find it remarked that in the tStuttgard collection of papers on "Children's Diseases," the occur- rence of purulent collections in the pericardium during scarlet fever is mentioned by Von Amnion, whilst effusion of pus beneath the periosteum and in the substance of muscles has been recorded by others. It is, therefore, possible that the rheumatism in this case had, in one sense, nothing in itself to do with the cardiac affection, but that both were the effects of one same and common cause, and that this cause was the same condition of the blood which gave rise jo every other manifestation of the scarlet fever, But it is said that the rheumatism occurs, like the dropsy, from 1856.] Dilution as a Principle in Therapeutics. 553 unnecessary or incautious exposure of the child to cold ; whereas, in the latter case, we find the disease will come on where no such exposure was known to have taken place. We frequently find this secondary rheumatism occur without any cardiac involvement arising, while the primary form, in children, is very far more apt to include the central organ of the circulation within its grasp than at other periods. Had it been my intention to treat of scarlatina or rheumatism substantively, I must, when speaking of the nature of these maladies and their complications, have said much about uric and lactic acids, of urea in the blood, ot a specific poison, of the ne- cessity of that poison being eliminated from the system, of the pecu- liar irritative action of the urea or some other poison in the blood upon the serous membranes, of an elective affinity in scarlatina for the kidneys, and many other topics of the like nature. But I should have felt it my duty to have impressed upon you at the same time, that these would but have helped us to hypothetical and very obscure explanations of points which it must be confessed an exact and va- lid pathalogy is not as yet able to include within its grasp. All that I now lay stress upon, therefore, is a certain observed sequence of phenomena Scarlatina, Rheumatism, and Heart-disease; a sequence observed sufficiently often, and under such intimate relations of time and place, to warrant us in associating these phenomena in casual connexion, however the true relations of this connexion may be af- terwards definitely fixed. I would also, in conclusion, recall to your memory, that whilst we have had recorded experiments on animals, in which the kidneys have been removed, or the ureters tied, &c, and cases related where the secretion of urine has been suppressed from stoppage of the ureters by calculi and new formations, and which cases and experiments have been followed by vomiting, dry- ness of the tongue and mouth, &c, intense thirst, altered or husky voice, serous profluvia, great perspiration, convulsions, deep stupor, and death. I am not aware that dropsy, affections of the synovial membranes, of the pleura, or of the pericardium have followed, as in scarlet fever. [Lancet. On Dilution as a Principle in Therapeutics. By Benj. Bell, Esq., Edinburgh. (Read before the Medico-Chirurgical Society.) [In the administration of remedies of a metallic nature, we may err in not having them sufficiently diluted. Our purpose should be to gain ready entrance for them into the blood : take for example iron. We know that the entire blood of an adult does not contain more than 30 grains, and that this is deficient in.anaemia. But what use can there be in giving such large quantities when so little is re- quired ? Our doses, then, ought to be small in quantity, and amply diluted. We may learn the same lesson by examination of medi- cines prepared for our use in the great laboratories of Nature. The 554 Dilution as a Principle in Therapeutics. [September, famous spring at Pyrmont contains about half a grain in the pint of water ; that at Tunbridge Wells only about one- third of a grain; the same also in the bromine and iodine springs of Kreuznach; they exist under the same condition of remarkable dilution. But we cannot doubt their virtue in glandular swellings and scrofulous diseases. May we not, then, take a hint from nature, and prescribe our metallic preparations in smaller doses, and largely diluted?] Of late years, I have seen reason to believe that all the benefit derivable from certain metals, as remedial agents, may be secured by comparatively small doses, provided that they are sufficiently diluted. I have seldom trusted to what could be called very minute doses; but so far as my observations go, I have a strong impression that, within certain limits, we do not increase the efficacy of such medicines by adding to the quantity prescribed. For example, eight or ten drops of the muriated tincture of iron in a large glassful of water, will, if useful at all, do as much good to our patient, as double or treble the quantity. And a similar remark applies, in my opinion, to the iodide or bromide of potassium, a single grain, or at most two of either, in a glass of water, being capable of effecting all the benefit of larger doses. We have already seen that the natural springs of world-wide celebrity present these ingredients in the pro- portion of one-third of a grain to sixteen ounces, and therefore we shall probably find, upon more extended trial, that corresponding doses of our pharmaceutical preparations, similarly diluted, will an- swer every purpose. It may be observed in passing, that although no strictly analogous argument, furnished by the chemical composition of natural springs, can be urged in regard to the administration of antimony, the prin- ciple of dilution is probably no less applicable to that important remedy. Without venturing to speak very dogmatically on the subject, I have a pretty strong conviction that we both increase its remedial power and lessen its tendency to cause sickness by diluting our antimonial solution. Many practitioners suppose, that without the production of nausea, we miss our object in subduing pulmona- ry inflammation, the principal disease for which that metal is pre- scribed ; but I doubt the soundness of this view, and am inclined to think that every object may be gained without sickening our pa- tient, just as iron and mercury can produce their curative effects without (he former causing headache, or the latter salivation. Our aim should be to bring the antimonial into contact with the capilla- ries of the inflamed part, and this, probably, will be best promoted by presenting it in a form fit for immediate absorption into the cir- culating fluid. When this is attended to I find it seldom necessary to give more than the sixteenth or twenty-fourth part of a grain of tartrate of antimony in successive doses. Another dpriori argument, in favor of this practice, may be ad- duced. Unless a metallic medicine be administered in a state of proper dilution, that condition will be secured by the secretion of 1856.] Dilution as a Principle in Therapeutics. 555 more or less fluid within the stomach itself, in order that the for- eign matter may be in a fit state for being taken up and appropria- ted by the blood. But it is evidently desirable that this secreting process should be kept within as narrow bounds as possible, in every case standing in need of tonic remedies, and therefore, if it can be rendered unnecessary, even in part, by previous dilution ab extra, we secure an advantage for our patient. If, however, we still ad- here to large doses of the active ingredients, it is obvious that, in order to effect the necessary dilution, we must increase the entire quantity of liquid so enormously as to oppress the stomach, and de- range the digestive process. Other advantages of moderate doses, largely diluted, taking their efficacy for granted, will be readily admitted ; for besides being less hurtful, it may be, to the teeth, they are also less unpalatable and better adapted on that very account for being taken and digested with the food, a point, the importance of which has been long fully recognised by practical men. That this last advantage is not ima- ginary, may be gathered from our familiar experience regarding the chloride of sodium. Mixed with the food at meals, although useful in helping digestion, it has no aperient action ; but the same quan- tity dissolved in water, and swallowed when the stomach is empty, before breakfast, will almost certainly open the bowels. In the former case, it is absorbed gradually in company with the food ; in the latter, being presented too abruptly and strongly to the fastidi- ous capillaries of the portal system, it is rejected by them, and hur- ried onwards through the canal, from convolution to convolution, and hence its qualifications as a purgative. But, if the solution be a concentrated one, it will probably never reach the bowels, but act as an emetic, and be rejected at once from the stomach. And cases are met with, in the annals of toxicology, where death itself was occasioned by large and irritating doses of common salt. Supposing it, however, to act as a purgative, the explanation of its action given seems preferable to the endosmosis theory, which appears to be too mechanical, and ignores entirely the vital affinities and endowments so conspicuous in the living body. We have supposed the solution of the chloride of sodium to be moderately concentrated, like sea- water, or in the proportion of about a drachm to four ounces ; but, if we double the allowance of water, we shall probably find that the action is no longer purgative, but diuretic. The salt has entered the circulation and will be eliminated by the kidney. It may be objected, perhaps, to the principle we are advocating, that it takes for granted that the whole of the medicine swallowed is absorbed and received into the blood, whereas, allowance should be made for a great part of it passing through the alimentary canal unchanged, and more, therefore, ought to be administered than we can expect the system to appropriate. That this superfluity does exist, when large doses are given, we have already suggested, and also that it is probably a source ot injury to the patient; but the 556 Dilution as a Principle in Therapeutics. [September, likelihood of such being the case, is obviously much less when the dose is small and well diluted. Moreover, we are very apt, I sus- pect, to over-estimate the quantity of any foreign substance which is needed, in order to act upon the human body. I have repeatedly seen so small a dose as the eighth of a grain of extract of belladonna taken into the stomach of a young person, cause full dilation of the pupil. Now, if we only consider how ex- tremely minute must be the portion even of this very small dose, when circulating through the blood-vessels, which could come into contact with the nerves of the iris, we may form some conception of the susceptibility and delicacy of our frame. To take another illustration, let us consider the remarkable efficacy of the muriated tincture ot iron in erysipelas, or in acute desquamation of the tubuli uriniferi following scarlet fever. An adult is labouring under the former of these complaints, with much febrile disturbance, as indi- cated both by the hot dry skin and the frequent bounding pulse ; we administer ten drops of the tincture every two hours, and after two or three doses, as I have often seen, the symptoms give way, the skin becoming moist and cool, and the pulse slow and soft. A few grains of iron, at the very most, have mingled with the circulating blood, and of these a mere fractional portion has reached,the congest- ed capillaries of the inflamed region, and occasioned the favourable change, and in this way, a comparatively small dos:e of a substance confessedly foreign to the system, comes to fulfil the purpose we have in view with all the efficiency of a larger quantity. A boy of ten years, we shall suppose, who has recently passed through an attack of scarlet fever, is observed to have oedema of the eyelids, a furred tongue, and a full, febrile pulse. His urine is of a dingy colour ; it deposits a dark sediment, and is scanty and albu- minous. Five drops of the tincture of iron in a glass of water, are administered every four hours; a speedy improvement commences, and in two or perhaps three days, the symptoms are entirely gone. Such facts, besides enforcing the principle we have been incul- cating, should leach us to deal tenderly at all times with an organ- ization so finely constituted, and to administer our remedies under a more settled conviction that, if potent for good at the right time, they may also be potent for evil, when the case and the occasion are not favourable. One mav express himself in this manner, without verging in the very least towards the credulity of those persons who profess their faith in the power of infinitesimal doses. It is one thing to recom- mend half a grain in preference to five, and a very different thing to stand up, with unabashed countenance, for the millionth or billionth of a grain. The human mind is baffled in forming even a concep- tion of such infinitesimal quantities ; and, therefore, they may be placed in a category by themselves, for the use of those who take pleasure in believing everything that ordinary people are compelled to doubt. But is there no truth in the allegation, that some of our 1856.] Dilution as a Principle in Therapeutics. 557 large doses of remedies, inteneed to enter the circulation and mingle with the blood, must startle and stagger many reverential students of the human frame and functions, and so create, it may be, a hurt- ful reaction in favour of homoeopathy, and other kindred eccentri- cities? I would venture to suggest, that some topical appliances those especially of a discutient nature may be rendered more efficacious and useful, by attending to the same principle of ample dilution. For example, the most efficient mode by far in my experience, of employing iodine locally, is a solution consisting of two grains of iodide of potassium and one of iodine, in an English pint of water. It must be used warm, as a fomentation to the affected part, by means of a sponge, twice or thrice a day, for five or ten minutes at a time. In cases of glandular tumour and of fibrinous exudation into the cel- lular tissue; in chronic enlargement of the testicle or epididymis; in short, in all that class of disorders where iodine or mercurial ointment would seem to be indicated, I have often found it remark- ably efficacious. The warmth of the application renders it more agreeable to most patients than if it were cold or unctuous, and at the same time probably increases its power by relaxing the pores, and so favouring absorption. It seems to be much preferable to the tincture of iodine painted upon the surface a favourite remedy with many. The latter certainly does good in some cases, but we may doubt, I think, if it produces its beneficial effects in the manner usually attributed to iodine and its compounds. It is a strong stimu- lating fluid, and sometimes occasions a good deal of local suffering; so that, when attended by favourable results, it probably resembles in its action a common blister, or the croton-oil ointment, and re- lieves inward congestion or chronic inflammation indirectly, by its power as a counter-irritant, and not directly, by hastening the pro- cess of absorption. The distinction is not unimportant; because some swellings, of inflammatory origin, may reasonably be expected to give way under a sysem of counter-irritation ; while other growths, of a slower and colder constitution, will be more amenable to a treatment less active and heroic. Another illustration of the same principle seems to be afforded by the outward uses of croton oil. When employed in a form tolera- bly concentrated, it induces, as we all know, an eruption of minute vesicles ; but when mixed with a large proportion of olive oil, and rubbed over an extensive surface, such as the abdomen, it some- times shows its power as a purgative, in the most unequivocal man- ner. One case in particular, that I attended with the late Dr. Thatcher, occurs to me, in which this treatment was eminently successful. A young gentleman seemed to be dying of obstruction in the bowels. As all the ordinary means of relief had been ex- hausted, and circumstances forbade the farther use of internal rem- edies, a liniment, composed of one part of croton oil and twenty- four oi mingled olive and camphorated oil, was used in an embroca- 558 Management of Placenta Prvevia. [September, tion to the belly ; and very speedily, and in consequence, as I believed at the time, the peristaltic action downwards was restored, and the obstruction overcome. Of course, we may have mistaken in this, as in other cases, the 'post for the propter hoc; but such facts seem to suggest the propriety and desirableness of new experiments in the same direction. The spiritus terebinthinae is another local remedy which we may probably employ with advantage, in a less stimulating shape than we are in the habit of doing. This has been suggested to my mind by witnessing the effects of small doses of turpentine in certain forms of iritis, and in rheumatic ophthalmia. In exercising these curative effects upon textures so remote from the stomach, the me- dicine must be supposed to enter the vascular system, and to modify the blood by stimulating one or more of the organs of excretion; and it is reasonable to infer, therefore, that the well-known remedi- al power and efficacy of terebinthinate embrocations in certain chronic forms of muscular rheumatism and neuralgia, may depend very much upon a simular therapeutic action. And on this suppo- sition, we should take care that the local remedy is not presented in a form too stimulating, our object being, not so much to cause counter-irritation by it, as to secure its absorption by the integu- ments covering the seat of pain. [Edinburg. Med. Journal. On the Management of Placenta Prcevia. By Dr. Robert Barnes. The author passed in review the actual state of obstetric science and practice in relation to the pathology and treatment of placenta previa. He showed that the prevailing belief was, that so long as the delivery of the child was not effected there was no security against haemorrhage, and that hence the rule in practice of pro- ceeding to forced delivery as early as practicable was almost uni- versally inculcated, the 011I3* exception consisting in the more or less general substitution of the plan of totally detaching the pla- centa. The author thus showed that, while the practitioner was anxiously waiting for the moment when the dilatibility of the cervix uteri would permit the passage of the hand, for the purpose of turning, the patient might perish of flooding; and that, there- fore, in the most severe class of cases, those of central placenta, some other resource, some means of placing the patient in security against renewed flooding, before the full dilatation of the os, was eminently desirable. Dr. Barnes then explained the physiological course of a labour with placenta praevia, and the mode in which Nature sometimes arrests the haemorrhage before the expulsion of the child. He illustrated, by the help of an ingenious and inter- esting diagram, that a stage of labour arrives when the recurrent contractions of the womb do not entail an}' further flooding ; that the pains return in their usual course, with the usual effect of fur- 1856.] Management of Placenta Previa. 559 ther dilating the os uteri, and forwarding the labour, but without causing any further flooding ; that the labour was in fact resolved into a natural one, and would be safely concluded by the natural powers. Reflection upon these cases had led Dr. Barnes to doubt the truth of the obstetric dogma, which declares that there is no security against haemorrhage, so long as the presence of the liquor amnii or the child in the womb prevents full contraction. Dr. Barnes then unfolded the anatomical, physiological, and clinical facts which led him to the conclusion that, under proper restric- tions, Nature might in many cases be trusted with more confidence than was generally believed. The clinical facts, he said, had come to him first, and led him to examine into the anatomical and physiological bearings of the case. He related cases in illustra- tion, and quoted a commentary upon one of these cases from the memoir he had published ('Lancet,' 1847), in order to establish his priority in the enunciation of the views he now laid before the society ; and adverted to the fact, that he had since the publication of that memoir, constantly taught, in his lectures on Midwifery, the same doctrine ; and stated that even the original of the dia- gram now exhibited, rudely sketched, was also figured in the memoir referred to. He had, therefore, believed his views to be original, and was surprised to find, in several numbers of the 'Berlin Monatschrift fur Guburtskunde ' for the present year, a controversy between Dr. Cohen, Dr. Crede, and Professor Hohl, in which Dr. Cohen for the first time expounded similar views to his own, whilst Dr. Crede, referring to writings of 1853-54, also claimed them ; and Professor Hohl assigned them to Dr. Zeitfuchs so far back as 1843. Dr. Barnes acknowledged, with pleasure, that Dr. Cohen's views of 1855 fully confirm those put forth by himself in 1847 ; but he found, in the writings of Crede and Zeit- fuchs, nothing whatever to show that either had, in the remotest degree, possessed himself of the points in question. But Cohen had gone beyond the author in proposing a new operation based upon the physiological and clinical facts expounded. This opera- tion consists in 1st. Determining the side of the uterus to which the smaller flap of the placenta is attached; 2. In rupturing the membranes and detaching the placenta from this half of its cir- cumference; 3. Exciting uterine contraction; 4. Hooking finger over edge of placenta, tearing membranes from the freed border of the placenta ; and 5. In separating the placenta in a circumfer- ence of 190 to 200. The greater half of the placenta, now freed from the dragging of the lesser half and membranes, is now drawn- back, just as in placenta lateralis, with the uterus. From this mo- ment there is no further danger. Cohen insists, like the author, on the impropriety of hastening labour unless urgent complications arise. Dr. Cohen refers to his experience to prove the efficay of this method, but does not recite any cases in illustration. Dr. Barnes pointed out that the difference between his memoir and 560 Management of Placenta Prcevia. [September, that of Dr. Cohen consisted simply in this : Cohen had, in 1855, carried forward the principle Dr. Barnes had enunciated, in 1847, by proposing the artificial partial detachment of the placenta, in- stead of trusting, as Dr. Barnes had recommended in certain cases, the execution of this operation to the powers of Nature. The au- thor then quoted from Sir Charles Bell passages showing that the anatomical distribution and physiological action of the muscles of the uterus accorded with and explained the clinical facts observed in the course of intermissions and cessations of ha3morrhage from placenta prasvia as set forth by Dr. Barnes. The author then ex- plained the mode and mechanism by which the haemorrhage in placenta prama is arrested. The opening of the mouth of the womb, and the detachment of the placenta adhering to this part, are effected by the active contraction of the longitudinal mus- cles of the uterus; this active contraction shortens the cervix, when it intermits a passive contraction goes on, which main- tains or even increases the shortening of the cervix. This short- ening necessarily compresses the torn mouths of the vessels, and checks the flooding caused by each successive detachment of fresh placenta, until the detachment has gone to the boundary line, beyond which point the further expansion of the cervix has no effect, and when all fear of flooding is at an end. It was not there- fore necessary that the uterus should be empty in order to arrest the flooding. The arrest depended upon the contraction of the cervix, which went on, although the fundus and walls were pre- vented from contracting. Dr. Barnes submitted the following as some of the conclusions dcducible from his researches : 1. In cases of placenta prasvia, the hemorrhage is sometimes arrested spontaneously before the complete detachment of the pla- centa, before the discharge of the liquor amnii, and consequently before the expulsion of the child or the pressure of its head against the cervix. 2. That this spontaneous arrest of the flooding is owing to the scaling up of the vessels torn by successive detachments of placen- ta, and the attainment of a stage of labour when no further de- tachment can take place until after delivery. 3. That dangerous and even fatal flooding sometimes occurs while the os uteri is still closed, and so undilatable as to render it impossible or expedient to have recourse to forced delivery. i 4. That in such cases it is eminently desirable to possess some means of diminishing the hemorrhage until the hand can be pass- ed through the os uteri. 5. The spontaneous or artificial detachment of the cervical por- tion of the placenta competes with two most formidable operations, dangerous to mother and child forced delivery, and the total separation of the placenta. The new principle of treatment may, in many cases, supersede forced delivery altogether ; since the pa- tient being secured against farther flooding to resort to turning 1856.] Medical Properties of Charcoal. 561 when the flood has ceased is an unnecessary proceeding, although the os uteri may admit of it. In many more cases this principle will be the means of gaining the necessary time to admit of turn- ing or other modes of forced delivery being performed with safety. In almost every case it may supersede the practice of wholly de- taching the placenta, since the end in view being the arrest of the flooding, it is better to detach only just so much of the placenta as will effect this end, than by detaching all, to destroy the child. %\_Medical Times and Gazette. Medical Properties of Charcoal. By JAMES BlKD, Esq. Pure charcoal is known to possess two singular properties, first, the power of absorbing gases to an almost incredible extent, and secondly, the capability of rapidly oxydizing any dead animal or vegetable substance placed in contact with it, as explained by the experiments of Dr. Stenhouse and others. As charcoal is not chemically affected by either acids or alkalies, and is quite insolu- ble, its admixture with other substances is not incompatible, so that it may be combined with any other kind of medicine, ad libi- tum. It is a powerful absorbent of fluids, whether aqueous or aeriform ; and as it ungergoes no change in the human stomach, it may with great truth be described as the only pure absorbent Ave possess, for the same cannot be said of aether, lime, magnesia, bismuth, or any other mineral absorbent, all of which form Salts with the acids they meet with, sometimes to the complete subversion of all their original properties, while the vegetable or farinaceous absorbents, such as flour starch, gum, &c, are changed by digestion, giving off frequently offensive gaseous emanations as the results of mal- assimilation. Charcoal is, therefore, recommended as a pure and effective ab- sorbent, applicable either alone, or in combination with other remedies, to a cure of a large number of the acute disorders of the mucous surfaces of the alimentary canal, and also of those of the uterine passages, and particularly in those instances where the secretions are inordinate in quantity, or offensive in condition. It may, perhaps, induce a more extended trial of charcoal pow- ders if a few instances were named in which the remedy has proved eminently serviceable. In the exquisitely painful small ulcers within the mouth, on the inner surface of the lips or cheeks, which, at irregular intervals prevail to some extent, and are extremely troublesome, the following wash will be found an excellent reme- dy: 3. Pulv. carb. ligni pur. ij.; mel. rosaa l\. - decoc. cydonh 1 iij. ; aq. dest. I iv. M. Ft. lotio saspe adhibenda. This lotion is also useful in excessive ptyalism ; it speedily mod- erates the discharge, and instantly corrects its fetor, and its appli- 562 Chronic Ulcer of the Leg. [September, cation is extremely soothing and agreeable. The same may be said of it when used as a gargle in ulcerated sore-throat, the sloughs separating rapidly and easily, leaving a healthy surface underneath. In the earlier stages of diarrhoea, a mixture composed somewhat as follows speedily gives relief: ty. Pulv. carb. ligni pur. 3j. ad 9iv. ; mucil. acacias 3 ij - ; syr. aurantii, tr. cardam. co. aa. 3iv.; aq. dest. 3iij. M. Sumat 4 drachms 3tia.vel 4ta q.q. hora. In the bowel affections of children, accompanied with worms, powdered charcoal, in doses of 10 to 15 grains, with one grain of ipecacuanha powder, and from 3 to 5 grains of rhubarb, taken at bed-time, acts like a charm, correcting disordered secretions with certainty and comfort, and promoting a healthy tone and action. In gastralgia and gastrodynia, charcoal powder, in doses of 30 or 40 grains, three times a day, in water, seldom fails to give relief; and in cases of severe tenesmus, accompanied by bloody or mu- cous stools, an injection into the lower bowel of one drachm of charcoal powder in a small quantity of thin arrow-root or gruel has been found to give almost instant relief. [Ibid. On Chronic Ulcers of the Legs. By F. C. Skey, Esq., F.RS. Abundant have been the examples of treatment of chronic ulcers of the legs by means of the internal administration of opium. I know of no treatment at all comparable to this, so rapid or so efficient. These cases have had many observers, who can bear testimony to its value. Exactly in proportion to the amount ad- ministered is the regeneration of the defective structure. Years will probably yet elapse before this principle will be universally acknowledged, before the medical community will admit that in opium we have an agent far more valuable than that derived from its comparatively worthless power as a sedative. It is notorious, that the chronic ulcer the disease of ten or even of twenty yearsT duration is unattended with pain. To suppose that opium effects its local marvels by any sedative property in the drug, appears to me worthy only the advocacy of a senile -female, or of an unin- structed youth. If we administer five grains of the soap and opium pill, night and morning, to a man advancing in life, who has been carrying about with him for ten years a large callous ulcer, with an ash-coloured base, surrounded by high walls of organized lymph, and in which there remains not a vestige of activity, good or bad, advancing or receding, the moisture from which is a hot ichor, becoming sanious under provocation, if we examine care- fully this surface at the expiration of forty-eight hours, we shall Jin < t it speckled with red points; these are future granulations, and, in ten days, the whole of the base of the wound will be carpeted with them. [Lancet. 1856.] Strangulated Femoral Hernia, 563 Practical Deductions from a Clinical Record of Twenty-six Cases of Strangulated Femoral Hernia. Mr. Birkett, in a paper read before the Medical Society of Lon- don, (April 26th, 1856,) commenced by stating that the object of the paper was, first, to bring prominently into the foreground the causes of death ; 2d, The circumstances by which those causea are brought about; and, 3d, The means by which they may be avoided. It was shown, by means of a table of the cases, that a certain number of unfavorable circumstances occurred in each case, and that, in proportion to the aggregate, as a general rule, the case was cured, or terminated fatally. But in some of the cases only two, three, or four unfavorable circumstances existed, and yet the patients died; and in these, as well as others with a larger number, the causes of death were sought for and demon- strated. Of the twenty-six cases, all of which were operated upon by the author, one-half terminated fatally. In the fatal cases, death resulted from causes over which the operation could have but little influence ; and it was undertaken only with the view to place the patient in a condition more favourable to recovery. The causes inducing the fatal result may be thus enumerated: 1. The consequences of a journey performed while the patient was suffering with strangulated femoral hernia. 2. The defective constitutional nutrition of the patients generally. 3. Irrecoverable prostration, the result of long continued vomit- ing and strangulation of the bowel in aged women. 4. Violence inflicted on the hernia. To this cause, the death df not less than five out of the thirteen is to be attributed. 5. The administration of purgatives before the operation. The author unhesitatingly preferred to reduce the hernia with- out opening the peritoneal sac in those cases in which the surgeon would be justified in returning the protrusion by the taxis, if it could be accomplished. In the twenty-six cases, the peritoneal sac was opened in twelve, and the causes which prevented the reduction of the hernia with- out so operating were the three following : 1. The contents of the sac. 2. The morbid condition of the contents of the sac. 3. The dimensions of the neck of the sac, and the unyielding state of its tissues. Six cases were related in which the author had reduced the her- nia by a simple division of the fibrous tissues about the neck of the sac, and external to that covering of the hernia known as the fascia propria. To this simple method of relieving the constriction around the bowel the author gave the name of the "Minimum Operation." The causes of death in the fatal cases were shown, hj post-mortem examination, to be referable to peritonitis, injury of the bowel inflicted in the taxis, exhaustion after fecal fistula, N. S. VOL. XII. NO. IX. 36 564 Myeloid and Myelo- Cystic Tumors of Bones. [September, phlegmonous inflammation, collapse, acute bronchitis, and perfo- ration of the bowel. Of the cured cases, the minimum of hours during which the bowel was strangulated was three hours; the maximum was seventy-seven hours. Of the fatal cases, the min- imum period of strangulation of the bowel was eleven hours, the maximum seventy-nine hours. Of the cured cases, the average number of hours during which the bowel was strangulated amount- ed to twenty-three. Of the fatal cases, the average period of stran- gulation of the bowel was forty-six hours. The causes of death were primary and secondary: 1. Prostration; peritonitis; gan- grene of the intestine ; perforation. 2. Bronchitis ; abscess behind the peritoneum ; phlegmonous inflammation and suppuration. The circumstances by which they were brought about : Age ; a journey; the defective constitutional nutrition of the patient; the morbid state of the canal above the strangulated piece of bowel \ injury of the hernia caused by the constriction of the ring, and by manual violence inflicted on it; the duration of the sufferings; the intensity of the constitutional sympathies ; fecal fistula ; neglect of the tumour ; the administration of purgatives ; the warm bath. The means by which they may be avoided are : By care in mani- pulation ; the early relief of the bowel from constriction ; the re- duction of the hernia without opening the peritoneal sac; the exhibition of opium, and the avoidance of all causes likely to in- duce exhaustion. [Med. Times and Gazette. On Myeloid and Myelo- Cystic Tumors of Bones: their Structure, Pa- thology, and Mode of Diagnosis. By Henry Gray, F.B.S. The author detailed the history of nine cases of tumors of this form removed during life, with a minute description of the results of his own microscopical examination of six of the tumors. The results at which he arrived were as follows : That these tu- mors were not of a malignant nature, although in several of the instances given they have been so regarded both previous to and after removal by operation ; that on the contrary, their minute structure bore the closest analogy with the normal constituents of the marrow and other elements of bone in the early periods of life: that their growth is confined to the osseous texture, or its investing membranes, the periosteum and dura mater ; that they , occur at a period of life when the normal constituents of the me- dulla exist in the greatest amount, and are developed in those parts of the osseous system in which those structures exist in a most distinct and well-marked form, (all the cases given took their origin in the epiphysial ends of long bones ;) that they are occa- sionally mixed with the other elements of bone in a rudimentary state, as fibrous tissue and cartilage, and even with bone itself; that they may probably occur in any bone; that since they are thus found to consist of an abnormal amount of some of the nor- 1856.] On the Dropsy of Pregnancy. 565 mal constituents of the medulla cells, the name "myeloid" given to them by Mr. Paget is most appropriate (the author proposes to add the term "cystic" to such of them as present a mixture of cysts with the structure above described, and regards their fibrous element as most probably derived from the organization of lymph effused as the result of chronic inflammatory action, or from some abnormity in the development and growth of the fibrous element of bone :) that they occur in all the cases at present recorded at an early period of life, and that their growth is generally much less rapid than malignant disease, both which facts afford important diagnostic marks to distinguish them from malignant growths ; that the absence of the malignant cachexia, of glandular lymphatic enlargements, and of diseased internal organs, combined with the facts that, although these tumors attain occasionally a considerable size, yet they present no tendency to ulcerate or obtrude exter- nally, and generally retain some surrounding shell of bone within which they have grown, serve as additional aids to the surgeon in forming a diagnosis between myeloid and malignant growths; that they do not return when entirely removed ; and that for all these reasons they are to be regarded as innocent tumors. [Association Med. Journal. New York Med. Journal. On the Dropsy of Pregnancy. By M. Becquekel. Four forms of dropsy are observed in pregnant women, which are far from being of the same importance. 1. Mechanical Dropsies, perhaps the most common, are due to the pressure exerted by the gravid uterus, their production being favored by the lesser density of the blood in pregnant women, and the slight diminution of albumen that exists in its serum. These dropsies are confined to the lower extremities, are of no import- ance beyond their inconvenience, and disappear after delivery. 2. Dropsies due to changes in the Blood, but unaccompanied by Albuminuria. The change in the blood which induces these dropsies, consists in a diminution in the amount of the albumen of the serum, a diminution that is sometimes considerable, and for which we can assign no other cause than the fact of the pregnan- cy, and its influence on the various immediate principles of the blood. This description of dropsy, like the two next, tends to become general. It is of importance to distinguish it from the two others, and especially the 4th, for it does not predispose to eclampsia. It is by analysis of the blood alone that we can estab- lish its existence. It disappears also after pregnancy, but far more slowly. It has been observed that women suffering from it remain feeble for a long period, their "getting up" being slow and difficult. 3. Dropsies with Changes in the Blood, and Albuminuria, but without Brighi's Disease, properly so called. These dropsies are the 566 Operation for Pharaphimosis. [September, consequence of the diminution of the albumen of the blood, pro- duced by its deperdition through the kidney. Until lately it was supposed that such loss might take place without material lesion of the kidney ; but from the investigations made by M. Robin and the author, it results that this albuminuria is due to a special mo- dification taking place in the epithelial cells of the tubuli, a modi- fication consisting in the infiltration of the cells and tubuli by numerous granules of a proteric nature. This infiltration is ana- logous to that which M. Eobin had already found in choleraic albuminuria, and like it is susceptible of cure. The absolute di- agnosis during life of this disease from Bright's affection is very difficult, and yet it is highly important, as the prognosis must be entirely based upon it. It is in women who are the subjects of these dropsies that we have to fear eclampsia, and the predisposi- tion to puerperal peritonitis. Eclampsia is not, however, a ne- cessary consequence ; and when we find general dropsy, change in the blood, and albuminuria co-existing, we still cannot affirm that this terrible accident will follow. On the other hand, when- ever we find eclampsia we are certain of finding, not only dropsy, but albuminous urine, and change in the blood. In respect to the termination of this form of dropsy it may be observed, that if eclampsia does not supervene, a cure is almost certain, while, in the case of its occurring the result is dependent upon that of the eclampsia. 4. Dropsies due to Bright's Disease. It is very important to establish the diagnosis of this form. We may lay stress upon the somewhat larger quantity of albumen, the presence of fragments of tubuli, of fibrinous filaments, and fatty globules. When eclampsia complicates this form it is invariably fatal ; and even when aclampsia does not occur, the disease is not arrested after delivery. The dropsy continues to increase, the termination proving, after a certain period, fatal. [London Med. Times, from Medico- Ghirurgicale. Operation for Pharaphimosis. At the session of the Academy of Sciences (Paris,) on the 21st of April, the following extract was read from a letter of M. Mal- gaigne: " With this strangulation, as with strangulated hernia, we at- tempt at first to accomplish reduction, and usually succeed. But when reduction is impossible, it is advised, as with strangulated hernia, to divide the bridle which strangulates it, even if it is ne- cessary to repeat this section at two or three points. The danger of strangulation is thus diminished, but the reduction still conti- nues to be impossible. At least I have never seen it accomplished after such an operation. What is the reason of this want of suc- cess? It is that the preputial ring, in producing inflammation, 1856.] Action of Digitalis upon the Uterus. 567 ^ulceration, sometimes even gangrene, of the parts strangulated, commences by thickening the subjacent cellular tissue, and by producing extensive adhesions between the integument and the cavernous bodies. Dividing the stricture, though repeated, does not destroy these adhesions, and does not suffice for the reduction, while destruction of these adhesions, even without division of the stricture, is sufficient to allow the return of the parts to their place. " Thus the study of this affection has led me to distinguish a new element, hitherto left in the shade. The establishment of this element gave a new indication, and this is the way in which I have met this indication. " A young man came under my care the 11th of this month, for a paraphimosis of five days' duration, and already there was seen upon the back of the penis a superficial ulceration, embracing more than half of the circumference of the organ. The internes tried to reduce it without success. The next day, at the visit, I was no more fortunate; the adhesions of the integument to the cavernous bodies presented an insurmountable obstacle to it. I slipped a narrow bistoury flatways between the integuments and the cavernous bodies, by means of which I divided those adhesions to the extent of one centimetre (four-tenths of an inch). This did not suffice. I carried a probe-pointed bistoury into the incision, to complete the division of the adhesions throughout their whole extent, and the reduction was accomplished with the greatest fa- cility. The next day, the engorgement of the prepuce had dimin- ished, the third day the ulcerated surface had cicatrized, and the patient went out the 20th of April, having been well several days, and without experiencing any kind of accident." Am. Med. Mon. On the Action of Digitalis upon the Uterus. By W. EL DlCKERSON. The writer commences his paper by stating that during the month of October, 1854, a patient in St. George's hospital, laboring under most severe menorrhagia, was cured by the infusion of digi- talis, exhibited for the relief of cardiac affection, from which she also suffered. In consequence of this he had been induced to try the remedy, by the permission of Dr. Lee, in a series of cases of uterine hemorrhage which had occurred in the hospital. These cases, of which a table is given, were seventeen in number, and the general results of their treatment were as follows : In every case of uterine hemorrhage, unconnected with organic disease, re- quiring the employment of active remedies, admitted into the hospital after October, 1854, the administration of digitalis was had recourse to as the sole treatment, and the discharge was inva- riably arrested by it. The time which elapsed before the hemor- rhage subsided varied with the dose in which the digitalis was exhibited. When large doses were given, as an ounce to an ounce 568 Eneuresis. [September, and a half of the infusion, the discharge never appeared after the second day; when smaller doses, it never continued beyond the fourth day. In uterine hemorrhage connected with organic dis- ease, the remedy acted with less certainty ; its exhibition was re- quired for a longer time, and the effect was sometimes transient. The author then spoke of the mode in which the digitalis operated in controlling uterine hemorrhage ; and after concluding that its effect could not depend on the sedative influence of the drug in the heart and arteries, he showed, by various experiments and obser- vations, that the arrest of the hemorrhage was due to the action of the digitalis on the ganglia of the uterus, by which the organ was stimulated, and the muscular substance powerfully contract- ed. [Dublin Hospital Gazette. Eneuresis. Two methods for treating this troublesome affection having been given in our May number, we present the following, which we adopted in our practice long ago, from the Medico-Chirurgical Be- view, of January, 1849. Memphis Med. Recorder. ty. Ex. Belladonna. Ex. Hyoscyami, aa. gr. xvj. Sacchari albi, 3i. Aq. Camphorae, 1 iss. Take a teaspoonful at bed- time. In obstinate cases we have sometimes repeated the dose two or three times in the same night. We have rarely failed of success, though in one case we were obliged to give up the remedy before the cure was complete, in consequence of the excessive dilatation of the iris. We remember one case, where the disease had con- tinued from early childhood till the age of seventeen, which was permanently cured by a week's use of the above prescription. The young man was unable to recollect a period at which he had not been constantly troubled with an attack on retiring to sleep. Where remedies so diverse cure the same disease, we arc naturally led to the hypothesis that, though the symptoms are identical, the pathology is different ; for example, we are disposed to think that where Dr. Merrill's remedy the Iodine was successful, irritation of the mucous lining of the bladder, was the cause of mischief, , while in cases where the present treatment effected a cure, (Bella- donna having a special tendency to the muscles of organic life.) the sphincter vesicas, had been the seat of the disease. D. F. W. On the Detection of Phosphorus in Cases of Poisoning. Mitscherlich has published a very simple and satisfactory me- thod of detecting phosphorus in forensic investigations. The matter to be tested for phosphorus is to be distilled in a flask with water and sulphuric acid, and the vapors conveyed through a 1856.] Bloodletting in Young Subjects. 569 glass tube into a vertical glass condenser. This condenser is sim- ply a glass tube which passes through the bottom of a wide glass cylinder filled with cold water, which is constantly renewed by a funnel. A vessel to receive the distillate is placed under the end of the condensing tube. (The arrangement resembles Liebig's condenser placed vertically.) If there be phosphorus in the sub- stance in the flask, its vapor passes over with the stream into the condenser, and a distinct light is seen in the dark where the va- pors meet the cooled portion of the tube. This light lasts for a very long time, and a luminous ring is usually observed. More than three ounces of fluid could be distilled from substances which contained only the Too'ooo f phosphorus without a cessation of the light. Even after fourteen days the effect was observable. An addition of oil of turpentine prevents the light, but alcohol and ether distil over, and then the light appears. In the distillate, globules of phosphorus may be detected and are easily recognized. These were observed even in a mass which contained but one- third of a grain of phosphorus in five ounces of matter. When the mass contains much phosphorus, the distillate contains phos- phorous acid, which is easily oxydized and detected. The author found that phosphoric and phosphorous acids do not pass over when distilled carefully with water. A fresh human stomach boiled with water gives no soluble phosphates ; on the other hand, a stomach in a state of decay yields to water phosphoric acid, which can easily be detected by ammonia and magnesia. \_Chem- isches Central Blatt, from Amer. Jour. Arts, &c. ' Bloodletting in Young Subjects. Dr. Beck justly remarks that young subjects do not bear the loss of blood as well as adults. They fall into syncope more readi- ly, and their lives arc almost endangered by it That their nervous systems are more powerfully affected, is considered by the fact that convulsions and coma more frequently occur after the loss of blood in children, than in adults. ISTor will a repetition of the remedy be so well borne by the child as the adult, and if carried only a little too far, children sink under the loss of blood irretrievably. Leeching exerts greater power over children than adults, because of the greater vascularity of the skin, the effect resembling more nearly that produced by general bloodletting. Hence the so fre- quently fatal effects of leeching, the difficulties of which are further increased by the uncertainty as to the quantity of blood drawn. Too great caution cannot be exercised, therefore, in leeching chil- dren. The operation should be performed with the child in an erect posture, and as soon as paleness of the lips or face appears, the bleeding should be arrested, and the patient should be closely watched to prevent hemorrhage, which may prove quickly fatal. Dr. B. recommends matico as the best astringent remedy for ar- 570 Sulphate of Cinchonia in Intermittent Fever. [September, resting this and other hemorrhages. The leaf is to be applied to the leech-bite and pressed upon it for a short time with the finger. For the cure of epistaxis, the powdered leaf is snuffed up the nose. Dr. B. thinks excessive bloodletting has been encouraged by the writings of Eush, who says, in his " Defence of Blood-letting," that " bleeding should be continued while the symptoms which first indicated it continue, should it be until four-fifths of the blood contained in the body are drawn away." The whole quantity of blood being estimated at 32 lbs., four-fifths is over 24 lbs. ! [Mem- p>his Medical Reporter. On Sulphate of Cinchonia in Intermittent Fever. By Dr. Jisro. S. Dukate, of Fredericsburgh, Ind. In the "Medical Observer," for January, 1856, 1 find an article entitled, "Report of fifty-seven cases of Intermittent Fever treated at the City Dispensary by the Sulphate of Cinchonia, by Dr. J. C. Welles." I have always held, that in order to test the therapeuti- cal virtues of any article of the Materia Medica, especially of the so-called specifics, we should administer it alone, if tolerated by the stomach without combination ; for who can tell, for instance, whe- ther cinchonia or quinia cured the patient, when both are given together or alternately ? Dr. Welles' article is not quite satisfac- tory, although very nearly so. In the account of case first, he states that the patient had taken ten grains of quinia combined with opium and pipeline. He had a chill on the 7th and 8th took cinchonia and had no chill on the 9th and 10th ; he was then put upon sub-carbonate of iron. On the 26th of September he had a severe chill, and was again put upon cinchonia, and convalesced. So far as this case is concerned the treatment was too complicated to be entirely satisfactory, but it is not so with nearly all the other cases. My object, however, in communicating this article, is to call the attention of the profession to the remedial virtues of cinchonia in intermittent fever, and to offer to them my experience with the medicine. Perhaps I may not have used the article so extensively as some others, but still my experience will, contribute something to the common stock, and assist in judging of the value of the remedy. I had never administered a grain of cinchonia until I saw Dr. Welles' article, when I determined to give it a fair trial in inter- mittent fever which I have had a fair opportunity to do, as it has prevailed extensively in my locality during the past spring. In order to test its remedial value I administered it alone in every case, or at least using no other antiperiodic. I preceded its exhi- bition, however, always by an active cathartic. I have noAv used three ounces of this article in intermittent fever, and have come to 1856.] Sulphate of Cinchonia in Intermittent Fever. 571 the conclusion, from what I have observed in using the above amount, that it is superior to the sulphate of quinine in the treat- ment of this peculiar and tenacious disease. Patients, also, seem to take it more readily than they will quinine, having, most of them, from frequent use become tired of its repetition. The following cases may possess some interest : 1st. Mrs. B., aged 24, contracted an intermittent fever last au- tumn, which was promptly arrested by quinine, but relapsed again and again; paroxysms continuing at intervals during the fall, winter and spring. She became anemic, with a tendency to drop- sical effusions. On the 1st of March I put her on the use of cin- chonia ordering her twenty grains divided into five grain doses, exhibited every four hours. It was of the tertian type, and on the day for the paroxysm she had some unpleasant coldness of the extremities, followed by slight febrile excitement. After this was over she took eight grains more, and has not had another chill to this date, (June 15th,) and is in the enjoyment of tolerably good health. She is now using, for enlargement of the spleen, the proto-iodide of mercury internally, and iodine ointment externally. 2nd. Mr. S. was attacked last fall with intermittent fever, which became chronic. All the so-called specifics were used, but to no purpose, except to arrest the disease for a short time. He was put, by me, on the cinchonia without combination with any other medicine; after using thirty grains his disease was arrested, and has not since returned. A period of two months has now elapsed since he has taken any of the medicine, and previous to this his ague had returned about every two weeks. 3rd. This was a case of chronic ague, which had resisted quin- ine, and nearly all other remedies. He was put upon the cinchonia, and has now been free from the disease about one month. This article might be extended by relating special cases, but it is unnecessary. It is sufficient to say that in every case of inter- mittent fever, whether recent or chronic, the sulphate of cinchonia has completely arrested the disease, and in but rare cases have there been any relapses. It may be thought by some that I have given the remedy more credit than it deserves, but I am of a dif- ferent.opinion. In every case I have given it alone for the pur- pose of testing its antiperiodic powers. No complication of effect has been produced by using quinine, piperine, salicine, strychnine, arsenic, or any other potent remedy. It is very clear that it is to the sulphate of cinchonia alone that the cures are to be attributed. I therefore feel justified in using it in all cases of simple intermit- tent in preference to quinine. I do not yet know enough of it to place that reliance upon it that I would on quinine in pernicious fevers, malarial neuralgia, &c, &c. Effects on the system. This article does not produce the same dis- agreeable effects upon the nervous system that quinine does. In 572 Treatment of Typhoid Fever. [September, no case has my patient complained of tinnitus-aurium, vertigo, cephalalgia or gastric disturbance. In short, patient's feel no in- convenience from its administration. Doses. I think from twenty to thirty grains of cinchonia are required to completely arrest an attack of intermittent fever. My mode of prescribing it is to weigh out twenty grains and divide it into five doses, one to be taken every three or four hours, between the paroxysms, and in the absence of fever. If this quantity does not completely arrest the disease, I then give from eight to ten more, and the object is certainly accomplished. The cinchonia I have used is prepared by Powers & Weightman, and costs me one dollar per ounce. [In a letter to one of the editors, from E. C. "Woolley, M. D., of Butler county, in this State, the following language is used: "I have used the sulphate of cinchonia exclusively, with very happy effects ; succeeding in every case but one, in arresting the paroxysms of ague by the first administration of the medicine. I think it not at all inferior to quinine as an antiperiodic." Eds.] [Cincinnati Med. Observer. Treatment of Typhus Fever. By Edwin B. Maxon, M. D., of Geneva, N". Y. What, then, are the indications in the treatment of Typhus ? Shall we bleed, purge, and starve our patients, and thus increase the debility which the morbific agent has produced? Or shall we strive to support the sinking energies of the system, and thus ena- ble it to bear up under and throw off, with its various excretions, the debilitating morbific agent it has so unfortunately imbibed. From my experience in the treatment of typhus fever, for the past few years, I am compelled to believe, that with a proper sus- taining course of treatment, nearly every case of typhus may be arrested, and the patient convalescent, by the fifth or sixth day; and that very few need be kept in longer than the ninth day, if attended to in season, and before any serious local inflammation has taken place. The indications then are, to remove from the alimentary canal, any irritating matter which it may contain; to equalize the circu- lation ; to promote perspiration ; and to support the sinking pow- ers of the system by tonics and a due amount of proper nourish- ment. I therefore usually give, at first, two or three blue pills, and follow with half an ounce of castor oil; use warm pediluvia, morn- ing and evening, the first day or two ; also, rubbing the whole length of the back with a tepid infusion of capsicum in vinegar; and, generally, give the sulphate of quinine and Dover's powders, of each, grs. jv, every six hours, at first, for a day or two. I then 1856.] Mode of Reducing Strangulated Hernia. 673 discontinue the Dover's and give pulv. camp. gr. j, with quinine sulp., grs. iij, every six hours, and continue till the fever is arrest- ed, giving crust coffee, with milk, at first freely, as nourishment, and as soon as the stomach will retain it, toast every six hours ; and, by degrees, other nourishing and digestible food, as the ap- petite generally returns and calls for it. Such are the means which I have found most effectual in ar- resting typhus fever ; and even in cases in which, through neglect, or maltreatment, local inflammation has supervened, I have found this course to do well, in conjunction with sinapisms, dry cupping, or blistering, as the case may require. [Buffalo Med. Journal. Mode of Reducing Strangulated Hernia, after failure of the Taxis, by a Bloodless Operation. M. Seutin, the eminent surgeon of Brussels, is endeavoring to establish, in a Belgian Medical Journal, the superiority of tearing either the inguinal or crural ring, over incising the same, for the reduction of strangulated hernia. He quotes experiments on the dead body, and several successful cases; and is confident that his method will soon supersede the operative measures generally re- sorted to. He places, first, great reliance on graduated taxis con- tinued with due precautions for a considerable period; and when this fails, he endeavors to hook his index-finger round the margin of the ring, by passing it between the tumour and the abdomen ; and by using a certain force, he causes the fibres of the external oblique to give way and crack to an extent sufficient for the re- duction of the hernia. M. Seutin defends his practice with con- siderable ability, and hopes trials will be made. [Lancet. Alkaline Treatment of Rheumatism. The (Burlington) Medical and Surgical Beporter gives a table of twenty six cases of acute rheumatism treated by the alkaline method, in New York Hospital, under the care of Dr. John H. Griscom. The average time that the patients were under treat- ment was about thirteen days, and the whole duration of the attack twenty-one days. The treatment consisted in the administration of the supertartrate of potassa and soda, every hour, and the appli- cation of an alkaline and opiate lotion to the swelled joints. As the urine became less acid, corresponding improvement in the symptoms was noticed. [Boston Medical and Surgical Journal. Danger of Employing Iodine Injections for the Cure of Hydrocele. M. Gosselin made an interesting communication to the Societe de Biologie, on the 24th of May. He has ascertained that in three cases where, after the death of patients, he has examined the testi- 574 Congenital Deafness. [September, cles, there is a peculiar danger in employing iodine injections in the vaginal cavity as a means of curing hydrocele. This danger consists in the absence of the secretion of a sperma fit for fecunda- tion. In these three cases, no spermatozoa were found in the seminal vesicle of the side, where a hydrocele had been treated by iodine injections. In experiments upon dogs, M. Gosselin has found, also, that after such injections, the production of spermato- zoa does not take place, and that the testicle becomes pale and smaller than before. \_Med. Times and Gaz. Etiology of Congenital Deafness. In a paper read before the French Academy of Medicine, M. Meniere states that the intermarriage of relations has more effect than any other cause in producing deaf-mutism. This is shown by the fact that the disease is nowhere so common as in those iso- lated comunities where almost all the inhabitants are related to each other, as the Canton of Berne, in Switzerland, where the de- generacy of the race is seen in all its deformity cretinism, idiocy and congenital deaf-mutism. [Gaz. desHop., and Boston Med. Jl. EDITORIAL AND MISCELLANEOUS. American Contributions to Medical Knowledge. The multiplicity of medical periodicals in the United States evinces a degree of activity in the medical mind of our countrymen that has no parallel elsewhere ; for while we have between thirty-five and forty regular medical journals, besides the periodical issue of the transactions of a large number of Societies, to say nothing of the publications by the Eclectic, Botanic, Homeopathic, Hydro- pathic, and other quondam brethren, we believe that the British and French have only about a dozen each, and that the whole of Europe does not furnish as many as we do. And yet it is very questionable whether this state of things will ultimately prove beneficial to the profession at large, or even to its American branch. Under existing circumstances, no one can become acquainted with the workings of the American medical mind without reading a number of pe- riodicals well calculated to stagger any but an editor, and even editors are not always proof against the accumulated load of their table. It cannot be denied that by increasing the number of journals we correspondingly multiply that of contributors. Many a physician, the result of whose ob- servations might be useful, will feel himself stimulated to write and to impart his experience to others, if a journal be started in his neighborhood, who would otherwise have remained silent. Others will be disposed to imitate his example, and unexpectedly, perhaps, realize the fact that they 1856.] Editorial. 575 also have views that ought to be made known, and that writing is not so difficult as they thought, nor the exclusive privilege of the favored few. Men are thus accidentally trained to the art of composition, and often be- come accomplished writers. In this way journals are eminently useful within the sphere of their influence, and we would be the last to approve of any diminution of their number. We would, on the contrary, like to see as many published as the profession can or will support. But we must repeat that, in the present state of things, much of most valuable matter intended to reach the general eye through such channels is never heard of beyond the more or less restricted limits of their own circulation. It cannot be expected that any practitioner in the United States will subscribe to all the American medical periodicals, besides those from abroad ; and if any were found so liberally inclined, it is not presumable that he would or could give them all even a hasty perusal. With the ex- ception of the copies we send to Europe in exchange for their publications, we may say that our periodicals are entirely unknown in foreign countries whereas several of their journals are reprinted in this country, and exten- sively patronized. The writings of Europeans are not only brought direct- ly to us, but our own journals cull most assiduously from them every para- graph supposed to possess the least interest. While our local periodicals are thus actively engaged in heralding the achievements of Europe, those of domestic origin remain unnoticed. In additidn to the extensive circula- tion among us of European journals and reprints, the publications of Braith- waite and Ranking give a degree of permanency to their papers which is denied our own. I say, denied our own, because it is quite notorious that these "retrospects" and "abstracts" are devoted to the propagation of European views, and almost entirely silent with regard to what is said or done in America. Take up these semi-annuals, number after number, and you will look in vain for any evidence of the mental activity to which we have referred. Can it be that we do or say nothing worthy of permanent record ? Foreigners are perhaps not so much to blame in this matter, when some of our leading periodicals make an equally meagre showing for us under their heads of " Domestic Summary," " American Intelligence," &c. There is indeed no journal issued in our country which contains even the slightest notice of one-fourth of the valuable contributions to medical knowledge by American writers. The petty jealousies of rival schools and cities, and the more significant evil of sectionalism, tend materially to fetter periodicals sustained by antagonistic interests, and consequently to restrict their sphere of usefulness. We might mention some important discoveries in diagnosis, and in the treatment of particular diseases, which have never been alluded to in rival cities and sections of the Union, while some of the verriest puerilities of foreign prints will be found going the round in every journal of the land. 576 Editorial and Miscellaneous. [September, Now, we need a remedy for the evils pointed out, and the object of these remarks is, to urge upon the profession the adoption of one that may be effectual, without interfering with the interests already involved in local journalism. Let a work be published by subscription, semi-annually, bear- ing the title at the head of this article, or any other of similar import. Let it consist of three parts : the first, to be made up exclusively of such papers contained in the original departments of American Medical Jour- nals, as may be deemed by competent supervisors, worthy of permanent record ; the second, to be devoted to the review of American books on medicine and its collateral branches ; and the third part, to contain ab- stracts of the contents of our medical journals, general medical intelligence, &c. Let the conductors of such a journal be men of industrious habits as well as of competent abilities, whose sole object will be to furnish us a com- plete and impartial reflex of the workings of the American medical mind during the six preceding months. Such a work, if well conducted, would enable us to become acquainted with the views of men of ability in every section of the country, and would at once become a standard book of refer- ence in Europe, as well as in America. "Writers might then enjoy the satisfaction of contributing to the literature of their own immediate neigh- borhood, and still feel that by so doing, their labor was not necessarily restricted to the limits of their local periodical. With the consciousness that merit would entitle their papers to a place in the proposed national work, they would be actuated by an incentive which they do not now ex- perience, and would strive to do themselves credit abroad, as well as at home. Such a work would not conflict with the interest of existing peri- odicals, because it would publish no paper that had not already appeared in a local journal, with the exception of reviews. Physicians would natu- rally continue to support the journal of their own neighborhood, and take also the national work for more extended knowledge, as they do now the reprints of European retrospects. We have no doubt that such a work, as we propose, would meet with the approbation and patronage of the American Medical Association, if the subject were brought before that enlightened body at their next meet- ing. We appeal to our editorial brethren, throughout the length and breadth of our great confederacy, to aid us in bringing about so desirable -an undertaking. Surely there are many men in our large cities who have the requisite qualifications for such a task ; and who, living where the faci- lities for printing and general dissemination are abundant, might find it advantageous to embark in the enterprise. Escape of Great Vessels by their Elasticity, from Balls. By G. H B. Macleod. There is no circumstance in gunshot wounds wdiich is more striking than the wonderful way in which the great vessels, by their elasti- 1856.] Miscellaneous. 577 city, escape from the ball in its transit. Thus bullets innocuously traversed parts where one would suppose a pin's head could not be placed, without wounding a vessel. True, the fact that such cases remain to be seen, re- sults from the vessel not having been opened, and we do not know in how many cases the result was not so fortunate, but still, viewed merely as hap- py escapes, they are curious and interesting. In the course of the femoral vessels, this phenomenon is particularly common. Through the axilla, through the neck, out and in behind the angles of the jaw, between the bones of the forearm and leg, balls of every size often take their passage without harm to the vessels. Take the following cases as examples : A soldier was wounded at Inkerman, by a ball which entered through the right cheek and escaped behind the angle of the left jaw, so tearing the parts that the great vessels were plainly visible in the wound. Three weeks after he was discharged without having had a bad symptom. A soldier of the Buffs was struck in June last, when in the trenches, by a rifle ball, in the nape of the neck. It passed forwards round the right side of the neck, up under the angle of the inferior maxilla, fractured the superior maxillary and malar bones, destroyed the eye, and, escaping, killed ano- ther man who was sitting beside him. This man made a recovery without a bad symptom. A French soldier at the Alma was struck obliquely by a rifle ball, near, but external to the right nipple; the ball passed seemingly right through the vessels and nerves in the axilla, and escaped behind. His cure was rapid and uninterrupted. Endless numbers of similar cases may be seen in any military hospital. [Edinburgh Med. Jour. Treatment of Erysipelas. M. Velpeau gives the results of his treatment of 1000 cases of Erysipelas. He places the greatest reliance in iron. He employs the proto-sulphate of iron in solution, about twelve grains to the ounce of water or as an ointment, eight parts to thirty of lard. In forty cases in which this was exclusively used, the erysipelas yielded in from twenty-four to forty-eight hours. The ointment is more easily applied to some parts than the lotion, but is somewhat less efficacious. It should be used about three times a day. The lotion should be applied by soft com- presses or cloths kept constantly moist. [Bull, de Therap. Boston Jour. Removal of Milk in the Breast. Mr. Gibbon states in the Lancet, that the application of belladonna to the mamma is an excellent means of checking the secretion of milk. With a lotion consisting of half a drachm of the extract of belladonna to half a pint of water, he has succeeded in ar- resting the secretion in three protracted cases, where a variety of expedi- ents had failed. [Boston Med. Journal. Formula for the Internal Use of Chloroform. M. Dannecy, pharmacien, of Bordeaux, recommends the following formula: Pure chloroform, half a drachm ; oil of sweet almonds, two drachms ; gum arabic, one drachm ; syrup of orange flowers, one ounce ; distilled water, two ounces ; mix the chloroform with the oil, and make an ordinary oily draught. The author also gives a very ready mode of testing the purity of chloroform. Mix the latter with some oil ; if the chloroform be quite pure, the limpidity of the oil will not be destroyed ; whereas, any chemical impurity, however small, will give rise to a cloud. [Lancet. 578 Miscellaneous. Rapid Detection of Sugar. M. Botte lias several times employed the method suggested by Liebig of quickly detecting sugar. A small quantity of ox-gall is dissolved in the suspected fluid in a test-glass, and a quantity of concentrated sulphuric acid equal in amount to that of the fluid in the glass is rapidly added, care being taken to pour it along the side of the glass. If sugar is present a beautiful purpurine is immediately produced. [Rev. Medicate Med. Times and Gazette. Vaccination in Relation to Blindness. Statistical researches show us that, prior to Jenner's discovery, of 100 cases of blindness, 55 were due to small-pox ; and Dr. Dumont, physician to the Hospice for the Blind, has recently supplied an interesting account of the progressive decrease of that proportion. Among the blind of sixty years of age, he finds this variety of cause in 12 per cent. ; in adults, it only exists as 8 per cent. ; and, in chil- dren, only as 5 per cent. We may take as a mean, counting all ages, about 7 per cent., which, as at the commencement of the present century, the proportion was 35 per cent., exhibits a diminution of 28 per cent. [Med. Temes and Gazette. Solution of Gutta Percha. Mr. Maisch, of New York, advises the fol- lowing method : Oue part of the best commercial gutta percha is cut into small pieces, and by agitation is dissolved iu twelve parts of chloroform. On standing for a day, all the coloring matter rises like a scum to the sur- face, leaving the solution clear. This may then be easily drawn off to the last drop. A wide glass tube, narrower at the bottom, and so arranged that both ends may be closed with corks, is the only instrument necessary. After the separation is complete, the upper cork must be removed, and the lower one loosened, so as to allow the fluid to run out slowly. The advan- tages of this solution over collodion consist in the absence of contractile power and gloss, and in its elasticity and greater resemblance to the skin in appearance. [Memphis Med. Recorder. Pectoral Sijrup. Take of ipecacuanha, one ounce ; seneka, three ounces ; refined sugar, two pounds ; sulphate of muriate of morphia, sixteen grains ; oil of sassafras, ten minims ; make two pints of syrup. Macerate the ipe- cacuanha in coarse powder, for fourteen days, in one pint of diluted alcohol, express, filter, and evaporate to six fluid ounces. Next digest the seneka in coarse powder, with ten fluid ounces of water, and two fluid ounces of alcohol, at a heat not exceeding 104 F., for six hours, strain, express and filter, adding, if necessary, enough water to make ten fluid ounces. Mix with this the tincture first obtained, and dissolve in it the sugar, at a gentle heat; strain, and while yet warm, add the morphine and oil of sassafras, dissolved in a very little warm alcohol. The dose is from one to two tea- spoonfuls. This is Jackson's formula as prepared by Stevens. (See Amer. Journal of Pharmacy, May, 1850.) The prescription is a favorite one with many Northern physicians, ;is an anodyne expectorant; and is, doubtless, a better remedy than any of the numerous compounds sold in the shops, all which have opium for their basis. Great mischief is undoubtedly done in pulmonary diseases, by the injudicious and extra-professional use of all these anodyne cough mixtures. It is far from being true that every case of COUgh requires or admits the use of anodyne remedies. [Poid. SOUTHERN MEDICAL AND SUBGICAL JOURNAL. (NEW SERIES.) Vol. XII.] AUGUSTA, GEORGIA, OCTOBER, 18ft. [No. 10. ORIGINAL AND ECLECTIC. ARTICLE XXV. An Essay Historical, Theoretical and Practical on Hydro- Thera' peutics. By Jno, Stainback Wilson, M. D., of Muscogee county, Ga. In writing an article designed to invite attention to the varied applications of waters the numerous indications it is so well calculated to fulfil -its great, and in many cases, transcendant re- medial virtues, we trust that our antecedents will be sufficient to relieve us from the charge of "giving aid and comfort" to a class of modern pseudo-reformers, who claim for this agent exclusive, universal, and almost omnipotent powers. And in order to remind regular physicians that they may speak and write of the remedial application of water, and use it too, ad libitum, in all its forms solid, fluid, or gaseous ; at all temperatures hot, cold, tepid, or warm ; to every part, generally or locally ; in every way by aspersion, by affusion, by submersion, by detersion and perfusion ; by wet sheets or shirts, cloths, blankets, or rags, without justly subjecting themselves to the humiliating imputation of being mis- led by the New Lights, we will give a very brief history of bath- ing, which will show that water has been used in most or all these forms, from the most remote antiquity, and sanctioned by the greatest medical writers of ancient and modern times. Iff. S. VOL. XII. NO. X. 37 580 Wilson, on Hydro- Therapeutics. [October, History of Bathing. As it would be foreign to our purpose to dwell on the remedial and religious uses of water, by the Hebrews, Egyptians, Greeks,, and Romans, we will only remark that it has thus been used by all nations, in all ages, and by all denominations Jewish, Chris- tian, Mahometan, and Pagan. We will now briefly refer to some of the ancient medical authors who advocate the use of "Nature's own remedy," of which we hear so much in these modern days. Hippocrates recommended bathing in pneumonia ; and cold affu- sions in inflamed joints, in gout and rheumatism, and in spasms, dislocations and fractures. Galen says: "Cold water quickens^ the action of the bowels; cold drink stops hemorrhages, and sometimes brings back heat * cold drinks are good in continued and ardent fevers they discharge the redundant and peccant humors by stool, by vomiting, or by sweat." He also commends- the internal and external use of water, warm and cold, in bilious- ness, spasms, headache, fever of the stomach, hiccough, cholera morbus, ophthalmia, and plethora, Celsus directs bathing in af- fections of the head, in fulness of the stomach, weak vision, deaf- ness, tremors, sinking, pains in the joints, diarrhoea, piles, hysteria, hypochondriasis, low fevers, digestive disorders, diseased kidneys, skin diseases, and hydrophobia. In addition to this strong testi- mony from the "fathers" in medicine, we can only mention), among the ancients, the names of Asclepiades, Oribassius, iEtiuSj Rhuzes> and Avicenna; and among the moderns, the names of Hoffman, Boerhaave, Haller, Floyer, Gregory, Cheyne, Lanzani, Harvey, Ambrose Pare, Larry, Macartney, Percy, Wright, Carrie-,. Jackson, Forbes, and John Bell ; and we might add the names of Sir Charles Scudamore, Drs. Johnson, Adair and Crawford, Mr. Mayo, Mr. Courtney, and the celebrated Liebig, several of whom have gone so far as to give their sanction to the " Water-cure processes. But it may be said by our modern reformers, this is all true \ the external and internal use of water has been recommended by .all the most distinguished physicians in the world, ancient and modern, in every variety of disease ; yet the immortal Priessnitz certainly did discover the wet sheet. We will see. " Dr. Cole gives an account of a stout young man in a delirium, who, escaping from his nurse, ran into a pond, where, standing up to his chin, he swore he would drown who ever came in after 1856.] Wilson, on Hydro- Therapeutics. 581 him. At his own time he came out of the pond and sat for many hours in his wet shirt by the bed-side. A physician was sent for four miles distant, who found him, upon his arrival, still in his wet sheet, or shirt, pertinaciously refusing to go to bed until, as he said, 'he took a notion.' This man recovered kindly. " Dr. Floyer, 150 years ago, tells us that the people of Stafford- shire, England, go into the water in their shirts, and when they come out they dress themselves over their wet linen, which they wear all day, and much commend."* But be this as it may, whether the idea of the wet-sheet pack originated with Priessnitz or not, it is doubtless a very valuable and convenient application, and we should not fail to avail our- selves of it, or any of the " water-cure processes," because they may have been abused and over-rated by a set of empirical hydro- maniacs : on the contrary, guided by a Catholic spirit of scientific eclecticism, we should, without hesitation, levy contributions from every quarter, remembering always that the difference between the scientific physician and the quack consists, not so much in the remedy used, as in the mode of using it. Having shown that Hydropathy (like Thompsonianism) has nothing really new about it, except its extravagant pretensions, we will next adduce some theoretical considerations as an essential preliminary to a rational exposition of the therapeutic application of water. For the sake of brevity and perspicuity, we will pre- sent this part of our subject in an aphoristic form, promising that we shall advance nothing but axiomatic truths, or facts well established by the researches of Liebig and other modern chemists and physiologists. Physiological, Pathological, and Therapeutic Aphorisms. Aphorism I. Animal life, in its ultimate analysis, is nothing more nor less than a continued transformation of matter an uninterrupted decay and restoration of the body the ceaseless operations of two opposing processes of supply and waste of de- composition and recomposition of vital and chemical affinity. Aph. II. These two grand processes comprise the functions of digestion, absorption, circulation, assimilation, respiration, and excretion. Aph. III. The above transformations and functions are render- *Prof. Bowling, in Nashville Journal, Jan. 1854. 582 Wilson, on Hydro-Therapeutics. [October, ed more active by exercise, and by cold, through the agency of the Vis Medicatrix Naturae, in her efforts to maintain an uniform standard of temperature. Aph. IV. The direct effect of water, of a lower temperature than the human body, is sedative. Aph. V. In its indirect or re-active effect, it is stimulant; and it possesses in addition the following properties, according to tem- perature and mode of administration, viz : Kefrigerant, anodyne, derivative, diaphoretic, diuretic, anti-spasmodic, astringent, (coun- ter irritant) and tonic. Aph. VI. The first impression produced by the application of cold water to the surface is, a vivid shock to the nervous system, with a simultaneous repulsion of the fluids upon the internal or- gans. The second effect (the result of the conservative powers of the organism,) is re-action, attended with a strong determination to the superficial cutaneous vessels, and perhaps to the capillary vessels of every part of the system. Aph. VII. Derangement or impairment of the nervous power is the primary link in the chain of morbid action. Aph. VIII. Derangement of the capillary system of vessels the organs of chemical and vital transformations (Aph. I.) is the second link in the chain of diseased action. Aph. IX. As a general rule, decidedly eold water should not be used on the surface of the body, in active internal inflamma- tions, and high fevers ; or in acute diseases generally, unless it could be continuously applied so as to avoid injurious re-action. Aph. X. The degree of re-action, after the cold bath is, in gen- eral, cceteris jxiribus, proportioned to the coldness of the water to the suddeness and force of the immersion to the vigor of the cir- culation in general, and more particulary that of the surface to the muscular movements in the bath to the friction and exercise after the bath ; and, finally, within certain limits, to the period of stay in it. Aph. XI. The cold bath is not positively contra-indicated in acute internal inflammations; on the contrary, its use in such ca- ses is correct, according to the modus operandi of the remedy ; the objection to it being the practical difficulty of keeping up uninter- rupted sedation. (Aph. IX.) Hence the following corollary, which demands our special attention, viz : Most of our medical writers, confounding the effects of water of different temperatures, or being mis- 1856.] Wilson, on Hydro- Therapeutics. 583 led by theoretical fears, are over cautious and restrictive in its use. The terms hot, cold, warm, &c, being entirely relative and not absolute, great confusion and misapprehension are almost inevita- ble, in estimating the effects of different kinds of baths. We will, therefore, in discussing this subject, venture to make the following innovation in our present nomenclature, which we think will ob- viate, to some extent, this difficulty. We will call all baths which act primarily as stimulants to the general system all bath above the active or relative temperature of the body, plus baths ; while all baths of primary sedative action all baths below the actual or rela- tive temperature of the body, will be designated as minus baths ; or, to be more specific all baths above 98, or above any other num- ber of degrees to which the body may be accidentally elevated all caloric baths will be comprehended under the former division ; and all baths positively or relatively lower than the above points, will be classed under the latter head ; while at the same time, the terms in ordinary use may be prefixed, or affixed, as convenience may dictate. Dr. Forbes, in his very comprehensive article in the Cyclopce- dia of Practical Medicine, has fallen into the difficulties above mentioned, if we are not much mistaken ; and as he may be con- sidered a fair expositor and representative of the views of the profession generally, his article on "Bathing" will receive special attention. He tells us, first, that the cold bath (33 to 60 according to his division,) is less applicable in infancy and old age, than in youth and middle life. This may be true as a general rule, still we are fully satisfied that it may be safely and beneficially used in tender infancy, and in trembling senility ; and even in great general de- bility of all kinds, if the temperature of the water be duly proportion- ed to the re-active powers, and if the proper means (Aph. X.) be used to ensure vigorous re-action. His second contra-indications to the cold bath are menstruation and pregnancy ; in the former positive, and to be used with great caution in the latter. The objections to the use of very cold baths during menstruation are no doubt well founded, still we think it possible, on theoretical grounds, that minus cool, or even cold baths might be resorted to with safety and advantage in some forms of dismenorrhcea and menorrhagia. As to pregnancy, although all violent perturbating remedies are inadmissible, we cannot see why this state should. 584 Wilson, on Hydro- Therapeutics. [October, in itself, be a contra-indication to the judicious use of the cold bath, either generally or locally. Our author, in speaking of the warm bath, says : "It may be stated generally that pregnancy, in relation to the warm bath, is to be viewed as a state of excitement, if not as an inflammatory disease. Admitting this to be true, cer- tainly nothing would more safely and effectually subdue the ner- vous and vascular excitement incident to pregnancy, than the local and general use of minus cool, or even cold baths of the higher temperatures; by the abstraction of excessive heat; by equalizing the circulation ; by removing internal congestions; by corroborating the whole system ; and thus preparing it to furnish suitable elements for the development of the new being, and to pass safely through the critical period of parturition. In short, we think that this is one of the cases in which regular physicians might, with much advantage to their patients, disregard the sug- gestions of pride and false theories, and follow the example of the Hydropaths, who use their wet bandages, general and sitz-batbs, in the cases under consideration, not onby with safety, but with great reputed success. And while on this subject, we would ap- ply the above remarks to the treatment of women after parturition. All physicians agree in the use of cold applications in post-partu- rient uterine hemorrhage ; and we are convinced that all the more reflecting are fully satisfied that the popular fear of " catching cold," so prevalent, is unfounded. They are also taught by daily experience and observation, that the throes of parturition leave the system in an irritated and excited condition bordering on fe- ver, which constitutes a strong pre-disposition to inflammatory disease. This being true, then, could anything be more safe, more agreeable, and more prophylactic than a general tepid, or even a cold ablution soon after delivery ? Far be it from us to advocate the rash and indiscriminate practice of many empirics of the pre- sent day ; but in order to show that cold water is not so dangerous in childbed, as some imagine, we will give the practice of the Hy- dropaths in such cases. As soon as the child is born, a pint or more of water is thrown up the vagina, which they say (with rea- son too,) causes the womb to contract immediately, and prevents after-pains. The patient is then washed all over in cold water, and a cold wet bandage is placed around the abdomen. When the patient awakes she goes into a cold sitz-bath fifteen minutes, the wet bandage is re-applied and continued a month, together 1856.] Wilson, on Hydro- Therapeutics. 585 with two sitz-baths, and three vaginal injections, daily. We must say that we consider this rather too much of a good thing, yet it serves to sustain us in the position we have taken, and should go far to encourage and confirm physicians in the judicious and sci- entific use of cold water, even within the very domain of ignor- ance, prejudice, and oldwomandom the lying-in-chamber. Dr. Forbes' third contra-indieation embraces great plethora ; a predisposition to active hemorrhages ; to local congestions in the more important viscera; in apoplectic subjects, and in tendency to haemoptysis, &c. As the plethoric contra-indieation will be dis- cussed under the head of the warm bath, we will only remark here, that the wet-sheet pack (which combines the stimulant and sedative effects of cold water,) is highly recommended by the Hy- dropaths in such a condition. The action of cold in hemorrhages and in internal congestions will now engage our attention. If we are correct in our views with regard to the action of cold water ; if it be a direct sedative and refrigerant; and if (as is admitted by Dr. Forbes and others,) parts not in contact with a refrigerating medium, contract through sympathy, then is the local, continuous (Aph. IX.) sedative appli- cation of this remedy strongly indicated in active hemorrhages of all kinds, haemoptysis not excepted ; the only cautions necessary being, to avoid carrying sedation too far, and yet to keep it up contin- uously, so as to prevent re-action. In passive hemorrhages, the same potent agent is at our service still ; but in cases of this kind, its stimulant, re-active, derivative, and equalizing effects are desired: it should therefore he briefly and suddenly applied ; while all the means already indicated as proper to ensure these results should he duly re- garded. (Aph. X.) As to the local congestion of internal viscera, we must be per- mitted to say that we could not possibly imagine anything better calculated to remove these congestions than the stimulant and de- rivative action of cold water properly adapted, in temperature, to the re-active powers of the system, and regulated according to the principles already annunciated. And we will add, even at the risk of being considered heterodox, that we know of nothing bet- ter suited to fulfil these indications, in the cases in question, and in passive hemorrhages, haemoptysis included, than the wet- sheet pack. Passing the fourth division of contra-indications, which does not require special attention, we will give the fifth 586 Wilson, on Hydro- Therajieutics. [October, verbatim : "It is generally inadmissible (the cold bath) in indura- tions, obstructions, or chronic inflammations of the internal parts of the body, more particularly of the principal viscera; likewise in all acute inflammations of the same parts, and also in chronic inflammations of the mucous membranes of the bronchi and in- testinal canal, except when these are very slight." Our views as to the principles which should govern us in the treatment of acute diseases, with cold water, having been sufficiently indicated, (Aph. IX. and XI.) we pass on to the consideration of one of the most interesting subjects within the whole domain of therapeutics, namely, its application in chronic diseases. This is a theme of ex- traordinary interest, on account of the well known obstinacy of such affections, their extensive prevalence, the inefficiency of our ordinary remedies in their treatment, and because, in our opinion our orthodox dogmas on this subject, need a thorough and radical revision. While it is admitted, even by the ultra Hydropaths, that cold water is not so useful in organic, as in functional dis- eases, we must dissent from the conclusion of Dr. Forbes, that " it is generally inadmissible in indurations, obstructions, or chronic inflammations of internal parts," for the following reasons: In chronic diseases, generally, there is a want of proper activity in all the organic processes; all the powers of life are below par, and consequently all the functions are more or less tardily and imper- fectly performed ; and this is true equally of the diseased organ itself, for though there may be a determination of blood to the affected part, this is rather a morbid than a vital stimulant, for it flows languidly through the hypenemic vessels of the suffering organ, and producing in short, all the pathological phenomena characteristic of passive congestion, rather than of active inflam- mation. If these premises be admitted, then are the stimulant and re-activc effects (Aph. V.) of the cold bath most desirable in almost every form of chronic disease to derive to the surface, to equal- ize the circulation, to eliminate morbid matters, to arouse the ex- crctorics, to quicken the chemical and vital processes of the capil- lary circulation, (Aph. I. and VIII.) to send the vivifying current through the stagnating vessels of the affected organ with a healthy impulse ; and in short, to re-animate the sluggish powers of the whole organism. We will even go farther than this, and say, if the premises be true, then the more chronic the disease, the more permanent the inflammation ; the greater the congestion or obstruc- 1856.] "Wilson, on Hydro- Therapeutics. 587 tion, the colder should be die water: provided always, that all the at- tendant circumstances of tiie case receive proper consideration ; and provided everything necessary be done to ensure vigorous re-action. (Aph. X.) The above observations are applicable to chronic dis- eases generally ; and a fortiori, to chronic inflammations of the gastro-intestinal and pulmonary mucous membranes, because of the well known sympathy existing between those membranes and the skin. Yet while this intimate sympathy tends to strengthen the indication for the cold bath, it at the same time requires cor- responding caution in using this remedy ; and this is the reason, no doubt, why it has been deemed wholly inadmissible in inflam- mations of the chest, by Dr. Bache, (IT. S. Dispens.) and almost all regular physicians ; while the same consideration, doubtless, in- duced Dr. Forbes to restrict its use only to ''very slight" chronic inflammations of the intestinal and pulmonary mucous membrane. From this we draw the following practical deduction, viz : While cold water is not by an}r means inadmissible, either locally or generally, in the affections under consideration, it will, as a gene- ral rule, be safer and equally as effectual to use it in accordance with the principles which would govern us in the treatment of acute diseases ; (Aph. IX.) for ceteris paribus a higher temperature will produce as great an effect in these affections, as a lower would in other diseases. We have thus given our views on the use of the cold bath in several morbid conditions, and endeavoured to establish correct principles for its administration ; we have felt much diffidence in expressing opinions adverse to the most autho- ritative writers in our profession, but we are prompted to the disa- greeable task, by the firm conviction, that the doctrines advocated (although to some extent theoretical,) will bear the test of the most rigid examination. We proceed next to another form of bath, concerning which greater errors are entertained, if possible, than those we have first been discussing. The Warm Bath. It has been seen that this bath, according to our division, in its primary, and we might say in its exclusive effects, is a minus or sedative bath ; being lower than the normal temperature of the body, its action is identical with the sedative action of the cold bath, differing in degree only from the latter, and not in kind: yet, with this important difference there being little or no reaction or 588 Wilson, on Hydro- Therapeutics. [October, shock to perplex us in investigating its modus operandi its phenome- na are less complex and more easily understood. This is undoubtedly a correct view of the subject; yet, as strange as it may appear, Drs. Bache, Forbes, and indeed most our medical writers, while they prescribe the warm bath in diseases of excitement, neverthe- less trammel its use with cautions, restrictions, and contra-indica- tions, which plainly show that they have confounded the effects of the hot and warm bath. The former writer says: "the warm bath cannot be deemed, strictly speaking, a stimulant." And he tells us again, that it has a soothing influence in certain states of morbid irritability ; and that it is proper in febrile and exanthe- matous diseases in which the pulse is frequent and the skin hot and dry. Yet "it is contra-indicated in diseases of the head and chest," according to Dr. Bache. (IT. S. Dispen., 115.) Now, the fact is the warm bath is not in any sense a stimulant, as we might be led to believe from the cautious language of this writer : for though, as he says, its temperature may be above that of the surface communicating to it a sensation of warmth, it is nev- ertheless below the normal standard of animal heat ; it abstracts caloric, soothes the nervous system, allays vascular excitement, restores the equilibrium of the circulation, and is, therefore, " strict- ly speaking" a minus or sedative bath and nothing else. And yet, notwithstanding all this, we are told that it is contra-indicated in diseases of the head and chest: in inflammatory diseases of these parts, we presume. But with what propriety such declara- tions are made we cannot possibly see, for we cannot imagine any way in which the warm bath could act injuriously, in such cases, unless it were by the retro-pulsion of the fluids, by the density of the medium surrounding the body ; but, admitting the possibility of this, we think that this result would be fully counteracted by the increased capacity of the cutaneous vessels, in accordance with well known physical laws. And apart from all theory, we feel Confident that we may safely appeal to the experience of every physician to answer the question as to whether he has ever seen any injurious effects from the warm bath, in the diseases under consideration, when the temperature of the water and all the at- tendant circumstances of the case were duly regarded in its admin- istration. The position we have taken is so rational and obvious that it would appear to be a work of supererogation to multiply argu- 1856.] Wilson, on Hydro- Therapeutics. 589 merits in its support, were it not that our most authoritative wri- ters, our preceptors in theory arid our guides in practice, advocate adverse (and we must say erroneous) views on this vitally import- ant practical point. For instance, the author to whom we have already given so much attention, (Dr. Forbes,) prescribes the warm bath (92 to 98) in chronic nervous diseases of a spasmodic kind; in cramps, spasms, and convulsions of various kinds, unaccompa- nied by a plethoric state of the system, or by fever. He prescribes it also in various painful nervous and spasmodic affections, such as neuralgia, sciatica, &c, in spare habits, and without inflammation ; also, in acute inflammations of the mucous membranes of the ab- dominal and pelvic viscera, with the loss of blood generally and locally, in all cases, or with very rare exceptions, in order to ren- der the bath a useful, or even a safe remedy. With these precautions it may be useful, if not contra-indicated by plethora, &c. Similar directions are given as to the use of the warm bath in chronic inflammations of the same parts. And lastly, he informs us that it has been used, more particularly on the continent, in the cold stages of severe fevers, and in the retrocession of cutaneous dis- eases. Certainly rather a strange remedy, according to our ideas, unless the temperature of the bath was above that of the body. We have italicised some of the contra-indications made by him in prescribing this remedy ; and we find by glancing over his ar- ticle, that five, out of the nine indications, contain cautions and restrictions plainly showing that he considers the warm bath a dangerous stimulant and excitant. He positively contra-indicates it,1 or enjoins great caution in its use in full habits, in plethora, in predisposition to apoplexy and hemorrhage, in organic diseases of the heart, in great relaxation of the system, in extreme sensi- tiveness of the surface, and " in all febrile diseases, whether accom- panied by visceral inflammation or not, where there is an active circu- lation and a hot dry skin." (Cyclo. Prac. Med., p. 277-279.) As we remarked, when treating of the cold bath, we feel great diffidence in opposing the views of one so distinguished as Dr. Forbes ; yet we must be permitted to say, that we can see but one proper contra-indication in all the above list, and that is in cases of " great relaxation." And we must say, in conclusion, that we cannot expect physi- cians to realize the extraordinary benefits to be derived from the warm bath, or to use it judiciously, when they follow, without 590 Howard, on Pneumonia. [October, investigation, the dicta of writers who make an " active circulation and a hot, dry skin," a positive contra-indication to it. The Temperate, Tepid, Vapor, and Hot Baths. As the cold and warm baths are the terminal and governing links in the chain of minus or sedative applications, and as the general principles established in reference to them may be readily applied to all the intermediate links of the same chain, above men- tioned as these differ in degree of action, and not in kind of action, from the warm and cold baths, it will be unnecessary to enter into any general discussion as to their modus operandi: we will only remark, then, that any peculiarity in the action of each, and par- ticularly of the vapor bath, will be noticed when treating of speci- fic diseases. The effects of the hot bath being obvious and well understood, it is equally unnecessary to multiply remarks con- cerning it. But the length of our article warns us that we must here dismiss this interesting subject, for the present; Ave will therefore defer, to some future time, that part of our " Essay " which we intended to devote to special Hydro-therapeutics, or the practical application of the principles advocated to specific diseases. In the mean time, we trust that our humble effort will tend to the establishment of more definite and philosophic views as to the modus operandi of the agent we have been considering ; and we hope that physicians will re- member, amid the intricate mazes of fallacious theories, and the uncertainties of a redundant Materia Medica, that Nature has pro- vided in the greatest profusion, a remedy of wonderful, varied, manifest, and in many cases, transcendant remedial powers IN PUKE SIMPLE WATER. ARTICLE XXVI. Treatment of Pneumonia. By C. C. Howard, Lowndesboro', Ala. The attention of the profession has been prominently directed, for the last few years, to the treatment of pneumonia ; and, inas- much, as I have some reason to be satisfied with the plan pursued by myself, it is here briefly given. The treatment of nearly every case of this disease, coming under my management, is begun and continued with calomel, quinine 1856.] Howard, on Pneumonia. 591 and ipecac, aided by other remedies to be hereafter mentioned. These medicines are usually commenced with in combination in something like the following proportions for an adult: ^ Calomel, grs. xvj. Quinine, grs. xxiv. Ipecac, grs. iv. Divide into eight powders. One to be taken every three hours until the bowels are moved two or three times. Should these medicines fail to operate in twenty-four hours from the time of commencing to administer them, give oleum ricini, ss, or a seidlitz powder, or some other simple cathartic ; and, if necessary, in two or three hours thereaf- ter, enemata. It will frequently happen, however, that the patient will have taken a cathartic before the physician is called, then the calomel should be given in smaller doses, with a view to its specific action only ; for, although a soluble condition of the bowels is desirable throughout the attack, purgation is to be avoided. According to the writer's observation, a great majority of pa- tients will be brought under the peculiar influence of quinine, in from twelve to twenty -four hours, if the medicine be administered in doses of two or three grains, every two or three hours. But in the more violent cases of the disease, I occasionally give five grains, at intervals of three or four hours. A little experience with still larger doses of this drug, i. e. ten or twenty grains, has fully satisfied me that in any of the diseases I am called to treat, (provided there is time to repeat the smaller doses,) there is no necessity for the very large quantities of this medicine sanctioned and recommended by some others. As has been already indicated, the calomel is given with a view to its cathartic or constitutional effect, or both ; the quinine and ipecac with a view to their action especially on the nervous sys- tem and skin. In the course of the treatment, therefore, one or another of these medicines may be left out, or the whole suspend- ed for a time, as the effect and existing symptoms dictate. Warm poultices, powdered with a little mustard, if there is much pain, are to be applied over the diseased lung or lungs. If the fever has not subsided by the second day's visit, the pain greatly decreased, and the patient improved generally, I apply a blister sufficiently large to cover the entire thoracic disease. In- deed, the maxim with me is, in every case of pneumonia when 592 Howard, on Pneumonia. [October, the inflammation is such as to make a blister tolerable, or when there is the probability that a blister will be required in the treat- ment at all, to apply it without delay, and re-apply it if necessary, that is to say, if the disease does not give way during the contin- uance of the first vesication. The calomel, quinine and ipecac, generally act well as an ex- pectorant, and some cases are treated without any other ; but fre- quently something like the brown mixture (IL S. Ph.) is given, preferring, however, flax-seed to the gum arabic, less liquorice, with some sugar, and in most cases wine of ipecac, to the antimo- nial wine. The flax-seed are decidedly preferable to the gum arabic, probably on account of the oil they contain. Indeed, oily substances generally will allay cough, and I suspeet cod-liver oil owes much of its efficacy in lung disease (if it has much,) to its oily nature. Latterly, I have frequently used the following oil mixture as an expectorant, and have been much pleased with its action : $. 01. ricini, . . Tr. opii., . . Loaf Sugar, Gum arabic, Aq. pip. ment., ?5S. 3i. 3i. 5 vss. M. secundum artem. One tablespoonful every one, two, or four hours, as occasion re- quires. If the patient has thirst he may allay it with water, which it is submitted is the most reasonable, natural, efficient and satisfactory means. When he wishes nourishment, the direction is to give him a little plain food, nicely prepared. Here let it be said, out upon those heathenish preparations of arrow-root, sago, tapioca, pulv. elm, barley, beef tea, and a hundred vile dietic compounds which ninety-nine cooks out of a hundred know nothing about, and which no sane man would ever select as food for himself in health. Though expressed somewhat in detail, such is the general plan of treatment pursued for several years, with some success, by the writer, and which he desires to recommend to those of his breth- ren, especially in the malarial districts of the South, who are dissatisfied with the result of the methods of treatment they now pursue. It may be added that, by a judicious application of these means the symptoms resulting from the nervous disturbance 1856.] Holt's Letters upon General Pathology. 593 will be removed ; the skin induced to act healthily ; the bowels with the viscera of the abdomen brought to the performance of their natural functions ; the cough kept in due bounds ; the in- flammation subdued ; the strength reasonably sustained, and the patient very satisfactorily cured. Usually, no other remedies have been found necessary to condtct my cases to a favorable issue. When these, however, have failed promptly to promise success, (as has occasionally happened,) then others have been selected and applied on general principles. "But do you never bleed your pneumonia patients?" I have not bled one in several years, but should not hesitate to do so if the grade of fever accompanying the disease was synochal ; but hereabouts it is nearly constantly of a lower or typhoid type. "Don't you give aconite and phosphorus?" Never a drop never saw but one patient who took them, and he died in two or three days with his pneumonia, marked by head symptoms, the result, however, I believed, of morphine with which the aconite and phosphorus had been aided. Hence it may be said that al- though opiates have been brought into the treatment suggested in this paper, still it has been found necessary to observe caution in their use ; even teaspoonful doses of paregoric were observed to produce decided effects in cases occurring in adults on the same plantation. But what of the veratrum viride ? I have seen a little of the action of this medicine and consider it, both from what has been seen and from its prominent impression on the system, as insuffi- cient to the cure of this and most other diseases ; and with due respect for its introducer and approvers, venture to assert that it has received its crown, which time and future experience will greatly fade. ARTICLE XXVII, LETTERS FMS SAIL. D. HOLT, M. D., UPON SOME POINTS Of GENERAL PATHOLOGY. LETTER NO. 15. Montgomery, Ala., August 28th, 1856. Messrs. Editors It is not so strange a matter, that derangement in the functions of the liver should constitute an important feature in the character of these, and indeed, of all other fevers in our cli- mate, if we examine into the causes which tend to interrupt the 594 Holt's Letters upon General Pathology. [October, secretion of bile, and to suspend its other important functions; as it is, that there should be in the present day, eminent men in the profession, who affect to believe that disordered functions of the liver constitute no very important or essential part in their char- acter. How they have arrived at such a conclusion can be imag- ined, only by supposing, that while the scalpel and dissecting knife has failed to reveal the work of inflammation, upon which they supposed the malignant forms of these fevers to depend, they have overlooked the important fact, that nineteen-twentieths of the deaths which occur from these diseases, are the direct result of functional disorder, consequent upon nervous depression, or a change in the healthy constitution of the blood, with which inflammation has no necessary connection. Or it may be that they have looked at them through glasses, adapted to the focus of popular prejudice against certain remedies, which, Old Fogyism was once simple enough to believe, had power to regulate their disturbances. However that may be, we will first notice some of the prominent causes which give rise to disturbance in the functions of the liver, and then show the consequences which result from such disturb- ance in connection with these (intermittent and remittent), and other fevers in our climate, and I design to be as brief as possible. The functions of the liver may be deranged and suspended from a loss of power in the secreting vessels, or from excess of excitabil- ity and irritation in the vessels of the liver. It may depend upon an excess or a deficient quantity of blood, upon its too slow or too rapid movement, and upon the character or constitution of the blood itself, as when, from excessive secretion and a loss of its thin or watery constituents, it becomes too thick for easy circulation ; or when, from a loss of its solid constituents, it becomes too thin and too much impoverished to sustain the functions of gecretion, or even its own vitality. The most common source of deranged and suspended functions of the liver is to be found in venous con- gestion, consequent upon an enfeebled condition of the capillaries of the portal vein, and usually attended with engorgement of the bile ducts, with thick inspissated bile, while its deranged and sus- pended functions, from excess of excitability or irritation in those vessels, depend neither upon venous congestion or bilious engorge- ment, though these conditions often attend upon it the former being the usual attendants upon the congestion, and the lattter upon the irritant and inflammatory forms of fever. Now, the dis- 1856.] Holt's Letters upon General Pathology, 595 turbance in the functions of the liver, which consists in an ex- cessive or defective secretion of bile, in defective or suspended elaboration of the nutritive materials brought to it by the portal veins, and in the defective or suspended depuration of blood con- sequent upon these, may, with the causes which give rise to it, be regarded as a chain of cause and effect, having the first link in such a loss of nervous power in particular parts, or of the whole system, as to interrupt and disturb the circulation and to cause an unequal distribution of blood, whereby it accumulates in certain organs and becomes so deficient in others, as seriously to interrupt the healthy performance of their functions, some of which, are employed in the office of supplying material to the blood for the support of the system, while others are employed in removing from the blood the noxious and septic matters which are the natu- ral product of disintegration and decay. The particular constitu- tion of the blood most favorable for an excessive secretion of bile is not an easy matter to determine ; but the general condition of the system which appears most favorable is a moderate degree of excitement, such as exists in the ordinary irritant forms of disease, the conditions of depression and congestion and of high excitement or inflammation, being alike unfavorable. In speaking of the exces- sive secretion of bile, I do not mean such a normal increase as often occurs under the influence of temporary and partial excite- ment, but when it occurs as one of the morbid phenomena usually attendant upon particlar forms of the fevers under consideration, the effects of which are to excite excessive and obstinate vomiting and purging, (the bile, itself, being under such circumstances acrid and irritating,) and thus to interrupt or suspend the process of di- gestion, assimilation and nutrition. Another effect of the exces- sive secretion of bile is to weaken the secretory powers of the liver, and thus to render it subsequently torpid and inactive ; but the most important effects of excessive secretion, in a pathological view, are those which relate to the changes thus effected upon the constitution of the blood; and for the better illustration of my views upon this subject, I will offer a few extracts from Dr. Wil- liams' Principles of Medicine: " Excessive secretions, if abounding in animal matter, may not only reduce the mass of the blood, but also affect its composition." " Urine contains a great preponder- ance of azote, and its excessive formation from the principles of the blood would have a predominance of hydrogen and carbon in N. S. VOL. XII. NO. X. 38 596 Holt's Letters upon General Pathology. [October, this fluid. The bile again abounds in hydro-carbon, the copious removal of which would leave a superfluity of azote The secretions of the liver and of the kidneys are intended to balance one another, and the removal of carbon from the lungsr and whe- ther the materials from which these eliminating processes are sup- plied, be the principles of the blood itself, or the decayed constitu- ents of tissues, or matters derived from the foodr the co-operation of all these processes will generally be required to maintain an uniformity in the composition of the circulating fluid: so, too, if one of these processes is more active than the others, the blood must suffer by the excess of those matters which the less active processes allow to accumulate in it." "We come next to consider the effects of a deficient or suspended secretion of bile, which being an important agent in the work of digestion, its deficiency necessarily enfeebles that process, and im- pairs the function of assimilation and nutrition. Thus, the blood to an extent becomes impoverished, which tends to diminish the tone and vigor of the whole system. Another effect of a deficient secretion of bile is to interrupt the regular peristaltic action of the intestines, which to some extent depends upon the stimulus of the bile, but being deficient in quantity gives rise to torpor of the bow- els, whereby the excrementitious matters are retained for too long a time, subjected to the action of the absorbents, and thus effete and noxious matters which ought to be thrown off, are taken again into the circulation along with the new materials of supply, which the liver in its deranged condition fails properly to elaborate, and which in their unprepared state are thrown into the general circu- lation, thus further impairing the healthy constitution of the blood' and unfitting it for the proper and healthy performance of its va- rious and respective offices. But by far the most important effect of the suspended secretory function of the liver is, the retention and accumulation in the blood of the elementary principles for secretion, and the effete, septic and noxious matters of excretion, " which are the product of disintegration and decay, whereby from a want of depuration the blood often becomes so depraved as not only to be unfit for sustaining the vital functions in their integri- ty, which depend upon its healthy constitution, but to exert a di- rect influence in the establishment of a still greater depravity, by depressing the power of the great nervous centres ; and thus, the liver, lungs, kidneys, &c., failing further in their work of elimin- 1856.] Holt's Letters upon General Pathology. 697 ation and depuration, the blood, in a great measure, loses its vital' ity, giving rise to those malignant symptoms which are character- istic of the highest grades, or most malignant forms of the fevers of hot climates. To show that these remarks are not mere as- sumption, I will quote again from Dr. Williams, who says" The concomitance of congestion with defective secretion, in the case of the liver, the kidneys and the mucous membrane, is well known, but either may be viewed in the light of both cause and effect. The most remarkable of the backward effects of defective secretion are instanced in case of the secretions (before treated of). The distinctive materials of the secretions of urine and bile appear to be positively noxious, and poison the system if not separated from the blood. Thus, the sudden suppression of urine or bile causes ty- phoid symptoms, extreme depression, and coma, which speedily end in death; and in such cases urea, or the coloring matter of the bile has been found in various organs Where the suppression is incomplete, the poisoning process is more tardy : various functional and visceral derangements are produced, such as delirium or le- thargy, dyspnoea, palpitation, vomiting, diarrhoea, dropsical effu- sions, structural degenerations, &c, which always proved fatal sooner or later, if the defective excretion be not restored.'1'1 Again " The^o- sitively noxious properties which excrementitious matter retained in the blood is known to possess, must be taken into account when we attempt to explain the states of constitutional irritation and depression with perversion of functions, which fevers so gen- erally present." Dr. W. continues his remarks concerning the effects of defective secretions, to which I find a note appended, which conveys my ideas so fully, respecting a condition frequently to be seen in some of our more malignant forms of fever, particu- larly the typhoid, that though somewhat out of place, I cannot let it pass : " Purpura, I have found to be often connected with he- patic congestion, and imperfect excretion of bile, and to be most effectually removed by remedies which promote the restoration of the proper secretions." I propose now, (and there can be no more appropriate occasion,) to examine the relation which these derangements in the functions of the liver sustains in the different forms and modifications of those fevers, which have their origin in a change of the organic nerve power, to which class we consider the fevers in question (intermittents and remittents) to belong, taking, first, those which 598 Holt's Letters upon General Pathology. [October, are characterized by nervous depression and congestion, (accord- ing to our classification,) and secondly, those characterised by excitement with irritation or inflammation, and lastly, those which approach to, and assimilate the typhoid character, I have already pointed out the manner in which general causes, acting with un- equal force upon different portions of the nervous system, increas- ing or diminishing the excitability of particular organs, thus de- ranging the currents and disturbing the balance between the venous and arterial portions of the circulation, causing determina- tions, and undue accumulations of blood, and thus interrupting the healthy performance of the functions of those organs, in conse- quence of which, the quality of the blood often becomes so chang- ed as to effect further and important changes in the nerve power, and in some cases, and in some forms of these fevers to destroy, in a great measure, the vitality of the blood. But it must be remem- bered that the changes thus effected in the condition and quality of the blood, in the first named or congestive forms of fever, do not so much affect its vitality, as they do, for a time at least, and to a certain extent, destroy its properties as a stimulant to the nervous centres and important vital organs, such as the heart,. lungs, &c, upon which their proper and healthy action depends. These changes, which consist chiefly in an accumulation of car- bon, or the hydro-carbonaceous products in the blood, are usually effected in this form of fever, in the manner described by Dr. Williams, or upon the same principles, namely, that while the liver, from congestion or loss of power in the secreting vessels or both, fails to separate these products from the bloodr heavy drafts are often made upon its albuminous and animal principles through the skin, hidneys and the intestinal mucous surfaces. Indeed, so uniformly is this the case, as to have induced the remark on a former occasion, that I had never met with a case of congestion and collapse which was not the result of some heavy draft upon the circulating fluids, or of some strong heavy epidemic influence. Hence it isr that when death ensues in this form of fever, it is from the loss or destruction of the organic nerve power, from a want of the stimulus of a sufficient quantity of oxygenized blood, and not from necrremia or loss of vitality in the blood, which often occurs in some of the more malignant forms of fever. It is thus, that thousands of cases of fever, pneumonia, and other dis- eases, not necessarily fatal in their character, have been brought to 1856.] Holt's Letters upon General Pathology. 599 a fatal termination from a rash and injudicious use of the lancet, emetics, cathartics, diuretics, and diaphoretics, all of which tend to destroy the nerve power, and none of them, under the circum- stances, to restore the secretions of the liver. The rational indica- tions for the treatment of all such cases are, to increase and sustain the nerve power, to arrest all excessive drains upon the circulat- ing fluids, and to restore and maintain an equilibrium to the circulation, and last, though not least, to secure the secretory functions of the liver. The fulfilment of one of these indications will go a great way towards the fulfilment of the others, and the remediable means required will generally be few, simple and effi- cient, if properly applied. Keeping in view the trite adage, that " an ounce of prevention is worth a pound of cure," the periodic character of the disease can never, with safety, be overlooked. To increase the power of the nervous system, the moderate use of dif- fusible stimuli, such as ether, ammonia, camphor, opium, and brandy, will be found the best. As a sinrple stimulant, the bran- dy is generally to be preferred, but for the additional purpose of allaying irritation in the stomach and bowels, I have found cam- phor and opium, as they are combined in paregoric, to answer better than any other combination of these remedies ; but to get their best effects the dose should be larger than that usually pre- scribed. I am in the habit of giving a tablespoonful, or half an ounce, and repeating it every hour or oftener, as long as there is a necessity for its use, and to children a proportionate dose. If the type of the disease is not positively known, it will be the safest practice to combine quinine with these remedies in proper doses, if the condition of the stomach is such as to retain it To restore a balance to the circulation, and to arouse the action of the remote capillaries, no means are so effectual as the steady and persistent application of dry heat. For this purpose, the pa- tient should be confined to bed, be well invested with blankets, or bed-clothes, and surrounded with bottles filled with hot water. If, from the internal use of stimuli, and the external application of heat, a profuse perspiration should be induced before the eviden- ces of reaction should be sufficiently manifest, it should be prompt- ly arrested, as its continuance will have the effect of retarding, and may prevent reaction. This may readily be accomplished by re- moving the bottles and blankets, and sponging the whole body and limbs with ice water, which will, generally in a few minutes, 600 Holt's Letters upon General Pathology. [October, establish a reaction. If it fail, the blankets and bottles should be re-applied. In the meantime, and as soon as circumstances will admit, calomel in the dose of 25 or 30 grs. with 10 grs. of Dover's powder, should be administered ; the best mode of administering which, is to rub it up with a little brown sugar, put into the mouth dry, and carried down with a swallow of water. If it should be thrown up, it should be immediately followed by an other dose of the same sort ; or if the stomach should be irritable with vomiting, it will generally be the best plan to increase the dose to 35 or 40 grs. and make it into a bolus which will be easily swallowed, but difficult to throw up. This dose will generally operate in 8, 10, 12 or 15 hours, and sometimes longer, and gen- erally the longer the better, for it will seldom fail to relieve the liver of its sanguineous and bilious engorgement and restore its secretions, and seldom requires to be repeated. That this is the most effective and safest manner of using calomel in this form of fevers, and in a like condition in other diseases, I am prepared from ample experience to testify. The liver having been thus re- lieved of its engorgement and congestion, the next important step is, to fortify the system against the recurrence of a similar condi- tion of things, and this will be effected by bringing it under the influence of quinine, in -anticipation of the period of depression according to the type of the disease, and its action may always be favorably assisted by confining the patient to the application of the blankets and bottles of hot water. In this manner the sweat- ing may be substituted for the cold stage, and whenever this is done, and the secretory function of the liver is re-established, the victory will be complete. The foregoing embraces all the principles of practice, with some slight modifications, (and most of the remedies, with the exception of some which served rather to add to the comfort of the patient,) with which I have successfully combated some of the most formi- dable congestive forms of disease, among which, besides the fevers under consideration, may be enumerated cholera, and dysentery, pneumonia, and other symptomatic fevers, some of which were of the most grave, and others of the most trivial character ; among the latter was the case of a gentleman in this city, who laid eighteen hours in a state of collapse, or asphyxia, in conscquenco of excessive purging with Epsom salts for a common bile. The next forms of these fevers which we shall notice are those 1856.] Holt's Letters upon General Pathology. 601 of the intermediate grades, as the irritant, congesto-irritant, and congesto-infiamviaiory. These are characterized by higher degrees of excitement, and generally have their type and periods of ex- acerbation well defined, whether intermittent or remittent. In these forms of fever, particularly the irritant and congesto-irritant, when the febrile movement becomes established, the lungs allow of such a free circulation as to furnish the nervous centres, and other vital organs, with an exuberance of oxygenized blood, giv- ing life and activity to those organs which have not suffered from previous debility or depression, and giving rise to irritation in those which have. In these fevers, the liver being measurably freed from engorgement, and being excited by a supply of well oxygenized blood, pours out quantities of bile, which, finding its way into the stomach and bowels, gives rise to the bilious vomit- ing and purging which, Avitli the delirium, and hot and moist skin and rapid pulse, are their characteristic symptoms. The indications of treatment and the details of practice are some- what different, in these fevers, from the congestive form, and as their tendency is to relapse into that form, when they do so, the principles of practice will be the same: they sometimes, too, spring up into inflammation, under which circumstances the prac- tice must be modified accordingly. In these forms of fever, during the exacerbation, if the skin be hot and dry, as is often the case for a short time during its height, refrigerative drinks, and spong- ing the body with cold Avater, will generally be sufficient to re- duce the excitement. Narcotic medicines and diffusible stimulants are generally required ; but there is no disease, or form of fever, in which quinine is more required, or in which its best effects are more manifest, than in this dangerous form of fever, and should be used with reference both to its stimulant or antiperiodic and its tonic effects : it may, in fact, be regarded as the shed-anchor in their treatment. Should there be (which is sometimes the case) engorgement of the liver, in consequence of a feeble and imperfect febrile reaction, calomel will be both necessary and proper; or if the flow of bile has been excessive, its use will generally be ne cessary, as torpor of the liver is apt to follow such action. In these cases, so Large doses will not be required to affect the liver 20 gr. doses will generally be found sufficient; but if the stomach and bowels are much irritable, large doses will be found to act better, for reasons already given. If the secretion and flow of bile have 602 Holt's Letters upon General Pathology. [October, been excessive, the use of saline diaphoretics and diuretics will be proper, and necessary to carry off the excess of azotic compounds left in the blood, by the withdrawal of the hydro-carbon through the liver. If, as there is good reason to believe, the character of these fevers depend upon a loss of tone in the nervous system, with a too highly annualized condition of the blood, the rational indications of treatment would certainly be to raise the tone of the nervous sys- tem, and reduce the animal constituents of the blood. Upon these principles has our practice in such cases been founded ; but in the use of remedies for fulfilling these indications, care must be taken not to excite too highly the circulation, by the use of stimuli, for fear of producing inflammation, nor to draw too heavily upon the circulating fluids, by bleeding or otherwise, for fear of producing debility, depression and congestion. These being the fevers in which, in times past, the lancet, emetics, and drastic cathartics have displayed their prettiest work of destruction. The next form of these fevers which claims attention, having, like the preceding, their origin in a change of organic nerve pow- er, are characterized by higher degrees of excitement, rangingfrom irritation to inflammation. These fevers, which are usually re- mittent in their character, are generally sustained or kept up by a greater amount of vigor and tonicity of the system, and a richer and denser constitution of the blood. We have maintained that fever is a sanative effort of the sys- tem to overcome some obstruction, to relieve some laboring organ, to restore some suspended function, &c. ; and we have advanced the opinion, that the liver was the seat of the origin of these fevers; and it now remains for us to examine the relations which the dis- ordered functions of that organ sustains to the particular form of fever in question. The torpor and inactivity of the liver, which we suppse, and know to exist in most fevers of this character, we have ascribed to the cause of long continued over-action, and this opinion is sus- tained, as well by the season or period when they mostly prevail, as by the character of the fever itself. The fact of their having slight cold stages, or stages of nervous depression, and prompt re- action, with a free pulmonary circulation, and a preponderance of blood upon the left side of the heart, manifested by a full, strong pulse and a hot, dry skin, which are characteristic features of this form of fever, arc sufficient evidences of the general condition of 1856.] Holt's Letters upon General Pathology. 603 the nervous system, and that the blood is not so loaded with hydro-carbon as to cause nervous depression. From the long con- tinued and excessive drain from the liver, which induces its debili- ty, we might suppose that the azotic compounds would be left in excess in the blood ; but the skin, if not the kidneys, (as these often perform vicarious offices for each other,) under the same influence as the liver, (atmospheric heat,) tends to preserve the proper condition of the blood, by throwing out the azote, while the liver is separating carbon. Though suspending secretions are among the characteristic symptoms of this fever, the termination of each paroxysm is usually attended with a restoration of some one or more of the secretions, generally the skin or kidneys, or both, and sometimes the liver; and thus the integrity of the blood is often preserved through many successive paroxysms. Although I have ascribed the suspended or interrupted func- tions of the liver, among other causes, to excess of excitement, to which we must assign the suspension of other secretions in this fever; yet it does not follow that the suppression of the biliary secretion in these fevers depends upon that cause. The fact that this secretion is performed by venous capillaries, from venous blood, while other secretions are performed by arterial capillaries, from arterial blood : and the further fact, that the means employ- ed to restore other secretions, by the reduction of excitement, has little or no effect in restoring the suspended secretions of the liver ; but that it requires the action of a specific excitement to do it, may be taken as prima facia evidence that the liver is inactive and tor- pid, in these fevers, from debility. This, we believe and it is an important matter to be kept in view that using the proper means for the reduction of excitement, care must be taken that too heavy draughts be not made upon the blood, by bleeding, purging, sweating, &c, until other measures have been resorted to for the restoration of the biliary secretion, lest such an excess of carbon be left in the blood as to cause depression in the nervous centres. How often has it been the case, that for the want of this precau- tion, and acting under the belief that reduction of excitement was the great object to be obtained, patients having strength sufficient to sustain them through a series of paroxysms, have in this way been suddenly precipitated into states of extreme depression, con- gestion and collapse? Where there has been no such drains upon the circulation, and these fevers have pursued their course through 601 Holt's Letters upon General Pathology. [October, a succession of paroxysms, the consequence of the suspended se- cretions will be, such an accumulation of effete, noxious and septic matters in the blood as not only to depress the organic nervous power, but to prostrate the animal powers also, and to a consider- able extent to destroy the vital properties of the blood itself, aud giving rise to a train of typhoid s3'mptoms, such as, a loss of mus- cular strength, a feeble pulse, low delirium, or coma, showing the poisonous influence of the blood upon the brain and other nervous centres; a dry, brown and cracked tongue; a sallow, icteric, or cadaverous appearance of the skin, with sudamina, petechias, hem- orrhage, offensive excretions, &c. showing, from the deranged condition and depraved character of the secretions and excretions, an evident tendency to putrescence of the fluids, from a loss of vitality in the blood. Hence it is, that it is not uncommon in localities where this form of fever prevails to find cases bearing a striking similarity to typhoid and yellow fever, in the low deliri- um, coma, sudamina, hemorrhage, jaundice, and even, in extreme cases, black vomit. But similarity must not be confounded with identity; and it must be remembered that this typhoid condition and necrajmic state of the blood, in bilious fevers, are consequential upon deranged functions, the result of organic nervous depression, and of poisons generated in the system during their progress while the fevers which they assimilate have their origin in causes or poisons which have been generated out of the system, and which, being taken into the circulation, tend from the first to destroy the vitality of the blood, and to prostrate the animal nervous power. The similarity between these fevers, which has given rise'to the doctrine and arguments in support of their essential identity, belongs rather to their termination than to their origin and progress, in which my own observation has satisfied me that they are essentially different. As this subject will constitute the theme of my next letter, I will make a few therapeutic remarks, in addition to the suggestions which I have already made, and leave the subject to the reflection of the reader. It seems almost a matter of supererogation to say, that the indi- cations of treatment, in this form of fever, are to reduce the general excitement, and restore the secretions, by raising the tone and excitement in organs in which it is too low, and reducing it where it is too high, and thus preserve the integrity and vitality of the blood. Another equally important indication is, to arrest the 1856.] Lecture on Impotence. 605 progress of the disease, by interrupting its periodicity by estab- lishing a state of excitement in substitution for the stage of nervous depression. These indications will be best fulfilled by a judicious use of the lancet, and saline diaphoretics and diuretics; by calomel in full purgative doses; by opium, to allay pain and check exces- sive secretions; and by quinine, to break up their periodicity and arrest their progress. Local inflammations, either as cause or con- sequence, must be treated upon their own merits, but with respect to the general condition of the system. The treatment suited for the typhoid condition in these fevers will be noticed in another connection. I have thus examined the character of intermittent and remittent fevers, according to the plan and classification which I at first proposed, which I think will cover all the forms and varieties (so far as their pathology is concerned) which have been noticed by Eu- ropean and American writers. It may be, that some of my read- ers may complain that I have given but a meagre account of these fevers, and a still more meagre plan of treatment. To such I will say, that it was never my purpose to enter into a minute detail of the causes, the symptoms, or the treatment of these diseases, but to consider them in the light of a general pathology, upon which their treatment was to be founded; and I regret it, if their expec- tations have been disappointed. It is my intention, however, to give, more minutely, the treatment in particular cases which I shall furnish in support, and in proof, of the principles which I advocate. As ever, yours truly, Saml. D. Holt. Lecture on Impotence. By Prof. Trousseau. In considering, to-day, the subject of impotence, I design to sub- mit for your examination a question as delicate as it is important. The disease about to be treated is but recently known ; it may, whatever be its nature, present itself every day to the practitioner; you will therefore understand how necssary it is to have all possi- ble information on this point, since for the patient it concerns an entire loss of health for years, and even death, and for the physi- cian cruel misapprehension, or, on the other hand, the complete cure of a disease apparently unconquerable. I shall, however, call things by their true names; the expose of facts will be conceived as far as possible in irreproachable terms, 606 Lecture on Impotence. [October, yet clinical instruction has its indelicate side, and I am speaking only to the professional, I will not disguise my ideas for the slen- der satisfaction of rendering my words a little more delicate. A seminal loss is an involuntary flow of semen, a passing out sperm without any erotic provocation, or at least without sufficient erotic provocation. An individual has an excremental mass of a certain volume accumulated in the large intestine ; he makes vio- lent efforts to eject it, and finally succeeds in overcoming the resistance of the sphincter. This mass pressed on the prostrate and ejaculatory conduits, it bore considerably upon the seminal vesicules, and at the moment of its ejection, it caused an emission of sperm. This comes under the cognizance of pathology for in the normal state, and even with those who are affected with obsti- nate constipation, these parts, by their elasticity, resist the difficult passage of hard faeces, without producing any such result. Another individual passes, in the first jet of urine, but especial- ly with the last drops, a thick, glairy, viscous fluid, which adheres sometimes to the meatus urinarius ; the consistence is characteristic, the odor sui generis, and microscopic observation reveals well formed and vivacious animalcule. These are two examples of seminal flow without erotic provocation. To produce ejaculation, there must be a previous act of greater or less duration ; for however strong be the desire of a continent young man, there ensues no seminal evacuation even when he is near the person who excites the desire. Voluptuous handling of the penis, and lascivious caresses, may occasion seminal issue, but there is not in that case sufficient erotic provocation. With men who are very reserved in the pleasures of love, noc- turnal pollution, the ordinary result of lascivious dreams, are, when they occur at long intervals, and when they leave after them no great feeling of weakness or discomforting symptom, a sign of health and virile power, and not of feebleness or disease. But if they succeed rapidly, several times a week for instance ; if the subject is left in a decided state of langor; if he has less ability for work ; in short, if he presents to a certain degree the general symp- toms which we are about to mention, health exists no longer, and disease has commenced. There also is there no sufficient erotic provocation. On introducing the virile member into the female genital organs, sume individuals ejaculate immediately, and very soon the erection ceases. Here again is an involuntary seminal flow, because there has not been due and sufficient excitement; the intromission of the penis ought to continue for a certain length of time. When- ever you know such a state of affairs, question and observe well the patient. Of these spermal issues during micturition and defecation, what may be the consequences ? Professor Lallemand, although some- what exaggerating the effects of these seminal losses, has not failed 1856.] Lecture on Impotence. 607 to throw much light upon the question. He regards involuntary flows of sperm as favoring the development of various nervous affections and mental alienations, and he is right; but his error consists in having singularly amplified the importance of this cause ; indeed he attributes to it the origin of a host of maladies. There is an aphorism which says, Omne animal post coitum triste. The same idea, more poetically expressed is found in the follow- ing line : Loeta venire Venus, tristis abire solet. It is a fact, that after coition man is generally fatigued and sad. If he repeat often the generative act, his body becomes weakened, his understanding more obtuse, and all his intellectual faculties less active. Almost immediately after copulation, the genital organ loses its rigidity, and it needs new excitement and a certain interval to reproduce an erection: there is then frigidity, but relative frigidity, since a quarter of an hour previous vir erat potens. From this point to impotence there is but a single step, for impotence is but contin- ued frigidity. Even when the seminal losses are not accompanied by the cynic spasm, they are not the less an active cause of exhaustion and lan- gor. With the woman, who experiences the spasm quite as strongly, or even more so than the man, it may be felt an almost unlimited number of times a day without any appreciable effect upon the general condition. It is not that, then, but the involun- tary emission itself, which produces the emaciating effect. An additional proof is that in nocturnal pollutions there is no cynic spasms ; and yet, when often repeated, they end by depriving the individual of reproductive power. Let us now examine what constitutes the difference between fri- gidity and infecundity. And first, listen to the relation of this authentic fact: At the beginning of the reign of Louis XIV., a certain lady sued her husband for a divorce, accusing him of being unable to cohabit. In the presence of matrons, congressus juridicus, the cou- ple attempted the conjugal act, and the husband experienced the shame of a defeat. They were divorced. The same man, accused and convicted of impotence, married again, and had seven chil- dren. This anecdote may, I know, give rise to various pleasant- ries, and yet there may be deduced from it a very serious fact, namely, that an individual reputed impotent may have more pow- er than he himself thinks, if in spite of an incomplete erection and precipitate emission at the moment of introducing the penis, his sperm possesses fecundating power. Now, the matrons declared this husband impotent because of his apparent slight physical readiness for coition ; nevertheless, as circumstances afterwards proved, he was sufficiently puissant to increase his family. Other individuals, on the contrary, very amorous and very excitable with women, showing themselves ex- ceedingly vigorous, often have no children at all,. 608 Lecture on Impotence. [October, Patients affected by seminal losses have a sad and morose clis- position ; they suffer from headaches, vertigo, weakness of sight, and often fall into a habitual state of hypochondriacal melancho- ly. Besides, they are often affected with paralysis, and especially with paraplegia and various nervous disorders, but less frequently indeed, than M. Lallemand has asserted. Which is the organ that secretes the seminal fluid ? The testi- cle, you answer, and you may think the question a singular one. But it is not the testicle. Tie up the deferent canal of the ramr that most amorous of animals, and you isolate the testicle complete- ly ; and yet the sexual connection takes place with the same ener- gy, and the emission is as abundant as before. Should a Menor- rhagia affect the testicle of a man, the epididymus becomes indu- rated, the origin of the deferent canal is closed, the same desires and venereal aptitudes exist, the emission takes place in equal quantity, but the individual remains unfruitful, and the ram just mentioned is no less so. Hence we conclude that the seminal vesicles secrete the spermatic liquid, and the testicles secrete the animalcuhe. The labors of M. Gosselin have perfectly elucidated this important point of physiological anatomy. We may now comprehend how young and strong men, athletic and vigorous in the duties of love, often accuse their wives of sterility ; most of the latter are so fruitful, that should they burden their conscience with a breach of conjugal faith, they would readily conceive. The husbands are affected with indurated epididymis; they are unfruitful, and thus are the cause of the sterility of their wives. Although the failing old man, who bows beneath the weight of years, and who has almost reached his century, may not have experienced a rigidity of the penis, nor have ejaculated for say forty years, yet he has still the deep voice of a man, and the an- gular feature of a male form. On the contrary, had he suffered castration at seventy years, his beard and hair would fall, his- voice would change and assume the tone of that of an old woman. The testicle was certainly of no service to him, yet it shows that organ marks and constitutes virility even with those who make no use of the virile attribute. Take one of the fowls castrated for the table, if one testicle should by accident be left in the abdomin- al cavity it will graft itself on the contiguous tissues, and the animal will remain a cock ; but the eggs of the hen will be unfer- tilized. In stomatitis the salivary glands secrete abundantly ; in an irri- tation of the neck of the bladder the kidneys do the same, and the quantity of urine expelled is notably increased ; in an intestinal inflammation the liver and the pancreas produce a more consider- able flow of bile and pancreatic fluid; in certain catarrhal affec- tions, the action of the nasal and ocular mucous membranes is manifestly stimulated. Well, in the irritation of the veru monta- num, of the prostrate mucous membrane, and of the entrance of 1856.] Lecture on Impotence. 609 the ejaculatory vessels, the same thing takes place ; there is an in- crease of secretion, and an abundant flow of the spermatic fluid. Professor Lallemand was of the opinion that in a given case of involuntary loss of semen there was always irritation of the veru montanuvi and of the prostatic mucous membrane. This explain- ed the spermatic flow. When urine escapes during the night from the bladder of a child, without the participation of the will, it is an evidence of what M. Bretonneau has noticed : that is, that the contractility of the bladder is more exalted than during the day, when the nrine was retained, and the child urinates in a continuous stream. In sleep there is a state of erethism of the bladder, a sort of te- nesmus of the vesical muscle, which contracts against the little liquid contained; hence the incontinence of urine. This takes place in the early part of the night, generally an hour or two after lying down. The same thing may occur with the seminal vesi- cles; an individual experiences in this region what the child does in the bladder: incontinence of the semen is analogous to inconti- nence of urine ; and where, in the one case, there is a sphincter and a bladder inert, in the other are inert seminal vesicles and ejaculatory vessels. Seminal losses, strangely misunderstood before the time of Lallemand, were empirically treated ; but in our day when this disease has assumed a position in the domain of pathology, it has been conscientiously studied. The following positions have been established : 1st. Seminal losses resulting from a chronic irritation of the prostate or of the prostatic portion of the urethra. 2dnly. Spasmodic seminal losses analogous to the nocturnal losses of urine. 3rdly. Passive seminal losses corresponding with the diurnal losses of urine in children. These divisions have been established because they appeared to be the expression of the facts observed, and also because they con- duct to therapeutic consequences of some importance. Lallemand from his point of view, thought that any medicament modifying the urethral irritation was capable of preventing the involuntary spermatic flows. He remarked that in a great number of cases the seminal loss followed a badly cured Menorrhagia, and that many men ended thus by becoming frigid and impuissant; and he believed that chronic phlegmasia of the urethral mucous mem- brane was the occasional cause of the affection under considera- tion. Notwithstanding the exaggerations contained in Lalle- mand's work, we must acknowledge that he could derive useful results from his treatment which consisted in cauterising by the aid of the consealed sound. When the cauterisation was ineffect- ive he had recourse to anti-blenorrhagic preparations, turpentine, copaiva, cubebs, and to tar injections into the bladder, &c; by 610 Lecture on Impotence. [October, these means the seminal losses were often cured, and nearly al- ways considerably modified. Lallemand, although not ignoring the fact that the involuntary seminal emission could be excited by other causes besides chronic urethral phlegmasia, was yet wrong in according to the latter a disproportionate degree of" influence. He did nothing for the spasms of the seminal vesicles, while it is necessary to act upon them either by internal medicated preparations or by interna) phy- sical means. Belladonna administered before going to bed, in doses of from one-sixth of a grain to one grain, constitutes a pow- erful and ever useful medicine in nocturnal urinary flows, and as the latter have a certain analogy with involuntary spermatic eva- cuations, it follows that the same remedy succeeds in a great number of cases. So far as mechanical means are concerned, their object should be to counteract the exaggerated contractility of the seminal vesicles, and to aid the resistance of the ejaculatory vessels. In 1825, at which time I was interne at the Maison Royale of Charenton, Dr. Bleynie, adjunct physician of the establishment, spoke to me of one of his patients affected with impotence, who, seduced by the deceptive advertisements on the fourth page of the newspapers, had consulted a quack who cured him by introducing into the anus a sort of plug of box-wood which he made him wear. It struck me to be some trumpery manoeuvre to excite the ex- hausted sense, or some lascivious resort like those of worn-out libertines in certain circumstances, and I took no more notice of it. Ten years later, in 1835, I had some little business with a young man twenty -six years of age, troubled with decided frigid- ity, and yet having an irresistible desire to marry. Seeing him plunged in profound melancholy, and learning that he seriously contemplated suicide, I sought in every possible way to relieve him. Then was recalled the remarkable cure mentioned by Dr. Bleynie. Immediately I contrived a kind of plug, and prescribed it to be worn in the anus, keeping it in position by means of ban- dages. Scarcely a fortnight had elapsed before several erections had appeared, and the seminal losses had become less frequent. My patient got married, and was fully competent to the discharge of the conjugal duty; he is living yet, and is by no means im- potent. I sought to understand the rationale of this remedy, and was soon convinced that the charlatan had employed a means, the true scope of which he was far from comprehending, like M. Jourdain, who made prose without knowing it. In fact the plug, pressing necessarily and immediately upon the prostrate and the ejaculato- ry vessels, hindered the spasmodic seminal losses. Since that time I have witnessed many patients affected in the same manner, and as I grow older I witness more of them, for one does not generally go to a young physician with a complaint re- garded as disgraceful, but rather to an old practitioner who is sup- 1856.] Lecture on Impotence. 611 posed to be more indulgent towards these cases. The same rem- edy has often been by me successfully used. Something after the fashion of the apparatus used to sustain hemorrhoids, I had prepared, an elastic band furnished with a metallic branch, very slight and elastic, at the end of which was fixed a truncated cone of ivory penetrating into the rectum and supported in front by two attached pieces connected with the band. This cone was arranged in a very solid manner : it did not incom- mode the wearer much because of the great elasticity of all its parts. Besides, if the anus became chafed, I covered the ivory with caoutchouc. Subsequently, I endeavored to improve the apparatus and to modify in some manner the form of the cone. M. Mathieu, a sur- gical instrument maker, then conceived a sort of plug shaped like a lengthened olive: this was a considerable improvement, but af- terwards M. Mathieu thought it possible to do without the band- age around the body, and to fix the plug or stopper without the assistance of bands. Hence he gave to the plug a sort of hour glass contraction, around which the sphincter ani closed strongly, and the large portion without kept the instrument in the proper position. An opening was made through its longest diameter which allowed the free exit of gas. The plug, retained in this manner in the rectum, presses upon the prostrate and on the sem- inal vesicles, and this very often suffices, after a week or two, to check involuntary spermatic discharges, to restore to an impotent man his former virile aptitudes, and to prevent uncomfortable accidents to the moral and intellectual faculties. I would recommend this little apparatus, not only in cases of involuntary seminal losses, but also for nocturnal incontinence of urine. By employing these means, I have often seen the bladder restored to its normal tone, and have witnessed the cure of one of the most inconvenient and unclean diseases. It is scarcely neces- sary to observe that this plug cannot be applied to girls. In their case, in incontinence of urine, it might perhaps be introduced into the vagina at the same time that a small plug was adjusted in the urinary meatus ; but you will readily perceive that you must re- sort to that only in the last extremity, when belladonna, and all other available therapeutic resources have failed ; for the deflora- tion of a young girl is always a serious thing, and a physician should assume that responsibility only when he has exhausted all other scientific means. I have frequently known my colleagues in consultations pre- scribe cold hip baths, but I always prescribed myself very hot ones. I tell my patients besides, " heat, to a temperature which the hand can scarcely bear, four or five pounds of fine sand in a dish ; tie it up tightly in a napkin and apply it to the anus, the perineum, the scrotum, and the penis ; keep it there a half an hour or so until cool, and do the same to-morrow on getting up." I do N. S. VOL. XII. NO. X. 39 612 Lecture on Impotence. [October,, not know a more energetic anti-phlogistic than caloric, nor a more severe irritant than cold. Put your left hand into warm water, and your right into cold water, the former will be chilly all day. while the latter will be warm. When heat is applied for any length of time to a particular part of the body it gives rise to a reaction. Thus sea-bathing is a powerful means of producing derivation towards the skin, and continued warm baths are potent agents in extinguishing its exaggerated sensibility. Physicians devoted ex- clusively to cutaneous affection, attack an eczema of the face by warm shower-baths repeated for two months. They put caloric in contact with the face, cold water causing eczema, which hydro- pathy proves conclusively. The action of caloric is coercive, an ti -phlogistic," the action of cold is phlogistic and fluxionary. This fact is conspicuously in- scribed on the records of hygiene. Have the cook, the pastry- cook, and the baker who pass several hours a day before ovens- heated to 160, red faces? While actually before the fire they may have, but do they afterwards ? Have the workmen who pour out melted ore, or who hammer red-hot iron a very high color? On the contrary, when away from the heat they are pale and sal- low. Fluxion succeeds defluction. Observe then that it is not in a contradictory spirit that I would substitute warm for cold, but because there are really strong mo- tives for so doing. In general, whenever I hear of any remedy,. I trouble myself very little as to the source whence it comes, I re- volve it about in my mind and endeavor to comprehend it. If it appears to me good and useful I apply it, and should it succeed, I recommend it. It matters little whether it comes from a quack or not if it is really worth anything. I may have for the originator the most profound contempt, but nevertheless I apply the idea for the good of my fellow-men. A very worthy physician, Dr. Lebatard, was very much sur- prised some time ago, to see all his patients troubled with sprains getting well under the treatment of a certain individual. He ob- tained information of the process used, and accordingly, putting it into practice, he kneaded or compressed the foot until the swelling entirely disappeared, and the patient was cured. M. Lebatard, being an honest practitioner, published the fact. This I call doing 1 a useful thing. Returning then to the use of caloric in the treatment of seminal losses,. I repeat that when this agent is applied for any length of time on a part of the body, it gives rise to a reaction. The sper- matic emissions may perhaps, under its influence, be augmented for the first and second night, but they afterwards rapidly dimin- ish and the erections become more and more firm. The compress- ing apparatus and caloric are then to be used conjointly with the means recommended by Professor Lallemand. 1856.] Suppurative Arthritis. 613 When the seminal losses are produced by relaxation, and you are assured that there exists no calculous affection, you must have recourse to cold baths and to a hydro4herapeutic regime. Thia state is diametrically opposed to the preceding, and it is not aston- ishing that an entirely different treatment should succeed. You may prescribe nux vomica internally, and apply the little com- pressing apparatus, etc. After very frequent spermatic losses, there may occur nervous disorders so serious as to endure even after the cure of the local affection, their proximate cause, Thia is an unfortunate complication, and you will have to consult those who have made these diseases these monomanias with hypocon- dria, and inclination to suicide, these paraplegias and general paralysis their special study. Should you devote your whole attention to the treatment of seminal losses, you would soon find yourself able to relieve nearly all, and even to cure the majority of cases. But be on your guard against those patients who are very rapidly cured, who set up too soon the cry of victory, and who entertain you about their recov- ered energies and their well tested prowess: for those who have once suffered from involuntary seminal discharges, alwa}rs run great risks, and if they are not careful, sooner or later may come the renewal of the infirmities which I have mentioned. In such case you will do well to make your patients take preventively the same medicine which may have succeeded at first, and to continue it for a fortnight two or three times a year. " Prudence" says the proverb, " is the mother of safety. [Charleston Med. Journal. Of the Possible Cure of Suppurative Arthritis with the Preservation of Mobility. By Dr. Hyppolite Blot, Chief of the Obstetric Clinic of the Faculty of Medicine of Paris. The object which I have proposed to myself to accomplish, is sufficiently indicated by the title of this essay. I wish to adduce facts, to prove what I have not seen mentioned in any, either of our classical treatises, or in monographs on the diseases of articu- lations, viz: that a termination of suppurative arthritis with the preservation of motion in the joints is, if not a common, yet at least a possible event. To demonstrate the correctness of what I have stated in relation to the opinion of surgeons upon the different modes of termination of suppurative arthritis, it will be sufficient to adduce a few passa-' ges from the principal authors that I have been able to consult in relation to this subject. Boyer and the surgeons who preceded him, do not describe at all the inflammations of the joints as distinct diseases; they include their history in that of white tumors, and in relation to these, they agree in stating that, when these affections are complicated with 614 Suppurative Arthritis. [October, purulent effusion into the joints, anchylosis is the most fortunate issue that can take place. To find these diseases separately considered, it is necessary to refer to treatises that are altogether modern. In the Dictionary of Medicine we find Velpeau stating that "the least that can happen, when suppuration occurs in such cases, is an irremediable anchylosis. In other cases he may be so fortunate as to find the discharge to cease, at least in part ; the general sym- pathies become quiet, the affection becomes purely local, permit- ting to the surgeon the possibilit}' of a complete removal f the disease by amputation, or resection of the articulation." In relation to articular ostitis, Sanson thus expresses himself: "Difficult to arrest, even in its incipient stage, it becomes almost impossible to check the disease when suppuration is established. We may then but very rarely hope for a cure, and that generally with an anchylosis of the bones." In the same work, (El. de Path. Med. Chirur., 4th Edit.,) in re- ference to traumatic arthritis, we read again : " When pus is formed in the interior of an articulation, the disease becomes much more' serious. Imprisoned in a capsule, the pus effects a change in the synovial sac, the cartilages become eroded, and terminates by evolving the spongy extremeties in destructive caries. Sometimes a point of the articular capsule is destroyed, and the pus burrow- ing in the cellular tissue forms often extensive sinuses in which it accumulates and becomes decomposed. The life of the patient is then doubly compromised, by the abundant suppuration and by the effect of its resorption; anchylosis is inevitable." M. Bonnet, in treating of the prognosis of arthritis, concludes by saying: "The gravity of those cases in which pus is generated in the articulations, is much greater than when it results simply in the formation of false membranes. The necessity of an amputation is then always to be apprehended ; and under the most favorable circumstances, if a large joint is affected, a year or two may be required to complete a cure, and then only at the expense of an an- chylosis.1,1 M. Begin, in treating of traumatic arthritis, concludes his article relative to the prognosis and termination of the disease, as follows: "In the rarest and most fortunate cases, the secretion of pus grad- ually abates; from all the parts surrounding the joint, from the synovial membrane as well as the cartilages, cellular and vascular granulations arise, which, coalescing, obliterate the cavity of the joint and cause a firm and solid adhesion of all the contiguous parts. The joint of the patient is then irremediably anchylosed.'1'1 . In the same work, (Diet, de Med. et de Chir. Prat.,) in speaking of rheumatismal arthritis, M. Roche says: "In some cases the synovial becomes inflamed and suppurates, the cartilages become eroded and ulcerated, the bones become softened and carious, and there is no resource but in amputation or in resection of the joint." 1856.] Suppurative Arthritis. 615 M. Vidal is no less explicit. " In all cases in which it becomes necessary to make a prognosis," says this author, "it should be given with much caution and reserve, for it is either due to an internal cause when it is complicated and will recur, or it is of a traumatic origin, in which case it becomes extremely grave; for if the patient is cured, it will only be at the expense of the functions of the joint." As to M. Nelaton, occupying a purely surgical point of view, and not having devoted a special article to the consideration of arthritis, he has not found it necessary to express an opinion upon the diverse modes of termination of this affection. In the Compendium of Surgery the following occurs relative to acute arthritis : " When it terminates by suppuration and the formation of an abscess in the joint, we have every thing to fear, and amputation may become necessary to save the life of the pa- tient." From all the citations that have been adduced, it is evident that authors are unanimous in the opinion that suppurative arthritis always presents an unhappy mode of termination, the patient sometimes succumbing from purulent infection, in others, amputa- tion above the joint or resection becomes necessary; and again, in others, more rare and perhaps more fortunate anchylosis occurs, and the patient is cured with loss of motion of the articulation. I will only add that, having interrogated most of our masters of surgery in reference to their having observed any other mode of termination than those above indicated, I have uniformly received a negative response. Besides, I have searched in vain for facts analogous to those which I shall report, iu the rich collection of cases published by Brodie upon this subject as well as in most of the leading French periodicals. It seems to me, therefore, interesting to report certain observa- tions made already some time since, which conclusively establish the fact that another and more fortunate mode of termination of suppurative arthritis than those before indicated, is possible ; a cure with preservation oftlie motion of the joint. These observations, although but three in number in the human species, added to analogous ones related by our colleague, M. H. Bouley, at the Society of Biology, as occurring in the equine spe- cies, will suffice to prove the possibility of the mode of termination we have designated. Future researches will determine in what proportion of cases of suppurative arthritis we may venture to hope for so happy an issue. One of these observations I owe to the kindness of M. Monod, who communicated to me the principal details of the case in 1848, during a conversation in reference to what I had myself seen. The second case was observed by myself in a patient introduced into the infimary of the Maternity of Paris, to which I was then 616 Suppurative ArOiritis. [October, attached in the capacity of intern. Both cases occurred in females soon after parturition. I will hereafter state what importance should be attached to this peculiarity. It is moreover to be well understood that we do not here treat of those multiple articular abscesses which are observed to occur in puerperal lever, but of mono-articular arthritis, freely developed and uncomplicated with any grave constitutional condition. In regard to the third case, it is borrowed from the clinics of Prof. Nelaton, who has kindly permitted me to treat of it in con- nection with the two preceding cases. This was a case of trauma- tic arthrisis of the knee, developed in a young man of eighteen years. Case 1. The female P., aged eighteen }^ears, a laborer, of good constitution and sanguine temperament, was born of healthy pa- rents and had herself never been sick. Menstruation commenced at sixteen years of age, and continued regularly until she became pregnant. During her entire pregnancy she suffered not the least illness. The 20th Feb., 1848, without appreciable cause, she gave birth to a male child weighing 2500 grammes,* at the eighth month of her pregnancy. A vertex presentation in the . The birth was natural after a labor of eighteen hours. No accident occurred during the day, but during the night a violent attack of colic oc- curred, for which she was conveyed to the Infirmary. Feb. 21st. Simple cataplasms with laudanum were sufficient to calm the pains. Feb. 23d. The abdominal pains had entirely ceased. She how- ever complained of pain in the right foot, which she compared to spasmodic pain. No marked local affection, however, could be detected by the most careful examination. Slight redness and tumefaction on a level with the internal malleolus was all that was observed ; but all movement of the tibio-tarsal articulation was very painful. Six leeches to the part tumefied; a bath, fol- lowed with a large linseed cataplasm. To secure the influence of position, the limb was elevated upon a cushion, and to avoid the pain of motion, the foot was fixed by bandages to a hoop that sustained the covering. General condition good; no appreciable fever. Feb. 24th. The patient was much relieved ; she suffers now but very slightly, when the limb is moved. Poultice renewed twice a day. Feb. 26th. The amelioration is not continued ; the tumefaction has increased, especially in the malleolar region ; fluctuation, how- ever, is not distinctly perceived. Treatment continued. March 3d. Since the 26th Feb. the tumefaction has continually * The gramme is about equal to 15 grains Troy. 1856.J Suppurative Arthritis. 617 augmented notwithstanding the means employed, and fluctuation in the malleolar region has become quite distinct. An incision, about an inch in length, was made on both sides of the joint, from which flowed a considerable quantity of laudable pus, mixed with strings of synovia, easily recognized by its yellowish color and syrupy consistence permitting it to be drawn out in long filaments. A soft probe introduced into the internal incision, penetrated more than two inches in depth, and passed without difficulty into the tibio-tarsal articulation. On withdrawing it, it was readily made to pass into several of the other tarsal joints by changing its direc- tion. "Without the joint the probe was arrested by fibrous bands. When the foot was moved, upon the leg it caused a sharp pain, and a rough friction sound, a sort of crepitation, could be distinctly heard and felt. This fact was confirmed by all the persons present at the time. Same position of the limb maintained, and the same treatment continued. March 4th. Very evident improvement; pain of the joint less severe; suppuration more abundant; proportion of synovia great- er than yesterday. Treatment continued. March 9th. Suppuration diminishes from day to day, the pus becoming more liquid and the proportion of synovia increasing. Pains none when the foot is not moved. Same treatment con- tinued. March 15th. Suppuration is completely arrested, and the pain has quite ceased. Even slight movements of the foot excite no pain. Same treatment continued. March 18th. the incisions are nearly closed; the tumefaction having ceased, the joint is restored to its normal volume; the pa- tient is able to move the foot without pain ; the friction sound and crepitation have also ceased. The cataplasm was replaced by a simple unguent. March 26th. The incisions being healed, and the movements painless, the joint may be considered as completely cured. March 29th. The articulation again, and without assignable cause swollen and painful, and the surface somewhat red. Cata- plasms. Elevation, March 30th. All the symptoms augmented, and apparently a slight fluctuation felt about the malleolus internus. An incision gives issue to nothing but blood. Treatment as before. March 31st. Patient improved ; suffers but slightly ; incision uniting. April 2d. Symptoms all disappeared. Treatment discontinued. Rest in bed. April 5th to 17th. During this period the patient gradually ac- quired the power of using the limb without inconvenience, and left the maternity without the slightest trace of anchylosis or rigidity. Case 2. Madame X., thirty -five years of age, of a nervous 618 Suppurative Arthritis. [October, temperament and good constitution, had a very fortunate first ac- couchment, with the exception of an unusual nervous prostration which lasted five or six hours. Lactation was quite normal. She became pregnant a second time, and now suffered much more than during her former pregnancy. A removal and the cares of a large household caused her during the last months to undergo great fatigue. Her accouchment, however, took place at term without accident, but shortly after that, singular nervous phenomena again occurred, accompanied this time with anguish and insomnia. The mammary secretion was but slight, and to- wards the fourth or fifth day after accouchment, simultaneously with the cessation of the nervous symptoms, a serous effusion oc- curred in both knee joints, which continued to increase notwith- standing every effort. At the end of a month, the effusion in the right knee was entirely absorbed, but the distention of the ligaments had been so great that the tibia was partially luxated outwards, and the motion of the articulation was considerably im- paired. In the left knee resorption of the fluid could not be obtained, and the joint remained greatly distended. Perfect rest with cau- terization were quite ineffectual. During the second month, an acute inflammation supervened without appreciable cause, termin- ating in suppuration ; a spontaneous and abundant discharge of pus soon occurred from the inferior and external part of the arti- culation. No serious constitutional symptoms occurred; several counter-openings were made at different points, and the healthy suppuration gradually diminished. About a month after the opening of the purulent abscess of the joint, the knee was cured. From that moment, the motion of the joint was gradually restored, but the power of flexion could never be carried beyond a right angle. 'o' CASE 3. Traumatic suppurative arthritis cured ivithout loss of mo- tion of the joint. A shawl-maker, eighteen years of age, punctured the left knee joint with the point of the scissors employed for shearing the shawls. At first he gave very little attention to the injury, bu1 after the eighth and tenth day, a considerable swelling of the joint occurred, and the patient solicited and obtained per- , mission to enter the Hospital St. Louis. The case presented all the signs of a penetrating wound of the knee. A very extensive, white, cedematous tumefaction had ta- ken place resembling that of phlegmasia alba dolens. The lips of the wound were flabby, whitish and cedematous. A sero-purulent liquid issued from the wound, increased by pressure upon differ- ent points of the articulation. Adopting the treatment extolled by M. Kleury, the entire joint was enveloped in a vesicating plaster. Notwithstanding this measure, the tumefaction remained unaba- 1856.] Suppurative Arthritis. 619 ted. The liquid flowing from the wound became more and more purulent, until it no longer contained any serum, and every day a considerable discharge from the original wound and from the counter-openings took place. Perfect rest in a wadded splint. Somewhat later, the discharge again became mure serous, which character augmented until it finally ceased. In six weeks the Wound was completely closed. The power of motion in a slight degree still existed. The difficulty at first existing became less and less, and at the end of three months, the patient presented himself to M. Nelaton, having completely recovered the motion of the joint. He now returned to nis former occupation of shawl- making. To the preceding cases I will add another, addressed to the So- ciety of Biology, by Prof. H. Bouley, of Alfort. Our colleague presented the t