SOUTHERN fttcMcai avto Surgical Imtttutl D BY HENRY F. CAMPBELL, A. M., M. !>.. U BFICIA1 iX" roiii-ArATlVi- IXATOXl IN TV. ItOBERT CAMPBELL, A. M., M. D., 1 IX THE Mi" ./, prends h bi n ou je U trouve. VOLUME XVII. X<>. X 1 1 . 1861. AUGUSTA, GEORGIA: DH. WILLIA PUBLISHER, 1861. 1402 SOUTHERN MEDICAL AND SURGICAL JOURNAL (sew series.) Wl. XVII. AUGUSTA, GEORGIA, JANUARY, Ml. NO. 1 ORIGINAL AND ECLECTIC. ARTICLE XXIV. FIRST UKPORT TO THE "COTTOX PLANTERS' CONVENTION" OF GEORGIA. On the Tert/iary Zdrru Formation of Georgia., by Joseph Jonsb, M. D., Professor of Chemistry in the Medical Col- lege of Georgia, and Chemist of the Cotton Planters' Association. (continued.) From these several analyses of the rocks from which these valuable wheat soils have been derived, it will be -1 First, Lime enters largely into their composition. The lime is found in combination with sulphuric acid, carbonic fcwid and phosphoric acid, and with chlorine. The sulphate of lime appears to he derived principally from the beds of Mini, which are found amongst the shales, ond. Magnesia is an important and constant con- stituent of the shales and limestones. These observa- tions in New York demonstrate that this element, when not in the caustic condition, but combined with carl. | other acids exerts beneficial influences upon cereals. Observations upon the influence of dolomites (lim< containing a large amount of carbonate of mag- in K- ' v :rc, Massachusetts, in England, and in other countries, f^M^istrate the cor of the conclusion Tertiary I /' [January, that magnesia saturated with carbonic acid gas is aol inju- rious to vegetation. Third. These rocks contain all the salts of soda and potassa, as well as those of lime and magnesia, necessary for vegetables and animals. Fourth. These rocks also contain organic matters which are supposed to have been derived from the plants and animals which lived at the period of the deposition of these rocks. According to the returns of the wheat crop of New York from 1*44 to 1845, the soils resulting from the decomposi- tion of the older and harder rocks, as those of the Taconic and Hudson and Mowhawk districts, yielded only from 8 to 9J bushels to the acre, whilst the soils of the western and central wheat district yielded on an average L5| bushels to the acre. The differences in the yield of the lands in these regions have been shown by Professor Emmons to be due to differ- ences in the physical and chemical constitution of the soil, and to differences of the chemical and physical constitution ot the rocks from which they have been derived. We might multiply examples to show that a deficiency n\ lime causes sterility, whilst its abundance promotes fer- tility. The following examples, however, in addition to those which we have just recorded, will be sufficient to place the question of the value of lime beyond all doubt or dispute. Long bland, if we except the drift upon its northern r that which faces the sound, lias been recovered from the ocean it is based upon a reef of rocks upon which Band has been washed up by the waxes, the soil is therefore ed almost entirely of washed sand, which is exceed- ingly porous, and contains hut little lime. Tt yields but pom- returns to the agriculturist, unless highly manured. The sea islands upon th >a8l o\' Georgia have a sim- stitutiou to Long Island, but they are in many cases e productive, on account o\ the vasl number of shells deposited upon them by the Indian-, and left upon the sur- ifter the last elevation of the Atlantic co 1861,] Of Georgia. 3 The soil from Schodack, New York, the analyses of which are recorded in the tahle, contains only a trace of lime and magnesia, is a very poor soil and is soon exhausted by culture. In Smitkfield, Rhode Island, a very luxuriant soil has resulted from the mixture of the detritus of hornblende rock and limestone. The effects of lime in rendering this soil fertile, is demonstrated by the fact that white and red clover, and other sweet grasses spring up upon it as they would do upon carefully limed soils.* The tertiary soils of Rhode Island, on the other hand, are wanting in vegetable matter and lime, and are correspondingly poor and easily exhausted. The Black Jack lands of York and Chester, South Caro- lina, which have resulted from the decomposition of porphry, and which contain, according to the analysis of Professor Tuomey, near three per cent, of carbonate of lime, and an appreciable amount of soda and potassa, prove, when pro- . perly drained and cultivated, to be equal to the best grain lauds in the State of South Carolina. From the disintegration of " rotten limestone " are pro- duced the richest prairie soils of the counties of Green, Sumpter and Marengo, in Alabama. In a still farther examination of these tables, the next fact which strikes our attention is : (b.) The proportion of Sand and Clay varies greatly in differ- ent soils. The texture of soils depends in great measure upon the proportions of sand and clay. Pure sand forms a soil without any tenacity. The effects of manures speedily vanish upon sandy soils. Pure clay forms a soil of the greatest tenacity, and a soil which is with difficulty drained. It would be important and interesting to consider these properties of soils in their relations to drainage, but we most defer the thorough discussion of this subject to the Jackson's Agricultural Report on Rhode Island, p. 128. 4 Tertiary Lime Formation [January, report upon the soils of Georgia, and confine our attention to their relations to lime. The texture of the soil has important bearings upon the action of lime, and determines in a great measure the amount which should be applied. And here again a knowledge of the chemical constitution of the rocks from which the soil has been derived is of great importance. The proportion of hard insoluble coarse particles in soils which are generally denominated sand, difter both in physical and chemical characters, according as the rocks from which they have been derived differ in these characters. Thus, we may have a coarse or a fine sand. Thus in the highland or primary districts of New York, the soil is coarse and the quantity of finely divided matter is evidently deficient, because derived from hard rocks which decompose slowly; whilst the soils derived from theTaconic rocks are finer than those of the Primary, and contain a greater proportion of finely divided matter, and yet they are inferior in fineness of division, from the soils of central and western New York, which have been derived from Sedementary rocks of a newer date, which arc still more rapidly decomposed. That texture alone will influence the fertility of a soil, might be illustrated by nume- rous examples; the following well established facts will, serve to show the effects of division: Soils composed almost entirely of coarse sand silex, allow the salts applied to enrich the soil to be washed out by the rains, and both their capillary power for fluids, and their absorbent power for gases are weak. The power of such soils to absorb moisture, and ammonia, and other leases from the soil, and to draw up by capillary attraction the water from beneath will be greatly increased by comminution or by adding sonic material which will absorb readily moisture, which will de- compose the coarse particles, and thus give tenacity to the soil. Now lime is precisely the substance which accom- plishes these effects. It has been calculated bv Professor Leslie that in a soil L861.] Of Georgia. o\* gravel, the pores of which are l-100th of an inch in diameter, water will ascend in these pores by capilliary attraction not more than four inches; whilst if the coarse sand have interstices oi only l-500th of an inch, water will rise through a bed of this sand sixteen inches ; and if the pores he still farther diminished to the l-10000th part of an inch, water will rise in such minute capillary tubes twenty- live and a half feet. The effect of the addition of lime to the soil is to diminish the size of its pores, and thus increase its power of capillary attraction. The effect of fine division upon gases is well shown in the case of spongy platinum if a solid piece of ordinary platinum be plunged in a stream of hydrogen gas no effect whatever will pe produced; whilst if finely divided pla- tinum be plunged in the hydrogen, it will condense the gas with such rapidity that it will become red hot, and inflame the gas almost instantaneously. In our own bodies the great changes of life take place in the delicate capillaries and in the minute blood corpuscles, not more than the l-3000th part of an inch in diameter. Division promotes contact, and close contact allows the play of those molecular forces which act only at infinitely small distances, and the greatest of these forces, which can alone be excited by close contact is chemical affinity, which generates electricity, and is the great force in all animal and vegetable existence. Chemical action is inseperable from activity upon our globe it is the great source of force in animals, and whether excited by the sun or by the secon- dary electrical forces generated in the bowels of the earth, it is the great force upon which vegetation absolutely de- pends. The following table will present a condensed view of many of the important physical relations of Lime to Soils : Tertiary Lime Formation [January, <4H o s s p p* 0 3Q pa 0 9 '~ ^3 c3 P >ri= U r-^- X 0) o d, fcJO J C S 222 IP Pi Hi B2* -/. 3 I~a: a S ) 1 0 GO b p o CQ E i - s il i i a B2fc fiaB'S* hh t. -. o o>j? T.l'4I-f l-l- - - ' = 5M J g-S.S^c-^ >, - r. - - 6u I I gS83$S98S ; z z jHO^oxet-e i : : BG -r -r S G i 10 1 rr _ . - i - z -ci-r'f-c s i -- r -I - . : -. ' : ". c)' e> od oo oo< CflOCOISflCI 4iflietiootoiain9H tie:- I 61.] Of Georgia. From a careful comparison of these results, the following conclusions, bearing more directly upon the employment of Calcareous manures in agriculture may be drawn : First: The tenacity of fine calcareous earth is less than one-tenth of that oi' sandy clay soil, less than one-twelfth of stiff clay soil, less than one-sixteenth of the tenacity of Btiff clay, and twenty times less than the tenacity of pure clay. The tenacity of calcareous earth is Less than one-four h the tenacity of arable land, and approaches more nearly to that of Humus, and of the richest and best garden earth. In wet weather stiff clay lands, o)i account of the rapid ity and extent with which they absorb, and the obstinacy with which they retain water, are soon converted into a stiff cohesive mud, which is worked with great trouble and dif- ficulty on account of the increased tenacity. In long con- tinued dry weather, stiff clay lands on account of the extent to which they contract and of the consequent increase of their tenacity, not only become so hard that they are with difficulty worked, but the roots of corn and cotton and of all vegetables penetrate the hard dry soil with great difficul- ty, and are greatly exposed and injured by the shrinking and cracking of the clay during drying. Not only theory and philosophical experiments performed in the Laboratory, but more especially practical agricultural experience, de- monstrate in the clearest and most indisputable manner, that the addition of marl and of calcareous manures gener- ally to clay soils, diminishes their tenacity in both wet and dry weather, counteracts the tendency to shrink and crack during dry weather, and thus renders them more easy of cultivation, and more suitable to sustain vegetation. oinl : Inasmuch as calcareous earth absorbs water far more rapidly and to a much greater extent, and retain.- it much more tenaciously than sandy -oils, and than even 1 arable land, it is evident that the addition of marls and calcareous manures generally to sandy lands will in crease the power of absorbing and of retaining water, and 8 Tertiary Lime Formation [January, thus remedy a most prominent and injurious defect in this class of soils. Here again the results of experiment and the deductions of reason, correspond with those of actual agricultural experience. Third: The Ilygrometic power of calcareous earth, is not only far greater than that of sand and sandy soils, but it is nearly twice as great as that of good arable land. The abil- ity to absorb moisture readily from the atmosphere is a most valuable property in its relations to the germination and development of the vegetable kingdom. The moisture in the atmosphere contains not only water, which enters so largely into the composition of all plants, but it also con- tains small quantities of Carbonic Acid gas, Ammonia, and in certain conditions of the atmosphere, Xitric Acid com- pounds which play an essential part in the economy of vege- tation. It is evident, therefore, that the addition of marls and of calcareous manures to sandy soils, and in fact to almost all arable lands, will increase their fertility, by in- creasing their power of absorbing water and valuable com- pounds from the atmosphere. Fourth : Calcareous earth absorbs heat less rapidly, and is far less subject to variations of temperature than sandy soils, and in fact, even than good arable soils. The rapidity with which soils allow their water to evapo- rate influences their temperature, for during the evaporation of the water the thousand degrees required to change the water to the state of vapor, is abstracted principally from the surface of the soil, upon which the evaporation is taking place. It is evident from this fact that soils which retain their moisture with tenacity, and consequently allow their water to escape by evaporation slowly, and at the same time absorb heat slowly and part with it cor- respondingly slowly, must necessarily possess a far more uniform temperature, and must as a necessary consequence be far more favorable to vegetation than soils which allow of rapid evaporation, and rapid aborption and radiation of )ieat. 1861.] 0/ Georgia. The addition of marls and of calcareous manures, gen- erally to sandy soils will render their temperature more uniform. A still farther comparison of the results embodied in the tables of the composition of the soils of various countries and States in Europe and America, leads to the observation that soils differ greatly in the proportion of organic matters. An accurate knowledge of the amounts of organic mat- ter in soils, is essential to the intelligent and successful ap- plication of calcaceous manures to land. The intelligent and successful application of calcaceous manures must depend upon a knowledge of the chemical relations of lime to the inorganic and organic constituents of the soils. (c) Chemical Relations of Lime to the Inorganic and Organic Constituents of Soils. The effects of lime upon the constituents of soils are not merely physical effects ; as marked and as important as are the physical effects of calcareous manures upon soils, the chemical effects are still more decided and important. l>y the following simple experiments, the planter may demonstrate to himself, that lime exerts chemical effects upon manures, soils and rocks. If lime be mixed with Peruvian Guano there will be pro- duced, almost immediately, a strong smell of Ammonia; the Hnie has displaced the Ammonia, and combined with the Carbonic Acid and other organic and inorganic acids which had formed with the Ammonia of the Guano, solid compounds; the same effect will be produced by the addi- tion of lime to stable or cow-pen manure. This effect of lime upon the compounds of Ammonia, is exceedingly in- teresting to the planter, as indicating the impropriety of ad- ding quick lime to manures which contain the valuable ingredient Ammonia. If we carefully wash out all the soluble matters from manure of any kind, and then add lime, we will obtain,, at- 10 Tertiary TArru Formation [January, ter allowing the mixture to remain for several hours, an ad- ditional amount of soluble matter. [f we place a definite quantity of soil upon a filter, and pass pure water through it until every trace of soluble mat- ter is removed, (which may be determined by evaporating the distilled water after its passage through the soil, in a clear watch glass or silver plate,) and then add to the soil lime, and allow the mixture to remain in a moist state for several days, and again pass distilled water through the mixture, we will obtain an additional portion of soluble matter, together with a portion of the lime which has been rendered soluble by chemical combination writh the ele- ments of the soil. [f we boil Felspar, one of the constituents of Granite, which contains the silicates of Potash and Alumina, with water, or even with acids, they will dissolve but little out of it, even after days and weeks ; if however, the Felspar be mixed with lime, the alkali Potash maybe readily dissolved out by means of acids, and even by water. These experiments clearly show that when lime is added to the soil it causes chemical changes in both the inorganic and the organic compounds of the soil. It is important that we should examine more closely the chemical effects of lime upon these twro great classes of compounds, which exist in all fertile soils. (d) Chemical effects of Lime upon the Inorganic Constituents of Soils. Every fertile soil is composed in large measure of insolu- ble Silicates, which are commonly called clay. The differ- ent varieties of clay, although possessing many properties in common, still differ in chemical constitution, and each variety, although apparently nothing but a plastic mass >! a homogeneous simple substance, is in reality composed of eral different substances. The varieties of clay will differ with the rocks from which they have been derived, and with the various changes through which they have passed. Thus kaolin or china clay may arise from the decomposition of 1861.] Of Georgia. 11 the same rock Felspar, under two different conditions; and the kaolin will be different in each case. When felspar, which consists of one atom of the silicate of potash, com- bined with two atoms of silicate of Alumina, decomposes in a wet or rainy atmosphere, the silicate of potash appear to be simply washed away by the water, and the resulting clay has the composition of three atoms of silica and two atoms of alumina; when however, the felspar decomposes in a moist, but drier atmosphere, the silicate of potash, instead of being entirely washed away, is first decomposed, the silicic acid combines with the silicate of alumina, and the potash escapes as a carbonate, and the clay resulting is composed of four atoms of silica and two of alumina. There are nnmerous other minerals which, during their decomposition, afford clay of various constitutions. To illustiate this important truth to the agriculturist, that clays are composed of a great variety of substances, we have selected as examples three specimens of clay, from one country (the Netherlands) taken from the Zuider- zee, and analyzed by E. H. Von Baumhauer. We shall, at a subsequent part of this report, present analyses of the Joint clays of Georgia, and not only illus- trate the propositions here announced, but also demonstrate their great value in agriculture. TABLE 30. CHEMICAL COMPOSITION OF CLAYS FROM THE ZUI- DERZEE. First. Second. Third. Insoluble Quartzose sand, wit h Alumina and Silica, - 57.646 51.706 55.372 Soluble Silica, - - 2.340 2.496 2.286 Alumina, - - 1.830 2.900 2.888 Peroxide of Iron, - - 9.039 10.305 11.864 Protoxide of Iron, - - 0.350 0.563 0.200 Protoxide of Manganese, - 0.288 0.3f>4 0.284 Lime, - - 4.092 5.096 2.480 Magnesia, - - 0.130 0.140 0.128 Pota - - 1.026 1.430 1.521 L2 Tertiary TJme Formation [January, First. Second. Third. Soda, - - - 1.972 2.069 1.937 Ammonia, - - - 0.060 0.078 0.075 Phosphoric Acid. - - - 0.46G 0.234 0.478 Sulphuric Acid, - - . 0.896 1.104 0.576 Carbonic Acid, - - - 6.085 6.940 4.775 Chlorine, - - - 1.240 .1.302 1.418 Ilumic Acid, - - - 2.798 3.991 3.428 Crenic Acid, - - - 0.771 0.730 0.037 Apoerenic Acid, - - - 0.107 0.160 0.152 Ilumic, Vegetable remains and Water chemically combined 5 3.324 7.700 9.348 Wax and Resin, - - - trace trace trace Loss, - - ~ 0.512 0.611 0.753 100.000 100.000 100.00 We are .at once impressed with the important fact that these clays contain all the elements necessary for the growth and development of plants and animals. We shall hereafter show that the Joint clay not only in like manner contains ail the elements necessary for the constitution of plants and animals, but also contains a much larger proportion of Phosphoric Acid, than theseclays; and has by the abundance of this fertilizing element rendered the soils with which it has been mixed exceedingly fertile and durable, and has through the vegetable kingdom exerted most marked and o o o important influences upon the physical structure ot^ the in- habitants. Xotwithstanding that many clays contain all the inor- ganic compounds necessary for the production of vegeta- bles, Btill, in almost every case, these compounds are insol- uble, andean be obtained by the plants growing in the soil, only in small quantities. Carefully conducted experiments have demonstrated con- clusively, not only that these inorganic salts are absolutely accessary to the existence of the higher spe* ies of plants QSed by man for food and clothing, but also that these salts 1861.] Of Georgia. 13 to be available to plants must be in a soluble condition. It is evident therefore, that whatever tends to decompose and render soluble the insoluble constituents of clays, will add to the fertility of the soil. This is precisely the effect accomplished by lime. By its action upon the inorganic constituents of the soil, the in- soluble silicates of the clay are decomposed, and alumina and magnesia, and the alkalies, potash and soda, are set free, and silica is rendered soluble. In adding lime to the insoluble silicates of the soil, the agriculturist acts in precisely the same manner that the chemist does when he wishes to separate the constituents of some insoluble and apparently undecomposable mineral as felspar. In both cases the silica is separated and the alka- lies liberated; and it is well known to agriculturists that these alkalies are of the greatest importance in the success- ful cultivation of corn and cotton, and in fact, of all plants. To substantiate the value of these alkalies combined with silicic acid, we need look no farther than to the valuable effects of the Green Sand of New Jersey, the chemical composition of which we have before given. See page 4(3, table 12. (e) Chemical effects of Lime upon the Organic Constituents of Soils. The organic matters existing in the soil have been derived from both the vegetable and the animal kingdoms. It is well known that these two kingdoms are mutually depen- dent the vegetable kingdom is a great laboratory, worked by the forces of the sun and fixed stars, in which materials are prepared and elaborated for the animal kingdom; whilst the animal kingdom' consumes these materials prepared by plants, and derives from their chemical changes precisely the same amount of force which was expended by the sun and fixed stars in the vegetable laboratory, it does not destroy this matter, but merely changes its form. The vegetable products, the starch, the sugar, and all the various compounds consumed by the animal kingdom, are 14 l\i !' i r >i L> me Formation [January, converted into various compounds and restored to the soil, and to the atmosphere. The principal portion restored to the atmosphere, the poisonous Carbonic acid gas constitutes an important element of the food of plants the same is true o{' the ammonia resulting from the decomposition of the feces and urine, and bodies of animals. It is admitted thai from the atmosphere, Carbonic acid gas, water, ammo- nia and the inorganic salts, furnished by the animal king- dom, all the various vegetable products may be formed. The vegetable kingdom in like manner with the animal kingdom, is liable to constant change, generation succeeds generation ; and as in the case of animals, the dead are ad- ded to the soil and atmosphere. The products of the de- composition of the vegetable kingdom which we call Hu- mus, have all existed in the atmosphere, at some former period in the form of gas, and will exist in some future period again in the atmosphere in the form of gas, and will again be sbsorbed by the vegetable kingdom, and under the influence of the heat and light of the sun these gases will again be decomposed, the elements combined with other elements so as to form solids, destined to go through the same round of changes. The great fact which we wish, by these well established facts, to illustrate and impress upon the minds of the plan- ters is, that the organic matters of the soil are in a state o\ change, and that this change is absolutely necessary to the existence of the vegetable and animal kingdoms. If the organic matters of the soil remain unchanged, vege- tation would go ow consuming the Carboni3 acid and Ammonia, and the nitrogen go o * U Eh -a -J 3 T3 :2 a = 2 c T3^ p hO <3 S |g KH3^ 9a o o jM is y S i> i- >. 3 > T3 T3 fcci c C5 Chloride of Sodium, Peroxide of Iron E0 r-H CO O 04' fc-OJ CO O - C tJ* CO . W a. QO 00 ^i CiCOSOiCO <3S CO r-i D i-tCOOt- -MMOOW i-h O i-H O O O 'HO i-J 04 rH O O CO Silica, NfflHHW00ON't< ~. coo-^ocnoO'ji :: r r-:^^xJi^-M i OQOiMWiOMOOirt 5 M "* -+ 90 *< . r- C4 0 US i-H 00 -00 0>MCH !M rH O O i-h o rH o o o o o Phosphoric Acid W050CWOOW10-*HN!0 Lime, s C r.soo^HOMJioo HMHMMWOlT)IKJl oj O oo co rf a. ' ; 3*. -* <4<.C4 r-4 rH ng( rH Tia rH Magnesia. Soda. Potash . oeo0(Neoflo5'*'>*rHcqec MCJlMJiHUOia C >^A4l M O 'J M .t- t- * l- co . 00 OO US 00 C CO 04 0C t- r~ Tf tK ooococoa z >. rH SH *-*OTto Chlorine x eo -.o * CC Lt Chloride of Potassium , Chloride of Sodium iOO ^ O h K O O '-O tJ< co >o eo Peroxide of Iron w.* :T ra. <^ : w. "*. ~ =! '(MNH .-< i .-i O O O t-I O i Silica. Sulphuric Acid. >> ~ ~ O i-l i-i O r* eo .-H Lime. CO*COrH HHOlOMt-lt SO Magnesia - r .- c ..-:^OL'5Ho>-fO09e'OHM'* OOhooonoiOO-* ?) c c; * 30 c t|i i>- Soda. t x -> x ec eo x co tc: WOSNON so OrlrlW^SHH Potash. cc eo 00 eo Ashes irf artificially dried plants; co o3 tj< -^ o* Ashes in 100 parts of crop as taken from the ground Ol ->1 "M ?1 "^ :.5-a . si ^ fcc5 J3 :** 2 33 '.2m TS 0 sc.2 - - ' o M>o o E O i ca m t. O O O a Mfe Q (-3 P? EC o ! a S a -a 5 J? eg o . M = 73 g o So 3 ~ c o o crj a ~. > ^ Chloride of Sodium CM -tJISMO >C 0OHO4N O Ut CO !N Tt< CO Peroxide of Iron ' ~ rji 1G CO i i 00 iO c> o" eo *n eo o ) 01 X i.". i- (> LO fO CO Tf H (OMHOCO t- ao n oi ua oo eOHHO^^er Silica C O Tit 5) H ffl O) 5 tt CO >! rn 1> * CO NXiOJ)NtO lO CM u-0 O CO OS t* ^t ^^ "^ ^ *^ *^ ^F i i r 1 1 i r < u i) o NCOtHWNC)^ s. Ci SmoiHhoo -* n -o c x t t- Sulphuric Acid T) 3 O ' M CO , .J3 "*J* CO 1 1 T ICffCO^T r ec - ic X 00 tJH X * oi CO . J3. eo >0 *- >c ec - .~ <;- o t? o t- o n oj QD a> o o x o o ic n r SoocOOOOiOO- ' iC N "J CO M CO t)I Phosphoric Acid p.-- * cc - ec so ?J ec ^XtOt-tOiOO o ^COt-XTj^Xi^^ Ph - CSt-Hf-H-^*-M t-asMcoc CO W CO IC N iC OQ0NH Oct totr. _ MO *- * t- t- a *C HHNr.t-Oi)( CO OC X lit lit xrj< m m * tj* ^ 1 < CO CO CO 'C lit OC O O) t- N *- CO OS - -o -^i co tj< a Jl CON/ X . ! oi '- t~ r- uo o fr- co o C* * CO C X * X iC C5 N CO Q -^ CO >0 C3 t-H r- 1 < i . to co *< o c -o -co - CO -O --T CO >1 t-- CO Soda eo as co '0oj> ooc X X =>oo Ashes in artificially dried = - I - . 93 <73 C^l 3^ CO ^ CO CO X CO Tji CO Plants * t}< CO CO CO CSI -r^rlOICO Ashes in I'M) parts of crop i- r ec us taken from the ground i-t i-i o a PL, o v. . / , - ! ! or ~E ' \b >. '" > l_ qj O O O O O q .O 73 "C "2 7T ~ - 2 a oSgoS C - o c 0 e a o &IT3*~ w-t ~ ~ rs ~ ~ "^ /.' "r o O o G - o75.- c - - . ?, o o o c o o -'- T3 -c 73 13 73 =M >\'~ E- p H < QQ Of Georgia. wOOOOP-Wuu ~1 CO - pq < Chloride of Sodium 1 :::::::::::? Peroxide of Iron ' -!'".=. ~. =. :t. = -'. -J ^ r 300003OOOt-iO Silica, * ! 2 ho ! 5 3 < 1 U H ?l cc :>! n l- M vt rs cc >o -- . --.- Sulphuric Acid : : "* :'. 1 ; o c o c c ~ o Phosphoric Acid X <* X ~ -. I K Z> - <4 cr i- ~ ~. -r. 7-1 ^r - -. ~ *- r ^r -r ,i- -. i- .- - X X C g ~ 7 g g taken from grotnd _; ^ ^ ^ ^ ,_',_',_;_;_; , puB[8a3 3 : : ui uMoxa c : rfiaq.u ajiq.u"^ -^ "S 'jMU*g pan - > ' ooob o o 24 Tertiary Lime tbrmation [January, Table 34 Proportion of Sulphur and Phosphorous in Plants and Grain, according to II. C. Sorby. Liebigs and Kopps, A. R. P. of 0. vol. 2. p. 12*. Sulphur and Phosphorous in 100 parts of substances, dried at 212. Poa palustrls and trlviaUs Lolium perenne Italian Rye Grass Trifollura pretense do (In Trifolium repens(very fine kit do do (ordinary do ) M go lupulina (very fine) Medicago Sativa do do do do tiva Kidnej Potatoes (solanum tuberosum). Top* of Kidney Potatoes Fruit of Kidney Potatoes American Potatoes Danous Carota, roots do do tops Beta Altesshna, roots do dc tops Delta do do do do tops Brasdca < Ueracca, (Swedish Turnip) do Oleifera, (Rap< . ;-, i Drumhead Cabbage. Wheal Plant entire, (Triticum Vulgare, after fiowerin do do do do Ear of the Wheat when the Grain was formed, but still milky Straw ofWheat when grain was formed. . 1.166 1.810 1.829 .107 .087 1.274 1.452 1.17 0 164 0.188 0.145 0.149 0.046 0.215 o.-Jl." (1.:.. -,7 I.05E 1.851 o.4il 15 0.075 II.. 'is- 0 0.860 0.4480.233 0.421 0.140 0.271 0.1. s: Ear of Wheat when ripe 'traw of Wheat when ripe Red Wheal Straw of Red Wheat White Wheal Straw of White Wheat Wheat 'harl' of Wheat Very fine Barley, (Hordeum distichum). traw of Barley Poor Barley riev Barley PI oat Plant (Avena Sativa) juat flowering. I 'at Planl in Flower Green Oats Straw of Green Oats B'ack Tartarian Oats Straw of Black Oats Si raw of White < )ats White Oats Straw of White < >ais Rye ears (Secale cereale)when young. straw of Rye R :ve. Bean 1'lant (vica faba) in flower 0.045 Beans 0.01 traw of Beans 0.14)- Peas I Pisium sativum 0.15 3traw i if Peas 0.214 Fine Hops (Humulus Lupulus) 0.1 Rind of Hops iO.OM 0.079 >,366 1.112 I. HO 0.262 0.498 0.087 0.066 L94 0.128 0.110 0.158 n.057 0. 0.160 0.258 0.600 0.206 0.076 0.574 Table 35. Ash of Yolk and White of Hen's Eggs Poleck.* Chloride of Potassium Chloride of Sodium Soda Potassa Lime Magnesia Sesquioxide of Iron Byarated Phosphoric Acid, Phosphoric Acid , Carbonic Acid Sulphuric Acid Silica Albumen. No. 1 [No. 2 41.29 9.16 28.04 2.36 1.74 1,60 0.44 4.83 11.60 0.49 +2,17 14.07 L6.09 1.15 2.79 3.17 0.55 3,79 11.52 1,32 2.04 Yolk, No. 1 No. 2 5.12 8.93 12.21 2.07 1.45 5.72 63.81 0.55 6.57 8.05 13.28 2.11 1,19 66.70 1.40 IE pp's annual report on i fee, for I860, vol. i, p. 879. 1861.] Of Georgia. 25 TABLE 36. ASHES OP MAN AND OTHER ANTMALS VERDEIL.* DoS. Ox. No.llNo.9 23.2421.11 L8.00 L4.40 6.60 8.76 0.47 0.59 1. _>:, 1.16 8.40 8.09 1.66 1.69 0.86 o.T' 9. IK) 8.80 6.571 6.49 Sheep. Pig. No. IN 0.2 Calf. Man. No.l 19.60 5.78 15.16 0.67 1.71 1-2.74 1.29 0.10 12.76 0.52 No.9 90.94 90.04 3.02 in. if. 4.:;s 1.08 9.S4 2.86 0.70 8.65 0.37 No.l 84.66 22.46 18.88 5.29 0.30 1.65 3. S3 L.88 1.00 S.70 7.09 No. 9 80.72 19.90 13.40 7.93 0.8-2 1.91 3.41 1.58 1.10 9.17 6.35 No.l 30.46 19.73 10.39 11.74 1.15 1.34 4.91 3.45 1.88 8.69 3.77 No. 2 86.18 23.40 10.41 9.81 1.19 1.21 3.76 2.97 1.60 7.80 3.57 No.l 87.60 24.49 2.03 12.10 0.99 1.70 7.48 1.87 1.68 8.06 1.48 No. 2 {Chlorine } Sodium 25 07 16.24 7.6-2 29 -21 l.'ai 1.71 10.61 1.68 1.20 9.10 0.61t 80.06 19.46 5.88 18.54 0.97 1.34 11.48 1.27 1.90 9.52 0.86 88.76 21.87 6.27 11.24 1 -16 1 64 Phosphoric Acid 9.74 1.36 1 85 8.68 Carbonic Acid 0.95 'Annual Chemical Pharmacy lxix vol. 3. 89. Leiblg and Kopp's Annual Report on Chemistry for 1849, Table 37 Composition of the Blood of Man and Animals in normal condition, in 100 parts, according to Poggiale.* Water Klxod Corpuscles Albumen Fibrin Fatty Matters Extractive Matters and Salts The Salts contain Chloride of Potassium and Sodium. Chloride of Calcium Phosphate of Soda Sulphate of Soda ite of Potasaa and Soda Phosphate of Lime \ide of Iron :ite and Sulphate of Lime... 5^ O o* a H B o 89 o 3 3 4 r5 2 V 3 779.9 767.6 796.1 788 2 835 6 798.0 831.0 798.0 812.0 785.0 130.1 143.0 1-23.1 1 26 . 2 92.6 10-2.0 91 .5 126.0 109.2 150.3 77.4 74.0 65.5 67 2 55.3 85.C 63.8 63.0 64.1 47.2 2.1 3.8 5.4 6.3 4.1 8.S 3,2 2.2 2.2 5.1 1.1 1.8 2.2 2.2 1.3 1.8 1.6 2.3 2.1 2.3 9.3 11.8 8.7 10.0 11.3 10.0 8.9 8.5 10.3 9.1 4.7 6.4 4.7 4.8 6.1 5.7 4 6 4.4 5.6 5.0 0.2 0 2 0 3 0 -2 0 3 0.2 0.3 0.1 1.4 1.7 0.8 0 8 1 1 1 0 0 8 0.8 0.9 0.8 0.4 0.4 0.6 o..", 0.8 0.6 0.6 0.5 0.7 0.4 0.5 0.6 0.4 0,9 0.4 0.? 0.4 0.3 0.5 0.4 0.7 0.7 0.5 1 0 0,8 0.7 0.6 0.5 0.7 1.2 1.3 1.5 1.8 1 4 1 1 1 1 1.0 1.5 1.2 0 8 o.a 0.4 0.2 0.4 0.3 0.2 0.3 0.1 0.2 0.3 0.1 0.2 0.2 0.2 0.3 0.2 0.4 0.1 0.2 0.2v 95.0 143.1 48.1 5.1 1.7 8.9 5.4 0.2 0.8 0.3 0.2 1.1 0.6 0.2 0.2 Annual report of the Progress of Chemistry, by Liebig and Kopp, vol. 2, 1847, 1848, p. 154. Table 38. Ash of Blood, according to Henneberg, 100 parts contaiu. Chloride of Potassium, Chloride of Sodium . . Soda Sesquioxide of Iron . . Lime Magnesia Blood Blood of of Fowls Turkey. 29.14 36.81 16.87 3.31 21.04 24.02 3.89 4.77 1,03 0.93 0.22 0.46 Phosphate of Soda and Potassa Phosphates of Lime, Magnesia and Iron. Sulphuric Acid Blood of Fowls 19.63 6.99 1.19 20,24 8.49 0.97 'Liebig and Kopp's annual report on Chemistry, vol. 2, p. 159. 26 lerUary Lime Formation [January, Table 39. Ash of Blood, according to Enderlin. In 100 parts of Ash. 0 r. i *" M - . _. >r; , m o a 2 B| - 7? t; A ?T3 7?- TTr; 7? = 3 K tna n K . ite ut" 1 r< >ii 11.07 . 8.70 :.:> 7.6 9.4 10.0 9.8 10.0 9.61 10.6 9.6 19 M | 13.26 J14.79 jl4.58 jlB.O J16.9 r iate of 6.04 8.47 13.2 12.1 13.4 17.8 7.!' 9.6 26.24 86.88 63.84 60.48 35.0 24.4 20.4 ' 34.9 28.0 m o Phosphate of Soda 6.1 8.11 7.19 26.4 31.3 17 1 (fl 4 Sulphal 2. 34 0.66 3.30 1.9 4.0 1.6 1.7 of Sodium 46.56 87.9 88.4 7.5 21.6 81.8 13.4 Silicate of . Silicate oiJPo- taBM 3.53 2.75 14.6 11 .4 Ash in 100 p:irts 1.519 1.28 1.23 1.18 1.20 1.29 1.55 L.08 0.84 1.11 *Loc. (Jit., vol. 2, pp. 15'J 160. The results embodied in these tables, not only sustain the proposition that lime is indispensable to all highly organized plants and animals, but they also establish nume- rous conclusions and principles of the greatest value to the agriculturist. We shall at present notice only those which have an immediate connexion with the commercial and agri- cultural relations of the tertiary lime formation of Georgia. (a). The proportion of lime varies in different plants and animals. (b). The proportion of lime varies in different parts of the same plant or animal. It follows from these two propositions : First, different crops abstract different quantities of lime from the soil, and if these crops be sent off the plantation, the loss of lime to the place will depend not merely upon the amount, but also upon the character of the produce. Second, if animals be raised tor market, the amount of lime abstracted from the soil through the vegetable king- dom, will depend upon the mode in which they are pre- pared lor the market. If they he driven oil' in the living condition, all the lime which they have abstracted from the soil 'will be losl to the place. If they be killed upon the place, quite a large proportion of the valuable salts which 1861.] Of Georgia. 27 they have abstracted from the soil will be restored in the form of blood. If they be consumed upon the place, the greatest proportion of the lime which they have abstracted from the soil will be found in the bones. Third, as animals, whether carnivorous, herbivorous, or graminivorous, subsist ultimately upon the vegetable king- dom ; and as the salts which they derive from the soil through the vegetable kingdom, are thrown oft' in the urine and faeces, it is evident that the lime will be transported in the bodies of the animals from one part of the place to the other, and will accumulate principally at the stables, cow- pens, and the habitations of man. (c). The proportion of phosphoric acid and of phosphate of lime, varies in different plants and animals, and also varies in different parts of the same plant or animal ; and hence different crops and animals abstract different quanti- ties of phosphorous and phosphate of lime from the soil. (d). Lime and phosphoric acid, although entering largely into the composition of plants and animals, are by no means the only inorganic elements necessary for the development and preservation of the animal and vegetable kingdoms. The salts of soda, potassa, magnesia and iron are equally essential to the perfection of plants and animals, and, as in the case of lime and phosphoric acid, they vary in amount in different plants and animals, and in different parts of the same plant or animal ; and hence different crops and ani_ mala abstract different quantities of these salts from the soil. (e). The quantity and character of the inorganic salts, although varying within certain limits, are still remarkably uniform in the same class of plants and animals. We have selected in these tables, to demonstrate this important agri- cultural fact (that each class of plants and animals must have a definite amount of inorganic salts of a definite con- stitution), numerous analyses of the same plant by different ob-ervers. It follows from this that the farmer can calculate not only the amounts, but also the character of the salts annu- ally removed from his lands. 28 lertiary Lime Formation [January, Tims in the following crops the amounts of ash in the right hand column would be removed from each acre pro- ducing the amount of produce to the acre, assumed in the table : Table W. Weight of crop per acre in lbs. A si i es per As gath- ered. Dried at 212. acre in lbs. Indian Corn Grain " Stalks, leavefe and fod- der "Wheat Grain 2250, 9000. 1000. 2000. 1450. 1500. 2200, 3500 2000. 8000. 900. 1900. 1300. 4300. 2000. 3200. 750. 550. 2700. 27ilO. 3000. 1000. 12. 288. is. u Straw Rye Grain 76, 29. Straw. 236. ( lata Grain 64. Straw 241 Tobacco Loaves son. 600. 3000. 3000. 9000. 3000. 108. Stalks Red Clover Hay 50. 236. Timothy Hay Potatoes Tubers Tops 153. 124. 150. Table 41. Table illustrating the proportions of the various inorganic matters, abstracted from the soil by 1,000 pounds of various kinds of produce. o i /. 1 5 a \ - > c 3 s "2. c 3. i. : /. ^ ft NAMK OF CROP. 9 9 : c -> 9- ~. ; ." : B lbs. Lbs. lbs. Lbs. lbs. lbs. lbs. lbT lbs. lbs. 0.40 Lbs. 0JL0 lbs. A sh of Wheat-Grain -.1 ?.r> 1 -til 0.96 0.90 0.86 4.00 o..M 11.77 " " Straw it 20 :.v 0..-7 0.80 85.18 Ash of Barley Grain 3 7" 2.90 1.80 Irur 2.10 0.19 28.49 Straw 5.54 o.T,; 1.46 0.11 O.'JO 1.1* L.60 ".7o 53 49 Ash of Oata Grain 6 . -'.7 0.14 19.78 0.10 38 80 Straw o OS 0.22 0.06 0.0-2 o OS o 7:' 0.12 ^.or. Asli of Rye Grain r, 83 1 2S 1.78 0.24 0.4-J L.64 0.46 ] 09 10.40 Straw 0.11 1.78 0.12 0.25 ::.:<: 1.7i 0.51 0.17 37.93 Ash Of] 4.15 B.16 1.68 1 . 34 O.K.) 2.93 o.U 01.36 " '" >tr:iw If. ,v, t; 24 o.ot 2 26 0.80 1.31 Aab of Field Pea -Seed 6.10 0.30 0.10 4.10 O..V 1.90 0 88 24.64 Straw S 85 .... 27.31 0.60 0 07 9.98 2. i" II (H 49.71 Ash of Vetch -8eed 6.22 L.t year, 8 in the second, 5 in the third, 1 after the third year, m2 remained living. In the Birth series the author shows that where the lead affection was Less marked there was a corresponding dimi- nution of the Injurious effect upon the product el' conception. 1861.] Kyi:. /. v 3 on 'Jun 88 ARTICLE II. ires on Tumors and Outgrowths of the Cervix Uteri, By Joseph A. Eve, M. D., Professor of Obstetrics and Dis- eases of Women and Children in the Medical College of Georgia. Lecture First Uteeine Polypi. Gentlemen: The subject of our present lecture will be Tumors and Outgrowths of the Cervix Uteri. If time would permit, we would prefer to treat of these affections in reference to the uterus generally, body and fundus as well as the cervix, but that would require a series of many lector At present, our attention will be restricted to those of the cervix, because they most frequently occur in practice, are most accessible to investigation and most amenable to treatment. The most useful and natural classification is into pedi- culatcd and sessile simple and malignant. Another di- vision might be instituted into those which arise externally and those which, originating in the body of the uterus, or in the cervical canal, either grow downwards into the va- gina, or becoming developed internally, are afterwards, by the contractions of the uterus, expelled into the vagina. We will, in the first place, call your attention to non- malignant, pediculated tumors, generally designated polypi from having a pedicle or footstalk, by which they are at- tached to some portion of the internal surface of the ute- rus. The term polypus is derived from two Greek words, Polus and Pous. Strictly speaking, it does not apply to the tumors in question, as they very rarely have more than one origin; although it is said one polypus has been known to have two pedicles, and on the contrary, two polypi have .filiated from one pedicle. They are called polypi from a supposed resemblance to the animal called polypus. Dr. T. S. Lee's definition of a polypus is a tumor growing from the internal surface of the uterus, attached to it by a stalk, and usually having a pyriform shape ; it is smooth, hard 84 Eve. Lectures on [January, and insensible, and gives rise to violent and frequent hem- orrhaj Causes. The causes of polypi are so obscure that we will not waste time with any discussion of the subject. They arc found at all ages, and under all circumstances, from early childhood to advanced age ; they are mostfre- quenl during the reproductive period, but rather more fre- quently, it is thought by some, in the unmarried than the married. I have found them Tnore frequently in married women and widows. Pathology. Our limits will not allow us to say much of the pathology of polypi. There are several varieties of polypoid tumors ; but there are three principal species which include much the larger portion of all polypi: the glandular, the cellular, and the fibrous. This is the divis- ion made by Dr. Churchhill, in his excellent work on dis- eases of women. We may occasionally meet with a case that may not conform strictly to the description of either of these species, but I believe they are very rare, such, at least, is the result of my own experience. i^t. The glandular polypi are enlarged Nabothian glands in the cervical canal. They may be found single, or two or more may exist together ; they are generally about the size of small grapes, attached by small and short pedicles ; they are usually of the color and firmness of glands ; it is -aid they sometimes contain some mucilaginous fluid. Some very small polypi about this location are found to consist altogether of mucous membrane, others of some- what larger size, consist of mucous membrane with the ad- dition of cellular tissue. I'd. The cellular polypus is the least frequent. I only remember to have met with two cases. They are said to appear singly or in clusters. The two which occurred in my practice were single. They bear some resemblance to the polypi of the nose ; they are described as of a violet or vellow color ; the two met with were not unlike a large oys- ter in color and consistence : their attachment to the ute- 1861.] Tumors^ 35 rua was exceedingly slight. I will refer to them again when detailing cases of each species. 8d. The fibrous polypi are by far the most common. They resemble fibrous tumors in the body of the uterus and other parts of the system. They are generally hard, but vary in consistence and density ; there will sometimes be a difference in different parts of the same polypus. It is said they arc sometimes hollow, and contain a fluid; such instances, however, I have never seen ; they are also said, in some rare cases, to contain hair and other substances. The same polypus, in different stages or periods of develop- ment, will be of different degrees of density ; from being very soft, it may become harder progressively, until it shall have assumed an osseous or calcareous hardness. They are, at least generally, covered bv the mucous membrane of the uterus. The connection with the uterus is, in some cases, by fibrous tissue extending into, or continuous with, the proper substance of that organ ; in others it consists simply of mucous membrane and cellular tissue. Except in rare instances, polypi are insensible ; I have not known an exception. I do not, however, doubt the ex- istence of such cases. 'Insensibility lias been consider- ed a means of diagnosis between a polypus and an inverted uretus, but it is not absolute, as polypi may possess sensi- bility. When this is the case they doubtless have an en- velope of uterine fibres ; in some instances this covering only extends to the pedicle, and then, although the body of the tumor may be insensible, the application of a ligature causes great pain. Their shape is usually ovoid or pyri- form, but it may be modified by the uterus or vagina, in which it is contained. They are of all sizes, from that of a pea to a child's head, and sometimes much larger. Fibrous polypi generally are found single, but there may be two or more, and after the removal oi one, another may descend into the cervix, or through it into the vagina. When a polypus has a pedicle continuous with the fibrous or muscular coat of the uterus, it is doubtless an outgrowth Eye. Lectures on [January, from the internal surface of the cervical canal, body or fundus of the uterus. But when it is merely attached by mucous membrane alone, or with the addition of some cel- lular tissue, it is most unquestionably a fibrous tumor which, originating in the walls of the uterus, has been enucleated therefrom into its cavity, and by its active contractions ex- pelled through the cervical canal into the vagina. This variety of fibrous polypus, I believe, occurs as often as that with a fibrous pedicle, if not oftener. These enu- cleated fibrous tumors have very short pedicles, are held very closely to the surface to which they are attached, and with difficulty expelled from the cavity of the uterus ; they frequently remain a long time partially expelled and require to be removed by passing the ligature, scissors, or polyptome, within the uterus. When separated, the tumor is generally more globular and has no neck or pedicle; and the portion by which it was attached to the uterus is only known by being denuded of mucous membrane ; whereas, the other variety is more pyriform and has a portion of its fibrous pedicle remaining. The uterine portion of the pedi- cle always sloughs off. It never has, I believe, been known to grow again. The polypus with fibrous pedicle is said to be generally denser than the enucleated fibrous tumor, and denser than the uterine walls with which it appears identical, with the addition of some cellular tissue ; this is, however, not al- w ays the case. These polypi, when developed in the ure- tus, are more easily expelled by its contractions into th vagina, and sometimes even through the vulva, as I have known in a remarkable cas-, which shall he related at the proper time. It is said the pedicle sometimes gives way, and the poly- pus thus becomes spontaneously detached. T have never known an instance of this kind, but consider it quite pro- bable, as I have known cases, in which the pedicles, wheth- onsistiug of fibrous tissue or mucous membrane, were wry slight, and easily divided, sometimes being ruptured 1861.] Tumors, by tractions made on the polypus, for the purpose of excis- ion. The spontaneous separation of polypi may he ac- counted for in various ways. The neck of the uterus may act as a ligature on the pedicle, suspend the circulation, and thus cause it to slough off; inflammation may produce the same result, or the weight of a large polypus may possibly hreak the pedicle, when very small. It is said by Dr. Lee, that -polypoid tumors may uuder- .11 the effects of inflammation." though "very rarely." "An abscess," he says, * -may he formed" in their substance and produce great discharge; ulcerations may arise in their surface, sloughings may occur, and even cancerous degen- eration may commence." Dr. Churchhill says "they are seldom attacked by inflammation or ulceration, and they never degenerate into malignant disease." While I concur with Dr. Churehhill in this opinion, I am ready to admit, with Dr. Lee, that sometimes "the pressure of the foreign body in the mucous canal excites a profuse and foeted pur- ulent discharge, under which circumstances, it has been mistaken for malignant disease," a mistake I once made self in consultation. This case will be stated at the close of the next lecture. The detention of clots in the vagina may also produce the same effect, and lead to the same error in diagno:-: Symptoms. The principal and most constant symptoms of Polypi are hemorrhage and leucorrhsea. But as these depend on so many other causes, they cannot be considered as diagnostic. The first indication is generally monorrhagia, which, af- ter a time, becomes usually very frequent, irregular and so profuse as to constitute alarming hemorrhages. There i-. generally more or less leucorrhoa, in the absence of the sanguine discharge. These losses of blood are attend- ed by their ordinary consequences, pallor of the face, orde- ma, disorder of the digestive organs and all the symptoms attendant on anemia. Hemorrhage is one of the most common symptoms attendant on polypi, whether con- 38 Eve, J Art arc* on [January, tained in the uterus or the vagina. It is also veiy frequent- ly present in the cases of fibrous tumors embedded in the uterine walls ; and there are some cases wherein there is no hemorrhage, at least for a long time, after the polypi have commenced t<> grow. Levrel and sonic of the older authors believed that there was no hemorrhage attendant on polypi, while contained within the uterus, but they had evidently mistaken the ex- ception tor the rule. I have, however, known at least one remarkable instance, in which there was no material hemor- rhage, until after the polypus was expelled into the vagina. When there is little or no hemorrhage, there is generally more leucorrhceal discharge. There is often as much, and sometimes very much more bleeding from a very small than a large polypus. This is positive proof that the bleeding is not always or altogether from the polypus ; for if so, it ought to be in proportion to its size. Polypi, doubtless, induce a very vascular condition of the uterus in the vicinity of their origin a congestion and de- termination of blood to that part, similar to what occurs at the time of menstruation. And this, I verily believe, is at least the principal source of the hemorrhage, although it may sometimes take place from the polypus or its mucous covering. Formerly, I sup- posed the bleeding was lrom the polypus itself, because when the polypus is removed or ligated, the bleeding ceases, but this results from the fact that when the polypus is removed, or its life destroyed by ligation, it no longer ex- cites that irritation which causes an afflux of blood to the uterus. They often cause more hemorrhage, while contain- ed in the uterus than after their expulsion into the vagina, an unanswerable proof that it depends on the irritation while internal: for it' the hemorrhage was mainly, or altogether from the polypus itself, it ought to be trained, while compressed by the uterus and much freer 1861.] lumors,c.f 39 after the compression is removed by its expulsion into the vagina. After fair and ample discussion of the subject, Dr. Lee arrives at the conclusion, "that the hemorrhage arising, iu the- may he attributed to the very vascular state of the mucous membrane, at the insertion of the polypus with the uterus: that the veins of the parts are the principle sources of bleeding, and when the mucous membrane is absorbed, the vascular net-work which envelopes these growths may add materially to the result. Even when the mucous membrance is uninjured, this envelope may mate- rially increase its vascularity."* Diagnosis. A vaginal examination is essential to diag- nosis. But when the polypus is contained within the ute- rus, a digital and eve 1 a specular examination will often throw little or no light on the subject. The uterus will feel larger and heavier, but to determine the cause of the increased size and weight will require further investigation. The speculum, especially with the aid of the speculum for- ceps to open the os, will sometimes reveal the existence of small polypi in the cervical canal, which the finger had failed to detect, or to afford a satisfactory idea of their form, size, cVe. When the polypus is in the cavity ot the womb, and the cervical canal not patulous, these means are totally inadequate : and a certain diagnosis would be impossible, were it not for other methods of exploration, for which the profession is indebted to the genius and enterprise of Prof. Simpson, of Edinburgh. I have reference to the uterine sound and the dilatation of the canal of the cervix by sponge tents. But a consideration of these valuable means of diagnosis must be deferred to another lecture, as we are now concerned with affections of the cervix, not of the body of the uterus. After the polypus has descended into the vagina, the di- aterinetu] - 4-1. 40 Eve. Lectures on [January, agnosia is genera1];: easily enough made out by a vaginal examination. J)r. T. Salford Lee says "when a polypus is found in the vagina, it is known by its being a smooth, bard, and generally an insensible tumor. This last char- acter, however, does not apply to all eases. When the poly- pus is form:",] by a tumor of the uterus, it may possess great sensibility. This is greater when the pedicle is thick, and becomes very great when a "muscular layer of the uterus covers the growth." If a polypus is attached by its pedicle to any portion of the body or fundus, the mouth of the ute- rus will form a soft ring all around the pedicle. If attach- ed to the cervix, the linger cannot pass all around the pedi- cle. If attached to the os itself, the pedicle does not enter the uterus at all, but the portion of the lip from which it arises seems to extend into the pedicle. We cannot conceive how a polypus in the vagina can possibly be mistaken for pregnancy, but an abortion slowly taking place might, by an inexperienced person, be mis- taken for a polypus ; thus if the membranes were contain- ing a firm clot of blood, or some round portion of the foetus, as the head, &c, were to protrude and remain some time stationary, without a knowledge or suspicion of the exis- tence of pregnancy, such a presentation would not appear very unlike a polypus. There might possibly arise some difficulty in distinguishing between pregnancy and an inter- nal polypus, but that does not appertain to our present sub- ject. The absence of all the signs of hernia would distin- guish a polypus from this affection. A vaginal hernia, too, I believe, is extremely rare. Vaginal eystoccle or prolapsus of the bladder into the vagina, or through the vulva, is of much more frequent oc- currence than vaginal hernia of the intestines. I have known Buch an error, but the diagnosis is easily determined by tin' variations in the position and size of the tumor, be- coming large and protruding through the vulva when dis- temled with urine ; again becoming small and receding after micturition, by its softness and elasticity, and by its 1861.] Tumors, $c. 41 being covered by the mucous membrane of the vagina. But if any doubt were to remain, it could be readily re- moved by the catheter, which, instead of passing as usual upwards behind the symphysis pubis, would descend into the tumor and cause it to disappear, by evacuating its con- tents It will be extremely difficult, sometimes, to distin- guish polypi from certain malignant polypoid outgrowths of the uterus, especially when the former arc in a state of ul- lccration. In general the absence of the peculiar symp- toms of malignant disease will suffice, but in some instan- ces, so many of those phenomena are present, that the dis- tinction can only be made by the microscope, determining the presence or absence of cancer cells. A polypus may be distinguished from a cauliflower ex- crescence by its greater smoothness and density, and gen- erally bv not bleeding: when examined by the finder ; but if one were mistaken for the other, it would not be important, as removal in either case would be proper. In cauliflower excrescence, however, no portion of the pedicle ought to be left, as it would be likely to grow again, and sometimes, at least, it assumes a malignant form. Prolapsus and procidentia uteri and the different flexions and versions, except inversion, could not, we think, be easily mistaken for polypi, for if a digital examination were to leave a doubt, it would certainly be dispelled by inspection if external, or by the speculum if m the vagina. Between polypus and inversion, the history of the case will, in most cases, decide, especially when of recent or sudden occurrence ; but when the case has come on slowly and imperceptibly, and has become chronic, and no reliable historv can be obtained, the diagnosis will sometimes be extremely difficult. A polypus is generally smooth and in- sensible, whereas the inverted uterus is rough and very sen- sitive, but as we have already said some polypi possess sensibility. If the finger fail to decide between polypus and inversion, the point may be determined satisfactorily by the uterine sound which, if it be polypus, would pass by the Eve. Lectures on [January, tumor, through the os uteri, the usual length of 2$ inches or more ; but if inversion, it could not enter the os at all, and could pass very lijtle way into the vagina. It' the question were to arise soon after delivery, the ab- sence <>r presence of the uterine glohe in the hypogastrum would he strong proof for or against inversion ; besides the symptoms of inversion occurring at such a time are usually well marked, and most decided, sudden collapse, severe pain, hemorrhage, l>;c. In inversion, if a male catheter he introduced into the bladder and the end turned downwards. it might be felt by a finger introduced high up in the rec- tum, but could not be felt if the body of the uterus were in its proper place, intervening between the extremity of the catheter in the bladder and the finger in the rectum. A polypus and inversion may exist together, the former being the determining cause of the latter, less perhaps by its weight, than by exciting the uterus to stong and long continued contractions for its expulsion. The polypus ovght fo be removed as quickly and easily as possible, and means promptly adopted to correct the inversion if practi- cable. Other methods are suggested by authors to determine the diagnosis between a polypus and an inverted uterus, but as they are uncertain and unreliable, we will pass them by. There are some polypi, which, though internal, occasion- ally protrude, and are therefore sometimes perceptible and at other times not discoverable to the sight or touch. The gnosis in such a case might require repeated examina- tions. This ought to make us guarded in our opinions in 3 wherein although the symptoms indicate a polypus, ii- presence cannot be readily detected. Tiic principal danger to be apprehended from polypi de- pends immediately, or remotely, ARTICLE III. Laudanum an Antidote to Starnmonium Poisoning. By A. G. Emorst, M. D., of Roanoke, Ala. Was called, on the loth of October, at night, to a mulatto boy, aged rive years, who was supposed by runner to be having fits. After my arrival I learned that, in the evening, an older negro had given the boy a handful of the shelled seed of Strammonium to play with, as he said, thinking them harmless. There had been an elapse of some hours (four or five) after this before I saw the patient, who was labor- ing under delirium of a lively, active, vivid character, alter- nating, in short periods, with the most apparent horrified fright ; seeming to dread the approach of some imaginary monster, and giving utterance in the most piteous appeals for help protection. His hearing was obtuse at times ; at others, natural. Pupil dilated to almost full size of iris ; tongue, mouth and fauces dry, with considerable diffi- culty in deglutition ; heat of surface elevated and dry ; pulse and respiration somewhat quickened (not more than could be accounted for from the fright and violent muscu- lar actions it had, which actions were very irregular.) The patient seemed to me to have very little control over the movements of the upper and lower extremities. From the circumstances, that the child had the seed, and the symptoms above, I was at no loss in forming a correct diagnosis that of Strammonium poisoning. Actuated by this, I immediately administered an emetic of Ipecac, though with some difficulty, from spadmodic action of muscles ahout the throat at each attempt to swallow. This emetic brought up a little mucus and persimmons. Ordered an enema of warm water, strongly impregnated with salt and soft soap, which produced a small fecal evacu- ation. Having noticed, previously, in your journal, an ac- count of this poisoning successfully treated with small and often repeated doses of laudanum, I determined to test its 4G Groover. Puerperal Fever. [January, efficaey in this case. I commenced "by giving three-drop doses, when, seeing no amelioration in the symptoms, I gave Beven or eight drops, and in one hour the child was en- joying a calm and profound slumber. Being called oft* at this juncture, I left a powder of calo- mel and rhubarb, to he given as soon as the child should wake, with instructions to re-commence with the laudanum in three-drop doses every hour, should there he a return of former symptoms, until relieved or sleep came on. Patient slept three hours and, on waking, there was a return of the same symptoms slightly ameliorated. The cathartic dose was given and laudanum resumed as directed; but before the second dose was given, voluntary emesis occurred, which brought up a great many seed, and in no great time, dis- charges, per rectum, showed that they were not in the least afraid to "follow suit," as they produced a teaspoonful of the little fellers/' Laudanum, in the meantime, being continued, soon brought rest to the little sufferer again ; after which there was no return of unfavorable symptoms, except some un- steadiness of gait and imperfect vision, from dilated pupils, which continued three or four days and left the patient well, thus giving an unmistakable demonstration of the thera- peutic autidolal power of opium over strammonium. ARTICLE IV. Pm r/h ral Fever Successful!)/ Treated by Blood-letting and Colo- mi I and Opium. By J. S. Groovkr. M. P., of Groover- ville, Qa. Linday, (negress), act 24, (belonging to C. G.,) confined September 12th, 1860. Labor natural, easy and of ordinary duration. Convalescence progressing normally up to the I'.'tli. At this time she was seized with chills about 8 a.m.; :it :>> p. in., 1 Baw her with the following symptoms : Fever; pain in Lower portion of abdomen, extending upwards ; in- 1861.] Umbilical Hcemorrhage. creased on taking long inspiration, or on pressure : pulse 12"): respiration 36 ; expression of countenance anxious; tympanitis well marked ; lochia scanty, but not offensive. I abstracted twenty ounces blood, when the premonitory symptome of syncope appeared. In fifteen minutes she was in gentle perspiration and pain very much relieved Ordered Ilydrary, Gub-mu, grs. ji, pulv. opi. 8J, every two hours, which was continued with an intermission of two doses at night, up to 9 a. m., 20th. I found her so well that the medicine was stopped, and ordered castor oil jg, and opium gr.j at night. Patient was discharged and con- valesced finely. The post-blood-letting debility required no tonic or stimulants. I have been induced to write out this case from seeing- two reported in the Xew York Medical Times, treated by infusion of digitalis, in Bellevue /Hospital, so as to show the superiority of the lancet over other means. The first case was under treatment from August 3rd to 17th, when convalescence began. The second, from August 4th to 13th. The opposition to the lancet, and the endeavors to find a substitute for it in that Institution and others, are turning many from the path of nature. Umbilical Haemorrhage. In the Charleston Medical Jour- nal and Review for November, Dr. A. X. Talley reports three cases of this unfortunate and troublesome accident. The first two were treated in the usual manner, not omitting the plaster of Paris recommended by Dr. Churchill. Remedial means were ineffectual, and both patients died. The third case was treated with Squiblrs liquor of the persulphate of iron. "The effect was instantaneous ; the haemorrhage, which, despite every appliance, had continued fearfully rapid, was at once ar- rested, and did not again recur. The child is now quite well, and has entirely recovered from the prostration consequent upon the excessive loss of blood." This one case is not sufficient to establish the merits of the agent employed ; but as the result was characteristic and in keeping with its well-known properties, hopes may be enter- tained of its usefulness in these formerly intractable cases. 48 (lent and Articular Rheumatism, &c. [January, On (If Employment of Saccharate of Colchieum in the Treat- :,! qffeout and Articular Rh umaiism. By Dr. Joyeux. From a great number of cases which have come under the author's observation, he draws the following conclusions : 1. That tin- Baccharate of colchieum, prepared with the fresh juice of the flower, is oneof the most reliable remedies whioh the physician can employ in order l< combal the symptoms which depend upon the gouty or rheumatic diathe 2. That the curative effects of colchieum are not owing to its irritating action upon the alimentary canal, but to the se- dative power oi the alkaloids which it contains; and that, lequently, it is of advantage to administer it in fractional and graduallv increasing doses, so as to avoid its purgative i ffect The saccharate of colchieum employed by M. Joyeux is prepared with 100 grammes of fresh juice and 500 grammes of sugar, and evaporated to dryness in vacuo, lie uses ako an extract of the juice of colchieum, evaporated in vacuo, as an external application, directing it to be rubbed on the pain- fid parts. The saccharate is given in the average dose of four grammes per diem, divided into ten parts, one of which is taken every hour. " Since I have made use of these preparations," says the author, " I have not met with a single case of gout which did not yield to treatment in two or three days. Acute arti- cular rheumatism disappeared in the space of fifteen or twenty davs. In subacute rheumatism, without an equally satisfying result, I have witnessed a great amelioration. I have found it of advantage, in the majority of cases, to let the parties take, as adjuvant, an infusion of lime-tree blossoms, contain- i,itre, in the proportion of two grammes to one litre of tea. Natural History of Stoni in the Bladder. A fisherman presented, says M, Zennaro, of Chicago, {Oaz. 3f< d ItaL, 1859,) symptoms ol stone in the bladder at the age of 54r, and refused all surgical interference. Seven years afterwards, a fistulous rture showed itself in the scrotum, and the man was obliged t. keep his bed. During the following 14 years live more apertures formed between the scrotum and penis, the patient Buffering, in the meanwhile, great torture. When 75 years ..Id, he iiad suddenly a sharp attack of pain, and during the piercing cries he uttered, calculus weighing s ounces escaped from oneof the perineal openings. The urine then freely es- caped by this aperture: but the man stil! refused all interfer- ad put up with this inconvenient mode of micturition. 1861.] Rabies in Early Ages. 49 Rabies as an Epizootic in Early Ayes. By Dr. Huseman. Rabies has found, on more occasions than one, some special historians, Among these may be mentioned Kru- gelstein, on account of his k' History of Rabies Canina and Hydrophobia/' Gothn, 1826 an account of which deserves all approbation for the labor spent on it. All writers on rabies canina, however, take their notes of it from modern times Krugelstein himself citing those only from the 18th century. And yet there were cases in earlier times, which came under the observation not only of contemporary medical men, but also of the chroniclers of those days. Thus, in the first part of a familiar historical book "Theatrum Europium," by Joannes Phillipus Abelinus (or Gottfried), Frankfort, 1634 we find the following in page 712 : " In addition to all the distress, and war, and great famine, which extended over almost every place at this time, still another plague appeared, from harvest to November, 1621, in Rheinthal and the the territory of Ap- penzoll, and the surrounding country. For, during the previous summer, the bodies of many thus dying having been thrown into the Rhine and then cast upon its shores, the dogs fed upon thern ; on which account they became mad, and afterwards attacked the cattle in every direction, and destroyed them. The loss of the people in this way was estimated at 25,000 gulden. At last they were obliged to turn out with spears, rifles, and poles, and destroy every animal thus affected. At this period, the trees, as in spring, both in these and in other places, blossomed, and the birds laid their eggs and hatched forth their young. " In Siebenburgen the dogs also run mad, and not only bit cattle, but even men, causing them to go mad ; so that they were obliged, with great labor and grief, to put such infected men and cattle along with the dogs, out of the way, to prevent still further misfortune and peril, which could not otherwise be avoided." It is worthy of remark, that Siebenburgen was specially affected, since, according to Beecher's statistics of the Aus- trian Empire, it still suffers, most of all the provinces of the empire, with rabies. That, in the year 1621, men af- fected with rabies "were put out of the way to prevent still further misfortune, and peril," is perfectly credible, when we think of the manners of the age and the country. 50 Rabies in Early Ages. [January, The erroneous idea, thai rabies, canina arose from de- vouring dead'bodies, was extensively believed in the 17tli and 18th centuries, and even finds an expression in the laws of the time. Tims, in the "Laws of the principality of Lippe," vol. iii, 1<>, the following circular may he found relating to the interment of dead cattle : " A> it is reported that the required interment of dead cattle has been neglected in some parts of the country, and in others it is not made deep enough, so that the dogs can dig the carrion out of the earth, eat it, and become mad; the authorities will take care to have a more strict compli- ance with the edict of May 4, 1771*, and bring those violat- ing it to punishment." That, by the consumption of carrion, a true epizootic might be produced in dogs, which should have a great re- semblance to contagious rabies, later investigations have shown. In the other volumes of the European chronicles of Abc- linus (the work is in 16 volumes) which Dr. lluseman has examined, he finds no record except that of this epizootic, among the dogs in the 17th century. But the misdeeds of wolves, that had gone mad, are recorded in various years. Thus, in 1651, it is stated that in Cologne, on March 31, a wolf, having lately gone mad at Ververs, destroyed twelve men before he could be slain. In his throat there was found a large piece of fresh human rlesh, which might have been from a soldier of Lothingia, as these were lying unburied in quantities in that region. In the woods or forests be- tween the Italian States of Pisa and Luca, six large, tierce wolves were seen together, who had become so famished that they not only attacked sheep and other flocks, but also their shepherds and herdsmen, destroying twenty of the latter. Hence, the Grand Duke of Florence despatched his upper master of the chase, with all his dogs and 400 soldiers, to exterminate these wolves, hut they were not to he found. Similar wolf stories are related of Bohemia, Erfurt, and Touraine, in the years 1652, L653, and 1671, which cannot here he discussed, since they possess no special interest, and the proofs alleged, merely illustrate the characteristics of the Btyle employed in the "Theatrum Europseum." 1861.] ' for Diabcs. 51 A I it for h By E. C. Bidwell, M. P. The only test for glucoscuria which I luive hitherto found satisfactory fermentation involves a delay which is often edingly annoying, and sometimes fatal to a ory and seasonable diagnosis. Those founded upon the reduc- tion oi% metalic oxides, besides being complicated and incon- venient for clinical use, are liable to various fallacies. A better test than any I have seen described, seemec! to me a desideratum one which should be delicate and conclusive, and at the same time ready and convenient. Moved by this sense of a want, to experiment for a new process, I have discovered one which seems to meet fully the needs of the : one, which, if it be not pre-eminently scientific, is nevertheless facile and reliable. For the benefit of any others who may have felt the same want, I herewith com- municate the result of ray investigations. Technically described, it is simply the conversion of the saccharine element of diabetic urine into caramel by heat. My mode is this. Upon a clean slip of tinned iron, place (me or two drops of the suspected material, and hold it over a spirit lamp : the fluid will speedily evaporate, leaving, if the process be arrested at that point, scarcely a trace upon the metallic surface. Continue the application of heat; in a few moments after the desication is complete, a spot of an inch or so in diameter, over which the drop had spread with the first ebulition, will gradually assume a rich reddish- brown color, with a brilliant lustre, as if coated with a film of varnish or Japan lacquer. A strong heat produc darker color, but the lustre continues till the heat becomes sufficiently intense to decompose the substances. This experiment has succeeded perfectly in my hands, when the urine on trial, previously known to contain glu- specific gravity less than 1030, and still further reduced by the adition of three or four times as much of water. It is thus proved to be a delicate test. I suppose it io be conclusive, also, for I have never yet found any other LStituent of urine, normal or abnormal, capable of pro- ducing anything at all like the same appearance under the treatment. The nearest approach is this : some oples of urine not diabetic, when treated in this way, leave a faint, dull, yellowish stain, easily distinguished from caramel by its paler color, and the entire absence of lustre. 1 need scarcely add, that a solution of sugar, uot diabetic, exhibits almost exactly the same reaction. 52 Action of Med Mental Faculties. [January, With tht; augmented interest attached to glucosurJa, since, besides being a Leading feature of a most intractable, but fortunately rare, disease, it is found Bymptomatically asso- ciated with several other diseases and injuries, an increased facility lor its detection is almost a necessity of the profes- sion. I trust they will find it in the simple and beautiful experiment above described. Action of Different Medicines on the Mental Faculties. By Professor Otto. All stimulant and exciting medicines increase the quan- tity of blood sent to the brain. If this quantity exceeds a certain amount, then most of the faculties of the mind be- come over-excited. Nevertheless the degree of this action is observed to vary a good deal in different cerebral organi- zations ; and it is also found that certain stimulants exercise a peculiar and characteristic influence upon special or indi- vidual faculties. Thus ammonia, and its preparations, as well as musk, castor, wine, and ether, unquestionably en- liven the imaginative powers, and thus serve to render the mind more fertile and creative. The empyreumatic oils are apt to induce a tendency to melancholy and mental halluci- nations. Phosphorus acts on the instinct of propagation and increases sexual desire ; hence it has often been recom- mended in cases of impotence. Iodine seems to have a somewhat analogous influence, but then it often diminishes at the same time the energy of the intellectual powers. Cantharides, it is well known, are a direct stimulant to the sexual organs, while camphor tends to moderate and lull rhe irritability of these parts. Of the metals, arsenic has a tendency to induce lowness and depression of spirits, while the preparation of gold serve to elevate and excite them. Mercury is exceeding apt to bring on a morbid sensibility, and an inaptitude for all ac- tive occupation. Of narcotics, opium is found to augment the eratic pro- pensities, as well as the general powers of the intellect, but more especially the imagination. Those who take it in ex- are, it is well known, liable to priapism. In smaller doses it enlivens the ideas and induces various hallucina- tions, so that it may be truly said, that during the stupor which it induces, the mind continues to be awake while the body is asleep. In some persons opium excites inordinate 1861.] Phosphorus and Phosphorus Add. 58 loquacity. Dr. Gregory Bays that this effect is observed more especially after the use of the muriate of morphia. He noticed this effect in numerous patients, and he then tried the experiment on himself with a similar result. Ee felt, he tells us, while under the operation, an invincible desire to speak, and possessed, moreover, an unusual fluen- cy ot^ language. Hence he recommends its use to those who may be called upon to address any public assembly, and who have not sufficient confidence in their own unas- sisted powers. Other narcotics arc observed to act very differently on the brain and its faculties from opium. Belladona usually impairs the intellectual energies; hyoscyamus renders the person violent, impetuous and ill-mannered ; conium dulls and deadens the intellect, and digiialis is decidedly anti- aphrodisiac. Hemp will often induce an inextinguishable gayety of spirits ; it enters into the composition of the in- toxicating drink which the Indians call bauss. The use of amanita muscaria is said to have inspired the Scandinavian warriors with a wild and ferocious courage. Tobacco acts in a very similar maimer with opium, even in those persons who are accustomed to its use ; almost all smokers assert that it stimulates the powers of the imagination. If the psychological action of medicines were better known, medical men might be able to vary their exhibition, according to the characters and mental peculiarities of their patients. The treatment of different kinds of monomania- cal derangement also might be much improved, and it is not improbable but that even a favorable change might be wrought on certain vicious and perverse dispositions, which unfortunately resist all attempts at reformation, whether, in the way of admonition, reproof, or even of correction. On (he Detection and Estimation of Phosphorus and Phosphorus id. By Professor Scherer. Within two years the author had occasion to gather much experience from a number of cases of poisoning animals, and of two men ; also from several attempts of poisoning by phosphorus. In one case, the phosphorus from thirty to forty matches, equivalent to half a grain, proved fatal to a woman in forty-eight hours. He establishes the presence of phosphorus by Mitcherlich's method, with the modifica- 54 Apoplectic Affections of the Retina. [January, tionof filling the apparatus with carbonic acid, generated from a fewpiecesof calcarious spar introduced into the acid liquid. No luminous vapors arc obtained, but little of the phosphorus is oxidized, and if the tube dips into distilled water, this is phosphorescent when agitated in the dark, and its vapor blacks nitrate of silver. To estimate the phosphorus, the last bottle containing the water is connected with another phial containing either neutral or slightly ammoniacal nitrate of silver, which ab- sorbs all the phosphorus vapors that have not been retained by the water. Any globules of phosphorus which may have been obtained are fused together and weighed; the water is added and then evaporated ; the chloride of silver is filtered off: the phosphoric acid, which is contained in the filtrate, is estimated in the usual manner, and calculated for phosphorus. Very minute portions of phosphorus may be recognized, after first ascertaining the absence of sulphhydrie acid, the vapors of which will turn sugar-of-lead paper black, and paper moistened with nitroprusids of sodium blue ; papers moistened with nitrate of silver are suspended over the acid liquid, which gently heated; in the presence of phosphorus the silver will be reduced with a black color. The papers may now be macerated in chlorine water or aqua regia ; the filtrate will, after evaporation, contain phosphorus acid, to be recognized as ammonio-phosphate of magnesia, or as phosphomolybdatc of ammonia If phosphorus has been wholly or partly converted into phosphorus acid, the residue from the first distillation is heated in Mitcherlich's apparatus with sulphuric acid and pure zinc, until the hydrogen ceases to be contaminated with phosphurctted hydrogen, which is conducted into the silver solution, and estimated as indicated before. Ameri- can Journal of Pharmacy. - m m Apoplectic A /Fictions of the Retina. Under the care of Dr- Dixon, Royal London Ophthalmic Hospital. London Ophthalmic Hospital. (London Medical Times and Ga- zette, June 23, 1860, p. 02:3.) The value of the ophthalmoscope is well illustrated in eral cases where diagnosis would have been difficult in the absence of this means of assistance. The instrument in fart completed the history of the disease, so far as the eye was concerned, and furnished information which for- 1861.] Apoplectic Affections of the Retina. 55 merly could only have been obtained by actual dissection . In Que 1, the patient noticed while at work that there was "a dimness before his sight," and, on closing the eves alter- nately, he found lie could not see with the left. The next morning the right eye tailed in the same manner, and, on further trying the eye, he could only make out very large capital letters. Ten days afterwards vision in his right eye had improved, but in the left it was not materially affected, strong light he could not see at all. The optbalmoscope showed traces of effusion from the choroid beneath the re- tina, at the yellow spot in both eyes, the most in the left. This was a well-marked illustration of symmetrical apo- plexy beneath the retina occurring in an apparently healthy man. Cast '2 commenced *-as a little dimness like a mist before the eye," followed by the appearance of black spots float- ing before it. * His general appearance on admission was not the blank look of total blindness, but he could find his way in the hospital, only slowly, and not without directing himself somewhat by feeling. The pupils were unusually large, and did not contract by light. He could see better with the left eye. The eyes were examined at the time by the opthalmoscope, and clots of blood were distinctly seen in the fundus. Xo marked improvement followed the treat- ment. Constant headache presented a complication in this . the pain being chiefly in the forehead. 3 afforded an example of apoplexy of one retina on- ly, but attended with frontal headache and epistaxis. The failure in the right eye appeared to have followed soon after a violent attack of bleeding from the nose. The headac were wholly relieved by the epistaxis. When last examin- ee described his sensations at night as follows : On look- ing at the ceiling, he sees a large "block," the size of two heads, the rest of the ceiling appeared pretty clear. (The pupils dilated by atrogine.) Upon making an examination of the eye with the opthalmoscope, a large irregularly circum- ibed patch was discovered, extending over and around the yellow spot, the ground of which was lighter colored than the surrounding parts, and on which were numerous dots of extravasation, very irregular, and in many pla consisting of five or six spots running into each other. Be- tween this patch and the margin of the optic entrance was found a large and apparently thick coagulum of a deep purple tint. Over the whole of the patch arc Small white 56 rate of Iron. [January, Boots, appently about the size of pins' heads. Several dis- tinct apoplexies lnust, in this instance, have occurred at dif- fereut periods. The whitish patches were, no doubt, those of oldest date. The case is of interest on account of the age of the man being exactly that at which a sister of his had died of crebral apoplexy, and because in his own case severe frontal headache and epistaxis had preceded the effu- sion into the eye. On the Employment of Stearate of Iron in the Treatment of Soft or Phagendic Chancres. By M. Ricord, (Pharmaceutical Preparations of M. Braille.) From a communication of M. Calvo, nephew of M. Ricord, we learn that the latter has employed for several months, in the Ilopltll da Midi, an ointment or plaster of stearate of iron, prepared by M. Braille, pharmaceutist of the institution, to whom we are indebted for excellent means of dressing soft or phagedenic chancres. This new preparation, which can be prepared at a low price, and is of easy application, is destined, without doubt, to render great service in all those cases of so serious a char- acter where the phagedenic action seems to resist the numerous means which science directs against it, and con- tinues its destructive march without interruption. Up to the present time, at least, it has fulfilled, in the hands ofM. Ricord, all that it seemed to promise, and has become of daily use in his hospital as well as in private practice. The modus facienai of these new preparations, as commu- nicated by M. Braille, is the following: O'ndmcnt of Stearate of Iron. IJr. Sulphate of Iron, 500 grammes; Marseilles Soap, 1000 grammes. Dissolve the sulphate of iron in about 1500 grammes, of water, and dissolve the Marseilles soap in an equal quantity of water. On pouring one solution into the other, a whitish- green precipitate is obtained, which is dried, and then melt- ed at a moderate temperature of 80 to 84 K.; add to the melted mass, <-;i cooling, 40 percent, of essence of lavender, jtir it constantly until it becomes perfectly cold. Sparadrap of StearaL of Iron, (Braille's Plaster.) ]{. Stea- >btained by the process directed above. ii at a moderate temperature, and spread it on muslin 1861.] Hydrochloric Arid in Chronic Dyspq>& 57 like the ordinary sparadrap. This mass gives an adhesive sparadrap, which does not crack like the soaps of lead ob- tained by double decomposition. Journal dc harm\ dochloric Acid in Chronic Dy& By Dr. Schottin, oi Dresden. Dr. Schottin has used hydrochloric acid with great suc- - of chronic dyspepsia. The curative effect of the remedy is attributable to two circumstances : First, it suspends, like other powerful acids, the process of fermenta- tion ; and, secondly, it serves to dissolve the proteinaceous compounds, being, to a certain extent, a substitute for the disturbed secretion of the gastric juice ; it is therefore, the most natural remedy. In children who suffer from gastric and intestinal catarrh, the author prescribes the acidium muriaticum dilutum of the Prussian pharmacopoeia, in doses of six to fifteen drops, in a mucilaginous mixture, and adds, until the bowels are regulated, a few drops of tincture of opium. lie orders the'medicine to be taken half an hour after each meal, and confines the patient to a diet of milk and broth. In old age. when the stength of the system is gradually falling, disturbances of digestion are very fre- quent, the cause of which is to be found, in many instances, solely in a diminished secretion of the gastric juice. A double indication is to be fulfilled in these cases : to arrest the process oi fermentation, and to stimulate the stomach, in order to increase the secretion of the gastric juice. Dr. Schottin recommends for this purpose small doses of chloride of sodium and sulphate of quinia, to be followed, a short time aiterwards, by sulphuric acid. The chloride of sodium is decomposed by this means into sulphate of soda, and hy- drochloric acid. lie prescribes ten grains of chloride of sodium and one-third of a grain of sulphate of quinia, to be taken four times a day wrapped up in a wafer, lets the patient drink some water, after it, and administers, about five minutes later, eight to twelve drops of the elixir acidum Halleri in half a wineglassful of water. The dyspepsia of drunkards requires a double dose of sodium and sulphuric acid. Dr. Schottin attributes the ef- fect of hydrochloric acid in typhus, anaemia, and chlon likewise to its property of suspending the process <.t* fer- mentation within the stomach, and i ing the deficient secretion of the gastric juice Archie der Houkunde. Prolapse of th Rectum. [January, onneckd with the Pathohqy and Treatment of i ' ' the Reetwu* By Henry Smith, F.R.C. S. It is not my intention in this paper to treat generally of the important subject under notice, but I am going to re- quest your attention to one or two particular points connect- ed with the pathological features ol prolapsus of the rec- tum, and with the treatment which is suited to certain forms i>\' the disorder. There has not been much room for discussion respecting the main pathological changes which take place in the pro- duction of this disease, for the simple reason that a prolaps- ed rectum can be readily examined on the living body, both by the eye and the fingers, and some most able sur- as have described in their works with remarkable ac- curracy the principal features ; but on one point there has been, and is now, a strong divergence of opinion as to whether most frequently the prolapsed part consists of the mucous and muscular coats of the rectum, or of the mucous membranes simply. Some of the older writers have leaned strongly to the opinion that the mucous membrane of the bowel alone was involved, while of late there has been an opinion expressed as strongly on the opposite side. There cannot be a doubt in the mind of any one who has investigated the subject by studying morbid specimens taken from the dead body, that, although in the majority of instances the prolapsed part consists of the mucous mem- brane alone in a relaxed and thickened condition, yet, in- some cases, the muscular coat of the bowel is protruded be- yond the sphincter as well as the mucous membrane. It is nol only an interesting hut an important fact to ascertain properly, because it will happen that the treatment which will be adapted for the one the form of disease will not suit the other. In cases where the mucous membrane is pro- lapsed lo.al measures, and those of a less energetic nature, are Buffich nt tor a cure, whereas in instances where the muscula is brought down beyond the spincter, local measures alone will either fail, or it will be necessary to loy means mmv decided and more severe. As an ilus- tration of the prolapsus consisting ^\' all the tissues of the bowel 1 may refer you to those large descents which are mtli Hants Medical and Chirurgical Society, 2, I860. !;. Wiblin, President, in the Ohair. Sept. 1861.] Prolapse of the Pedum. 59 somestimos seen in children as the result of some irritation in the intestinal tract or in the bladder. ~\\re know what a difficulty there is occasionally in keeping np such a prolapsus after it has been carefully returned, and that the best regu- lated local measures will not suffice for a cure until the general health of the child is improved by nutritious diet and powerful tonics, which especially tend to enhance the power of the muscular system. We know how elaborately the muscular tissues are supplied with blood-vessels, and how largely their nutrition and power of action are under the influence ol remedies which increase the tone of the system. The other instances in which we find that there is pro- trusion of the entire structure of the bowel are seen in those cases of long standing pro]apsus in adults, where the pro- trusion is of immense size, as large as the fist or a foetal head, and coming down on the least exertion of the patient. Within the last week, I have been consulsed on a case of this description, occurring in the case of an old gentleman, of a weak frame and feeble circulation. The prolapsus had existed for forty years, and it has reached its present enor- mous size in consequence of neglect of proper surgical treat ment. In such cases as this, there is no doubt that at first, the mucous membrane of the bowel was simply protruded, but afterwards the other tissues became involved, and at length the tumor consisted not only of thickened mucous membrane, but the muscular coat also was extended beyond the sphincter. In those cases of prolapsus of the rectum of much more frequent occurrence, where the disease is more limited in extent, and where the mucous membrane alone is pro- truded, there is a considerable difference in the pathological features, and that, too, of considerable practical importance, ially when viewed in relation to a mode of practice I am in the habit of adopting. In some of these cases it will be found that the mucous membrane is simply extended beyond the sphincter, in but a very slightly altered con- dition, the whole circumference of the lining membrane of the bowel may be down, or only one or two semi-circular folds may be prolapsed ; in either instance, however, besides this prolapsed membrane, the protruded part may consist of the muco-cutaneous lining of the sphincter, in a highly con- gested and thickened condition, forming in fact, the greater portion of the disease. This is protruded first, and may 60 Prolapse of the Rectum. [January, be scon as a dark blue ring around the anus, while situ- ated above it is the proper mucous tissue of the bowel simply relaxed and prolapsed, but otherwise in a normal Btate. There is a point of considerable importance, both patho- logical and practical, in connection with prolapsus, to which I wish to call your attention, and which has not been suf- ficiently alluded to by writers; this is the condition of the sphincter ani. In some cases we shall find that this muscle acts in a normal manner and that the anal aperture is not larger than ordinary, although there may be a considerable prolapsus of the mucous membrane ; in other instances the sphincter seems to have losta considerable degree of its con- tractile power, the aperture is enlarged and easily distended eel ; in a few cases to such an extent that the whole fingers, when formed into a cone, may be passed into the rectum. In these instances this laxity of the sphincter is the chief cause of misery, for when it exists in a great degree the patient loses, either partially or entirely, control over his rectum, and the frees escapes involuntarily. A remarkable instance of this fell under rny care in the person of a patient, aged TO, who had suffered for twenty years with prolapsus, and indeed it was this circumstance which drove him to consult me. When there is a partial loss of the power of the sphincter the patient is continually harassed by calls to the closet night and day, although there may be any actual in- voluntary discharge of faeces. Of course this loss of power of the sphincter is the greater misfortune of the two, but in e instances of prolapsus of the mucous membrane when the sphincter is in a healthy condition, the following acci- dent may and does occur, especially when the protruded membrane has on its surface one or more distinct hemorrh- oidal tumors, the protrusion occurs on one occasion, to a larger extent and the patient cannot return it as usual, the mosl severe symptoms of course rapidly set in, and although this accident is very likely to be followed by a cure in con- ce of sloughingof the constricted parts, yet one would b very unwilling to bring about this condition purposely, for death has followed upon the intense amount of inflam- mation which has occurred. X<>t long since! was called to Id lady, 7< years of age, to whom this accident liappen- and not being in a healthy condition she was reduced to a great amount of suffering, for violent in ilammation and ighing of the protruded membrane had taken place; 1881.] Prolapse of the Rectum. Gl this latter process was hastened hy placing ligatures around the diseased parts, and she made a good recovery. The treatment which should he adopted in case of pro- lapsus of the rectum must differ according to the pathologi- cal condition of the part, especially as regards size and the state of the sphincter. It lias hitherto heen customary anions: surgeons to use the ligature in most of the cases of prolapsus requiring surgical operation, and of these I am only now talking : and undoubtedly, where the disease has become very extensive, and particularly when associated with distinct hemorrhoidal tumors, 'the ligature must be used, if there be not any contraindication to a surgical ope- ration. This is especially .the case when, from the large size and the peculiar feel of the tumor, there is every rea- son to believe that the muscular coat of the bowel is protru- ded as well, for any operation short of the ligature will be useless in removing the disorder. In some f the cases also alluded to, when the prolapsus is voluminous, and there is a very relaxed state of the sphincter, the ligature alone can be depended upon ; but for such instances, which are by no means nncommonly met with in old people of the middle and upper classes, I have lately put in practice an operation which I do not wish to claim as particularly new, for it is a combination of two agencies employed before for similar conditions, but which I particularly wish to bring before your notice. It consists in first applying the strong nitric acid, on one or more occasions, to the mucous membrane ; and subsequently, when this agent has had some decided effect, to remove with curved scissors narrow strips of skin and mucous membrane frem around the verge of the anas at right angles to the orifice. The latter remedy alone was employed both by Hey and Dupuytren, and lately recom- mended by some ; but my experience tells me that alone it is not to be depended upon ; but if the mucous membrane, which is always in such cases in an extra-vascular and re- laxed condition, is first brought into a more healthy state by the contracting and slightly escharotic powers of an agent like nitric acid, the effect of removing the loose fold of skin which are so generally associated with the relaxed state of the sphincter, is very admirable. Two objects, in such in- stances, are sought by the surgeons, and indeed are abso- lutel}7 necessary for an efhcieient remedy, viz : the contrac- tion of the mucous membrane, and the biacing up of the sphincter : these two results are brought about by the com- 62 Prolapse of the Rectum. [January, biiicd proceedings mentioned. I must, however, not omit to state thai it is perfectly useless to employ the nitric acid in those instances where the prolapsed mucous membrane has become tinned and indurated, as is very often the case: the agent will produce no good effect; both patient and surgeon will be disappointed. The application of the acid is more especially advisable in those cases where the mucous membrane is granular, very vascular, and readily bleeds : the effect of one application in such an instance is sometimes really astonishing. But there is one caution I wish to im- press; and that is, that the surgeon must not be misled in- to the abandonment of further measures because after one application of the nitric acid he finds that the bleeding and prolapsed bowel suddenly disappears. It will sometimes happen that one application will be followed by remarkably good results like these, and that afterwards the symptoms return. It is better, in cases of extensive prolapsus, that the acid should act gradually than suddenly; the effect will be more permanent. It will be necessary to apply the nitric acid when the disease is extensive, on several occasions per- haps four, six, or eight times ; but it is generally attended with so little pain, that the patient does not object to sub- mit to it. If the sphincter ani be not in a weak condition, but acts normally, there may not be any necessity of cutting away the thin slips of muco-cutaneous covering; but if there are any pendulous flaps of integument, these should be exercised. These operations, which should be effected by sharp curved scissors, are of course painful; but the ap- plication of the freezing mixture of ice and salt will much deaden the pain. This treatment may be considered as perfectly free from danger, and is so admirably adapted for those cases where the "patient will either not submit to the ligature, or where there is some contra-indication to this proceeding. For instance, many of the worst cases of prolapsus oecur in aged people who are, or who consider themselves too old to undergo the ligature; others have some symptoms of lurk- ing organic disease about their brain or heart, and it would be highly perilous to use the ligature, but the treatment I advocate may be used with perfect assurance of safety. To illustrate this important fact I will allude to two cases which have lately lately been under my notice. The first wras a gentleman aged 73. lie had a bad prolapsus, and when told by me that I could only recommend the ligature with 1861.] Prolapse of the Rectum. 63 confidence, to destroy his disease, lie refused to undergo it. I tried by some applications of nitric acid to remedy it, but lie became dissatisfied and consulted a surgeon of great eminence who strongly recommended the ligature and ap- plied it; the patient died three or four days after from an attack of apoplexy. Tow, there were certain indications about this gentleman which would have prevented a surgeon who knew them and carefully considered them, as Iliad done, from frequent ob- servation of his case, from performing this operation. The patient was very peculiar in his manner and habits, and thought by his friends to be very "strange," as the term goes, and in addition to this he had almost entirely lost the control over his bladder during the few last months of his life, without the existence of any stricture or disease of the prostate. Xow, these two facts indicated some lurking mischief about the nervous system, and should have prevented the surgeon from operating. Xo doubt the stimulus of the operation of the ligature which is much more severe than is imagined, lit up the lurking mischief in his nervous sys- tem and destroyed life. To this the eminent surgeon who performed the operation readily assented when he was ques- tioned by me. The other instance is that of an old military man nearly TO, who has had prolapsus with severe pain and bleeding. He was anxious to get some relief; he had a peculiar nerv- ous twitching about his face, and a feebleness of his lower limbs; and on making inquiry of one of his family, I ascer- tained that he had something approaching a fit on two oc- casions. I at once decided against employing the ligature, for this reason, and resorted to the employment of the treat- ment I have advised with great benefit. It is not to be supposed from the remarks I have made that I am averse to the ligature in suitable cases, but if it can be dispensed with, and a milder mode of treatment can be suc- cessfully adopted, the surgeon is bound to put it in force. For, although I believe, when properly performed and in healthy subjects, the operation of ligaturing portions of the mucous membrane of the rectum is by no means dangerous still we cannot conscientiously tell a patient there is no risk; independent of the peculiar danger attending the proceed- ing, such as pycemia or tetanus, some serious and annoying <;i Ptolapse of the Mectum. [January, accidents are Liable to follow this operation, and I shall here draw attention to some of these. One very peculiar and unlooked-for sequence of this ope- ration for prolapsus worthy of relation occurred in practice not long since. I operated upon a fat old lady who had not much stamina the circumstances of the ease were such us to demand a speedy and efficient operation; I used the ordinary precautions in the process, and the patient did wvy well the first day or two. On the third day, however, to the greal surprise of her medical attendant and myself a severe hemorrhage suddenly took place from the part, and had such an effect on the patient that it made me very anxious. 1 was at a loss to account for this very unusual occurrence, wherencither the knife or scissors had heen used; hut on going to make an examination I found that there had heen a rapid slough as large as a shilling formed by the side of the rectum, laying hare the muscular coat of the bowel for near an inch in extent, and no doubt one of the inferior hemorrhoidal arteries had been opened up and hence the bleeding which was so profuse and which occur- red on a second occasion ; but fortunately by keeping up pressure, and local application of strong nitric acid, the sloughing process was stopped and the patient made a good recovery. But this might have destroyed the patient had it gone on further. The cause of the sloughing was this : The patient, who wras very fat and heavy, lay a great deal on her back after the operation, and the pressure of the bed induced the sloughing of the part already of necessity irri- tated by the close proximity to the ligature. We learn from this interesting case the importance of not allowing patients to lie much upon the back after this operation, they should rather be induced to lie on their side. There is another point connected with the operation of the ligature of the mucous membrane of the rectum which there is considerable divergence ^\, made of belladonu:.. ayoscyamus, or opium. One very good expedient, whio will often entirely change the character of the ulcer, is I anesthetize the part with ice, as practiced prior to opf rating. When the lymphatic glands become affected, antiphl gistic measures must be employed; and when chron' alteratives, tonics, liniments, etc., according to the peol liarities of the ease. The treatment of milk abscess is F ereal importance. It should be prevented if possible, proper management at the outset. When the nipple 4 deficient, or, from any cause, apprehension is deemed ii-c 1861. J . [fections of (he Female Breast. 69 sible, it is decidedly improper to attempt nursing. In other cases, prolonged and judicious efforts should be made to render the organ useful. The first tiling is to take per- pendicular pressure off the top of the nipple, by some device to prevent the dress from forcing it in, and this, if possible, should be commenced early in pregnancy. For this pur- pose a shield should be employed, which will cause a pitting of the anterior surface of the breast, and a projection of the nipple. When called upon to treat a rudimentary nipple, after parturition, the effect must be more prompt. In many cases the organ may be made available by causing it to erect itself by simple titillation by the finger, and imme- diately applying the child : or by placing a thick layer of collodion, around it on the areola, which, drying, elevates the nipple. Then, by keeping the reservoirs empty, ab- 5S is prevented. To aid in this, we have various tubes and pumps, but all of which are objectionable. A puppy is often used, but it likewise is liable to irritate and exciriate the nipple. The only proper way is by the mouth of an adult, varying the pressure of force to suit the tenderness of the part. A very useful class of measures are those to suppress the etion, and thus relieve the distention, as opium in large )s, or applied as an ointment ; but belladonna seems to have acquired most renown. Numerous instances are re- ported of its great value in such cases. Much depends upon it- strength and application by inunction till the production of its characteristic effect upon the system. Cold, as a local remedy, is beneficial. The temperature of the breasts for this purpose should be kept steadily at about 40 or 4oc. as by water running through an india-rubber enveloping the organ, or the application of a bladder. No bad effects are to be apprehended from it. Internally, a saline cathartic may be given ovovy other day, and two grains of iodide of 3ium every four hours will materially assist. \>ute inflammation, the effect of congestion, is apt to be extensive, and will require energetic treatment. Warm fomentations may be applied for the first few hours with the hope of establishing the secretion of milk. A decided ion will often turn the balance in favor of resolu- Immediately after this, the use of the veratrum viride may be commenced in doses of six drops every four hours, till the pulse is brought down below the normal standard, and kept there. One grain of calomel, with a quarter of a 70 Affections of the Female Breast. [January, grain of sulphate of morphia, may he given, if the pain is urgent, say every four or six hours. A lotion of one part of sulphuric ether to two parts of alcohol will he a good soothing adjunct, after the inflammation becomes perma- nent. These measures should not he abandoned for warm poultices until suppuration is clearly evident, by which plan we may often limit the extent of this process. . In this state of the gland, the most moderate means only should be em- ployed to draw the breast. Retained milk is not the cause of inflammation here, as in milk abscess. If glandular in- flammation is complicated with that of the reservoirs, the treatment for both must be combined, as local and general antiphlogistics with means to arrest the secretion and empty the reservoirs. Chronic inflammation will be cured by treatment similar to that for other glandular inflammations, as leeches, mer- curials, iodine, and vegetable alteratives, internally and ex- ternally. Much reliance can be placed upon well-regulated pressure with adhesive straps, pressing the diseased part against the ribs ; or with collodion thoroughly incasing the breast. When pus forms, evacuate it early, though where the abscess is deep, it is desirable to wait until the pressure from within has caused condensation of the overlying tissues otherwise a large opening will be required. In milk ab- scess the earlier and smaller the opening the better. The effect of suppuration and evacuation of a milk reservoir is often to destroy its cavity, but in some cases a milk fistula is formed. This may be closed by an occasienal application of the nitrate of silver. Worse than these are the tortuous lacuna1, that sometimes result from the deep glandular ab- scess of the breast, and which are generally very difficult to cure. Injection of iodine is most to be relied upon. This may be done by inserting a soft, flexible catheter to the bot- tom of the canal and throwing the injection through it so as to apply it without dilution to the bottom of the fistula. This favors the shallowing instead of the narrowing of the cavity. Of course it is never advisable to slit up these ob- stinate puriferous ducts, because of the amount ot tissues that might be damaged, which it is desirable to save. Chi- cago Med. Exam. 1861.] Leucocythamia. 71 A Gisc of Leucocythcemia. By Dr. George Sheaber, Resi- dent Physician, Royal Infirmary, Edinburgh. A young man aged twenty-four, a miller by trade, admit- ted to the infirmary under the care of Dr. Gairdner, afford h an interesting illustration of leucocythfiBmia. Three weeks elapsed from his admission to the time of his death, and k the following is a summary of the facts of the case in regular sequence: Ansemi, languor and debility; epistaxis; headache; bleeding from the gums; renal pain, with lithi- asis ; febrile symptoms ; disappearance of lithic acid, and appearance of lithates and albumen; diarrhoea; re-appear- ance of lithic acid ; uncontrollable epistaxis; haunatemesis; otitis; exhaustion and death." The crystaline deposit in the urine, on third or fourth day after admission, consisted mainly of hexagonal crystals of the lithic acid, with a few of the ordinary rhomboidal crystals. These, we have already said, afterwards disap- peared. Post mortem examination revealed leucocythaemia, enlarged spleen, fatty liver, petechia? on the mucous mem- brane of stomach and on the serous surfaces of the pericar- dium and endocardium. The case detailed by Dr. Shearer gives him a field for re- flection, which he discusses in the following suggestions: 1. Enlargement and activity of the spleen is not the only condition involving increase of the white corpuscles, there being at present a ease in the infirmary in which this con- dition of the blood eo-exists with enlargement of the whole lymphatic system -of glands, without detectable enlarge- ment of the splenic organ. 2. The fact of a great excess of white corpuscles in the blood in cases of leucocythsemia being accompanied by con- stant diminution of the red discs, appears to militate against the theory put forward by Wharton Jones, and supported by Bennet and others, that the latter are derived from the former by liberation of their included neuclei ; for, accord- ing t<> their theory, increased activity in the formation of the white ought, paripassu, to be attended by increased de- velopment of red discs, while the reverse is the case. Comparative increase of the white corpuscles is seen in a variety of organic discuses, especially chest affection.- ; but it also occurs in dysentery, diarrhoea, paraplegia, etc.; in all of which one general condition was observed, viz: depreci- ation of the appetite, and emaciation. These facts, Dr. Shearer thinks, point to the blood itself as the primary 72 Santonin. [January, source of origin of the red discs, and in the diseases men- tioned there is either a deficiency of nutritive pabulum taken into the blood for the production of the red corpus- cles, or these are rapidly melted down to supply the ele- ments of the discharge. In leucocythsemia, again, the nutritive pabulum is appropriated for the formation of the white corpuscles, the blood being thereby impoverished to the extent to which these are increased ; development of the red discs is consequently kept in abeyance, and anaemia is again the result. 3. The deficiency of color in the urine and the salts ob- tained from it depends probably upon the same cause as the pallor of the general surface, viz : deficiency of red globules and hsematin in the blood. 4. Careful study of the deposit of lithic acid seemed to warrant the inference that the common or lozenge-shaped crystals is derived from the perfect hexagonal form by shortening of the lateral planes of the latter; but this does not explain the formation of the true rhombic crystal, which is an irregular form, 5. Hemorrhage from various mucous surfaces form as prominent feature of this disease, and may depend partly upon the increased tension maintained in vessels by the absolute increase of volume in the mass of the blood, and partly upon the imperfect nutrition of the walls of the capil- laries from the inferior quality of the blood for histogenetic purposes. 6. The white corpuscles, we know, are closely allied to fibrin in composition and character ; fibrin is increased in febrile and inflammatory diseases, and accompanying this is an increased elimination of lithic acid, or lithates, by the kidneys. Can any relation exist between the lithuria present in this case, and the increase of white corpuscles in the blood? On Santonin. By Profssor Falck, of Marburg, and l)rs. V. Hasselt and lieinderhoff. Professor Falck communicates in his treatise the result of fifteen experiments made by himself and Dr. Manns, with the view of investigating the physiological effects of san- tonin. The conclusions at which he arrives are the follow- ing: 1. Santonin and santonin-soda arc poisons; at the same 1861.] - 7o time it is not to be denied that they are valuable remedies. 'J. A solution o\' santonin in dilute alcohol, introduced in proper quantity directly into the blood, rapidly causes the death of a dog, and undoubtedly also that of any other ani- mal. 3. Injected into the subcutaneous cellular tissue santonin soda is absorbed into the blood. Also, if introduced into the Btomach, santonin as well as santonin-soda may pass into the blood. 4. ruder conditions not completely known, santonin as well as santonin-soda are changed, within the animal body, wholly or partly into a substance which is secreted with the urine, and can be demonstrated in the latter by means of caustic alkalies. ~>. The change of santonin, respectively santonin-soda, into this substance which reacts, on the addition of caustic alkalie-, with a red color, may take place under certain cir- cumstances, in a very short time. The elimination of the substance with the urine, lasts, under certain conditions, a very long time. o\ Under the influence of santonin and santonin-soda the urine assumes readily a peculiar, yellow color. This color is evidently owing to the substance which is formed, in the animal body, out of the santonin. 7. On evaporating urine containing this substance, in a water bath, the latter is changed so much that it does not react any more with a red color on the addition of caustic potas 8. The urine secreted under the influence of santonin is not always of a saffron tint, but may occasionally assume a red color, viz : if ammonia is formed by decomposition of area, or if the santonin has been administered in combina- tion with alkali' Santonin and santonin-soda exert a remarkable influ- ence on the brain and the organs of vision : they produce incoherency of ideas and chromatopsy. 10. The chromatopsy caused by santonin or santonin- soda is undoubtedly connected with the formation of the substance, reacting with a red color on addition of caustic notassa; we, t!: call this condition "xanthopsy." more the blood contains of this substance, the greater is the ehromatop 11. Chromatopsy can not be caused by dropping an aque- ous solution of santonin-soda directly into the eye. /tin. [January, 12. The phenomena produced by santonin poisoning are different according to the difference of circumstances and conditions, heath is almost always preceded by convul- sions. Deutsche Klinik. 2. Messrs. V. Hasselt and Eleinderhofi* publish, in the Nederl. Tijdschvoor GeneesL, 1860, " a contribution to the toxicodynamic knowledge of santonin." They draw from their experiments the following conclusions, important to the practitioner as well as to the toxicologist : 1. Santonin can act as a poison. 2. As it seems to belong, in general, to the class of nar- cotica spinalia, without leaving in the dead body any per- ceptible sign of its irritating secondary effect, although symptoms of it are observed in man during life. 3. Its action, on the administration of large dosei analogous t<' that of tetanic poisons. 4. In relatively smaller doses, for instance of sixgrammes, il produces, in dogs, slight symptoms of poisoning. 5. [n large doses of sixty to ninety grammes, it can act fatally on these animals with relative activity. antonin manifests its action then, at first, in the sphere of the motory nerves, which action is shown by spasmodic contractions of the muscles without an increase of sensibil- ity. The course of the affection makes it evident that the motory pail of the spinal narrow is acted upon progressive- ly from below upward. Tin1 fatal termination seems to be owing to spasms of the respiratory muscles and of the muscles of the larynx. These spasms may be considered the cause of the asphyxia which finally takes place. 7. The post-mortem appearance, hypenemia <>\' the lungs, engagement of the heart, hypenemia of the eere- bro-spinal membranes, and capillary injection of the medulla spinalis and oblongata, arc probably in causal relation to the spasmodic contractions of the muscles as well as to the death by asphyxia. Without having the intention of assuming, from their ex- periments, that the effects upon man are equal to those upon rs still believe that, considering their obser- vations in regard to the action of santonin upon man, they have sufficient reasons to conclude that santonin is, by no rnea yarded as an innocent remedy. Med X< uigh 1861.]. Mania a Potu. 75 Digitalis in the treatment of Mania a Potu. By G. C. Cat- lett, M. D. The experience of the physicians of this city, so far as my knowledge extends in the treatment of Mania a Potu, lias been very unsatisfactory. Most of the attacks assuming a remark- ably accute fcrm; with great violence of delirium, furious mania, and persistent mental aberrations, have generally re- el the opium and stimulating as well as all of the former established methods of treatment for this unfortunate class of sufferers. So great has been the mortality from this disease during the last four or five years, notwithstanding we have attempted to discriminate between the chronic and the acute forms, that we have become apprehensive that we have not been treating alcoholic poison. Indeed so general has become the impres- sion that the various alcoholic drinks generally used, contain a foreign poison, that those who are in the habit of becoming intoxicated are significantly said to have taken passage on the strychnine line for an unknown destination. While the symp- toms of the numerous cases that have come under my obser- vation do not, in the slightest, resemble those from the poison of strychnia, yet, the great apparent difference in the charac- ter of the Bymptoms as well as in the result of the disease produced by excessive use of alcohol at the present and former periods, that it would very naturally create apprehen- sion and strike terror the spirituaily infatuated. There have been a few persons, by a prolonged debauch have induced inflammation of the mucous membrane of the stomach or at least, such a degree of irritability that a continu- ation of indulgence was impossible, -as nothing introduced in- to it would be retained, soon, therefore, from the withdrawal of the stimulous, delirium tremens would supervene, charac- terized by intense hallucinations, great tremulousncss, incapa- city to sleep, irritability of stomach, tender epigastrium, and deticiency of the secretions. Counter irritation to the epigas- trium, a mercurial cathartic, stimulants judiciously adminis tered (I prefer Tinct. Serpentaria ; and Tinct. Valerian, equal proportions,) and Morphia^ro re nata, will generally in my hands relieve such cases. But that form of this disease that is produced by the constant daily use of alcohol long continued, poisoning the blood and resulting in acute mania, is the fatal form, or properly Mania a Portu. in relation to this form of the disease Prof. Stone of New Orleans says : " Brain fever and apoplexy arc terms often kindly substitut 76 Mania a Pot a. [January, ed as being more respectable; but names do not alter tacts. Mania a Potll usually occurs with the robust who habitually iN'1 alcoholic stimulants, hut not to any great excess, except upon occasions, and when they are carried to a certain extent, a necessity for their continuance is created, and their excessive use cannot, or will not, he resisted until the stomach gives way and finally reject them. During this process the mucous membrane becomes engorged, the digestion, and finally the a] (petite, entirely fail, and the patients is sustained for some days after, by stimulants alone, until furious delirium sets in. "This madness is not due to the stoppage of an accustomed stimulant, for it often sets in while the subject is in the full use of it, but it is plainly due to alcoholic poison and the ab- sence of proper nutritive matter in the blood. I think I may add another cause which has often something to do in causing the delirium, and certainly much to do in causing death, under some modes of treatment, and that is suppressed excretions. So long as the stomach is intact, and the apetite and digestion good, an immense quantity of stimulant may be disposed of without serious immediate consequences ; but when the organs finally from constant excitation, became engorged, nutrition ceases, and the alcohol is retained more in the blood, instead of being carried off" by excretions, and a wild delirium soon fol- lows. "It is plain, under these circumstances, that the indication- arc to establish the excretions, disgorge the system of the al- coholic poison, and to introduce proper nutriment. The first two are accomplished by one and the same means. The stomach is generally irritable : at least, there is frequent vomit- ing; but it is owing to the accumulation in the stomach of morbid secretion, rather than from inflammation of even irri tation; fur calomel in small doses, frequently repeated, arrests it with great certainty. If the subject is governable, and will take medicine willingly, calomel should be given in two or three ^rain doses every hour, or oftener if the case is urgent, until fifteen or twenty grains are given : if medicine has to be given ; by force, it is best to give a full dose at once; and this is the better, for in the worst cases the stomach is not nauseat- cd. ami the eedative effect, of a large dose of calomel calms the nervous excitement, and at the same time produces the ap- propriate effect upon the excretory organs and mucous coat of the Btomach and bowels. It requires some hours for this ef- fect to be produced, and it is improper to give anything to promote its action upon the bowels under ten or twelve bonis. 1861.] Mania a Potu. and I think even a longer time would be better, if the case is not urgent. Small and frequently repeated doses of saline medicine are the best after calomel (sulphate of magnesia is best), which promotes the excretions, disgorges the stomach and bowels, and clears the system of its alcoholic poison, to its great relief. An active cathartic may afford some relief, but the system is not so well disgorged by it ; more or less serum from the blood is carried off, causing weakness ; while, in the other process, by giving time for the action of the calomel, and then promoting it by gentle but continued means, the organs exercise a selection in excreting, and thereby a large amount of effete matter is discharged, and the patient feels the stronger for it, being freed from an incubus that was weighing it down and producing apparent exhaustion. After this process, we should lose no time in introducing nutriment, and for this pur- ducing apparent exhaustion. After this process, we should lose no time in introducing nutriment, and for this purpose milk is almost universally applicable ; and as the mucous membrane of the stomach seems to be denuded of its eptheli- 11111, the addition of lime water renders it particularly grateful and soothing. Patients in this condition generally loathe ani- mal substance, but milk is almost always grateful to the taste aud is particularly appropriate, for it furnishes the most inno- cent solid for the bowels, that have been long deprived of their wholesome stimulus. If it should happen that a patient could not take milk, well boiled corn-meal gruel is the next best diet most likely to be relished ; ond for something more substantial, strong, well-seasoned broth, frozen, will be the most likely to agree. In all acute cases, alcoholic stimulants should be withheld, for they act like poison and will often bring back delirium. Should stimulents be thought necessary (and it is not often really necessary) the carbonate of amonia, or the aromatic spirits of amonia are preferable ; or it may be proper, in some case, to allow malt liquor. Opium in all forms should be pro- hibited, until the system is relieved of its alcohol and even then I find it can generally be omitted : and when it can be, the patient recovers sooner and better. The patient is not ex- pected to sleep well, but if the blood is renewed by its appro- priate nutriment, natural sleep will follow. Occasionally, when, previous to the debauch which imme- diately caused the mania, a free use of stimulants had been in- dulged in some time, we have an exalted state of the nervous system, attended with hallucinations and sleeplessness, which rerpiire special attention. Potent stimulants operate badly, 78 Mania a Pot a. [January, and opium alone docs not operate well, though in large doses sleep may be forced, though not without some risk, in some cases, to the brain; but equal parts of morphia and tart, anti- mony, given in small and repeated doses, will soon calm the nervous system and induce sleep without injury either to the 1 train or stomach. There is nothing that cools off the heated imagination in these cases like nauseating doses of tart, anti- mony, and opium in some form maybe added, if it is thought necessary. The too general opinion that sleep is the all-im- portant thing in the disease has led to fatal errors in treatment. ( )pium, given freely, as it often and very generally is, while the blood is charged with alcohol, produces a very unfavorable effect upon the nervous system, and tends to check the excre- tions, which are already diminished, and the patient, without being narcotized, often goes into a stupid state resembling the effects of uremic poison ; and if about one-half (about the usual proportion), by the vigor of their constitution, weather it, in spite of all the poisons imposed upon them they recover slowly, and their organs are left in bad condition." We make this lengthy extract from Prof. Stone's communi- cation on this subject, because he makes the important distinc- tion between delirium tremens and Mania a Potu, and in his usual clear manner points out the rational treatment in the two forms of the affection, those views, we think, should be more thoroughly impressed upon the profession, notwithstanding Ave are satisfied that the difference in the two forms of alcoholic poison is clear, the treatment of Dr. Stone is the rational treat- ment, yet the Mania a Potu that has occurred in this city for the last few years, has been remarkably fatal, and all methods of treatment very unsatisfactory. Therefore I determined to try the Tinct. Digitalis in large doses, recently two cases presented an opportunity, The first a man, the second a woman. A description and treatment of one case will describe both in all essential particulars. Mr. after a debauch of several weeks, and while yet stimulated to as great a degree as all the varieties of alcoholic drinks could produce: in attempting to light a segar, fell upon the floor in the most frightful convulsions, raving and foam- ing at the mouth, and mutilating his lips, tongue, hands and arms with bis teeth. In a half an hour after this convulsion he was furiously delirious, recognizing no one, muttering his imaginary Pears, and now and then making fearful struggles to escape from his bed, his face almost livid, eyes deeply inject- ed and eyes greatly swolen, pulse one hundred and sixty, weak and thread-like. 1861.] Cataract, Iritis, &c. In the interval of the convulsions, and before my arrival. one-half a grain of morphia had been administered to him. I immediately administered five grains of Ipecac and two grains Tarter Emetic, and repeated it every fifteen or twenty minutes until he had ejected everything from his stomach. This occu- pied several hours when his symptoms were not in the slight- est improved. I then determined to watch the action of the digitalis and commenced by administering a large spoonful every half hour. The first dose improved his pulse, it dimin- ished in frequency and increased in volume. The second dose lessened his ravings and made a more palpable improvement in his pulse. The third dose was increased one-half, when all of his symptoms in one hour, were manifestly improving. I then increased the dose and lengthened the time of adminis- tration, in about seven hours from the taking of the first dose his pulse was fult, slow and regular, his delirium had entirely vanished, and he was sleeping though interruptedly, now and then disturbed by his hallucinations. I then continued the Tinct. Digitalis in smaller doses, giving a mercurial cathartic. His sleep became sound and tranquil, he awoke in about six hours, sane in mind and almost well in body. The only re- maing vestage of disease, was extreme nervousness. I ' then prescribed Tinct. Valerian and compound tincture of cinchona in equal quantities. The second case was almost a severe as the first and was treated in like manner and resulted as favor- ably. If Digitalis acts by sedation, will not Veratria be a more efficient remedv in Mania a Potu \ \tio Atropice Glycerinea; a P reparation for the Dilata- tion of the Pwpil in Cataract, Iritis, &c. Br Charles E. C. Tichborne. Since atropia was first brought into notoriety for the above application, by Heisinger, it has completely superceded bella- donna where introduction into the eye is necessary, but the extract is still resorted to for painting the eyebrow and cheek in such operations as absorption of cataract or anything simi- lar, where it is indispensable in order to prevent adhesion of the iris to render the dilatation permanent ; no preparation of the alkaloid yetintroduced being applicable to the exigencies of such cases. A few of the objections to the use of the ex- tract may be enumerated as follows : Liability to produce cutaneous irritation ; secondly, its requiring great attention in keeping the surface moist with some some lotion to prevent Su tract. Iritis, &c. [January, its drying; and thirdly, want of cleanliness, as the extraneous manner of this inspissiated juice are certainly very much out of place when manipulating with so delicate an organ as the eye; in some. eases complete failure results either from the use of a bad preparation or non-absorption from harshness of the epidermis. Some time ago glycerine was found to possess great solvent properties, particularly as regards the alkaloids and some of the nun-nitrogenous organic principles. The author has de- termined its action and solvent power in connection with atropia with a view to its use as an elegant and efficient mode of exhibiting thissubstance where permanent dilatation of the pupil is requisite. A saturated solution in glycerine gave, on analysis, four per cent. (=gr. xvijss. ad. 5 i.) of the vegeto- alkali. It does not dissolve readily in the acid, but is soluble to almost any extent on applying a gentle heat ; the excess, if it is not great, deposits on cooling in fine transparent colorless prisms, but if the amount is considerable it becomes, when cool, a solid mass. From this it is evident its solubility in glycerine is much greater than in water, it requires 189 parts of the latter menstruum to dissolve it in the cold ;* indeed the atropia is recoverable to a considerable extent by precipita- tion on the addition of water to the glycerolic solution. The easiest method of making this solution is as follows : One decigramme (1,553 grains.) dissolve in a few drops of alco- hol is added to 20 grammes (=368.680 grains) of distilled glycerine ; the mixture is then subjected to a gentle heat, viz: 110 Fah. for half an hour in an evaporating capsule to vola- tilize the spirit. This will contain one-half per cent., i. <\, 2.187 grains to the ounce, and may be labelled "Fortior." On smearing the surrounding parts of his eye the writer found (without dropping in any solution) the dilation of the pupil perceptible in 15 minutes, from which it steadily increased. A weaker solution, i. e., one containing one-fourth per cent, made by using one decigramme to 40 grammes, may be used I'hv author was induced to enter into the examination of the solubility in water from observing tin- non-conformity of works of reference on this subject. Bis experiments gave as a mean result 1 part atropia, to be soluble in 189, generally given as soluble in 800 parts, whilst Lowig gives ii a- requiring 2000; the writer thinks this must be a typographical error and must be intended for 200 parts. This diversity might he accounted for in -ouie degree, a- an amorphous modification, produced by action of atle heat, as apparently much more soluble. This uncrystallizable variety ia equally efficient with the other in dilating the pupil. II.] < Si to determine the dilation, by an-occasional application, and also to allow for absorptioi olution inglycerine ofatropia may be made containing 16 grains to the ounce, without any danger of its crystallizing out. The advantages to be derived from the use of this pre ation, ar properties of the glycerine, which, by softening and relaxing lows fption of the active principle ; secondly, the certainty of ab ie alkaloid in the soluble form, and . Lai distribution from the hygrostatic properties of of the glycerine, which could not be obtained from the u- anyscqueous solution, even in the form of a malate, as in the extract, and also itse pplication, freedom fr ntion as it always remains moist; and lastly, the certatnty appertain- ing to the employment of all medicaments of a definite cohi- ion. ( ' W8. [Many of the following extracts are from the valuable month- ly summary prepared by Dr. 0. C. Gibbs, for the Ameincan 'lied Monthly. Eds. S. M. & S. Jo: .In the Chi Medical M , for No- vember, there is a published report upon praetici cine, furnis Dr. C. Goodbrake, for the Illinois St; deal Society. Under separate heads we shall allude to a few of the more novel opini , then, of scarlet fever: Dr. J. N. Niglas' trea and contains nothing local treatm - : -'The region of the paroti 1 and submaxillary glands, from the beginning, I advise jd with cotton, and mel wrapped around the neck n as the slightest swelling com to be pe . -. a liniment composed of _ la!, dale, oij., liq. ammon. 5>j.5 nii. 5j., gum camphor gr. x , is repeate bed ('faring the day. tin I around ; and glad am i that , nunc of the C under my charge were lost by consecutive suppuration." Dr. Prince would control the pulse with the veratrum viride and then use the stimulating trea sly and fr< Dr. Hiram recovi . full .' carbona e of ammonia, that he thii kJ must have ation. 1: (ammonia) \va Lmended by a French physician, and Dr. X: ria. [J iiiiuai'v ly allied in nature, or in thera ' -. and sclarlet fever. ific poison, affecting the system ically. We have noi Bpace to enlarge ic tincture of iron, quinine, and rvice in ml diph- ng benefit in Bcar- V- no doub 3 of quinine ents that can be fever. Though foreign from our excused for quoting from a trans- journal in support of these views. In the London American reprint,) Dr. J. Hawkes, For those who may have such cases to m >ul t they occur only too recommend the use of quinine. My at- > it in thi by the excellent Eood, in which lie so strongly urges ion in all forms of scarlet fever. I have put his plan .1 a large dispensary practice, and have every reason to bear - an addi \ idence in support of the tonic and stimu- lating treatment in scar! ain (juote from the number of the 1 Dr. T. J. Graham, speaking also <>f malignant scarlet fevei . is abundant evidence ie profession in proof that the sesquicarbonate of am- monia p pecilic powers over the worst forms of scarla- tina, and that, when the eruption recedes, no means known iwer in repi : it, and relieving the lent." ::' fully con vinced that this prep of ammonia, administered regularly, day and .':. and trusted to alone, with a mild aperient and a suitable . will be found fully equal to the restoration of the patient. nt medicine in half apprehended." J)i new or Dr. P ays that the local applica- tion 'this ex; 3! "A fusion of capsicum and a saturated solution <>!' chlorate .f p 1 m, have proved more satisfac- ocal application to the mur. tr. iron to answer the all ; that came under our treatment. We II.] Diarrh Uldren. S8 tried the nitrate of silver, sulph. of copper, alum and sulph copper combined ; but the ti the ilVct in our hands. The best remedies internally seemed to be quinine, tinct. of iron, chlorate ofpotassa, and good porter or brandy, with good nutritive diet." No allusion is made to asaturated solution of tnon salt, ,s a wash or gargle to the throat; this, of all means, has pleased us the best. WYhave applied tins remedy to the throat for another trouble, which we may as well men tion here as elsewhere. A lady of oar acquaintance had, for man years, been subject to frequent attacks of quinsy, which always passed on to suppuration, hi tin.' last year, we have aborted two severe attacks by the local application of muriated tincture of iron, applied several times a day. We have re- duced the remedy with about two parts of water to one of tincture. Diarrhea i of Children. In regard to tl tse, wo .-hall quote that one remark from the report. Dr. J. O. Harris re- marks upon the treatment as follows : "I found that after exhausting all the usual remedies ad- vised by our standard authors, and by my brother physici that quinine in full doses, frequently repeated, (acted or seem- Imirably. lthou me that I was pre- scribing empirically, and now I do not. pretend to explain the of the remedy. [ only know this, thai my patients recovered under the use of quniue, and I still frequ . it. when I see no particular indications for its Typhoi I Dr. Nance's treatnn of this form of fever: My treatment, stated in brief, con-:-:* .1 of spts. nitri. dale, 5viij., Norwood's tinct. veratrum viri one teaspoonful to an adultevery tin . the active stage rem reasing i requires. It may be ne< mtinue this medicine for eight or ten , or more. rescribe at the e time turpentine emulsion, usuall combined with tinct. opis.: prescription the activity of the ] favorably npon the urii iratory . the latter, containing laudanum, q . promoti and the spts. turpentine has its ^jx-c-i ii<- action npon th" glands of the mucous membrane of the When conva es- cenc* iblished, or if the mpport. "My pi Ion during the fall, un< If- mop/ . [January circumsti nl. conchonia, grs. iij.; camphors . iij. Mix, and give every four hours and alteraatc from two to three teaspoonfuls." We apprehend 1 in the treatment of ty- hoid fever consists in "prevenfing" rather than "treating" bad symptoms. Many p re turpentine only when the tongue is dry and the bowels tympanite will heal* the ulcerated state of the bowels, which ' . in the late asonable to suppose that, in :' this condition, ii may act curatively and prevent the diarrhoea, tympanitis, the red and dry tongue*, &c. Many only support the syst< death seems imminent Tonic-, such as quinine modified by opium and wine, can he irted to much earlier than they often are in this disease. When prostratio decided, we think Dr. Nance's two or three teaspoonfuls of wine will nol bring out the full influ- atment. We have given n tolerably full synopsis i I this report, be- cause i f modern treatment, among rn physi( some of our more common disea .// r, of Iron, dkc. In the ( Examine?1, for November, Prof. N. avis reports an alarming ease of hemoptysis, occurring in a lady l; ! years old, who had a decided hemorrhagic diath( inasmuch as the father of the patient and one sister had previ- ously died from hem unon salt, gallic acid, acetate of lead, opium, alum, tinct matico, gelseminum, oil turpentine and quinewere thoroughly tried, with partial and temporary benefit. "Atthi of the case," he says, "we advised the tinct. ferri muriatis, and tinct. o . equal parte which forty drops were taken every two bours. Under the use of this mixture the hfiemorrha than 24 hours, and In Diphtheria. in "October, Dr. S. P. iencewith diphteria. With- in the la In these c all b culiar diphteritic exudation. We Dr. Bryan's remarks upon the treat- ment in lull, for [uite judicious; and, besides, 3 hut one: but want of space will prevent. We simply copy his recapitulation : limited ( n the light in rard meaeleB, variola and typhoid fever, bu1 duration may be materially abridged, as well as its 1S61. menorrhcea. violence greatly mitigated, by prompt and proper I ment. 2. "The milder cas ui-re no than the local appli and the internal use of chlorate of potash, together with -oner- ous diet and the cautious use of such mild aperient m vll maintain a soluble condition of th mon - may generally be very promptly controlled, if -the treatment is early i ced, by the addition quinine, and occasionally of brandy and ' - the for ing. "Depletion in this d whether din [-let- ting, or indirect by purgation, &c, is not only a vain. pedient, but, in consequence of its debilitating effects, is posi- tively injurious, by favoring the accession of typhoid symp- toms, and preventing .1 rapid and cenc The nitrate of silver is applied 20 grains to the ounce by thorougly in the thr< r four times a 1 This followed, hall' an hour later, with a solution of chlorate or potash 5ij- to iv to water Oj . In severe is main di [uinine, which, to adjal ins a day. "T 5, "appeared I the fever, ai of the di rred to, in from two to five days." ! [e says further : "It ; the quinine urative influ- inferior to thai whic srts in ordinary malarious hich before -1 rapid. numbering in - Von: L20 to 140 heats per mini ce, fuller, stronger and sloi Dysm rg. Jou\ . mber,Dr. J. B. Snelson has an articl u dysme- norrhoea, in which he recommends quinine in combina with pri 1, particularly in tic or neural- He would treat the menstrn pium and the warm bath, and the in' with the followin Iph. Quinine, M . Divide into pills No. xx. On 1 be tal morning, noon and night ; tl mtinued dur- le intermenstrual ." [f we rightly remem- Throat Di nary, p, : hi the /. ! L851 . re" line in < with sulphate of iron or most of the unnatural manifes- We are not certain that From the change which strych- mr hands over the rheumatic or neuralgic difficul- p, we would suggest it in connection . in dysn oea. /' morrhage. in the Lancet and tber, Prof. G ML"endenhall reports a of post-partum uterine haemorrhage. The usual mean tout benefit; the hand was inserted the uterus, also lumps of ice, but still with no check upon ren, but with no perceptible atheter was introduced to the uterine three ounces of the saturated solution of of iron injected through it into that organ." ion was I for a few minutes by the hand in the nterud. The injection produced no pain, but >m that moment not another drop of fresh blood was dis- charged from the uterus and vagina.'' The patient "recovered without an unpleasant symptom." it Distemper" of the Last Century. In the Surgical Journal, for November 15th, Dr. Q. II. Gay republishes a paper upon the above subject, written by Jonathan Dickinson, of Elizabethtown, }\. J., in the year 1738, and published in Boston in 1740. Dr. Gay 3 that ti use described, and for which direc- given for treat was none other than diph- ia. Dr. Dickinson d ss no less than six varieties ud some of the symptoms do conform very irately to those of the last named d When he whole throat,and sometimes the roof of the ith and nostrils, vered with a cankerous crust, whic us parts, and frequently tcrmi- sonable applications embling diphtheria. 3 mi epidemic, often it fatality ' hoarseness, difiicull mal bubo-like ulcerations, >n of large quantities of tough, whitish we also recognize con- Li in diphtheria. Again, in uni- rmptoms, L L] ST "The tonsils first, and in a Little time the whole throat, is red with a whitish crustula; the tongue is furred and the breath foetid." Bu1 other symptoms rationed that show a dissimib diphtheria, as ' itself; thus, the 2nd, 3d or 4th day, if pro- per methods are used, the patient is covered with a ml eruption,ins mblingthe measles; in like the scarlel fever, (for whic mper it has frequently been mistaken,) but jn very much resemble* influent small pox."' It may be interesting to notice, in this connection, a remark or two in regard to treatment. local means to the throat, h< found the following method most successful : Take Koman vitriol,! lie as near the fire as a man can bear h id, till it be thoroughly calcined and turned white ; put about 8 grains of this into halfapinl of water; lay down the tongue > a spatula, and gently w. s much of the crust as will easily separate, with a line ra< lo end of a pi or stick, and wet in this liquor, made warm. This opera- aid be i py three or tour hours." Ln conclusi Dickin treatment of which is reported to larkably d in all forms of the dis- administration of a "de< [uaw-root," pre- pared in the foil of this I in a quart of i he adds, when two ounces of loaf ar, and b the consumption of one-quarter tienfs frequently to drink, and i gargle their thr< i alio-. the conclusion." . Jn the Medical and tfurgu . 27th, and November 3d, the pape ilton i which only Lts in the argument. [1 I ally ecretion the of opium ; yet there practical importance, and \ tate it in Vm [January, Dr. Hamilton. "P< ion is nearly al- wa\ 3ed by a moderate or full dose of opium, and d activity of the cutam halents is gener- ! by an n of the heart and wu in such ised color of the Dr. Hamilton considers the various in which opium is appropriate. Wehave notspace lor an abstract. We will only instance peritonitis, dyi bery, typhoid fever, and various forms of inflammation. In his paper various distinguished physici- ans took part. We will here refer to only one idea: Prof. taking upon this subject in reference to conges- lion and inflammation, says, that in congestion of the lut the administration of opium has always a tendency to in- crease it. We wry much doubt the correctness of tins rtion ; we believe that opium has a tendency to relieve all internal congestions. We know of no remedy that will he cutaneous circulation, and produce free per- spiration, as will opium, lu congestion of the lungs, a harassing and perpetual cough but ii the congestion. Opium, by allaying this cough, determining the circulation to the superficial blood-vessels, and the free perspiration consequent upon this, can have no other influence than to tie internal congestion, Here we leave the subject, referring our readers to the paper of Dr. Hamilton, and the discussion following, as worthy of attentive consider- Vari ins of the Leg. In a former number, we re- ferred to the treatment by subcutaneous ligation, as prac- I by Dr. R. J. 1. Philadelphia. In the Med and Surgical Reporter, for Xovember 17th, Dr. Levis has an ani i this subject. Ee regards varix of the log as. practically, a disease of the saphena veil proper treat- ment he beli consist in the obliteration of this vein. manner of its accomplishment is described in the paper I to. lie thinks the operation is best performed while the pa tanding. To have the limb at a con- venient height, he would have him stand upon a chair or table, and so placed that the patient can steady himself insl the wall. He prefers a round, straight needle, to i one with the common surgical needle | I the n< inserted licularly, until ii reaches the under service of i. The - then de oint pa- L861.] Broncl under the vein, and passed out on the opposite side. The needle is now made to enter at the orifice of exit, and pi ing now ahove the vein, em I the point o[' original entrance, it should have been observed that the needle should previously be armed with a silver or iron wire of small size. The wire is now drawn down upon the vein. tightened, and fastened by twisting. Adhesive or isinglass piaster is novv* applied over the wounds, and the limb is bandaged from the toes to the knee. Dr. Levis regards this treatment as eminently - ul, and accompanied with no danger. onic Bronchitis A New Remedy in. In the Medical and > Reporter j for November 17th, Dr. II. AVilson has an article upon the treatment of chronic bronchitis. He regards local medication as of the first importance, and aiders in review most of the means, the use of which has been recommended in this manner. Suggesting a new remedy, lie For several years past I have been in the habit oi using a remedy, which may not be new, but which tar surpasses that of any other which I have tried in relieving, and in many instances entirely eradicating, the affection. I refer to the leaves of the common mullein, (verbascum thapsus,) dried and smoked in a pipe. In that form of the disease in which there is dryness of the trachea, with a constant desire to clear the throat, attended with little expectoration and eonsiderable pain in the part ailect- ed. the mullein, smoked through a pipe, acts like a charm and affords instant relief. It seems to act as an anodyne in allaying irritation, while it promotes expectoration and removes that glutinous mucus which gathers in the larynx: and at the same time, by some unknown power, completely changes the character of the disease, and, if persevered in, will produce a radical cure/" He says the remedy should be used as indicated abov< . a day. Ra I )f Obliqi lal Hernia. Or. 1). Ihi Agnew has invented new instruments for the radical cure blique inguinal hernia. The pri of cure does not differ materially from that put in pi ers: the instrume 1 may enhance the coir. of the ope- ration. We have !. 'ption. it to say, that the scrotum is in va linal .!. and i- hold there, andthc canal rendei by 00 BeUadonna in Sore Throat [January, an instrument not unlike a bivalve speculum. A long, ar-pointed, curved needle is now armed with a wire, car- 1 up in the groove of the blades, and made to pierce the integurn cning out through the walls of the abdomen. Th< < '.id of the wire is now threaded, and the needle is made to pierce again the | >ut a short distance from the first insertion. The wire is now drawn down and fas- tened ; the objed being to make a plug of integuments fill- ingthe inguinal canal. Several stitches are now taken nal.in front of the cord, the object of which is bo aid tl in retaining the invaginated portion of the 1 thus forming a permanent tegumentary plug, filling the canal, and thus preventing the descent of the howel. We condense the above from an article in the I Surgical Reporter, for Xovember 17th. Bearing upon this point, we might remark, that Prof. Tyme, of Edinburgh, says that all apparatus for this opera- tion is unnecessarily complicated. "A piece of candle," he , "with a little piece of twine through one end. will i r all purpo- adonna in Sore Throat. In the Medical and Surgical Reporter, for Xovember 10th, Dr. J. W. Thompson has an article upon belladonna. He has used belladonna in inflammation of the breasts with good effect. He dissolves &ij. in fj. of water, and applies to the inflamed brei We use the fluid extract without dilution, and it has never disappointed us, when used to prevent inflammation incases of delivery of still-born children. Neither has it disap- pointed us in tl, >f inflammation of the breast, where suppuration had not already commenced. We ] i rre< I to the paper of Dr- Thompson more for the purpose of giv- ing his experience with belladonna in sore throat. He says. "My experience with it in incipient sore throat would lead me to rank it almo iifficiently early. My plan is togive the sixtieth of agr. of atropii I rely m it confidently if given within six hours of thefirstap- of inflammatory symptoms. I have tried it ionm; and have to ilure." I influem limited to th ihrymal Duct. : November L7th, Dr. -i. 1'.. Macdonal des- ration. Ee done il.] Dyspnm. 91 away entirely with the direotor, and only employ a blunt- pointed, narrow, aim Blightly curved bisctoury, the blade of which is only about three-quarters of an inch long, the heel about three-sixteenths of an inch broad, and which tapers to a fine blunted point, a very little probe-shaped. It is sharp on its concave edge, cutting to the point, which is very narrow: and to provide for its strength, the back is somewhat stout, and delicately clubbed at its extremity." Dyspnoea from Cardiac Disease relieved by the Inhalation of Oxygen. In the American Medical Times, for November 17th. Dr. J. C. Acheson, reports a case, in which a troublesome dyspnoea was relieved by the inhalation of oxygen. In the rase reported, the pulse was imperceptible, with other symptoms corresponding. Pic says : "Within 15 minutes after the patient began to inhale the oxygen, signs of relief were apparent. The restlessness ceased; the breathing be- came much easier: pulse became perceptible at wrist; -in- telligence began to return ; and waking from his lethargy, he complained of the coldness of his body, and desired more clothing." The patient died, but the benefit resulting from the inhalation of oxygen argued better results in more favor- able En extreme dyspnoea, in the last stages of con- sumption, we have resorted to the inhalation of small doses of chloroform, with very decided benefit. Diphtheria. In the Cincinnati Medical and Surgical JS< for November, Prof. TV A. Iieamy has an article upon this -non. He says he lias treated 250 cases, and remarks: "I will here assert, that, in my humble judgment, any one who will, at the very outset ot the attack, administer full to i grs. to children 8 to 0 years old) of sulph. of quinine, and continue its use, in connection with chlorate of potash, and apply nit. silver in solid stick locally, avoid- ing mercurials in any quantity or form, catharticizing as little as possible, will find such su< cess attending his treat- ment as will lead him, if he had doubts as to t\\o nature and pathology of the disease, to settled and satisfactory fusions. Id many cases, I deem it better to use nitric I in connection with the quinine treatment, than chlor- of potash." Diphtheria. Jnth< al Re- , for November, one of the editors, Dr.T.S. Case, has an article upon diphtheria. We take pleasure in y Charles Bland Radcliffe, M. D.. Kellow of the College, Physician to the Westminister Hospital, etc. Mr. President and Gentleman Of the three Lectures which T haveHhe honor of delivering before you. I pro] to devote that of to-day to the Physiology of Muscular Mo- tion ; and this J do because 3 to be necessary to re- id. T the whole of this subject, and to change our opin- py important particulars, bef< an hope to I ingthe theory and therapeutics of convulsive di I opinion r> g muscular action, I ! 1 1 ; need scarcely say, is, that muscle is endowed with a vital perty of contractility, and that the state of contraction is brought about when this property is called into action. When the muscle contracts, thai is to say, this vital proper- ty of contractility is supposed to be roused or excited, or stimulated into action, and the more the muscle contri the more is this property supposed to be thus acted upon. But this is not the only opinion which maybe held respect- ing muscular action. On the contrary, it may be held that ;rue type of muscular contraction is to be found in rigor mortis. It may be held, indeed, that muscle contracts, not because a vital property of contracility has been roused into action by a stimulus, but because some antagonizing influ- ence has been withdrawn, which previously prevented the free action o\' common muscular attraction in the muscular tissue. When, upwards of ten years ago,* I endeavored, for the first time, to show that the latter view of muscular action the correct one, I believed that I stood alone in this ion. In point of fact, however, others had gone before me, whose thoughts were, more or less, akin to mine. Writing in 1832,fDr. West of Alford, in Lincolnshire, says: pvous influence is imparted to muscular fibre for the n of the will, and of all other deposers to contraction, withdraw for a while this influence, so as to al- pcrty of muscular Able (contractility) to w itself/' And in support of this opinion he appeals, amongst other arguments, to the fact of rigor mortis being deferred until all traces of nervous action have disappeared, and to the fact, not less certain, of spasmodic action taking- place when we have evidence of co-existent nervous debil- ity. It would appear as if this idea had been suggested by a remark of Sir Charles Bell, for Dr. West refers to a lecture at the Royal College of Surgeons of England, in which, < saying that the question of the modus operandi of motor nervous influence could never be settled, Sir Charles adds, that he had been led to suppose that muscular relaxation might be the act. and not contraction, and that physiologists, :' Vital motion. 8vo. London : Churchill. ! - er Muscular Contract] mIod al Journal, edited by Michael Ryan, M. I >. Vol. 1. 04 tures on [January, in studying the subject, had too much neglected the con- sideration oi the mode by which relaxation is effected. !n years later Dr. "West is followed b\ physiologist ofn name Professor Duges, ofMont- pellier who maintains that all organic tissues are the seat of two o movements expansion and contraction; and that contraction, which is in no sense peculiar to muscle thing more thau the cessation of expansion "in con- tion musculaire ne consiste que dans i'annihilation de expansion."' The muscle contracts, he thinks, in virtue of its elasticity, just as a piece of caoutchouc might contract, ( fr< e from a previous state of extension ; and an analo- gy is hinted at between the expanded state of the muscle and the :lui 1 state of the fibrine of the blood, and between rigor mortis and the coagulated state of the fibrine. Analo- in its effects to electricity, the vital agent is supposed to accumulate in the muscles and produce expansion by causing the muscular molecules to repel each other; and contraction is supposed to be brought about either by the sudden discharge (as in ordinary contraction) or by the gradual dying out (as in rigor mortis) of this vital agent. Ir apposed further, that the rhythmical movements of muscle are caused by successive discharges of the vital at, which discharges arc brought about whenever this at acquires a certain degree of tension; and that the cramps of cholera, or the spasms of tetanus or hysteria, are produced by the development of the vital agent being for the time suspended. After Professor Dugesi' comes the present distinguished occupier of the Chair of physics in the I niversity of Pisa. Writing, in 1847, about nervous influence. Professor Matteucci says: twCc fluide, developpe principalement dans les mus repand. et, doue d'une nave repulsive entre ses parties, comme la fluide electricque, il tient les elements de la fibre musculaire, dans unetat de i analogue a celui presente par les corps electrises. Quand ce fluide nerveux cesse d'etre libre dans le muscle, de la fibre musculaire s'attirent entre eux, ime on le voit arriver dans la roideur cadaverique . . . . Suivant la quantite de ce fluide quie cesse d'etre libre dans e de Physiologic Comparee de V Homme el des Auimaux. s\<>. March 17th, 1847. loin atraction est plua ou moim hypothesis appears to have beeD framed partly ii quen< lerationswhi bow that the | ntraction" wasowingto the in the muscle in which the "induc- ing contraction'1 anifested an idea originating with M. Becquerel and partly in consequence of the analogy which is found to exisl between the law of contraction in muscle and the law of tl barge in electrical fishes; but it is right to at Prof Matteucci does not appear to have attached weight to his opinions upon the subject.* Xext in order, f and preceding myself by not more than a month or two, is Professor Ennel, then of Zurich, now the ipier of an important chair in the University of Vienna. The action of nervous influence, according to this physiolo- i antagonize muscular contraction, and this opinion Hinds upon the fact that rigor mortis supervenes when all signs of nervous action arc at an end, that the muscles are more irritable when removed from the influ- rhc ner. intres, and that cramps and other rive muscular contraction are often seen to happen spontaneously in paralysed parts. And later still,! . the date of my first publication on the subject a similar jpectingthe action of nervous influence upon mi sd to Professor Stannius, of [ have received several pamphlets, Columbia. U. S. of Ann in which i determines a state of ac- and that contraction proceed- from the with- The protrusion of the tenacles ol the snail and ;' the head and limbs of the muscular r. Mackall thinks, are unintelligible withoul igaticn. And that contraction is the al l]v- . athor aims, for it i- die a muse] which . K'oii. ( : sellsch. den a and Todl !. Heilkunde, Stuttgart. 1- 96 lures on [January, Rostock, by bod oua experiments, in which lie has >r mortis relaxing, and the losl irritability returning to, the muscle under the injection of blood into the vess< I do no1 stand alone, then, then, in thinking that a great change i iry in the theory of muscular action a change amounting to no less than a complete revolution: and i am glad that it is so, for, thus supported, I am more b >ld to challenge attention to the arguments upon svhich I opinion. h is only within a comparatively recent period that it has been possible to demonstrate the necessity of a fundamental change in the theory of muscular action. When I wrote first on the subject, I did not command the facts which are ntial to such a demonstration, and I do not think that the writers whose names I have mentioned were a whit re fortunate in this respect. Now the ease is cntirely erent, and the present difficulty is, not to find facts, hut to make a selection, and to marshal those that aie chosen in 1 1 10 short time at our disposal. The true key to the interpretation of the phenomena of muscular action, as it seems to me, is to he found in the weries which have recently taken place respecting tin- electrical condition of muscle and nerve; hut before at- tempting to find and apply this key, it will he well to see how muscle behaves under the action of blood and nervous influence. I. Arguing from the comparative anatomy of muscle it would seem as if muscle were not most disposed to contract when it is most liberally supplied with blood. It would if the degree as well as the duration of contraction- were inversely related to the supply of blood. Thus the degree and duration of contraction) is greater in the volun- tary museles of fishes and reptiles than in the voluntary muscles of mammals and birds : greater in the muscles of any given animal during tli pe of hybernation than during the fever of summer Life. The fact, moreover, that rigor mortis may he "relaxed," and the lost irritability restored to the muscle by the injec- tion of blood into the vessels a fact which has been abun- dantly demonstrated by Dr. Brown-Sequard* and Profes Comptea Rendus, Jnhe 9th and 25th, L831 would appear to bo in direct contradiction the idea that the muscle is in any way stimulal con- ; by the blood. One of Dr. Brown-Sequard's experiments pon the arm of a criminal who had been guilotined at 8 a. m., on the 1-th of July. 1851. The experiment, whi< in injecting and re-injecting a pound of defibrinated d blood into the brachial arte fourteen hours after decapitation. At tb in a state, of perfect rigor morti into the vessels, som sd in different parts of tb rm, of the arm. and more particularly of the wrist. Tb larger, and the skin acquired tb has in rube- ola. Soon afterwards the whole surface had. n reddish-vio- let hue. A little later, and the skin natural living color, elasticity, and softness, and the veins stood out distinct and full as during life. Then the in the fi ly in the shoulders, and on ex- amination they were for.: Lave recovered their lost irritabili uarter t muscles were i irritable than they had been at five p. m., at which time the as first exam and this incr was kept up without abatement until 4 a. m., when fiiti r to abandon the experiment was commence and that of the room 6 The of another experine n rab- which I. ; killed by [uard waited until ri hen I the defil one lie hind lim m the body. Fifteen minut tnent d re- adily t Ivanic in From this time, through the night, until day, the blood intervals of to 3d minute.-, and during tb time the ma All this whi >ther hind limb < limal, and of the rest of t' mor- >Op. cii. 98 iures on [January, p. in. the injections were discontinued. On resuming the experiment after this interval of an hour and a half, the limb, with the exception of a few bundles of fibres here and there, had again become rigid. The effect of I tions was precisely as at first; and when, from the of the evening, the experiment was again aban- doned, the muscles were perfectly soft and irritable. On the morning following, the limb upon which the injections had been practiced was in a state of perfect cadveric rigid- . while the muscles of the rest of the body, which had 1 left to themselves, were already beginning to pass out his state. On the third morning, the rigor mortis of the Limb was undiminished, and the other muscles of the were soft and in an advanced state of putrifaction. About the time Dr. Brown-Sequard was engaged in these resting experiments, Professor Stannius, without the knowledge of what was being done in Paris, was carrying out an analogous series of inquiries in Rostock. On the 21st of July, 1851, at 7.1 a. m., Professor Stannius a ligature around the abdominal aorta and crural arter- ies i ppy. About a quartea past ten, the muscles had begun to stiffen in the parts from which the blood was ex- cluded. At a quarter to eleven, both hinder limbs Avere stretched out, and perfectly stiff and cool. At twenty minutes past eleven, the ligatures were loosened, and the blood was seen and felt to penetrate into" the empty vessels. At a quarter to twelve, the natural warmth had returned in some degree, and the right hinder limb was a little more Hexible than the left. At noon, both the limbs had recover- ed their flexibility, and it appeared once as if the left had moved spontaneausly, but no sign of ] . caused by pinching the toes. At half-past twelve, the muscles of the paralyzed limbs cantracted everywhere upon the applica- tion of the galvanic polos ; and at one point the galvanism cause pain, for the animal, which was before quiet gave a sudden plunge iorwards. Death happened unex- ; edly at twenty-( i nutes past twelve p. m. A similar experiment was performed upon another pup- arly in the morning of the following day. At noon, . there was no evidence of stiffness in either of hind limbs, but the muscles below the knee had ceased e touch <-f lee electrodes. At a quarter- limbs were stretched out and nd all e Li'ritibility were at an end. At 1861.] wulsive Diseases. twenty-five minutes to three, the ligitures were unti< twenty-five minutes to four, the application of the eh caused strong contraction in the muscles of both tl;i and weaker contractions in the muscles of the lel'i low the knee, while, at the same time nearly all tn rigidity had disappeared from both limbs. At tw< minutes to six, every trace of stiffness had disappeared, i the muscles responded- perfectly to the prick of a h well as to the touch of the electrodes. On the follov morning the animal was found dead, and with the rigi< of death fully established everywhere. Now, that the stiffness of which mention is here made is perfectly identical with rigor mortis will appear frefm the following experiment. In this experiment, the aorta and crural arteries of another puppy were all carefully tied. Four hours afterwards, the muscles behind the ligature were perfectly rigid, and all traces of irritability had cl: peared in them. In the evening' of the day following, the animal was still alive at least in its anterior half and, upon the whole, it was comparatively fresh and quiet. Twelve hours later, the animal was found dead, with the parts before the ligature in a state of rigor mortis, and with the parts behind the ligature, which had been rigid before death, flaccid, moist and partially putrescent; in other words, the parts behind the ligature were in the state which comes on after rigor mortis, and hence it follows that the stiff] which existed in these parts before the complete death of the animal must have been identical with rigor mortis. Here, then, are certain experiments which would seem to show that the influence of the blood, be this what it may, ;ercised in counteracting the contraction of rigor mortis; ! this inference, which I had drawn from the experiments of Dr. Brown-Sequard before my attention was directed to- those of which Professor Stannius, is the same as that wl the last-named physiologist has drawn from his own experi- ments. There are, however, certain facts* which that muscle is affected differently by arterial and by venous ive led Dr. Brown-Sequard to think the omee of arterial blood is to minister to the n tion of muscle and other til i of 'Compter Rendus, Xo. xvi, J Oo [January, of power, and that office of apply a stimulus, by which the power called "mto action a view the function of the black Mood is no conomy than that of arteriai guuient in favor of the idea that venous blood adowed with these stimulating properties is based upon well-known fact, that the muscles contract violently en the wholi >:." blood becomes venous, as in as- xia. Another argument is derived from the fact, also fjui. the phenomena of asphyxia, that the left ventricle of the heart appears to pulsate more violently dur- moments of the process of suffocation; for at .e pulse is firmer and fuller, and the mercury higher point in the haemadynameter. Other ' asedupon some original experiments of Dr. Brown-Sequard, in which it was seen that certain involun- tary museles might be thrown into or out of a state of i ion by injecting alternately black and red blood into their ve these experiments, the uterus of a pregnant rabbit parated from its connexions with the spinal centres, and blood injected into the aorta. On injecting black blood, the uterus contracted, and two or thrc ere expelled; on injecting red blood, these contn Lediately passed off. But, it may be asked, is it not possible that these convul- !(1 contractions may be due to the want of arterial d rather than to the presence of venous blood ? And iplanation the less difficult of the tw It violently con- ed when as when it is strangled to th. Ct is certainly true, thai ay, that an animal is ddenly emptied they are all luddenly d with blackbiood. AndtL mrely the convi ttending upon heemorr- of arterial blood seeing h cases rather than to of ven- eingthat this cause can only L1 any rate, with the fact of convul- : it is evident that ntial to convulsion. c allowed that the fuller pulse of the first 1.] Conmrts 101 moments of -Buff is due to increi mulation of the left ventricle on the part of the venous blood, for this phenomena may be the result Lifficulty which nnarterialized blood experi< trough >mis capillaries a difficulty by which the ordinan i traction of the venti in distending tin >f the intermediate arteries. And it is certainly unn( any stimulating properties in the venous blood to explain the contraction of the uterus which by injecting such blood into the aorta of a pregnant for is it not a well-known fact that the uter ten < on- tracted and expelled its contents \ regnant animals have been bleeding to death in I It would seem, also, that an argument in favor of the idea that the contraction in these several cases is really due be absence o al blood may be found in a recent experiment, in which Dr. Ha r that stri nia and brnsia act, in part at least, ] alization of the blood. 1: scperiment, measures two equal portion :alf into and mi; - all quantity of strichnia with portion. Then, after thoroughly saturating the blood in ea c 1 1 I re p eatedl y shaking it wi tl l f re si i quantity up with 100 air, and A hours the air within tl 1 by Bu and. it of thi found I whic in contact with tains mo vnandi- mic acid than the air which had b in contactwith the simple blood th i position ion of Air after h hav- ing b< Li in Common Air mtact w ' Blc i 'iOUl a i n i n / 17. . . . 79. .71 100 .00 tares on [January, [no chuia has prevented the blood ..t'ii and giving off carbonic acid. It has say, from becoming arterial, and for this reason the action ofthe poison may he said to of blood. I be -aid, in- i! to very copious loss of blood, for in experimi suits are given in the accom- panying ddition of a very minute portion ofpoi- red as equivalent to a loss of two-thirds of the whole amount of blood, inasmuch as this addition - of the power which this blood had of sygen, and of so becoming arterial. When brucia is be only difference is one of degree. The f the blood, then, be that what it may, would : i to be exerted in counteracting, rather than in causing muscular contraction. At any rate there would seem to be bo far as we have seen, for supposing that blood se a stimulous to muscular contraction. II. It is very far from certain that muscular contraction is produced by any stimulation derived from the nervous em, * On the contrary, there are certain facts which seem bher fatal to such an opinion. One of these (acts is to be found in the extraordinary in- muscular power in the hind legs of a frog after . of the spinal cord. In illustrating this fact, Dr. Brown-Sequard attaches a small hook to one of the hind 3 a little above the ankle, and tests the muscular power the limb by hanging weights upon this hook. First of all, he finds a weight which is just a little heavier than that which the muscles of the Limb are able to lift, when they thrown into contraction by pinching one of the toes. This done, he then divides (he spinal cord immedi- ihind the second pair of nerves, and goes on testing the of the paralysed legs by changing the upon the hook. The results are very strange. Im- : yi : of the cord, the muscular pow- er pul forth by the weighted leg when it.- to is pinched is -7. but generally i1 is about a third or a fourth of] was befo operation. Fifteen minutes later idently rallying. In twenty or twenty-rive had lost. At the end of an r than it was before the operation- perhaps An lion: Later still, it is certainly doubled n bled: and from this time up to the twentv-fourth A. B. 60 10 60 80 GO 130 100 140 120 140 130 150 140 150 140 1851.] h uses. hour, when the inert rally attains its maximum, il i on slowly augmenting. The particulars of two experi- ments with very fine frogs (A and B) were as follows, (weights raised being expressed in grammes : - experimented upon . n of the spinal i Immediately aft< In five minutes . In fifteen minutes . Grammes raised after In twenty-five minutes . the division of the^ In one hour .... spinal cord. In two hours .... In four hours . . . In twenty-four hours In forty-eight hours At this la int the muscular power may remain nearly stationary for six, ten, fifteen, or twenty days. In a month, if the animal lives, the power in question will, in all probability, have fallen to its original value before the ope- >n. In six, seven or eight months it may not be more than a third or a fourth of this v It is possible, how- . that some part of this failure might have been pre- vented if care had been taken to exercise the paralysed limbs Ivanism. other experiments, moreover, which show plainly that the muscular power is similarly augmented n the muscle has been altogether cut off from the spinal thus contradict Dr. Mar [all's no se of muscular power, after division of al cord, is due to increa aulation on : of the cord, which ;ed stimulation has come into' ] controlling influence of the brain lias b In one experiment, for example, Professor Engel clips out whole of the cerebro-spinal system of a frog, bones all, and, after five or ten minutes, lie finds that the mua irritable as to be thrown into a state of ".on by a blow upon the table. lie finds, indeed, under these circumstances are quite a re in the case of a narcotized fr< lit, Dr. Bro . behind the roots of the brachial r this he cuts through ;. res proceed- f the hind . he 104 Lectures on [January, th hinds limbs from the body, and on compar- ing their irritability by pinching and galvanizing the nerves, thai the "irritability is augmented*' in both limbs, which had been previously cut oil" from rd by the division of its nei But what of this augmented irritability? There is, no bt undue readiness to contract on the part of themuscles undue readiness to bring about contraction of the part but there are sundry difficulties, of a very e character, which must be removed before it can be allowed that this change is owing to augmented irritability. Two such difficulties are presented by the two following sriments in Dr. Harley's very valuable investigations Biological action of strychnia and brucia. In one of these experiments the hearts of two frogs arc cut 3 in distilled water, the other in a ': solution of strychnia or brucia. Placed in distilled water, the heart is found to go on pulsating for a longer time. still, even for hours; placed in the poisoned solution, heart is found to cease beating almost immediately, and ate of rigor mortis before the other heart has any of its power of contracting rhythmically. In the other experiment, instead of the hearts of two frogs. the two hind limbs of the same frog are placed, one in dis- tilled water, and the other in a solution of strychnia or brucia strength, and arrangements are made for test- he irritability of the two limbs by galvanism. This is experiment. The result, which is not less marked than in thi .lie re the hearts are concerned, is that the limb imni< n e 1 in plain water contracts strongly for some time 1 the limb is immersed in the solution of strychnia or brucia Is d into the state of rigor mortis. It would seem, indeed, as if the poisons acted upon the irriti ues in the same way as that in which they have bees i act upon the blood; for, as Dr. Harley points if the irritability of the muscle may I to imply the suspension of that process of ab- onic acid the so-called le whs inly most energetic marked." But be the expla- . tl mains, that the so-called ir- rapidly when the irritability is said ited tor in no the irritability ntedthan : f rychnine poisoning: 1861.] Con and thus, instead of ascribing the undue disposition to i tract to augmented irritability, it. would seem more in ac- cordance with the fact to BUppose that this undue disposition ro contract ia dues to a change which is the very opposite of augmentation. At any rate, after what has been said. it is impossible to refer the phenomena of a so-called aug- mented irritability to augmented innervation. Nor docs the permanent contraction, which comes on sooner or later in paralysed parts, appear to be in any way dependent on the sitmulus of nervous influence. This per- manent contraction comes on sooner or later in all paralysed parts, and the fact may easily be verified experimentally. Thus, after destroying the spinal cord in the lumbar region of pigeon, the muscles of the paralysed parts are at first soft: in a few days they become somewhat hard : after a few - they pass into a state of permanent contraction con- traction by which the legs are kept extended and divergent. The muscles, indeed, would seem to become contracted, because the action of the nervous system upon them was suspended, and to remain contracted because this state of things was permanent. It would seem, also, as if the facts which still re the background are equally unfavorable to the idea that cular contraction is produced by any stimulation derived from the nervous system. It is impossible, for instance, to look upon the convulsions produced by haemorrhage, and find a reason for believing that they arc connected with undue stimulation on the part of the nervous system. For if it be a law in physiology, as it undoubtedly is, that the functional activity of an organ is proportion to the activity of the circulation in that organ, then it follows that the ac- tion of the nervous system must be at zero during the con- vulsions of haemorrhage, seeing that at this time the vc are alim ty of blood, and the heart is well-nigh still. The inference, also, which maybe drawn from the general fact of convulsion in haemorrhage is confirmed and rendered more circumstantial by some re< erimental investiga- tions of Dr. Kussmaul and Tenner/"1 of which the import- ance cannot well be overral In one of the experim hysiolo- :. v.. Xatii chen. u. d. Thii vol. ii. Frankfort. I Ift!1) 5 on [January, gists, Is are passed behind tL innominate and rabbit,* and arrangements which these thi be tied and untied in a moment. On tyi the animal was violently com ligatures about si onds : at their he"; were instant] ight to an end. Convulsion is brought on, thai of blood to the brain, the medulla oblongata, the upper part of the spinal I, and the cervi< al ganglia of the sympathetic nerve ; and nvulsions are instantly suspended by allowing the blood to return to those organs. In other words, the con- vulsions would seem to be connected with a state ol inaction of one or more of the nervous centres named ; for how can there be any action where blood is wanting ? Xor can it be said that there may be over-action in the rest of the spinal cord and in the thoracic and abdominal ganglia of Lpathetic system over-action in consequence of part of the blood which cannot find its way to the head and neck Ided to the blood which, under ordinary circum- ices finds its way to these organs for there is another experiment which furnishes conclusive evidence upon this poi\ In this experiment the subclavian arteries of a rabbit are tied at their origin, and a ligature is also placed around the ; of the aorta, a little beyond the opening of the left subclavian artery. The ligatures, that is to say, are so placed as to bring about a result which is the very opposite of that which was secured in the last experiment. In that blood was cut off from the head and neck, and the circulation confined to the trunk and limbs; in I the blood is cut off from the body and limbs, and the circulation I to the head. In tl to say, I of the brain, medulla oblongata, upper part of the spinal cord, and the cervici Le sympathetic nerve. p< than th< : for all the blood of the body is diverted in this direction; while the i abdominal : at all. tnmenco inde- 1861.] Convulsive Diseases. 107 And what is the result? The result is paralysis of the parts behind the ligatures, without convulsion. In one or two instances the paralysis was preceded by trembling; but in no instance was there convulsion, or anything approach- ing to convulsion. It Was ascertained, also, that this ab- sence of convulsion was not due to paralysis of the spinal cord from want of blood, for on compressing the carotids so as to prevent the flow of blood through these vessels the animal was instantly seized with violent convulsion. Here, then, are two experiments, the significance of which cannot well be misunderstood. In the first, we see that convulsion is instantly arrested by allowing the blood to re- turn into the great vessels of the neck ; in the second, we see that convulsion is not caused by cutting oil' the blood from the body and limbs, and in that way increasing the rush of blood to the head and neck. In the first we see, further, that convulsion is instantly brought about by tying the great vessels of the neck ; in the second we see that the same result is brought about by compressing these vessels. In other words, we see that convulsion is absent when the presence of an undue quantity of blood may be supposed to imply an over-active state of the cranial and cervical nervous centres, and that convulsion is present, when, from com- plete want of blood, these centres must be supposed to be in the very lowest degree of activity compatible with life. In the second of these experiments, we may also find proof that the convulsion is equally unconnected with an over-active state of the spinal cord, and of the thoracic and abdominal ganglia of the sympathetic system; for, after the circulation lias been for some time at an end in these ner- vous centres, and when, therefore, the functional activity of these centres must be nil, convulsion is brought about by compressing the carotids. And lastly, an indirect argument in support of the infer- ence arising out of these experiments that it is the absence and not the presence, of blood in the cranio-cervical nervous centres which ha3 to do with the convulsion may be de- rived from the fact that drowsiness, and not convulsion, is the consequence of that capiliary injection of these centres arising from the division of the sympathetic nerve in the neck, or of that venous engorgement brought about by ty- ing the jugulars, or that double artcrio-venous eonjection which happens when the sympathetic nerv< divided [Janua in the neck and lie jugular veins in the same animal. with blood, then, so with the "nervous influence," the evidence throughout would seem to be altogether opp< to the idea that the anion upon muscle isthatofa stimulus to contraction : but upon this point it may be well to refrain from forming an opinion until we have bad an opportunity onsidering some facts which find a place more conveni- ently in following sections. [TO BE l ED.] Rhus 71 idronin Paratysis. By Dr. Michalowe Dr. Michalowski advises the use of fresb rhus toxicoden- i in paralysis, and reports the following ease in support of his recommendation : A farmer, 35 years of ag< years with violent rheumatic a tiie bones and joint.- of the j olumn and of the lower extremeties. At last -welling' of the joints supervened, and exostoses of the size ben's egg appeared at many points of the vertebral column, and two similar tumors, as large as a child's head, on the transverse rami of the pubic bones. The lower ex- mities of the patient were completely pa] ; his di- Ld his urine was discharged by drop-. many different ithout success, \h\ Micbalowski tried the extract of rhus toxidendroi .red fron the plant, freshly gathered in botanical gardens. He administered one grain of the extract, made into a pill, with half a grain of the leaves. After t lie patient had ta] ounces of the extract and one ounce of the leaves be was npletely cured. During this treatment the swelling the bones dimini ud of the cure the patient had the t and in the sacral were pricked by pins: be also had the ing of a current going from the sacral region down into bis Once only, the a< the medicine had to be interrupt the patient complained of pain and a burning sensation in his 1861.] 109 EDITORIAL AND MISCELLANEOUS. OUR PRESENT NUMBER, Our readers will observe that our present Dumber contains over one hundred pages of reading matter. This issue opens with the valuable investigation into the Marls of Georgia and the Adaptation of the various Soils of this State to different kinds of Culture, by our colleague, Prof. Joseph Jones, Chemist of the Cotton Planters' Convention. This valu- able scries of papers is now concluded, its completion having been pre- sented in the form of an extended Heport to the Association. As many of our readers must have been deeply interested in Professor Jones' agri. cultural researches, we refer them to the Book Stores of this city for the volume containing this Report. It is the privilege of the country prac- titioner of Medicine to relieve the tedium and drudgery of the daily round ^cultural pursuits, on a more or less extended scale, and we there- fore, have no apology to offer for occupying a portion of our pages for the several last numbers with matter bearing on Scientific Agriculture ; but those who may have felt less interested in the-discussion, have still no reason to complain, as, from an unusual press of original and selected matter, t: number is nearly one-half larger than our usual edition. We call the attention of our rca l ming Lecture ot a . on Outgrowths of the Cervix Uteri, by Dr. Joseph A. Eve, Pro- r ot Obstetrics, etc., in the Medical College of Georgia. Dr. Eve's vast experience and extended reputation in this department of his branch, will certainly give great value to these Lectures and render them a most contribution to the Literature of these important snbj of this journal has been greatly delayed, but ju requires that we should exonerate our indefatigable and liberal publisher : any charge of delinquency. The delay was solely attributable to r, a severe dissecting wound having incapacitated him for fur Dishing editorial for the number, and even now, ehirography is performed, without pain. ill remember that this is the beginning of our 110 'f /((<>/(< . [January volum > be filled with useful, practical matter, doing credit to the Medical Literature of the .South and contributing its to that of American Medicine. We invite their earnest ith us, in keeping this journal what it has ever been, the liberal exponent of true Medicine, a garner for the treasures of all parts of the world1, and tfylTdispensor only of Medical doctrines wherever it may bo read. On Urc i^y Professor Jakscjii. Vierteljahrsrli riff fur die ilkund, xvii. Jahrgaqg. 1860. The author of this pa- per holds that these arc two varieties of uraemia which should be carefully distinguished; one being caused by the decomposition of urine and ab- ;.iii df carbonate of ammonia into the blood (ammonaemia), the other being the variety which accompanies Bright's disease of the kidneys. lie has secu the former occur under the following circumstances : 1. In torpor and paralysis of the bladder. 2. [n dilatation of the pelvis and callices of thekidneyin consequence of the ureter- being blocked up. bscess, renal tuberculosis and sacculated kidneys. The following are the main differences characterizing the two forms of uraemir ; we shall, to save circumlocution, use the word ammonaemia as :iic of the one, and Bright's uraemia as the name of the other : ;. In advanced ammonaemia the urine discharged from the bladder man; 'ong ammoniacal odor, which Professor Jaksch has never noticed in any sta^e of Bright's uraemia. qs, either acute and febrile, or chronic and afebrile, have not been observed in ammonsemia. .'). Advanced ammonaemia is characterized by persistent dryness of the mucous membrane covering the mouth and fauces, as if every particle of moisture had been removed by blotting-paper; the membrane looks dry and shining, and the dr\ . extends to the mucous membrane of the nose, the conjunctiva, and even to the chorda? vocales; these syrup-' il occur in Bright's uraemia. 4. The distinctly ammoniacal odor of the air exhaled, and of the cu- taneous secretions of patients affected witli ammonaemia, does not occur in Bright's di,- 5, Patients suffering from ammonaemia always show a marked dislike to meat, and especially brown meats, even if their . have not very far; a feature rarely seen in the other variety. > r Jaksch bus never observed in Bright's disease the violent intermittent rigors, stimulating intermittent fever, which occur in animo- none of the < i r epilepti- Qor oroupy or di exudations notl 8. Disturbed vision, a I in Bright's disease by exudation on appear to tube place in ammonaemia. nie ammonaemia is characterized by a uniformly pale and tal- 18GL] Mi ill low complexion, and by gradually increasing emaciation ; very acute and advanced aramonsemi I with very rapid wasting ol turcs, and muscular debil to paralj 10. In all caj b ran a rapid course there vomiting, with concurrent or consequent diarrhoea ; in chronic an naeniia both phenomena were often entire! . or only occurred temporarily. 11. In ammonsemla, whether acute or chronic r Jaksch has always seen death occur after sopor, varying in duration from several sf vend days. The author d interesting paper gives numerous illustrative of 1 and^enters very fully into the various questions connected with diagnosis and treatment, fur which we are un- able to make room. 0)i Glycosuria as an accompaniment of Marsh Fever. By Dr. Bcrdel, Physician to the Vierzon Hospital. (L' Unioi Medicate, No. lo9, 1859,) Dr. Burdel regards marsh poison as a myth, and looks upon marsh fever as result of a perturbation of the cerebrospinal centre and the sympathetic system, adopting very nearly the same phrase as the " ich Bernard defines glycosuria. The author of the pre- . in his researches into the nature of marsh fever, has con- firmed the above view of its character by ascertaining in the majority of of sugar in the urine. Dr. Burdell employed the test with liquor potassae, Felling's liquids, the test with bismuth and potash or carbonate of soda, and the yeast test, ecially in the fi tencement of the attack that the quan- tity of sugar was considerable ; it diminished gradually towards the ter- mination of the paroxysm, and generally disappeared entirely during the interval. The closer the attacks approach one another, the larger the amount of sugar. In 80 ca 11 marked intermittent fever the author uniformly- found sugar; in CO other cases, in which the fever was at first in- subsequcntly become remittent, the sugar was present, but only in small quantity and for a brief space. In of inter- mittent fever following- typhoid fever, a considerable quantity of sugar was shown to be present. In the cases presenting the 1 y of sugar, as much as 10 per 1000 was found. TVoorara. Dr. Vella, the physician who applied this subscance in a case of " itanus on the battle-field of Magenta, reports to the Academic Sciences, a number of experim by him to establish its value lie claims that woorara besides being a sovereign dy in tetanus is almost an roia, to which conclu Gonorrheal Treated with T . In an article in the Medical Journal and. Review, by Dr. P. Poroher, I 11:2 Miscella emetic is recommended in gonorrhoea. Tn regard to his method of using it, he baa the following : "In the formative stage of the di q after its appearance with- in the first 1") to 36 hours, if possible and before the inflammation has made any advance, order the recumbent posture to be preserved and the use of warm mucilaginous drinks, with nitre and doses of tartar-emetic sufficient to keep up constant nausea. The sedative circulates to the remote parts of the system, the progress of the inflammation is thus put an cud to, and in my experi snee, with hut one exception, tlie disease* ipletelv arrested." Hoffman's Anodyne in Dilirum Tremens In the same article above referred to in the same journal. Dr. Porcher speaks highly of Hoffman's anodyne in delirium tremens. He says he has used it- with satisfactory results in eight cases "one drachm being administered, diluted with water, repeatedly, until nervous tremor was allayed and sleep induced." In the insomnia connected with this disease, he thinks opium has better effect when combined with tartar-emetic, as follows : "11. Tr. opii., gtt. xl ; T. emetic, peated every half hour till sleep is induced." Large Doses of Opium in Centric Convulsions in Children. In the same paper above referred to, Dr. Porcher commends opium in full doses, in cases of convulsions in young children, when not dependent upon worms or errors in diet. An illustrative case is reported. Dr. Porcher ;ests that a combination of chloroform and laudanum would probably be beneficial in these cases. For the last five years we have been in the habit of trusting these cases to chloroform by inhalation, and the re- sults have been so satisfactory that we have had ; to seek further remedial aid. Neuralgia. In the Charleston Medical Examiner for June, Or. L. D. Ilobinson has an article upon neuralgia, in which his views of its pathology are given, and also his plan of treatment. We subjoin only the treatment. In a case reported, the treatment advised, which he says was that usually advised by him, . lowing: R. Chinoidine, l24 grs. Pulv. Capsicum, 5 grs. Strychnia, 1 gr. M. flat. pil. No. 10. Dose a pill before each meal. After using the above sufficiently long to break down the paroxy and give the patient relief, we prescribe the following: 1\- Quevenne's iron, GO grs. Quinine, 60 grs. Ext. Hyosciami, 40 _ Pulvis Capsici, 20 grs. wde into 40 pills. Dose, a pill after each meal and to bo continued until completely relieved of debility." SOUTHERN MEDICAL AND SURGICAL JOURNAL (new series.) U IV1I. AUGUSTA, GEIIICIA. FEBRUARY, 1861. KO. I ORIGINAL AND ECLECTIC. ARTICLE V. The Diagnosis [Physical and Differential) of Phthisis Puhno- nalis. A Clinical Lecture, delivered at the City Hospital, leb. Qth, 1861, before the attending Class of the Medical Col- lege of Georgia of 1860-61. By William Henry Doughty, If. D., Hospital Physician. Gentlemen : Perhaps, if I had canvassed the entire cata- logue of diseases to which humanity is heir, no single one of them could have brought greater claims for its consider- ation, or have made stronger demands upon our patient and earnest attention than the one that has been selected. The history of our profession abounds in lengthened essays, learned disquisitions, and numberless memoirs upon this subject, all of which attest the profound interest that has been felt in it. The annals of the past show that some of the brightest intellects of the profession have been ardently and scientifically devoted to the pursuit of a full establish- ment and recognition of those features both signs and symptoms which might be assuredly taken as indicative of phthisis, distinct from all other diseases of the respiratory organs. I remark again, tl^at profundity of thought, acute- of observation, penetrating research, and logical acu- men, together with most careful comparison, have been 114 Doughty. Clinical Lecture on February, deeply exercised in order to its fall accomplishment. How far they have succeeded, the doubtful response that rises instantaneously in the mind of every practitioner will suf- ficiently attest. This response, doubtful though it be, will not be regarded as the negativing of the proposition, but simply as expressive of the doubts and difficulties which still hang around some of the cases submitted for examina- tion. In a large majority of cases the land-marks, both physical and rational, are so plain and distinct as to render unequivocal the existence of the disease ; but the remain- ing minority, often requiring of us a most positive opinion are enveloped in doubt and encircled by the shades of ob- scurity. The former, from their unmistakable characters at once release our minds from farther consideration of them except in a pathological and therapeutical view, whilst the latter, from their indistinctness and subtle nature, be- come anxiously interesting in a diagnostic view. Putting out of mind the pathological interest of all cases, we do not fear to assert that the latter the doubtful have been those to awaken the energies of the profession, and to contribute most largely to the present exactness of diagnosis of phthisis. It is but common experience and observation in every de- partment of life, that the grandest results are the fruits of the hardest toil, whilst ease engenders superficiality. So it has been in this instance, where openness of features and distinctiveness of characters were well marked, it has, in a measure, paralysed energy, but where evidences of disease were obscure and pathological changes or manifestations were ill-defined and mystic, all the powers of a nice dis- crimination have been taxed, and the highest energies of the system bent to the unravelling of its diagnostic phe- nomena. Thus the diagnosis of tuberculosis comes to us as second to no other question that appertains to the subject, and per- haps only equalled in importance by those of its pathology and curability. 1 have selected this subject solely on account of its practical 1861.] Phthisis Ptdmonalis. 115 importance and because of the prominence which it assumes in the case upon which I have twice endeavored to lecture. Of its practical importance you cannot be too sensibly im- jsed, for though it were rehearsed in your hearing daily you would still have need of assiduous attention in order to remain practically familiar with it. Of course, gentlemen, all that I can do is to repeat to you the conclusions and deter- minations of others whose time and labor have been almost exclusively devoted to the study of diseases of the chest, and whose ripened experience and enlarged observation, therefore, entitle them to our willing acceptance and judici- ous verification. Prior to the discovery of auscultation by Launec, and of percussion by Auenbrugger, in the early part of this century, no just apprehensions of the phenomena which characterize the various diseases of the respiratory organs could be form- ed by reason of which the utmost confusion existed, both in regard to their nature and their treatment. The dia- nosis of these various affections was particularly obscured, insomuch that bronchitis was often mistaken for more serious pulmonary lesions, pleuritic changes were also mistaken for disease of the lung structure itself, and every form of chronic pulmonary disease confounded with phthisis pulmonalis. It did not stop even here, for affections of the heart and its membranes, as well as the larger blood-vessels, were fre- quently regarded as pulmonary maladies. At this period the profession was wholly dependent upon the rational symptoms ot disease, and by reason of the community of action existing between the respiratory organs and their vari- ous parts, it became hardly possible for them to escape the commission of errors of diagnosis. But since the inaugu- ration of this superior method of examining these diseases, viz : by physical exploration, a greater part of the obstruc- tions to correct diagnosis has been removed, and the com. munity of action to which we have referred, has been made to illuminate, instead of darkening, the path of the explorer, by developing the study of their correlative signs. Thus> 11(5 Doughty. Clinical Lecture on [February, as it wore, the beclouding circumstances of former periods have become, through scientific analysis, the instrument of light, the lens by whose converging rays objects of vision have been rendered bright and intelligible at this date. But you are not to suppose that the results obtained by the latter method are so grand and overshadowing as to render useless or unworthy of attention the other mode. By no means. These results, though grand, constitute but apart of that brotherhood which must necessarily exist between the signs and symptoms of disease. Were we to confine our- selves to the signs educed by physical exploration alone, we would be overtaken in numerous instances, by the most palpable and egregious errors. Yea, more : should we ignore the rational symptoms of diseases of the chest we wrould not only be involved in error as were our ancient brethren, but, and I am sure you will agree with me in the assertion, we should be far less excusable than the latter. From these remarks you will at once perceive that we are not to cultivate or adopt either method of examining disease to the exclusion of the other, but to associate them together, and to interrogate both alike upon all the patho- logical phenomena that you may be called to pass judgment upon. Connected or related to each other in this manner, each will become an assistant to the other, and in doubtful ciises, either a correlative or a corrective. The latter obser- vation also extends to the various methods of physi- cal exploration, each having to the other a reciprocal rela- tion which is as steadfast as the principles of physical science themselves. Tn the absence of this proper correlation each ulso becomes a corrective of the other. Furnished, then, with these various methods for the interpretation of diseases of the pulmonary organs, we are prepared, fully prepared, in a vast majority of instances cor- rectly to understand them and rightly to appreciate them. Hence we can be no longer justified in the commission of those errors of diagnosis, with their evil effects in practice, which were formerly abundant. On the contrary, abun- 1861.] Phthisis Pubnonalis. 117 dant facilities for qualification being afforded us, we are bound by duty and conscience to acquire a knowledge them in order that we may discharge, satisfactorily, the ob- ligations which our relations to society devolve upon us. And I may bo allowed to remark in this connection, that, under no other circumstances in professional life will you be enabled to experience more gratification than flows from the conscious discharge of your whole duty, than in the pre- sent particular. But, having made these general observations by way of introduction, let us proceed now to a direct consideration ot^ the subject. The power to diagnosticate tubercular con- sumption presupposes a full acquaintance with the natural history of the disease, as its hereditariness, as well as its ac- cidental acquirement ; its relations to age and sex ; its mode of commencement usually insidious and almost insensible ; its almost universally slow progress and development ; its pathological cause and changes, viz ; the tubercular deposit, its character, its changes and its results ; the laws which the latter seems to observe, both in the points of its earliest de- posit and its mode of progress to other portions ; the re- lations of hemoptysis to it as evidence of tubercular deposit already taken place, and its frequency as a symptom; the products of the changes wrought in the lungs as manifested by the expectoration ; its constitutional sympathies, as in- creased frequency of the pulse, hectic fever, dyspnoea, night- sweats, diarrhoea, chronic laryngitis, and general marasmus. Besides this, we must have a practical acquaintance with all of the physical signs that are discoverable in diseases of the respiratory organs, for, as you should not fail to remember, there are "no special pathognomonic physical signs" which belong to it. You need never expect to find a certain set of physical signs present in all cases, incident alone to the conditions of the pulmonary structure induced by this dis- ease, for the tubercular deposit may and does vary greatly its place of deposit, its extent, its character, as when in an isolated, scattered manner or coniined to a single spot. ain, these would vary with its location near the super- 118 .Doughty. Clinical Lecture on [February, fices of the lung or deep within its structure. For instance, let us suppose the existence of a deposit near the pleural iring of the lung, under the progressive softening and maturation there occurring, the pleura becomes ulcerated, and an admission of air allowed into the pleural cavity, we would then have the physical signs of pneumo-thorax su- per-added, whereas if a similar deposit existed deep with- in the structure of the organ, we should only have develop- ed the ordinary signs by percussion and auscultation. Or if it existed in the form of milliary tubercles scattered irregu- larly throughout the organ, the physical signs would again be found to vary from those evolved from a circumscribed deposit in any portion of it. Then again, there is nothing special in the sounds elicited from pulmonary tissue hardened by tubercular deposit, for the same or similar sounds would be produced if the solidi- fication proceeded from any other cause, as inflammatory adhesions, etc. The signs afforded by auscultation of a tuberculous cavity wherever seated yield no distinctive dif- ferences from those given forth from a similar cavity, the result of any other species of diseased action: in otherwords, the physical signs are the same whether it be a tuberculous cavity or a local abscess resulting from pneumonitis. The same remarks might be extended to any of the physical signs for they represent morbid conditions whether the re- sult of the tubercular cachexia or not. In the language of Professor Flint, "the phenomena which it embraces belong also to other affections. They represent morbid conditions not peculiar to tuberculosis, but existing in other forms of disease." He further remarks thus : " isolated from other other signs, and dissevered from symptoms, pathological laws, and associated circumstances, none of the physical phenomena which have just been considered would possess marked diagnostic importance. Nevertheless, from their combinations, their conjunction with vital phenomona and with facts pertaining to the natural history of the disease, acquire a positive value, and are hardly less significant than if they belonged to it exclusively." 1861.] Phthisis Pulmonale. ' L9 The physical signs produced by tubercles in the In fer according to the stage or state of the deposit If the chest be examined during their existence in a crude Btate they will be observed to differ widely from those produced during the stage of softening or after the formation of* ities. This is very apparent, ami you must be prepared to meet these differences in practice, otherwise you will often be foiled in your efforts. It is common to divide tubercu- lous disease into several stages, founded upon the condition of the deposit itself as that of crude tubercle, of its soft- ening, and of excavation. Connected with physical explor- ation, this division is not so convenient as that suggested by Professor Flint, because we are not always able to define the exact state of this product, and very often these various states are united. Some of the earlier deposit may be ma- turating and breaking down the vesicular structure into ab- jses, whilst at other points it may be in a crude con- dition, and this Btate of things may exist, either in the differ- ent lungs or in different parts of the same lung. Besides this, the term crude tubercle simply expresses the state of the deposit itself, without regard to the mode of it- di bution through the lung, whether ag^ into mat or disseminated in minute particles throughout it. It i> more or less indefinite, and sugj of lew of the signs incident to its presence. Professor Flint suggests the following basis of division, viz: (1) "Small, disseminated tuberculous deposits;" (2), "Abundant deposition, involving considerable solidification ;" and(3), "Tuberculous dis< inced to the formation of cavities." Size and mode of distribution are the distinguishing feature.-: in the first two divisions, and are, to a greater or less extent various physical signs incident to them ; the third ie cal with the corresponding one in the other division. \V come to apply this in practical auscultation and perc you will then find that it is not an unim] matter, for it will require but a limited experience to quaint you with the material differences whic 120 DOUGHTY- Clinical Lecture on [February. tween the physical phenomena elicited from a lung or lobes of a lung occupied in the one case by small disseminated tubercles, and in the other by an abundant deposit. In the former, the intervening portions of healthy vesicular struc- ture, particularly if they assume a complcmental action, will modify the percussion sounds to such an extent as to render them, in some cases, almost inappreciable, certainly doubtful, whilst the auscultatory signs may be so obscure as to require the nicest tact for their detection. In the latter, however, the aggregated mass, limitable and circumscribed, affords the clearest evidences under both methods of physi- cal examination. The correlative phenomena in the latter instance, associated with the semeiological and historical fea- tures of the case establish the diagnosis, whilst in the other, doubts only become confirmed. There is a law in tubercular consumption of which you should, at an early period, be apprised, viz : that "the de- posit, in the vast majority of cases, takes place at or near the apex of the lung." This is not invariable, though exceptions to it are rare. In examining then for tubercu- lar deposits you will first direct your attention to this point and any evidences, however slight, of solidification when not owing to the natural disparity existing between the two lungs becomes highly suspicious, and if accompanied with increased vocal resonance, and with any of the elements of broncho-vesicular respiration, may warrant a positive opin- ion. If occurring in a patient liable to its inheritance and accompanied with symptomatic manifestations, however slight, it may be regarded as certain. Usually this deposit occurs "at the summit of the lung on one side before the other lung is attacked," though the other is subsequently invaded. Hence it is observed that "in the bodies of per- sons who have died with tuberculosis, the two lungs almost invariably are found to be diseased, but the deposit is most abundant or the ravages are more extensive on one side." 1 1 you remember, the case in connection with which these remarki are mad presented this feature or rather conform- 1861.] Phthisis Pulmonalis. 121 ed to this law, and this fact becomes presumptive of tuber- culosis. By reference to the notes of examination, I find the following statement : Percussion over apex of left lung anteriorly and posteriorly, gave appreciable dulness; of right lung, over apex, marked dulness, extending in a varying degree, over the entire upper third of the lung. The correlatives o\' auscultation were, in the left lung, broncho-vesicular respiration, and increased conduction of sound; in the right, bronchial respiration, the expiratory murmur being greatly prolonged, and much greater conduc- tion of sound than was observed on left side. Here, then, we have the evidences of structural disease at the apices of these organs, more advanced and prominent than in any other portion of them, and farther advanced on one side than the other, thus, according to the law of tuberculosis to which I have adverted, affording strong pre- sumptive evidence of tuberculous solidification. In regard to the normal disparity between the right and left lungs, it is said that "distinct dulness, however slight, on the left side, is highly significant, while on the right side, if slight or moderate, it is to betaken as a morbid sign with considerable reserve." And again, "distinct dulness at the left summit, be it ever so slight, in connection witli the di- agnostic symptoms of tuberculosis, may almost suffice to es- tablish the fact of the existence of the disease, when, if situated on the right side, other corroborative evidence is requisite." In our patient above, unfortunately all of the diagnostie symptoms of tuberculosis arc not present, not- withstanding the evidence of extensive solidification in both 'ungs, so that the diagnosis is not in every particular con- firmed. Hut few diagnostic symptoms arc present, and they are not such as you would expect from the advanced appearance of the case. They are pain in the chest rati obtuse than lancinating, slightly increased respiration, paroxsymal cough with mixed .ration, scanty and tight, and general emaciation, with lose of muscular strength. Those absent are hectic fever, niLrht-s\veats, diarrl 1 __ Doughty. CUniccU L e on [February chronic laryngitis, and the thick suppurative expectoration common to consumption. About thirty years ago he recol- lects having "spit blood," but his subsequent history rather militates against t\ic supposition that lie Jwas then tubercu- lous. He is not hereditarily predisposed to the disease, and, until thirteen months since, was as hearty and robust as any one. At that time lie contracted a severe acute disease ot the chest, probably pneumonia, and has been declining ever since. But let us return to the division which we have adopted and pursue the course there marked out. What physical signs may we expect to find when the tuberculous deposits exist in a small, disseminated state ? Of course we can expect little or no aid under this state of things from any of the collateral methods of physical cxpploration, as inspection, palpation and mensuration ; for the lung maintains, to a great extent, its natural resiliency and elasticity, thereby abolishing all evidences usually afforded by them. In this condition of the deposit, our resources are limited chiefly to the two modes, percussion and auscultation, and in order that the signs elicited by these be diagnostic, they must establish their proper correlation, and must be conjoined with the symptomatic phenomena however obscure. Percussion usu- ally affords what is termed appreciable dulness or simple dulness, or technically diminished vesicular resonance. If the deposit though small, be confined to the apex or a single lobe of the lung, as the upper, this diminution of reso- nance will extend only over that particulai region, or if it be disseminated throughout the entire lung or lungs, as it oc- casionally is, it will be found to embrace the entire super- ficies of the chest. The dulness will correspond to the degree of encroachment of the masses upon the vesicular structure or the relative size of the m [f the encroach- ment be small, the variation of the vesicular resonance will ' versa. But sometimes the vesicles im- mediately surrounding these small deposits become em- physematous or assume an increased action, and acquire an 1861.] Phthisis Pulmonalis. 128 increased capacity, in this case instead of appreciable dry- ness on percussion, you wil or may have an increased sonor- ousness, but not of the normal vesicular quality it is called tympanitic resonance. This abnormal clearness need not be confounded with the normal vesicular resonance, if at- tention be paid to its quality and pitch. It is non-vesicular and high in pitch. The normal vesicular resonance has a certain timbre or tone, and is low, grave in its pitch, whilst tympanitic sonorousness is always high in pitch and its quality has a type in the sounds elicited by percussing over a hollow organ. This sound is one of the characteristic signs of emphysema of the lungs, and when evidence of tubercu- lar disease is most apt to to be found over the left lung on account of its anatomical relationship with the hollow ab- dominal organs. Of this relation you should at all times be mindful, since the gastric sounds are frequently transmitted over its surface, and under numerous circumstances are found modifying the percussion resonance. Sometimes you will find instances in which the normal vesicular resonance is not abolished, and yet there are some of the indications of tympanitic resonance present. It is neither strictl}^ vesicular nor non- vesicular, but a combina- tion of the sounds of each. This modification is called vesiculotympanitic resonance, and is entirely compatible with certain relations of the solid deposits to the adjoining pulmonary structure. In the next place let us consider the signs elicited by aus- cultation from a lung occupied by this species of deposit. In a large majority of cases they consist in simple modifi- cations of the healthy respiratory sounds. And yourability to detect them necessarily depends upon the degree of your familiarity with the latter. The chief of them, the most important because most frequently met with, have types or representatives in the healthy respiration to which they arc referred and with which they are compared. Thus we have a certain abnormal respiration charact* - bronchial respiration a sign which is constantly present in extensive 124 Douc.hty. Clinical Lecfure 011 [February, solidification of the lung whenever occurring because its characters have a more or less exact resemblance to those sounds produced by the rush of air to and fro through the larger bronchial tubes in health. The normal vesicular res- piration has certain distinguishing features, the absence or modifications of which become the signs of disease. I would impress you, gentlemen, with the importance of this great truth as the first requisite to skilful and accurate ausculta- tion, the absolute necessity of a knowledge of the charac- ters oi' normal respiration in each and all of its branches. Possessed of this knowledge, you will find physical auscul- tation comparatively an easy task, whilst in its absence, you will often be involved in error and darkness. The most commonly observed modification of the healthy respiration is that called broncho-vesicular respiration by some called rude, and by others, harsh and dry respiration. The former we adopt because it piesents the types with which it must be compared, and also because it suggests the particular place whence it must be evolved the smaller bronchial tubes, and the vesicular portion of the lungs. But what is the broncho-vesicular respiration, or how may you recognize it ? In the language of Prof. Flint, who first proposed it, if all of its characters are present, "we shall have an inspiratory sound, neither purely tubular nor vesicular in quality, but a mixture of both, (broncho-vesicular,) the duration somewhat shortened, (unfinished) the pitch raised ; a brief interval followed by an expiratory sound, prolonged, frequently longer and more intense than the inspiration, and higher in pitch." It includes, then, modifications both of the inspiratory and expiratory sounds, and implies a sub- stitution of certain features of bronchial respiration (normal) in certain parts of the vesicular structure of the lungs sometimes a few only of its features may be recognizable. The normal features of the vesicular murmur, may not be ob- literated, yet they are so far obscured by those which belong to the other, as to have its low-toned, soft, expansive mur- mur supplanted by a rude, harsh sound. This kind of (lis- 1861.] Phthisis Pulmonalis 125 ordered respiration is always heard when the encroachment is but slight, or has not extended to a great degree of solidi- fication ofthe parenchymatous structure ; when the latter is accomplished well-marked bronchial respiration is pro- duced. Sometimes the expiratory murmur presents the very ear- liest indication or becomes the earliest cognizable physical sign of tuberculosis. In health, there is but a small propor- tion of individuals one-third in whom a well-marked ex- piratory sound may be heard, when, therefore, it exists in an appreciable degree and possesses any of the characters which pertain to broncho-vesicular respiration, it may be taken in connection with associated symptoms as evidence of disease. The most usual changes which it undergoes in the early period of tuberculosis are a prolongation and ele- vation of pitch, in these respects occasionally outstripping the sound of inspiration. It is not difficult to understand the reason of its prolongation, for the elastic recoil of the lung is impeded by the presence of these deposits, conse- quently the escape of air from it is retarded. The expira- tory sound is, upon an average, only one-fifth the length of the inspiratory, therefore, any material prolongation of it becomes at least suspicious, and justifies us in attaching great importance to it when other corroborative evidence exists. Another modified respiratory sound occasional!}- discover- ed in this condition ofthe tubercular deposits is exagger- ated vesicular respiration. It is rather significant of dis- at neighboring points to the region over which it is heard, and is not essentially abnormal. It is synonymous with puerile respiration, and exemplifies what I have allud- to as the coinplemental action of a part. This sound is not so frequent an attendant upon disseminated tuberculous deposits as upon abundant deposit of circumscribed dimen- sions. In the former, it is obscured by the presence and universality of the broncho-vesicular respiration. A very important physical sign usually available also is 126- Doughty. Clinical Lecture on [February, increased vocal resonance an increased conduction of the sounds of the voice into the ear of the observer. In auscul- tating the healthy chest over the vesicular pulmonary struc- ture, the act of speaking is attended with a peculiar vibration not, however, possessed of much intensity. It varies great- ly with individuals, and in the two lungs, and in different parts of the same lung. There seems to be no direct trans- mission of the sound, but a widespread diffusion of it over the porous structure. It is too extensively diffused to ob- tain much intensity, but when, from any cause, the vesicu- lar structure becomes solidified, it acquires an increased conducting capacity, and this latter corresponds with the degree of solidification. Therefore, increased vocal reso- nance becomes an important physical sign of tubercular de- posit, whether aggregated or disseminated; in the latter in- stance, being the correlative of diminished vesicular reso- nance and the broncho-vesicular respiration. But, again, if these scattered deposits have becomes often- ed and are being discharged by expectoration, you will have superadded to these various signs, some of the adven- titious rales, i. e., such as have no natural type in the healthy chest. It may be, that in one part of the lung they are being discharged, whilst in another they are still in a crude state, under which circumstances some one or other of the moist rhonchi will be heard, most probably the sub- crepitant. You are aware that these rales are produced in the bronchial tubes, and are most generally treated of in connection with bronchitis. If the time and occasion war- ranted I should be glad to digress at this point and make further allusion to them. Let us briny recapitulate : the percussion sounds are di- minished vesicular resonance or dulness or ''tympanitic dulness' ' or the vesiculotympanitic variety: the ausculta- tory signs are broncho-vesicular respiration, increased vocal nance, perhaps exaggerated vesicular murmur, and some of the adventitious rales, as the subcrepitant. There is a manifest tendency in such deposits as we have 1861.] Phthisis Putmonalis 127 considered, ultimately to become consolidated, both under the usual progress in deposit and the resultant soitening of the pulmonary structure. Hence the physical signs here enumerated would become gradually intensified, and final- ly merged into those of the second division of our subject which I will now proceed to discuss. In cases of abundant tubercular deposition, involving ex- tensive solidification, most of the auxiliary methods of physical examination become available, and the evidence adduced by them is by no means unworthy of notice. If you remove the patient's clothing and inspect the chest you will very probably discover some depression either in the post-clavicular or sub-clavicular regions, caused by the di- minished expansion of the lung beneath, and also be able to detect diminished respiratory movements on the diseased side or at the diseased point. Palpation will reveal to you an increased sense of resistance over the solidified por- tion, abnormal vocal fremitus, and diminished elasticity of the thoracic walls. Mensuration will also disclose deviations from the natural dimensions, and thereby assist, although this method is much less needed in this disease than in some oth Percussion over an abundant deposit yields much great- er dulness than in the other division marked dulness is the term used to express it. If the bronchial tubes includ- ed in it remain open, especially if they be at all dilated or enlarged, or if the surrounding vesicular structure be high- ly emphysematous, it will partake, more or less of a tympa- nitic sonorousness. The signs commonly afforded by auscultation arc well marked bronchial respiration occupying the seat of the de- ':. broncho-vesicular respiration, and some of the adven- titious rales in the immediate vicinity of it ; exaggerated vesicular respiration may also be present at some points. The crepitant rhonchus may be heard, indicating circum- scribed pneumonitis, or the sub-crepitant, indicating capil- lary bronchitis or the presence of the softened tubercular 128 DoufliiTY. Clinical Lecture on [February, materials in the smaller tubes, or any of the moist or dry rales may be present The latter only become diagnostic of phthisis when heard at the summit of the chest in the vicinity of a tuberculous deposit. They are incidental and depend in most instances upon the existence of circum- scribed bronchitis or pneumonitis. "Their value is en- hanced by association with other phenomena, physical aud vital, pointing to tuberculous disease." The correlatives of the voice are also well developed there is well-marked bronchophony over the solidification, and in many instances, pectoriloquy. In the latter there is a transmission of the articulated voice it is " articu- late through indistinct speaking/' There may be also an abnormal transmission of the heart sounds in addition . Another sign that frequently accompanies abundant tuber- culous solidification is a bellows sound attendant upon whis- d words. It is said that "this sign may be present in a lotable degree, when the bronchial respiration, broncho- phony, or exaggerated vocal resonance are not strongly marked/' "When the tuberculous deposit has advanced to the stage of excavation it is exceedingly difficult to be able at all times to diagnose it. Indeed it is not always possible be- cause the varying size, position and relations of the cavi- ties often prevent the evolution of those signs distinctive of their existence. Repeated examinations are frequently necessary to settle the question of their presence or absence. More or less solidification always remains in connection with these cavities, hence the most of the physical phenom- ena which we have just considered still remain though combined with those peculiar to cavities. Cavernous respira- tion is the technical name for the latter. The features of this sound are different both from those of bronchial respi- ration and the vesicular. Thus Professor Flint describes them as follows : "They consist of an inspiratory sound. non-vesicular or blowing, but compared with the bronchial inspiration, low in pitch, hollow, more slowly evolved; and L] Phthim Putmonatis 129 of an expiratory sound if present, lower in pitch than the sound of inspiration." (page 481.") All of these characters may not be distinguishable ; von may have only the inspiratory sounds present ; the distinguishing characteris- tics are lowness of pitch and absence of the vesicular qual- ity. Bronchial respiration generally exists in the vicinity of the cavity, with which you may compare it, and for which you should not mistake it. Recollect that the chief ele- ments of the latter are tubularity of sound and highness of pitch. Cavernous respiration is a variable sign, and may be present at one examination and absent at another. This variableness depends, to a great extent, upon the amount of tluid matter contained in it at different times, and also upon the rigidity of its walls. Thus if it be filled of course it will disappear, and with the discharge of its contents by ex- pectoration will re-appear. Hence it is recommended in the examination of patients for cavities in the lungs, not to do so shortly after rising in the morning, but to wait some hours so as to permit the discharge of the matter accumu- lated during the night. This sign is much more available when one large cavity exists than when a number of small ones are scattered throughout the lungs. In the latter case, their size prevents its perfect formation, and it is often or apt to be, obscured by the co-existing bronchial sounds. Under the act of coughing sometimes in a large cavity, a gurgling may be detected. This is conclusive of the existence of a cavity when heard ; they are rarely so large, however, as to render it of much value. Pectoriloquy is a vocal sign supposed by some to be in- dicative of a cavity, but by others said not to be exclusively so. It may accompany solidification of tisssue either with or without an excavation. You will recollect that this sign was quite prominent at the posterior angle of the scapula in in our patient, on the right side: it may or may not be in- dicative of a cavitv there. 1 was unable to detect the cav- l30 Doughty. Clinical Lecture on [February, it! 11 his respiration at that point. When associated with the hitter in any ease it may be regarded as diagnostic. Metallic tinkling is another incidental sign produced as a vocal or tussive phenomenon, supposed to be produced when a cavity of some size is partially filled with air and fluid. I can only mention it and pass to the physical signs educed by percussion. As in auscultation, those of solidifi- cation still remain with modifications or superadditions. Thus if the cavity be full of fluid it will be remarkably dull on percussion, perhaps fiat; or, if empty and of some size, it will give a circumscribed tympanitic resonance, or some- times a modification called amphoric resonance (a metallic sound) or a cracked metal sound (bruit de potfele.) The first "maybe imitated by striking the cheek when the jaws are moderately separated and the integument rendered somewhat tense," and the second "by folding the palms of the hands loosely and striking the dorsal surface on the knee, in the manner frequently done to amuse children, producing a sound as if pieces of money were placed be- tween the palms." "The production of this sound is now generally attributed to the air being suddenly and forcibly expelled from a cavity communicating with the branchiae by several free openings, precisely as the blow on the knee expels the airbetwecn the palms in the experiment mentioned by which the sound may be imitated." (Flint, page 120.) Thus, gentlemen, I have viewed in detail the three di- visions adopted, imperfectly, but I trust truthfully. And wherever the combination of signs and sounds here men- tioned occur, or whenever these various correlative physical signs are present associated with the usual symptomatic phenomnea which belong to tuberculosis, your diagnosis is positive and complete. But in some cases, the symptomatic evidences are few and dubitable, and then the importance of the physical signs becomes greatly enhanced and demand on your part a most skilful survey and judicious consider- ation. Under these circumstances, the differential diag- is of tuberculosis acquires almost exaggerated import- 1861.] Phthisis Pulmonalis. 131 ance because the same physical signs may he common to other affections, as dilatation of the bronchial tubes the ultimate result of bronchitis or chronic pneumonitis. The latter is so rare as scarcely ever to give rise to discussion but the other is not so infrequent. When the diagnosis devolves mainly upon the physical signs it is exceedingly dif- ficult, if not impossible, always to discriminate between tuber- culosis and dilatation of the bronchial tubes. I confess my inability in the patient up-stairs. The difficulty originates in the fact that has already been mentioned, that there are no physical signs peculiar to tuberculosis, but any or all of them may be attendant upon the physical conditions giv- ing rise to them, however produced, whether from tubercu- lous changes or any other diseased action. It is onlv in the exceptional cases, however, that such difficulties arise ; for, as a general rule, the diagnosis is plain and satisfactory. But you must be prepared to meet these exceptions, for come they will in practice, and it may be that the only test of your opinions will be found in the results of your prac- tice. AVhen I conceived this lecture, gentlemen, it was my inten- tion to confine it to the differential diagnosis of tuberculosis, and dilatation of the bronchial tubes. But upon reflection I thought it would be of more interest to you to dwell upon the simple diagnosis of the disease, without special refer- ence to any other. If, however, you will indulge me I will give a brief summary of the chief points involved in the dif- ferential diagnosis. Bronchophony, increased vocal fremitus, and bronchial respiration are physical signs of dilatation of the bron- chia?; and in its saccular variety, you may have superadded cavernous respiration, gurgling, and "in some instances pectoriloquy." If there be any degree of bronchitis present as there usually is, more or less of the moist rales will be found also. Bronchial dilatation usually affects the upper lobes, though not especially the apex like tuberculosis. The bronchial voice and respiration are due more to the enlarged L32 Doughty. Lecture on Phthisis Pulmonalis. [Feb., calibre of the tubesthan to the solidification of tissue, and hence are not bo intense as in tuberculous solification. Di- latation of the bronchiee is not progressive, in the sense in which that word may apply to tuberculosis, and usually exists on one side. But, says Prof. Mini : "the point to which most importance ia to be attached is the absence of the rational evidence of phthisis derived from the history and symptoms. In cases of dilatation, cough and expectoration generally have existed for a long period. If the affection he tuhcrculous. certain events are to he expected which, if the affection he dilatation, the case will not be likely to pre- sent. Among these events and results the most prominent are progressive and marked emaciation, loss of muscular strength, pallor of the countenance, hemoptysis, lancinating- pains in the chest, diarrhoea, marked acceleration of the pulse, hectic paroxysms, night perspirations, chronic laryngitis. If all these are absent, the fact favors the supposition of di- latation being the pathological change giving rise to physi- cal phenomena which, associated with more or less of the svmptomatic phenomena just enumerated, would devote un- equivocally the existence of tuhcrculous disease. Occasion- ally, however, it happens in cases of phthisis, that nearly all these rational indications are wanting. Hence, under these circumstances it is not safe to decide positively from their ahsence that tuberculosis ma}' not be excluded." How shall I determine that this is not one of those occasional cases of tuberculosis, in which "nearly all these rational indi- cations are wanting?" The most important ones wanting acceleration of pulse and respiration, hectic fever, night and chronic laryngitis. Thirty years ago he had hemop- tysis, but never had a cough until thirteen months since, at which time he contracted some acute disease of the chest, probably pneumonia; he is not hereditarily predisposed to consumption. The history of his cough and expector- ation furnishes no light. Finally, gentlemen, following the admonition of the learned professor to whom I have refer- red, I consider it unsafe to declare that tuherculosis does not exist. 1861.] Dugas. A Case of 133 rCLE VI. Iremity }mly orted by D. ;.\s. M. D., &c, Professor of Surgery in the Medical Coll< rgia. On the 18th of January last Mr. James Gaines, of I);r. boro', in this State, brought his man servant (Reed) to me for j nal advice, and gave me the followingh istoryof the ease : Reed is a negro about twenty years of age ; fine constitution, and well developed muscular system. He was out with some friends hunting at night about two month". . when they utreed a coon." While Reed held up a torch Tor his comrades to cut down the tree the blows of the axe caused a large dead limb to fall, which prostrated him. His friends ran to him and found him unconscious and ap- parently insensible. They removed the branch which still ed upon him : lifted him up, and in a short time he re- red his consciousness and was carried home. His ma- ter examined him and found that he had entirely lost the >f the right arm, and that it was insensible to any de- gree of pinching. Medical aid was obtained i as pos- sible, and it was found that the blow had been sustained alone by the right shoulder. This wag considerably bruised and somewhat swollen; the: skin over tin- deltoid muscle and just beyond tin- extremity of the acromion process was abraeded : but the most careful examination could de- tect neither fracture nor dislocation of any of the bonc<. The pulse at the wristwas normal, the surface of the limb was (.-old, the insensibility complete from the lingers to the upper part of the arm. and the patient unable to move any stele of the limb. There was no injury to the h< . any other part of the body. >re-arm was put in a sling, lotions applied to the shoulder, and stimulating frictions made to the limb for A month without a mendrnent. Electric shocks and cur- rent >rted to for sometime, and it was found that he conld feel th ks above the elbow' but not be. 134 Paralysis. [February, low it. They did not seem, however, to excite any muscu- lar contractions, and were discontinued. It i nowjusi nine weeks since the accident. On strip- ping the patienl and examining him in the erect posture no inequality of height can ho detected in the shoulders, and the only visible difference between them is the partial atro- phy of the deltoidand scapular muscles on the affected side. The entire right limb is smaller than the left; it is percept- ibly cooler than the other; the pulse is normal; severe pinching can he Blightly felt above the elbowr, but not at all w this: he can move neither finger nor any muscle of the limb and shoulder. I now proceeded to make a most care- ful examination of the scapula, clavicle andhumerusandjoint without being able to detect any fracture nor any displace- ment whatever. The roughest manipulations werepainless and not the least cripitation could be induced. Everything was in its proper place andposition. The ulnar nerve was insensible to pressure at the elbow. The limb dangled by the side of the body as if dead. Xow what could have occasioned this paralysis if not an injury to the axillary plexus by being suddenly and violent- ly jammed against the ribs by the shoulder joint? And yet there arc some who deny that this is possible. This case derives additional interest when taken in con- nection with several others I have had occasion to report within the last few years. (See Southern Med. $ Surg. Jour- nal for 1857, p. 323^ and for 1859, p. 741.) It is worthy of remark that in the two first two cases I published, and in which the drooping of the shoulder consequent upon frac- ture persisted, the patients continued to suffer much pain in the limb ; whereas in the third and in this (the fourth I have seen) they suffered none after the subsidence of the immediate effects of contusion. In the former cases the axillary nerves continued to be pressed upon and irritated in the latter they suffered only at the time of the blow. 1861.] Convul D /. By Charles Bland Radcliffe, M. D., >llege, Physician to the Westmini Hospital, etc. LECTURE I. CONCLUDED. Iii the able hands of Prof, du Bois-Keymond,* the gal- vanometer has recently brought to light certain facts which appear to be essential to the full interpretation of the mode in which muscle is affected by electricity. Of these facts those which require to be mentioned first in the present inquiry are these: that* there are electrical cur- rents in living muscle and nerve ; that these currents die out J ' with the irritability of the nerve and muscle : and that they have finally disappeared before the occurrence ot' vigor mortis. The next fact to which I would prominently direct at- tention is this, that the electrical currents of muscle and nerve are weakened during ordinary muscular contrac- tion. In the beautiful experiment by which this weakening of the muscular current during contraction is demonstrated by Prof, du Bois-Reymond, use is made of the gastrocne- mius of a frog, with a long portion of the sciatic nerve at- tached to it. The muscle is placed upon the cushions of the galvanometer, and the nerve is laid across the poles ot an induction coil, which coil is not then in action. Onplacing the relaxed muscle upon the cushions of the galvanometer, muscular current transverse the coil, and the needle is deflected to a considerable distance from zero. Passing a series of alternating induction currents through the nerve, and so producing a state of tetanus in the muscle, the needle swings back, and for a moment or two passes to the other side of zero. Under the current of the relaxed muscle, that is to say, the needle passes from zero; when contraction is produced, the needle passes towards zero. How, then, is this : Is the needle acted upon by a reverse current during contraction, or is it left free to < late back to its point of rest in consequence of the cessation of the current which had previously kept it away from this point! To answer this question, the experiment just des- cribed is modified in the following manner: Having fin tained the point to which the needi bnngenuto sche Eloctrioitat. 8vo. Berlin. ! 136 Lectures on [February, deflected by the current of the relaxed muscle, the current of the coil is broken, and the needle allowed to return to rest at zero. Then, throwing the muscle into a state of tetanus, the circuit of the coil is closed. In other words, the experi- ment is so conducted as to test the current of the contract- ed muscle. And what is the result? It is this: that the needle moves in the same direction as that in which it moved under the current of the relaxed muscle, but not to the same distance from zero. That is to say, the current of the gastrocnemius is found to be weakened during the con- traction, not. reversed. I have often verified this fact, and I shall be happy to show the experiment after the lecture to any who may be sufficiently interested in the subject to remain. In showing the corresponding weakening of the nerve- current, the ischiatic nerve of a frog is divided in the ham, and dissected out for a sufficient length towards the spine. This being done, the divided end of the nerve is bridged over the cushions of the galvanometer, so as to touch one cushion with its end and the other with its side, and a note is taken of the degree to which the needle is deflected by the nerve-current. The frog is then poisoned by placing a little strychnia under the skin, and when the tetanus occurs, the needle is seen to recede three or four degrees nearer to zero ; and this not only during the principal attacks, but also during the more transitory shocks which are produced on touching the animal. It is seen, further, that the needle again diverges from zero when the spasms pass off. For this fact also we are indebted to Professor du Bois-Rey- mond. And thus in ordinary muscular contraction as well as rigor mortis, the phenomenon of contraction would seem to be coincident with the absence rather than with the pre- presence of the natural electrical currents of muscle and nerve. The influence of artificial electricity in muscular action is a difficult problem ; but even here there are facts which show that the full solution may be hoped for before long. When the hind limb of a frog is attached by means of its sciatic nerve to the conductor of an ordinary electrical ma- chine, and the conductor is in turn charged and discharged^ the Limb js seen to be at rest in the former period and to be convulsed in the latter. Xow, in this experiment, the limb as part of the conductor, must participate in all the changes 1861.] Convulsive Diseases. 137 X-, "^ O T4 fl 5 ea W W 6h- -*-- zZ z 0 ^ u s: 02 b/D 0 W -t-> > rj O S5 Oj M '6 -4 ' 0 on O O o c C 0) of charge or discharge which pass over the conductor; and in thiscase therefore the muscular contraction would seem to he related to the dis appearance of ordinary electricity from the muscle, and not to the pre- sence of ordinary electric- ity in the muscle. The muscular move- ments resulting from the action of a galvanic [cur- rent are not a little com- plicated, and their full in- terpretation',! ^proportion- ately difficult. The muscular move- ments, resulting from the action of a galvanic cur- rent upon a motor or mixed nerve, provided nerve "be divided and its end lifted up are divisible into periods of double, alternate, and single con- traction. In the first period that of double contraction there is con- traction at the beginning and end of the current, and the only point to be noticed is, that the con- traction at the beginning of the "direct" current* is the strongest. In the second period that of alternate contraction the contraction occurs al- ternately at the beginning of the "direct" and at the end of the inverse current. In the third period that O O 3D g g = p^ ^ w ^ 1 H 0 1 1 c: Q ~ O ZL U > -- O 03 Q 00 -7- Q 0 5 -3 0 Q g H O -r 0 "3 '-Zz b p ~ 3 *-~ cj - . p - 5 ~ O if 5 r: S. C - y 0 ~ S> a y r w ~ _ The current is spoken of as "direct" when it passes towards the muscle, s "inverse" when it passes from the music. In other words, the current s ''direct'' when the positive pol is farthest from the muscje, and "in when nearest to the muscle. L38 Lectures on [February of single contraction there is, first of all, contraction at the beginning of the direct current, and at this time only; and, later still, there is apparent irregularity. Later still, that is to say, contraction may attend upon the beginning of the inverse current, after it has ceased to attend' upon the bc- ginning of the direel current; and not only so, but it may return to the beginning of the direct current after it has ceased to attend upon the beginning of the inverse current. Ney, these alternate revivals of contraction, which are known as "voltaic alterna- tives," may occur several times in succession upon thus reversing the current. The muscular movements resulting from the action of a galvanic current upon a loop of nerve are found to he divisible into the same three periods of double, al- ternate, and single contrac- tion ; but the movements themselves occurin very dif- ferent order within these pe- riods. In the period of double contraction, the contraction at first is strong at the begin- ning of both currents direct and inverse ; and then, a moment or two later, it is strong'only at the beginning of the inverse current. In the period of alternate con- traction, the time of the contraction is at the end of the direct and at the begin- ning of the inverse current. In the period of single con- traction, the contraction, first of all, is at the begin- ning of the inverse current; and aftcrwa r d s, without any a p pa rent regularity, now at the b eginning 0 .2 W? p H , I o a .. U- o3 03 '4-1 y* m C3 +J "t| rt O O a 3 o r < 03 .2 O o o O *c3 W ><* -J- 4-3 bD" VJj *J > 2 y g o S3 c o 03 o c3 ;_, M'5b -4-> ~- +j +- ^ 03 0 /. o 3 o | O O O O jb * j_. J! c3 o .2 o ^j be 'Zi *--> ~t-> . . o o o o H r^ 03 o3 c^ Ph S< Sh tn * * ^ f^ ~g d +J -M rt o o O U> O O o o o C3 g go pq d c Ph o .2 <^ tf'd xc '43 o .. .. 11 ^H p o3 o3 .. .. ^ bo ~t-> 4-^ 1 1 - o in > < pq 6 o O i d o -t-> 1 < O rt o o d o (3 O o o 0 '+3 a H o 4-3 c3 33 5 "7. 0 .2 W O -* a t+H o *^ 3 S3 O P | o c c3 w Tj r^ 5 i i ^ o O 3 H P4 l.] D 139 of i lie direct, and now at the beginning of the inv< current. It is only, indeed, in this final of appar- ent irregularity, or "voltaic alternatives," that the movements correspond with those which result from the n of a current upon a nerve which has been divided and lifted up at its end. All this may he seen at a glance mparing the ahove (able with one preceding it.?; In commenting upon these phenomena, i( is convenient insider them as belonging to the three groups in which they have been arranged. And first, of the movements be- longing to the first period that of double contraction. In looking at the movements belonging to the first peri- od, it is not difficult to find a reason which will, in some dc- , explain how it is that contraction is confined to the Beginning and end of the current, and to these times only. It is not difficult to see that the beginning and ending of the galvanic current in the nerve may involve certain changes in the strength of the nerve-current, and that these changes may in their turn give rise to momentary induced currents in the nerve and in its neighborhood; for such momentary currents are induced, not only when a current begins to pass and when it ceases to pass, but also at the mo- ments when it undergoes any change of strength. It is not difficult to see, also, that the muscular fibres to which the nerve is distributed may be the seat of some of the second- ary currents thus induced, and that these fibres may on this account be made to contract. Xor is it difficult to see if the contraction be thus connected with the induced current that there will be no contraction in the interval between the besnnnins: and ending of the inducinc; galvanic current; for if this latter current passes steadily there is no induced current in this interval. It does not follow, however, that the contractions are caused by the presence of the induced hot Claude Bernard has recently stated that a period of si Contraction precedes the three periods of which mention is made a | od which i- distinctive of the undisturbed and perfectly unexhausted and of which the el. iture ia contraction at the beginnii the two currents, inverse as well as direct. On farther inquiry, however, I think Prof, Bernard will per le phenomena a titled to this pr< significance; for, d in a recent communi- cation to the Royal Society, [find that they are producible at \ ill in the the period of double contraction bj under particu- lar circnm>tan 140 Lectures on [February, currents which are thus developed. On the contrary, these currents are no sooner communicated to the muscle than they arc with drawn from the muscle, and it may be that the contractions arc really due to this withdrawal. At any rate, it is in connection with the induced currents of which mention bas been made that we seem to have a reason which will, in some degree, explain why it is that contraction is confined to the beginning and end of the galvanic current, and to these times only. In considering the movements belonging to the second period that of alternate contraction the first thing to be done is to ascertain how it is that the order of contraction as set down in the first table is reversed in the second table and this thanks to Dr. Rousseau, of Vezy, is no very diffi- cult matter.* A\ lien the current acts upon a loop of nerve, it is not enough appose that the only current is that whicb passes direct- ly between the positive pole and the negative pole. On the contrary, there is a more roundabout way a way which is made up partly by the portions of nerve beyond the poles, and partly by the intervening muscles of the thigh: and along this more roundabout way another current will pass in a contrary direction to that of the other current. In this case, that is to say, in addition to the first current, which is distinguished by the name of primitive current; there is a second current, which is known as the derived current. Where, on the contrary, the galvanic current acts upon a nerve which has been divided and lifted up at its end, the only current acting upon the nerve is the primitive current. In this case, indeed, the circuit of the derived current is broken, and for that reason there can be no derived cur- rent. 2sow, it is in the action of the derived current that Dr. Rousseau has found an explanation for that reversal in the order of alternate contraction which takes place in the case wbere the galvanic current is made to act upon a loop of nerve through ordinary poles. One proof of this is afforded by an experiment in whicb the galvanic current is passed through a rheophorc bifurquc a Vhcophore. that is to say, in which one of the poles (say Logons sur La Physiologie et Pathologic du Systeme Serveux. P latide Bernard. Tom i. Leoon 10. Paris. 1858. 1801 .] Diseases. 141 the negative) is forked and so arranged as to receive the pther pole (the positive) between its prongs. It is Been, in the first place,that the portion of nerve which lies across the p< [od upon by two primitive currents, and that these cur- rents pass in opposite directions from the central positive pole to the outlying negative poles. It is seen. also, that there no outer or derived current, and that there can he no such cnrent in this case, inasmuch as the two out poles are both of the same character both negative. It is obvious, more- over that there will be no difference in the result where a nerve which has been divided and lilted up at its end is laid across the rheopliore bifurque ; for where there is no deriv- ed current it cannot matter whether the circuit of this cur- rent is interrupted or not. What, then, it may be asked, is the result of using this arrangement of the poles? Will the two primitive currents neutralize each other, and pro- duce no action in the muscle ': Theoretically, such a con- clusion is not improbable ; for it is a well-known fact that opposite currents of equal value do neutralize each other. Practically, however, the muscle is found to contract; and not only so, but the order of contraction is found to be one and the same in the case where a loop of nerve is acted upon, and in the case where the nerve acted upon is divided and lifted up at its end. It is found, also, that the muscle responds to the current which passes in the portion of nerve nearest to the muscle to which the nerve is distributed. In other words, it is found that the reversal of the order of alternate contraction which occurs where a loop of nerve is acted upon by the ordinary poles of the galvanic apparatus is due to the action of a derived current; for on excluding this derived current by means of the rheophore bifurque, this order of alternation is made to merge in that which irs where a nerve divided and lifted up at its end is acted upon, and where there can be no derived current. or does Dr. Rousseau content himself with this negative >f. On the contrary, he shows very clearly that the ac- tion of the derived current will reverse the order of alter- nate contraction in the case where a loop of nerve is acted Q by ordinary poles. Passing through ordinary poles, the inverse primitive cur rent gives rise to contraction at the moment when the cir- cuit d. It acts, that is to say, as the direct current when there is no derived current to complicate its action. v, if the order of alternate contraction is reversed bv the 142 Lectures on [February, action of a derived current, and if two opposite currents (ah n in tlic experiment with the rheophore bifurque,) it is that which passes through the portion of nerve nearest to to the muscles which acts upon the muscles. It may, also, do this by because the current acting upon the muscles actr ing upon the portion of nerve nearest to the muscles, is not the primitive inverse current, but a portion of derived cur- rent the course of which is diametrically opposite that is, direct. In other words, the acting current, underthese cir- cumstances, is one which ought to be attended by contrac- tion at the closure of the circuit, for it is a direct current. We arc now enabled to sec why the direct primitive cur- rents acts like an inverse current, when this current is made to act upon a loop of nerve through ordinary poles ; and this it may do because it will show that the current acting upon the muscles, by acting upon the portion of nerve near- est to the muscles, is not the direct primitive current, but an inverse portion of derived current. In a word, the act- ing current is inverse, not direct ; and, therefore, we should sxpect to have the result of the action of the inverse current contraction at the end of the current. In this period of alternate contraction, then, there would ;u to be one and the same law for the muscular move- ments resulting from the action of the galvanic current upon nerve a law by which the muscle is made to contract at the beginning of the direct and at the end of the inverse curent. In the period of alternate contraction, then there would seem to be one and the same rule for the muscular move- ments resulting from the action of the galvanic current upon nerve a rule by which the muscle is made to contract at the beginning of the direct, and at the end of the inverse currents. How, then, is this ? Why is it that muscle contracts thus alternately V It is, perhaps, too much to expect a full ans- wer to this question at present ; but a partial answer, as it seems to me, may lie found in the collation of the three facts which follow. The first fact is this that the direction of the nerve-cur- rent in the sciatic nerve of a frog (except in those last mo- ments in which the action of the galvanic current upon the the uervegives rise to the "voltaic alternatives") is inverse or centripetal. In these lasl moments the nerve-current may ometimes inverse and sometimes direct; and this change II.] Convulsive Diseases. 143 may take place more than once, but, except in these last moments, the direction of this current is, as I have said, al- ways Lnv< The second fact is furnished by Professor dn Bois-Rey- mond in an experiment in which the two ends of a Long portion of nerve are placed upon the cushions of two gal- vanometers and the middle of the same nerve is laid across the poles of a galvanic apparatus. Looking at the needles of the galvanometer before passing the galvanic current, these needles are seen to diverge under the action of the nerve-current, and from the direction of this divergence it ident that this current sets from the end to the side of the nerve : looking at these needles while the galvanic cur- rent is passing, one needle is found to move still further from zero, the other is found to return towards zero. The third tact, which has been recently furnished by Professor Eckhardt,* is to be found in an experiment which may be illustrated as follows: In this experiment the nerve of the leg of a frog, properly prepared for the purpose, is placed, one portion (that nearest to the leg) across the poles of an induction coil, another portion across the poles of a galvanic apparatus. Having done this, the leg is first thrown into a state of tetanus by passing a scries of induc- tion currents, and then, the tetanizing influence still con- tinuing in operation, the continuous current of the galvanic apparatus is transmitted in turn to and from the leg. This is the experiment. The result, which is not a little remark- able, is : that the tetanus ceases when, the inverse current passes, and continues when the direct current passes. Nor is this result altered by inverting the order in which the continuous and induction currents are made to act upon the nerve. Thus applied after the direct current the induction current produce contraction, but not so if they are applied after the inverse current. Nay, it would even seem as if the direct current is actually favorable to the production of tetanus; or, with this current passing, a solution of salt, which of itself is too weak to cause tetanus, will have this effect In observing this fact, Professor Eckhardt proceeds as follows First of all, he tetanizesthe limb by placing the portion of nerve nearest to it in a strong Bolution of salt ; on Medical Electricity, \>. 111. Bj Dr. Althaus. 8vo. 144 hires on [February, after this, he adds water until the strength of the saline solution is no longer sufficient to provoke this state of con- traction in the muscles; and then, all things being- as they were, lie passes the direct current. The result is that the tetanus immediately returns. Now, on comparing this last fact with the two previous facta, we may have, as it seems to me, some insight into the mode by which the galvanic current acts upon the nerve in the period of alternate contraction. On the one hand,itisseen that tetanus is prevented or arrested by the inverse current. Tetanus is prevented or arrested, that is to say, when (as the first and second facts show) the galvanic current coin- cides in direction with, and imparts power to, the nerve- current. On the other hand, it is seen that tetanus is not prevented or arrested by the direct current. Tetanus is not prevented or arrested, that is to say, when (as the first and second facts still show) the galvanic current differs in direc- tion from, and diminishes the power of the nerve current. The one result, indeed, is in harmony with the other; for if contraction is counteracted by imparting power to the nerve-current, it is to be expected that contraction will be favored by detracting power from the nerve-current' And this result, moreover, is not at variance with the premises. For has it not been seen that ordinary contraction is coinci- dent with the discharge of ordinary electricity, and with weakening of both nerve and muscular currents ? And has it not been seen that rigor mortis is associated with abso- lute and permanent annihilation of the two last named cur- rents ? And if this be so if in this manner the inverse current antagonizes, and the direct current favors, contraction then it seems to be possible to apprehend, in some degree, why it is that contraction occurs alternately at the brgin- ning of the direct, and at the end of the inverse current. When the inverse current passes, the influence upon the nerve current is one which antagonizes contraction, and hence it is not to be wondered at that there should be no contraction at the beginning of the current ; when the in- verse current ceases to pass, there is an end of the influence which antagonized contraction, and contraction may there- fore follow as an equally natural consequence. When, on the other hand, the direct -current passes, the influence upon the nerve current being one which favors contraction, the occurrence of contraction at the beginning of the current 18G1.] 145 may be accounted for : when the direct current ceases to . the influence which flavored contraction is at an < and therefore the absence of contraction at this time is not to be wondered at. In the third period that of single contraction the mus- cular movements resulting from tl. d of a galvanic current upon nerve i d somewhat perplexing, hut with a little thought it may n that the key will apply to their interpretation. If. as ha.- just been seen, contraction attends upon the be- ginning of the direct current because this current is found to favor contraction, it is not difficult to find a reason which will explain, not only why in the first period of double con- traction the contraction at the beginning of the direct cur- rect is strongest, but also why in the first part of the period at present under consideration that of single contraction : there should lie contraction at the beginning of the di current, and at this time only. Xor arc the apparenl ilarities in contraction the "volaic alternatives" which ir in the latter part of this third period of single cont tion entirely inexplicable ; for it may he that these apparent irregularities this apparent shitting of contraction from the beginning of the direct to the beginning of the inv< current, and so backward and forward once may be thing more than the natural conserpience of the chai which at th'. and are taking place, in the direction of the nerve-current. Looking back, then, at the arguments which have been advanced in the pr< ction, there would to be littl i for su] - vital property of eon- lility has been called in: >n during contraction by ricity; for has it not appeared that r mortis ident with the utter extinction of nerve and muscular currents ': that ordinary contraction i- mded by weak< tion attends upon the d' of stntical electricity'.' and that contraction i- favored when tl, vanic current is to detract power from the nerve-curr* is it not I that contraction is antagonized when the action of I current is found to impart power to the nerve-cui oking hack, indeed, i, i as it muscular coincident with id contraction with the. 10 146 Lectures on [February, of this action. In a word, it would seem as if mus- cular m< otliing more than a physical proci it is quite in accordance with what we know of the physi- cal action of electricity that should mark the impartation of this action, nnd that contraction 3hould attend upon its ah- ion. Lt would seem, also, thai this view of muscular motion under the action of electricity is one which tallies well with what h;; 'ready said concerning muscle under the ion of nervous influence and blood. Indeed, knowing i we do of the action of electricity, and knowing also that the nerve-current is a componant part of, and the only intelligible idea in, nervous influence, is there not some dif- ficulty in supposing that nervous influence can do other- than counteract muscular contraction ? And with re- t to the blood, is there not some ground for believingthat - fluid must counteract contraction by keeping up those mical changes in the muscle and nerve upon which the electrical currents of muscle and nerve may be supposed to be based : At any rate, the view of the action of electricity upon muscle, which has been advanced in the present don, is one which appears to support and explain the view already arrived at respecting th< of blood and nerv- ous influence upon muse LY. In constructing a theory of muscular motion, there are many facts which still remain to be considered, and some of which must not be left unexplained. How is it for mple, that muscle undergoes no change of volume in contracting ; that contraction is brought about by "mechani- cal irritation;/' that muscle contracts with diminished power as it contracts upon itself; that the waste of muscle is proportionate to its contraction ; and so on? An - to be explained without the aid of a vital property of contractility and a doctrine of stimulation ? The fact that muscle contracts without undergoing any change in volume the gain in breadth being precisely loss in length has been often appealed to as an argument that the process of contraction is beyond the | >e of any physical explanation ; but, in point of fact, this nge in muscle has its strict parallel in the change which passes over a bar or iron under the action of magnetism. The experiments of Mr. Joule* are quite conclushe upon phical Magazine, February and April. 1SG1.] ' 1 the latter point. In 01 i be magnetl in the ated copper wire. One end of this bar was I was attached to i of levers by which an} length was multiplied 3 rectangular iron wire, one-fourth of an iuch ith of a an inch thick ; the i in length, and one-third of an inch in _ the coil with a current c bar to saturation, or nearly so, the index of the multiply aratus sprang from its position, and vibral at a point l-10th of an inch in advance a distance giving L-oOOOOth of an inch for the actual elongation of the After a short interval the index cei rate, and be- to advance gradually in of the bar under the heat radiating from the coil; and continued to do until the ci bar demagnetized, when it immediately vibrated abou l-10th 01 an inch lower than that to which it . pre\ attained. In order to show that the bar under- went no change of volume in thus elongating, Mr. Joule placed a bar of annealed ir< yard long and half an inch square, in a gh y inches long, an inch and a half in diameter, and surrounded by a coiled conductor ipperwii l-20th of an inch in di- amel 110 yards ii xtremity ot this was closed ; the other v. as fitted with a stopper, the centre of which was pierced with a graduated capilliary tube whi division was equal 0000th part of iron bar. This being done, the tube was filled with water, the Btopper adjusted so as to force t r to a convenient height in the capillary tube, and the coil alterternately con- nected and disconnected with a Daniell's battery of live or sixc . apparatus of sufficient power to m; iron bar to the full. T ! he experiment. Th atno perceptible occurred in th fluid in the eapilliar i making or on breaking with the battery, and this equally whet! try, orwhel sing or falling any inperature acco bar. T riment, iud hich ail'- moat conclusive proof that the bar und volume on being magnetized or dei tjon of the bar which tai on m : tiou Lectures on [February. had not been accompanied by a corresponding loss in breadth water would have been forced through twenty divisions of the capillary tube wheneverthe circuit of the battery was plcted. Under the influ< magnetism, therefore, there arc a in a bar of iron which are strictly parallel to tbo.se which take place in muscle ; and this parallelism extends also to that point which is so characteristic of muscle, viz: suddenness with which the contracted and elongated state- may alternate one upon the other ; for, in Mr. Joule's experiment, the bar was seen and heard and felt to jam}) suddenly from the longer to the shorter form, or from Bhorter back again to the longer, according as the elec- tricity was communicated to, or withdrawn from, the coil. is a vital property of contracility at all necessary to iain the next fact the contraction which i- brought about by what is called " mechanical irritation." ( >n the contrary, it is very possible that this phenomenon may nothing more than the natural consequence of the mechani- cal interference with the electrical currents in nerve and muscle. It may be supposed, as in a previously related e, that a certain interruption in the nerve-current will a result of the pressure which is implied when a nerve is subjected to a ''mechanical irritation;"' and that, conse- nt upon this interruption, momentary currents will be induced in the nerve and in the neighborhood. It may be -apposed, further, that the muscular fibres to which the nerve is distributed are the scat of some of the secondary currents thus induced, and that these fibres are thrown f contraction by the disappearance of these currents.' . also, when the muscular fibre is directly subjected to mechanical irritation, it may be supposed that there has :> some interruption of the muscular current in the part I upon, that this interruption may give rise to mo- atary induced eurrentsin the neighboring muscular fibre and that the disappearance of these induced currents may ilarly bring about contraction in the fibres included within the circuit of the currents. And, surely, after what id, it is easy to believe that the contractions rc- mechanical irritation" arc thus due to definite ; intelligible changes in the nerve and muscular currents cribe them to au unintelligible "irritation" of a not very intelligible vital property of "irritability" in n< and mm 1 i:"1 Nbristhe ' fca with diminished power as the muscle conl elfan argument that the law of muscular contraction is different fromany known physical law paction. \i is no don M. inted out that the force of muscular conti the muj ipon itself; but rgumen mus< different from the law of all physical attn Indeed, ela $, in shrinkin Dgation, behave in ev riment, and undoubtedly coutracti< hysical proc ipeal cannot be made to the fact that the - proportionate to the amount ofmucular >n, in order to show that muscular contraction is the tional activity in the muscle ; ter what has y that this waste has not been iucur- :n restoring the- At any rate, i; tain that the electrical condition of nerve and muscle which. according to the prei is connected with the state relax rid not with the state of contraction, which cannot be kept up without a, correspondin nical in the tissues concerned, conclusion, (for thoug <-\i- :d there is no time to bring it forward) ; argument? i- i ion rather than contraction h- it not this I whirli are said to belong ntractility which is called irritability . lertain ag that the nt contract: referred to that form of contractility w [eristic persiste: which antagonized contraction during lid ? And if so, what need is there of the doctrine of stimu- i which is founded thereon ? > doubt, a difficult matter to abaudoi d in the mind, [is that which .ntractility to ; itractility ii when !i. 1 final purpose of L50 L loses. [February, traction, aud particularly thai form of contraction which is of the will instead of being brought about by the infusion of more life into the muscle, ht about by the induction of a change which is re- xtent in rifformortis. But this difficul- tly which diminishes when it is steadily looked in the face. Solar as the will is concerned, the theory under consideration requires one to suppose that voluntary muscular contraction is brought about, not by im- parting something to the muscle, but by removing some- thing from tl "lc which had previously antagonized contraction. idea changes with reference to the muscle, but nor with reference to the vital activity of the will, for in either case and equally the will is a living act- ing power. And as to the rest, it is surely as easy to sup- pose that the willacts through the instrumentality of a force ii must belong to muscle as a physical structure, as it suppose that it requires the super-addition ot a vital tractility, and a special provision for stimu- ls, I repeat, a difficult matter to abandon old views, ami, turning round completely, to regard muscular contraction as a process which is most fully realized in rigor mortis; but we have at least this advantage in so doing that we gain an explanation which is physical and intelli- gible an explanation, moreover, which applies to rigor as well as to ordinary muscular contraction. For what is the case with respect to rigor mortis? The case is -imply this: that as long as there is any sign of " irritabil- " or any trace of nerve-current or muscular current. long is there is no rigor mortis. If these signs and traces diiy, as in persons in whom the vitality of the >een exhausted by long life, or by chronic disease. as consumption, the muscles become speedily rigid ; if and tra< -low in dying out, as in persons en cut down suddenly in the full glow of health. arc equally slow in passing into the state of ca- rigidity. Once contracted, moreover, the muscles remain contracted until the supervention of putrefaction rent which mosl speedily in the casewhere the . in their physical integrity least perfectly. The d, which arc utterly unintelligible upon the hy- that contraction depends upon the stimulation of vital property of contractility, are precisely what they lit to be according to the premises : for according to the premises all I ' the commencement ofri }uon dying out of that action in muscle and nei of which the electrical current is one of the signs ; and all t'TU | jsaryto its continuance is the absence of thia .. and the physical integrity of the muscular structure. - the premises, indeed, there is no difficulty in explainii unexplained, and hitherto contradict cnar. ihis form of muscular contraction; . it would seem that rigor mortis ma; type of muscular contraction in general, and 's in favor of the theory of muscular tion of which I have had the honor of sketching the broader outlines in the present lecture. o modern da ns of the use \e Treat) Syphilis. ByDr.ETHae Grriefswald. The contention concern];. admissibility of mercury 1U the treatn iilis (Die Xaehtheile der Murkurial- kur. Vienna. 1859. 8) recently excited by Dr. Hermann __:, ike that of the advantages resulting lation and blood-letting, must be witnessed at each generation, has virtually, in my opin- io hings of Virchow and Waller hr. 1859. 111.) The following lines ,1 onlv as a supplementary examination of the rts adduced by the opposers of mercury to -rain their opinions. The very first li ireface prove tha r happily belongs to that class who are fully con- the glorious progress we have made." "The in- lercurial treatment were but little known uutil our times : indeed, ancient physicians scarcely ha< indi isgivingthat mercury incorporated into ns man in the organism, and may pro- . various destructive and often incur- igation of the present til ,r kiDd, are du- ration of mercury. ' dof proof that what we designate a .itional syphilis was well known to the earl- jrvera 152 Mercury in the [February, of syphilis at the time of its general prevalence at the end of the 15th and during the first decade of the 16th centuries. Now Hermann asserts that this constitutional syphilis" originated from the administration of mercury to cure the hitherto far milder diseese. Hermann supposes that "consti- tutional syphilis firsl occurred when mercury began to be used, particularly about the middle of the 16th century, by Francis 1.. and in the form of Barbarossa's pills." Although these words do not place the historical know- ledge of Hermann with his subjectina very favorable light, yoi his immediately following explanation as to the method by which those physicians arrived at self-deception concern- ing the true nature of constitutional syphilis, does so in a much less degree. "The first physician," says Hermann, after asking the reader to 'imagine" himself in their position, "treated syphilis, doubtless both chancre and gonorrhoea, with mer- curials." Notwithstanding the complete ignorance evinc- ed by tb 'Is. in regard to the earliest periods of syph- ilis, tiie recommendation is made to "suppose" one's selfin the position of those physicians, when a recommendation to study their writings, winch are accessible to every one in the collection of Luisinus, Gruner, Fuchs, etc., would have been more to the point. By such a proceeding the com- piler would soon have made the discovery that "primary syphilis" did not at all present itself "undoubtedly" to those sicians as gonorrhoea and chancre, and that they least of all treated gonorrhoea and chancre with mercurials. The cardinal assertions of Hermann amount to this, that -constitutional syphilis is the product of mercury," and wthis fact which has been, for the first time, verified by the exact investigation of the present time," might better be road "by \h->. Hermann, Lorinserand Kletzinsky." Lei us examine whether these assertions are founded in tact. The earliest observers of syphilis did not determine to ly mercurial inunction until a long-continued opposition. they feared the most injurious consequences from Iness," particularly in cutaneous affections, which, prominent sympl ped a very large share ention. Besides, the powerful effect of mercury upon the mouth was well known, as it had for a long time been a common remedy in various cutaneous dis- L861.] Treatment of Syphilis eases.* The su Pits application observed in i' diseases induced its use in this new malady also; soon be- coming a remed leral use among physicians, but op- .1 ly many, its abuse by the profesi ion, and the dangers salivation being depicted in the most frightful colors. Many writers also affirm that mercury was by no means a certain remedy in syphilis; consequently, the use of guiac- uin became for a time the pr ; mode. li to understand that the mercurial treatment fre- quently produced the worst consequences, and in); infre- quently death, when we read in Torella, for example, that a salve weighing 54 ounces contained 4 ounces of mercury, and that inunction with this of the whole body was con- tinued for nine days (Luisinus, p. o2T). Yet the assertion that "constitutional syphilis" was produced by mercur wot found in the writings of any of the early writers. They had, as Hermann says, w- no idea " of this effect of the metal. Among i he most decided opp . mercury is Leoni. His detestation of it is as great as could be desired. wiThere is nothing more injurious to those affected with syphilis than to use mercury externally or internally, under the form <>i ointments or fumigations. From such applications per- always suiter in important organs/' (Luisin. p. 904.) "Important organs" arc the brain, from which was suppo to flow the material of the saliva, the lungs, the heart, the liver. Leoni likewise describes the gummata, the no the pair nit he had "no idea that these mi be artificial . Yet even at that time such objections were not wanting. y are most definitely discussed by Fallopia, the anato- mist, during the late period of the guiacum method of cure. Fallopn the gummata, tophi, etc., of the major- ity of cai I of mercury, and puts the riod of tb >f syphilis, ai earliest and most important: Mi mus^ a S in his lime-wa1 "ad libiti . .rulara el ana, ed L54 Mercury in the Treatment of Spyhilis. [Feb., stress upon this opinion. "The causes of the tumor Fallopia, "originate in the affected viscera, but, in most the inunction by mercury." (Luisin. p. 826.) Accordingly, Fallopia asserts that gummata, etc., may be produced by the disease itself, but occur most frequently after the use of mercury which has not cured the disease. He explains this pro follows : "When these parts arc anointed tluy become enfeebled, and are thus then selected by the di He believes, therefore, that gummata, etc.. arise because the mercury has weakened the particular part, thus inviting the disease there." .Luisin. p. 827.) But. irom the preceding words, it appears that evenFallopiafinds a residue of cases in which gummata are not to be ascribed to mercury. On the other hand, Fallopia attributes caries of the bones in syphilitic patients entirely to the influence of mercury. "The infection of the bones in syphilis is terrible and the more so because they are infected in such parts as do not permit of a cure, as the bones of the head which are designed to inclose and protect the brain, and these I have seen so much affected as to be all carious. I have many examples. Some times the bones of the palate are so much involved that the whole palate decays, and not these only, but the usual bones also ; and it should be borne in mind that it is not in every inveterate case of syphilis that this oc- curs, but only in those in which mercurial inunction has been enployed." (Luisin. p. 827.; Notwithstanding, Fallopia had not the idea that mercury produced only injurious effects under all circumstances, for wit! i all these objections, he considered mercury capable of overcoming the disease. (Luisin. p. 810.) We quote also the following, from the same source : "A third most excel- lent methodis with pure mercury, which being absor overcomes the disease, expelling excrementa at the palate. For me it does this admirably/' (Luisin. p. 782. The principal reason for the distrust with which Fallopia regarded mercury was his preference for the "cura regia," . by the use of cvacuants and the methodic employmenl guiacum. "Why use mercury by which health is not certainly nor If it does not cure, it ravatesand the disease becomes more stubborn.'" Fal- lopia does not therefore doubt the curative power of i . . but considers it less certain than the cura re Whether this opinion was well founded, we may learn from what bur author says further; "I do not approve of this StH.J Mer Treatment of & licament, bu1 i by the curia r The cura regia, there- bre, sometimes fail d, and then Fallopia had i - to 'ii ry, under what circumstances and with what suc< e following quotation will show: "I have seeu a young Dan lahorin g under syphilis in which ( led. An empiric cured him with mercury. Where! [have made use of it in stubborn and desperate cases, and ieularly where L have first tried all other methods.*' And many others after him who ne weary of declaiming* against mercury, had, like him, recoui ibborn and desperate ca Every died them, but unlike Fallopia, they did not dways honorable let the world know the truth. If the quotations hitherto given from the writing- of the opponents of mercury are but little calculated to support the opinion of Hermann, that constitutional syphilis first ap- >eared after the employment of this metal, and that sarher } 3 had "no idea" of such an effect produced ertions of other physicians, who did not parti- cipate in the opinions of those named in regard to mercury. ire still less favorable to his vicv Thai mplaints mentioned by Hermann were not in the earlier periods of the general prevalence of from the fact that several physicians de- ny pointedly and fully against these objections. mple, Leonardo Botallo, one of the most experienced . syphilis in the lGth century, says : " * the body become inflamed and uL .en not being exempt, in patients who have mercury? Why does their color become lead- VThat produces, keeps up and increases other various yraptoms before mercury has been used, ui id hurno: Then, as now, thoe :ury care- fully, and by such use not only produced no constitutional but, on tl . avoided tl unfounded are such objectipns. pie of tli ired ili turn membrorum do rcula et nod L56 Wasting Paraly, [Februa Effects which remind mo of Sigmund's process followed myself in many cas< So much for a doctrine which, like its predecessors, \ in a short time, and it is to he hoped forever, he consigi to oblivion, a place assigned to it by a. non-professio write!* 3 I since, when, as at the present, the most founded aspersions were heaped upon physicians who w< at least our equals, and the "exact investigations" of t present are boasted without the examination having be made, as Waller has shown, as to whether mercury m not be found even in the urine of persons who have been syphilitic and have never been subjected to a mercur treatment. Wasting Paralysis. By William Roberts, M. D., Londo Physician to the Manchester Royal Infirmary. The next case, which has only recently come care, is one of the best marked examples of wasting pal that I have witnessed. The disease is presented simple ai uncomplicated, without neuralgia or rheumatic pains, wit out cramps or contractions of the muscles, and without tl least trace of nervous paralysis. In the parts affected, combines the two instances before related ; for the atropl has seized upon the upper segments of both the upper an lower extremities, leaving the lower segments umnjurd and thereby occasioning a strange and curion aorij The patient is a healthy-looking man of 38 years. B was formerly a warehousemen, and subsequently he 1 a school. He thinks the muscular strength has been slow! declining for 16 or 18 years, but during the last two or thr< years the disease has made much more rapid progrei When he is stripped, the nature of his ailment is at oil aled, without the necessity of asking a question. Tl two upper arms are like those of a child so small and thi: while the shoulders above, and the forearms and hands b low, are of the full proportions of a moderately muscul man. The odd appearance of the shoulder-blades likewil immediately strife beholder. Instead of being bona s surface of the ribs in 1 JcapuJ lie loosely beneath the shin. attempt i moving the arms, their lower angles are thrust backwal and upward above the level of the arm-pits; and they pn fl.] Wat 1 1 1 t uuder I prominently as to look like a pair of nt wings. This singular condition arises from the lal destruction oi the muscles binding the shoulders to trunk, namely: the serrati, the rhomboidei, thepector- c trapezii, and the lav. dorsi. In the lower extremi- atrophy has followed a corresponding course. The Irhs are greatly emaciated, while the legs are stout and muscular action is weakened in proportion to the phy of the muscles. The hands and fore-arms pos iction all their proper movements. The patienl with facility, and grasps with force. The forearm flexed and extended with readiness, but so feebly, two-ounce weight in the right hand and a four-ounce in the left, suffices to overcome the utmost resistance [the biceps and brachialis anticus. atient stands erect, the abdomen is protruded d a corresponding dee}> concavity occupies the lumbar behind. He walks slowly and with evident difficul- accomplish considerable distances three or n* miles if permitted to walk at hi iding Irs is a painful labor to him. right and left are affected almost exactly alike, and onfined to four groups of muscles on each in the upper limb, (a) those which unite the :st, (b) those which move the elbow-joint ; id in the lower limb, (c) those which move the hip, and (<1) it. igularity in the upper limb which is ab- m the lower, that the scapulo-humcral muscles, com- the deltoid, the supra and infra-spinatus, the sub- ;-is and the teres major and minors, continue vigor- 1 well-nourished, isolated betwecnthe group above and up below, of which the muscles have degenerated to the verge of annihilation. baracteristic feature of wasting p . is here represented. I allude to i1 irse the singling out of a muscle or a part of a musle id the decay of the surrounding scicuius in tolerab lie of each trapezius is lil pared. KVha ins of the wasted muscles is perfectly under ic control of the will. The skin is acute! . anda elim ly complained of. [February Concerning the determining' cause of this man's corn plaint, then rching inquiry has failed to elicit an; ig satisfactory. The most reasonable explanation is on'i red by the patient himself who, I may remark, is a mar musual intelligence that it has arisen from excess exposure to cold. When occupied as a warehouseman, h< lied to work in rooms di fire. The cold y iclt by him at the time, and lie frequently be benumbed. It is from this period that he -t commencement of his ailment. - By far the largest number of cases of wasting palsy are produced by undue and too long continued strain on the muscles ; accordingly artizans are found to be the most fre- quent victims of partial atropy, and the disease Hills with unerring certainty on the groups of muscles most tried, same fact comes out with clearness when the frequency of the disease in the right arm, and the left is considered. On a comparison of a large number of cases, I found that the right arm was more than three times more frequently eked than the left : and in the two hands the proportion was three to one in favor of the right. Masons and mechanics, who wield heavy hammers, have the muscles of the shoulders first attacked ; shoemakers, tailors, and milliners are iirst seized in the hands. A Middleton silk weaver lately under my care, exhibited an example of wasting palsy, confined to a single muscle. When he was employed at the loom the index linger of the right hand was used to lift up a portion of the machinery ach throw of the shuttle. This was effected by the con- traction of the extensor indicis. Xow the power to elevate the index with sufficient force to lift this weight had been failing in this man for the last eighteen months, lie was able to work for a time as usual, but in half an hour or so the linger was thoroughly fatigued, and he was compelled to repose. By alternate periods of work and repose he was able to do about a quarter of a day's work. The grasp of the hand was powerful, and there was no alteration of sensation. On uncovering the forearms no different perceived. No doubt this arose from the small magnitude and deep position of the extensor indicis, but the nature of the case was rendered clear by its perfect analogy with corresponding ailments in writers, tailors, and er artisans, m all whom the atrophy falls on the muscles most used. 1.] Wasting Parol: L59 muscnlar atrophy froi rk, well-marked group, easily recognized, and not Their pathology and mode ot production ap- 3 plain. The fatigued muscles suffer in their nutriti :,r o[' duerepose, and become a prey to fatty and ular degeneration of their fibres. There is no tendency .tension of the disorder to the muscles of the trunk the exciting cause has only a local operation. IT early, perfect rest of the injured n will generally suffice to bring about restoration, but if >phy have existed a twelvemonth or more the rase is well i hopeless ; and even, if seen early, I have never been to obtain success in treatment unless the patient has particular work which had pro- , fortunately it is seldom that an ar n do this upport of his family depends upon . and he persists in the labor that is slowly ; rely lermining all his usefulness. The hest advice to give a patient i - his occupation at once. The Middleton weaver above-mentioned, acting under my ion, became a gardener, and is now doing well in that >ne of the tailors turned letter carrier, and he dates himself on the change, which appears nbtun- igresg he has since made continues, to lead ration of his hand. A writer should be immended to accustom his left hand to do the work ot the ri that the latter may rest. iderable number of cases of wasting palsy are pro- duced by cold and wet. These also form a concise group, ervers have wished to set apart under the rion ot "rheumatic form of muscular atrophy." The invasion of the complaint when thus caused is often some- what sudden, and the v ccompanied by cramp.-. rheumatic pains; but eculiariti warrant a separation into a dis- hat set in with the so-called umatic complexion, subside soon after into the ordinary story of the groom, whoe describ< art oft:. , betrays much of the rheu- tic natui ! from neuralgi< through- - the whole of his illness, yet it does not appear that cold iate .-hare in producing the atrophy the thigh. On the other hand th miner, whose Led, although the m< ting Parab/ [February. constantly immersed in water, never suffered pain during the four years that his complaint had endured. The frequency of excessive muscular exercise, and of ex- ; re to wet and cold as determining causes of partial wasting palsy, explains why tt\e great majority of such cases occur in the male sex. In ten eases of this sort that I have i only two were women ; one a domestic servant and the other a iactory hand. palsy has sometimes been known to be conse- cutive to other disorders. The boy whose case was related first, had an attack of infantile paralysis previously to the setting in of the wasting- palsy. An old pupil brought me tild about three months ago, in which the left upper arm was excessively wasted, with good preservation of the forearm and hand. The history of the ease pointed un- equivocally to the infantile paralysis of the whole limb as the first disorder. The forearm and hand recovered in a months, but the muscles of the upper arm underwent a gradual atrophy until they had been completely de- stroyed. It is well known that acute diseases aie sometimes fol- lowed in the course of convalescence by partial or total a very inexplicable nature. Typhus and ty- id fever, dysentery, cholera, and diptheria, the three especially, have furnished frequent examples of such paralysis. Avery curious circumstance in the history of wasting palsy s disposition to run in families. There has been pub- lished an account of at least ten families in which the dis- ease has appeared hereditary. In four of these it was con- fined to two brothers in each. Another family, whose his- tory has been supplied by Dr. Meryon, had four boys affect- ed, and there were eight healthy sisters. In another family mentioned by him all boys, namely: two, had wasting palsy 1st the two sisters were sound. A sea-captain mention- u'an had lost two maternal uncles and a sister from the disease, but two other Bisters and three brothers con- tinued healthy. In a later instance recorded by the same observer the patient's two aunts had died of general muscu- lar atrophy. In a family known to Oppenheimer two uncles and a cousin of the patient were already deceased, while another cousin and two brothers still suffered from ting palsy. Altogether, these ten families included twenty-nine indi- 1861.] Wasting Paralysis. ltil viduals struck with wasting palsy, and of these only lour were females. This great preponderance of males is quite inex- plicable. It cannot depend, as in the previous case, on the greater exposure of one sex to the common exciting cause cold, wet, and hard work because in the hereditary rases the disease frequently appears in early youth or child- hood, longbefore the sexes are unequally subjected to fatigue and exposure. Cases of hereditary origin have another peculiarity. In nearly all of them the wasting spreads eventually to the en- tire muscular system, consequently they tend to a fatal ter- mination, and offer hut a small chance of recovery. Such - are not, however, absolutely hopeless. I have recent information that, in the family mentioned by Dr. Meryon, although the three eldest sons have died, the fourth has every prospect of surviving, and for more than four years has exhibited a steady improvement. AVasting palsy is essentially a chronic disorder. Wc measure its advance by months and years. Some cases complete their history in six or eight months, others linger tor many years. I found the mean duration of a consider- able number of cases to be a little over three years. The disease may terminate in one of three ways, namely : in recovery, permanent arrest, or death. The second mode of termination occurs when the wasting of the muscles ceases, and the limb continues tor an indefinite period in its maimed condition, neither amending nor deteriorating: the muscles, which are entirely destroyed, do not reappear, and those which are only partly consumed continue to ex- ercise their feeble powers under the control of the will, hut do not regain their former bulk or vigor. This stationary condition being once ushered in by the arrest of the atrophy the disease may be said to have reached its ultimate term, and the skeleton-like footprints it leaves behind are to be. regarded not as the malady itself, but, like the scar of a healed-up wound, only as the commemoration of a morbid activity which has now altogther passed away. Generally speaking, when the disease has fairly entered on the stationary phase, and has continued so a year or two, there is very little danger that it will resume its active ca- reer. Individuals have lived twenty and even thirty years with their crippled limbs unaltered. There are cases, how- s', where the malady, after lying torpid lor years, ha- awakened to new activity. Aran has related three info 11 162 Wasting Paraly* [February, Lng examples. One was a woman who, when a child, had atrophy of the muscles of the right hand, from which she recovered completely in her twelfth year. When forty years of age she was attacked again in the .same place. In another instance, the right leg became the subject of wast- ing palsy, but gradually recovered. Sixteen years after the shoulders were seized, and the disease involved both upper extremities, and several muscles of the trunk. In a third case, the right leg was the seat of debility and atrophy. Alter remaining quiescent for eight years, the disease start- ed into fresh activity in the left leg and right arm. On the question of the nature of wasting palsy and its true pathology, opinions are divided under two suppositions. Some suppose thalthe seat of the disease is in the nervous centres, and that the muscles are affected through their nerves, while others, and I reckon myself of the number, consider the muscles as primarily affected. I will not weary the reader with a discussion at length on this point, but must refer those who are curious on the subject to my essay, where the question is fully debated. I may, however, shortly state the results of postmortem examinations where the disease has proved fatal. The wasted muscles have always, of course, been found diseased; usually there lias been found fatty degeneration of the primitive fibres. In other cases the fibres have simply withered away until nothing remains but the empty sarcolemma, and, at length, even this disappears. The two conditions maybe found to- gether in the same subject. The muscles of the lower ex- tremity appears more prone to the fatty change, while those of the upper extremity more frequenty suffer simple atrophy. Hence ilie wasting is a more conspicuous symptom in the latter than in the former. The muscles in the calf have been known to be completely changed to masses of fat, without, any material change of shape or bulk. The state ot the brain and medulla oblongata has invari- ably been that of perfect health, hi nine out of thirteen autopsies of cases of general wasting palsy the spinal cord was sound, but in the remaining four there was softening or degeneration. Cruveilhier found, in two eases, atrophy o\' the anterior roots of the spinal nerves, and this has been found since, in two instances. In live other eases, where this pecularity was especially searched for, it was not found : on the contrary, the anterior roots possessed their usual . and showed no sign of degeneration. 1861.] Pathogenesis of (Morot L68 The nervous branches, which supply the wasted muscles, have been examined in a few instances. Cruveilhier and Virchow found the muscular branches much atrophied. Dabonlbene, however, found no change in the peripheral branches, and Mr. Partridge, who examined one of Dr. Mervon's cases, states briefly that the tendons and nerves were unchanged. Amid this conflict of evidence, it is im- possible to come to a certain conclusion regarding the pa- thology of the disease, but the weight of evidence inclines very strongly to the belief that the muscles are primarily affected, and that the morbid changes sometimes found in the several parts of the nervous system are secondary. Wasting palsy is especially liable to he confounded with lead palsy and reflex paralysis, especially the essential par- alysis of infancy and childhood. Lead pal sy is distinguish- ed by its comparative sudden invasion. In a day or two, or a fortnight at most, lead palsy has reached its height, and the muscles assailed arc reduced to complete immobil- ity, whereas, in wasting palsy, the waning strength keeps pace with the gradually decreasing volume of the muscle, aim the precursory symptoms of lead palsy are very marked. These are colic, anaesthesia, tremblings of the limbs, general dyscrasia, undue mobility of the emotions, especially the depressing ones ; inline, all those anomalous symptoms and conditions embraced by the term lead cach- exy. It is also usually easy in such eases to trace wry dis- tinctly the entrance of lead into the system. London Med. U'.e Pathogenesis of ( nloro* It is known that fewer colored blood-corpuscles are found in chlorotic than in healthy blood : while in the latter, one cubic millimetre contains from four and a half to five mil- lions, the number in the former falls as low as to two and a half millions in the Bame quantity. It is known, too, that the colored blood-corpuscles contain iron, and chlorotic blood is, therefore, deficient in iron: and, further, that the deficiency of chlorotic blood in colored blood-corpuscle-, and in iron, is the consequence of an impaired Btate of the formative funct; tamorphosis), and not the resull of increased waste (Eatamorpo >r the urine of chlorotic patients is poor in solid materials. Lastly, it is known that the small amount of iron which the healthy organism ap- 1 1>4 Pathogenesis of [February, propriates to itself from the most varied diet as from flesh, milk, eggs, water, etc., fully suffices for the needs of the system : especially as in the healthy state the bile is the only secretion that contains iron, and yet the ferruginous con- tents of the bile are in great measure re-absorbed from the alimentary canal. How, then, is the occurrence of chlorosis in a healthy girl to be explained? She receives still the same ferruginous articles of food; it cannot, then, depend upon a want of iron, or upon a withdrawal of iron from the system, for these conditions do not exist; and yet I he girl, with a constant supply of the same amount of iron, becomes chlorotic, i e., there is a failure in the formation of red blood-corpuscles. What is this owing to? The vi- talist, who ascribes to the sanative power of nature a Pro- metheus-like contrivance and action in the preservation and restoration of health, is compelled to have recourse to a sup- posed error or caprice in regard to the direction that this sanative power takes, in order to explain the occurrence of chlorosis. But I am glad that the time is past in which such phrases and terms are deemed satisfactory, and in which it was fancied that an already obscure subject was to 1m- explained by something utterly unintelligible. Xow, when we ask for a substantial reason as to why chlorosis should occur with a sufficient supply of iron, the theory hitherto held is at a loss for an answer. The theory, to be sure, contains the truth, but it does not contain the whole truth ; a link is wanting in the account of the origin of the disease. The organism, in fact, lacks the power to apply the iron furnished it to the formation of a hematine. Upon what does this want of power depend? We find the an- swer to this fpiestion in a discovery of Lehman n. Physio- logical chemistry has, tip to this time, made various excre- tions the objects of its researches, and especially the urine Its results, therefore, at best, have been of interest only as means of diagnosis. But where it has more thoroughly investigated the changes of tissue, fruitful results are to be found for practice, for pathology, and for therapeutics. I may mention, for example, the value of that beautiful dis- covery of Halwachs and Kuhne, that benzoic acid in its pas- through the liver is converted into hippuric acid by the decomposition of the glycocholic acid. From this, Falck inferred that benzoic acid must be almost a specific against the condition known as icterus ; and experience has proved il t. I.,- so. In like manner, for the explanation of the ori I.] CM 165 of chlorosis, I will show the value of Lehmann's discoi ery, that hematine is a glucoside. We know from Bernard that the liver is a sugar-secretipg an : and, we know, also, that in disease the seer*' of the different glands vary in amount, appearing at one i iiu- Lvely increased, and. at another, diminished even entirely suppressed. There is no conceivable reason why this should not be the case with the seerction of si in the liver; indeed, we know already that this secretioi increased in many forms of diabetes mellitus, and that in all febrile diseases it is entirely suspended. We will supposo, for a moment, and the supposition does not stand a! all in our way, that the sugar-secretion of the liver has for some time been diminished : what will be the first co quence of such diminution? Inasmuch as the hematine requires sugar for its formation, (for, according to Leh- mann's beautiful discovery, it is like saliein, phloridzin, tannin, >mbination of sugar or a glucoside), there- fore, when there is a failure in the supply of liver-sugar, formation of the coloring* matter of the blood will not be 'inplished, even when the amount of iron is sufficient, a? and, consequently, the construction of colored blood-eorpusclcs will be stopped; or, in other words, the chlorotic condition will originate. The essential cause, then, of the occurrence of chlorosis is a deficiency or cessation of the secretion of liver-sugar; the feet that the supply of iron in forming hematine, is only a consequence of the former circumstance, and it is not the real cause of the If the supposition thus made be true, viz: that chlor depends upon a defective secretion of sugar by the liver a supposition, the corr of which has, we think, been proved analytically and synthetically three inferences may Irawn from it : cured by means of sugar, which supplies what is wanting through the failure of the liver. 2d. Chlor > be treated by every means which can ire the sugar-making function of the liver to the norma! condition. 3d. T\ the preparations of iron with whicli chlo mpirically treated, effect the cure. not. as is universally believed, by supplying the requisite iron to the large doses operate by promoting and Li tion of sugar in the lr 1<)<) Pathogenesis of Chlorosis. [February, I. [f the deficiency of Liver-sugar is to be supplied by the ingestion of sugar, it must be a sugar like that of the liver, i.e., grape and not cane-sugar. For though the health or- ganism may be able to convert the cane-sugar into grape- sugar, yel the question is whether the impaired digestion of chlorotic patients is equal to the task. l)oes grape-sugar, then, cure chlorosis? In northern Schleswick, where I practiced medicine for twelve years, and, as I have been told, in many parts of Hanover, honey is a popular remedy for chlorosis; and lean attest its efficacy from my own ex- perience. Even though the honey may contain a small por- tion of iron, yet this is not the curative agent, for other ar- ticles of diet which contain just as much iron, are entirely powerless. As honey, by long-continued use, in large doses, may produce flatulence, acidity, colicky pains and diarrhoea, it may be well to combine it with suitable correc- tives, as the hitters, carminatives, etc., and to take it fasting in the morning in the dose of a tablespoonful. II. We are still entirely in the dark as to the means which increase or diminish the secretion of liver-sugar. There is here a wide field open for inquiry into the powers of remedial agents. But, little as we know with regard to this subject, we are yet acquainted with one agent which promotes the secretion of sugar, and we find it efficacious in the treatment of chlorosis; it is nothing else than cold water. It was shown, some years ago, by Dr. Fetters, in the "Prager Yierteljahrschrift," that the secretion of sugar iii diabetes is increased by drinking cold water copiously; and the experience of every hydropathic institution pioves that chlorosis may be cured by the same means. Many physicians regard the free use of cold water as a means which acts only by powerfully increasing the waste of tissues ; and, therefore, they give no credit to the assur- ances of hydropathic physicians, that chlorosis is cured by this means; for, according to their theoretic views, it must aggravate the disease. 1 n chemical processes, water at one time plays the part of an acid, at another that of a base ; it has, also, a twofold ac- tion as a remedy. Acting in one way it greatly increases the waste of tissue (Katamorphpsis) ; acting in another, it promotes its formation (Anamorphosis). Indeed, a glance at the development of the foetus throws light on the action of water in the organism, and may remove some rusty pre- judices. Schlossherger has shown that in the earliest con- 1861.] Chlorodyne. 167 dition of the foetal life, the blood is of all the parts poorest in water, while alter birth it is richest. Since, then, the vouncrer the foetus is, its vegetable life is the more energetic ^ . and the formation of tissue is more active than its waste, ii is evident that this formation is increased in activity by ;i large amount o\' water. ill. Whether the last of these three inferences will be verified the future will show. What is chiefly needed in the inquiry is an accurate method of investigation, in order to measure exactly the variations observed in the secretions of liver-sugar alter the employment of different agents. When Buch a method is found, then the question as to the effect of iron will he easily decided. These remarks are not vet sufficient to prove beyond all doubt that a failure in the secretion of liver-sugar is the im- mediately cause (A' the disease; yet, I think I have shown the insufficiency of the prevailing opinions on the subject to explain the morbid process, and on the other hand tic high probability of the new theory. The future may give sentence in the matter. Should every doubt be finally re- moved, it would then be shown that chlorosis and diabetes mellitus are, in their essential nature, diametrically opposite morbid processes ; and experimental pathology might one day succeed in producing chlorosis artificially, as has been done in the i diabetes, so that the means would thus be found for the radical cure of diabetes. Maryland and Virginia Med. J Ghlorodj/m . V>y Dr. Edward Squibb, of Brooklyn. This most extraordinary humbug does not deserve a mo- me; onsideration ; and wTere it not for the cir- cumstance that physicians occasionally resort to it by name or by it* misrepresented, and without a due know- its heterogenous composition and quackish charac- be little else than waste of time and space to allude to it. It claims English origin, or rather to have n invented in the English East India service; and in order to secure for it the magical power of mystery and nam ;omposition was concealed, or indefinitely stated as a u of perchloric acid and a new alkaloid. i it was stated to have been analyzed by a Dr. Ogden : latter i snted as having given the formula L68 Chlorodync. [February, by which it i.s prepared. As it nevcrcould have been either invented or analyzed, it is not improbable that its whole story and career are fictitious. It mainly consists of chloro- form and muriate of morphia, but contains besides,perchloric acid, oil of peppermint, hydrocyanic acid, tincture of capsi- cum, molasses, and tincture of cannabis. Such a villianous mixture could never by any possibility have been invented, though it may have resulted from some uncommon degree of empirical ignorance and stupidity; and such a mixture, once made, would have defied the skill and knowledge of any analyist whatever, chemical or logi- cal. And yet an analysis is said to have been made, and i he proportions are given in drachms, drops, and grains. Then, of its properties. It is said to be twice as heavy as water, which, from its composition, is impossible. It is said lo be sedative, diaphoretic, astringent, antispasmodic,diuretic, etc., and to improve the pulse in all imaginable respects, including that of increasing it by decreasing the frequency of the beats ; and finally, the sum of its impossibilities ac- complished, lias the accustomed climax of such cases, viz: that it cures consumption in about the usual proportion of cases, viz : eight out of twelve, and all of the usual un- doubted diagnosis and gravity. That any mixture not ab- solutely antagonistic in its elements, containing two-thirds of its weight of chloroform, and eight grains of muriate of morphia in nine drachms, beside hydrocyanic acid and Indian hemp, should be sedative in effect, is not suprisiug ; and the molasses, capsicum, and peppermint are so many ad- ditional shot to be fired into the bushes ; but the perchloric acidis a novelty. Hitherto regarded chiefly as a chemical curiosity, it now makes its appearance in the materia medica, under circumstances most unfavorable for obtain- ing any definite character or classification. In the small quantity in which it enters the company of these power- ful narcotics, its chance of effecting anything more than the peppermint and molasses, is remarkably small. The whole thing is, in effect, an absurd sarcasm upon the appetite for novelty and complexity, which appetite, in a proportion of the medical profession, is industriously catered to by the crowd of nostrum or rather money makers, who are so easily found in the rauks of all sciences and professions. American Med. Time*. 1861.] Relapsing or E rr< ni /' L69 \rrent Fever. By Dr. Tweedie, Physi- cian to the London Fever Eospital. Relapsing or recurrent fever 1ms been thought by some to resemblethese*Weor sweating fever of Normandy and by others the yellow fever of the West Indies. Pr. Wardef] say 8: "There were undoubtedly some considerations which led to the supposition that the epidemic relapsing fe bore resemblance to the suette, or sweating fever of Nor- mandy. In a few instances, though these were of rare oc- currence, the epidermoid tissue was raised into vesicular eminence, varying from the size of a millet seed to the sec- tion of a small pea, these vesicles containing a transparent fluid, and quite unattended with any areolar blush. On the third day they become shrivelled and opaque, and desqua- mated in thin, furfuraceous scales. From the occasional presence of these bullae with other more logical characters, some degree of similarity certainly was manifest between il and the suette. There were physicians who endeavored to show its near alliance to the yellowfever of the West Indies indeed gave it as their opinion that, in some respects, there was a positive identity between the two, only that the epidemic prevalent in this country had become greatly modified by climate and other circumstances calculated to alter its general features. When we take into consideration the usual number of yellow eases, together with two or three cases of less important correspondent symptoms, we are compelled to admit thatthe assertion is not wholly unfound- ed. Xo trace of its importation into Scotland, however, could be found, which has generally been the ease where yellow fever has been communicated from one country to another." Relapsing fever has always appeared to the author to be a form intermediate between the continued and periodic, but having a more close analogy to the latter. lie has been led to this view by considering the suddenness of the inva- sion, the abrupt termination of the symptoms after a defin- ite period by copious and apparently critical sweat, the in- terruption of the convalescence by a similar, though shorter paroxysm, or it may be paroxysms of nearly certain dura- tion, and a final abrupt cessauouof the disease generally af- sweating. Even in the more sevej -. ii which there was gastric disturbance with jaundi ! oc- casionally cerebral symptoms, the resemblance to the ma- lignant or pernicious periodic fevers, more particularly those 170 Relapsing or [February, included under the bilious remittents of tropical climat* striking. Symptoms and 'progress. In relapsing fever the invasion Is sudden. Thepatient, previously in good health, without warning, is seized with a feeling of indisposition, complain- ing of chilliness or shivering, acute headache, Languor and lassitude, Bevere muscular aching and arthritic pains. The appetite fails, the skin becomes hot and dry, the tongue white, the desire for fluids cosntant, and the urine scanty and high-colored. Towards evening the symptoms are ag- gravated ; the night is passed either in restless agitation or snatches of unrefreshing sleep. Occasionally the heat of the skin is relieved by irregular Bweating,but still the other symptoms suffer no diminution. Vomiting of bilious fluid, often accompanied with pain at the epigastrium, is an early and nearly constant symptom. It may occur in the first or primary fever only, or it may come on in the relapse also. A.s the disease progresses, the patient becomes more pros- trate and disinclined for bodily or mental exertion, the pulse more rapid and tense, the tongue more thickly coated. the bowels constipated, the muscular and arthritic pains more acute ; and the nights are passed in restlessness and wakefulness, unless the nervous system be calmed by the aid of opiates. About the third day a marked remission of the symptoms is often observed ; but whether there be a remission or not, at a period varying from three to seven days more com- monly on the fifth day a copious general sweat breaks out and almost immediately afterwards the fever vanishes, leav- ing the patient unexpectedly free from the painful Symp- lon is with which a few hours previously he had been har- assed. Dr. Cormack, who watched the phases of this sin- gular disease, tells us that the change for the better was often sudden and complete, thepatient one day moaning and groaning in pain, and the next at his ease and cheerful. complaining only of hunger and weakn< This apparent convalescence, however, is not of long du- ration, for when the patient and his medical attendant rea- sonably conclude, from the favorable change that lias oc- curred, that the fever is at an (Mid. and that time only is re- quired for complete restoration to health, a sudden and un- lo >ked for recurrence of the pre aptoms takes place This relapse happens at Borne period between the twelfth and the twentieth day (from the beginning <*\' the disease), 1861.] irrmtFi 171 oe on orabout the Beventh after thecrisis, and without appar- ent cause or indiscretion on the part of the patient The relapse is indicated by the same symptoms as the primary fever rigors, headache, muscular aching, ho1 skin, thirst, quickened pulse (the rapidity being o\' often disporportion- ate to the other symptoms) coated tongue, and Loss of appe- tite. After a few daya two, three, lour or five this Becond attack suddenly ceases after a profuse sweat, and the patient becomes a second time convalescent. The return to health is comparatively rapid and complete in the young and and vigorous, but in the aged, and especially in those who have been previously in indifferent health, the strength is more slowly gained. Nor does the mildness or severity of the relapse appear to he influenced by the previous attack; for it has been ob- served that the symptoms of the second are sometimes more mild, and at other times more severe, than those of the primary fever. In some instances, for example, in which the first attack was by no means severe, the second has been characterized by delirium, deep jaundice, violent purg- ing, and other grave symptoms. Such cases are, however, immon, metimes. again, a second but mild relapse takes place, generally about the twenty-first day: and I have already al- luded to the circumstance, that patients have suffered thi four, and even live separate and distinct attacks. Such frequent relapsinu-s have been seldom noticed in the epi- demics in England. Other anomalies are/jn some instances, observed. Thus the symptoms of the relapse, instead of appearing suddenly, come on gradually and insidiously ; or, instead of the ordin- ary well-marked progress of the symptoms, there may b< only Blight acceleration pulse, and a little increased heat of skin, to mark its occurrence ; occasionally, in place of the abrupt termination of the attack by sweating, the crisis ha-' apparently been connected with some other evacuation, such as hemorrhage from the nose, diarrhoea, or the n trual discharge. In some on the other hand, in which the ordinary symptoms of the first attack have b well marked, there has been no relapse, nor anything a] - recurrence. There appears, too, to be n greater tendency in relapsing 172 Relapsing or [February, fever than in other acute diseases in pregnant women to abortion or premature delivery. 80 invariably, indeed, according to Dr. Wardell's experience, did this happen. that throughout the whole duration of the Edinburgh epi- demic a period extending over at least fourteen or fifteen months ho never discovered even a solitary instance of the impregnated uterus not expelling its contents; and the statements of others, whose opportunities of observing this fever were equally ample, confirm this statement. The same tendency to abortion was observed in the patients received into the London Fever Hospital. The relapsing fever sometimes, however, assumes a more severe character, the aspect of the symptoms from the com- mencement indicating a much more serious disease. The rigors are violent; the heat of the skin is intense; the heart's action depressed, indicated by the softness and com- pressibility of the pulse; the patient complains of extreme prostration, and feelings of exhaustion or sinking; there is often incessant vomiting of bilious fluid, accompanied with a more or less deep-jaundiced appearance of the skin, though the evacuations exhibit no deficiency of bilious ad- mixture, but the urine is generally loaded with bile. In some cases, sudden collapse takes place the pulse be- comes rapid and feeble; the skin universally cold, more especially the hands and feet; the face livid ; partial or com- plete unconsciousness succeeds; the sphincter become re- laxed, and death takes place after a few hours. The diagnosis of relapsing fever may be given in a few- words. It differs from other forms of fever 1, by its sudden in- vasion; 2, by the short duration of the primary fever, and its termination by an evident crisis ; 3, by the almost uni- form occurrence of a relapse occasionally a second or third : 4, by the unusual number of cases with more or less jaun- dice or yellow color of the skin, accompanied often with gastro-enteritic and gastro-splenic symptom ; and 5, by the absence of characteristic rash. The small mortality, or death-rate, of relapsing fever shows its comparative mildness, being about one in twenty - nve, or under 3.9 per cent. Anatomical characters. This singular form of fever, if un- complicated, seldom proves fatal. In examination of the fatal cases, no special lesion, so invariably present as to in- 11.] Recurrent 1 dicate the anatomical character of the disease, has been dis- covered. The blood lias in some cases been found throughout the body in a fluid state indicating a decrease in the normal amount of fibrin. lam not aware that it has been subjected to further chemical analysis. The brain, with the exception of a moderate amount of sub-arachnoid serosity, and perhaps an increased quantity in the ventricles, shows no remarkable deviation from a normal state. The heart and lungs exhibit no evidence of disease. The liver has been found enlarged from congestion, and the gall-bladder more than usually distended with bile ; and what may be considered worthy of being noted, no obstruc- tion to the free escape of the bile through the ducts, even in cases in which the jaundice had been well marked, can be detected. Xo disease in any portion of the alimentary canal is dis- coverable. The spleen exhibits the most marked and constant lesion, more especially as to the size or volume. It was noticed in a considerable number of cases in the Edinburgh epidem- ic, in 1*43-4. Dr. Wardell saw several in which this or- gan was three or four times larger than natural ; in one, it weighed twenty ounces. This splenic enlargement was ob- served by other physicians during the same epidemic; tli us. in a fatal case examined at the London Fever Hospi- tal, the spleen weighed thirty-eight ounces. It thus appears that, this organ is occasionally larger in relapsing than in cither typhus or enteric fever. Urea has been found in the blood. In a fatal case re- led by Dr. AVardell, in which the patient fell into a state iipor twenty-four hours before death, crystals of nitrate of urea were discovered in considerable abundance in tin- blood taken by cupping, ordered for the relief of the cere- bral symptoms. It thus ap] >ears that, with the exception of splenic enlarge- ment a lesion common to the other forms of fever, con- tinued and periodic there is no special lesions found after death in relapsing fever. If structural changes is discover- ed, they are to be regarded as accidental, and due to some ondarv or intercurrent affections. Laneet. 174: Cretinism. [February, Cretinism. In a former number oi the London Medical Review we ad- verted to the increasing spread of one of the most hideous and loathsome diseases which afflict mankind, viz : leprosy. It is now our object to draw attention to another equally distressing malady, which owing to its nature and close affinity to scrofula, affords many points of interest for consideration, al- though, fortunately we may claim an almost total exemption from it in this country. The most common continental seats of the affection are the hern provinces of France, and certain districts in Switzer- land, and in the north of Italy. The inhabitants of the two great chains of mountains, the Pyrenees and the Alps, where it has existed from a remote period, suffer most severely. In addition to these European localities, China, Syria, Northern India, the bleak shores of the Polar Seas, and some parts of the continent of America, furnish frequent instances of cretin- ism, and the kindred disorder, goitre. The causes and treatment of cretinism are so amply discus- sed in most systematic treatises on medicine, although the etiology of the affection has not yet been clearly solved, that we shall not dwell upon this portion of the subject further than in making the consolatory remark that it is, to a large extent, amenable to judicious treatment and removal from the affected districts, a fact which is sufficiently evidenced by the circumstance referred to by Dr. Watson, in his lectures, that, ont of the total number of patients admitted into Dr. Guggen- buhPs special hospital for cretin children, during twelve years, one-third became perfectly restored to health and reason, while the rest were improved in mind and in body. The statements of most recent French and Italian writers upon cretinism tend to show that it is upon the increase, and we. therefore, in accordance with the sound principles enun- ciated in the aphorism, Venienti succurrite morbo, and in the hope of obtaining information upon the point from medical gentlemen residing in those districts of this country in which fcre may be said to be endemic, publish, at full length, the iiication of cretinism, given in a recent memoir \L Morel, avIio has paid considerable attention to the sub- We need scarcely permise that numerous modifying a dependent upon the climate, mode of living and cus- tho locality, must determine, more or less, marked diffi rences in the character of the disease. First Division. Goitrous individuals with symptoms of II.] Mm. cachexia and of mental dulness. All the cduntries which con- tain cretins, joitrous individuals, and no example can be given in opposition to this fact. Nevertheless, goitrous >ns do not necessarily become cretins, and goitre docs nor form an indispensable accompaniment of cretinism. When I have visited districts where goitre is endemic, such as certain Localities in Meurthe and Moselle, people have not failed to tell me that I should find no cretins there, but an attentive rvation of tacts has proved to me that goitre is the start- ing point of cretinism. In countries where goitre is endemic, we may already distinguish the iirst lineaments of cretinism in the appearance of individuals ; the lips arc thicker, the nose is rounded and slightly flattened, and the zygomatic arches are more prominent, hi other cases the respiration is sibilant, difficult and sometimes stertorous ; the cretinous cachexia begins to show itself. In these same countries when there is a complication with malarious elements, the degene- ration is displayed in an aspect which approaches still more closely to cretinism ; we observe the lymphatic temperament, hernias, tumid abdomen, mental dulness, &c. There is a close connection between the goitrous and the 'ions epidemicity, the goitrous being only the iirst stage of the cretinous, and it is very rare that we find actual cretins where there are not also goitrous individuals. ;ond Division Cretins possessing the power of continuous reproduction. The cretins in this second division are capable of continuing their species, and many of them marry. They have the ordinary appearance of the healthy individuals of their country, but begin to be distinguished from them by a more faulty conformation of the skull. They often have the head flattened at the posterior and upper parts, whilst it is considerably enlarged laterally. They present a greater de- velopment of the zygomatic arches ; the nose is more flatten- the lips are thicker, and the chin is square : the distance; fmm the root of the nose to the commissure of the lip . the bones are coarse and large, and the thickened articular surface are unsymmetrical ; there is generally a dis- proportion between the upper and lower extremities. Goitre - a characteristic of the individuals in this division. cretins never surpass a certain intellectual limit ; their 'i and embarrassed. Third Division. The cretins in this division may be divided into two The first is composed of those who can, although only with difficulty, propagate their Bpecies ; the nd. of those who are sterile. i7<; ('/etinism. [February First Seel ion Cretins limited in their fecundity. These are remarkable on account of the Bmallness of their stature, which makes them appear like stunted dwarfs, and by their uncertain and wavering gait. Their hair is very dark and bristly, their skin is black and rugged, and probably contains more pigment than in the normal condition. The f imdamental principles of cretinism are strongly shown in the superior and posterior flattening of" the head, and in the exaggerated devel- opment of the temporal portion and of the zygomatic arches. The nose is small, rounded and crushed down at its upper part, the lips are thick and coarse, the tongue is hypertrophi- cal, the flesh is soft and flabby, and the chest is narrowed. Menstruation is tardy and irregular, and is in proportion to the limited fecundity of these degenerate beings, who produce only an abortive offspring, or scarcely living children. Second Section Sterile Cretins. The external appearance is the same as in the preceding ; the stature and physical con- stitution are also identical. In both sections the upper eyelid is disproportionately elongated, void of contractility, and over- Laps the eyeball in an ungraceful manner; the tongue is thickened, and the speech cmbanasscd. The difference arises in the internal characteristics. The organs of generation are either atrophied, or only sparingly developed. Many of the cretins in tnis class have no second dentition; their average length of lie is limited, and at twenty-five or thirty years of age they present symptoms of decay. Goitre is very rare in this division. Fourth Division. Cretins presenting complex degenera- tions.-In all countries where cretins exist, we may observe individuals who appear to deviate from the ordinary type of inism by a grouping of frequently very variable peculiari- ties. Amongst them we find all the varieties of misshaped heads, from the prcternaturally small head up to the hydro- cephalic, and also many goitrous persons, deaf-mutes, and in- dividuals suffering from single or double hernia, or afflicted with diseases of the hip, or congenital dislocations. The ano- malies shown in the organs of generation are remarkable ; in fact, in contradistinction to the sterility of some, we mayper- ceive a development of the genital organs in other.-. Fifth Division Deformed Cretins. These cannot walk. bu1 drag themselves along, or remain fixed to the place where !. They only present to the view a shapeless j; their eye- are blear and lustreless, and the saliva drib- between their thickened lips; their skin is black and and their hair bristly ; sometimes they have enor- 18G1.] itment of Skin D 177 mous goitres. The speech, which is rudimentary and incom- plete in the third and fourth division.-, is replaced in this by inarticulate, wild cries; and the perceptive facilities are obtu- \don Med-. ./* view. On the Employment of Chloride of Zinc in the Treatment of Skin 1> After having for a considerable period employed the chlo- ride of zinc, exclusively in its property of a caustic, in cs of Lupus and some analogous cutaneous affections, Dr. Yeiej, of Caustadt, has extended its use to the treatment of chronic leers of the legs, of sycosis, of chronic eczema, &c. He uses either an alcoholic solution (composed of equal parts') or an aqueous solution, consisting of ten parts of chlo- ride of zinc, and ten parts of hydrochloric acid to 500 parts; of water, or the solid caustic moulded by fusion into cylindri sticks. In tins last form. Dr. Veiel propose-, like all other surgeons, to produce an energetic caustic action. He has especially had recourse to this methad of treatment in thirteen cases L861J DywMnorrhaa and SteriUty. 18] included under the general head of Mechanical Causes, and those are, by tar, the most frequent in this country. Thai congestion should be considered a mechanical cause, may, al first appear Btrange, yet, upon reflection, it will be seen thai its operation or influence upon the catamenial flow, attended. is, with swelling o\' the cervix, at the expense of its canal, thus oftering a barrier or obstruction, is essentially of a chanical character. The causes above enumerated will, at once, be recognized by the observant practitioner, as operating, in the majority of -. in the production of Dysmenorrhcea. Now, if eonges- , membraneous exfoliations, and a narrowness (congenital or acquired) of the canal of the cervix produces painful men- struation, through the mechanical obstructions which the) offer to the flow, the proposition is tenable that the same ob- struction will pro-cut itself to the admission of the male mah into the cavity of the uterus, and, hence, conception under such circumstances, is a physical impossibility. In either the one or the other of these conditions, namely, Dysmenorrhcea or Sterility consequent upon the mechanical can- umerated, the indications, in treatment, must be same. No one would hope to cure a painful menstruation ing from congestion, without directing bis treatment to that cause, endeavoring to unload the turgescent vessels of the lb, and thereby relieve the patient. This condition being and the canal restored to its original capacity, in tin- act of coitus the sperm is permitted to enter the uterus, takes place. The Bllbjectof this, condition may be either of the *anguin<' i the nervous temperament. In the due case, the patieni ;- plethoric and robust in appearance, but usually indolent, raking little exercise, subsisting upon a rich diet, rendered the tnulating by the free use of the various condiment-, and the drinking of wines, &c As the result of this modi lite, the chylo-poietic viscera are kept in an over-excited state, tiie venaportarum and liver are over-tasked, and a general venous congestion of the whole abdominal viscera i- present, including the rectum and uterus ; hence, in these cases, we are also liable to encounter hemorrhoids. The c :* treatment indicated in these cases is obvious- Alteratives and purgatives are to be administered for several days preceding the expected menstrual period, with the view'' ofexcitin tions and unloading the vessels, and thus relieving the ted state of the womb. But, sometimes, it occurs that (this condition having continued some til 132 Dysmenorrhea and Sterility. [February, there will be a permanent construction of the cervical canal, the same as would result from congestion or inflammation of the urethra. In these cases, as in stricture of the urethral anal, you should dilate the stricture at the same time that the treatment above named is followed, and have the patient placed upon a prescribed diet. [t is proper that inflammations, when encountered, should be treated as under other circumstances ; but often, when it is chronic, and confined to the canal, the use of the bougie, in dilntation, will be sufficient to excite a healthy action in the part and cure the case, without any other specific interference. In that form of Dysmenorrhcea, known as ''Membraneous Dysmenorrhea," we usually meet with the same general and local conditions as just described, with the exception that the patient, during the "period," passes a membrane from the in- terior of the uterus, some times entire, retaining the form of the cavity of that organ at others, in shreds : in either case, she suffers intensely, which is due to the transit of the exfoli- ated membrane through the constricted cervical canal. The treatment indicated in this case is the same as in the simple form of Congestive Dysmenorrhcea. Many cases of this character, in married women, have fallen under my observation; iti the majority of which, the patients have consulted their physicians on account of barrenness, rather than for relief of their sufferings ; and in many of them which had been considered hopeless, so far as possibility of conception taking place was concerned, the women have, after dilatation was effected, conceived and borne children at the lull term of gestation. But it is in that form of Dysmenorrhcea which authorities denominate "Mechanical Dysmenorrhcea," or rather Dysmen- orrhcea arising from mechanical causes, in which the treat- si icut by dilatation should be expected to accomplish most. Now, the immediate causes of this form of disease are vari- ous, consisting, usually, of stricture at the external os, within the canal, or at the internal os, and to these is added tumors. occupying the canal. In these cases, there may or may not be congestion pre- sent, the patient complaining merely of excessive pain during tin.- whole menstrual period, with bearing down, and sickness a[ the stomach. She tells you that it is necessary for her to take the bed. whenever she menstruates, her sufferings are so exquisite. Upon examination with the speculum, it will be discovered, possibly, that if an external os exists, it is difficult to discern it, and that, in passing the uterine sound over the I.] Dyt rhcea and Sterility. L83 cervix, aa presented through the speculum, a mere depression or dimple marks the ^p<>t whore the month of the womb should be. It' the sound is now pressed firmly upon this point, po bly the instrument will enter the canal, or, as sometimes occurs, you will timl it necessary to make a small incision be- fore the instrument will pass. In otlu in, there will he no unusual appearance about the external os, hut, on passing the sound beyond, into the canal, it will he suddenly arrested in its progress, by ;i stricture, either in the eanal itself, or at the internal os. When the instrument is arrested at the internal os, it may be due to a simple stricture of that part, such as described of the externa] a retroversion of the body and fundus of the insider the shape of the uterus, its great Ha bility to displacement, particularly backward, and the. effect of this retroversion upon the shape and direction of the cervi- cal canal, we can understand how this character of trouble must be productive, more or less, of stricture at the point at which the organ i> doubled upon itself; and, further, that bo il continues, so long must the patient be the subject of Dysmenorrhcea, and, if married, be disqualified for the per- formance of that function upon the consummation of which depends, in many instances, the happiness of both husband and wife. To illustrate tic- effect of Retroversion upon the shape and direction of the cervical canal, it will be but necessary to take 11 of cylinder of paper, bend it on itself, and it. will bo that the two sides of the cylinder will approach each otht to narrow. \<:vy materially, the caliber of tin- tube. The same effect, exactly, is produced on the cylindrical the cervix, in backward displacement of the womb. 1 am . i viction, from an extended observation in this cases, that no one cause of Sterility is so common in women, otherwise healthy, as stricture of the cervix, and, in a large proportion, this is dependent on Retroversion. A- ha a ted, the treatment, in these ease-. ; n'all al in its character, and consists in dilating the strictured part, whether it be of the simple variety or due to Ret] In the latter case, however, this treatment it- indicated only after the ordinary means for righting the ut< have failed. I can:: propria * Me medical al\ i -ion of this organ, dooming hi pati- spair, by concluding that it will be im- lier to ever become a mother ; or, at least, until lS-i Dywrienorrhasa and Sterility. [February. he has made every effort to overcome the constriction, and thereby cure the case. Vet this is the daily practice of many, and women are too frequently rendered, through these hasty opinions on the pari of their physicians, the subjects of cruelty or desertion ; when a well-directed course of treatment might, in a very short time, overcome her difficulties, and bring comfort and happiness both to herself and husband, when per- haps hope had seemed to have faded. In my remarks before the Medico-Chirurgical Association, already referred to in this paper, and which will be found in the report of the transactions of that body, the particulars of treatment in these eases were given, and consists, 1st, in the introduction of a piece of compressed sponge to the point of stricture, previously guarding it with a ligature, by pulling upon which it may, at any time, be removed. This is allowed to remain intact for twenty-four or forty-eight hours, when it may be removed and replaced by a fresh piece, which may usually be carried higher than the first. When the dilatation, through this means, has been carried sufficiently far, the Knghsh elastic bougie is to be substituted. This should be introduced at least once in forty-eight hours, and at each ope- ration one a size larger than was used previously, should be selected. The daily or tri-weekly introduction of the bougie must be continued some weeks, (as in the treatment of an urethral stricture) or until the part ceases to contract (at least to any extent) ; when, not unfrequently, to the satisfaction of patient, friends and physician, the object of their solicitude is attained, and the woman finds herself, in a short period, likely to be- come a mother. The foregoing lias been written rather with a view of call- ing the attention of practitioners to the frequent causes of Ste- rility in this country, and the importance of surgical interfer- ence in the class of cases referred to, than to establish any claim to originality in their treatment. In conclusion, I would remark, that in many of the cases which have fallen under my care, I have entirely failed in the attempt to use the compressed cones of sponge kept in the stores for sale, and made after the suggestion of Prof. Simp- son, of Edinburgh. The difficulty has been that they were much too large, and, therefore, I prepare my own tents, as follows : Select a tine piece of cup or "surgeon's sponge," and lui\ ing melted a quantity of blanched beeswax in an ordinary 1, the sponge is to be dipped into the liquid wax, and im- mediately placed between two smooth surfaces (board or mar* 1861.] On Union of Fractv/rea in Syphilis. 185 ble) and a weight applied sufficient to compress the sp< and free it from the surplus wax : in a few minutes it will \>^ ready tor use. By this process, a ilat cake of compressed sponge is obtained, from which pieces may be out, of such size and at such times as required. The piece to be intro- duced should be well oiled and carried to the point of stric- ture by means ot a long and Blender forcep. Reports of cases, illustrative of this general plan of treat- ment, will be furnished for the next number of the Medical Pre.. On ttu Union of Fractures in Mercurio-SyphUitic P By Prof. Sigimmd, of Vienna. A young man in the Hospital of Vienna, while undergoing treatment by means of mercurial inunctions, on account of syphilitic ulcers of the skin and affection of the bones, met with an injury : as the result of which, he sustained an oblique, fracture of the humerus, about an inch below the tuberosities, accompanied with considerable contusion of the soft parts, and extravasation of blood. Cold applications were made use of, and the arm was put in splints, in the usual way ; no unpleas- ant symptom occurred, and consolidation of the fractured bone was complete on the thirty-third day from the receipt of the injury. Around the united ends of the bone there was ;i very considerable bony swelling ; in other respects, the form and direction of the limb were quite normal. On the day when the fracture was sustained, the patient had undergone the ninth of a series of fifty mercurial inunctions : this treat- ment was not discontinued, but was carried on uninterrupted- ly until the disappearance of the syphilitic symptoms. Prof. Sigmuna has met with five case- where syphilitic pa- tients have sustained fractures while undergoing mercurial treatment. The bones broken in the were, the righl radius (twice.) the left fibula, the left clavicle, and the humerus. Complete union of the fractured bone had occurred on the twenty-third, the twenty-sixth, the thirtieth, the twenty- second and thirty-fourth day- respectively. In all the the result- were satisfactory. In none of tin- was the mercurial treatment discontinued, nor was any change mad- in the diet of the patient It is well known that in syphilitic patients no important viation from the normal course occurs in the heal in L86 Phagedenic Ulcers. [February, of the soft parts. Prof. Sigmund has had occasion to perform numerous and various operations in syphilis, and his observa- tions entirely confirm the general opinion. Prof. Sigmund does not believe that the bones of syphilitic patients, whether or not they have been treated with mercury, are more readily fractured than the bones of those who have not had syphilis, and have riot taken mercury. Boston Med. and Surg. Journal^ Phageden it Ulce rt . Phagedenic, from the Greek word phago, I eat, is much more expressive, of the literal meaning of the word whence it is derived, than most ether medical terms derived from the Latin or Greek. The margins of a Phagedenic Ulcer have a strong resem- blance to a worm-eaten substance, or the surface ot a sub stance upon which a mouse has been gnawing. What is a Phagedenic Ulcer? The Phagedena Gangreno- sa, or Hospital Gangrene, so common in some of the European cities, is never known on this coast. But there is a true Phagedenic Ulcer often seen here, attacking the integument and subcutaneous cellular tissue, generally about the face, and is extremely difficult to cure. Sometimes it attacks the deeper- seated structures of the face, as well as of other parts, even the tendons themselves, resulting in a most alarming destruc- tion of the tissues, without any assignable cause. The fingers, for instance, are sometimes attacked, and the bones laid bare by the ravages of the disease, in a few days. The remedy we have found available, in such cases, is calo- mel and morphine, in the following proportion- : lv Morph. Sulph. - i llvd. Sub. Mur. 5ii- M. Sigria. Apply to the ulcer every day twice. If the con- stitutional effects of the morphine become manifest to an undue extent, the preparation must be used very sparingly. Thisis the only remedy upon which we repose confidence in the treatment of the Phagedenic Ulcer of California. ! Francisco Medical Jyrcss. I860.] Diphtk 1ST 7% f Diphtheria. The Union Medicale has recently published two letters from M. Loiseaa and Trousseau on the use of tannin and alum locally in the treatment of pharyngo-laryngeal diphtheria. M. Loiseau, considering the false membranes, in all cases, to be but consequences of diphtheria, and, with the exception of croup, rather useful than injurious, provided their putrefaction be prevented, again lavs stress upon the beneficial action of styptics, and especially tannin; these seem to convert the morbid secretions into an imputrescible epidermis, which af- fords protection to the denuded surfaces and promotes their cicatrization. M. Loiseau performs insufflation of alum five or bix times a day, and of pure tannin equally often ; he states that a cure may thus be effected in three or four days, on the >ame principle, which M. Trousseau adopted in his practice in 1S2S. A quotation from an articte published on the subject in 1833, by M. Trousseau in the Dictionnaire Medical, has elicited from the learned Professor a reply which we repro- duce, as it explains the changes his views have undergone on the efficacy of the medical treatment of diphtheria, and more especially of croup. "It i> perfectly true," says M. Trousseau, at the date September 20th, "that in the epidemics of diphtheria, which from 1S18 to 1^2S prevailed in the departments of Indre-et- Loire, Loir-et-Cher, and Loiret, the disease of the lances readi- ly yielded to frequent insufflation of alum, and to cauteriza- tion with muriatic acid or nitrate of silver. It is equally true- that, when the complain! was met in its early stages, foe; tive days were sufficient to effect a cure, excepting, of course, when diphtheria had invaded the larynx. "For ten years past, however, diphtheria has acquired in Paris and in the provinces a degree of gravity and of malig- nancy which it did not, by any means possess thirty years ago ; and I declare that it is now a long time since I have had the good fortune to see genuine pharyngeal diphtheria yield to treatment in four or live day-. Common pseudo- membranous angina, or herpes of the fauces may be cured in twenty-four or forty-eight hours, but not real diphtheria such ;i- we too frequently meet with. I resort to the same d au and perform in- sufflation into the throat every two hour-, and even e> hour, if necessary, alternating the use of equal p mgar and alum or tannin. From time to time I brush rather rougnrj the uvula and tonsils, before restoring to insufflation, in oi 188 Treatment of Eruptions around the Anus. February, that the medicinal agents may come into immediate contaet with the mucous surface, and I consider myself very fortunate when, after ten days' treatment, all trace of false membranes lias disappeared. "In live adults whom, within the last few months, 1 attend- ed with my friends, Drs. Bernard, Patouillet and Blond eau, the disease lasted nine days in one case, and more than a fort- night in the others, and 1 repeat that it would have been utterly impossible to use with more persevering energy the remedies extolled by M. Loiseau, which I consider most use- ful, namely: alum and tannin. "Appealing to the testimony of my learned colleagues of the Hospital for Infancy, JVI. M. Blache, Bouvies, Roger, Sec, and of Dr. Barthez, Iiind their statements are perfectly simi- lar to mine, and that they agree with me in thinking that the singularly rapid, extraordinary and numerous cures effected by M. Loiseau may perhnps be accounted for by his not hav- ing allowed himself sufficient time to establish an incontrover- tible diagnosis. "It is difficult at first, and especially in children, to distin- guish genuine diphtheria from pharyngeal herpes; and although in doubt I prescribe the local application of alum and tannin, I do not flatter myself that I have effected a cure of tonsillary diphtheria when, after twenty-four hours, I cease to detect in the throat any peculiar concretions.*' We are happy to be confirmed by so competent an authori- ty, in the remarks we have offered above on the importance - >f diagnosis in the appreciation of the various remedies recom- mended for a disease the gravity of which, far from subsiding, seems rather on the increase, especially when observed in an epidemic form. Treatment of Eruptions Around the Anus. By J oseph Bell, Ksq., Gateshead. Occasionally Ave see obstinate cutaiieou- ulceration surrounding the anus in children. Considerable tumefaction attends it betimes, and deep fissures are occa- sionally seen. This disorder is probably herpetic, and al- most always can be cured with yellow wash. The propor- tions being from 1 to 1} grains of hydrarg, bicblorid, to 1 ounce aq. calcis. The part is to be frequently bathed with it, and should the lotion produce pain, it is to be diluted with water, and when at rest, a little lint, soaked in the lotion is to be applied and left on the part; deobstruents being at the same time administered. Med. Time* J- Gaz. 1861.] Editorial 180 EDITORIAL AND HISCELLANEOUS. A COMPENDIUM OF HUMAN HISTOLOGY, 1 . 3Ior el, Professor Agrege a la Faculte de Medicine Je Stras- bourg. Illustrated by Twenty-eight Plates. Translated and edited by W. H. Van Buren, M. D., Professor of General and Descriptive Anatomy in the University of New York, &c., &c. Bailliere Brothers. New York : 1861. pp. li>7. Dr. Van Buren and the Brothers Bailliere have certainly rendered an important service to the profession iu the translation and publication of this valuable work. Our readers must know that we cannot always read thoroughly the works which it is our duty to notice as journalists. This, however, is one of which we can speak witha personal knowledge and we have found it both concise and comprehensive very interesting and advanced to the last hour, of pathological investigation. The author, after defining in his introduction the object and purpose of the science of Histology, presents us with what we consider a wi\ convenient and simple division of the ultimate organic elements : D the present state of Science, all of the simple elements of which the body is composed may be reduced to one of the following typical forms, viz: 1st, Structureless Material; 2d, Cells; 3d, Fibres; 4th, Crystalline Substance." In accordance with this brief and, at the same time, most philosophic itication of the elements, our author proceeds to arrange them iutu the several tissues which they arc found to compose, and, to systematize Ilia labor, ho divides the work into ten convenient and rather brief Chap- Chapter I, Cells and Epithelial Membranes; Chapter II, Fibre-: Connecting Tissue; Chapter III, Cartilage, Bone, Teeth: Chapter IV, Muscular tissue ; Chapter Y, Elements of Nervous Tissue ; Chapter VI, Vessels, Arteries, Yeins, Capillaries, and Lyphatics ; Chapter VII, Glands : Chapter YHI, Skin and its Appendages ; Chapter IX, Intesti- nal Mucous Membrane; Chapter X, Organs of Sen* iu the treatment of these several departments, our author is clear, . id happy in his illustrations With the description of each tissue, 190 31iscellaneous. [February brief directions are given for the selection and preparation of specimens for microscopic examination which is, in itself, a most valuable feature of the work. The book is evidently preparedfor the elementary student "11 as for the more advanced pathologist, and, on this very account, must soon become generally popular. Dr. Morel is very decidedly a follower of the celebrated Yirchow, whose doctriue of ''Cellular Pathology" seems to have taken firm hold upon his belief, and appears to enter as a necessary part into all his reasoning. "The Plasmatic Cell" takes a place in the minds of these pathologists, almost of every other element of nutrition as the very cause, orgin, sole agent and pcrfecter of all organic processes self- governed and uncontrolled by any other element in the entire organism. Though to all this, we cannot, as yet, give our full assent, "still it can- not be totally denied that some processes of nutrition are completed with a certain degree of self-government in the system of organic cells ;'* ;iud both Yirchow and our author may be, in the main, correct, though only out of time, being a little too much in advance of the general ideas now dominant in the world* of Physiology and of Pothology. The above work will be found in this city at the Book-store of Messrs. T' Ttiehards & Son. In addition to the above work we have received also from Messrs. BaiJliere Brothers, the notice of work on the now all-important subject of Diphtheria. The work itself has not yet come to hand, but doubt- less will and shall receive due attention in our next issue. We refer our Students at present in the city to Messrs. Richards k Son, where the work may probably be purchased. Price, $1 50. AN ELEMENTRY TREATISE ON HUMAN ANATOMY. By Josi:rn Leidy, M. D., Professor of Anatomy in the University of Pennsylvania, &c, &c, ao, &c Philadelphia. 1S61 J. B. Lip- pincott & Co. pp. 663 octavo with three hundred and ninety-two Illustrations. For sale by Messrs. T. Richards & Son. As an elementary Treatise on Human Anatomy, Dr. Leidy's work \> certainly a success. So long accustomed as we have been to the house- hold words of Anatomical nomenclature, we arc scarcely abfe to do justice in any attempt on the part of an author to simplify these terms, altering ; from Mr. Doubovitsky, of St. Petersburg. This letterwe maj publish in a future number of this journal. 1.] MisceUanec 191 what, by dint of long use, has become, to us at least, familiar as the al- phabet This impression, however, must not receive too much import- ance in the mimls of teachers in recommending a work for beginners, they must remember, if possible, as Dr. Lckly seems to have done, the mountain in the way, which the nomenclature of anatomy present- ed, and, knowing that simple terms are easier of acquisition than more ot mplicated ones we should give full credit to the task accomplished by our aathor. The work is filled with clear and beautiful illustrations, the text open and large, with each principal word or subject struck in large block type to fix the attention of the student and the cream-colored paper on which the print is executed is, by no means, an inconsiderable point c value. The authors descriptions are clear and concise, evidently from oil' he is known to be, thoroughly familiar by daily and constant handling with every portion of his subject. Camphor as an Antidote to Strychnine Poisoning. In the Pacific Medical and Surgical Journal, for June, Dr. M. T. Dodge reports a case of poisoning with strychnine, entirely relieved by the ad- ministration of camphor. According to the report, five grains of strych- nine had been taken three hours previously. Ten grains of camphor given in emulsion, and repeated every half hour or hour for seven hours, when the spasms entirely ceased, and the patient rapidly recover- ed. It would certainly be a fortunate discovery should camphor be found to be a reliable antidote of strychnine. The case reported lacks at least two essential points to make it available as proof upon this point. thought by many that much of the strychnine in use is nearly inert and if taken as claimed, there is no proof that the article was genuine. More than this, there is no proof, but the patient's statement, that the five grains of strychnine had been taken at all. There is certainly one tuspicious fact in the case, that must in some measure detract from our confidence in the antidotal power of camphor. Three hours had elapsed from the taking of the poison before remedial aid was had, and yet the patient was sitting up, and presented no very alarming symptoms. Prof. Wood says that, in cases of poisoning from strychnine, the alarming ims usually folkw the administration in from ten minutes to half an hour. One of two things is evident : the five grains were not all taken or the poison was not of standard strength ; either would effect the result ; as relate^ to the antidotal powers of camphor. Ra medyfor Burns from Phosphorus. The skin should be wetted with a solution of chloride of lime or of soda, or if these are not at hand it should be dipped into a vessel with lead water. 1 92 Miscellaneous. Glycerine in Skin Diseases. This substance has been justly recom- mended in various affections of the skin, and especially in those attend- nd with desquamation. In that troublesome affection pityriasis capitis, in which the hairs become dry and fall off, during the abundant epidemic exfoliation, undiluted glycerine may be applied with excellent and dura- ble effect. In pityriasis rubra and pityriasis simplex, a mixture, composed of equal parts of oil of almonds and glycerine, and one-half of oxide of zinc, has proved very useful. Dublin Hospital Gazette, May 15, I860,;;. 158. On the Therapeutic Methods of Preventing Pitting of the Face in Confluent Small-Pox By Dr. Stokes, Dublin. During the last five years Dr. Stokes has employed gutta percha and collodion in a con- siderable number of cases of confluent small-pox, for the purpose of pre- venting pitting of the face. In most of the cases the crust came off in large flakes or patches, composed of the dried exudations and the cover- ing material, leaving the skin uninjured. This kind of treatment was most successful in cases of a typhoid character, but appeared to be not so well adapted to those presenting a more sthenic type. Dr, Stokes considers that the application of poultices over the face is the surest method of preventing disfigurement in small-pox. Their use should be commenced at the earliest period, and continued to an advanced stage of the disease. In most cases they may be applied over the nose, so as to cover the nostrils, This plan should fulfil three important indications of treatment namely, to exclude air, to moderate the local irritation, and to keep the parts in a permanently moist state, so as to prevent the drying and hardening of the scabs. The best poultice is formed of lin- seed meal, which should be spread on a soft material ; such as French wadding, and covered with gutta percha paper or oiled silk. The con- clusions to which Dr. Stukes arrives are the following . 1. That the chances of marking are much greater in the sthenic or inflammatory than in the asthenic or typhoid confluent small-pox. 2. That considering the change in the character of disease observed during late years, we may explain the greater frequency of marking in former times, 3. That, in the typhoid forms of the disease the treatment of the surface by an arti- ficial covering, such as gutta pcocha or glycerine, will often prove satis- factory. 4. That in the more active or non-typhoid forms the use of constant poulticing, and of every other method which will lessen local inflammation, seems to be the best mode of preventing disfigurement of the focc. British and Foreig?i Mcdico-Chirurgical Review. Atropine. Strength of Solution Used. "When it is wished to dilate the pupil for opthalmoscopic investigation, the strength of the solution used should not be more than one-halt' a grain of the sulphate i an ounce of water. This will suffice for the purpose, and the unpleas- ant effects of a stronger solution will be avoided. SOUTHERN MEDICAL AND SURGICAL JOURNAL (new sbru [flL , AUGUSTA. (iEOMl. MAM, 1861. ORIGINAL AND ECLECTIC. ARTICLE VII. -1 ( By A. AY". Bailey, M. D., Clinical Clerk of Jackson Btreet Hospital, Augusta, ( It is needless for me to endeavor to give a treatise on this< all who may desire to acquaint themselves fully with the subject can, by reading some Surgical work, or Dr. Bozeman'a pamphlets, gain more knowi an! would be able to impart. It being my object merely to report a case, havin a several successfully treated by Drs. Campbell during my in their Hospital as a private student, and to add to the already cured by the profession, and iour- the attempts for the treatment of the disease, no matter how formidable the case may appear. Dr. Bozeman. of Montgomery, Ala., the pi :i. is indebted for the mofi Lplanforthe f this af- Aljout tw> man published his mam lure, andth which he had met within the the button suture and silverwire. I:. his the sir lighter and "less likely to yield un isure, admits a higher polish, and allow- the wires drawn thro the small holes without dragging :" but admitting all this. 1 194 Bailey. A Case of [March, I lis experience has taught him that the button suture made of lead is by far the most preferable for several reasons. In using the silver button the Surgeon has to have a regular smith, who may not understand' the nature of the parts, and even if he did, there arc many little modifications in shape required which he could not give unless the operator was present to point them out; but with lead it is indiffer- ent. The Surgeon can make his button while around the operating. table, and beat it into any shape he may desire ; for it is not until he has adjusted his sutures, that ho can tell exactly the shape of button required. Lead is also more flexible, and can be made to adjust itself to any sur- face that may be presented to the operator, and hence more likely to bring the parts in adj uxtation, and thereby cause a more successful closure and adhesion of the fistulous open- ing. I having assitsed in several operations performed by Dr. Bozeman's plan with a leaden button suture, and hav- ing taken great interest in taking notes on the cases from the time of their entrauce until their departure, have select- ed it as the subject of the present paper. Vesico vaginal fistula generally occurs, as all are aware, by the pressure of the child's head against the soft parts, or the improper use of instruments during first labor, though it is liable at any period during child-bearing when the labor is such as to give rise to this dreadful complaint, for instance in impeded labor when the head has descended low down into the pelvis, and presses against the vagina and urethra sufficient length of time to produce inflammation, gangrene, and sloughing, or when the instruments have to be used to effect delivery, which very often produces abrasions, and also brings on sloughing of the parts. As to the position, shape and space that the fistula may occupy, is altogether owine to circumstances. Bozeman adds two more that the operator may be enabled to classify all eases that may pre- en1 themselves under its appropriate head. Velpean's classifications are as follows : "The first class eml I] those fistulas which cause a communication 1861.] Vest nal Fistula. between the urethra and vagina; tin 1 class ie made up of those which are established at the expense of the tri- goone vesiealis ; the third class comprises all those situated in th< 'id o( the bladder." Dr. Bozeman adds the following two agreeing with Velpean so far as he " The fourth class embraces all those fistulas formed at the expense of a part, or the whole of the vesical trigone, and the root of the urethra: of trigone and the bas-fonc1 of the bladder: or, all three of the regions together. The fifth class include all those complicating the cervix uteri, either with or without injury." The following is a case in which the posterior wall and fundus have sloughed away to a considerable extent. implicating the cervix uteri, and forming an opening in the shape of a horse shoe, or segment of a circle, the point <>i which severed the left ureter. .lane, servant girl of Mr. X. J., of Fort Gaines, Georgia, age eighteen, of robust constitution, ordinary height, well proportioned and had always enjoyed good health. This accident occurred, as 1 have formerly stated it does, in ing birth to first child about twelve months previous to entering the Infirmary. Ber labor was a very protracted one and finally required the use of instruments to effect de- livery. From the patient's weakened condition, and other circumstances connected with her, not necessary to mention here, an examination was delayed for nearly three weeks after her entrance. May 23d. An examination Was made byUrs. Campbell, and "the opinion was that an operation would be attended with but little success: a further opinion would be taken at another time. May 26th To-day a second examination was made, and the opinion of the 23d strengthened, as the parts had slough- ed to I greater extent than they had su die 1 ore the operation with apparently SO little pain that it was noted as an indication of gangrene having taken place. May 81at A third examination was made to-day. and a 196 Bailey. A Case of [March, prospect of a cure very unfavorable. It was, however, de- termined that an attempt would be made as soon as all things were more favorable. The patient did not complain very much from excoriation or scalding, nor did the secre- tion of calcarious matter take place to a great extent. In- jections of warm water and castile soap were used several times a day up to the day of the operation, the main object being to strengthen and have the system in as good a con- dition as possible. This was accomplished by nutritious diet and tonics of iron and quinine in five grain doses three times a day, in syrup. July 29th. Gave an ounce of castor oil to put the bowgls in a suitable condition. .July 31th. To-day an operation was performed by Drs. Campbell, assisted by myself. The patient being placed on her breast and knees with a mirror situated so as to throw the reflection of the light on the parts to be operated upon. The edges of the fistula were thoroughly pared to their full ] '.; ilver wire were made with Simp- 3 needles ; the edges were then approximated as much as practicable, and secured with shot over the leaden but- ton ; the ends of the wires were partially twisted and lapped with a piece of linen, and allowed to hang from the vulva. This operation lasted nearly four hours, the delay being chiefly occasioned by the irritable and nervous condition of the patient, and the knife having wounded some small blood-vessels at the farther end of the fistula, and caused slow but troublesome hemorrhage, filling the vagina with clots of blood and obscuring the veiw. Injections of acetate of lead were used, vagina washed out, and the patient was then put to bed, a catheter introduced and kept there con- itantly, save for the purpose of cleansing, when it was re- moved twice a day. Recipe tine, of opium in twenty drop doses wTas given, the purpose being to constirpate the bowels and secure rest for the patient. August 9th. The sutures were removed to-day, and (lis- 1861.] Vaginal Fistula. 197 covered that there is an opening :h end of the line of adhesion, and the result of non-union was suspected the entire length of the opening, from the fact that the bladder was not relieved entirely by the catheter, hut that a portion oi" the urine came away through some pari of the fistula while the catheter in situ. LUgustlOth. The patient is losing strength and flesh from irritation and confinement to bed. R. Tartrate iron, potash and quinine in live gr. d<> three time a day ; diet, heef soup, bread, &c. August 16th. Improving-, goes about the house and yard, feels a little uneasiness, other than that caused by the un- natural discharge of about half the urine, the other half re- maining in the bladder, and passes off at intervals through the urethra. August 30th. General health improving, hut urine pass- ed oft* as at last note. October 14th. Up to this time the second, operation has been put off from time to time for several unavoidable causes. She has been subject to fevers occasionally : these paroxysms have been successfully met with quinine, and also her periods < ration are irregular and painful. At this operation the edges of theoj a button applied on one requiring two sutures, the other one. The wires being well clamped, were cut off to the shot, and the vagina plugged with lint to prevent the recto vaginal septum from being wounded by the ends of the wires, besides the protruded wires from the vulva are liable to be jarred to some extent from the movements of the patient, and may cause displacement of the button. \v;is placed in bed, opiate- given, catheter introduced, and removed occasionally as before. This time all the urine was conveyed from the bladder by the catheter, as none could be discovered coming from any other source. v were not sanguine on this point, as the pi suf- ficient to prevent its passage into the vagina. O 24th. Removed the buttons and sutures, and 198 Ford. Report of a [March, find only one of the openings partially united, the inferior one at the neck of the bladder ; to this the application of solid nitrate of silver was made, hut with little effect; the other openings where the fistula crossed the ureter, there was Little hope of union taking place from the impractibil- ity ol' reaching the point sufficiently to insert the suture carefully owing to its length and direction. The severed end of the ureter, they were also unable to direct into the bladder for the same cause. A third operation was, however, determined upon which succeeded only in partial closure of the fistulous openings, still leaving two small holes, one the size of a small pin's bead, and the. other a little larger. Repeated applications of solid nitrate of silver at intervals of every ten or fifteen days were again made, which succeeded in the cure of the case, though at first seemed to be of but little or no benefit. The great obstacle in this case which made it of interest to study and take notes upon, arc the following : 1st. The direction and extent of the fistula. 2nd. The great amount of sloughing and consequent loss of tissue the greater and lesser curves of the opening were so disproportionate that when the edges were pared and drawn together there were formed on the edge of the greater curve duplications or pouches, and this was really the cause of non-union at each end. 3rd. The difficulty of directing and securing the bisected ureter in its normal position. ARTICLE VI I i. .: Case hi which portions of a Foetus made their way from the us through the Abdominal toalls by Ulcerative 7V Patient R I. By DbSaussurb Ford, M. P., Demon- of Anatomy, &c., in Medical College of Georgia. Mrs. li , widow aged 35 years, stated she had been delivered of three children one still living, the other died 1861.] // - 199 ismus nascentium with a third child had beeo preg- nant, about five and a half months, up to January, L860, when she aborted, the presentation a footling; the trunk. superior and inferior Limbs protruding beyond the vulva. the head remaining confined tightly by the contractions which must have been anomalous of the 08 tinsse. f ing detection, (for her pregnancy was the result oi criminal she cut off that which was hanging from her, when, to use her own language, the bead went hack. She supposed the foetus to have been dead about nine days. When questioned, she denied that there was any bleeding, or other discharge at the time, and could give no account of >rd, or placenta. April 18th. Four months after this most strange and unnatural occurrence. Mrs. H was admitted into the Augusta City Hospital, with a fistulous opening immediate- ly below the umbilicus, which was discharging, very freely, a dark yellow and offensive matter, undoubtedly partly fecal which could be accounted for after the extraction of the bones. She continued in this state until July 25th, when k charge of the Hospital, discovering the bones of a ,1 head protruding through this opening, then about two inches in diameter. In receiving a report not a detailed <>ne from the attendant physician before my service, I gathered : that she was affected with chronic constipation, which was at first relieved by enemas and cathartics, which latter castor oil was generally used he thought could be tected in the secretions from the fistulous open:: At first I this a case of extra-uterim indeed the opinion was unsettled, until the examination had . with th( in a deplorable and emaciated - prompt relief, b; the 27th. It was ii' aary tor an i of the abdomen, but bone after bone rounding them having been disorganized was extra by a rotary traction with a pair of strong for- hich 200 Ford. Report of a [March bones were the following: two parietal ; two temporal, without petrous portion attached ; one petrous portion ; one malleus; one tympanic bone; sphenoid ; one malar ; occipi- tal; frontal, in two pieces; one scapula; radius and ulnar, with phalanges and metacarpal hones of one linger. These bones arc, in development, as near the size of a six months foetus as could be determined, which fact substanti- ates her story. that she had been pregnant about six months. After these bones were extracted, a digital examination dis- closed a large cavity, answering to the internal form of the uterus, which cavity, in the mesian line, had an outlet like the form and position of the passage through the cervix. This large cavity communicated, by an extensive opening, with the ascending colon, the finger readily tracing the interior of the intestine, above and below, as far as it could reach. The 28th day after the operation, prescribed: ]}. Valet's Proto. Carb. Ferri, Sg5j "Water gviii M. Give a teaspoonful three times a day. Apply to the wound, cloths wet with a solution of chlor- ide soda. Had taken g castor oil this morning no effect Fecal matter discharging through opening. 29th. This morning passed aliving worm, 4 inches long, through fistulous opening, with large quantities of fecal mat- ter. Had an action through rectum yesterday. Ordered an ma of warm salt and water. 30th. Ordered daily enemas of warm water every morn- in<>\ an hour after breakfast. Fecal matter dischanmia;. 31st. Fecal matter still discharging, though much di- minished in quantity. Strength better. August 2d. Passed a worm through the opening. Had an action through rectum, after enema. Ordered, instead of enema in the morning, castor oil 5g and spts. turpentine gtls. v. ' A.ugus1 1th. Fecal matter still discharging. Continued enemas. Strength much improved. II.] // Case. 201 August 6th. Continue treatment Condition some bet- ter. Left the city and record was not kept until August 14th. la having natural operations through the rectum, with very little discharge from opening. Strength and general condition improved. A.ugust L8th. Had an attack of ^astralgia. Ordered . xxx tinct opii. and mustard over epigastrium. Con- tinued to improve daily, havingnatural evacuations through rectum, with fistulous opening very nearly healed, and no inconveniences from discharges. Mrs. 11 left the ptember 7th, two months and ten days after the extraction of the bones. Remarks. The fact that a foetus has escaped through the abdominal walls, by ulceration, and the patient recovering, indeed, impregnation existing, after such an accident, is by no means novel. (See report of a very remarkable case of Extra-Uterine Foetation in Keatino-'s edition of Rams- botham's System of Obstetrics, page 580.) In this case it will be noted that a fistulous opening was made, by ulcer- ation, into some portion of the intestinal tube, and still the patient survived, but exactly the counterpart of the case of Mrs. II . I cannot find, in which the uterus itself re- tained a part of a fioetus, that part ulcerating through its wall _ extracted as detailed. The fiendish criminality, and un naturalness of the act of cutting off a foetus, on the part of the mother, and the ap- parent discrepancy of her account, together with some of the bones extracted, viz : a radius, ulnar, scapula, phalan would seem to invalidate the opinion formed of the ca . however, when we consider all the circumstan cially the fri s Icitudeof the mother in any attempt, however enormous, to avoid detection. The fact of t! bones of the arm having been found will explain, in a m . the difficulty of the delivery, in that a footling presenta- >ne of the arms remains impacted with thehead, could have I aily delivered, it' the head was not ab- normally ment, the inferior and superior 202 Ford. Report of a Hospital Case. [March, limbs and trunk hanging out, to the contrary notwithstanding. The absence of the presence of a humerus ; a second malar bone ; a second petrous portion of temporal bone ; a second tympanic bone, &c, explains a statement she made, thatsomc small"bones had come out of the fistulous orifice, from time to time. Why, then, the number of these bones indefinite, might not bones have escaped, which would show the case one of extra-uterine foetation ? Because, by examination, after the remaining bones had been extracted, neither the opening into the colon, nor the passage through the cervix uteri, could have been confounded with the openings through the fal- lopian tubes, their size, form, position excluding the possi- bility of such an error. The time which elapsed after she aborted, before the first appearance of the opening in the abdomen, could not be determined, and the exact condition of Mrs. H from the time she severed the body of the foetus from the head , to thetime she was admitted into the Hospital is unknown, the probability, however, is that the detritus of the foetus passed out per vaginam, and the uterus contracting down upon the bones of the head caused them to ulcerate their way through its walls. Adhesive inflammation was set up, which prevented the escape of the discharge into the perito- neal cavity, the exudation of plastic lymph, forming a distinct cavity, by agglutinating the edges of the uterus with those of the abdominal walls. The fistulous opening into the colon was, most probably, formed by the bones cutting through its walls. The exudations of plastic lymph, as in the external opening, formed adhesions similar to artificial annus. This internal opening, so to speak, had closed en- tirely before Mrs. H left the Hospital, as evidenced by the absence of any fecal discharge. It is unfortunate the patient did not remain in the Hos- pital until the perfect closure of the opening through the abdominal walls had been effected; it was, however, granu- lating healthily, then about J inch in diameter; this fact, with her generally improved condition, warrants the opim 1861.] tures on Convulsive 1 ion of recovery, the principle difficulty (the opening into the intestinal canal) having already been perfectly closed. Mrs. I] was much agitated at the probability of legal investigation, suggested by some of her female ene- mies, who, hearing' the horrible enormity of her mode of delivery, seemed determined to torture the unfortui wretch, by exposure. With this anticipation hang- ing over her, she left the city by stealth. Means were em- ployed to follow her, but with no success. hares on the Theory and Therapeutics of Convulsive Diseases, especially of Epilepsy, By Charles Bland RadclifFe, M. D., Fellow of the College, Physician to the "Westminister Hospital, etc. LECTURE II. In my last lecture I endeavored to show, as far as was Bible in the time, that it is necessary to adopt a new theory of muscular motion. I endeavored to show that a fundamental change in this matter is absolutely demanded by many of the facts which have come to light during the past ten or twelve years, and chiefly by the messages which may be said to have been telegraphed, along the three miles of wire which enter into the coil of a galvanometer, such as that which was then upon the table. For what are ti One is, that there are electrical currents in liv- ing muscle and nerve. Another is, that rigor mortis does not occur until the final extinction of these currents. A third is, that these currents are weakened in ordinary mus- cular contraction. A fourth is, that contraction is produced when the nerve-current is weakened by the action of a gal- vanic current upon nerve. A fifth is, that contraction is not produced when the nerve currentis strengthened by the action a galvanic current upon nerve. In a word, the needle of the gavanometer appears to show that muscle elongates under the action of the muscular and nerve currents, and that mm rhen this is weakened or inted out also, keeping with these facts, that inn- tion if connected with the T<>r- dinary electricity, and not with the charging or charge, 204 Lectures on [March, I endeavored to show, further, that there are no sound reasons for supposing that "blood and nervous influence pro- duce contraction by acting as a stimuli to a vital property of contractility, and that there are many grounds for believ- ing that these agents act upon muscle in the same way as electricity, antagonizing contraction, not causing it an- tagonizing contraction, possibly, by means of electricity nervous influence by the nerve-currents blood, by keeping up the muscular and nerve currents, for it is easy to suppose that these currents may be kept up by the respiratory or chemical changes which are produced by blood in muscle and nerve. As to the rest, I endeavored to show that there was no need of a vital property of contractility, and of the doctrine of stimulation founded thereon, to explain certain other facts which must be accounted for by any true theory of muscular motion. I endeavored to show, for instance, that the fact of muscle undergoing no change of bulk in con- tracting, the gain in breadth being precisely equal to the loss in length, has its exact parallel in the change which a bar of iron undergoes in passing out of the magnetic state that contraction under "mechanical irritation" may be nothing more than the natural effect of the discharge of secondary currents, which currents are induced by mechani- cally interrupting the nerve and muscular current that muscular waste is proportionate to muscular action, not be- cause contraction is the sign of functional activity, but be- cause a given amount of waste is necessarily incurred in that renewal of the muscular current which is necessary to relax the muscle after each contraction that the will may act in voluntary contraction by suspending the muscular and nerve-currents ; that rigor mortis, which is utterly un- intelligible on the accepted theory of muscular motion, may be the natural result of the action of the common molecular attraction of the muscular tissue upon the final dying out of the muscular and nerve currents. To briii"; forward all the arguments belonging to so com- prehensive a subject within the space of one lecture was manifestly impossible, even with the additional moments which you, sir, so graciously placed at my disposal; and thus I was obliged to leave much unsaid. I said nothing, for instance, about the rhythmical movement of the heart and other muscle, though 1. might have found in the theory a key to their physical interpretation, and in them no small 1861.] Convulsive D 205 confirmation of the theory, I said nothing about the par- turient contractions of the uterus, though in the theory I may have hoped to have found the way of explaining how it is that^ these contractions, begin at a certain time, and continue until the completion of birth. Butthough obliged to leave much unsaid, I hope I was able to say enough to show that a fundamental change is necessary in the theory of muscular motion, and to prepare the way for what 1 have now to say upon the theory of convulsive diseases. Epilepsy is at once the great type of convulsive diseases, and the key to their interpretation. Epilepsy, however, is a name which indicates much less than it did formerly. Thus it does not indicate the epileptiform convulsion which is connected withcertain positive diseases of the brain, with fever, with uraemia and other retained excretions, with "ir- ritation" in the gums and elsewhere, or with the moribund state. And it is difficult to say precisely what it does indi- cate ; for, as our diagnosis gains in exactness, epilepsy changes from a special malady into a mere symptom, or congeries of symptoms. At the same time, it is convenient to take an ideal type of epilepsy, and regard it as a special malady ; for there arc numberless cases, in which, in their earlier >taLres at least, it is very difficult, if not impossible, to recognise the disease of which the convulsion is merely a symptom. AVhat, then, I would begin by asking, is the theory of simple epilepsy ? Upon which theory of muscular motion is it to be based '." And, first, what are the facts? An epileptic will often say never oftener than upon the very eve of an attack "I am quite well," and many are ready enough to echo what he says; but he and they have little right to say so. Where the malady has not made much progress, there may be a cheerful countenance, a sharp digestion, a firm limb, and at the first glance it may not I to say what is wrong; but, in this case, there are always certain features which are incompatible with true health and strength. In many instances there is a want of tire in the countenance, and a dilated and sluggish State of the pupil, which point to the brain as lacking in energy: ami in keeping with these signs, it is found on inquiry that the memory is more or less treacherous, the ideas more or h-ss incapable, the imagination more or less dull, the temper more or Less irritable, the will more or les< 200 Lectures on [March, feeble, the character more or less undecided. It is, no doubt, common enough to meet with epileptics, who, with- out a i iv want of candor on their part, will maintain that their minds are free from all infirmity; but if care he taken to examine their history, it will always be found that their friends have very different opinion upon this point. In very many instances there is a marked disposition to tremulousness and cramp; thus in upwards of seventy cases which fell under the notice of my friend and colleague, Dr. Reynolds, these symptoms occurred at one time or other and in one form or other, in more than half of the whole number. In very many instances, again, if not in all, the hands and feet are cool or cold, the pulse is weak and slow, and a feeling of chilliness is almost habitual. Indeed, so far as my own experience extends, the powers of the circulation are always very defective in ordinary epilepsy. In confirmed cases, these general features are so marked as to be altogether unmistakable. Not only are the pupils dilated and sluggish, but the under eyelids are puffy and coarse. Often, moreover, the complexion has accpiired a dull tinge a change which appears to depend in part upon an habitually bloodshot state of the skin. At any rate, this bloodshot condition is rarely absent, and where it is most marked, as about the forehead and eyelids, it is often accompanied by numerous spots of ecchymosis of about the size of a pin's head. The torpid features are now rarely lighted up with the fire of feeling or thought, the seme- are duller than ever, the memory more treacherous, the ideas more confused, the power of attention more distracted the imagination more drowsy, the temper more uneven, and the will more incapable. At this time, also, there is, for the most part, little of that fine susceptibility of feeling which is necessary to enable one to be miserable about any- thing. This change for the worse is particularly marked after the fit. Indeed, at this time the senses may be so blunted and the mind so clouded and confused, that the features of the epileptic may become blended in those of the demented person. Or symptoms of mental aberration may show themselves, and transform the epileptic for the time into the; lunatic. The fits, also, mayrecur so frequently, that the mind may never have the chance of clearing up in the in- terval, and in this way the general features of the convul- 1861.] Convulsive Di$eai J<<7 Bive malady may never cease to be confounded with thos dementia or insanity. Xot unfrequently, also, there is the gravest degree of mental infirmity from the very first, and instead of ending in dementia the history of the epileptic may begin in idiocy, hi deed, epilepsy is so frequent an unpaniment of this saddest of all conditions, that it can scarcely be said to be an accident. The signs of the approaching paroxysm are very variable. The patient himself will generally say, and say truly, that the lit takes him by Burpise ; and certainly the signs of dan- ger are not those which are likely to arrest his attention. These signs also are very apt to vary in the same person. As the time of danger approaches, the, patient may be- come unusually fidgety, irritable, moody, forgetful, absent, 6r drowsy ; or he may sleep restlessly, grinding his teeth, snoring or snorting, dreaming about things which distress or terrify him, or even somnambulizing; or he may have a disagreeable feeling of tightness about the throat, with cramps or tingliugs in the limbs and elsewhere; or he may be unusually "shaky,'' or may be annoyed with shudderings of a very disagreeable and violent character. Another sign of danger mav be giddiness or headache; but, so far as the latter symptoms is concerned, I should not be disposed to lay much stress upon it as a warning in simple epilepsy. Occasionally, the pupils may be more dilated and slug- gish than usual, or one pupil may be more dilated and slug- gish than the other ; or the eyes may be rotated in a pecu- liar manner. Usually, so tar as my experience goes, the pulse may be- come feebler than it was before ; and not unfrequently the patient will complain that nothing will warm him or k him warm ; or he may sigh in a way which shows that he is not breathing as freely as he ought to do : or, if as] rep, the breathing may at times become imperceptible and in- sufficient as to suggest the idea of death. The breathing fails in this remarkable manner before the tit in a patient at present under the joint care of a medical practioner in the country and of myself, and we can both testifyas to the Later still, there maybe certain vague and (indefinable nations or movement varying in their eharaeter, but all comprehended under the term aura sensation pain, numbness, tingling, and a feeling as of cold vapor, 208 Lectures on [March movements, of shuddering or spasms, beginning in a distant part, as in the hand or foot, and travelling towards the head. In other words, there maybe symptoms which, as Dr. Watson thinks, are in some degree analogous to globus in hysteria, or to the numb and tingling feelings which arc the precursors of paralysis and appoplexv. In some cases there may be special premonitions. In one of my patients, the lit is invariably preceded by an intense feeling <>1* hunger. In another patient, since insane, a little blue imp made its appearance, and grinned and mocked at him as he lost his consciousness. In a third, a guitar seem- ed to be roughly grated close to the ear. But these signs are of little value, for they arc only perceptible to the pati- ent, and not even to him until he has ceased to be able to bestir himself. Last of all, there is a sign which is very difficult to catch and this is the death-like pallor which overspreads the countenance immediately before the fall. M. Trousseau called attention to this sign five years ago as one which is diagnostic of epilepsy ; and, since that time, I have seen it in every instance in which I have seen the fit from the very beginning. "II est une signe," says M. Trousseau, "quie se produit du moment de la chute, et qui n'est inst- able pourpersonne : e'est la paleur tres prononcee, cadaver- ique, qui couvrc pour un instant la face l'epileptive. ]STous ne le voyons pas, parceque nous arrivons toujours trop tard, alors que la face est dija d'une rouge tres pronunce." M. Delasiauve has also noticed the same phenomena in several cases. In the severest and most characteristic form of the parox- ysm, the patient utters a peculiar choking noise, or a sudden and startling cry, and at once falls down convulsed and in- sensible. The convulsions are usually more marked on one side of the body than the other. They drag the mouth to- wards the side which is most affected, and twist the face in the opposite direction until the chin may press upon the shoulder. They push forward the tongue, and crush it be- tween the teetln They clasp the thumb upon the palm, and hold it down with the force of a giant. They seize the walls of tin- chest and abdomen, and prevent the possibility of breathing. They stiffen the limbs, so that the joints can- not be bent without some risk of breaking the bones. In sonic instances, they even take hold o\' the bladder, the bowel, <>r the seminal vesicles, and expel the contents ; in 1861.] Omvulsi 209 others they may be bo violent as to bite ofl a large portion of the tongue, to break the tooth, orto dislocate a limb. At first, it seems as if the Bpasms would never relax; but after- wards they are separated by intervals, which grow wider and wider as the paroxysm draws to an end. The con- vulsions, that is to Bay, are tetanoid at first clonic after- wards. At the instant of the fall, a corpse-like paleness over- spreads the countenance ; a few instants later, and the livid, black, and bloated head and neck, and the hissing, gurgling choking sounds proceeding from the throat, BUggest the idea of a person struggling undei the bowstring of some in- visible exeeutioner. At times, however, the signs of suffo- cation are absent, and the ghastly pallor of the beginning re- mains throughout. When the lit is at its height, a quantity of flrothy salvia is usually blown or puffed from the mouth, and this is not anfrequently reddened with blood, if the tongue or cheek happens to have been bitten. Jf the eyelids are open, the eye is seen to be projected and distorted, with the pupil dilated to the utmost, and ab- solutely insensible to light. As rule, however, the eye- lids would seem to be closed: and well it is that they are so, for it requires some nerve to meet the hideous stare of the epileptic eye. All this while, it is usual for the hands and feet to be cool, and bedewed with clammy perspiration. Except the head and nook, indeed, the whole body is cooler than na- tural, and any little additional warmness of the head and neck would seem to be simply due to the fact that their are more distended with venous blood. The other and less obvious features of the paroxysm are in keeping with the At first, it ma}- be difficult, perhaps impossible, to tool the pulse, and the heart acts very feebly; but if the liin of one hand kept upon the wrist, and the other hand Ik- placed upon the bosom, it is found that the pulse rapidly acquires a force and fullness which it never had in the in- tervals between the fits, and that the heart beats more and more tumultuously and violently as the pulse In . instances, however, the pulse may remain almost lent, and the action of the heart be extremely feeble from the beginning to the end. From the first all conscioui happily suspended 210 Lectures on [March, lli is is our only consolation in so sad a spectacle ami the most powerful stimulants fails to evoke any sign of action in the dormant mind. The water which may be thrown upon the face (with few exceptions) causes no blinking in the eye if this be open and staring; the fire upon which the patient may have fallen may char the flesh without causing a single pang. After continuing for two or three minutes, which seem drawn out to hours, the convulsions cease, and the patient is Left with all his muscles unstrung, like a person dead- drunk, or struck down by appoplexy. The lungs, no long- er restrained by the suffocating spasm of the earlier part of the fit, resume their play with deep inspiration, and then act with loud and strenuous breathings ; and as the respira- tion rightss itelf, the veins of the head and neck become unloaded, the natural color returns to the surface, and pre- sently the patient wakes to an obscured and troubled con- sciousness. "Je suis brise," Calmeil tells us were very of- ten the first words of the returning epileptic at the Salt- petriere or Charenton. The time during which the patient lies in a fit before awaking is very variable, but (except in a first attack) it is rarely more than half an hour, and it may not be more than two or three minutes. This is the usual, but by no means the invariable, course of the fit. Often, indeed, the attempts at rallying may be very imperfect, and fit after fit may recur for a long period without any interval of waking; and occasionally all rally- ing may be prevented by death. "After waking, there are generally some symptoms of re- action in the circulation, but in simple epilepsy these are never marked. They may be enough to give a dull flush to the cheek and a little fulness to the pulse for a short time after the patient wakes ; but, as a rule, they cease when the coma ceases, and coma is never much prolonged in simple epilepsy. Usually the patient is headachy and exhausted, listless and stunned, moody and iritable, until a night's rest has enabled him to recover the balance of his shaken nervous system. The jaded countenance also tells plainly of the past struggle, even though it may present none of those numerous and minute dots of ecchymosis about the eyelids and upon the forehead which are such un- equivocal signs of a severe attack of epilepsy. - time goes on, the mental faculties recover more and more imperfectly, and more and more tardily, and at last 1861.] Corv&aU - 211 their habitual state may bo one of pitiful fatuity from which single ray of the Divine principle beams forth. Or the moodiness and irritability which often follow attacks may >me more and more marked, until at last they mi into attacks of downright mania. Orsymp may make their appearance. Or death may happen in a fit. mortly afterwards. The natural tender. >ilepsy is assuredly towards dementia: and dementia is the frequent doom of the epileptic, if his disorder be uncheckd and life prolonged sufficiently; but at the same time it is possible for an epilectic to live many years, and to have many fits, without losing- powers which are necessary to render him an agreeable and serviceable member of society. When death happens, it appears to be, most generally, from ex- haustion in the period of prostration immediately following the paroxysm. But the symptoms of epilepsy are not always so startling as have been represented, and in some instances they may i softened down as to be recognised witli difficulty. In the slightest form of the malady, the patient pauses suddenly in the midst of anything he many happen to be doing <>r saying at the time, Ins countenance becomes pale and blank, his lungs cease to play, and, after a moment of absence or giddiness, he is himself again. His memory has kept no record of this sad passage in his history, and if it had escaped the notice of others he might remain in happy ignorance of it. Or in addition to those symptoms, a lurid flush may succeed to the paleness of the countenance the veins of the neck and forehead may start out in prominent relief, the face may turn slightly towards one of the shoul- ders, and there may be some convulsive twitching in tin- . neck and arms, hi such a case there is no scream or . no fall, no bitten tongue, no foam at the mouth, and at st there is only some obscure gurgling in the tin son, j rni> and some slight moistening of the lips with salvia. In such a case the convulsive movements are very partial, rarely extending beyond the face. neck. <-; arms, but in some few instances the whole frame may be agitated by one or two violent convulsive Bhocks. Tins te of giddiness and al rad partial spasm may be followed by fatigue, loss of memory, confusion of thought, depression i irritability of temper, and at tu it may end in drowsiness or actual sleep; but usually recov- ery is almost instantaneous. At the same time there is rea- 212 Lectures on fMarch, son to believe that dementia is a more likely as well as a more Bpeedy consequence in this, le petit mat, than in ordin- ary epilepsy, lc grand mat. In some of these cases, moreover, it would seem not only that the patient does not cry, or foil or suffer from general convulsion, but that the state of intellectual eclipse the ; characteristic symptom of epilepsy is far from com- plete. Esquirol says : uil est dcs acces dans lesquels on n'obscrve pas la perte de connaisance ;" and M. Herpin di- rects particular attention to these cases. Cases like these are common enough in certain chronic diseases of the brain as meningitis or tumor: but in simple epilepsy they are by no means common, if other proof be wanting than the mere rtion of the patient. I have met with tour such cases, and have put them on record in various places. The morbid appearances after death from simple epilepsy arc necessarily very obscure, if the case have really been one of simple epilepsy, and not one of epileptiform convulsion connected with some special disease. In cases fatal during the fit the brain has been found to be congested ; but this appearance is clearly owing to the mode of death, and it is allowed to be so. In cases, again, where epilepsy has been complicated with insanity, the brain or its membranes may present various signs of inflammation, or of changes more or less akin to inflammation ; but these signs are clearly referable to the mental disorder, and for no other reason than this : that they are as common, or more common, in insanity without epilepsy. In other cases there are signs of degeneracy, such as pallor of the grey matter, softening, induration, atrophy, dropsi- cal effusion ; but these are the very signs which belong to the demented state. It is this very fact, however, which furnishes some grounds for supposing that signs of this character may have something to do with epilepsy. It docs so, because the demented state is intimately connected virh convulsive disorder for if a demented person be not epileptic, he is almost sure to be affected with palsied shak- ings, or cramps,* or spasms, in one form or another. In other cases, again, theskull may be thicker and heavier than usual, and several internal projections as the* clinoid proc< m maybe considerably developed, or various parts of the dura mater may be converted into bone. Indeed, ther< are no constant changes in the brain proper or its 1S61.] Convulsive Diseases. 213 coverings not even that change in the pituitary boch which bo mnch has been said by Wenzel ; forwritic Rokintasky Bays that he lias "frequenly failed to discover it in those who had notoriously suffered from epilepsy and convulsions," and that he has "met with it in others who were thoroughly healthy." It*is in the medulla oblongata, indeed, that we alone meet with any appearances after death which can be regarded as constant. In early cases of epilepsy, it is true, we may fail to find anything' character- istic even here ; but in confirmed cases Wm medulla oblon- gata is often harder than natural, from the interstitial lot' a minutely granular albuminous matter, or i softened, swollen, and presenting evident signs of fatty de- generation. Professor Van der Kolk, who was the first to detect these appearances, has also detected some marked changes in the bloodvessels, of the part, andto these changes he directs particular attention. lie has examined fifteen epileptics after death, and in them all the posterior half of the medulla oblongata, on making a transveise section, was found to be redder and more hyperaemic than it ought to and this was the case whether death happened in an. attack or not. On more minute examination, he found the bloodvessels dilated to thrice their natural dimensions, and their walls much thickened. And on comparing the me- dulla oblongata of several epileptics who bit their tongue, with the medulla oblongata of other epileptics who did not bite their tongue, he found (what is a very curious fact) that the capillaries were especially dilated in the course of the hypoglossus and the corpus olivare in the former case the tongue was bitten in the fit, and in the course of roots of the vagus in the latter case, where the tongue not bitten in the fit. These discoveries of Professor der Kolk are the most recent as well as the most important - in connection with the post-mortem appearances of epi- lepsy. What, then, is the theoretical purport of the foregoing To which view of muscular motion do. dntV And first for herein may be found the key to the whole matter what is the theory of simple epilepsy to bo dedu from the facts which concern the circulation and respiration of the epileptic? 1. No very certain conclusion is to be drawn from a con- ration of the state of* the circulation and respiration in the interparoxysinal period, except this that plethora in 214 Lectures on [March, the form so often exemplified in the butcher is never met with, and that feverish activity, even as an accident, is of rare occurrence. There are, indeed, cases of epilptiform diseases which the circulation may exhibit at times some signs of activity ; but these cases, as we shall sec in the next lecture, present no objection to the conclusion which is forced upon us by ilio, tacts that the pulse is rarely other- wise than weak and slow in the interparoxysmal period of simple epilepsy. In the fit itself, the facts, when fairly read, admit of one conclusion, and one only. At the instant of the fall, a corpse-like pallor overspreads the countenance and the pulse dies out at the wrist phenomena which seem to be only intelligible on the supposition that the arteries are nearly empty of red blood. A moment or two later, and the black and bloated face, the choking sounds, and the absolute sus- pension of all respiratory movements, show very plainly that the formation of red blood is arrested for the time. During the course of the convulsion, indeed the state is one ofsuffocation. I hiring the convulsion, that is to say, the supply of arterial blood is cut on at the fountain-head. There is, however, one fact which, at first glance, might o to show that there is an increased injection of arterial blood during the convulsion. Such injection is manifestly very imperfect at the onset of the fit,for upon no other suppos- ition can we explain the corpse-like paleness of the counten- ance and the feeble and imperceptible pulse. But if the fin- ger be kept upon the wrist during the convulsion, it will be found that the pulse will go on rising until it has acquired a force and fullness which it never had in the interparoxys- mal period ; and if the hand be placed on the breast, it will he found also that this rising of the pulse is accompanied by increased action of the heart. These facts arc evident and unmistakable, but they do not show, as without reflec- tion they might seem to do, and as they are often supposed t'> do, that red blood is being injected in greater quantity into the arteries during the convulsion. W"hcn the proc< piration is arrested, the right side of the hcaii and the venous By stem generally are soon gorg- ncl distended with black blood. (Tnder these circum- indeed, the gorged and distended state of the1 right of the heart may reach a point in which the folds of the tricupsid valve are forced widely apart, and an opening 1861.] Oonvulswe Diseases. 215 loft through which the beatings of tlio ventricle are made to toll almost as much in driving the blood back through the auricle into the veins. a> in sending it onward through the pulmonary artery into the lungs. But it is not right to suppose that the left Bide of the heart and the arterial trunks are empty of blood; and this may he readily verified by watching the changes which take place in the carotid and jugular of a rabbit during the process of suffocation. On exposing the 3, the artery is seen to bo filled with red and the viens with black blood. On suffocating the animal by tying a ligature around its windpipe, the color of the blood in the artery darkens rapidly, and in about two minutes and a half it is every whit as black as that of the blood moving in the neighboring veins. Nor is the vein CI O o m _ed and distended and the artery comparatively empty. On the contrary, the artery is felt to pulsate as strongly under the rush of black blood as it did previously under the rush of red blood. Nay, the pulse of the black blood is actu- ally stronger than the pulse of the red blood ; for, on testing with hsemadynometer, the late Professor John Reid (who first directed attention to these facts, and who has investi- 1 the condition of the circulation in asphyxia more care- fully than any other observer) found the mercury highest at the moment when the blood in the artery had become thoroughly venous and black. A full pulse and a throbbing heart, therefore, must be looked upon as natural accompaniments of asphyxia : ami thus the full pulse and the throbbing heart of the epileptic paroxysm, instead of showing that a larger quantity of red blood is being injected into the arteries at the time, may show that these vessels are then laboring under a load of black blood, as they do in asphyxia. And that the full pulse and the throbbing heart of the epileptic paroxysm must have this Latter significance is evident, for the livid black, and bloated head and neck, and the complete suspension of all respiratory changes, show very clearly that black and not red blond is coursing through the vessels at this time. When the convulsion is over there is little to notice in the the circulation and respiration. When the spasms . the respiration is speedily re-established, and the re- admission of arterial blood into the system may be attend- ed with some transient and inconsiderable febrile reaction ; but rion has nothing to do with the convulsion, for when reaction is present convulsion is absent, and if con- 216 Lectures on [March, vulsion returns, it is not until every trace of reaction has taken its departure. Regarding, therefore these facts the corpse-like paleness and the comparative pulselessness at the onset of the parox- ysm, and the signs of positive and unequivocal suffocation by which this stage of paleness and pulseness is succeeded and remembering the previous arguments, which show that the convulsion is not to he ascribed to the presence of the Btimulous of venous blood, there appears to be only one conclusion, and this is, that the convulsion of epilepsy is connected with the want of a due supply ot arterial blood in the vessels. Nor is it an objection to this view that the convulsions cease when the blood has become thoroughly deprived, of its arterial properties. In order to discharge their office of conductors, it is certain that the nerves must be supplied with a sufficient quantity of arterial blood. If, for example, the principal vessels of a limb be tied, the nerves of that limb, wanting their due supply of blood, are unable to carry messages to the mind, or to transmit mandates from the mind to the muscles, until the collateral circulation is suf- ficiently established ; and. hence it is a fair inference that there must be a point in the process of suffocation where, wanting a due supply of arterial blood, the nerves must cease to be conductors, and where, consequently, the con- vulsions will come to an end ; for, upon an}' hypothesis, the convulsions will come to an end when the nervous centres cease to be in proper connection with muscles. But, it may 'be asked, is there no change in the blood itself? Is there not. some important truth in the "humoral theory of epilepsy," as recently advanced in this place by the late lamented Dr. Todd ? "I hold,*' said this distinguish- ed physician, "that the peculiar features of an epileptic seizure are due to the gradual accumulation of a morbid material in the blood, until it reaches such an amount that perates upon the brain, in, as it were, an explosive man- ner; in other words, the influence of this morbid matter, when in sufficient quantity, excites a highly poralized state ol the brain, or of certain parts of it, and these discharge their nervous power upon certain other parts ofthecerebro- ;il centre, in such a way as to give1 rise to the phenomena of a m. A very analogous effect of that which results from the administration of strychnia, which is best seen in a cold- blooded animal, like the 1'vo^. You may administer the 18G1] Convulsive / 217 drug in very minute quantities for some time without pro- ducing any sensible effecl ; bul when the poison has ac- cumulated in the system up to a certain point, then the smallest increase <^l' dose will immediately give rise to the peculiar convulsive phenomena. This is the humoral theory of epilepsy. It assumes that the essential derangement oi' health consistsin the generation of a morbid matter, which infects the blood : and it supposes that this morbid matter has a special affinity for the spinal cord. The source of this morbid matter is propablyin the nervous system, it may be in the I) rain itself. It may owe its origin to a disturbed nutrition an imperfect secondary assimilation of that organ and in its turn will create additional disturbance in the functions and in nutrition of the brain." And again : Ling to the Immoral theory, the variety in the nature and severity of the fits depends on the quantity of the poi- sonous or morbid material, and on the part of the brain which it chiefly or primarily affects. If it affect primarily the hemispheres, and spend itself, as it were, on them alone, you have only the epileptic vertigo. If it effect primarily the region of the quadrigeminal bodies, or if the affection of the hemispheres extend to that region, then you have the epileptic tit fully developed." This theory is based upon the well-known connection be- tween the presence of urea in the blood, or carbonate of ammonia resulting from the decomposition of urea the i It of defective renal action and one form of epilepti- form convulsion; and it might also have been based upon the connection between convulsion and blood overloaded with bile. But if there is any evidence in these facts in favor of the existence of this hypothetical morbid material, there is none in favor of the idea that the modus op< randi of the material is in exciting a highly polarized state of the brain, if by this state is meant anything like a condition of excitement. On the contrary, it ia certain (as will be shown in the next lecture) that the action of the brain and of the em generally is reduced to the very lowest ebb at the time when convulsion is brought aboul by the accu- mulating i and bile in the blood; and it is not less tain that strychnia, instead of actin , Todd e iting a highly poraliz< ing the stimulating powers of the blood and by diminishing the sfion of both nerve and muscle. 218 I ."lures on [Marcli, There is little doubt, however, thai retained excretions must play an important pari in the production of epilepsy A free discharge in the office of excretion, not only in the kidneys and liver, bul in every excretory organ, is essential to the preservation of healthy blood ; and it may well be believed thai an imperfect discharge of the office of excre- tion, in oik' or other of the excretory organs, may lead to the accumulation of eftete matter in the blood, and that this accumulation ofeffete matter may be a not unimportant cause, in bringing about an attack of epilepsy. Hut there is no reason for supposing that \\w blood under these cir- cumstances become stimulating. On the contrary, the con- clusion which arises out of the history of the cases where the area or bile is suppressed, is the natural conclusion, and this is, that blood thus altered is less fit to discharge its several offices ; in other words, less stimulating. Nor does there appear to he any reason for supposing that venous congestion has a more important part to play in the production of epilepsy than that which has been assigned to arterial injection. No doubt the veins of the brain and head generally arc congested from a \cvy early moment, butthere is a moment antecedent to this in which the death- like pallor of the face is a sufficient proof that the veins were emptier than usual before they became congested. At any rate, the acknowledged anatomical difficulty must be overcome before it can be supposed that Dr. Marshall Hall's hypothesis of trachelismus or the prevention of the return of Mood from the brain by the spasm of certain muscles in the neck has anything to do with the causation of epi- lepsy. Et would seem, then, as if there was something utterly uncongenial between epilepsy and arterial excitement. Jt would seem, indeed, as if the spawns, as well as the loss of consciousness and sensibility, were connected with want of arterial blood empty vessels in the first instance, ves- sels tilled with black blood afterwards. It is not imp bable, also, that the blood may have been previously rendered less stimulating by the retention of something which ought to have been eliminated by one or other of the organs of excretion. In a word, the phenomena are entirely in harmony with the previous considerations re- specting muscular motion ; for according to them, the ac- tion of arterial blood is to antagonize construction, and not i. it. . 1861,] Convulsive Disecu 219 '1. Interrogating the nervous system, the facts are found to have that theoretical significance which the state of Hie circulation and respiration would lead us to expect. These facts will scarcely warrant the idea that epilepsy ifconnected with anything approaching to over-action of the brain proper. On the contrary everything seems to point to a state which is the very opposite of over-activity. Thus, the comparative want of memory, intelligence, fancy, and purpose, which marks the intcrparoxysmal condition; the utter annihilation of everything mental in the fit itself; and the gloom and prostration following the fit, are facts which can have no double meaning. Xor is a contrary opinion to he drawn from the morbid appearances which are disclosed after death. If these chance to indicate previous inflammation, it does not fol- low that convulsion had any direct connection with the in- flammation as inflammation ; on the contrary, the convul- sion may have happened hefore or after the inflammation, when the energies of the brain were prostrate or exhausted an alternative which we shall see to be the correct one when we come to speak of elcptiform disease connected with special disease of the brain. And surely it is not pos- sible to draw any but one conclusion from the appearances which arc common to epilepsy and dementia pallor of the grey substance, atrophy, chronic softening and induration, dropsical cfl'usion and the rest? But what of the state of the medulla oblongata V for, as r Schrosder Van der Kolk has well shown, the seat of the characteristic spasms, the bilateral character of the spasms, and the appearancespresented after death, all point to this organ as one which is specially concerned in bring- ing about the epileptic paroxysm. The spasms of epilepsy begin in muscles which receive nerves from the medulla oblongata in muscles, that is to . which are supplied by the facial, the accessory, the hy- poglossal, and the portio minor trigemini; in slighter <; they are limited to these muscles. The spasms of the walls of the chest and abdomen, which are the most prominent and marked features in the complete attack of epilepsy, and which may be so fierce and unyielding as i fatal suffo . also point to the same nervous centre; for a similar state of things is brought about by the action of a strong stimulus upon the great afferent nerve of tins centre the pneumogastric. 220 Lectures on [March, The bilateral character of the spasms is another argument that the medulla oblongata [ally affectedin epilep- sy. The lateral halves of this organ are connected in the most intimate manner by transverse fibres and commissures much more intimately than the lateral halves of the brain and spinal cord ; and hence it is that the corresponding nerves belonging to the two sides of the medulla oblongata are under a stronger physical necessity to act together than that which rides the corresponding nerves "belonging to the two sides of the brain and spinal cord. In the ease of the two latter centres, the nerves belonging to one side may be paralysed or otherwise affected without any obvious injury to the nerves of the other side; hut not so in the case oi the latter centre. Indeed, it is evident that the actions which eminate from the latter centre the play of the fea- tures, the motion of the tongue, the vocal adjustments of the larynx, the respiratory movements, kc must at once come to an end unless there he the strictest sympathy and concert in the action of the corresponding nerves of the two sidi Xow in epilepsy the spasms are always more or less bi- lateral, and for this reason, therefore, it may he supposed that they have some special connection with a nervous centre of which one lateral half cannot act without the other. The appearance after death point also to the medulla ob- longata as especially concerned in the production of epilepsy. In an early stage of the disorder, we may fail to find any characteristic changes; hut, in confirmed cases, the texture is harder than natural, from the intestinal deposit or a minutely-granular albuminous matter, or else softened, swollen, and exhibiting signs of evident tatty degeneration. The posterior half of the oblongata is redder and more hypersemic than it oughttobe; and, on examining the hlood- 3els in this congested portion, they are found to be of thrice their natural dimensions, and with their walls much thickened and altered this dilatation and alteration being chiefly in the corpus olivare and in the course <>f the hypo- in the ease of epileptics who bite their tongues, and in the course of the rool vagus in th< fepilep- . who d<> qoI bite th< ir tong It is evident, then, that the medulla oblongata is especial- ly affected ii sy; but it does not follow, as Profee Van dcr Kolk supposes, that the essential cause of the con- 1861.] 221 vulsive affection is to be found in an exalted sensibility and activity of the ganglionic cells of this centre. In favor of this view that epilepsy is dependent upon exalted sensibility and activity of the ganglionic cells ap- peal has been made to the fact of spasms, to the presence of a full, bounding pulse, and to the freedom from attack which is for some time the fruit of an attack, particularly if this has been violent ; but the answer is not necessarily that which Professor Van der Kolk supposes it to be. After what lias been said about muscular motion in the first lec- ture, it is not possible to allow that spasm in itself is an argument in favor of exalted sensibility and activity in gang- lionic cells. After what has just been said about the phenomena of the circulation in epilepsy, it is impossible to allow that the condition of the circulation favors spasms by bringing about a more active state of the medulla oblongata, 'the functional activity of this, as of every other organ, be- ing in direct proportion to the activity of the circulation of red blood in the organ;) for it has been seen that the bounding pulse to which reference is made, is- filled with black blood, and not with red. Xor can the freedom from attack, which is for some time the fruit of an attack, be ap- pealed to as a certain proof that the attack is the sign of the discharge of some overcharge of excitability previously pre- sent. On the contrary, it maybe argued with some degree of plausibility, from certain facts which have to be mention- ed in the next lecture, that the attack was preceded by de- pression of the circulation and innervation, that the convul- sion supervened when the depression had reached a certain point, and that the recurrence of the attack was prevented tor a time by the state of reaction in the circulation and in- nervation, which is a conserpience of the convulsion. The may be one, indeed, of which the history of the rigors of ague may serve as so inapt illustration ; for here we hi first, the circulation failing more and more until the bathos of the cold stage is reached; and, secondly, a state of re- action which banishes the rigors most effectually so Ion . it contin It would even seem as if appeal might be made to the appearances after death, and to the actual condition of the circulation in the fit, for positive arguments against the idea aything approaching of the medulla obi- Ti. of fatty degeneration can have but one signifi- 222 Lectures on [March, cance under-action, not over-action. The interstitial de- posit, also, implies an equivalent absence of healthy nerve- structure, and so does the dilated condition of the blood- vessels; and this absence of nerve-structure must necessitate a corresponding absence of nervous action. The appearances after death, indeed, ifthey show anything, show that the medulla oblongata of the epileptic is damaged in structure, and because damaged in structure, weaker in action, than it ought to be. The ureal argument against the idea of anything like over-action of the medulla oblongata in epilepsy, however, is to be found in the state of the circulation; for if, as may safely be assumed, the activity of any organ is in direct re- lation to the activity of the circulation of red blood in that organ, how far from anything like over-action must be the state of things in which as is the case in the epileptic paroxysm, the vessels arc at first comparatively empty of red, and afterwards completely filled with black blood ? Nor can the curious discovery of Dr. Brown-Sequard, that certain injuries of the spinal cord are followed by an epilep- tiform affection, be construed into an argument that there is anything like a state of exalted action of the spinal cord in epilepsy. This curious result, which is brought about by puncturing or dividing more or less completely almost any part of the spinal cord, is developed, not immediately, but in the course of three or four weeks after the injury. The attacks, once developed, occur spontaneously at various in- tervals, often several times a day ; they may also be brought on by pinching or otherwise irritating the portion of the skin which corresponds to the region of the whiskers in man. This excitable spot is supplied by twigs belonging to the suborbitary, the auriculo-temporalis, the second, and perhaps the third, cervical nerves ; and it is a curious fart, that the irritation which brings on a tit when applied to the skin in which these twigs terminate, has no such effect when applied to the twigs, themselves. Any other part of the skin may be pinched or irritated with impunity, butthis one spot can scarcely be touched without at once bringing (Hi a lit. These facts are very curious, and in the main, very un- intelligible : but this much at least is evident, thatthey do not countenance the idea of any over-action of the spinal I in epilepsy. The fad thai the epileptiform affection - doI make its appearance until four or live weeks after ] m;i.] Convulsive Jbiaeat 228 the injury would appear to show very clearly that the tits have nothing to do with that local inflammation in the cord which may be supposed to have been Bet up in the first in- stance by the injury. After such a lapse of time, indeed, is it not the natural conclusion, that any over-action of the cord arising from the inflammation produced by the injury must have died out, and left the cord damaged, weakened, under-acting! Nor is a contrary conclusion to be drawn from the excitable condition of the nerves proceeding from the neighborhood of the cheeks ; for both sides of the face are thus affected, if both sides of the spinal cord have been injured. What the full significance of this curious fact may be we may have yet to learn, but at any rate there is no reason to suppose this excitable condition of the skin im- plies an over-acting condition of the nerves or nervous centres concerned in the phenomenon. The excitable por- tion ot skin is not over-sensitive, for the animal manifests no signs * f uneasiness when it is handled immediately after a lit. Over-sensitiveness, moreover, would seem to have nothing to do with the matter. At any rate, pain, and not convulsion, is the consequence of handling those portions of the skin of the animal which may have been rendered highly hypersesthetic by the injury to the cord which brought on the convulsions. It i^ certain, also, that a some- what similar condition ol' excitability is brought on when, in several experiments related in the first lecture ante. June-July, the skin is cut off from the full influence of the nervous -: and hence the natural inference would be, that the action of the nervous centres in the epileptic guinea- nus rather plus. As in the former instances, however, so here; we turn to the condition of the circulation ami respiration in order to know what is the actual functional condition of the spinal cord in epilepsy; and so turning, we see that the action of the cord under these circumstances must be almost or alto- gether nil. For what action can there be when little or no arterial blood is injected into the vessels? A similar argument will also dispose of the idea of over- activity of the ganglia of the sympathetic system as a a ible that the contracted state of the arteries, which is implied by the death-like pallor of the countenance and the comparative pulsel al the wrist, may show that the coats of the vessels are in a state of : and it ifl also possible that the cause of this spasm 22 1 Lectures on [March, may have to be sought in the sympathetic system; hut it docs not follow that over-action of this system is this cause. On the contrary, the experiments of Drs. Kusmaul and Tenner already referred to show most conclusively that strong epileptiform convulsion is possible when the action of the sympathetic ganglia is entirely suspended by arrest- ing the supply of blood to these organs. And certainly no opposite conclusion is to be drawn from the vague and undefinable sensations or movements very varying in character, but all comprehended under the term sensations of pain, numbness, tingling, or a feeling of cold vapor; movements of shuddering or spasm, begin- ning in a distant part and travelling towards the head ; for the most probable interpretation of these symptoms is that of Dr. Watson that they arc in some degree analogous to the numb and tingling feelings which are the frequent pre- cursors of paralysis and apoplexy, or to the globus of hys- teria phenomena which by the most perverse process of reasoning can scarcely be supposed to indicate other than a state of defective innervation somewhere. But, it may he asked, is there nothing else ? Is there no peculiar state of the nervous system in epilepsy? Is there no morbid irritability.? In order to answer this question, it is necessary to ask another What is morbid irritability ? It is not inflammation; it is not fever; it is some indefin- able and negative state which occurs frequently in teething, in worm disease, in uterine derangement, and in many other cases a state in which the patient is unusually de- pressed by depressing influences, and unusually excited by exciting influences. But what is this state ? Is it any- thing more than lucre exhaustion? In difficult teething, the strength is worn away by pain and want of sleep ; in worm disease, the parasites help to starve and exhaust the em; in uterine derangement, the health is undermined, in all probability, by pain and by sanguineous or other dis- charges. In each case there is unequivocal exhaustion of body and mind, and the signs of morbid irritability appear to be nothing more than the signs vf such exhaustion. A weak person is more affected by the Beveral agencies which upon the body from within and without, and he is so because he is without some of that innate strength which which belongs to the strong person : and the person who is morbidly irritable, is in reality one who, \\yr want of this principle of strength, responds impatiently to the several 1861.] True Ringworm. stimuli, whose office it is to elicit his vital phenomena. Tn a word, this undue morbid irritability may be nothing else than the natural consequence of that general want of power the signs of which are written so legibly upon the vascular and nervous systems of the epileptic. There is no neec - then, to look upon this morbid state of irritability as an evidence of the existence of any peculiar condition in some part of the nervous system ; for, thus interpreted, it only shows that the state of muscular contraction is ill antagon- ized by nervous influence. Thus interpreted, indeed, mor- bid irritability only becomes another name for inefficient innervation. The theory of simple epilepsy, therefore, which may be deduced from a consideration of the facts relating to the nervous system is in harmony with that to which we have been led by a review of the state of the circulation and res- piration in the epileptic ; and this theory is one which tal- lies as completely with the view of muscular motion set forth in the first lecture, as it disagrees with that commonly received opinion according to which the muscles are sup- posed to contract convulsively because they are subjected to excessive stimulation. Clinical Report on True Ringworm (Tinea Ton By Jonathan Hutchinson, Assistant-Surgeon to the London Hospital, and Surgeon to the Metropolitan Free Hospital. The diagnosis of ringworm to the practised eye is not usual- ly difficult. Its patches differ from those of eczema, impetigo, and common porrigo, in that they have no inflammatory crust, only a thin branny desquamation being present, hi the latter, the hairs are not destroyed, but simply matted together in the crust, while in ringworm they are broken off short. The roundness of its patches, and their abrupt definition; together with the paucity of scales, distinguish it from all the forms of psortasis ; and the latter are beside- veryrare on the scalps of children. In alopecia circumscripta the patches are glabrous, (piite destitute of hair, and free from even the Bmallest scales, a in which ringworm departs from its usual type for instance, if attended by inflammation its differential diagi comes difficult. In all Buch cases the appeal is to the microscope. To make a Satisfactory diagnosis with the microscope the hairs from the patch should be carefully pulled 15 226 True Ringworm. [March, out with tweezers, and some of the branny scales should also be scraped off. Those should be put into a drop of glycerine on the microscope-slide, and covered in the usual manner. The addition of acetic acid renders the hair structure more transparent, and the sporules, therefore, more conspicuous, but glycerine is usually quite sufficient. After observing the general size ot the hair-fragments, etc., with a half-inch ob- ject-glass, a quarter-inch, or a fifth, should be employed^ Microscopic Diagnosis. The presence of sporules of a fun- gus is an essential character. These are usually best seen in groups on the outside of the hairs ; but a little practice will o enable the observer to detect them in great numbers in the interioi of the hair-shaft itself. It any hairs have been pulled out with their bulbs the sporules may most probably be Been very distinctly in the lower and less opaque part of the latter structure. But. the peculiarities presented by the hairs themselves (apart from the actual demonstration of parasitic elements) are very marked. Instead of being round, of regu- lar thickness, in long portions, and partial translucent, they are black, in short broken fragments, swollen, bulging at parts, and with their external layers split off in places. The black tint (which is due, not to pigment, but to altered refrac- tion from disturbed arrangement of the hair-fibres) is arranged in longitudinal bars, giving the hair a fasciculated appearance. If the extremity of a ringworm-hair is brought under view it is seen to be broken and split up into fibres, resembling on a small scale the stump of a worn besom. In, and on, the epi- dermic scale sporules will also be found. It is consistent with my own observation, that the younger the patient the more likely is the disease to be restricted almost solely to the hairs of the scalp, whilst in those beyond the age of about, ten years, the epidermic scales are often attacked, the hairs being less extensively affected. When the patches are situated on the skin of the trunk, neck, or anus, t\io small hairs of the part are almost always attacked, but they do not become infiltrated in the manner so often seen on the scalp, nor do they usually break off. In these regions the disease is primarily one of the epidermis rather than of the hairs. 1- tine Ringworm Contagious? The popular#belief in the extreme contagiousness of ringworm is of old landing, very firm, and ver) widely spread. It i- also Bupported by the experience of most dermatologists. ( me or two authors, how- ever giving descriptions by which it is placed beyond doubt that they were writing about the disease in question), deny it- contagiousness. Thus, one authority writes: "Thia dis- 1861.] True Ringworm. 227 ease is not contagious ;" and adds, "that it is not communi- cable by inoculation/' I am not aware that any evidence is on record supporting the view that it is not inoculable, while there are many tacts conclusively proving the opposite. The experiment is one easily tried, and on such a mailer the anus prubandl certainly rests with those who deny it.""' Mr. En- nuis Wilson, after broaching the theory that the Buppi cryptogamic sporules are in reality oil-globules, the result of fatty degeneration of the hair-shafts, has the following extra- ordinary passage : w* Another consequence naturally follows the admission of the explanation here given, which is, that this disease being in- herent in the hair, and being due to an abnormal nutrition of the system, is in nowise contagious. I need scarcely observe, that this is a question of the utmost importance as affecting the peace and happiness of families and the education of youth. The disease occurs as commonly among the children of the wealthy as among the poor ; and when the idea of its being contagious is entertained the scourge is rendered doubly severe." Thus it would appear that a theoretic conjecture as to the pathology of the affection is to decide this important question, there being no need for clinical investigation as to what is really the fact. Let me ask any one who has glanced ever so cursorily over the cases I have cited whether he would to try "secure the peace and happiness of a family,'' or "promote the education of youth,'' by assuring an anxious mother, <>; the head of a children's boarding-school, that the disease in question cannot sj^read by contagion, and that no precautions need be taken ( The clinical proof of the contagiousness of true ringworm is as conclusive as is that of similar nature in respect to scabies. When we see a disease in itself slight and easily curable by local means, suddenly showing itself in live or six individuals in the same family of different ages and states of constitution, and none of whom were ever liable to it before, it is surely futile to allege that constitutional causes are sufficient to explain the occurrence. The case is yet stronger, if possible, the affected children belong to different families; and it culminates when we find that the disease has spread to *It is . 231 The different modes of preserving fish give rise to chemical processes which cause the formation ot poisonous mal Injurious consequences from eating salted fish, particularly salted sturgeon, are frequently observed in Russia. But also codfish, and the smaller kinds of preserved fish, have given rise to Byniptoms of poisoning. Cases of poisoning from her- rings are perhaps the rarest, and this is probably owing to the fact that the time f>r catching herring is limited to a certain n, that they are salted without delay when still at and that they are more rapidly consumed. The character of the poison generated in preserved fish is still doubtfnl : at the first the poisonous substance was thought to he of cryptogainous growth, or a tatty acid ; more recently Schlossberger advanced the view that the propylamin (tri- methylamin) contained in the brine is the poison in question but this opinion has been refuted by the experiments of Buch- lieim. Clinical Report on Epithelial Cancer of the Lip. By Jona- than Hutchison, M. D. This report embraces a statistical analysis of one hundred ami twenty-seven cases of epithelions of the lip, occurring in hospital practice, in allot' which operations for the removal of the disease had been performed. The lower lip was air ed in ninety per cent, of the cases, the upper in four per cent, and the angle of the mouth in six per cent. From the series, we rind that women are subjects of the disease in the propor- tion offive t every hundred males, and when they are affect- ed, it frequent in those who are in the habit of smoking. of the patients was fifty-eight years, the tremes being twenty-eight and eighty-two years. In all cepting about twelve cases was the disease primary. The results of the operations for the removal of cancer of the lip in one hundred and twenty-seven cases may be :ned up a- follow tree patients died of erysipelas within ten days of the operation : in seven, the cancer returned in the wound : nine had a return of the disease in the cicatrix at different periods r the operation; in five the lymphatic glands becami ibsequently; three had the same ion the op- posite part of the lip : and one hundred and five are reported as having recovered from the operation, having left the hos- 232 Diagnosis of Apoplexy. [March, pita! with sound cicatrixes. Inasmuch as most of the reports were made within a few months of the operation, a sufficiently long period had not elapsed to discover whether the disease had returned in a larger proportion of cases than above indi- cated. Diagnosis of Apoplexy. Mr. Foelman, the Professor of Physiology in the University of Ghent, communicated to the Academy of Sciences at a re- cent meeting, an account of some curious phenomena which he had observed in a a dog, with some remarks upon an exami- nation which he made of the animal after its death. During several months, while attending a family as physician, he had noticed a dog which appeared to be in perfectly good health, and possessed of all his instinctive faculties, but which was totally unable to co-ordinate his voluntary movements; fre- quently, during the course of the day, he was observed to whirl himself round, always in the same manner, and for more than a quarter of an hour at a time. Upon making an examination of the body, M. Poelman found nothing peculiar in the thoracic and abdominal vicera, but in the cerebellum, and especially in the middle cerebellar peduncles, there ex- isted a considerable number of calcareous concretions which gave a very firm consistence to these parts ; the scalpel, which he employed for the purpose of cutting into this substance was much notched; in short, the cerebellum, with the exception of the vermiform process was, so to speak, petrified. M. Flourens who brought the communication before the Academy after commenting upon the exact relation which was shown in this case between the pathological phenomena, and symptoms and the functions of the disordered parts, said : On this occasion, I request the Academy to permit me to make some general remarks upon the diagnosis of apoplexy, the feasibility of which appears entirely proved by my re- searches upon the encephalon. By these researches I have shown that the encephalon, considered as a whole, is com- 1 of three distinct parts essentially, that is to say, function- ally. 1. The brain, properly so-called, consisting of the cerebral or hemispheres, the seat of intelligence. The cerebellum, the seat of the co-ordinating power. :t keeps in equilibrium the movements of locomotion. The prolongation of the spinal cord, or more exactly at part of this prolongation which I have named 1861.] Delirium Iremens. 233 the vital protuberance or point, the seat of the principle of life itself. Hence, three classes of apoplexy may be arranged; the cerebral apoplexy, the cerebellar apoplexy, and the bulbous apoplexy. The symptoms of these are only deranged func- tions ; the functions once known, nothing is more easy than to trace the symptoms to the organ which is injured or diseased, intelligence marks the seat of the apoplexy to be in the brain properly so-called (the cerebral lobes or hemispheres) ; the derangement of the balance of the movements of locomo- tion denotes the seat of the apoplexy to be in the cerebellum ; whilst sudden death would lead to the opinion that the seat of the apoplexy (apoplexie foudroyante), was to be found usually in the vital protuberance, although sudden death may depend, of course, upon a certain degree of lesion in several other parts of the encephalon. I suppose, here, simple cases of apoplexy, because 1 speak from a physiological point of view, the science of thh physiolo- gist being to separate organs and their peculiarities, in order to arrive at simple facts. In pathology, facts are almost al- ways complicated ; it is seldom that a single organ only is dis- ordered, and several organs are frequently, more or less, in this condition. Hence, for the physician diagnosis is more dif- ficult than fur the physiologist; but the plain laws, laid down by physiology, may serve as guides, and lead to the unravell- ing and analysis of complicated cases. London Medical Re- Hoffman!* Anodyne in Delirium Tremens. F. 13. A. Lewis. I was at Deer Island Hospital for a few months after my graduation, and while there treated quite a number of cases of delirium tremens, and of intemperance, the latter in- cluding those who had irritation of the stomach, and the "shakes," as some term the state, but not amounting to de- cided delirium. I employed the various means presented by the text books, and watched the success of students in the same Institution, with variable success ; and atone time, think- ing that Hoffman's anodyne might answer the indications, I : it in 17 cases of delirium tremens and 14 cases of intem- perance, in doses 5-s. every hour, and of the 31 cases I did not 'ne. Perhaps this will not in the least interest you, but as I see the journals tilled with new treatments for this dis- . and being a subscriber to the Journal, I thought it pos- sible it might deserve a space in its pages. Huston Mea.dk Surg. Journal. 234 Continued Fever. [March, On the use cf stimuLents in the treatment of Continued Fever. By I). Tweedie, Physician to the London Fever Hospital, &c. Speaking upon this subject in his recent Lumleian lectures before the Royal College of Physicians, Dr. Tweedie says : " It is always necessary to watch the effects of the h'rst few doses of wine, and if the pulse abates in frequency, becomes soft and fuller, the tongue moist, and the heat of the skin not increased ; and, when there lias been delirium, if the- patient becomes more calm, and has intervals of sleep, we may feel Bure that the wine is doing good. On the other hand, if the pulse increase in frequency and strength, the skin becomes hotter, and the patient restless, flushed and excited, with throbbing of the temporal and cartoid arteries, we may con- clude either that wine is -not suited to the case, or has been given too earh', and should therefore be withdrawn. But, as a general rule, it is perhaps better to give wine a little too early than a little too late, since, if it appears to disagree, it is easy to suspend its use ; but it may be very difficult to restore the vital powers if they have been allowed to remain too long unsupported. "Nor should the wine or brandy be discontinued until con- valescence is fairly established ; but as the symptoms for which the stimulants have been prescribed disappear, the quan- tity should be gradually abridged by giving smaller portions and at more distant intervals. "In regard to the amount of wine and alcoholic stimulants that may be administered in typhus, no precise rule can be laid down, as the ever-varying circumstances presented by in- dividual cases can alone determine this. It is prudent to be- gin with half an ounce or an ounce, and to repeat this amount at longer or shorter intervals, according to the effect produced, from six to twelve ounces may be considered to be an aver- age daily allowance, but sometimes it is necessary to give two or three pints, or even more, in twenty-four hours, and, it is surprising to observe, without the slightest intoxicating effect, even when the patient has been previously unaccustomed to stimulants. Indeed, in low lever-, the exhausted state of the nervous system appears to be antidote to the effects of stimu- lants in short, to create a tolerance of vine and diffusible stimulants. 'The wine should always be conjoined with nourishment, in onicr to assist its due assimilation, though in many cases the digestive powers are so feeble that they are unable to elabor- 1861.] tinned Fever. 285 ate oven the Lighest articles of \'oo(\, and therefore the wine or brandy may be given simply diluted with water. "I have just alluded to the daily quantity of wine that it may be necessary to prescribe in typhus, and stated th.it no precise rules can be laid down, as the circumstances of each must determine it. You are doubtless aware that there is a great tendency in the present day to revive the Brownon- ian Bystem, which flourished for a time in the latter part of the last century, in all acute diseases, including fevers, without regard to individual peculiarities. The doctrine inculcated by some teachers with respect to inflammation is, that this process being a deranged nutrition, involving supply and waste, and the waste being considerable while the inflamma- tory process lasts, there must be a compensating supply ; that as the supplies for the formation of the abnormal products of pus and lymph must be drawn from the blood, or from both, the vital powers become exhausted, in proportion to the or- ganic disintegration that takes place. Hence it is concluded, that the more the inflammatory process drawn upon the blood the greater will be the exhaustion of vital force, and the con- sequent effect upon the whole frame. "Upon this physiological theory of the phenomena of inflam- mation is based the overthrow of established therapeutic prin- ciples, on which the treatment has been for ages conducted. But surely'even the abettors of this theoretical view must ad- mit, that the object of treatment is to anticipate or prevent those. so-called destructive processes : in other words, to pro- mote resolution by all available means. Is this to be accom- plished by extravagant doses of wine and brandy, regardless of the ever-varying condition of the sufferer or period of the disea- "Similar reasoning is adduced in regard to the phenomena - whatever be their type or special circumstances. It gainst the indiscriminate employment of stimulants in fever that we protest, being convinced that their proper adminis- tration requires as much consideration as is generally bestow- ed on other measures employed as curative agents. "The enormous quantities of wine and brandy recommend- ed in even the early stage of fevers, whatever be the form, the individual circumstance.-, or whether there be local affections present, have often surprised me, and inclined me to doubt the accuracy of the statements. 1 have certainly Been inter- current inflammations materially aggravated by the injudici- ous stimulation adopted, and on more than on< n all the ordinary characters of acute delirium tremens supervene 236 Acute Rheumatism. [March, when the unlimited administration of brandy had been left to (lie discretion of a nurse, who fancied that she was only obey- ing instructions when she poured down dose after dose of pure brandy. There is surely no practical philosophy in such in- discriminate abuse of a really valuable remedy when given on rational principles; and I deem it the duty of every physi- cian who is convinced of the dangerous tendency of the Brownonian doctrine applied indiscriminately in the treatment of diseases, acute as well as chronic, to express his opinion boldly and decidedly, that the young and inexperienced prac- titioner may be warned of the dangerous consequences of this recently revived doctrine. ":;" "':' "Let me also allude to the importance of giving the wine at stated intervals, and only when the excitement is moderate. It is especially necessary to give it during the night, when there is often great exhaustion. A dose of wine judiciously given at this diurnal period is often followed by calm, refreshing sleep; and hence the incalculable advantage of an interested, experienced nurse, on whom so much responsibility indeed the life of the patient often rests.'* The conditions attending every attach of Acute Rheumatism . By Dr. Wheelock, of Belfast, Maine. An experience of twenty years, we are told, has convinced the author that every access of acute articular rheumatism is immediately preceded by a special condition of the nervous system, induced by mental anxiety or by the action of the de- pressing passions; and that if, when the body is in this con- dition, a suppression of the sensible or insensible perspiration have taken place, the result is invariably acute rheumatism. "This truth," Dr. Wheelock natively adds, "though a simple one, is to my mind, startling, and, without egotism, the most important pathological discovery in the present century." Reference is made to fifty cases of acute rheumatism as supporting this view, and a dozen of these is given in illustra- tion, which can scarcely be regarded as altogether conclusive, seeing that few human beings suffering from any malady will not present some traces of the action of mental anxiety or de- ing passion, if such traces be sought after. This view, according to Dr. Wheelock, suggests an addition- al indication of treatment. "It is to bring into operation the requisite normal influences. The patient is to be made to 1861.] Purpura Hemorrhagic*. 237 understand the true nature of the disease and its cause. Though it cannot be expected that every individual shall exercise the force necessary to the forgetting or ignoring mental agitation in these cases, yet it may be presumable that a knowledge of the real producing cause may not only prevent a recurrence of it, but will greatly assist in fortifying the sufferer against its protracted continuance. In my own experience, I have found, when patients are informed that it has been brought on themselves by a mental agitation that might seem to have been avoided or was inexcusable and needless, the disease has been shortened in its course or immediately stopped ; and where there had been successive attacks, the patients had thus been apparently spared these recurrences." On the use of ScsquleJiloride of Iron in the treatment of Pur- pura Ilemorrharjia. By M. Pize, of Montelimart la Drome. This paper, which was read before the Parisian Academy of Medicine, is divided into two entirely distinct parts ; one relating to the exposition of practical facts, the other to the modus operandi of the remedy. M. Pize holds, without much show of reason, that the drug has a sedative action upon the heart ; and this opinion led to a prolonged and futile discussion in the Paresian Academy of Medicine upon the action of medicine in general. The practical facts are of considerable interest. In the tirst case, a girl, twelve years of age, presented for six days all the symptoms of typhoid fever, and simultaneously suffered from epistaxis, turgidity and sanguineous exudation of the gums, expectoration, emesis, sanguinolent motions and urine ; numerous ecchymoses were disseminated over the surface of the limbs. This condition had persisted for a wholo :. in spite of sulphuric acid, lemonade, extract of rhatany. . mustard poultices, &c. three and a half ounce mixture, containing fifteen grains of liquid sesqui chloride of iron, was prescribed. In twenty- four hours, the hemorrhagic tendency was checked, the urine alone remaining sanguinolent. The pulse, which had been very frequent, returned to 80 pulsations. On the following day no blood was discharged, and the spots of purpura as- sumed a dark hue. From that period, the disease proceeded rapidly towards cure. 238 Purpura Hemorrhagla. [March, The subject of the second case was a lad of sixteen, who, after considerable growth and hard work, with insufficient food, was seized with febrile symptoms, extreme prostration of strength, and, on the fourth day, presented numerous spots of purpura on the limbs, witli sanguinolent motions and epis- taxis ; the pulse rising to 100 pulsations. A four-ounce mixture, with fifteen grains of sesquichloride arrested the hemorrhage in twenty-four hours, and reduced the pulse to 90 pulsations. The p"btion was continued the next day, and all the symptoms ceased. The Medicine was then discontinued for two days. Epistaxis returned twice, but with less violence than before. The pulse again rose to 100. The mixture was resumed ; on the ensueing day no hemorrhage took place, and the pulse declined to 82. Con- valescence was very rapid under the influence of the sesqui- chloride, which was continued for several days; a small quantity of substantial food and wine were also prescribed. M. Pize's last case refers to an unmarried woman, twenty- five years of age, who, two years before, had presented symp- toms of chlorosis. After live or six days' indisposition, intesti- tinal hemorrhage appeared, epistaxis and numerous spots of purpura on the limbs. The pulse was weak, and rose to 119. The day after the use of the chalybeate potion, hemorrhage ceased, the pulse returned to S6, and fell two days later to 02. The disease terminated as in the two preceding cases. M. Pize then adverts to the analogous case, published sub- sequently to his own, by Bourguignon, a case in which the reporter deemed it expedient to add a fourth, recently publish- ed in the "Gazette Medicale de Strasbourg,'' by Sir. Leroy, de Saint-Ybars. The following, in M. Pize's estimation are the obvious infer- ences from these four eases, all relating to purpura hemorr- agia. 1. Sesquichloride of iron is pre-eminently the agent for the cure of the disease ; it arrests the hemorrhagic tentendeney in the space of twenty-four or fourty-eight hours, and, con- tinued, for a few days, rapidly brings about the convalescence of the patient. 2. This medicine produces an immediate diminution in the rapidity of the circulation, decreases the quickness of the pulse; in twenty-four hours Irom 110 to SO pulsations, and may therefore fairly be considered as a direct sedative of the ac- tion of the heart. 1861.] Observations on Syphilis. 239 Observations on Syphilis. In an essay read before the Rutherford County Medical Society, May 3, 1860, Dr. L. M. Wasson, of Murfreesboro, Term., attempted to prove syphilis to be the parent of scrofula (Nashville Jour, of Med. and Surg. But this asser- tion, although admitted in part by others, is loosely based upon the impaired vitality, prostration and cachetic condi- tion of the system, induced by syphilis, and resulting in the "lymphatic temperament, which is the temperament of scrofula." The system is thought to become inclined to the scrofulous diathesis, because every fibre of the economy cannot but be affected by "blood vitiated with ingredients so incompatible with every tissue of the body," as the venereal virus. Supposing that to be true, as far as it goes, it does not follow as undeniable fact, "syphilis does pro- duce, in every particular, the scrofulus diathesis," nor that it is "a most powerful and frequent cause of scrofula." In order to corroborate the assertion of Dr. Cullerier that hereditary syphilis is always %due to maternal influence, [Memoires de la Societe de "Chirurgie, torn, iv., p 230) Dr. Xotta has published a memoir containing a number of ob- servations which go to show, that the issue will be free from the disease when at the time of conception the mother was free from it, notwithstanding the father may have been affected either at the time or previously, but that syphilitic children will be the result where the mothers have been subjected to the influence of the virus previous to concep- tion, while the father was then suffering or had passed through the disease. In registering these facts, we are not prepared to admit the conclusions drawn from them, pre- ferring to wait for the result of a more ample experience. Arch. Gen, de Jlcdec. Prof. Sigmund, of Vienna, finds the proto-iodide of mer- cury only applicable to the papular and pustular forms of syphilis, and even there it is slower in effect than other mercurial preparations. Its reputed peculiarity of not in- ducing salivation is groundless ; even when combined with opium, it gives rise to diarrhoea, and in obstinate forms of the disease, it is of little or no use, while in anemia it is positively injurious. It by no means deserves the prefer- ence given to it in the treatment of children, and admits only of further trial in some obstinate" forms, combined with iodide of potassium, but not in subjects disposed to catarrh 240 Observations on Syphilis. March, of the longs, stomach or intestines. Wien Wochensehr.: Mai Times and < < Prof. Ik-bra has given, in one of the late meetings of the Medical Society of Vienna his experience since 1858 of the treatment of syphilis by syphilization. Taking the matter from a simple chancre, he continues the inoculation as long as pustules are formed, or until all the syphilitic symptoms have entirely disappeared. Patients, upon whom no more pustules arc produced, even by repeated inoculations from different chancres, are pronounced "immune." The inocu- lations were made three times a week, commencing with four punctures in the side or upper arm and then in the thighs. The aggregate number of punctures reached from 7 to G04. The earliest immunity ceased after the nineteenth inoculation, or the forty-second day, with seventy-six punc- tures; the latest by 219 punctures after 150 days. The pa- tients, with the exception of two, received no medicine, not even a warm bath, but were allowed nutritious food and walking at pleasure. The artificial pustules were covered with a piece of oiled linen : frequently it took from three to six weeks to heal them up. A few patients, in whom inoculation had not been pushed to immunity, were attack- ed again with syphilis. Out of twenty-four (three with pri- mary chancres, nineteen with secondary syphilis, two with non-syphilitic lupus serpiginosus) fourteen had been dis- missed, the rest remaining under treatment. The applica- tion of mercurial ointment in two cases did not influence the development and course of the artificial pustules. All patients made perfectly immune are permanently cured. They feel perfectly well during the inoculation, improve in appearance and gain in weight; by and by all syphilitic symptoms disappear. Parallel experiments, however, prove the decided superiority of mercurial treatment. Wien Wochensehr.: Oglethorpe Med. and Surg. Jour. Against syphilitic chaps and fissures of the toes, an oint- ment containing litharge, white precipitate and a few drops of laudanum, has been used with marked success in many of the hospitals of Germany. The same ointment is recom- mended for the serpiginous and phagedenic ulcers which asionally supervene upon vaccination in children of a Bcrofulous or syphilitic- constitution. The process of cica- trization is practiced by bathing the soivs with a decoction of hemlock and marsh-mallows. Med. CJdr. li 1S61.] mors of the Breast 4J U On (he Diagnosis of Tumors of (I '. By John Erich- Ben, Professor of Surgery and of Clinical Surgery in Uni- versity College, &c. [In the present article Mr. Erichsen treats principal! the diagnosis of cancer of the breast from cystic and adenoid tumors of that organ.] These cystic growths, though not so common as cancer and the other solid tumors, are yet of by no means infre- quent occurrence. They are of three distinct kinds : 1. Those in which the tumor consists of a singular unil- ocular . 2. Those which consist of several independent segregated together into one tumor multilocular 3. Those in which a series of small cysts are dif- fused through a fibrous or hypertrophied mass; in fact, a combination of cysts with a chronic mammary tumour. Two theories are in vogue as to the origin of this form of ic development. According to one set of pathologists, it is produced by the obstruction and subsequent dilatation of a lacteal duct. But this theory, I think, is weak : from the fact of our not being able to trace one of these ducts into the cyst ; from the fact that the fluid contained in these cysts Bhowfc no trace of lacteal origin ; and from the fact that such cysts are met with elsewhere, in places where no lacteal duct previously existed. The other theory is, that these cysts entirely new formations ; and this, partly for the reasons before mentioned, and partly because tin- closely resemble those met with in other secretory glaj both as to structure and contents, appears to me to be t more tenable of the two. These tumors, I must premise, whether unilocular, mul- tilocular, or consisting of cysts diffused in a mass of fibrous or hypertrophied gland-tissue, are always composed of thin Avails, formed of condensed cellular tissue, and containing in their interior a fluid variable in amount and character ; being in one serous, in another glairy, and in a third bloody ; it is very commonly of a light straw color, not unfrequently it is brown, and sometimes sanguineous, but these differ- ences are accidental and of no importance. We will now consider the diagnosis of tin growths from cancerous and other solid tumors of the breast. And, first, with regard to the unilocular cyst ; this is the most common form, and occurs generally in women at what one might call the "cancerous age," forty-five to fifty ; it is frequently referred to pressure, or to a 'blow on 10 242 Tumors of the Breast. [March, the part, or it may be connected with uterine disturbance at the period of the cessation of the mensus. Thus so far as the age and proximate cause are concerned, the history throws comparatively little light on the subject, and the diagnosis has therefore to be made entirely by palpitation and examination of the tumor. Xow you can easily con- that, depending only on manipulation to form a cor- rect judgment of the nature of the tumor, the surgeon may be exceedingly liable to form an erroneous opinion. I could relate to you many cases in which error of diagnosis has occurred, but I will confine myself to a few of the more illustrative. I was requested some time ago, by my friend, Mr Wal- ter Wilson, to see a married lady, aged 45, who had in the it breast a tumor oi about the size of an apple, hard and painful on pressure. This, she said, had been diagnosed as a fibrous tumor by a surgeon in the country, who had re- commended her to come to London and have it removed. On examining the tumor I suspected it to be a cyst. It had not the stony hardness of a solid tumor, but felt obscurely elastic on deep pressure. Acting on this supposition, I in- troduced an exploring trocar and let out about two ounces of dark serous fluid ; the cyst never refilled, and the patient went borne perfectly cured. I was requested one day to see an unmarried lady, aged On going to the house I found her bathed in tears, and Bisters in great distress around her. I was told she had a tumor of the breast, which had been pronounced to be a or. On examination I found a tumor in the right nma, about as large as a pigeon's egg. It had been no- ticed about fourteen months previously, and the patient had been under both medical and surgical treatment for it. It rounded, circumscribed, situated at the outer and upper pari of the gland, hard but smooth, and not heavy to the feel, On close manipulation, I felt some elasticity. I told the patient that I did not think it was a cancer, but a cyst, and that if I punctured it and drew off the fluid contained in it she would probably have no further trouble. She >rmed me that she had seen an eminent surgeon, mii.) had pronounced it to be a cancer ; had explained that ration was necessary ; that the whole of the breast removed, and had fixed an early day for its perfor- i requested to meet this gentleman, but this was ed by the patient and her friends; and as our opinions 1861.] Tumors of the .Breast. 243 differed so widely, it was agreed that she should have the benefit of Sir B. Brodie's opinion. That distinguished geon saw the case with me the next day, and, lie haying acquiesced in the opinion I had expressed, I tapped . and let out about an ounce and a half of yellowish serous fluid. The tumor collapsed, all idea of operation was abandoned, and the patient has continued well up to the present time. I saw the other day a very similar case. It was that of an unmarried lady, aged 48, who had had for about twelve, months a tumor in the left breast, which had gradually in- creased in size, until it had attained the magnitude of a Tangerine orange. It was hard, circumscribed, situated at the axilary border of the gland; it had also been pro- nounced to be scirrhus. But, suspecting from its elasticity that it was cystic, I punctured it with an exploring trocar, and drew off about ten drachms of clear fluid, causing the immediate subsidence of the tumor. Xow here were three cases of simple cystic or fluid tumor of the breast, which had erroneously been pronounced to be solid, and which would have been submitted to amputa- tion of the mamma if the mistake had not been discovered in time. It is of very great consequence, therefore to be cautious in these in pronouncing a definite opinion, and to neglect no means in perfecting your diagn< How is this to be don : As l have already stated, the history very often throws no light on the nature of these case*. Cysts occur at the same age and among the same class of people as cancer of the breast, but there is one cir- cumstance of great importance to which you must al . attend, and that is the presence or absence of elasticity. This last character may be said to be the great diagnostic point between these tumors and cancer; and whenever you feel, or even suspect, elasticity, you ought to introduce an exploring trocar. If the tumor is c^ystic, the fluid escapes, and you probably hear no more of the case. But if, on the contrary, it is solid, a drop or two of blood only oozes out, the puncture soon closes, and no harm is done. In making tin* puncture, there is one little point to be attended to, and that is, if you use an exploring needle, take care to posh it aight in, and not to make the puncture in any way valvu- lar: for if you do, the fluid may not escape, and rims , rious mistake may arise ; it is, however, far better, in all cases, to use the exploring trocar in preference to the grooved needle. -44 Tumors of the Breast. [March, If this little operation tapping does not procure the closure of the cyst, you must resort to other measures, such as injecting it with iodine, introducing a seton, or, if these fail, excision of a piece of the cyst-wall. But you will gen- rally find that tapping and the subsequent use of iodine lo- tions will suffice to effect a cure. The next kind of cyst the multiloeular is more difficult to diagnose than the unilocular; firstly, because it is gene- rally seated deeply in or beneath the gland, while the unil- ocular occurs chiefly at the border or anterior surface, and because there is not so much fluctuation, owing to the fluid being divided among several cysts. But vet there is that never-failing sign of cystic disease elasticity. You will find, however, that there often exists a good deal of con- densed fibrous matter round about these tumours, and hence the removal of the whole gland may be required, the extir- pation of the cystsalone being impossible. ( )ne reason why cyst-tumors are often so difficult to diagnose as such., is that they arc often associated with cancer. There great difficulty exists, especially in the early stage ; and these eases are ex- lingly liable to be confounded with cystic sarcoma, and indeed in some cases you cannot make your diagnosis until the tumor is removed, and then only by a careful micro- scopic examination. A woman, aged 45, was admitted into this hospital with a tumor of the size of an orange, situated in the right mamma deeply over the pectoral muscle. It had existed for about five years, was not adherent to the skin, and there Were several cysts of the size of plums. .At the upper part of the mass, which could be felt through the lately mucuous co- vering, the nipple was not retracted; there was only one slightly enlarged gland in the axilla. Now here were all the characters of a "cystic sarcoma" slow growth, no adhe- sions, eysts, and no material glandular implication; and yet. after the removal of the breast, the microscope reveal- ed the tumor to be distinctly and decidedly cancerous. ?OU will sometimes find that tumors of a tixed, possibly a semi-malignant character, occur with cyst.-, and give rise to great difficulty in the diagnosis of their exact nature, and render it Impossible for you to pronounce with certainty whether tiny are benign or malignant. The following is a of this kind. An unmarried lady, 40 years of age, and in excellent health, was sent up to me by my friend, Mr. Tuxford, of 1861.] Tumors of the Breast. 245 Boston, last November, with a tumor of the right breast, which, without assignable cause, had commenced growing about live years and a half ago : it increased slowly until it had attained the size of an orange about two years since, but afterwards much more rapidly, until at last it reached the size of an adult's head. The skin covering it was not reddened, and though thinned, was neither adherent nor in- filtrated. There was no pain at night, or after handling it; and no enlarged glands could be felt in its neighborhood. The superficial veins were much enlarged over the tumor, and a good sized artery was felt to pulsate over its upper part. It was elastic, lobulated ; and a large mass, of a cvs- tic character, projected from its anterior surface. There were no adhesions between it and the pectorals, or to the skin. The operation was performed on November 10th. On removal, I found that the tumor weighed ninety-six ounces, and consisted of large encapsuled masses, of a dull grey or brown color. One section, it was solid in parts, and infiltrated with a gelatinous fluid; in others, there were large cysts, containing several ounces each of dark stringy mucoid fluid. Dr. Harley, who examined it, pronounced it to be colloid. There were also masses of fibroplastic deposit in some par Now her*1 was a case that approached closely to malig- nancy in its local characteristics, without any constitutional symptoms of cachexy ; and which presents an appearance nn examination that renders it doubtful whether it may or not yet recur. The next class of cases to which 1 would direct your at- tention are the chronic mammary or adenoid tumors. These are uf exceedingly common occurrence ; and there are two or three coeditions with which they are often ass< the knowledge of which materially assists the surgeon in his diagnosis. 1. With regard to the age, they generally ;r before the cancerous age, in early womanhood, be- tween the ages of 18 and 25. 2, They are almost invaria- bly slow in their progress. 3. They are lobulated, dist: non-adherent to the skin or pectorals and eireumscrl 4. There is no cachexy or glandular enlargement: and, in fact, they appear to be ^uite local and benign. T usually I to which they can be assigned ; but I be- lieve that they frequently occur in young women of nervous temperament, and are commonly associated with uterine disturbance kind. The chief diagnostic points are, 246 Tumors of Ike Breast. [March, therefore, the age of the patient, the slowness of growth of the tumor, and the perfect freedom from constitutional symptoms ; but yet any one of these conditions may be present in cases of undoubted cancer of the mamma. Scirrhus very rarely occurs at the early period at which the adenoid tumor is common ; but yet it is occasionally met with in young women. Some years ago I removed in this hospital a tumor from the right breast of an unmarried female, aged 23. It was as large as a small flattened orange, was hard, nodulated, but not adherent to the skin. There was no retraction of the nipple, and it had been growing for about eight months. No cause could be as- signed for its appearance, and it was supposed to be adenoid. However, on account of the large size of the tumor, as com- pared with that of the somewhat atrophied mamma, I removed the whole of the breast, together with the tumor ; and it was well that I did so ; for, on microscopic examina- tion, it was found to be scirrhus. The patient subsequently married : and when I last heard of her, two years after the operation, she was in good health. Now here is a case in which cancer occurred within the period usually assigned to chronic mammary tumor ; and hence you cannot rely altogether on the age of the patient as a means of diagnosis. Next, with regard to the slowness of growth ; although it is an undeniable fact that benign tumors usually grow slowly, and that rapidity of growth is generally a sign of malignancy of action, yet this rule must also be taken with exceptions, as in the following case : Last June, I was requested to see an unmarried lady, I 40, of a nervous sanguineous temperament, who had been in bad health tor many years, suffering from uterine disturbance, dyspepsia, and latterly from pulmonary symp- toms. At the age of 18 that is, twenty-two years previous to my advice being sought she noticed for the first time a small tumor in her left breast. This continued perfectly stationery, and about the size of a pigeon's egg, until last February, when it for the first time became painful, and be- rapidly to enlarge. Being at this time in Italy for the (it of her health, this lady saw two distinguished .an surgeons, who, after careful examination and ex- ploratory punctures, pronounced the tumor to be a " mye- ." and recommended extirpation of the mamma. The patient, however, preferred to return to England, and have the operation performed here. On her way home she saw 1861.] Tumors of the Breast. 247 Velpeau in Paris, who with a great accuracy of diagu pronounced the tumor to he benign, and gave her a written statement to that effect. AVhen I saw her, on her return to this country, in June last, I found a tumor of the left: mam- perfectly mobile, firm, solid, inelastic; it had attained the size of an adult's head, and was rapidly increas There was no glandular enlargement in the axilla ; the skin was thinned and reopened, but not adhered; the super:' vessels were much enlarged, a tortuos network of veins and one or two large arteries running over the tumor. There was no constitutional cachexy : but the patient's health and strength were at the lowest ebb, from general and J standing constitutional derangement: and she could not sleep at night, not so much from pain (which, however, was constant, and at times very severe,) as from the constant anxiety of mind which the presence of the growth pro- duced. Sir B. Brodie and Dr. Walshe, who saw the case in consultation with me, both agreed that it was probably benign, but that no operation was practicable until the patients state of health was improved. However, by atten- tion to diet, and by being put on a proper plan of treatment this was so much ameliorated that in July last, I was ena- bled, with the assistance of Mr. Marshall and Dr. Cowan, of Glasgow, to perform the operation for its removal. This was attended by no difficulty, and by very little hemorrhage, notwithstanding the size of the tumor, which weighed rather more than live pounds. The patient made an excel- lent recovery, and was able to leave town in less than three weeks. On examination after removal, the tumor was found to be lobulated on its surface. The section showed it to be homogeneous, and of a uniform greyish color, with no soft points or cysts, but distinctly and firmly encephalous. Dr. Harley, who examined it microscopically, found it to be a specimen of the chronic mammary tumor of Sir Astley Cooper. In the plastic matter taken from different lobules, examples of the glandular tissue were found. Some of the blind tubes were remarkably distinct, and well filled with cells. There was no trace of cancer. Xow here was a tumor which, after remaining of sm;ill size and stationary for more than twenty years, suddenly, and without obvious cause, began rapidly to increase : so much so that in less than six months, it had increased in size from that of a pigeon's egg to the magnitude of a mas- weighing more than four pounds. Here was extreme ra- Tumors of the Breast. [March pidity of growth without malignancy of character. In fact, this extreme rapidity of growth resembled rather what is not un frequently found in cncephaloid disease, than what we exped to meet with in the chronic mammary tumor, and rendered the diagnosis not a little difficult; the more was possible that the chronic mammary tumor, which had existed for so many years in a stationary and ive condition, might have suddenly undergone malig- nant degeneration, and thus taken on rapid increase of bulk. This, however, was disproved by the careful micro- pical examination made by Dr* Ilarley, who found that tumor did riot present a trace of malignant structure. It is, however, important to hear in mind that cystic and told tumors may remain for a long time inahenign and ive state, and then assume a malignant character. This happened in the case of a woman, aged 48, who was sent to the hospital by my friend, Mr. Adams, two years ago. At the age of 27, she had first observed a tumor in the left breast. This had slowly increased in size, until it had at- tained, at the end of fifteen or sixteen years, the size of the foetal head. When I first saw it, in January, 1858, one of the cysts <>f which it was composed, had ulcerated, and a thin sero-sanguineous discharge oozed out of the opening. The general health was good. There was no glandular en- largement iu the axilla, or adhesions of the skin, except, around the ulcerated parts. It was freely moveable on the pectorals. An operation for the removal of the tumor was ] >roposed, hut this the patient refused to consent to. At the end of six months, she returned with a large ulcerated cavity in the centre of the tumor, and fungati ng masses sprouting from the bottom of it. There was still no cachexia or enlarged glands in the axilla. The patient now consent- ing to an operation, I extirpated the whole mass with the ama. <>n examining the tumor after its removal, it was found to he cystic. There were several large cysts, of the size of pigeons' containing turbid hut light colored us fluid. The central portion of the tumor, and that at : the fungus were .-olid, grey, and rapidly under- going softening and disintegration. (>n squeezing the por- tion of the mas# (the base of the fungus) a milky juice led; and Dr. Ilarley who examined the tumor, stated n to be encephaloid. the sarcomatous structure heyond this, constituting the general mass ^l' the tumor, appeared 1,. be adenoid. The Burface oi' the fungus, when exposed and protruding heyond the cyst, was epitheliomatous. 1861.] On the Treatment of Favus. 249 Now here were cjt oma, cncephaloicl and epithe- lioma, associated in one growth. The encephaloid was staled by Dr. Ilarley to be cellular, without fibres, showing- rapid development. The epithelioma was confined to the surface of the fungus. The history of this case, the very lengthened period (more than twenty years) that the tumor had existed, the absence of all constitutional cachexy, ot deep adhesions, or of glandular enlargement or other secon- dary deposits, and its appearance only six months previous to removal, all pointed to primary simple cystic disease of the mamma, in which, as the result of secondary changes, encephaloid had developed itself; being an instance of the conversion of a simple into a cancerous tumor of the breast. This patient died about a twelvemonth after the operation, of gangrene of the foot and disease of the heart. The cicatrix was quite sound ; but in the substance of one of the ventricles a nodule was found, which was considered by those who examined it to be of a cancerous nature. MedicalJournal, April 14, I860,;;. 279. On the Treatment of Favus. By Dr. W. T. Gairdner, Physician to the Royal Infirmary of Ediuburgh, Lecturer on Clinical Medicine and on Practice of Physic. [In the case which forms the text of the following re- marks, the head was at first covered with yellow crusts, of long standing ; exactly four days afterwards, there was not a vestige of a crust to be seen, nor even any broken sur- face, though the patches of absolute baldness and the stunted and diminished hairs in many places, showed clearly the deep hold the disease had taken. The change was en- tirely due to the successful poultices of linseed meal.] tuch has been written about favus. and so many perfi - have been recorded in periods varying from six week veral months, [am almost afraid t<> state my conviction ti result above mention obtained in four days under linseed meal poultices, was quite as much entitled to the name of a cure a- any that I hav< -i or heard of either in the nature or in tic cord with <>PI ortunitn ion emending over less than a year or two [fi idence of nothii than the 250 On the Treatment of Fat [March, most entire ignorance of its habits. I do not, however, doubt the cure of favus. Soap and hot water, with abun- dant scrubbing, the hair being kept short, will commonly keep the yellow crusts indefinitely in abeyance : as will also, perhaps, more thoroughly and effectually, the simpl oil inunction. There seems no reason, therefore, to beli< (though hospital physicians can but seldom hope to witness the result) that those simple means, long and perseveringly usea\ will not erl'cct the cure of a disease which owes its origin and perpetuation to nothing else than want of clean- lin< - Under ordinary circumstances, what takes place after an apparent cure of favus, is this : So long as the hair is kept shaved, and an alternation of oily applications with soap and water is maintained, the disease does not reappear: but on neglecting these precautions for a few weeks, yellow dots begin to crop up. and these rapidly extend so as to become distinct favus crusts, which in no long time, if uninterfered with, will cover the whole head. I have repeatedly kept eases under observation after the head had been completely cleared, in order to observe the first beginnings of the erup- tion after the suspension in the treatment ; and I have also employed a great variety of medicated ointments and lo- . tions, including sulphurous acid, iodine and sulphur oint- ments, empyreumatic oils, mercurial ointments, and mixed medications of various kinds. After most of these, I have seen the disease reappear about as quickly as under the simpler treatment b}T oil and soap. If there is any of them in which I have faith more than another, it is in empyreu- matic oils, as the juniper tar oil or common pitch ointment. But the inveteracy of the disease evidently depends, not on the difficulty of removing its visible traces, but on the com- plete infiltration (so to speak) of the scalp with the sporules of the fungus in all old standing eases ; and no treatment will be of the slightest avail towards a radical cure that is not deliberately and carefully pursued until a complete growth of scarf skin has been obtained, perfectly tree from all traces of the noxious germs. This must, of course, be the work of a considerable time: just as it i^ a work of time, and of unwearied attention to simple details, to rid a virgin soil of ragweeds and whins, or even of stones. No application of a specific can he expected to meet the one any more than the other. One point, not always Observed by those who have writ- 1S6L] Ulceration of the Rectum. 251 ten on this subject, is, that favus is often, perhaps even in the majority of cases, implanted on the basis of a previous eruption ; in other words, that the fungous crusts, or vege- table mould, are sown on a soil already the seat of impetigo, eczema, or some other variety of disease of the skin. Some- times the original disease has died out when the favus first, comes under treatment ; at other times, it still persists and requires separate treatment. In the corirse of considerable and varied experience of true favus, however, I have not seen a single case that did not at once yield to local treat- ment, to the extent I have indicated above ; and I am very far from believing that any constitutional disorder has to do with the production of the fungus, further than that favus and other diseases may arise simultaneously, under exposure to the same causes of filth, neglect and hygienic errors of every kind, in every variety of boclilv constitution. Edxn. Med. Journal, May, 1860. p. 1003. On Ulceration of the Lower Extremity of the Rectum : its Va- rieties. Diagnosis and Treatment. By James Rouse, Esq., Assistant Surgeon to the Westminster Ophthalmic Hospital, kc. Xotwithstanding the numerous works published on dis- eases of the rectum during the last few years, there appears still to be great difference of opinion as to the best mode of treatment ; more particularly with regard to those ulcera- tions situated on the mucous membrane lining the sphinc- ter ani, and in the fossa immediately above that muscle. There are three forms of ulceration of the lower extremity of the rectum, which gave rise to very acute suffering ; and although they vary considerably in position, have neverthe- been described by most authors under the general head of fissure. It is proposed, in the present paper to po'ntout that three distinct forms of ulceration occur in this region, which, by ordinary investigation may be distinguished from each other, and which require different modifications of treatment. The most common form of ulcer found at the lower ex- tremity of the rectum is that which is known i re of the anus. This disease does not seem confined to any par- ticular period of life, though it rarely or ever exists until 252 aeration of the Rectum. [March, after puberty. It is more particularly common among per- who lead a Bedentary life, and for the same reason it is rather more frequent in women than men. The fissure ap- pears to be by a tearing of the mucous membrane lining the sphincter ani, by the passage either of hardened > of a foreign body contained therein. The follow- ing cases will, however, show that fissure of the anus may lally be the result of external violence: Case 1. A gentleman, aged 24, was riding a restive horse, when it. suddenly bolted. He was thrown with some violence, on the hind part of the saddle before he recovered his seat. He felt some pain about the anus at the time, and, on changing his shirt, he noticed a lew drops of blood. For the next few 'lavs he experienced a slight burning pain during the evacuation of the bowels, and in about a week the characteristic pain of fissure was established. On an examination being made, a small crack was perceived on the posterior surface of the sphincter; it commenced about two lines within the anus, and extended upwards for about half an inch. Various local means were tried without benefit, and an operation to he hereafter described, was had' recourse to with perfect suet Case 2. A captain in the navy fell off a ladder, and came to the ground on his buttocks, with considerable force. He did not observe any particular pain until he went to stool the- following morning, when he experienced considerable smarting, and noticed that he had passed a small amount of florid blood. About a week alter the accident, he ap- plied for advice, lie then, alter every evacuation of the bowels, had pain, which lasted for several hours. On ex- amination, an ulcer was found on the posterior surfac the lining membrane of the sphincter : e not indurated, and the surface was florid. An ointment, con- taining mercury, was applied twice a day : and in the course oi' a week a cure was effected. Persons afflicted with this die describing the origin of their Buffering, frequently state that while -training vio- tly a1 stool, tlicy felt something give way, and on look- heir evacuations, they n>lice< were so bard that it was from the an This crack or fissure is almost invariably situated on the ! surface o\' the sphincter. 1 have seen upwards of 1861.] ration of the Rectum. a hundred cases, and in only six did the position vary; in three of these the fissure was situated on the perineal sur- face of the muscle, and all occurred in women ; in two it was Bituated on the leftside ; and in one on the right. It commences about three lines from the margin of the anus, and extends upwards in a straight line to the extent, usual- ly, of half an inch, though sometimes as high as the supe- rior margin of the sphincter. It the fissure he seen within a week or ten days of its occurrence, it presents the appear- ance of a bright red line with a sharply defined edge, and does not appear to extend through the thickness of the mucous membrane. A little later, if no treatment he adopted, one or two florid granulations may frequently he D protruding ahove the margin ; and it is during this . v that a small amount of blood is voided on going to stool. This appearance is very soon changed ; the edges hecome everted, and more or less hard, and the surface of the ulcer itself looks excavated and pale, like any other in- dolent sore. The pain caused by this solution of continuity is at first trifling, and only exists while the motion is pass- ing ; hut it soon becomes most severe. It usually com- mences about half an hour after the bowels are relieved (the sensation up to that time being only uneasiness) and continues for live or six hours. As the disease progresses, the pain becomes more continuous and easily excited, and even walking or sneezing will bring it on. At this stage, the ulceration is found to have extended through the sub- mucous cellular tissue into the fibres of the sphincter; there is a constant desire to pass urine, a serious addition to the other suffering, and this continues until relief is obtain- ed by means of an operation. This second form of ulceration is situated immediately in front of the os cocygis, and was first described by Sir B. Brodie, in a clinical lecture delivered at St. George's Hospi- tal. This ulcer, which is almost invariably co-existent with an enlarged and varicose state of the veins about the rec- tum, does not, like the one just described, appear to be Bed by a tearing of the mucous membrane. Mi". Quin Btates, in his recent work 'On the Diseases of the Rectum ' that he has noticed a case in which, "the disease having been of no long duration, and the suffering comparatively slight, the membrane appeared to be thinned from beneath." The ulcer, once formed, soon increases in size, and usually remains quite superficial for a considerable time ; but at 254 Ulceration of the Rectum, [March, -!h, from the continual irritation, the edges become and hard. The surface, however, seldom becomes so indolent as in cases of ordinary fissure ; and in this form of the disease the ulceration seldom, if ever, implicates the fibres of the sphincter ani. The pain which, as in fissure, -used by the evacuation of the bowels is most intense; there is usually very little spasm of the sphincter, but the patient complains of severe lancinating pain, which gradu- ally subsides into a sensation of burning, which continues for three or four hours. The third form of ulcer is situated in the fossa which ex- ists between the external and internal sphincters; it is by far the most painful and serious affection of the three. It appears to be caused either by the lodgment of a small por- tion of hardened freces, or by injury done to the mucuous membrane in that situation by the passage of some foreign body, such as a fish-bone. Two cases are known to me where the presence of a polypus of the rectum (the extre- mity of which was pressed into this fossa every time the bowels were relieved) caused an ulcer in this position. The ulcer, at first, is seldom more than the eighth of an inch in diameter, and it is generally somewhat deeply exca- vated. As the disease progresses, the ulceration extends into the substance of the sphincter ani ; so that, when the finger is passed into the rectum, the end of it sinks into a small cup-like cavity, the inferior part of which is formed at the expense of the superior margin of the sphincter. Except in cases of long standing, the edges are not indura- ted, and the surface almost invariably remains florid. In this disease a certain amount of pus and blood is passed at each relief of the bowels. If this ulcer be not cured by means of an operation, it leads to a most troublesome form of stricture of the bowels. The constant irritation set up by the action of the bowels gives rise to inflammation of the submucous cellular tissue ; this causes thickening and hardening, by which means the calibre of the outlet is seri- ously diminished. The following case will illustrate this kind of termination : Mrs. S., aged 23, complained of very severe pain before, during, and after the relief of her bowels. She had consulted a surgeon, who, on examination, found an ulcer immediately above the external spincter. An inci- sion was made through the ulcer into the tissue below ; but this did not produce "the slightest relief. Six months after 1861.] Ulceration of (he Rectum, the operation, she noticed that the discharge was much in- creased in amount, and she found more difficulty in passing her motions, which were small and flattened. A year sub- sequently to the operation, I saw her, and, on examination, discovered an ulcer of considerable size situated on the posterior surface of the rectum, and involving the superior margin of the sphincter, and such extensive thickening of the submucous tissues that the finger could not be passed through. Subsequently, by means of bougies, considera- ble benefit was obtained. In these cases, the pain complained of is most severe, and there is more spasm of the sphincter than in simple fissure : in some of these cases the amount of spasm is so great that the muscle increases considerably in size. The pain ap- pears to commence some little time before the bowels are relieved, probably this is caused by the pressure of the load- ed bowels upon the ulcer. Diagnosis. The diagnosis of these cases is by no means difficult. The peculiarity of the pain complained of, the fact of its coming on either during, or soon after, the action of the bowels, and the ease with which these ulcers may be detected by the finger, when it can be introduced into the bowel, render a mistake almost impossible. There exist only two diseases with which these ulcers may be con- founded : to wit, a syphilitic ulcer and spasmodic contrac- tion of the sphincter. Neuralgia in the neighborhood of the sphincter has such well-marked symptoms of its own, that it can scarcely be mistaken. With regard to the syphi- litic ulcer, its characteristic appearance, the class of persons affected, the existence of syphilitic ulceration about the va- gina, remove all doubts as to the nature of the complaint. The diagnosis between spasmodic contraction of the sphinc- ter and fissure is rather more difficult; in fact, it is only by a most careful examination that the surgeon can determine whether an ulcer exists or not. There arc, however, a few points of difference which it would be well to remember. In spasmodic contraction of the sphincter, the muscle very rapidly increases in size ; the anal orifice becomes so con- tracted that even a gum catheter cannot be introduced with- out producing extreme suffering. This amount of spasm is most rare in ulceration, and it is the pressure caused by the finger on the ulcer itself that produces the pain. rin, in ulceration, it matters little in which form, sooner or later, there is always discharge of pus and blood : in Ulcerations of the Rectum. [March, smodic contraction, this never occurs. Lastly, the pa- tient having been placed under the influence of chloroform, a careful examination of the bowel can he made (which it is impossible to do without producing insensibility) and, as in the following case, no ulcer is found to exist. George , aged 45, a man of spare habit, sal- low complexion and depressed vital powers, complained of intense pain, which occured during the lime the bowels ting, and for several hours after. The pain was not Lnuous, but came on in paroxysms every few minutes. The motions were very small and flattened ; but there was no discharge or appearance of blood. On examination, the Bphineter muscle appeared more developed than usual, and the anus was so contracted that it was impossible to intro- duce the finger. A speculum ani was employed, and the most careful examination failed to discover any ulcer. Un- der these circumstances, a small bougie, about six inches long, was introduced every other night. At first the pain caused was very great, and he was unable to retain it for more than three or four minutes ; but he was soon able to bear it for a longer time. The size of the bougie was grad- ually increased, and he was ultimately cured. Case 5. A gentleman, aged 35, of spare habit and ner- vous temperament, had suffered with symptoms like those just described, for six months, and the pain had become so severe that he could not take exercise; he had tried various means to obtain relief without success. The most careful examination failed to discover any ulcer, but the sphincter was immensely hypertrophied. Bougies were employed for two weeks without producing the slightest relief, and the patient was so worn out and irritated by the pain he suffered, that he could not be induced to continue the use of them. It was therefore decided to divide the sphincter, and with the exception of the pain produced by the passage of the fieces through the wound, this patient never suffered any inconvenience afterwards. I should not have insisted so strongly on the existence of this disease, but one of the most recent writers on diseases of the rectum doubts the existence of simple spasmodic Dstriction of the sphincter. There is one other precaution necessary in these cases; and that is, to be quite certain that only one ulcer exists. It is not very unfrequent to find two; they may be either . above the other, or situated on opposite sides. 1861.] Ulceration of the Rectum. 257 The treatment required for the ulcer in front of the os coccygis, and for fissure, varies according to the si the disease. If it be treated before it has become indoli local applications, and attention to the state of the bowels, are all that is necessary. Grey oxide of mercury and s] maceti ointment, (half a drachm to the ounce) or a scruple of calomel to an ounce of lard, with ablutions night and morning, and after each relict' of the bowels with yell soap and water, will usually effect a cure. Great cure must be taken in the choice of a laxative, the object being not to purge, but to render the faeces soft, so that as little stretch- ing as possible of the ulcer should take place. Confection of senna or milk of sulphur generally produce the desired effect. A very common medicine in these cases is confec- tion of pepper : this, combined with confection of senna very useful in cases of hemorrhoids, but it is apt in all cases of ulceration to produce considerable aggravation of the patient's suffering. When the ulcer has once become indo- lent, the best and only treatment (likely to prove beneficial) is by the knife. The operation is best performed in the following manner. The patient being placed on the right side, with the knees drawn up to the chin, the forefinger of the left hand is to be introduced into the rectum, and the knife passed up in front of it; the incision is then to be made, commencing a few lines above the superior margin of the ulcer, and to be carried through it down to the ex- ternal skin, care being taken not to cut into the fibres the sphincter, except in those cases where the disease has already involved that muscle. After the incision has been made, a small piece of oiled lint may be introduced into the wound. It is better not to allow any action of the bowels to take place for two or three days after the operation ; this may be effected by giving a small dose of opium or n milk diet. The treatment required for the ulcer situated above the sphincter is division ot the muscle. Local remedies never appear to afford the slightest benefit, but only tend to wear out the patience and spirits of the sufferer. The operation is to be performed in the same way as for fissure : but, in- stead of merely making an incision into the submucous tissue, the sphincter must be divided by one cut, the wound is then to be dressed in either with oiled lint or silk. It is of course always prudent to try local means before proceeding to an operation ; and the best application is the 17 268 Essential Nature of Asthma. [March, ointment of grey oxide of mercury, already mentioned. most satisfactory method of applying the remedy is by >fa suppository tube. The tube should first be lu- bricated outside, and then filled with the ointment ; it is then to be passed into the bowel to the extent of an inch or an inch and a half, and the piston then pushed down; by this means the entire surface of the mucous membrane lining the sphincter is covered by the ointment. Some surgeons recommend the application of nitrate of silver for these forms of ulceration ; but it seldom proves very beneficial, and the pain it causes is quite as severe as that of the division. If it be attempted, a speculum should be introduced into the bowel ; by this means, the ulcer is brought into view, its surface should be dried by a piece of sponge or list, and the caustic freely applied. British Med. Journal, May 12, 1830, p. 358. On the Essential Nature of Asthma. Bv Dr. II. Hyde Salter, F. R. S. There are two ways (which I have not mentioned in my work) as indicated to be by my friend, Dr. Brown Sequard, in which bronchial spasm, when once established, may be kept up by the very conditions which it generates; one is, the power which carbonic acid gas possesses of producing contraction in smooth muscles. In asthma, the deficient standard at which respiration is carried on, and the dimin- ished interchange of the gases, produces an accumulation, in the air locked up in the air passages, of carbonic acid to an unusual degree. This, by the action to which I have just referred, sets the bronchial muscles still further con- tracting, and thus increases the very condition which at first caused the accumulation of the effete gas. In this way, asthma keeps up asthma. The other way is by the bronchial 3m stimulating the afferent or perceptive nervous fila- ments, and thus giving rise to retlex muscular contraction ; just as the stimulation of the sensitive roots of the spiral nerves produces reflex muscular phenomena in the parts to which the corresponding motor nerves are distributed. In way, muscular spasm becomes a stimulus to muscular But in both these, as in the other ways 1 have indicated iu my book, the bronchial spasm is secondary to an antece- dent nervous condition. British Medical Journal July 28, 18M, p. 589. 1861.] Gonorrheal Rheumatism. 259 Reasons for regarding Ghnorrhceal Rheumatism and Ophthalmia as simply Urethral Rheumatism or Ophthalmia, fie. By Dr. Elliotison. u My first knowledge of the disease in question," says Elliotson, "was obtained from Sir Astley Cooper's lectures, which I attended at St. Thomas's Hospital in 1806-7, and 1807-8. How many years previous he had mentioned or seen it, I cannot say. He pretended to no merit of discov- ery, but related, in the most artless manner, the communi- cation of the facts to him by a patient. 'An American gentleman,' he said, 'came to me with the clap, and I told him he might think himself well off to be so little affected.' 4Oh,' said he, 'a clap with me is a serious thing. When I had it before, I was attacked a few days after the infection with an obstinate inflammation of the eyes that was follow- ed by rheumatism.'" "I thought," continued Sir Astley, ''that he might have caught cold while taking mercury; but he said he had taken none. I therefore watched the disease, and in a few days his eyes became inflamed, and after that one of his knees swelled, and then the other became affect- ed with chronic inflammation. He was attended by Dr. Relp, of Guy's Hospital, and myself, for many months. He left this country uncured; but I heard that he got well on his voyage. Since this case I have seen a great many more such." "It was very natural to suppose, before our experience became enlarged, that the disease was the result of gon- orrhceal contagion, and that the appelation gonorrhoeal rheumatism, given naturally to it from its alliance with gonorrhoea, must have increased the tendency to this view. We cannot, therefore, at Sir Astley Cooper believing that the ophthalmia was produced, not indeed by the application of gonorrhoeal secretion accidentally to the eye, as may happen with any careless patient, but still by the absorp- tion of it into the system, and that the proper treatment of the rheumatism, produced to his view of course by the same poison, was the same as of gonorrhoea half a drachm, ac- cording to him, gradually increasd to a drachm, of copaiba, with spirits of turpentine three times a day. We have no ific remedy for gonorrhoea, any more than for measles, latina, or small-pox ; and those drugs must in many -Tavate gonorrhoea; and they would aggravate many cases of the rheumatism. Copaiba, cubebs, and some analo- 260 Gonorrhoea! Rheumatism . [March, goua drugs, arc useful occasionally in gonorrhoea, but not more so than in similar uncontagious affections of the geni- tal passages, and possibly of some other mucous membranes. If there is no reason to ascribe specific powers over gonorr- hoea to them, neither is there any to conceive that they can be remedies of the rheumatism bearing the distinction of gonorrheal. Xor are the}'. "The belief now generally prevalent, of the rheumatism in question rheumatism with urethral discharge and in- deed of the ophthalmia, being really the product of gonor- rhoea! poison, is, I am satisfied, as unfounded as previous generally prevalent disbelief that rheumatism and ophthal- mia arc ever connected with gonorrhoea. It was long be- fore this struck me; for I had always read of these forms of disease, and heard them spoken of, with the epithet gonor- rheal ; and had not seen them except in gonorrlicoal patients. After a time I received the assurance of one or two patients that the affection of their genitals could not have arisen from infection ; but it made no impression upon me, be- cause I am familiar with the untruths which arc often told upon these subjects, and because patients do really some- times fondly deceive themselves as to the character of those with whom they intrigue. But, as years passed on, more instances of the alleged impossibility of infection presented themselves to me and some such patients, I felt certain, could have no reason to deceive me, were too much endowed with self-respect to stoop to an untruth, and were too acute to be themselves in error. Some have told me this, long afterwards, when they had ceased to incur the possibility of catching any disease of the genital organs. I knew no one inclined to this view till five years ago, when, accidentia meeting with a surgeon, a married man and a father, who had consulted Sir Astley Cooper and myself twenty years at least previously for what we had all termed gonorrhecal rheumatism, and since which time I had not heard of him, I was told by him that, before he married, he had again suffered a few attacks of rheumatism and urethral discharge, "ii which occasion the idea of infection was altogether out of the question, as he had not been exposed to the possi- bility of risk. At this period he had no inducement to de- ceive me as to his former lite; and formerly he had always been candid when suffering for irregularities. He added, that since his marriage he had occasionally suffered in the Bame twofold manner as when he was irregular and single. 1861.] Gonorrhml Rheumatism. 261 I was much pleased, and I communicated to him that my convictions of these affections being improperly termed gonorrheal was as strong as his own. Farther experience, up to the present moment, has set the question completely at rest in my mind. Indeed, al- though the circumstance is not noticed by the profession, some writers clearly entertain this opinion, and state facts which establish it, and yet lay no stress upon its difference from the commonly received views. I have just found that Sir Benjamin Brodie, in his Pathological and Surgical Ob- servations on Disease of the Joints, published in London in lsls. gives live cases of the disease witnessed by himself; and remarks that in one the patient could not ascribe the discharge to infection, and in another patient suffered from strictures in the urethra, and, although rheumatism took place twice with gonorrhoea, it took place twice also when there was no gonorrhoea, but the urethra was in a state of irritation and discharge through the mere introduction of bougies employed on account of the strictures. He there- - it may occur without infection. Brandes also con- siders that the rheumatism may be re-excited after all gon- orrhoea lias ceased, if the urethra is irritated by any common cause; and speaks of this rheumatism as blenorrhaqique (gonorrho&al) and trawrnatiqiie (such as from the introduction ot a foreign body into the urethra.; Marechal gives a case o{ rheumatism, that had followed an urethral discharge pro- duced by nothing but the immoderate use of new beer, and had never occurred in the man before. "My own experience, extending through so many years, renders it impossible for me to doubt that specific and con- tagious nature i< unnecessary to the urethral irritation which in certain persons gives rise to rheumatism and to ophthalmia also in others that the mere irritation is suf- ficient, and in fact La the cause, and that the gonorrhoea], conts character is incidental only. The combination f other writers with my own will, I hope, settle stion. The single case of syphilitic infection of a lady by secondary symptoms in the hand of her maid record- ed by me in the Medical Times of September 4th, 1 removed all possibility of farther doubt respecting the occurrence of infection from secondary sores. The d< mination of the production of rheumatism by simple urethr- al irritation is effected by the repeated experience of many of us continued through a large number of years. The im- 262 Gonorrheal Rheumatism. [March, pedimenl to the perfect knowledge of what is known as gonorrhoea! rheumatism was its extremely rare occurrence among the instances of rheumatism at large on account of comparatively small number of persons affected with irritation of the urethra, and the still smaller number of ons among these that have the unfortunate peculiarity of liability to rheumatism from it. The impediment to the knowledge of simple irritation of the urethra being the cause was still greater on account both of the great rarity of simple oared with gonorrhoeal irritation of the urethra, and of few individuals indeed being the subjects of both simple urethral irritation and liability to rheumatism from irritation of the urethra. Those who, from habit, regard this kind of rheumatism and ophthalmia when allied with gonorrhoea as, therefore, gonorrheal, must remember that very case of gonorhcea there are two circumstances united the irritation of the urethra and the specific nature and that the latter cannot exist without the former may * without the latter. Consequently, no case of gonor- rhoea! rheumatism or ophthalmia depends upon the specific the gonorrhoea! nature of the urethral affection, and not upon the irritation irrespective of specific nature. V little experience of this rheumatism impressed me, as it has done many others, with certain characteristics, audi detailed them in clinical lectures above twenty years ago. 1. I saw and see it so frequently in the feet that when- ever a rheumatic man has walked into my library lame from rheumatism of his feet, I have startled him with the question how long he had been suffering under gonorahoea. It not unfrequently affects the hands, perhaps, as I once saw, a single joint only; the wrists and elbows; but the lower extremities most frequently, the knees as well as the feet : the lips also. It may effect any joints, and several at one time or in succession ; the loins also and back of the neck. I saw it once in the joint of the jaw. 2. Its obstinacy and extreme duration are remarkable. The longest ease 1 ever saw was the jaw, and after two or three attacks imperfect rigidity, I believe, became promi- nent. 3. I am not aware of ever bavins: seen it in a femal e. Bui gonorrhoea is comparatively rare in women, as one loose t!<- contaminates Bcores of men, and, however great the number of Loose women, the number oi'men who have been 1861.] Gonorrhce.al Rheumatism. 263 occasionally loose is almost equal to the number of all men. 4. But the most important and perhaps an invariable point in its character, is its inflammatory nature at first, and for a very considerable time. This struck me before I had seen many instances of the disease, and I did not find that it had been noticed. But Sir Benjamin Brodie, whose book upon diseases of the joints I had never seen, had possibly made the same remark ; for previously, in fact above twelve years before I was aware of witnessing the disease, he had written that colchicum was the best remedy for it ; and the great utility of this medicine against rheumatism I believe to be in the inflammatory form. Not only is the disease, but its inflammory nature, disposed to coutinue very long. Yet at length, and after a long period, the time may arrive when the iodide of potassium, tonics, and general and topi- cal stimulants are the suitable means ; and forcible exten- sion of the joint may be proper. Till that time arrives, the treatment should consist of patient abstinence from ferment- ed and distilled liquids and flesh food, the removal of exter- nal stimulants, rest, and a position which favors the presence of as little blood as possible in the affected part or parts, the discreet use of colchicum and other purgatives, and the re- peated application of leeches. The same kind of treatment is suitable to the ophthalmia, which, however, is seldom so obstinate. I believe that the rheumatism occurs in general earlier than the ophthalmia; it often occurs alone, and and there may be differences in these two particulars in the same individual in different attacks. 5. These two affections bear no relation to the intensity of the urethal. The smallest discharge will produce the rheumatism, and perhaps the ophthalmia likewise, in the predisposed ; nor is the intensity of duration of these in proportion to the degree of the urethal ; and they, or one of them may continue after the urethal. [ have known several persons suffer from gonorrhoea more than once without either of these consequences, and then become subject to them ; but only one individual es- cape an attack of rheumatism after every occurrence of gonorrhoea when once rheumatism had followed the appear- ance of urethal discharge. I have seen the predisposition to this urethal rheumatism in several men of the same fami- ly, whether the irritated state of the uretha was gonorrhoeal or not. 2G4 GonorrhcBol Rheumatism. [March, "The predisposition is a great misfortune, because, as , as the urethal affection begin, the patient feels certain of an attack of chronic rheumatism; and though it may take place in a few days, it may not for a considerable time, but is sure to come ; and the mildness of the urethal affec- tion dors not foretell a mild attack. UI will tinish by relating two cases one illustrating the benfit <>f employing the living hand in treating urethal rheumatism, the other the power of rigid abstinence in diet to prevent it. "Mr. C , set. 29, a married man with a young family, living at 25, C G , got wet while affected with gonorrhoea, and was seized suddenly out of doors with rheu- matism. He became crippled, and could walk only with ;-.v- sticks, for the parts attacked were his hips, knees, and soles of the feet. His eyes become inflamed. He took a large quantity of medicine, and the medical attendant honestly told him that drugs would do him no good. When he had thus suffered for four months from rheumatism, the having recovered, it was resolved to try the effect of merely drawing a hand very lightly, slowly, and straight, along the affected parts for half an hour daily. This treat- ment was commenced on September 24th. In a fortnight his pain was lessened ; in another fortnight so great was the improvement that he could walk a considerable dis- tance ; in another he declared himself nearly cured, and be- fore the end of another he was well and able to work. Without this treatment he, no doubt, would have been crip- pled till at least the end of the year. Although the disease was excited by cold and wet, yet, as the man was laboring under gonorrhcea at the time, he will henceforth probably be attacked with rheumatism whenever he catches gonorrhcea. The case is interesting ffording an example of urethal rheumatism originating from ordinary exciting causes during the urethal affection, for in general these have not been noticed in the first attack ami certainly are not requisite for the production of subse- quenl ones. "The other case is mosl important. A married gentle- q had labored under very obstinate rheumatism of the m his last two contractions of gonorrhoea. T had no btthat this would occur now as often as he caught a rhoea, and i begged him to let me sec him as soon he found he had contracted it again, lie did so a 1861.] Short-Sight. 265 year ago, and I immediately prevailed upon him to abstain entirely from all fermented and distilled fluids and every description of flesh food. Ho strictly obeyed my injunctions for several months, and has perfectly escaped rheumatism, although the urethal discharge continued slightly all the time in spite of injections weak and strong and of all kinds, for, although he lived low, it was not in his power to refrain from walking." Or the Surgical treatment of Short-Sight. By Mr. J. V. Solo- mon, Surgeon to the Birmingham Eye Infirmary. Mr. Solomon appears to have hit upon an operation by which the focal range of short-sighted persons whose corner are not conical, may be doubled in length. He has found the plan especially successful, whether the eyes are promi- nent or small, the aqueous chambers deep or shallow. He has tested the operation on cases varying from the age of twelve to fortv-five vears. A man of the latter aire, who had worn double concave glasses of immense depth (Xo. 16) for a great number of years, and, unaided by lenses, could vith clearness the features of a person to know them at a distance of nine feet only, obtained at once by the opera- tion an increase of seven feet in his focal ranire. In a child o of twelve years of age, the operation increased the reading distance from four to eight inches, and the power of identi- fying persons' features from twenty to forty yards : and in one sixteen vears of age, the effect was still more remark- able. These results have been obtained by dividing in a trans- verse direction some fibres of the muscles of the lens the ciliary muscle. Mr. Solomon does not consider it material which part of the muscle is selected for division, but gener- ally prefers either the upper or the lower part of the circle. Supposing the latter situation to be selected, and the patient to be seated in a chair, the operator stands behind, and fixes the globe with the left fin.: in extraction, hold- ing a cataract knife in his right hand, with the fiat of the ie directed upwards, he pushes the point in succession through the corneo-selerotic union, the pillars of the iris, I the ciliary muscle. The direction given to -tru- ment is obliquely downward and ontwai is taken that the incision in the muscle is of the same Length as the L2GQ Strangulated Hernia. [March, puncture of entrance, namely, about two lines or two lines and a half in diameter. In some cases Mr. Solomon has found that the power of adapting the eye to distant objects has been increased by practice and lapse of time. In a young man who had been myopic from his child- hood, and had suffered for the last three years from conges- tion of the retina, the visual power and focus have been so much increased that the outlines of large buildings at a dis- tance of a mile and a half can now (six weeks after the operation) be distinctly made out ; whereas before the cili- ary muscles were divided they appeared as mist. A new method for the reduction of Strangulated Hernia. By Mr. Walter Jcssop, Surgeon to the General Hospital and Dispensary, Cheltenham. In May last, Mr. Jessop was called to a case of strangu- lated hernia (left oblique inguinal), in a man aged fifty-two years. The accident had occurred some thirty-six hours previously. The taxis, opium, chloroform, hot baths in short, all the ordinary modes of treatment, had been perse- veringly applied, without success. At the time of his visit, he found his patient in a partial state of collapse, in a profuse cold perspiration, with great tension of the abdomen, and symptoms of hiccough and nausea coming on. The patient complained bitterly on his lightly attempting an examination ; indeed, the part seem- ed so exquisitely painful as at once to negative all hope of success irom further direct efforts at reduction. An imme- diate operation was proposed, but firmly declined by the patient and his friends. Desiring them to seek further ad- vice, Mr. Jessop left the room, but was immediately recalled with a request that he would permit an hour's delay. Agreeable to this, and while waiting in the house, a thought struck him that it might occasionally be possible to relieve a patient under such circumstances without having recourse to the knife. On explaining this to the patient and his friends, they at once consented to a trial of the means pro- posed. Calling a male attendant into the room, he directed his patient, still lying on his hack, to the edge of the bed, and with assistance, separated his legs, placing one over each shoulder of the attendant, who, facing the bed, stooped to receive them; and, in this position, by passing his hands 1861.] Strangulated Hernia. 267 round the fore part of the thighs, was enabled to obtain suf- ficient purchase to permit of his raising him on to his head and shoulders on the bed, thus throwingthe intestines baek upon the diaphragm, and to some extent necessarily making traction behind and directly from the scat of strangulation. After two or three minutes' manipulation of the abdomin- al parietes, he found the tumor become less tense, and drawing forward the integuments round the point of rup- ture, he made lateral upward, and downward movements jerking as it were, occasionally, the parts immediately con- tiguous to the structure. This seemed to excite but little suffering ; in fact, the patient, so for from uttering complaint declared himself, after the first two or three minutes, decid- edly relieved that "the dead sickening weight that killed his groin," as he termed it, was better. Continuing these efforts, and varying them as they seemed to occasion dis- tress, he presently felt a slight gurgling under his head, and almost immediately had the satisfaction of finding the hernia reduced, and his patient in a comparatively safe state. The whole proceeding did not occupy ten minutes. Slight peritoneal tenderness existed for some days, but the man eventually did well. The rationale of the proposed plan is simple. A mass, large or small, of displaced intestine or omentum must as- suredly be more readily withdrawn from its point of incar- ceration or strangulation by traction from behind, than by the best directed efforts of the taxis. Any one, for illustra- tion, taking the trouble to put a fold or two of his handker- chief in a ring formed by his finger and thumb, and lightly strangulating it, will, on attempting to return it by pushing or kneading from before backwards, find indefinitely great- er difficulty in effecting his purpose than it he were to make traction from behind. In short, the employment of the taxis is at the best a clumsy and most uncertain mode of pro- ceeding, and in future the author intends to make it mere- ly supplementary to the plan he now advocates. "One swallow fails to make a summer," and it may be said that the practice of turning patients a posteriori up- wards is opposed to all orthordox notions of propriety. Ad- mit all this. Others, with greater opportunities, may hap- pily be enabled to add to this single case; and granting that the position of the patient may be dot positive inelegance, it may, at any rate, contrast favorably with our proceedings in lethotomv, and in many other operations on the perineal region. 268 Phimc [March, New operation for Phimosis. By M. Ridreau. The well-known operation lor phimosis, practised by M. Ricord, leaves scarcely anything to he desired under ordi- circumstances, at least in the opinion of the majority. Some, however, object to the permanent exposure of the glans which asive a removal of the foreskin entails. To meet the views of surgeons holding this opinion, we quote the description of an operation, designed and success- fully practised by M. Ridreau, a French military Surgeon. 'Stretch the prepuce by drawing the mucous membrane forward, and the skin back, so as to lay bare the orifice of the foreskin: introduce a slender cylindrico-conic wooden rod into the aperture of the prepuce ; perform a circular incision at about half aline from the mucous margin, di- viding the skin only, which immediately shrinks backward on the glands: maintain the mucous lining upon the wood- en rod, and remove circularly a sufficient quantity of it to give i'veo play to the glans in the aperture resulting from the operation. Join the edges of the wound of the skin and of the mucous membrane by a few small needles and twist- ed suture. If a vessel bleeds, apply one of the sutures on that spot." The wounds heals in a few day.- with water dressing, and then the condition of the organ is perfectly normal, the glans being covered or exposed at will. Examination of the anatomy of the parts explains the success of this operation. The constrictionis seated in the mucous membrane, and this is removed. Moreover, the skin of the penis unites with the mucous membrane, not by a diminution of its substai but by accommodating itself by numerous wrinkles (in the usual manner of skin surrounding the sphincters) to the destined aperture; accordingly, the moment it is divided iilarly, it may, without difficulty, be drawn back upon the penis. This operation p - peculiar io 'i; a very limited portion of the texture is removed, a ring for the glans is retained ; no deformity results: the . icatrix is Li: imperceptible as to be mistaken for the natural junction of the skin and mucous membrane, and is entirely concealed when the prepuce is drawn forward upon the glans; the portion of mucous membrane removed be- ing rephn-ed by integuments. 1861.] Editorial EDITORIAL AND MISCELLANEOUS. BOOKS FOR REVIEW. We have received recently, from authors and publishers, quite a num- ber valuable works ; some of which are the following : Researches upon the VcDom of the Rattlesnake with an Investigation of the Anatomy and Physiology of the Organs concerned, by S. Wier Mitchell, M. D., Lecturer on Physiology in the Philadelphia Medical Association. Tins thorough and elaborate Essay is a publication of the Smithsonian Insti- mtion, aud is presented in 145 pages 4to. When we can devote time to its examination we feel assured that its condensation and review will be of much interest to our readers. From Messrs. J. B. Lippincott & Co., of Philadelphia, the two follow- ing works, viz : Lectures on the Diagnosis and Treatment of the Prin- ciple Forms of Paralysis of the Lower Extremities, by Dr. Brown- Sequard, pp. 118, octavo. 18G1. Also, by the same author, A Course of Lectures on the Physiology and Pathology of the General Nervous System, delivered at the Royal College of Surgeons of England, in May, 185S, published in this country in i860, pp. 265, with beautiful illustrations. From Messrs. Blanchard & Lea: Diseases Peculiar to Women, in- cluding Displacements of the Uterus, by Hugh L. Hodge, M. D., Pro- fessor of Obstetrics and Diseases of Women and Children in the University of Pennsylvania, pp. 469, octavo, with numerous illustrations. Phila. delphia. 18G0. From same: Diphtheria, Its Nature and Treatment, with an account of the history of its prevalence in various countries, by Daniel Denson Slade, M. D., being the dissertation to which the Fisk Fund Prise wa.s awarded July 11th, 1*60, pp. 85, octavo, with illustrations. All of the above works have been trasnmitted to us through Me Thomas Richards & Son, of this place, at whose store they will be found by purchasers in this section. Volume loth of the Transactions of the American Medical Associotion has also come to hand, which, together with the other valuable works above noticed, shall receive careful attention at our hands at a future time. 270 Miscellaneous. [March, Tartro-Ci/ric Lemonade Prof. J. Lawrence Smith expresses (American Journal of Pharmacy, September, 18G0) his surprise that the tartrate of Soda should have given place as a purgative to the citrate of magnesia, a preparation which he very justly considers as obnoxious to very many objections. Among these he enumerates "the not unfrequent irregularity of its operation, sometimes not acting as promptly as de- sired, at other times with too great and continued energy, requiring ano- dynes to arrest its operation. Again, owing to the manner in which it is made, and the want of uniformity in the composition of the commercial carbonato and calcined magnesia, the amount of free acid in the solution varies much when made at different times by different lots of materials. There being sometimes two or three drachms of free acid present in a bottle, and besides, under all circumstances, the mixture must be quite acid in order to retain for any length of time the citrate of magnesia in so- lution. Mitscherlich and Bcnce Jones has have both made experiments on citrio acid, and they consider it a poison analogous to oxalic acid. "Yet another objection to citrate of magnesia is the certainty of its undergoing decomposition, resulting in the deposition of an insoluble citrate of magnesia, a change that takes place very rapidly when the bot- tle is opened. "With these facts before me, I compounded a preparation of tartrate of soda with lemon syrup and water (at first I introduced a small portion of citric acid, calling the mixture tartro-citric acid lemonade.) "It is free from the objections of the citrate of magnesia, is a prompt and certain purgative, without excessive action, and uniform in compo- sition, does not undergo decomposition even after the bottle is opened, even more agreeable to the taste and less costly than citrate of mag- nesia." " Sal soda 21 lbs. 14 cz. avoirdupois. Tartaric acid 15 " " Sugar (white) 24 ' Water to make 25 gals. "It is then put into strong twelve ounce bottles, and thirty-five grains of bi-carbonate of soda added to each bottle, and immediately corked and fastened with twine or wire. "This preparation has been used in Louisville for about six years, and is gradually extending over various parts of the west and south." Banquet to M. Ricord. The banquet given to M. Ricord by his confreres came off on Thursday evening. December, 20th, at the Hotel du Louvre. The great dining room of this establishment, itself one of the lions of Paris, afforded hospitality to about two hundred members of the medical profession, who assembled for the double purpose of doing homage to the great syphilograph and justice to a very copious and recherche dinner. Great Britain, Germany, Sweeden, Ilussia, Greece, Italy, the United States and South American Republics were all duly represented on the occasion. London T^anrct. 1861.] Miscellaneous. 271 Strychnine in Typhoid Fever. In a clinical lecture, delivered at the Mercy Hospital, and reported for and published in the Chicago Medical Examiner, Prof. N. S. Davis remarks upon the treatment of a bad case of typhoid fever. Quinin, alcohol, turpentine, &c, had been used and yet the patient contiued to sink. At this juncture, in connec- tion with the turpentine, a tea-spoonful of the following admixture was givcu, and directed to be repeated every four hours : R- S try chin, i. gr. Nitric Acid, 5 j- Tine. Op ii, 5 *! Water, ij. From this date the patieut improved rapidly. In reference to the use of strychnin in continued fever, the doctor remarked, that in many cases between the fifth and fifteenth days, the impulse of the heart be- comes weak, the voluntary muscles unsteady, the capilary circulation feeble, with an evident tendency to passive congestions in some of the internal viscera ; and in such, he had seldom failed to find a remedy strikingly beneficial. In a review of Dr. Reeves' work on Enteric Fever, and published in the Monthly for September, 13-39, we made use of the following lan- guage : "There is one agent that Dr. Reeves has not alluded to, which, be- cause of its peculiar adaptation to certain conditions frequently present in enteric fever, should not be passed over in silence. When there is subsultustendinum, low muttering delirium, and the evacuations are in- voluntarily discharged, all showing a complete prostration of the nervous system, there is probably no combination of medicines equal to strychnin which may be beneficially combined with small doses of opium." S3 far as we know, we were the first to use and advise strychnin in typhoid fever, and we are glad to see that so able an authority and ju- dicious an observer as Prof. Davis should coincide with us in opinon. Med. Monthly. Deaths of Distinguished Physicians. We find noticed in the re- ibreign journals the deaths of Dr. Edward Rigby, President of the Obstetrical Society of London, at the age of Dtj ; Sir Henry Marsh, M D , of Dublin ; Dr. Andrews, of Birmingham, Professor of Physiology in Queen's College ; and Dr. Franci3 Broussais, last surviving son of the celebrated Broussais, and himself an author of many valuable articles in the medical journals. We reget to record the decease of the distinguished Dr. John W Francis, of New York, which took place last week. Dr. Franci.g has been for a long time at the head of the profession in his adopted city, and his death will be widely lamented. 262 Ifisccllaneous. Sulphate of Quinia and Fcrrocyanurct of Iron in Rheumatic Dysmenorrhea. Dr. J. B, Snelson states (St. Joseph Medical and Surgical Journal, November, I860) that he has employed the sulphate of quinia with the fcrrocyanurct of iron, for several years in rheumatic dysmenorrhea, with very satisfactory results. lie commences the treat- ment by emptying the alimentary canal by purgatives : during the men- strual period he uses the warm bath, and gives opium combined with camphor and ipecac to relieve the pain. After the period has passed, he commences with a pill composed of two grains of sulphate of quinia and an equal portion of fcrrocyanurct of iron, to be taken morning, noon and night. These arc to be contiuuod during the intermenstrual period. Frequency of Accidents or Irregularities during first Labour. Dr. Richard McSherry states (Maryland and Virginia Medical Journal, October 1860) that, in looking over his notes, he could not but observe, with some surprise, to how great an extent primiparce are more liable to accidents than multipara). In his own practice he has- had notable irregularities or disturbances to contend with in more than 33 per cent, ofhisprimiparac, while in multipara) this has happened in only 10 per cent. The Stereoscope. It is said that Sir David Brewster, in inquiring into the history of the stereoscope, finds its fundamental principle was well known even to Euclid ; that it was distinctly described by Galen 1500 years ago ; and that Gambatista Porta had in 1599 given such a complete drawing of the two separate pictures as seen by each eye, and of the combined picture placed between them, that we recognize in it not only the principle, but the construction of the steoreoscope. Chemist and Digest. Ague. M. Eissen states that quinic ether, when inhaled during prr* oxysm of ague, arrests the attack, and prevents the recurrence of future attacks. This, however, is open to doubt, as the ether only oontains kinic acid, which is known not to possess the tonic and antiperiodic properties of quinine. Homaipathic College. The Hahnemann Medical College, of Chicago, has closed for want of support. The concern matriculated three students on credit. Hahnemann taught, the smaller the dose the better the re- sult, a statement singularly verified in this instance. Spina Bifida treated by I?ije/tions of Iodine. Dr. Emil Fisher reports (North American Medico-Chirurgical Review, Nov., 1860) two cases of spina bifida treated by injections of iodine, by Prof. Gross, at the surgical clinic of the Jefferson College. Both terminated fatally. SOUTHERN MEDICAL AND SURGICAL JOURNAL (new series.) < * Vol. XVII. AUGUSTA, GEORGIA, APEIL, 1861. NO. 4 ORIGINAL AND ECLECTIC. ARTICLE II. (CONCLUDED FROM JANUARY NUMBER.) Lectures on Tumors and Outgrowths of the Cervix Uteri By Joseph A. Eve, M. D., Professor of Obstetrics and Dis- eases of Women and Children in the Medical College of Georgia. Lecture Second .Treatment of Fibrous Polypi. The only appropriate treatment for fibrous polypi is by excision or ligation, although, when they have very small pedicles, they may be twisted off or torn away and are sometime detached, by traction intended to bring them in proper position for excision, by the bistoury, scissors, polyptome, or ecraseur. Some authors and practitioners prefer the ligature from a belief that it is safer. The correctness of this opinion is, we believe, by no means established. The only danger to be apprehended from excision is hemorrhage, which, it is admitted, very rarely occurs, and then is easily arrested by astringent injections, such as a strong solution of sulphate of zinc, or of copper, or the persulphate of iron, or most certainly by the tampon or colpeurytner. In two hundred cases of polypi, removed by excision, Dupuytren had hemorrhage only in two, and in these, it was promptly arrested by proper means. Lisfranc had 18 274 JEve. Lectures on [Apri hemorrhage to occur only twice in one hundred and sixt; five cases, in which excision was performed. In both < these it was stopped by the tampon. I have never know hemorrhage after excision. The only instance in which have witnessed hemorrhage, was one in which a very lar<; polypus was detached by traction, without excision or lig; ture. It ceased immediately on application of a tampon. You thus perceive, the danger of hemorrhage is imagi] ary. The advocates of the ligature assert that the polypi is more effectually destroyed by ligation. This we consic er a mere assertion unsupported by facts. It is as effectua ly destroyed by one method as the other, for the remnant ( the pedicle always shrinks away or sloughs off. By exci ion, the polypus is removed at once, and the tedious unce] tain process of sloughing avoided. There is no danger c local inflammation, constitutional irritation, or pyemia froi the absorption of pus or putrilage into the blood. I hav no hesitation myself in giving a decided preference to e^ cision over ligation, and this decision is supported by a larg majority of tho most eminent authors who have written o these subjects. When the stem is very large, or when a artery can be felt pulsating in it, prudence might dictat the application of a ligature previous to excision, whic should be performed below it, the ligature being allowed t remain a day or two as a security against hemorrhage. J3u this precaution would, I think, rarely if ever be necessary In such cases the ecraseur might be the most eligible in strnment. Dr. Churchill says "there are other cases in which excis ion would be impossible or hazzardous, as for for instance when the polypus has only just descended through the o uteri. If doubtful, the ligature should be used." In thes< very cases I consider excision most decideclly preferable, a being more easily accomplished and much safer. But tin difficulty of applying the ligature is not so great as the dan ger to 1)0 apprehended from allowing a metalic instrumen t<> remain in contact with the internal surface of the uterus 1861.] Tumors, fa liable to irritate or pierce through its walls, and form a pu- trid mass contained within it for several days. No antiseptic vaginal or uterine injections could be re- lied on to prevent absorption from the sloughing tumor. It sometimes becomes necessary to tighten the ligature repeatedly, or to apply a second ligature. The time neces- sary for separation by ligature is indefinite. Days are al- ways required and sometimes weeks ; during all of which time the patient is confined to bed, kept in a state of anxiety, and liable to fever or phlebitis from the absorption of putrid matter. If the polypus could not be drawn down low enough for the pedicle to be divided, by a suitable pair of curved scis- sors or the polyptome, I would infinitely prefer a method proposed by Prof. Sympson, which is to crush the polypus, and thus destroy it, by a properly constructed pair of for- ceps, or to divide and bring it away piecemeal. When a polypus is discovered, during pregnancy, or dur- ing or soon after parturition, some authors advise to defer its removal, unless delivery be obstructed by it, as the uterus is more disposed to hemorrhage under such circumstances, in consequence of its vascular system being so much more developed. But as a polypus is itself a great determining cause of hemorrhage, it would, I think, be the much safer practice to remove it, if practicable. J )r. West says : "the general rule, and one, concerning the wisdom of which there can be no doubt, is not to meddle with a uterine polypus, either in labor or after delivery." It is always with regret and deference I differ from author- ity I respect so highly. I would not willingly mislead you: J give you my opinion with diffidence ; I may be wrong ; I have had very little experience with polypi during pregnancy orparturition. Dr. West's experience has doubt- been much more extensive, and his judgment is reliable. Numerous and various instruments and methods have been devised for applying ligatures to polypi and polypoid tumors time would fail were I to attempt a description of one- half of them. 270 Eve. Lectures on [Ap The double Canula, invented by Dr. Gooch the inst inn it I now exhibit to you is, perhaps, equal, if not super! to any other. Various changes have been suggested ; bu is doubtful whether it lias been improved. There may an advantage in some cases to have the extremities curv The instrument and its use cannot be better described tl in Dr. Gooch's own words : "The instrument which I for this purpose consists of two silver tubes, each eij inches long, perfectly straight, separate from one anoth and open at both ends. A long ligature, consisting strong whip cord, is to be passed up one tube and down other, and the two ends of the ligature hang out at lower ends; the tubes are now to be placed side by s and, guided by the finger, are to be passed up the vagi along the polypus, till their upper ends reach that part the stalk around which the ligature is to be applied; t now the tubes are to be separated, and while one is fix the other is to be passed quite around the polypus, til arrives again at its fellow-tube and touches it. It is ol ons that a loop of the ligature will thus encircle the sta The two tubes are now to be joined, so as to make th form one instrument; for this purpose two rings joined their edges, and just large enough to slip over the tubes, to be passed up till they reach the upper ends of the tu immovably. Two similar rings, connected with the up; by a long rod, are slipped over the lower ends of the tu so as to bind them in alike manner; thus the tubes, wh at the beginning of the operation were separate, are n fixed together as one instrument. By drawing the end* the ligatures out at the lower external ends of the tu and then twisting and tying them on a part of the insl ment which projects from the lower rings, the loop roi the stalk is thereby tightened, and, like a silk thread rot a wart, causes it to die and fall off." Dr. Churchill says: "In many cases I found great vantage from the cautious use of Musaux's forceps. continued gentle traction, it is quite possible to draw 1 1861.] Tumors. 277 polypus within view; often to produce it externally, so as to apply the ligature without any difficulty, after which the forceps should be removed, and the polypus permitted to return into the pelvis. It may doubtless, by gentle tractions, In m 3, he drawn through the vulva ; hut T cannot agree with Dr. Churchill that it should he permitted to return : when once it makes its appearance externally, it never returns with my consent ; it is too late then to think of ligatures; it should he removed at once by the bistoury, 3ors or polyptome. I have sometimes applied a ligature as a means by which to draw down the polypus for the purpose of excision ; but this could rarely be necessary, if supplied with suitahleYor- ceps. unless the polypus were too soft to afford a sufficiently firm hold to the forceps. I was formerly much inclined to the application of a igature before excision as a means of traction, from a belief hat the hemorrhage was from the surface of the polypus; but I now believe that is certainly not the principal source. The removal of a polypus by excision is generally easily effected. The patient may lie on her back or side, with her knees drawn up ; the operator should then insert one or two lingers, high up on the polypus if practicable on the pedicle as directors for the forceps, which should be intro- duced, one blade at a time, as obstetric forceps, and then united at the lock, after their extremities are firmly fixed on the polypus; gentle traction should then be made until the polypus, if practicable, is brought out of the pelvis, when it should be cut off, as near the os tincae as possible. Some, I am aware, advise to divide it far from the os tincrc ; but I cannot perceive that there can be any advantage in this pours -poets excision; it may be proper sometii even necessary in applying a ligature, as the pedicle is in pome ositive near the uterus, in - nee of an extension of the uterine tissue. There is so much pain sometimes that it becomes necessary to remove the ligature; but excision of the sensitive portion could be attended with 278 Eve. Lectures on [April, no bad effect, beyond a slight momentary pain. The patient' B suffering may be partially or entirely relieved, if necessary, by chloroform. When the pedicle cannot be drawn beyond the vulva, it may be divided in the vagina by a pair of curved, blunt-pointed scissors, or by the polyp- tome. The pedicle may sometimes be divided by the polyp- tome without traction, and afterwards removed by the for- ceps or the lingers. The polyptome resembles a small, blunt hook with the inner or concave edge sharp. It is a very convenient and valuable instrument which I have found very satisfactory in practice. One pair of forceps or hooks may sometimes prove not suf- ficient for drawing the polypus down, and two or three pairs may be required. It may even occasionally be neces- sary to have recourse to obstetric forceps to deliver a large polypus from the vagina. I employed obstetric forceps in one case, but I believe serrated polypus forceps and hooks would always answer a better purpose. It is advised to plug the vagina in every case after excision; but in a large majority of cases it is certainly unnecessary ; it is time enough when a disposition to hemorrhage is evinced. Although not so essentially necessary, as after ligature, it is advisable that the patient should remain in bed a few days, and not be neglected by her medical at- tendant, that hemorrhage or any other unpleasent symptom, may be detected in its incipiency and promptly treated. A Large Internal Polyus Mistaken for an Ovarian Tumor. The 15th of August, 1846, Mary, a negress about thirty- five years of age, the property of Mr. Wm. Jones of Colum- bia county, was sent to this city for treatment, on account of a large tumor which had existed, a considerable time, in her right side. On examination I supposed it to be an ovarian tumor. Although she had not borne a child, dur- ing the last seventeen years, notwithstanding she had en- joyed comparatively good health most of that time, to my great surprise I discovered that she was pregnant. As it 1861.] Tumors, $c. 279 was apprehended that she might have a difficult, if not a dan- gerous delivery, she was allowed to remain in this city until after her confinement. After a protracted and difficult labor, she gave birth, on the 19th, Jan., 1847, to a large healthy female child. She had a favorable convalescence and was able in a month or six weeks to return to Columbia county, the hard tumor still in her right side uninfluenced by treat- ment. About August, 1851, four years and a half after this la- bor, my friend, Dr. John T. Smith, of Columbia count}', attended her in another accouchment, in which she was soon delivered of a fine girl ; but in this case the placenta was retained so long, and its delivery attended with so much difficulty, that Dr. Smith sent to Augusta for a con- sultation. Dr. II. F. Campbell delivered the after-birth after a retention of twenty-four hours. It was detached and extruded from the uterus into the vagina, so that Dr. Campbell had not an opportunity to introduce his hand into the uterus, where he would probably have discovered the true nature of the case. At my request, Dr. Smith very kindly furnished the fol- lowing succinct history of this patient subsequent to the placental delivery by Dr. Campbell: "Her recovery was rapid. About six months after delivery, I was called to see Mary ; found her suite ring with prolapsus uteri ; replaced the womb, and after removing inflammation, used a glass globe pessary to keep it up. At her monthly periods, she suffered with menorrhagia and in the intervals with leucor- rhea ; I was called to see her on the night of January 24th, 1853 ; found her laboring under considerable mental ex- citement suffering some pain ; on examination discovered a large tumor protruding through the vulva ; being at night I could not inspect it satisfactorily ; directed cold astringent applications, and an opiate for the night ; called early next morning ; the opiate produced a pretty good night's rest. On examining it carefully I found, instead of an inverted uterus, a large polypus. After you removed the tumor she 280 Eve. Lectures on [April, complained only from a little soreness ; the stalk soon sloughed off, and she has been perfectly well ever since, a period now of several years." On the night of the 25th January, 1853, 1 saw this patient with Dr. Smith and Dr. Thomas. The patient was suffer- ing very much ; her pulse very feeble and frequent. There was a large tumor protruding five or six inches beyond the the vulva. It was perfectly insensible when touched or pricked with a pin; but when moved, it caused severe pain at the connection with the uterus. Having put the patient under the influence of chloroform, we made gentle traction on the tumor, until we brought the os tincae in view, after which we divided the pedicle very near to it. This tumor was pyriform ; about six inches long and about four in width. It was redder and softer than most of the fibrous polypi I have seen, not much firmer than muscular tissue. From the length of time it had been retained in the uterus, I would have supposed it to have been a fibrous tumor that had been slowly enucleated from the parietes of the uterus into its cavity, thence expelled into the vagina, and finally from the vagina through the vulva ; but its pyriform shape and thick pedicle clearly identify it as an original polypus. Had it been primarily a fibrous tumor, embedded in the walls of the uterus, it would most probably have assumed a move globular shape, and certainly would have had no fibrous pedicle connecting it to the uterus, its only connection with the uterus could have been by mucous membrane with the addition perhaps of some cellular tissue. From the larsre size this tumor had attained, at the time of her pregnancy, in 1846, it must have existed some years before, during all which time, during the interval between her two gestations, and during the time Dr. Smith treated her for inflammation of the womb and prolapsus, it must have been internal. It is impossible to determine precisely at what time it was expelled from the uterus into the vagina; but from all I have been able to ascertain of the history of the case, she was certainly not subject to hemorrhages, at least 1861.] Tumors, #c. 281 the greater part of the time that the polypus was unques- tionably internal : whereas she was subject to monorrhagia, when it is fair to conclude the polypus must have been in the vagina. It is a very singular feet that, although living with the same husband, she was sixteen or seventeen years sterile, had two children while the polypsus was in the womb, and has had none since, notwithstanding she has enjoyed good health. Ir is to be regretted that we have not a more particular history of this most remarkable case ; but Dr. Smith's notes were unfortuately lost, and the account furnished was prin- cipally from memory. The next case I will describe was a large enucleated fibrous tumor. The subject of this tumor was a lady of first respectability, about forty-three years of age. She had been in bad health for twenty years. During several years pre- vious to the time I saw her, she had been reduced by hemor- rhage to the last extremity. This patient was brought to me in May. 1853, by my friend, Dr. Pinkerton, of Hancock county. She was at that time very feeble and anemic from frequent hemorrhages. On examination I found an insen- sible tumor, filling the whole pelvis, as large as the foetal head at terms; the pedicle could not be reached; ligation appeared to be impracticable, if deemed expedient. Dr. Pinkerton and myself requested the counsel and assistance of our friends, Drs. L. D. Ford and R. Campbell. In con- sultation it was determined to deliver the tumor by a deli- cate pair of obstetric forceps and divide the pedicle. TTith difficulty we introduced the forceps and produced the tumor partially through the external parts, at which juncture the forceps losing its hold, we seized the tumor with two crotch- ets and brought it through the vulva. To our surprise it came away detached, no vestige of a pedicle remaining; the only sign of attachment to the uterus was indicated by a small portion being denuded of mucous membrane. During the passage of this tumor through the external parts 282 Dugas. Lecture on [April, there was a slight laceration of the perineum which I think was attributable to the slipping of the forceps ; with the in- struments now presented to you (a strong pair of plain poly- pus forceps, and another pair with strong hooks, both separable from each other like obstetric forceps) this accident might possibly have been avoided; but it was most probably inevitable under the circumstances, as the tumor was very large and hard, and the patient had never borne a child. It was, however, not extensive and the patient recovered from it without any unpleasant conse- quence. This was the only case in which I have known removal of a polypus followed by any material hemorrhage ; and this was only alarming on account of the very feeble and anemic state of the patient ; it was promptly arrested by a sponge tampon. This patient convalesced rapidly and was soon restored to Ood health. b [Other oases related in the lecture are here omitted.] ARTICLE IX. A Clinical Lecture upon Rheumatism, delivered at the City Hospital. By L. A. Dugas, M.D., &c. Gentlemen : As we have here several cases of Rheuma- tism to which I desire especially to direct your attention hereafter, I beg leave to read to you the following paper which I published in one of the early numbers of the Medi- cal Journal of this city, and which contains a brief history of some of the views I have long entertained upon the sub- ject. I will then add some of the results of subsequent ex- perience : Rheumatism is a disease of which we find no satisfactory account prior to the sixteenth century, towards the close of which the attention of the Profession was called to it by the justly celebrated Ballonius, under the singular appellation it still retains. Subsequently, the able pen of Sydenham delineated its characteristics in bold relief, and made it a prominent feature in Nosology. 1861.] Rheumatism. 288 The term Rheumatism, according to Villencuve, (Diet. des Sciences Med. torn. 48) is now applied to "a dis< classed amongst the Phlegmasia, located in the muscular and fibrous tissues of animal life, and attended with the following symptoms: pain; more or less intense, either con- tinued or intermitting, fixed or wandering, and with or without heat, tumefaction, redness, and pyrexia. It usually terminates by resolution, sometimes suddenly, followed or not hy metastasis, rarely by suppuration, and still more sel- dom by gangrene. Lastly its course is extremely irregular, and its recurrence very frequent." Scudamore defines rheumatism to be: "Pain of a peculiar kind, usually attended with inflammatory action, affecting the white fibrous textures belonging to joints, such as ten- dons, aponeuroses, and ligaments, the synovial membranes of the bursas and tendons ; and nerves ; occasioned by the influence of variable temperature, or by direct cold, or by moisture." It is called either acute or chronic, according to the intensity and combination of the above symptoms. The causes of this disease are extremely obscure, although they have, by universal consent, been referred principally to atmospheric vicissitudes. Exposure to a cold and humid air is peculiarly favorable to its development. Whether the low temperature and hygroscopic condition of the atmos- phere, alone concur in such cases to give rise to rheumatism, is extremely questionable. I believe it by no means im- probable that the electric state of this medium is highly in- fluential in the production of rheumatic pain, as well as of many other phenomena connected with nervous affections. It is not my design on the present occasion to inflict on the reader even a recapitulation of the numerous predisposing and proximate can- ied to this disease. The pro- rioo is happily becoming satiated with speculations on causes which must ever escape ourprcsent means of investi- D ; and we are now disposed to cultivate a more fruit- ful field that of effects. Let us, therefore, hasten to the nature or pathology of rheumatism. 284 Dug as. Lecture on [April, V,rc have already said that it is now generally regarded as an inflammation of the muscular and fibrous tissues. This is, indeed, the doctrine which has prevailed, more or less, from the earliest notice of this disease. It is true that many have considered this inflammation as of a peculiar kind. Sarcone and other believers in the agency of animal- culsa, &c, in the causation of disease, explained this pecu- liarity by referring it to the action of those diminutive be- ings on the white humors of joints, &c. Quarin viewed it as a constriction of the vessels, from cold. Boerhaave call- ed it an inflammation not sufficient to cause suppuration. Cullen admits the inflammation, but adds that the muscu- lar fibres are in a state of rigidity, which impedes and ren- ders painful any movement. "It is," according to this dis- tinguished pathologist, "an affection of these fibres which gives an opportunity to the propagation of pains from one joint to another, along the course of the muscles ; and which pains are more severely felt in the extremities of the muscles terminating in joints, because, beyond these, the oscillations are not propagated." (Cullen's 1st lines.) Bichat and Scudamore insist that it is a peculiar inflam- mation, but do not attempt to define its nature. Villeneuve states that "several authors, without determining whether the proximate cause of rheumatism be spasm, irritation, or debility, affirmed in general terms, some that rheumatism was a peculiar affection of the nerves, others that it was a lesion of sensibility, and a third class that it was a special modification of the vital powers." (loc. cit. p. 462.) Villen- euve admits that the nerves of animal life may be the seat and even the primary seat of rheumatism, but does not think those of organic life ever invaded by it. Scudamore, in his definition of rheumatism, enumerates very specially the nerves among the tissues affected by this peculiar inflamma- tion. Sciatica is accordingly considered by him a rheu- matic affection of the nervous trunk itself; whether of the nervous matter or of the neurilemma, he does not de- termine. 1861.] Rheumatism. 285 It is- evident that all the writers above cited looked upon rheumatism as located alone at the seat of pain. Of late vears, however, attention has been called to a peculiar con- dition of the spinal marrow as intimately connected with lesions of sensibility, as well as with many of those affec- tions classed among the Xeuroses. It appears that as far back as 1821, Mr. Player, in a letter to the editor of the Quarterly Journal of Science, stated that "the occurrence of pain in distant parts (from the spine) forcibly attracted my attention, and induced frequent ex- amination of the spinal column ; and after some years' at. tention, I considered myself enabled to state, that in a great number of diseases, morbid symptoms may be discovered about the origins of the nerves which proceed to the affect- ed parts, or to those spinal branches which unite them ; and that if the spine be examined, more or less pain will com- monly be felt by the patient on the application of pressure about or between those vertebrae from which such nerves emerge." In May, 1828, Dr. Thomas Brown published in the Glas- gow Medical Journal a very interesting article "on Irrita- tion of the spinal nerves," the substance of which he asserts he read before the Medical Society of that city in 1823. In this paper he refers the morbid phenomena of the spinal nerves to a state of increased irritability of their origin, which he terms "spinal irritation." This affection of the spinal marrow is attended with more or less pain on pres- sure of the vertebrae at the diseased point. Some of his cases were evidently rheumatic, and indeed had been treat- ed as such by the previous attendant. His treatment con- sisted principally of applications to the spine. Dr. Darwall, early in 1829, inserted in the Midland Medi- cal and Surgical Reporter, his "Observations on some forms of Spinal and Cerebral Irritation." He would estab- lish the principle "that disorders attacking the origins of nerves, or their attachment to the central mass, whether 280 1)U(JAS. Lecture on [April, this be the brain or spinal chord, always disturb the func- tions of the organs to which such nerves are destined." "A treatise on neuralgic diseases, dependent upon irrita- tion of the spinal marrow and ganglia of the sympathetic nerve," by Thomas Pridgin Teale, was issued from the London press in 1829. This invaluable publication has opened to our researches one of the most fertile fields ever explored by the profession ; one from which have already been elicited some of the most important truths in the do- main of pathology. The observations of Teale not only confirm the views of those who wrote before him on Spinal Irritation, but are also extended to lesions of the sympa- thetic ganglia. I would, however, at present, refer only to that portion of his work which relates to our subject. It contains a number of cases illustrative of his doctrines, some of which, like those reported by Brown, had been consider- ed as rheumatic by other physicians, and indeed presented symptoms such as are usually said to characterize some forms of this disease. It is not a little remarkable that with such facts before them, neither Brown nor Teale should have thought of treating the more acute forms of rheumatism in the same manner. They make no reference to it, and the merit of introducing a new and rational mode of treatment of rheumatism, was reserved for our country- man Dr. J. K. Mitchell, of Philadelphia, who, in May, 1831, published in the American Journal of Medical Sci- ences, his first article on the subject. In addition to the eight cases then reported, Dr. M. inserted five and thirty more in the same Journal, August, 1833 ; all of which con- cur in confirming the spinal orgin of rhematism, whether acute or chronic. I must confess that neither of the transatlantic publica- tions to which I have referred, had led me to reflect on the nature of rheumatism; nor was my attention drawn to it until the appearance of Dr. Mitchell's first paper. On read- ing this, however, and comparing his doctrine with the pre- vailing theories of the Pathology of this malady, I became 1861.] Rheumatism. at once convinced that it was Impossible to reconcile the various symptoms of this disease, on any other principle than that of spinal irritation, and that with this view of the subject, the treatment would be perfectly simple and effica- cious. From the definitions usually given of rheumatism, the pain is manifestly considered as dependent on the inflam- mation of the parts in which it is seated. That simple in- flammation of the muscular or fihrous tissues should be the sole cause of the pain, I cannot admit. It is true that the patient's sufferings are generally proportioned to the de- gree of the apparent inflammation, and consequently that acute is more distressing than chronic rheumatism. But, I would ask, why are not other inflammatory affections of the same tissues equally painful ? It is impossible not to per- ceive, on a close examination of the phenomena of rheumatic inflammation, that they present several peculiarities, which evidently distinguish it from ordinary inflammations ; and indeed they are so strong as to have led some eminent pa- thologists to deny that they constituted a whole, entitled to the denomination of inflammation. Inflammation is usual- ly said to be characterized by redness, heat, tumefaction, and pain, all of which we find united in the most violent forms of rheumatism. But there are sequela? or tcmina- tions enumerated as belonging to inflammation, which never follow rheumatism. Inflammation terminates by resolu- tion, suppuration, or mortification. Its rise, progress, and termination, are more or less gradual ; subject to certain laws, and it is in most cat vptible of removal by antiphlogistics. Rheumatism obeys no such laws of develop- ment, progress and declension ; but, not [infrequently mani- If and disappears with a degree of suddenness ut- terly at variance with the course of ordinary inflammations. \x< mode of termination is invariably the same (by resolu- tion) never proceeding to suppuration, nor to mortification; ami finally, it rarely, if ever yields to the antiphlogistic 288 Duu as. Lecture on [April treatment directed to the seat of pain.* The theory of spinal irritation is that alone by which all these peculiarities can be explained. If the point from which, a given nerve arises be diseased, the functions of this nerve must neces- sarily be vitiated; and if its functions be vitiated, the con- dition of those parts to which said nerve is distributed must also be morbid. In the case of rheumatism, the morbid condition of the parts deriving nerves from a diseased por- tion of the spinal chord, consists of inflammation of a pe- culiar character, increased sensibility of the nervous ex- tremities, amounting usually to pain more or less acute, and, in many instances, diminished motility. All admit lesions of motility to depend on an affection of the motor system of nerves, and, inasmuch as the motor cannot be separated or distinguished from the sensitive fibres after their union in a common nerve, such lesions are referred to the spinal chord. Why, then, should we not also regard all lesions of sensibility not the result of local injury, f as at- tributable to a morbid state of that chord which presides over this function ? Again, we see that not only the onset of rhematic inflam- mation, but also its termination or cessation, is in many instances extremely sudden, and indeed that sudden me- tastasis is by no means unfrequent. These circumstances are most satisfactorily accounted for by the fact that nerves arising very near each other may be distributed to parts very remote. For instance, the nerves of the right hand, though very distant at their termination from those of the left, arc nevertheless very near them at their origin in the *I am aware that there arc eases on record, of suppuration and even of mortification having occurred in parts affected with rheumatism, but they arc so few that we may be permitted to doubt their authenticity, or rather to look upon them as mere coincidences, dependent on complications or peculiarities of habit. The success of the antiphlogistic treatment direct- ed to tin1 scat of pain, is equally doubtful, especially when we bear in mind the strong tendency of rheumatism to translation or sudden cessation without appreciable cause. I (lout, rheumatism and neuralgia. 1861.] Rheumatism, 289 medulla spinalis ; and hence a slight affection of the medulla might for a time exist in one column, and subsequently ex- tend or remove to that adjoining it; thus producing at first a derangement of function on one side of the bodv, and then on the other. My opportunities have not as yet been suf- ficient to cnable]mc assert, from observation, that metastases of rheumatism are limited to the periphery of nerves arising in the proximity of each other. This, however, I am strongly inclined to think, will most frequently he found to be the ease. Whenever an upper and a lower extremity are simultaneously affected, they most frequently belong to the same side of the bod}\ It will probably also be observed that the justly dreaded translation of rheumatism to the. heart, is a much more common sequel of an affection of the upper than of the inferior extremities. The difficulty attending post mortem examinations of the medulla spinalis, has very much retarded our knowledge of the pathological anatomy of this organ. Its condition in fatal cases of rheumatism has never been systematically in- vestigated. We find, however, on record, a few eases which I think calculated to throw much light on our subject. One of these is reported in Johnson's Medico-Chirurgical Re- view, (Oct, 1*27, p. 4G4) under the title of "Inflammation of the Spinal Marrow." A youth, some time after bathing in the Seine, experienced wandering pains, which subse- quently extended to the whole surface of the body, and be- came so intense that the least touch would occasion loud cries. The pains continued unabated, delirium and diar- rhoea ensued, and he died on the ninth day. On opening the spine, the medulla was, from the 7th cervical to the 8th dorsal vertebffi, evidently softened and infiltrated with pus. In the same periodical (Jan., 1828, p. 184) is contained another ease, in which the patient had suffered severely from rheumatic pains in the upper part of the back, shoul- ders, and arm-, and finally became paralyzed in his arms. Dissection evinced that from the 5th cervical to the 11th dorsal vertebrae, the membranes of the spinal canal were in 1" 290 Dug as. Lecture on [April, flamed, thickened, and covered with a bloody effusion. The marrow itself, for the same space, was similarly inflamed and softened. Dr. Mitchell gives the history of two cases of spinal dis- s, as corroborative of his views of rheumatism. The first* was one of caries of the lumbar vertebrae, in which one ankle, and the knee of the opposite side were tumefied, red, hot, and painful, afforded a fair specimen of acute rheu- matism. Relief promptly followed leeching and a blister to the affected spine, although the ordinary treatment for rheumatism had been previously resorted to without effect. The second case was that of a physician who, after receiv- ing an injury of the cervical vertebrae, experienced an at- tack oi acute rheumatism ot the hands and wrists, which "was always relieved by remedies applied to the affected part of the spine, and aggravated by pressure or rough fric- tion there." These four cases conclusively establish the fact, that irri- tation of the spinal contents is attended with the train of Bymptoms known to characterise rheumatism. May we not, then, by legitimate deduction, infer that there is a spinal disease whenever we encounter this train of symptons ? If further evidence be requisite, it is abundantly furnished by the numerous instances in which genuine, uncomplicated rheumatism has been speedily cured by medication applied exclusively to the spine. Dr. Mitchell, reports 41 ca successfully treated on the new principles. Pressure over the vertebrae corresponding to the origin of the nerves supplying the seat of suffering, though in many instances attended with more or less pain, is not uniformly In some, not the slightest uneasiness is produced by it. I cannot, however, coincide with Dr. Mitchell, in consider- ing the tenderness, merely a proof of an irritated condition "American Journal of the Medical Sciences, M.-i\. 1831, p. 56. American Journal of the Medical Sciences, Aug., L833, p. 880. 1861.] Rheumatism. 291 of the "spinal braces ;" for, whenever this tenderness does exist, it almost invariably corresponds to the origin of the affected nerves. The degree of sensitiveness may perhaps be indicative of the condition of the membranes alone of the medulla. In the case before us, we have a happy illustration of the importance of localizing, and properly localizing diseases ; for so lone; as rheumatism was thought to be an affection of the whole system, manifesting itself indifferently in one joint or another, all remedial agents were directed to the general system. How many poor wretches have we not seen subjected to the cruel inflictions of a regular mercurial salivation, a systematic course of sudorifics, antimonials, guaiacum, sarsaparilla, &c, the ordeals of steaming, vapor- izing, sweating, &c., and after all, the patient doomed to limp the remainder of his days ! But I say that it must be properly localized; for those who view the disease as con- lined to the seat of pain, will torture their patients with fric- tions, fomentations, vesications, &c., with as little success as those who endeavored to drive out or neutralize the con- stitutional impurity. We have now, I trust, traced rheumatism to its true source, and every remedy based on this belief, gives ad- ditional evidence of its correctness. Regarding the disease as seated in the spinal marrow, and believing its nature to be irritation or sub-inflammation, the treatment to be insti- tuted is perfectly obvious. The local abstraction of blood, by leeching or cupping the surface over the affected medul- la, followed by the more permanent revulsive action of vesi- catories, constitutes the most efficient treatment of rheuma- tism. In many slight cases, the mere application of a sina- pism will readily allay the pain; in others a blister will be required and may be, or not, preceded by cupping, ac- cording to the tenderness of the spine, the constitution of the individual, &c. AVhen the local affection is 80 intense as to induce high febrile excitement, it may be prudent to take blood from the arm, though this should not be carried 292 Ls. Lecture on [April, to excess. The opiates will occasionally be found useful adjuvants. In obstinate chronic cases, the counter-irritation will be most advantageously kept up by the ointment of tartarized antimony, and should be persevered in, as long iis the (1: a tendency to return. With this plan of treatment, I repeat, the disease will be found almost uniformly to yield in a few days, and without any internal remedies, or applications to the seat of pain. Yon perceive that I have, in the paper just read, used the term Rheumatism in a general sense, and without discrimi- minating between the different forms assumed by the dis- ease. 1 will, therefore, add a few remarks in order to pre- vent any misconception as to the pathology advocated, and which 1 still regard as entirely applicable to every form of rheumatism, with the exception, perhaps, of the acute arthritic variety, in which other elements are added to the spinal. There is a form of rheumatism usually designated by authors as acute articular rheumatism, the peculiar character- istics of which are a fixed inflammatory action in one of the joints, attended with intense pain, more or less tume- faction, and high general febrile action ; all of which symp- toms will continue, in spite of our endeavors, a certain length of time, usually varying from four to eight week-. This is, therefore, a self-limited disease, the intensity of which we may abate, but whose duration we can rarely shorten, fn this form of rheumatism we never find more than one joint affected at a time, and this is usually one of the larger joints, as the knee, ankle, elbow, or wrist. It is in this form of the disease that we observe the heart so of- ten implicated. According to my observation the cardiac affection very rarely supervenes as a complication of any other form of rheumatic disease. Again, acute articular rheumatism differs radically from all other forms of rheu- matism in the circumstance that one attack usually secures complete immunity from any subsequent attack of the same affection. II.] Rheumatism. 293 That this form of rheumatism is, like the oilier varieties to be hereafter noticed, dependant, to a certain extent, upon a lesion of the spinal marrow, I firmly believe ; bul ii i i also evident that this docs not constitute its whole patholo gfVi for it is attended with a degree of constitutional disturb ancc that cannot be accounted for either by the spinal lesion or by the local inflammation. \\re moreover find that a radical change is effected in the composition of the blood in such cases, and that these obey many of the laws which govern the diseases said to beoi the blood. It is, therefore, no! surprising that the treatment which is applied directly and exclusively to the spinal lesion, should only mitigate and never arrest the disease. I know of no treatment en- titled to much confidence in the curation of this form of the disease. Yet, I must acknowledge that [ have some- times thought that I derived advantage from the use of opiates, quinine, antimonial emetics, lemon juice, &c. But there is another form of rheumatism also called acute, in which there are usually several joints implicated simul- taneously, and in which there may be considerable febrile excitement. This form of the disease is usually the effect of exposure in inclement weather, and the patient will gener- ally state that he has caught cold in all his limbs. AVc not unfrequently see violent cases of this kind in which the morbid sensibility invades most of the joints, as well as the muscles and even the cutaneous surface; all of which are exceedingly painful tothetoueh or upon the slightest motion, so that the patient can neither move nor turn over in bed without excrutiating pain. It is in this form of rheumatism that we find revulsives, applied over the origin of the nerves affected, most signally beneficial ; for without any other treatment the disease will yield usually in a few days to cupping and blistering over the affected region of the spine. This variety I would, therefore, designate as acute neuralgic rheumatism, in contradistinction to the former which I would term acute arthritic rheumatism. You will perceive that there can he no difficulty in cs- 294 Dugas. Lecture on [April, tablishing the diagnosis as well as the prognosis of these two forms of disease, [n the former the attack comes on without any evident cause, affects but one joint, and that a largo one, is attended with high febrile excitement and yields t no remedy, but goes on steadily increasing in intensity until it has reached its acme in three or four weeks, and then gradually declines in about the same length of time. The latter is, on the contrary, usually induced by exposure, affects more than one joint, is not attended with so much febrile excitement, and yields very readily to treat- ment. I should also add that whereas the former usually attacks the young and the robust, the latter affects all ages indiscriminately, and one attack so far from securing im- munity from others, rather predisposes the patient to them in after life. It is in this neuralgic form of the disease that quinine acts most advantageously and may sometimes be substituted for the more painful spinal revulsives. There is finally a third form of rheumatism, very general- ly denominated chronic rheumatism. This variety usually affects one or more joints, is not so painful as the two we have just considered, occurs most frequently after the meridian of life in the temperate, and is very common with drunkards of all ages. This, like the last described variety has also its origin in the spinal marrow, is amen- able to the same treatment, but is apt to recur more or less frequently in subsequent life, especially with the intemper- ate, in whom I have never known it to be permanently eradicated. The tendency to relapse may, however, be en- tirely overcome in persons of good habits, by a faithful per- severance in the use of revulsives to the spine. While I place no reliance in the use of liniments, nor in frictions of any kind, in this and the other forms of rheu- matism, there are yet cases in which the joints, after re- peated attacks, become so much involved that their tea will not return wvy speedily to the normal con- dition. In these cases frictions with neat's foot oil, opo- deldoc, "i- even stimulating linaments, at the same time that 1861.] Rheumatism* gentle motion is imparted to the joints, are advantageous. I have derived derided benefit from the application to them of the tincture of iodine once or twice daily as long as it could be tolerated. I have also used advantageously a so- lution of shellac. This may be made by dropping bits of shellac in alcohol, successively, until the solution acquire the consistency of mucilage. This, when applied with a soil brush or mop, once or twice a day, will form a thick and adherent pellicle which should he reproduced as fast as it. may he disposed to scale off. L will now read to you, from my note hook, a lew cases to illustrate and impress upon your minds the several forms of the disease I have just endeavored to define : Acute Articular Rheumatism. January 31st. Mr. A. L., aged 25 years, of robust con- stitution and of full plethoric habit, was, last night, without any evident cause, taken with pain in the right knee, which to-day confines him to his bed. Is rubbing the knee with with liniment. Ordered cream of tartar as a laxative, and allowed the frictions to he continued. 22d. Pain increased: has some fever; knee a little tumefied : very little tenderness at the lower end of the si tine, which is ordered to he freely cupped. 27th. lias heen gradually getting worse under the use. of tincture opium applied to the knee, morphine taken in- ternally, and cooling beverages. Has refused to be blister- but is now willing to submit to the application of tartar emetic ointment to the spine. Morphine continued, pro re . and a tahlespoonful of tine, guaiac. to he taken three times a day. 29th. Pains increased ; fever high ; unable to move his limbs in the slightest degree without intense pain ; tume- faction increasing. Took 24 ounces blood from the arm. Ordered the knee to he poulticed with flaxseed and laudan- um. 31 st 1 '-ease still progressing. Ordered the spine to be 2&6 Dugas. Jjcctureon [April, freely cupped to-day and to-morrow, and then blistered, pulv. dov., at bed time. February 8th. Xo amendment. He-apply the blister and lake denarcotized opium as freely as may be necessary to relieve pain. L3th, Still suffers dreadfully ; fever still high and con- tinuous. The blistered surface has healed. Ordered another blister and the anodynes to be continued as hereto- fore. 18th. Febrile symptoms less intense, and pains not so excruciating. Thinks his knee would feel better if rubbed. Ordered a liniment consisting of oil, tinct. opii. and sp. tereb., also tinct. guaiac. and morphine internally. 28th. Is gradually improving; same prescription con- tinued. March 10th. Has improved very little since last date, with the exception of a considerable diminution of the fever. Ordered a blister to the knee. Continued the guaiacum and anodynes. Bowels kept open with laxatives. 16th. All symptoms subsiding rapidly ; knee blistered again; ung. ant. applied to the spine. 26th. Still improving ; knee blistered again. April 5th. Case discharged, although the knee is so stiff as to allow but little motion. The patient ordered to con- tinue frictions with neat's foot oil, and to exercise the limb as much as possible until he regain its free use. Remarks. We have here the details of a case such as we have denominated acute arthritic rheumatism, which occur- red without evident cause in an individual in the full vigor of life; which alfccted but one joint; which ran its course uninterruptedly and without being modified in the least by any remedy prescribed, whether directed to the spine or to the general system ; and which continued upwards of 70 days, attended with a degree of febrile excitement entirely dispr portionedto the local affection. This gentleman had neve suffered from rheumatism before, nor did he experi- any subsequent attack for fifteen years afterwards, [861.] Rheumatism. 297 when he died of a dropsical affection which may have been occasioned by some disease of the heart, consequent upon the above attack of rheumatism. I did not sec him in his last illness. His exemption from subsequent attacks of rheumatism is the more remarkable from the fact that he became very intemperate a number of years before hisdeath, ami that intemperance is a very common cause of one of the other forms of rheumatism. Acute Neuralgic Rheumatism. January 20th. Thomas Bernard, a native of Ire- land, about 30 years of age, and of sanguineous tempera- was taken about the first of this month with rheumatism when working on the railroad; was subjected to a variety of treatment by a country physician, the details of which are unknown. I found him stretched upon his back, with- out the power to move either of his limbs, and complaining of the most excruciating pain in the loins knees, ankles, shoulders, elbows and wrists. Fever high, pulse full and strong, great thirst, no appetite, and costive. Ordered free blood-letting from the arm. 01. ric, and diluent drinks. January 21. Fever still high; cathartic operated well; passed a wretched night, without a moment's rest. Upon examination found the spine extremely painful on the least pressure over the origin of the nerves of the lower extremi- ties. Tenderness also existed, though to a much less de- gree, in the upper portion of the dorsal vertebrae. Pre- scription To be cupped freely over the origin of the nerves of the superior and inferior extremities ; pulv. dov. at night; light diet ; diluent drinks. January 22. Pains much less intense ; can draw up his 3. Cups repeated; pulv. dov. at night. January 23. Can turn over in the bed, and feels pain only when he move-; swelling at the joints reduced, blisterover lower end of spine. January 24. Legs entirely relieved with the exception 208 Dug as. Lecture on [April, of a little weakness. Fever entirely subsided. Cups to the upper portion of the spine. January 25. Arms much better. Cups repeated. January 26. Can rise and move about the room, though stiit' and weak. Ung. tart. ant. to be applied at each ex- tremity of the spine. January 28. Has improved so rapidly that he now walks about the streets, and the case is discharged. February 4. Exposed himself considerably, and has again taken his bed, with great pain in the upper and lower extremities. Blister to the lower end of the spine, and ung. ant. to the upper. February 5. Much better. Fulv. do v. at night. February 6. Walks about the room. Saline carthartic ; pulv. dov. Februaiy 11. Feels quite well in every respect. Chronic Neuralgic Rheumatism. February 17. Resumed his work on the railroad. Case 1. March 21. Mr. J. Gr., aged 25 years, had syphi- lis abont eighteen months ago, for which he was treated successfully with mercurials, but was seized with rheumatic pains about six months afterwards in various parts of the body, which he says have returned repeatedly under ex- posure to bad weather. He has now been suffering severe- ly several days with pains in the knee and wrist of the left side, both of which joints are swollen and very sensitive to the touch; has slight fever; pressure upon the spinal column reveals great tenderness over the two lower lumbar vertebrae alone. Freely cupped over these vertebrae, and also over the uppermost dorsal and the cervical vertebne. March 22. Feels no pain whatever; swelling consider- ably diminished; feels a little stilt'. Ung. tart. ant. to be rubbed over scarified surfaces, and a plaster of the same kept on all night. March 23. Js apparently well, and complains of nothing but the soreness of the scarified parts. Case discharged. 1861.] Rheumatism. 200 April 4. Has had qo return of pain and continues well. ise 2. February 3. Mrs. C. P., aged about 20 years, of* robust constitution, experienced, about a week ago, pains in her limbs, which, in a few days, were locatedinthe knee and wrist ot' the right side, whichare now very much swollen and painful. Liniments have been used freely without the least relief. Pressure on the spine causes slight pain only in the upper dorso- cervical region ; no fever. Ordered sina- pisms t<> the upper and lower portions of the spine. Februry2. Pains much alleviated; sinapisms repeated. February 8. Swelling rapidly diminishing, particularly in the knee ; no pain of consequence. February 7. Walks about tlie house, and complains of nothing but a little stiffness. Case discharged. Case 3. January 31. Mr. G. F. P., about 30 years of age, has been suffering excruciating pain from rheumatism of the head for three weeks, during which time he has been subjected to venesection, cathartics, a low diet, frictions, void affusions, to the head, &c, without relief. Pressure over the last cervical and first dorsal vertebra) produces considerable pain. The hair had been shaved from the upper part of the neck and a small blister applied, but this did not extend as low as the sensitive part and it produced no diminution of pain. I now ordered the application of another blister of sufficient length to extend from the upper cervical to the second dorsal vertebra?. February 1. Blister has drawn very well, but still suf- n much as ever. Ordered simple dressing. February 2. Pain rather less severe ; ung. tart. ant. to be spread over the blistered surface. binary 3. Much relieved. Same prescription. February 4. Quite well and gone to work. This case illustrates the importance of making the revul- sive application immediately over the seat of irritation, or, in other words, over the painful vertebra in order to insure success. 300 Dugas. Lecture on Rheumatism. [April Bub- Acute Neuba^lgki Rheumatiim. April 1. Mr. S. W., about twenty-five years of age, s circus rider, 1ms just arrived from a country tour wit! severe pain in the right shoulder and right hip, which In says he has had nearly a week. He can neither stand upoi the a Heeled leg, nor remove the arm from the side of the body. The aftected joints are tender to the touch, and sc are the vertebrae at the origins of the nerves of the nppei and lower extremities. He has some fever, and is confined to his bed. lie begged to be relieved as speedily as pos- sible, without regard to the severity of the treatment, as h( was an important member of the company to which hewai attached. I accordingly ordered him to be cupped freeb over the tender vertebrae at each end of the spine, and t( have the scarified surfaces immediately covered with blister ing plasters. April 2. Patient much relieved, and states that he wa enabled to move his limbs with but little pain immediately after the cupping. Ordered simple cerate to the blisters. April 3. Entirely relieved. April 4. Resumed his performances at the circus. Symptomatic Lumbar Pain. March 26th. Mr. II. J., affected with orchitis for several days, complained of pain in the lumbar region tc such a degree as to prevent any rest at night. On exami- nation found that he could not bear the least pressure ovei the vertebrae of that region. Ordered a large sinapism tc be dept on as long as he could bear it. March 27. Relief complete. March 30. The sinapism was re-applied and he has since had no more pain in the back. In this case the pain in the loins was probably symptom- atic and not rheumatic. Yet it was very promptly relievec by the same treatment. 1861.] / won Convulsiv I 301 ores on the Theory and Therapeutics of Convulsive Diseases, '>/ of Epilepsy. By Charles Bland Radcliffe, M. I >., Fellow of the College, Physician to the Westminster Hospital, etc. LECTURE III. (CONTINUED PROM MARCH NUMBER.) Iii the last lecture I spoke of simple epilepsy, and en- deavored to show that the facts are more in accordance with the theory oi' muscular motion propounded in the first lec- ture than with that ordinarily received theory which would ascribe the convulsion to over-stimulation on the part of one or other of the nervous centres. In doing this, I insisted particularly upon the asphyxial state of the circulation and respiration, and argued that the want of red blood during convulsion must necessitate at that time a corresponding want of action in every one of the nervous centres. In the present lecture I propose to continue the inquiry, and see whether the same theory is applicable to convulsive diseases generally. I also propose to add a few words upon the thera- peutics of these maladies. I. The Theory of Convulsive Diseases Generally. In pro- ceeding to a cursory examination of convulsive diseases generally, I shall divide these diseases into three catego- . of which the distinctive signs respectively are tremor, convulsion and spasm. In the examination itself, I shall do as I did when speaking of simple epilepsy, and consider first the condition of the circulation and respiration, and afterwards review the several nervous phenomena, other than tremor,jconvulsion, or spasm, which must not be pass- ed by in silence. /. Tlu Theory of Tremor. The category of convulsive diseases of which the distinctive mark is tremor, includes the tremblings of delicate and aged persons, of paralysis aiis, of delirium tremens, the rigors and subsultus of ers, and the shakings of slow mercurial poisoning. 1. The state of the circulation and respiration in these ral conditions is sufficiently obvious. There is no doubt that both these functions are much depressed during common trembling ; for this is evident as well in the paleness and chilliness of the person trembling as in the decided relief afforded by wine. In delirium tremens, the perspiring skin, the cold hand, the quick compressible, fluttering pulse 302 Lectures on [April, arc all significant and unmistakable facts. It is evident, also, that the trembling is connected with this state ofthings; for if the dry skin and excited pulse of true meningitis make their appearance, the trembling is at an end. On the other hand, an argument to the same effect is to be found in the fact that tremor is exaggerated into subsultus, or even into convulsion, as the heart and pulse fail in the downward course of the disorder. Rigor, moreover, is coincident with a sense of coldness, a feeble pulse, a sunken countenance, a corrugated skin, and subsultus, with a pulse faltering in itsfinal throes; and that this coincidence is not accidental, is seen in the fact that rigor disappears as the pulse and warmth return, and that subsultus may be checked for the time by the use of wine. And in mercurial tremor, an in- ference as to the real state of the circulation may be drawn from the general practice prevailing amongst the subjects of this disorder of resorting to gin and other stimulants to make themselves steady. 2. The nervous phenomena, other than tremor, arc in accordance with the foregoing facts. In a bout of ordinary trembling the mental faculties are all unstrung ; and in the permanent and extremest form of this trouble, as in paraly- sis, they have altogether succumbed before the inroads of age or disease, . leptiform Convulsion, 1. Cn a case oi general epileptiform convulsion, the state of the circula- tion is as Ear removed from anything like excitement as it is in simple epilepsy. There is, indeed, the same failure of the pulse at the commencement of the lit, and the same state of positive BnfTocation during the fit. In the case of partial epileptiform convulsion, the only difference is one of degree. In any ease, the pulse is scarcely to be felt at the beginning of the paroxysm, and everything shows that the circulation is at a very low ebb ; and if the pulse acquires any sem- blance of power as the paroxysm proceeds, the dusky and livid color of the face, the interrupted breathings, and other unequivocal signs of suffocation, afford sufficient proof that this phenomenon is due, not to the increased injection of red blood into the arteries, but to the impeded circulation of black blood, as explained in the last lecture. Xor is there any evidence of a contrary character, in the antecedent history of epileptiform convulsion, for in those cases in which the malady is of an inflammatory or febrile character, it will be seen that the lit occurs either in the period oi prostration which precedes the development, or else in the period of collapse which comes on after the dying out of the fever or inflammation. In chronic softening of the brain, the habitual coldness of the hands and feet, the weakened and perhaps degenerated heart, the atheromatous or calcareous deposits in the arterial coats, are amongst the many signs which show the innate weak- - of circulation a weakness to which fever and inanima- tion are alike uncongenial. In chronic meningitis, as might be expected from the un- mistakable evidences of a scrofulous, habit, and from the state of weakness and exhaustion which are so generally present, the pulse, for the most part is quick, weak, and much affected by changes of posture. There may be some hectic excitement in the evening, the cheeks flushing, the eyes shining, and the aching head becoming a little hotter than it was before ; but this faint excitement is not sufficient to raise the pulse to a normal pitch of activity. In no case, indeed, is this reaction of the circulation a marked and conspicuous phenomenon, and in the majority of instances it is scarcely sufficient to impart even a semblance of power to the weak and feverless pulse. And if there is little vascular excitement in ordinary chronic meningitis, there is. if possible, less in that form of the dis< which is known as chronic hydrocephalus. 20 300 Lectures on [April, In tumor of the brain the pulse is quick, weak, irritable, fluctuating, or if not, it will be so as soon as pain, want of sleep, and despondency common symptoms of tumor have had time to bear their natural fruit of weakness and exhaus- tion. In induration of the brain, such as met with in lead-poison- ing, &c., the phenomena presented by the circulation differ very little, if at all, from those which occur in advanced stages of ordinary epilepsy, and any difference there may be, is one which indicates a state still more fully removed from fever. In atrophy of the brain, as in simple epilepsy, there is no evidence of anything like excitement in the circulation. In congestion of the brain, the head and face are congested and dusky, the lips purplish, the jugular, full, the pulse and respiration slow and labored, the hands and feet habitually colder than the head. There are, indeed, many evident signs which show that the circulation is not carried on with proper vigor, and which appear to point to imperfect arteri- alization of the blood as one cause, of this defect. In apoplexy the convulsion is most apt to happen at the end rather than at the beginning of the period of coma, when the purpled lips and the inadequate breathings show the respira- tory changes are rapidly failing. Or, if it happens at the be- ginning, it is in those forms of apoplexy in which the con- dition of the circulation at the time is more akin to collapse than anything else, and not in those forms in which there is an excited pulse, and strong determination of blood to the bead. In inflammation of the brain, the condition of the circula- tion may vary a good deal with respect to the inflammation, but little with respect to the convulsion. Simple meningitis begins with paleness of the skin, a feeble depressed pulse, cutis anserina, vomiting, rigor, perhaps con- vulsion. Then follow rapidly the symptoms of high febrile reaction and cerebral inflammation, the pulse becoming hard and frequent, the breathing irregular and oppressed, the skin particularly the skin of the head hot and burning. After continuing for two or three days, these symptoms of high fe- brile reaction give place to an opposite state of things, in which the |>ulse loses its force, and becomes weak, small, irregular, and the breathings are interrupted by frequent sighs and pauses. ( )r, if at this time the pulse retains any degree of re- sistance, it is evident, from the dusky color of the skin and the Buspirious and labored respiration, that the whole of this re- 1861.] Con* i 307 sis stance is not due to the injection of arterial blood into the artery. Now, it is in this stage of collapse, or semi-suffoca- tion, which follows, or else, in the cold stage which precedes, the febrile and inflammatory excitement, and never during the period of excitement, that the convulsion happens. And this rule is constant. Indeed, the history of Simple meningitis shows most conclusively that vascular excitement is as in- compatible with convulsion as it is with rigor and subsul- tus. In tubercular meningitis, the pulse is weak and variable from the first, now quick, now comparatively slow, rising in frequency when the head is raised from the pillow, and falling when it is laid down again ; and from the very first the respira- tion is irregular, unequal, and interrupted with frequent sighs and pauses. For some time there may be little disturbance of a hectic character, particularly in the evening, but this soon conies to an end, and the prostrate pulse forgets to put on even this taint semblance of fever. In some cases, there may, indeed, be a short stage of fever, and something like active cerebral inflammation, especially in young children; but as a rule the symptoms are altogether of a passive, non-febrile, non-inflammatory character. In any case, however, the con- vulsion is connected with a depressed state of the circulation, and never with febrile and inflammatory excitement, if such state there be. In rheumatic meningitis, also, there is little or no febrile ex- citement fr<>m the beginning, and the pulse has become powerless and utterly weak before the convulsion happens. In general cerebritis, the pulse, at first Blow, soon becomes variable and readily affected by change of posture; the respi- ration, also, is very variable and suspirious. From the first, indeed, there is scarcely any fever, and little heat of head, ex- the phenomena of cerebritis are mixed up with those of simple meningitis ; but if such symptoms are present, they . pass off, and give place to Bymptomsof slow .-inking a in which, hour by hour, the breathing is more interrupt- ed with sighs and pauses, %and the pulse more powerless, un- '.- may have a fictitious power, from the presence of more or less black blood in the artery, in which case the dusky countenance and the purple lips will show very clearly that any increased injection of red blood is at this time out of the question. In partial cerebritis there is even less febrile disturbance than in general cerebritis, ami at no stage of the malady is there anything like increased vascular action. LectUTi [April, The immediate antecedents of the epileptiform convulsion which may attend upon the onset of fever arc paleness of the face, coldness of the hands and feet, a feeble, soft, and fluctu- ating pulse, a respiration that is short, accelerated, and inter- rupted by frequent sighs. The immediate antecedents of the convulsion which may attend upon the: end of the fever are, a weak and thready pulse, a frigid hand, and lungs too much gorged with blood to allow oi any proper respiration a state in which, febrile reaction having long since died out, the hand of death is already upon the heart or brain. The convulsion which may attend upon fever, indeed may take the place either of rigor or subsultus, and like these forms of muscular disturbance, it is associated, not with the state of depression, which is as much below the natural standard as any febrile excitement is above that standard. In the convulsion connected with dentition, there may have been little or no previous fever, and by quick degrees the pulse may have become excesssively weak, or there may have been symptoms of cerebral inflammation with high fever, and afterwards a state bordering very closely upon collapse. In any case, the immediate antecedents of the lit are indicative of great vascular depression great vascular depression brought on slowly without any very obvious fever or deter- mination of blood to the head, or else that which precedes or succeeds active fever and determination. And so likewise with the convulsion which is connected with worms or other sources of irritation in the alimentary canal; for if there has been any febrile disturbance, this has passed off, and left the patient not only feverless, but pale and chilly. Nor is it otherwise with those forms of convulsion which are referred to uterine irritation. In the convulsion connected with men- struation, the circulation is in the state in which it is in ordin- ary epilepsy or in ordinary hysteria ; and a similar remark a] iplies to several of the convulsions which may happen in the course of pregnancy. In the convulsion of flooding, the face and even the tongue is blanched, the hand frigid, the body bathed in cold sweat, the pulse fluttering and well-nigh imper- ceptible, the breathing a continuous sigh or gasp. In the convulsion occurring in labour without flooding, the head is often greatly congested, and the aeration of the blood seri- ously interfered with, partly in consequence of the way in which the lungs sympathize with the semi- comatose brain, and partly because the regular expansions of the chest are inter- fered with by the constant efforts at straining. In such a case the pulse may be full; bnl if bo, the venous color of the lips L861.] Ckmrnd* 309 will show that this fullness is due to the circulation of black blood rather than to the circulation of red blood in the ves- sels. \\\ the convulsion. which may happen daring puerperal r, the vascular antecedents are the same as those which may happen towards the end of every fever. And lastly, the condition of the circulation before the convulsion which is re- ferred t> "irritation" of a sexual character, it' it differs at all from that which is met with in ordinary epilepsy, differs only in being one of still deeper depression. Nor is there any trace of vascular excitement before the convulsion which may happen in the moribund state. In the convulsion attending death by haemorrhage ov asthenia, the blanched face and tongue, the frigid hand, the sighing or gasping respiration, the faltering pulse, art signs which re- quire no comment; and in the convulsion attending death by idy or gradual suffocation, the state of things is equally opposed to the idea of vascular excitement ; for how to ask this question once more can vascular excitement and a state of suffocation be compatible conditions i In a word, there is no instance in which epileptiform con- vulsion can be supposed to have any connection with an ex- cited state of the vascular system, and there are many instan- ces in which the circulation is as far as possible removed from such a state : and the only conclusion which can be drawn from these facts is one which seems to harmonize with the physiological premises, and with the previous conclusions re- specting simple epilepsy. '2. In a case of general epileptiform convulsion, the mental faculties are as completely suspended as they are in epilepsy. The dilated pupil remains immovable under the brightest light ; the ear is deaf to the loudest noise ; and when the patient recovers if he do recover his memory is absolutely blank as to everything which happened during the lit. In partial epileptiform convulsion, such as occurs not unfrequent- lv in chronic softening or tumor of the brain, as in partial epileptic convulsion, the mental faculties may not be altogether ended, and the memory is occasionally able to recall some of the circumstances attending the fit. In the case of general epileptiform convulsion, therefore, the condition of the mind is evidently one of inaction. Of this there is no doubt. Nor can there be any doubt that the state of the mind is one of parative inaction in partial epileptiform convulsion : for the utter bewilderment, the inability to collect and control the thoughts, the trepidation, and the want of power over the muscles, are all signs which cannot be mistaken. 310 Lectures on [April, It would seem, also, that the brain is not less inactive than every other centre of nervous action, for (to repeat the argnmenl already u>v<\ so often) none but the very lowest degree of action is compatible with the circulation of unarteri- alized blood in the vessels. Nor isthere anything contradictory in this conclusion in the tacts which remain to be mentioned. In chronic softening of the brain the fits are preceded by unquestionable, and often very marked, impairment of the mental faculties, and in some cases the mind may be a total wreck. Fire and energy are dyingoutand dulness and drowsi- ness point to the coming coma, ofwhicb they are the forecast shadows. The brain, also, is blighted, not inflamed. Jt is pallid, whiter than it ought to be, deficient in red spots, and in parts, softer than natural : and, on microscopic examination the softened substance is found to consist of broken-down brain tissue, with a greater or less number of cells containing oil, and sometimes reddened with blood corpuscles, (for haemorrhage is a common consequence of softening) but with- out any of the products of true inflammation exudation and pus-corpuscles. Impairment of the mental faculties, progressively increas- ing, is also a prominent symptom of chronic meningitis im- pairment which would seem to be more marked by peevish- ness, impatience, fidgetiness, and not unfrequently this wan- dering may settle down into insanity. Or there may be no positive symptoms of any kind. After death the principal sign of disorder is effusion of serum beneath the arachnoid or into the ventricles, and this is often the only sign. In some instances there may be congestion of the pia mater, or evi- dences of tubercular degeneration in this membrane and in the contiguous parts of the brain ; but, ajs a rule, the appear- ances are altogether negative. Indeed, in some instances, where the quantity of effused fluid is large, as in chronic hy- drocipalus, the brain has a blanched, bloodless appearance, and the effused fluid is much less rich in solid constituents than the serum of the blood a fact which is somewhat calcula- ted to show that inflammation has no share in its production. In the majority of cases of tumor, the intelligence does not appear to suffer in any very marked manner, and when it is otherwise, it is owing, in some degree at least, to the presence of chronic meningitis. The pain, however, the want of sleep, the depression of spirits, all combine to exhaust the brain, and this exhaustion is generally shown by vagueness in the ideas, by inability to fix the thoughts, or in some other manner. Nor is the pain, which is usually so very prominent and dis- 1861.] Convulsive J) 311 3ing a symptom, an objection to the idea, that the brain is acting inefficiently in these eases, indeed, pain in the head is a sign that the brain is insufficiently supplied with arterial blood, ir ceases, and gives place to delirium, when the arterial injection increases. Nay, in some instances there is reason to believe that the nervous energy is lessened during pain, and that pain may be as much a sign of want of action in a senti- ent nerve as spasm is a sign of want of action in a motor nerve. At any rate Professor dn Bois-Raymond has shown that the nerve-current in the nerve of a frog fails when the cutaneous ramifications of the nerve are subjected to a treatment which must give rise to pain. But be this as it may in other instan- ces, in tumor of the brain it must be difficult to regard pain as a sign of over-action, for the companion symptoms during life, and appearances after death, are alike opposed to such a conclusion. In induration of the brain, there is as little evidence of any excitement in the mental faculties as in any of the previous cases, probably less ; and the condition of the brain after death affords no countenance to the idea of inflammation, for the brain is harder, darker in color, drier, more bloodless than it ought to be. In cases of atrophy of the brain, where the condition is con- genital, the probability is that the patient is idiotic as well as epileptic. In cases of hypertrophy of the brain, which cases are occasionally met with in children, while the bones are suf- ficiently yielding to allow expansion in the enclosed organ, the patients have not had any other inconvenience beyond the deformity a taint argument, possibly, that want of brain and therefore want of cerebral action, had really to do with the convulsion which would seem to be a constant phenomenon in atrophy of the brain. A person suffering from congestion of the brain is less "bright" than he was, his conceptions are wanting in clear- ness, he is deficient in the power of attention and spplication, his sight is dim, his hearing dull and perplexed with ringing or rumbling sounds, he is drowsy, and feelings of weight in the head and pain arc familiar .troubles. Everything, indeed, indicates an oppressed and inactive brain. In apoplexy, the mental antecedents are those of congestion ir softening, not of inflammation as such. There would, in- deed, appear to be a strange absence of inflammatory tendency in the brain in apoplexy; and if there are any evidences of inflammatory action around the clot, it will generally be found that this action was anterior to the hemorrhage in point of ! 1 1 2 Lee lures mi f Apri ] , time that, in fact, the blood had escaped in consequence of a previously softened state of brain. It is possible, also, that an argumenl in favor of a tendency directly opposed to the idea of inflammation may be found in the fact pointed out by M. M. Andral and Gavarral, that the blood in apoplexy is deficient in fibrine ; for if the effect of inflammation be to increase the amounl of fibrine contained in the blood, it may be supposed that a deficiency of fibrine indicates a state of things which is the reverse of inflammatory. Nor is there the least reason to believe that any over-action of the brain is concerned in bringing about the convulsion which is connected with inflammation of the brain. In simple meningitis, convulsion may attend upon the very onset of the disorder. In this case, it coincides with the cold stage which ushers in the true inflammatory reaction, a stage of which the mental signs are, depression, confusion, perhaps drowsiness. Or convulsion may attend upon the period of final prostration which follows the true inflammatory reaction, a period in which the mind is rapidly sinking towards a state of coma. Convulsion may occur at one or other of these times but it never occurs in the true inflammatory stage, when the pupil is contracted to the size of a pin's head, when the im- patient sensitiveness of the eye and ear is scarcely to be quiet- ed by absolute darkness or silence, and while there is agoniz- ing pain in the head or fierce delirium. hi tubercular meningitis the acute pain, the wild delirium, the intolerance of light or sound, which mark the outburst of simple meningitis, are wanting, and the course of the disease is insidious. Inordinary cases, "where the symptom set in thus stealthily, the usual period for the convulsion is after the brain and the system generally have given many unequivocal signs of exhaustion. In other cases, where there may be more marked febrile disturbance, the convulsion may happen in the initial cold stage, or after the febrile symptoms have calmed down and Left the system in a jaded and exhausted state. As a rule, however, the idea of inflammation has as little to do with this affection as with phthisis pulmonalis ; for when the diseased products are examined microscopically, they are found to consist, not of products of inflammation, but of the well-known elements of ordinary tubercle. In rheumatic meningitis the convulsion observes the same rule, occurring either in the initial cold stage of the fever, and preceding the accession of the violent pain and delirium, or else waiting until the excitement has passed off, and. the patient 18 left drowsy and semi-comatose. L861.] Cbnv '' i 313 In general cerebritis anything like wild delirinm or acute pain in the head is absent, unless the affection is complicated with meningitis; and the characteristic state is dulness and drowsiness, rapidly progressing into typhoid prostration. In partial cerebritis the course of the disease is less rapid, and the downward progress may be interrupted by pauses of longer or shorter duration, but in other respects its characters are the same. From beginning to end, in either case, there are no evidences of an excited condition of brain to be gather- ed from an analysis of the mental phenomena, or at any rate there are no such evidences at the time the convulsions make their appearance. In fever, convulsion may precede the establishment of the febrile excitement, in which case the mental state is one of great depression, oppression, prostration, stupefaction. In other words, it may occur in the initial period of collapse or rigor the cold stage ; or it may occur in the final period of prostration, when a few incoherent mutterings are the only traces of the previous delirium when the last traces of men- tal action are rapidly succumbing to the drowsiness of ap- proaching death. It may occur at one or other of these times, but not during the active period of fever. In epileptiform convulsion depending upon retention of urine, the patient before the attack is drowsy, stupid, listless, despondent, his eyesight dim, his hearing dull, his speech drawling ; and in convulsion depending upon retention of bile, delirinm is at an end, and drowsiness has beceme well-nigh comatose before the time for the attack has arrived. In difficult dentition the brain is exhausted by pain and want of sleep, and drowsiness is taking the place of fretful- a and wakefulness before the occurrence of the fit ; or if there be any cerebral inflammation, the tit follows the rule which has been already laid down. In worms, and in other forms of irritation in the alimentary canal, the mind as well as the body is not braced up to the proper pitch of health, and the patient is jaded, irritable, and drov. In convulsion arising from ''uterine irritation" the mental state is that which belongs to either epilepsy or hysteria. In the convulsion of flooding the pupil is dilated, the thoughts are undefined and incoherent, and before the tossingg change into convulsion the last trace of mental action has died out." In the other convulsion occurring during labour the brain is exhaut pain and straining, and upon the point of lapsing into a Btate of coma when the convulsion happens. 314 ProstatorrhcBa. [April, In the convulsion of true puerperal lever the mental con- dition is the same as in the convulsion of ordinary fever. And, lastly, the epileptiform convulsion referred to "sexual irritation" has the same mental accompaniments as ordinary epileptic or hysteric convulsion, one or other. Nor can there be any doubt as to the condition of the brain connected with the moribund state. In death haemor- rhage or asthenia, mental action fails pari passu with the flowing of the blood out of the vessels, and the sufferer has become altogether insensible to pain and trouble before he is seized by the convulsion. And when death is brought about by suffocation, whether slowly or rapidly, it is no less certain that all mental action fails pari passu with the failure in the respiration, and that the last spark of mind has vanished be- fore the time for the convulsion has arrived. Whenever epileptiform convulsion makes its appearance, therefore, the attack is preceded by some evident failure in mental energy, and in several instances this failure is almost or altogether complete. Nor is it possible to suppose that this state of inaction is confined to that part of the nervous system which is the scene of mental life ; for the depressed or op- pressed state of the circulation which precedes the attack in- volves a corresponding degree of inaction in the complete chain of nervous centres. In a word, there is nothing in the history of epileptiform convulsion which is not in perfect accordance with the history of simple epilepsy, or which may not be interrupted in the same manner. (to be continued.) On the nature and treatment of Prostatorrhra. By Professor Gross, of Philadelphia. J Vostatorhoea is denned to be a discharge from the prostate gland, generally of a thin mucous character, dependent upon irritation, if not actual inflammation, of the component tis- sues of that organ. It has generally been confounded with other lesions, as gleet, or chronic urethritis, seminal losses, and cystorrhcea, or chronic inflammation of the mucous membrane of the bladder. It does not often occur among children or old people, but is most common during the ac- 1861.] Prostaiorrhasa. 315 tivity of the sexual organs, and is most frequently met with in those whoso sexual propensities are the strongest. The exciting causes are not always evident, but the disease lias generally been traceable, either directly or indirectly, to venerea! -, chronic inflammation of the neck of the Madder, stricture o{ the urethra, or some affection of this canal ; it may have its origin in diseases of the rectum, and the me ot internal remedies, as cantharides; turpentine, may excite a temporary prostatorhoea ; a common cause in young men is masturbation. The symptoms are a discharge of mucus, generally perfectly clear, ropy, varying from a drachm upwards in twenty-four hours ; in efforts at defeca- tion the flow is greatest. It is attended, also, with a pleasurable, tickling sensation sometimes. Prostatorrhoca may be distinguished from urethritis by the gradual super- vention of symptoms, the transparency of the discharge, the absence of charges in the urine, or difficulty in micturition. The pathology of this affection consists in a disorder of the follicular apparatus, leading to an inordinate secretion oi its peculiar fluid. This may be due to inflammation, but in some instances the organ appears to be entirely healthy, in which case it is supposed to be due to a heightened func- tional activity. The prognosis is generally favorable, as this affection is not a disease, but a symptom of disease, usually slight, and easily removed ; it is often, however, very obstinate, and when the mind deeply sympathizes with the local affection is very difficult of management. The treatment should be directed to the removal of the cause, and to this end there should be a thorough exploration of the genito-urinary apparatus, the anus, and the rectum, and a careful inquiry as to the habits of the patient. If he is weak, gentle exercise, nutritious diet, wine and tonics arc indicated. The tincture of the chloride of iron in union with tincture of mix vomica is especially recommended ; if he is plethoric, the antimonial and saline mixture is useful; the most useful topical applications are cooling and anodyne injection* ulard's extract with wine of opium in the proportion of one or two drachms each in ten ounces of er, three times daily; in obstinate cases, cauterization i a week may be necessary; the cold hip bath is also important, and if the symptoms do not yield, leeches should be applied around the anus and to the perinreum. 3 16 Goitre, [April, On the treatment of GoUreby the external application of Biniodide of Mercury. I>v Dr. Frodsham, Physician to the Farring- don < General Dispensary. Dr. Frodsham reports veryfavorably respecting this plan oftreatmenl :i plan to which we have already directed at- tention ("Abstract," XXVI, 150), as having been carried out with marked benefit in India, by (/apt. Cunningham, of the 11th Irregular Cavalry. "I have myself," says our author, "had considerable op- portunity of testing its efficacy, and always with a most for- tunate result. A certain amount of difficulty is, however, experienced in its application, as the influence of the solar rays appears to he absolutely essential to its curative action, and therefore in this country it can only be adopted with perfect success during a few of the summer months. The following is the plan I have invariably pursued with the patients under my care: . "An ointment of the biniodide (biniodide of mercury, six- teen grains ; lard, one ounce) has been first rubbed into the swelling for several days. Then seizing the opportunity of a powerful mid-day sun, the patient has been exposed to its influence, the throat being thoroughly smeared with the same application, and the head well elevated. It is gener- ally borne for upwards of an hour, when a severe sensation only of blistering is produced. The patient should then be allowed to return home, and cautioned not to rub off the ointment. "Dr. Moreal suggested the application of artificial heat; and thinking it possibly might have a similar influence, though in a modified degree, I made several experiments, though, I regret to say, with but little success. In one case I caused the patient to sit before a large fire; in another, I held a hot flat-iron a short distance oft* the swelling. In the latter case, the pain was so great as to demand immediate discon- tinuance. "Some of the cases in which this treatment was most eminently successful had been of long standing, and all the usual remedies, both internal and external had been tried in vain. One woman had Buffered from the swelling for tour years, and for upwards of one year had been taking the iodide of potassium internally, and applying the iodide of potassium ointment externally, but without deriving the Blightest apparent benefit. The biniodide was only applied e ; and before the expiration of a month a diminution of 186L] Delirium Trent* 317 two inches, by measurement, in the Bize of the tumor had taken place. At the end of six months no Bign of the form- er disease was perceptible, "The superiority of this mode of treatment consists in its great cleanliness, its not discoloring the skin, and causing no external breach of surface, together with its speedy remedial action (one application generally sufficing). As to the modus operandi, whether it is due to rapid absorption or to chemical changes, is, I believe, as yet undecided." On Delirium Tremens. By Dr. Jeffrey A. Marston, Assist- ant Surgeon, Royal Artillery, Maine. [The following paper by Dr. Marston is a most sensible one, and they wrho are now treating all cases of delirium tremens without alcohol will do well to consider it. Few are more strenuous advocates of total abstinence from all stimulants than ourselves in cases of health, but in certain diseases we have found it indispensable to carry the patient over certain periods of exhaustion. Dr. Marston says : First of all, let us see that our terms are precise and clear. I would say that there are three separate and distinct forms of the disease in (question ; that if any one plan of treat- ment be pursued in all, and if, without reference to their distinctive features, they be individually and severally heaped together under one head, we can obtain no reliable data. Xot a little misconception, it seems to me, has arisen from this very source: I. Delirium e potu, or Delirium Ebrictatis properly so called. II. Delirium Ebriosorum. penal III. Delirium Hepatic complicated < Gastro-Enteric > Diseases, with Cardiac ^Central J 1'rofessor Todd, in one of his clinical lectures, has some admirable remarks upon the two first forms, and their dis- tinctions. The first I would illustrate thus : It happens in the younger and more acute drunkards (if I may so term them.) The disease follows quickly after a debauch within 21 or 48 hours. The symptoms are the tongue 318 Delirium Tremens. [April, very foul and tremulous; great headache; face rather flushed : tenderness often upon pressure of the epigastrium; nausea; sometimes vomiting ; perfect anorexia ; sleepless- ness; tremors; hallucinations; illusions; restlessness; an excited manner; a quick, sort, and tolerably full pulse; and often t lie re is present a smell of spirit. Now, these - are by far the most frequent. The disease occurs in a man whose means prevent a regular steady soaking, but in one who drinks very hard whenever his pocket allows it. I [owever frequently this may be, there is always a good and distinct interval weeks or months. The subject of the disease goes in for a heavy night or so at a time his money is exhausted he does or does not go to prison, but at any rate he does not drink again for some period, for the best of all reasons want of means. Here is the ordinary form of the disorder : An acute alcoholism the drink being in the man. An emetic purgative, with quiet and repose for two or three days, sets him all right again. The second form is a delirium of drunkards, in contra- distinction to a delirium from drink. The illustration of this form will be : The subjects of it arc older have the outward and visible signs, and bring the history of a habit of drinking; hard drinking indeed, if the aggregate be looked to the steady weekly consumption of spirits, to wit but less hard than the first variety in a given space of time. Those men who have kept out of the guard-room, and are shrewd enough to keep aloof from their officers ; bear a good regimental character; arc seldom, if ever, in hospital ; and although long suspected in the regiment of being secret drunkards, yet are only proved so by some ac- cident as turning out at night to a tire or admission into hospital lor some trivial disease. At last he is caught, and lodged in the guard-room ; or by some means or other he is with all suddenness deprived of his drink ; and delirium tremens sets in, appearing from the second to the seventh day after confinement, while perchance the man is awaiting his court-martial. In short, you get the history of a man who has drank for years and years ; during which time he has performed his duty under sharp supervision, and has not suffered from any disease, lie is deprived suddenly of his stimulus, and takes delirium tremens. Complicated Form. This variety will take in the various symptoms of any organic disease present, and complicating 1861.] Delirium Tremens. 319 the case. It would be impossible and needless to enume- rate the various complications, further than to remark that that their recognition and diagnosis is all important ; the difficulty of their treatment very great ; and that the mor- tality tar exceeds that of the other and simpler forms of the disease. The visceral or glandular derangements become evident for the first time during the attack of delirium tremens the man never having been before in hospital and are then only arrived at, from the fact that some unusual symptoms, as convulsions, jaundice, oedema, persistence and peculiarity of the delirinm, or albuminous urine, make them apparent. The treatment of such cases must necessarily be modified according to the diseased state and its indications. Having premised this much, let us turn to the points in dispute, which appear to be : That the theory of the causa- tion or etiology of the disease hitherto propounded is wrong, its pathology wrongly stated, the indications for its treatment misunderstood, and the special modes of treat- ment themselves (particularly that by opium and stimulants) have been erroneously and injuriously pursued. It is often better to watch than correct, and I would ask how many cases classed under the first form have be enumerated with the second and third varieties ? I fane that by far the larger number of the so-called statistics con- sists of individual cases of the first form, and if so, the generalization from them cannot fail to be vitiated, when applied to the whole disease. Dr. Watson expressly says, that some cases occur after a long debauch, and others in which the patient has not ab- stained, but is continually fuddled ; and here the disease arises because the man goes from his ordinary positive to the comparative degree. There is no doubt that those cases are numerous, and their plain inference is "poisoning;" but so much has been made of them, as virtually to exclude the occurrence of other forms. FMology. Taking the objections seriatim, the etiology ; Watson says, the predisposing cause is drink; the exciting cause, the privation of it. Against this view there is urged the frequency of the disease following a debauch, &c, with- out any privation ; in short, the frequency of the first form. Such frequency it is argued, proves the disease to be the result of poisoning, and the sufficiency of the poison alco- 320 Delirium Tremens. [April, no! to form at once the exciting and predisposing cause. The occurrence of some disease, such as catarrh, influenza, gastric disturbance, in a drunkard, may he also an exciting cause. Lastly, the statistics of prisons are against the theory, it is said, of privation. The first objection is shortly this, that we have proof of one cause (toxaemia from alcohol) being sufficient, and hence it is unphilosophical to seek a second. I can only meet this by stating, that there are dif- ferent forms of the disease, which may have different causes, nay, a plurality of causes. Besides, I shall adduce positive evidence of the disease following the withdrawal of alcohol. With regard to prisons, I can only speak of military ones. No cases occur in them, I am aware, and am not suprised at the fact; hut they occur antecedently, coming on in the guard-room, where, if a man be tried, he awaits his court-martial, probably for many days ; and I state as a fact, that, cases of delirium tremens commonly occur from the first even to the seventh day after the priva- tion of liquor. The guard-room statistics would hence be every bit as strong the other way. I am aware that statis- tics do not settle the fact, they do not prove cause and effect, viz : deprivation of accustomed stimuli as a cause of delirium tremens ; but they cannot certainly be urged against it, for they support at least the view of this priva- tion being frequently an antecepent to the appearance of the disease. Is it a necessary antecedent ? I believe it is in some cases. Take the following : Sergeant D., ?et. 39 years in daily expectation of a good- conduct medal. Admitted April 13, suffering from a small boil upon the lobular appendage of the right ear ; in per- fect health apparently. Upon the afternoon of the 14th, I noticed that he was very tremulous and nervous, and asked him privately about his habits. lie denied m the most positive and awful terms, that he drank hard, and refused my offer of a glass of brandy. Upon the morning of the 15th, I learnt that he had slept badly, and found him suf- fering from a decided attack of delirium tremens. He talked incessantly, was bathed in perspiration, had illusions, and fancied he saw strange animals, and heard strange noises. His tongue was coated, and very tremulous ; the eves ferrety, the pupils moderately contracted. lie was or- dered a sharp purgative, and cold douche to the head, fol- lowed by a basin of beef-tea. At 12 noon he took 33 of Laudanum, but was sick, vomiting nearly it all ; at 2 p. m. 18G1.] / >> It'rium Tremens. 321 lie had some warm brandy and water, with 5js of lauda- num, which he kept down ; about 3 p. m. lie had more -tea, and said he thought he should sleep, lying down for that purpose ; I happened to be in the ward at the mo- ment, and my attention was arrested by his livid face and heavy breathing. In about a quarter of an hour he had an epileptiform convulsion ; two or three followed after a short interval, and in about three quarters of an hour he died with symptoms of apneea. Besides cold douche, artificial respiration by Marshall Hall's method, and enemata of brandy, were tried without avail. The post-mortem. wras made most carefully by myself, and I could detect no organic disease to account for his death. The left ventri- cle of the heart, however, was in an advanced degree of fatty degeneration ; and, besides some venous congestion of the membranes of the brain, there were a few drachms of fluid in the cerebral ventricles. Xow, I would remark how strong is the tendency of the evidence, negative and positive, of the facts here. A man is entitled to a good-conduct medal which presupposes eighteen years' absence from the defaulters' book as regards courts-martial. I learnt from his wife, subsequently, that for six or eight years he had drank very hard, and that, al- though she had never seen him drunk, yet she could not say that he was ever perfectly sober any night ; that she did not remember his ever having been in hospital, or suf- fering from any disease. He comes into hospital, is de- prived of his liquor directly, and in fifty-six hours is dead. This appears to me a strong case, but it is not by any means an isolated one ; and others, equally positive, will be cited, tar more than sufficient to meet the logical requirements of one grain of positive against a bushel of negative evidence. Pathology. Dr. AVatson's views may be epitomised thus : The disease is "Exhaustion with nervous irritation ;" the remedy, "sleep." Against this is urged the toxemic view, and the positive chemical evidence of the presence of alco- hol in the cerebral ventricles, and that sleep is an effect and siirn of the improvement in the disease, and not the cause ofit Dr. Watson uses his terms advisedly. He does not pass them for more than they are worth. Are there not certain acquired physiological conditions or states of system which produce uncontrollable cravings and desires ? and are not se eravincrs instinctive desires of a need felt by such an 21 322 Delirium Tremens. [April, abnormal system ? and supposing them unyielded to, do we hot get nervous exhaustion and depression ? Is it true that horses fed upon arsenic fall into a had state of health when its exhibition is discontinued ? The facts related of the Styrian and Hungarian peasantry relative to their frequent sc of arsenic, and the evils which almost invariably arise om its discontinuance ; the almost universally spread in- stinct in man to the use of narcotics, stimulants, &c, (such as opium, betel nut, tobacco, cocoa, with the rest); the growth of the custom into a habit, and the way in which men are impelled to the continuance of that habit, from the fear of the chain of morbid phenomena which follow the cessation of it ; do not these run very parallel to the facts we observe from the use and abuse of alcohol ? Chossat's experiments upon the effect of starvation on animals would indicate that the nervous tissues undergo remarkably little relative loss compared with the other tissues, in spite of the great quantity of fat they contain, and their almost fluid consistence. This has been held to explain the cause of the curious psychical phenomena preceding death by starvation. Restlessness, delirium and prolonged sleeplessness, are common precursors of death in such cases. Xow it will be said, that no analogy can be established between such cases and the same phenomena following the withdrawal of alco- hol. But I am not convinced of that. The whole doctrine of diets, however satisfactorilyjit maybe settled on a chemi- cal basis, is decidedly not settled upon equally certain phy- siological data. We have facts in abundance to prove that the chemical value of food is not the physiological one, and that both man and animals live and grow upon substances, and in proportions, perfectly different from what a chemical view would indicate or conceive possible. When we ob- serve how spirit is meat and drink to a drunkard ; how his Bystem affords the proof of an altered and abnormal nutri- tion ; how, in short, he has a special physiology of his own, ins to me a natural and rational consequence that the poison to him is no poison, but, on the contrary, a special fuel lor his nutrition and development albeit, dis- eased. Liebig has shown how the chemico-physioiogieal theory oi the action of stimulants upon the human system, is in accord with the actual experience of landlords and others, viz : that a far larger amount ^[' food is consumed by the abstainer from alcoholic fluids, than by one who par- takes a moderate quantity of them. It seems to be a well- 1861.] Delirium Tremens. 323 ertained fact, that alcohol economises the food and tis- sues, by arresting the amount of secondary metamorphosis. Then Ave have the influence of the custom producing a habit, and its known effects upon the body. Can any habit be suddenly discontinued and broken without some, nay, even a grave effect upon the nervous system ? There seems to me to be no end of evidence to prove that the sudden curtailment or withdrawal of any habit may produce nervous exhaustion ; and if so, why, irritability is a necessary concomitant and index of that condition ! In regard to sleep. A drunken sailor knows very well that if he can "sleep it off," it is the best and most natural way of terminating his fit. Xo doubt the tendency to sleep is a sign of improvement in a case of delirium tremens. Dr. Watson and others urge that sleep is the necessary pre- cursor of improvement ; but if I understand the objection raised to this view aright, it amounts to this, that before a patient recovers from delirium tremens, and as a sign and effect of his improvement, he sleeps very probable ; but I am sure the jwst hoc is often a propter hoc, viz., not that he sleeps after he improves, but he improves because he has slept. 'se. G. S., aged 30, admitted June 8, 1858, from the guardroom, where he had been confined two days. Had been for years a hard drinker. It was stated (but not upon reliable evidence), that prior to enlistment he had been con- fined for a few months in a lunatic asylum. Upon inquiry it was found that he had been drinking very hard for some days, and that the debauch terminated about three days prior to his admission into hospital. He was laboring un- der all the symptoms of unmistakeable delirium tremens. After the administration of a purgative and a saline anti- monial mixture for twenty-four hours, without any amend- ment, opium in grain doses was commenced, and continued until his pupils became somewhat contracted, when it was omitted, itc was allowed milk diet, with a basin of soup at bed-time. Forty-eight hours having elapsed in hospital without any sleep, and his delirium, tremor, and symptoms of exhaustion augmenting, it was determined to give him chloroform, for which purpose another assistant surgeon with myself, alternately, sat at his bedside all night ; and he was kept, at intervals, under its influence for eight hours, during the greater part of which time lie slept soundly. At the expiration of this period he awoke, and .".-I Delirium Tremens. [April, i-i partook of some broth. lie appeared far less tremulous, had lost his rapid delirious conversation, but retained his suspicious manner, and was evidently haunted by illusions. After some interval he was again put under the influence of chloroform, and slept for four hours deeply. Awaking, Jem he was still more rational and restored ; and after drinking two bottles of porter, he spontaneously fell asleep. In this state lie continued six hours, and awoke rational and well, lie was retained in the hospital for some period, on account of some dyspeptic symptoms and boils, and with the view to invaliding on account of his uncontrollable habit of drinking. This man was a dipsomaniac indeed. I think I never beheld features so expressive of a true drunkard in my life. During his fits he seemed to have labored under certain dominating passions, and these had left such im- pressions upon the facial muscles as to have permanently altered his whole physiognomy. Xow, here we have a case of delirium occurring in a chro- nic drunkard, who had been deprived of his stimulus for two days. lie is admitted into hospital, and does not sleep, his symptoms becoming worse ; by the aid of chloroform he slept for six or eight hours improves and by the ad- ministration of more chloroform with the aid of porter, he sleeps again, and is cured. A. B., a mess sergeant in a line regiment, had always been suspected of drunken habits. One day he absconded with some money, was caught, and confined to the guard- room. Whilst there, he became the subject of delirium tremens, and was brought to hospital, with the history of having endeavored to poison himself with arsenic. This case was a very severe one, for the patient had an ever-pre- sent sense of his crime, a fear of punishment, and was, moreover, suffering from all the symptoms of the disease. Numerous means were used (including opium) without any benefit, and a fatal prognosis was formed of his ease. The regimental surgeon administered chloroform by inhalation, and procured artificial sleep for many hours. The man awoke so much improved, that its administration was re- commenced, and he was quite restored by its aid. Here we have the symptoms continuing for a certain pe- riod without any improvement, while induced artificial ( or narcotism was attended with such marked improve- ment as to have impressed the medical attendant with the belief that his patient owed his life to the chloroform. 161.] Delirium Tremens. 325 It would be tedious to cite other cases proving the same ing. I conclude from them, that to procure sleep is and, excellent advice, the i:ood effects of which arc borne t by actual experience. Treatment. The use of stimulants (alcoholic) in cases oi tlirium tremens with the view of removing the exhaustion, laying the morbid irritation, and procuring- sleep, would 1 looked upon as even more wrongly directed. If the iology usually propounded be radically and totally erro- ^ous, then Ave are guilty of adding more poison to an al- ady poisoned blood, to procure what is not needed, and hat the presence of alcohol in the system is preventing sep. G. M., aged 45, but grey, and looking much older, was Imitted into hospital for some gastric disorder. This man is, and had for years been, a very hard drinker, and his itures, particularly the nose, indicated "potations deep." :ie morning (after he had been in hospital for some days) vas called to him. He appeared insensible, was breath- very heavily, the face and lips dark and turgid, the ipils contracted. "Whilst examining him he had a coll- ision of a tetanic character, the body being arched in the isition of opisthotonos. The muscles of the fore-arm 3re so tense that the radial pulse could not be felt. The sarts' impulse was scarcely perceptible. Having thrown bucket of cold water over the head, I took advantage of few moments of apparent consciousness to pour a glass of )t brandy and water into his stomach; and he recovered most immediately, so much so, that the medical officer, hose patient he was, could scarcely credit the state in Inch I found him. G. P., aged 3G, admitted April 14, 1858, from the guard- om, where he had been confined two days. His disease is unequivocally delirium tremens, and no remedial mea- res seemed to benefit him. He was tremulous, restless, lirious, and did not sleep even with the aid of the fresh ad- pistration of opiates. Two bottles of porter were given him bed-time, and he was observed to smoke during the day lie strong tobacco. His hands were so tremulous that the :lerly had to hold the pipe in his mouth. By these means slept and slept well, and made a good recovery, after hav- been dosed unavailingly for four days previously to pro- re that result. At this moment I have a soldier in hospital who has always 326 Delirium Tremens. [April* drank freely. He lias been under treatment upwards of eight days for trivial bronchitis, and symptoms of incipient delirium tremens appearing now, necessitate the use of alcohol and opium with manifest advantage to the man, as regards sleep, appetite and the disease itself. These cases illustrate two points : the actual occurrence of delirium tremens, after and during the privation of liquor; and the speedy removal of the symptoms by the re-establish- ment of the custom, when other means failed. I have purposely selected these cases, because they illus- trate also the fact, that whilst the men were taking their ac- customed stimuli, they continued well, for they were men who never appeared at hospital at all. I shall not give cases of apparent cure by the adminis- tration of opium, as they can be found in any work ; and, after all, they are no proof that your patient recovered by the treatment, but, perhaps it will be urged in spite of it. The most curious cases are those in which the delirium con- tinues for a long period, but in a modified degree ; the patient sleeping tolerably every night, eating and drinking, and per- forming all his functions well. It is well to look out here for some complication (particularly renal or hepatic disease) for it is surprising how small an amount of urea circulating in the system may give rise to a persistence of anomalous symptoms. Besides the ursemic, we have a peculiar and difficultly treated form of the disease when jaundice is present, whether arising from fatty degeneration, cirrhosis, or other hepatic disease. These cases, of course, are more frequently fatal ; but I find that, after local depletion, purging, or diuresis, stimulants, more particularly gin, are not only not contra-indicated, but are decidedly useful, more particularly if the patient be an old chronic drunkard. The most fatal form by far is that in which we have deli- rium tremens occurring in a person already the subject of ty- phoid fever cases by no means uncommon in this climate. Having separated, however, these cases, there will remain many in which a chronic derangement of the nervous system is manifested, the patient sleeping night after night, for longer or shorter intervals, and performing all his functions well. In a few cases, opium given in full doses at bed time will secure a deep sleep and manifest improvement. In others, a liberal but regulated allowance of stimulants will prove ad- vantageous, when everything else has been tried in vain. In some, do plan .of treatment will succeed, although the patients frequently reaocrer gfibei a Jong fnteryaj, while others lapse 1861.] Delirium T 327 into chronic mania, melancholia, or some form of Insanity, ending their days in a lunatic asylum. With reference to that singular phase of our mental life- sleep, Sir Henry Holland advances views which my observa- tion of the sleep of delirium tremens patients lias led me to think perfectly truthful. He is of opinion that sleep is not a unity of state, but a Beries and succession of states, ever varying from moment t< moment These variations having every degree of diversity, from complete wakefulness to the most perfect -hep of which we hove cognisance. It has long occurred to me that the p of drunkards, and in delirium tremens, differs much from the normal standard of intensity. Every one must have experienced in his own person, whenhe was anxious to awake at a certain hour, how he awakes at that time with a feeling that he has not slept well, or at all, although he may he as- sured that he has slept very soundly. Sir \\. Holland's observations are so good upon sleep and dreaming, in relation to delirium and insanity, that I shall quote his words : "I know of no principle so capable of afford- ing a guide, as that which views all the forms ot' insanity, in- cluding delirium, in their relation to corresponding healthy states of mind, tracing this connection through those interme- diate grades, which are so numerously exposed to us in the various conditions of human existence. The diversities of mind in what is accounted its healthy state, the effect of pas- sions in suddenly altering its whole condition, of slighter emotions in gradually changing it, and of other incidents of life in affecting one or more particular faculties ; its subjection periodically to sleep, and casually to the states of intoxication, somnambulism and reverie; its gradual transition in fever from a state where there is consciousness of vague and wan- dering ideas to the state of perfect delirium ; all these furnish so many passages through which we may follow sanity into insanity, and connect the different forms of disordered intel- lect as well with each other as with the more natural and healthy functions of the mind." To sum up, I would say that the first and most frequent form an i liers of this disease requires rarely indeed opium, particularly at the commencement of the attack ; in short, no specific treatment is necessary. In the second variety, J would give it cautiously in moderate doses, after free purgation, provided I did not find my patient improving by and tranquility. The opium had better be given at any rate in a full fore the accustomed hour of sleep. Should it 328 Opening the Joints. [April, not succeed, my experience would indicate a "hair of the dog that bit him," in the shape of porter or hot brandy and water, spite of what has been urged to the contrary. If the surgeon avoid both opium and stimulants, and his patient goes on badly, depend upon it the chances are in favor of another doctor ad- vising one or both these noxious agents, with much advantage to the patient, to the no little chagrin of the first medical at- tendant. Where great irritability of the stomach is present there is nothing better than a sedative dose of calomel (gr. vj.), with or without opium, and a large enema. Supposing the physiological effects of opium upon the system to be manifested, without sleep, or improvement following, I should omit its use for some hours, give my patient some good broth, flavored with brandy or wine, and induce artificial sleep at night by the aid of chloroform. I trust it will be seen that the use of opium is advocated as a measure requiring discrimination and caution, but as a re- liable one in many instances. Of course the complicated forms require that the greatest discretion should be exercised in its administration. Where an embarrassed circulation exists, marked by venous conges- tion of the mucous membranes and duskiness of the face, it is better avoided altogether. Pulmonary emphysema, if exten- sive, cardiac disease, or indeed any thoracic complication, will require also great care, if they do not indeed prohibit opium in any form. Edinburgh Monthly Journal. On Opening the Joints. On Opening freely the large Joints for the purpose of Discharging Purulent Matter, as well as for the Better Treatment or Ulcerations of the Articu- lar Surfaces. Remarks upon the Inocuousness of Atmos- phere admitted into the Joints, &c, &c. By E. S. Cooper, A. M., M. D., Professor of Anatomy and Surgery in the Medical Department of the University of the Pacific, San Francisco. This is the first of a series of articles I design publishing on purpose to show truths which, for the most part, are in direct opposition to all established authority upon the sub- ject, and are as follows : 1st. That admosphere admitted into the joints or other tissues is not a source of irritation or injury, excepting where it acts mechanically ; as when admitted into a vein 1861.] Opening the Joints. 329 by producing asphyxia, into the thoracic cavity "by its pres- sure producing collapsion of the lungs, or when, by the long-continued exposure of a large amount of surface of any of the internal organs whose normal temperature is much above that of the atmosphere, it reduces it so as to pro- duce a morbid action. 2d. That the division of entire ligaments about the joints, is not only no impediment to their ultimate strength but facilitate the cure by enabling the surgeon to open the af- fected part fully, for the purpose of applying medical sub- stances to the articular surfaces when these are ulcerated or otherwise diseased. 3d. That the only true mode of treating ulceration of bone, however slight, within a joint, is to lay it open freely and apply remedial agents directly to the part affected. 4th. That opening the joints early in cases of matter bur- rowing in them is far more imperiously demanded than the opening of other parts thus affected, and the operation pro- duces no further pain or inconvenience to the patient, in any respect, than when performed upon parts remote from the joints. 5th. That after opening a large joint, the knee, for in- stance, by an incision several inches long, the wound should be kept open by the introduction of lint or other similar substance until the parts within the articulation become healthy, and in all cases it should be made to heal by granu- lation. 6th. That extensive wounds opening freely the large joints, such as the knee, (even when lascerated as by a saw, which must necessarily heal by granulation) do not as often give rise to violent symptoms as very small wounds, such as are made by the corner of a hatchet, an adz, or a pen- knife, which heal on the outside by first intention. 7th. That there are no known limits beyond which a ten- don or ligament will not be reproduced after division, pro- vided the parts are made to heal by granulation, and that the present acknowledged rule of two inches being the maximus, distance in which the divided ends of a ligament to tendon can safely be separated, has not the least founda- tion in fact. Each of the above propositions has been fully tested by experience in numerous cases, which, during the course of this series of articles, shall be drawn upon a3 largely as brevity will admit. Case 1st. Mr. A. J., set. 29, received a penknife wound 330 Opening the Joints. [April,, in the knee joint, immediately on the outer edge of the pa- tella, which being small and causing little inconvenience, gave him no concern whatever. The wound healed by first intention on the surface, and he continued his work as drayman as usual for two weeks, having nol the least suspicion that mischief was brewing. At the end of that time, however, the joint began to in- flame, and shortly after attended with the most excruciat- ing pain. The inflammatory action rapidly extending, the tissues of the whole joint were soon involved, and in a week more, when I was called, extensive fluctuation could be dis- tinctly fell not only about the articulation, but in the lower part of the thigh. Chloroform and morphine had been used extensively, affording only temporary relief from the in- tense pain. The case being a common one, I at once opened the joint freely by two incisions, eight inches long each, just back of the patella, on the internal and external side of the leg, which gave exit to nearly a quart of purulent matter, which was burrowing in the joint and lower part of the thigh. The smarting of the incisions had hardly subsided before the patient pronounced himself relieved, and the following night slept as well as if nothing had been the matter. The incisions were filled with lint, wet in an evaporating lotion composed of one part of alcohol and ten of water ; a roller wet in the same was applied all over the limb as tightly as the patient could conveniently bear, commencing at the foot. About 24 oz. of spr. mindereri were given every 24 hours for the first three days, and an opiate administered occasionally. On the fifth day, the wound being in a state of suppura- tion, the cold lotion was discontinued and poultices applied instead. The roller was still continued upon the limb from the foot to the upper third of the thigh, a small opening simply being left at the most dependent portion of each incision. The poultices were applied outside of the roller. The lint was permitted to remain in the wound for about two weeks, when it was removed. Tincture of iodine was applied every day all over the joint after suspending the use of the evaporating lotion. A gentle motion was instituted about the tenth day, and kept up through the major part of convalescence, which lasted about nine weeks, when the patient was able to walk 1801.] Opening the Joints. comparatively well. He improved rapidly after that until very was complete, though the wound was not entirely cicatrized for over five months. Not the least immobility followed in this ease, and the patient recovered completely in every respect. Remarks, In this case a single incision would doubtless have answered the purpose, though not so well as two. The true plan of operation in these cases is not only to discharge every drop of purulent matter that may he collected, hut likewise prevent any more collecting; and free incisions kept well open until the parts inside become healthy, to- gether with a roller tightly applied to the limb, are the means of securing this object. The operation is not a severe one when well performed, as it may be done safely with great rapidity. The knee-joint is surrounded by a large number of ten- dons covered with sheaths lined by bursre mucosa, which on being wounded are liable to cause the burrowing of pur- ulent matter among the surrounding parts, and may there- by give rise to symptoms almost as violent as when the mat- ter forms in the joint itself; and though not so apt to gene- rate a disorganizing disease of the joint, still, if neglected, this often would occur, and it is difficult to ascertain before an operation whether matter has formed internal or external to the capsular ligament. In the treatment, however, it makes but little difference whether the capsular ligament contains the pus or not, so far as the operative procedure is concerned, because it is nearly the same in both cases. The surgeon should be sure that he opens the parts to a sufficient extent to admit of the discharge of all the puru- lent matter that may be accumulated, and it is immaterial whether he involves the joint or not in the operation. It is necessary to keep the incisions well open, other matter might burrow still after the operation, and the worst con- sequences ensue. To sum up, it is the accumulation of purulent matter that is to be prevented or removed in the treatment of injuries about the joints ; and without this, all remedial measures will be abortive, and local, and constitutional symptoms of the highest grade will crime on. jeopardizing the limb, if not the life of the patient. When matter forms between the d< ed facia and capsular ligament, involving the bursa* mucosa lining the 332 Opening the Joints. [April, Bheaths of tendon about the knee, the pain is almost as great as when within the capsular Ligament The bursffi mucoso being tin- same instructure as mucous membranes, are disposed to suppurate under slight inflam- mation ; and being extensive here, pus is rapidly formed as soon as the parts are lighted up by inflammation. Case 2d. M. R. set. -!4, received a wound on the outer side of the knee by the corner of a sharp new hatchet, which gave exit to a drop or two of blood. The external wound was about half an inch in length, and. as it gave him no pain, was not the source of the least anxiety, and the patient continued his employment of day laborer as usual for a week. At the end of that time the knee became painful, which induced him to go to bed. From this time on, for live days, when I was called, the pain he suffered was most agonizing. Finding fluctuation all over the knee, I at once made an incision seven inches long, which gave exit to more than a pint of purulent matter, and with it perfect relief. After the pus had been discharged it was found that the capsular ligament had not been opened, but that the pus had. collected between it and the deep-seated fascia, which had not been freely opened by the knife. After Treatment. The after treatment was the same as in case first, excepting that the tincture of iodine was not used. Gentle motion was instituted, in about one week from the time of the operation, and continued more or less every day, until the patient recovered sufficiently to walk, which was seven weeks. He has since recovered perfectly, without the least weakness or immobility of the joints. Remarks. The incision was made on the outer side of the knee, which is the point of election in all cases where one incision only is made, for the better discharge of puru- lent matter in or about this joint, seeing that the patient nearly always wishes to take a position on his back, with the knees separated, and the diseased limb flexed, which brings the wound on the outside of the knee, in the most dependent position. Without giving this matter due con- sideration, I have occasionally operated differently, but seldom with entirely satisfactory results. In the next two articles I shall give cases ot division and reproduction of the ligamentum patell. American Medical Gazette, 18G1.J Origin of Cow-Pox. 333 Ni to Experiment Regarding the Origin of CowPox. The opinion of Jenner regarding the origin of vaccinia, alternately supported and contradicted by various observa- tions, is at present, at Toulouse, being tested by new experi- ments, of which, Dr. A. Fontan has given the following ac- count, dated Toulouse, May 24th, 1860 : "A happy accident occasioned my passing through Tou- louse at a time when a question of the highest importance waa being submitted to experiment, I mean the question of the origin of vaceinia. The following is an abstract of the principal facts: Some weeks ago, M. Sarans, of Rieumes, observes that several mares brought back to his establish- ment for the second or third time, were affected with the grease (eaitx-aux jambes.) There was a sort of epidemic of the affection, for nearly a hundred horses were found to be suffering from it. The variety of grease was the pustular form. "One of these mares was taken to Toulouse to the veter- inary school, where the learned Professor M. Lafosse recog- nised the true character of the epidemic. He inocculated with some of the matter of these pustules the teat of a cow, in the presence of his assistant and numerous pupils. Soon afterwards, fine pustules made their appearance on the ud- der of the cow. One of the most distinguished physicians of Toulouse, Dr. Cayrel, the official vaccinator of Toulouse, vaccinated with matter from the pustules of the cow, several infants who had never been vaccinated. Well character- ized vaceine vesicles followed, presenting their pearly as- pect, central depression, and rose-colored areola, increasing m size from day to day without any trace of erysipelatous inflammation. A second cow was vaccinated with matter from the first cow, and infants were vaccinated with the matter from the second cow; the results were equally satisfactory as in the former case. At present they have arrived at the fourth vaccination from the first cow, and at the third from the second cow. I was present at this vaccination ; the Lclee were very fine. One was photographed in my pre- sence, with a tolerable satisfactory result. The vesicle pre- ted the most characteristic appearance of vaceinia. When pricked, no purulent matter escaped, but gradually rous fluid oozed out in great abundance, with which several infants were vaccinated. 334 Chronal Laic of [April, "The new matter is very active, and succeeded in the case of a pupil of the veterinary school, vaccinated in infan- cy, and in whom all attempts at re-vaccination had failed. I saw a vesicle in an infant produced by the virus of this pupil, finer and more developed than three other vesicles produced by an ordinary vaccination in the same infant. (Xo doubt the two vaccinations were performed simultane- ously.) -Already thirty infants have been vaccinated at Toulouse. Xo unpleasant symptoms have manifested themselves in any ease ; and in all, the result has been most satisfactory." "Dr. Izarie, formerly vaccinator in Paris, considered the vesicles so good, that he had his son vaccinated this morn- ing with virus from one of the infants." "An official commission has been named by the Prefect to carry out these experiments. A report will be drawn up and communicated in due time. Edin. Med. Jour. A Treatise on a Chronal Law of the Pulse. By Alex. Mc- Bride, M. D., Beria, 0. In 1850, I treated more cases of bilious fever than any pre- vious year. The cases were mostly in and about a marshy district. In the course of the season I observed that dur- ing the principal part of the fever the pulse was, in the men patients, at 96 per minute; in the women generally higher. This was so uniformly so as to attract my attention ; and further observation through the season confirmed the fact ' that 90 in man and 108 in woman was the standard pulse of the season. In cases where there was gastro-enteria, or gastro-cntcric irritation or inflammation, or other special irritation, superadded to the ordinary fever, the pulse rose to a higher point. I further observed, during the same sea- son, that quinine would not interrupt the fever in man, un- less the pulse was at or below 72, nor in woman till at or below 84. My observations this season, 1860, have con- firmed, accurately, the above, having treated numerous - of miasmatic fever. Recently I was struck with the remarkable fact that those numbers which the pulse usually indicated were exact multiplies of 12, and that the stages of increase and dimi- nution were 12; from which I conceived that there must be some exact law of gradation. I began, therefore, a 1861.] the r 335 Belies of careful observations on the pulse of individuals in all conditions, both of health and disease, which resulted in a remarkable confirmation of the conception, and from which observations I deduce the following ehronal law : 1st. The number of pulsations per minute in the adult man, in a state of health and repose of body and mind, arc 00; of the adult woman, 72. There arc a few exceptions, in which they will be found respectively 48 and 60. Both in sickness and health, the corresponding grade of woman's pulse is twelve above man's. '2nd. Uneasy attitudes, and various disturbing causes, vary these numbers. The pulse of men, generally, during business hours, and also of women, is often found from 12 to 36 above these numbers ; hut it is seldom found to re- main long on any other point than one of the multiplies. 3d. The accidental variations from the multiplies of 12 are more common in ordinary health than in fever. 4th. In fever the pulse will always be found, when regu- lar, at 72, 84, 108, 132,144, 156 ; above which last point the patient will die, if a woman, and when above 144, if a man. In some exceptional cases the patient will die with pulse not above 108 up to the time of death, or until it is lost. In other cases the pulse will arise to 144 or 156, near the time of death, and then descend with some regularity till lost a short time before death. 5th. The pulse will be found at intermediate points for a brief period during the transit from one point to another, and while thepateint is under temporary excitement, either mental or physical ; but under permanent or continued ex- citement it will settle on a regular point. 6th. The lowest grade of febrile pulse in man is 72, in women generally 84, except in some peculiar typhoid states, when it falls actually below standard. But it is questionable whether fever really exists in such a state. 7th. The pulse of children obeys the same law of grada- tion by 12, though it is often difficult to keep a child quiet long enough to make an accurate observation. 8th. There are some apparent and probably some real ex- ceptions to these laws ; but in by far the most cases, when a pulse is found to vary from these numbers it will settle to the grade above or below in a few minutes except regular sub-grades, which frequently continue longer. 9th. In person- iu ordinury health there will be found more variation when hungry, when greatly fatigued, and Chronal Law of [April, after a full meal, than at ordinary times. Excessive use of tobacco, and other causes which weaken or derange the nervous force, cause irregularity. 10th. A pulse of 84 or 96 is not of rare occurrence in per- sons of ordinary health, during business hours; 72 and 84 arc the most common numbers during the day. 11th. In many cases, hotli in health and disease, the pulse will rapidly increase or diminish in frequency when first manipulated, and in some persons this irritability will continue several minutes, so that it will be found at any ir- regular point between the true point and the grade next above and below; but unless there is some peculiar state or disease, it will generally soon settle on a regular grade or sub-grade. The regular differences of number between ly- ing, sitting and standing, are by grades and sub-grades de- pending upon the nerve force of the individual. 12th. There is a regular sub-gradation by six found in persons of ordinary health, while standing, sitting, etc., and in convalescents: these pulses of 54, 66, 78, 90, etc., but in most cases of short duration. There is also a more tran- sient under sub-gradation sixths and thirds of 12, which gives pulses of 58, 62, 64, 68, 70, etc., as high as 154 ; these are all more transient than the regular sub-gradation by 6. Uneven numbers are of exceedingly rare occurrence. Pulses of the under sub-grades and uneven numbers may all properly be called transition pulses. Remarks. I think the reason we often have pulses re- ported at irregular numbers is, that they are not care- fully counted long enough. Example : An error of count- ing of one in a quarter, or two in the half minute, gives an error of four in the minute ; hence we get 64, 68, 76, 80, etc. An error of one in the minute gives 61, 70, 73, 83, etc., which must generally be erroneous. Another fruitful cause of error is the omission to notice the irregularity of the first ten or fifteen seconds. Since discovering the facts of the above laws I have not seen much of continued fever ; but what cases I have seen were confirmatory. Phthisis, and diseases of the heart, are obedient to the same laws, but for obvious reasons are more subject than fever to transient variation in time. I think any one who has carefully observed in continued fever can call to mind particular cases in which the pulse remained tor days at some of the numbers given above. The following observations will suggest some reasons why this 1861.] the Pulse. 387 t gradation has not been noted by many : Most pi eians examine the pulse without counting by a watch: I many of those who do use a watch count only a minute, or a part ot' a minute, by which means it is impossible to arrive at accuracy. The other qualities of the pulse than its lency convey different notions of frequency through the je of touch, to wit: A very round and tolerably soft pulse, without jerk, bound or vibration, conveys the notion of unfrequeney : a hard, jerking, bounding, or vibrating pulse conveys the notion of frequency. The particular men- tal or physical condition of the observer varies his percep- tion of time, viz.: when one examines a pulse when drowsy, or just after rising from sleep, the pulse seem to him more frequent ; when one is in a hurry it will seem slow, and the like. There is only one way to arrive at accuracy, and that is to carefully and for a length of time count by a watch. The subject is so new that it would be premature for me to attempt many deductions at this time ; but if these are found to be the real time laws of the pulse, the conclusion is obvious that important hints can be taken from them in diagnosis, prognosis, and treatment. I shall only venture the following: L) . I have already intimated that quinine oper- n antiperiodical when the pulse in the two sexes is at or below 12 and 84, which are the lirst fever grades ; but I suppose if the pulse, during an intermission, were, in conse- quence of special excitement, at or above these numbers, the medicine would operate nevertheless. Let it be borne in mind that quinine is an anti-intermittent, and not an anti- Littent, and then it will be apparent why it operates with 1st- below the lirst four grades ; itifl simply because it is an intermission. Then, if this be true, we gain some light on the question of administering quinine in the various forms of continued fever, viz : we need not give quinine in continu with a view to terminate directly the fever, because it is not intermittent. It is continued by some cause over which quinine has no direct control ; and 1 1 1 i may know by observing the grade of pulse; and many will ing the rale, a I; rant of the medi< When we visit our fever patient, and I the pulse averaging below the grade on which it was stationary the previ . we may rest ; that the fever is about abating on grade, at least ; if we find it above 338 Chronal Law of [April, we are sure the fever is increasing by a regular amount. If our woman patient has a pulse of 108, we know that she is not more sick than the man witli a pulse of 96. If the wo- man's pulse arises to 144, we do not conclude that she will certainly die ; but if the man's pulse arises to that point, and above, we announce to his friends that they have no grounds of hope in the case. This at least is the general rule, and the exceptions are few. I give below numerical statistics of observations with tin- prominent peculiarities of each case briny noted. I give the particulars of such a large number of observations, so that it may be seen that I have not formed my conclusions from a partial or hasty view. While engaged in the obser- vations, I have been careful to note all the cases carefully observed, as well as those which give regular grades and even numbers, as irregular and uneven numbers; and it will be seen, in nearly every case where there is an irregu- lar number, that tnere was some reason for it. I have not noted the pulse of all the patients visited during the time, because I could not always have time and opportunity to carefully count the pulse long enough to get its true num- ber. Those persons who were examined in ordinary health were sitting, unless otherwise noted ; others were in bed, or sitting, as noted. My method of examination is to continue the observation in each case till the temporary excitement, if any exists, abates, and then count the beats from one to live or more minutes, and then immediately note down the result and the particulars of the case. In some cases the Note. T do not court controversy with those who talk of curing bilious fevers with quinine, or of breaking up terrible western fevers by giving the quinine in the high febrile stage: I merely say I cannot do it. I know very well that quinine may sometimes, during theparoxysm of an intermittent, and if he does not happen to vomit it up, take good effect during the intermission ; hut 1 never found it profitable to either the patient or mysclfto give it in that way. During one Beason J made numerous attempts to break up remitting bilious lever with the medieine, given both during the paroxysm and the remission : the result was that a good many doses were wasted by vomiting. I concluded that ipecac cheaper and better emetic than quinine, and so hit off that kind of prac- tice. However, in some cases ox bilious fever, where the patient is ooma- witli thick, yellow, hrown, or black coat on the tongue, quinine w ill aid in changing the action. 1861.] 339 minutes gives as true an indication as longer time ; but frequently it requires several minutes. As it is the chronal law that I am aiming to demonstrate no attention has been paid in my notations to any other qualities of the pulse than its cnronal oualities. In my note book the learly all more fully described than in the synapsis; but I deemed it more important to present a large number oi ban to present a few more fully des- cribed; for it is the numerical character aimed at solely, and the larger the number of op 'lited the more near- ly we approach the truth. - my numbers and facts appear tome conclusive, it only remains for the reader to consider whether my observations have been carefully made and faithfully recorded and pub- lished; in proof of which I have nothing to offer but the here stated, and leave it for each person interested to prove by his own observations, which he can do in a very lays, by careful observation. There will be found a larger proportion of irregular pulses in the city than country, for very obvious reasons. [Dr. McBride here adds a tabular statement of more than 100 observations of the pulse, giving in detail t\ic occupa- tion, mdition of health or, disease, etc., etc., of each individual. This table is of considerable length, and we take the liberty, with our press of matter, to crowd It out: remarking, however, that these observations in a remark- able degree confirm and justify the deductions of the essay. Eds.] There are carried out in the table 120 actual observa- tions, which give : Regular multiples, '.til; sub-grades, 8; irregular, 31. Total, !-!!>. Proportion: 2^ regular, \o 1 Bub-grade and irregular. With a view to further confirm or refute the principles declared in the chronal laws, I recently, in November, 1800, carefully made and noted 4o observations, not one of which a regular fever ; 5 were on a woman who had nearly died of monorrhagia, : 3 on a boy with atonic hydrocepha- lus; several were upon persons drinking and smoking, te of whose pulses would oi course be irregular; several upon p> bo had come in from hard labor, riding, .. in cold, windy weather; some hysterical, etc., etc. In nearly every irregular case there was some very obvious causes apparent. They resulted thus: Regular multiples from 00 to 132, b-grades from 54 to 114; 31, 340 Popliteal Aneurism. [April, irregular and under sub-grades from 56 to 98, 9 the multi- ples in this medley of cases being one more than half, and the irregular cases one-fifth of the whole. It will also be seen hereby that there are more irregular pulses at this season of the year than in the fever season. Cincinnati Lancet Sf Observer. Popliteal Aneurism Cured by Digital Compression. By George C. Blackman, M. D., Professer of Surgery in the Medical College of Ohio, Surgeon to the Commercial, St. John's, And St. Mary's Hospitals. In June, 1859, I was consulted by Joseph Humbrick in reference to a large pulsating tumor in the left popliteal space. He was an American, and was 27 years of age. For some years he had been engaged in carting lumber, and consequently was often compelled to sustain heavy weights. He was not aware, however, that he had ever received any injury upon the part affected. About thirteen months be- fore I saw him he suffered excrutiating pain, which extend- ed along the inner part of the thigh and calf of the leg as far as the heel. About three days afterwards he noticed a small pulsating tumor, about the size of a pigeon's egg, in the middle of the popliteal space. His case was regarded as acute rheumatism, and he was treated accordingly. The swelling continued to increase ; and when I first saw him, on the 5th of June, it measured about four and a half inches in the axis of the limb, and five and a half in its transverse direction. It had a pyriform shape, the apex being above. For two months the pain had been severe ; and at the time of his visit he was unable to extend his limbs completely. Having noticed the favorable reports of cases which had been treated by the London surgeons by flexion, I deter- mined to unite this to the combined method of compression, manipulation, and the internal administration of veratrum viride, which I had successfully employed in a case of femoral aneurism of large size. On the 7th of June, after having given four drops of Norwood's tincture, I broke up and dislodged sonic of the layers of fibrin in the sac, by means of pressure with my thumbs and fingers ( Fergusson's mani- pulation); after this I applied a bandage, as recommended by Prof. Dudley of Lexington, in 1818. The foot and leg were bandaged from the toes to the inferior margin of the 1861.] Popliteal Aneuri 341 aneurism, over which a compress was placed, and a still firmer one along the coarse of the femoral artery reaching to Poorpart's ligament These were covered by the ban- dage which extended to the groin. The leg was strongly flexed upon the thigh, and secured in that position. The only effect of the veratrum was to cause an intermission of the* heart's action every thirteenth heat. For an hour alter the manipulation the pain was intense ; but morphia, freely administered enabled him to pass a comfortable night. On the following day, however, the patient became exceedingly restless, and the compressor and bandage became deraged. After a week's trial. Dudley's dressing was abandoned and Petit* s tourniquet substituted. At the expiration of another week this was changed for Skey's. At this time the tumor had diminished somewhat, but still pulsated strongly. Under the use of digitalis the patient's pulse rose from 85 to 110, and it was discontinued. Compression was continued for another week, by the alternate use of the tourniquets above mentioned. The patient now left for his home in Xewport, Ky., the tumor having diminished about one- third in size, but the pulsation being quite distinct. On the 1st of July I requested my pupil, Mr. John Bil- lings, and Mr. Charles Greenleaf, then a medical student, to go to the patient's house and try digital compression at the goin. This was employed for three hours, when the pulsation entirely ceased. On Monday last (February 4th, 1861,) the patient came before the class of the Medical College of Ohio, and declar- ed that his left leg was as good as the right. The contracted and indurated aneurismal tumor can still be felt, by pulsa- tion has never returned. It is a question whether this in- durated mass will ever disappear ; for M. Paget has report- ed an examination of a case fifty years after the cure by ligature John Hunter's fourth patient and even after this long period a hard, olive-shaped mass still occupied the pop- liteal space. Shortly after the treatment of the above case, a patient came under our care having an aneurism of the innominata of small size. Instead of ligating the subclavian and caro- tid on the distal side, I applied Bourgery's tourniquet, or compressor, for the subclavian, while a truss was adjusted to the neck to compress the carotid. Veratrum in this case had a happy effect in moderating the force of the circula- tion ; and with compression above mentioned, I succeeded 842 Post Partum Detachment of th Placenta. [April, in producing a temporary consolidation of the aneurism. In a few hoars, however, pulsation returned, and in the course of fl few days it became again consolidated. Thus alternating, matters progressed for several weeks, when, after trying digital compression for some hours, at era! trials, it became evident that all our efforts were in vain. The patient left the country, the tumor constantly increasing; and in a few weeks more, after reaching and enormous size, it hurst internally and suffocated the patient. A post mortem revealed an aneurism of the innominata ; and the opening communicating with the sac was of large size. Cincinnati Lancet Obsert A New sign of Post Partum Detachment oft) By John Ctay, M.R.S.C., of Birmingham. From investigations, with a view of improving upon the old plan of management of the delivery of the placenta, Dr. Clay ascertained that a very simple sign existed, by which its separation, after the birth of the child, might he indicat- ed, having tested it in upwards of nine hundred cases. Be- fore dividing the umbilical cord he applies two ligatures. If tin; maternal part is now examined, it will he found in a flaccid condition, and almost live from blood ; hut after an interval of from om4 to three minutes, it will he found to have acquired specific weight, and that the vessels are more or less tilled with blood. The one fact may he ascertained by poising the cord on the fingers; t]\v other by slightly grasping the cord near the vagina, with the thumb and fore- finger of the left hand, and, with the right hand, suddenly compressing it, when a well-marked sense of fluctuation is perceived, a kind of resilience like that felt when an elastic tuhe filled with fluid is suddenly compressed. "When the placenta is detached the cord loses its increased specific weight and the hydrostatic property just mentioned. This is so invariable, that the loss of the previously acquired hy- drostatic properties of the cord after the birth of the child constitutes the sign of detachment. The whole <>t the phenomena are manifested in three stages flaccidity, repletion, flaccidity. It' the cord be tightly grasped by a spasm of the os, or by irregular contractions of the atertts, the loss of the hy- 1861.] The Nervous System. 343 drostatic properties may lor a short time be delayed. These signs are not, of course, equally marked in every case. When the uterus is tlaecid. they are but slightly manifest- ed, though perfectly reliable. When, on the other hand, the contraction is firm, the most inexperienced may detect them. In eases of partially adherent placenta, the disap- earance of the hydrostatic properties, and the failure to de- liver the placenta by the usual manipulations indicate the necessity for artificial detachment by introducing the hand. In twin cases, the signs persist till after the birth of the nd child, except where the two placentas are present. It sometimes occurs that the placenta is separated simul- taneously with the birth of the child. Here the first series of phenomena are absent, and it may be be generally effect- ed with safety. The practical value of these facts is obvious, as the pla- centa, when thus known to be separated, may be at once extracted. The prompt delivery of the placenta is very im- portant, as the uterus then contracts more effectually, the risk of hemorrhage is not so great, and it may be fairly as- sumed that the convalescence is less protracted. To inexperienced practitioners it might be a safe instruc- tion to impart, not to interfere in the extraction of the pla- centa, so long as the hydrostatic properties herein defined nt Dub. Quar. Jdur. action of Alcohol, Anaesthetics and the Carbonic Gases upon the Cer >>l Nervous System. M. Lallemand read the following memoir containing his own views and those of MM. Pemn and Duroy upon the comparative action of alcohol, anesthetics, and the carbonie : the cerebrospinal nervous sytcm : "When etherization was first discovered Flourens demon- strated that there are successive stages in the action of sul- phuric ether and of chloroform upon the nervous centres, and that the sensibility and motive power of the spinal mar- row are abolished by both of these4 agents- In repeating the experiments of Flourens we have studied the action of these in the same manner, and we have ascertained that while alcohol andamylene, like ether and chloroform, abolish the sensibility and motive power of the spinal cord, the inhalation of carbonic acid and carbonic oxide al- 344 The Nervous [April, lows those properties to be retained up to the moment of death in animals subjected to the influence of the two gas< Action of Alcohol ami Anaesthetic Agents. Into the stomach of a C\o^ of middle size we introduced 100 grammes ofalqoliol, at 21 degrees, dihfited with an equal quantity of water, in three doses at intervale of fifteen minutes. One minute after the administration of the first dose the animal was in a state of complete Intoxication. The limbs were flaccid, the skin had lost its sensitiveness, as had also the ball of the eyes ; the pupils were dilated, the pulsations of the erural artery were 120, and the acts of respiration 22 in a minute. The posterior arches of the last three dorsal viriebne were then elevated, and the spinal marrow WW laid bare to the extent of about twenty-five centimetres. The posterior and anterior columns were pierced, and the posterior and anterior roots of a spinal nerve were seized and drawn out with the forceps. Xo sign of sensibility was elicited, and not the slightest muscular action. Four hours after the operation this lethargic condition gradually passed off; the tongue and jaws of the animal began to move, and the eyelids closed when the balls of the eyes were touched. Upon piercing the cord again the animal uttered mo and the hinder limbs were convulsed. The dog was then strangled." Experiments with cloroform, sulphuric ether and amylene, from which analogous results were obtained, are described, after which the authors of the memoir continued as fol- lows : "Thus the action of alcohol, chloroform, ether and amy- lene completely interrupts the sensibility and motive power of the spinal cord and nerves. We have also ascertained that by passing an electric current through the spinal mar- row, when its action is thus suspended, its excitability may be aroused, and may be manifested by muscular action. ^\*e would add that the interrupted properties of the cord and nerves will reappear upon the cessation of the disturbing influence of the agents that have been adminis- tered. Action of the Carbonic Gases Carbonic Acid. The erior arches of the last two dorsal vertebrae of a la were removed, and the cord exposed to the extent of ul three decimeters. The animal was then made to in- carbonic acid mixed with a very small quantity of 1861.] \ S stem. 846 water. Ai the end oflO minutes it was entirety insensible and motionless, and the arterial blood had assumed the dark venous hue. The posterior columns 01 the cord and the posterior root of one of the nerves were then pierced with a pointed instrument, without producing any manifestation of feeling : bu1 by puncturing the anterior root and the an- terior columns, violent agitation of the hinder limbs was oc- casioned. The sciatic nerve being exposed and irritated, convulsive motions were excited in the muscles of the limb to which it was distributed. The muscular contractions produced by irritating the cord and nerves grew more and more feeble, but did not entirely cease until the animal ex- pired. Another experiment in which the oxide of carbon was used, gave results similar to those just described. The preceding facts allow a very distinct line of demarka- tion to be drawn between alcohol and the anaesthetic agents chloroform, ether and amylene on the one side, and the carbonic gases on the other with respect to their physio- logical action. I. Alcohol, chloroform, ether and amylene act primarily and directly on the nervous centres, in the substances of which they may accumulate. II. The carbonic gases exert their primary and special in- fluence on the blood; carbonic acid imparting the venous hue to the arterial blood, and carbonic oxide altering the condition and physiological properties of the blood corpus- cles. It seems difficult not to admit that the insensibility pro- duced by inhalation of these gases is merely the secondary and consecutive effect of an alteration of theblood. It is known, in fact, that innervation is accomplished only under the physiological condition of the excitement of the nervous em by blood ; and it is also known that when the blood cannot obtain a due supply of oxygen as in asphyxia pro- duced by a mechanical obstacle to respiration, or in cronp an anaesthetic condition supervenes betokening imminent danger, and, indeed, the speedy extinction of life. Amesthetic agents, then, depress the factions of the nerv- ous system, and by their progressive action suspend the respiration ; which is under the control of the medulla ob- longata. They produce anaesthesia primarily, and asphyxia secondarily or indirectly. Carbonic acid and carbonic oxide, on the other hand, S46 Epilepsy. [April, modify the properties of the blood disqualify it for sus- taining innervation, and thus produce asphyxia primarily, and anaesthesia secondarily or indirectly. Conclusions. 1. Alcohol, chloroform, ether and amylene art immediately upon the nervous system. 2. Carbonic acid and carbonic oxide act immediately upon the blood by modifying its properties ; and it is by means of this modification of the blood that they produce insensi- bility. These substances then are only pscudo-ances the lies. Jour, des Connaissanccs Medicates. Woorara in Epilepsy. By M. Thicrcclin. M. Thiercelin, struck by the counteraction of artificially- produced convulsions by woorara, has been led to adminis- ter the drug in the treatment of several convulsive disc; more especially epilepsy, and with most marked effect. Particulars of two cases of epilepsy, which had resisted a variety of previous treatment, were laid before1 the mem- bers of the Academy of Sciences at their last Bitting. One of the subjects treated by woorara was a young man, aged 23. In him the disease was hereditary and congenital. The patient had passed 4 years at Charenton, and was ac- counted incurable. The number of attacks during the month amounted to 20, whereof the greater part was most re. The second case was that of a girl of 17, a suffer- er from epilepsy for 8 years past, and during the last 12 months subject to daily tits. Under the influence of the woorara, treatment, (the drug being applied daily in d< varying from #ialf a grain to a grain to the suppurating sur- face of a blister,) the attacks dimished in frequency so con- siderably that in the first case they tell in number from 20 to 5 per month, and in the second, from 29 or 30 to S. only did the frequency of the fits decrease, but a striking general improvement occurred in the health of both patients, and a marked diminution of the nervous irritability always accompanying epilepsy was also noticed. Unfortunately, the treatment could only be persisted in for 8 weeks, as the stock ot woorara ran short; nevertheless, the results ob- tained were decidedly of a nature to encourage other prac- titioners jn following in the footsteps of* M. Thiercehn. Lan iV) Editorial. 347 EDITORIAL AND MISCELLANEOUS. THE MEDICAL PROFESSIONITS GRATUITIES. Th following paper has boon in our hands for sonic time ; but has es- caped our notice till this late period. We deem the subject of culling the attention of the public to the unjust draft made ou the Profession, of BO much importance, and also for the able manner in which the grievance is presented, that we here make room in our editorial department for the Memorial of the Committee appointed by the Medical Association of rgia : To the Senate and House of Representatives of the State of Georgia : MEMORIAL. At the Annual Meeting of the Medical Association of the State of iblcd at Rome, April 11th, 1860, the following Resolu wore adapted, viz : Resolved^ That this AfiBOOiation Memorialise the Legislature of >lish the Professional Tax upon Physicians, and to urge the passage of an Act requiring the Inferior Court or each county to set apart such portion of the county tax as the (J rand Jury shall recommend to poi ngsfor the use of the poor. Th gned were appointed a Committee to bring this matter bc- r honorable body. In performing this duty wv, beg respectfully to submit a few reas f'u- this appeal to the Laic Making Power . It is a fact, apparent to every observing mind, that Medical men, far more than any other class of citizens, contribute gratuitously, their time, and money, to the relief of the indigent. And as it i s the duty of State authorities, and not of a particular class to bear the burden, gratuitous services can ; 1 in no other light than centri- ng to the State. per centagc of population requiring those crviecfl is by no means inconsiderable. Taking thecomr 1 as an average county, obser- vations have been made by which we arc enabled, confidently, to 8 348 Miscellaneous. [April, that the amount thus donated by medical men in Georgia, in the single article of quinine can scarcely fall short of Thirty Thousand Dollars per annum, with a strong probability that it largely exceeds that amount. Tf, in connection, with this startling fact we consider the value of the time and labor and other Medicines contributed, it is evident that the amount of this gratuitous outlay of physicians to the State is enormous. It is remarkable that the public, and especially the Legislature, has so little appreciation of the extent of these gratuitous labors of medical men. True it is that the Inferior Court, under existing laws, is re- quired to provide for the poor, and the physician pays his part of the annual tax, levied for this purpose. But, whether from defects of law, or gross neglect of the Courts, it is well known that the instances in which the poor are thus provided for are very few, and the procuring of medical services and drugs do not seem to be regarded as belonging to their list of duties. Indeed, except in cases of Lunacy, or in extreme and rare instances of helplessness, where the subject has been entirely abandoned by his acquaintances, it is seldom that the Courts make any provision whatever. Yet even in these extreme cases, deserted by all, the physician alone is expected, without compensation or thanks, to give not only his personal attention, but his money, to the relief of the suffer- er. At all seasons, in all kinds of weather, in the dark hours of night when others are asleep, the medical man passes from one scene of dis- tress to another, bestowing his labor, risking his own health, and dispens- ing drugs to the indigent sick. To this course he is impelled by two powerful forces. The first and greatest is the demand of humanity, which to a conscientious man leaves often no alternative by which to es- cape the call. The second is the force of public sentiment which will no^. tolerate in the physician that freedom of action which it allows to others. The merchant may refuse credit to whom he chooses. The druggist may decline to sell to an insolvent customer and it is well, but the physician who exercises this liberty brings upon himself the severest censure, and consequent injury to h\$ character and business. To the many cases of casualty and death which occur in this fast age, a large proportion of which is amongst the poorer classes, the physician stands a ready servant, subject to every beck and call, and is expected and required to have in readiness all the appliances and material, at whatever cost adapted to every emergency. By his promptness and benevolent agency he relieves large numbers, and oft times rescues them from impending death. When, under analagous circumstances, a party is snatched from a burning dwelling, or a watery grave the individual 1861.] Jllisccllaneoits. 349 who performs the deed is exalted into a hero. When a mariner rushes to the rescue of a distressed crew, he gains for himself Laurels of Praise and Medals of Honor. Not so the Physician. He is regarded as hav- ing discharged a mere common-place duty, and scarcely meets with a passing commendation. And such is the tyranny of custom and law, that if he fail to respond to every call, he encounters the indignant frown of the community, and failing from want of proper facilities or other cause to adopt the most scientific treatment he becomes liable to prosecu- tion and heavy damages. Although medical men, as a class, are pro- verbially benevolent and kind, and are ever ready to heed the call of suffering humanity ; and while they claim and desire no special exemp- tion from the moral responsibilities and duties incident to their noble profession; yet* they feel that the public authorities can and ought to do more than is or has been done for the poor in this particular, and that they ought not to require the physicians services nor his drugs without compensation ; much less to heighten the infliction by imposing a speci- fic tax. If it be urged that a physician's profession is his capital and, therefore, ought to be taxed, we reply that it is taxed, and that heavily in the manner, and for the reasons above stated. The calls of humanity, and the necessities peculiar to the practice of the medical profession ; the exposure, irregular hours, impairment of health, encountering contagi- ous maladies and raging epidemics, witnessing painful scenes, suffering and death, and the moral and legal responsibilities incurred ; all bear heavily upon the practitioner, and can find no adequate compensation, even though the tax were removed, and the ordinary fees allowed in all cases. We, therefore, respectfully petition your Honorable body to abolish the specific tax, and extend such relief to the poor and the medical pro- fession in the matter under consideration, as wisdom and justice may suggest to the patriotic Representatives of a great State. And we feel well assured that such legislation so obviously necessary, so manifestly just and proper, and so highly called for by the growing philanthropy and benevolence of the present age, cannot foil to meet the sanction of a liberal and enlightened constituency. Robt. 0. Word, M. D., Home, Georgia. Robt. Southgate, M. D., Augusta, Georgia. .1. . George Hayward, M. D. Solomon D. Townseno, M. 1>. Charles T. Jackson, M. ]). J. Baxtkr Upham, M. J). February, 186 1. Have you known death to occur from the inhalation of pure Sulphuric Ether ? Where did this occur ? " At what date ? For what purpose was Ether administered ? What method of inhalation was adopted .' What kind of Ether was used ; was it pure Sulphuric Ether, Chloric Ether, or Ether combined with Chloroform ? At what period after the inhalation did death occur, and how did death take place ? 1 'lease state may other circumstances connected with the case. (Signed) 1861.] Miscettmec 351 ON DISEASES PEC/ULIAR TO WOMEN, Including Displacements cf the Uterus. Bj Hugh L. Hodge, M. D., Prof of Obstetrics and Diseases of Women and Children in the L'niversity of Pennsylvania. With original illustrations. Philadel- phia. Blancha&d & Lee, lsGO 8vo. pp. 470. Book-making is so often resorted to as a mere trade by persons of in- experienee, that we instinctively welcome the productions of those who, like the author of the volume before us, bring forward the result of ex- tensive observation, enlightened intellect aud mature judgment. Zeal- ously engaged in the practice of his profession in a large field for up- wards of forty years, the unostentatious record of his final conclusions must be of great value ; and although he may sometimes differ from whose opportunities are equally advantageous, the student of truth will thus, like the juror in a court of justice, have the benefit of argu- ment upon both sides of difficult questions. In the author's neat letter to Prof. Meigs he says : "I know well that our productions each char- acteristic of its author differ exceedingly in theory and in practice; but aevet be student who examines each book may discover the truth more clearly, and be prepared to render such truth more efficient. The very opposition, which may be perceived in the views of experienced men in the profession, is often beneficial ex collisione scintilla." .Prof. Bodges1 work is divided into -\ parts; the 1st comprehending the"! of Irritation;" the k2d, 'Displacements of the Uterus;" and the 3d, the "Diseases of Sedation," As the limits of this notice will not permit any comments upon the special views of the author, we can only indicate the scope of the work by a brief reference to its contents. In Part 1 he treats of Nervous Irritations and its consequences; irrit- able uterus, its local and general symptoms, its progress and result.-, its and pathology, its complications, and its treatment. Under the bead of displacements of the Uterus, we find chapters devoted to the anatomy of the pelvic organs, to the various displacements of the uterus and their causes, to the symptoms of these displacements, and to their :ient by hygienic and by mechanical means, of which latter he pre- fers the "Lever pessaries," designed by himself. The diseases of seda- tion are disposed of in three chapters on sedation and its consequences, sedation of the uterus, amenorrhaca, and diagnosis and treatment of lion of the uterus. This volume is destined to take a conspicuous place among the most valuable original contributions to American medical literature. We, therefore, cheerfully recommend it to the attention of our readers. 352 Miscellaneous. THE BLOOD IN MANIA. In England the investigations of W. C. Wood, M. D., as far as they go, indicate that there is a marked deficiency of fibrin during the period of maniacal excitement, and a correction of this deficiency during con- valescence. RESIGNATION OF PROF. MEIGS. We learn that Dr. Charles D. Meigs has resigned the Professorship of Obstetrics, etc., he has so long filled with marked ability in the the Jef- ferson Medical College, Philadelphia. Professor M. is a Georgian by birth. Hydrocyanate of Iron in Ejrilejisy. The Cincinnati Lancet & Observer says: "Dr. G. S. Bailey, a retired physician of Iovra, states in a letter to the editor of the Journal of Materia Medica, that his only son after having been treated six years for epilepsy with every remedy that medical skill could suggest, without success, was finally cured with the hydrocyanate of iron, by Prof. D. L. McGugin of Keokuk. The formu- la employed corresponds with the one used by Dr, Treat (Cin. Lancet & Obs., June, 1860, p. 388); hydrocyanate of iron, one drachm; powder of valerian, two drachms ; extract of Indian hemp, one drachm, being originally added by McGugin. Make into one hundred and twenty pills. One of them is to be taken three time3 a day. gradually increased to four. How to Improve the Taste of Cod-Liver and Castor Oils. The Louisville Medical News says : "Cod-liver or castor oil, shaken up with an equal volume of water distilled off the leaves of the wild cherry-tree, in a manner similar to that directed in Edinburgh or Dublin Pharmaco- poeia for cherry laurel water and left to rest forty-eight hours before separation, acquires by this simple operation an extremely sweet per- fume and agreeable taste of almonds ; the taste remains as long as the digestion lasts. Oil flavored in this way could be taken by many patients who reject it in its natural state. Castor oil is not affected in its purgative action by this process." Criminal Insane. A State Asylum for the Criminal Insane comj prising 290 acres of land, and accommodations for 500 convicts, is about to be completed in England. The number of this class of persons has steadily increased for several years, until, at the beginning of the pre- sent year, not less than 731 were reported. American lournal of Insanity. SOUTHERN MEDICAL AND SURGICAL JOURNAL. (NEW SKIM! [TIL AUGDSTA, GEORGIA, HAY, 1861. NO. 5 ORIGINAL AND ECLECTIC. ARTICLE X. Tape Worm The Symptoms, Progress, Development, Duration and Spe< ." itment of a case* The writer was for several years a subject of the disease of tape worm ; a statement of his case may prove beneficial to others similarly affected. It is given as follows : During the year 1835 he had frequent attacks of what was Bupposed to be cholic, returning at Intervals, to Janu- ary, ISoT ; but not of a character to excite much alarmy though accompanied by sick stomach, predisposition to vomit, and piles. The usual alleviatives for the supposed disease, were re- sorted to without relief; the patient being also subject to frequent cramps of the abdomen, in the region of the right side, especially after inclining the body downward in that direction, on resuming an erect posture. At the' time last named (January, 1857) the disease was demonstrated to . be tape worm, by the voluntary es- *T!. -port is by a distinguished gentleman of the legal profesion in this city. We regard the paper a highly useful <>ne, for while this report ;:.d intelligently made, the statement is freed from a vast nt of unnecessary detail, which too often encumber the reported The al>-. ihnical terms, apologized for, is not to be deplored and will be regarded by ourreadera rather a relief limn otherwise. M. & >. Joub.1 28 854 A Case of Tape Worm. May, cape of several separate joints, crawling away, they being alive and continuing to move l>y extension and contraction. The specimens were of rather a fiat round, an inch in length near the size of a common broom straw, square at one end and tapering at the other, and most exceedingly tenacious oflife under experiments, to which they were subjected. The escapes, either voluntary, in detached pieces, or on being expelled by remedies, sometimes in joints and at others in continuous pieces, varying from 3 to 14 feet in length, continued to May, 1841, at an average per day of 12 joints, or one foot; though irregular, sometimes daily and then at intervals of 3 to 5 and 10 days, increasing in quan- tity in proportion to the length of the interval, the voluntary escapes producing an unpleasant itching and tickling sensa- tion about the anus. In these intervals the abdomen became distended and painful, the breathing short, with frequent cramps, such as before described, accompanied by an internal lowering down of the intestines and aggravation of the piles. Throughout the disease, contrary to the generally existing belief in the subject, that in such cases the patient was sub- ject to a ravenous appetite, in this instance it was the re- verse, being quite moderate, the health very delicate, and a general debility of the system. From the development of the disease to the cure, many physicians wrere consulted ; but four of whom professed any practical knowledge as to the disease or its treatment. It being, I suppose, somewhat rare, there being but two who pi-escribed remedies producing any sensible relief. The first was the family physician of the patient, the late Dr. Milton Antony, distinguished for his skill in the sience of his profession, at the head of which he stood in this, his native State, and the first President of the Faculty, and founder of the Medical College of Georgia, which position lie retained during his lite. He was first consulted and pre- scribed spirits of turpentine, which finally effected a remedi- al cure. 1861.] AQiseofTape Worm. The other was quite a young, bat very intelligent gentle- man, Dr. Thompson, not a graduated M. D., hut a man of reading, who was met with in 1838. in Louisville, Ky. lie prescribed assafoetida and gum camphor, in parts of of the former to J of the latter. This produced temporary re- lief; the assaf etida, acting as a gentle cathartic, relieved the bowels of the accumulation of the disjointed pieces of the worm; while the camphor counteracted the too great relaxing tendencies of the other component on the system. These. two remedies were resorted to alternately from 1838 to 1840, the pills "being taken from 3 to 5 at a dose. The prescription of Turpentine and the mode of adminis- tering it were as follows : Fast 12 hours (or rather abstain from all hutliquids), then empty the bowels with salts ; afterwards take a teaspoon- ful of spirits of turpentine in loaf sugar, and this repeated in 15 or 20 minutes, and followed by castor oil in thirty minutes. This course was always effectual in expelling portions of the worm; but its effects on the system of the patient were such as to deter a repetition until compelled by after ac- cumulations and the accompanying symptoms before des- cribed ; it leaving the patient under strangury and a gener- al affection of the kidneys and spine, and consequently was not resorted to except from necessity, and at intervals of 2 months. In the meantime the pills were taken for temporary relief; but the odor being so offensive as to deter their use as long as could be dispensed with. The gentleman who prescribed the pills, though not a lar practitioner, had been compelled to put into requisi- tion his skill, as an acting Assistant burgeon, at a United States Military post in the West, in the absence of any one larly in charge, of that department, and during such time he stated that two cases of similar disease had been temporarily relieved by that treatment; and in the case of the writer the prescription came fully up to the representa- tion. 356 A Case of Tape Worm. [May, In 1839 the lamented Dr. Anthony was one of the early victims of the yellow fever of Augusta of that year, and the patient was deprived of the further benefit of his skill and left to the use of his prescribed remedy at discretion, and having read some few miscellaneous articles on the subject, and attetively noticed the effects of the prescription in the disease, as well as on the system, it occurred to him in the fall of 1840 that there might be propriety in varying the manner of administering the turpentine from two tea- spoonfuls at an interval, to that of the wholejquantity at one dose. He made the experiment, taking a desert spoonful at one time. The change was successful, acting instantane- ously and directly on the worm, aiding the oil as a cathartic wihont entailing the previous injurious effects on the kid- neys and spine and resulted in expelling 14 feet. Thus encouraged, it was repeated at shorter intervals, with similar success, the specimens exhibiting irregular and imperfect formation ; but showing that there was a square break-off, leaving a portion behind. Again, in 1 to 4 weeks this treatment was repeated till 1st of May, 1841, when 5 feet was expelled, tapering from the full size at one end to nearly a point at the other, having rather a soft, jelly-like appearance. This suggested the propriety of immediate perseverance, and the treatment was repeated in 3 to 4 days, which happily resulted in bringing at that time 3 feet, about half the usual size at the large end and tapering to a point at the other, not longer than the point of a common darn- ing needle, perfect in formation, the joints shortening as they decreased in size. At the time, this was believed to be an entire relief from all remains of the worm, and has been verified by a lapse of near 20 years without any return- ing symptoms whatever. It may be remarked as showing the obstinacy of the dis- ease and the tenacity of the worm, that during its continu- ance the writer was, in 1830, a subject of the yellow fever, having a dangerous attack, and for which he was treated with the appropriate remedies for that disease. On conva- 1861.] Bkbad. Thpe Worm. 357 Lescing, he flattered himself that the remedies for the fever had subdued the worm; but was disappointed in finding that by the time lie was able to Leave the house the old dis- ease returned in all its symptoms. The appearance of the disjointed portions have been des- cribed. Those connected, of various lengths, resembled gourd seeds strung lengthwise on a thread, and varied from 3 to 14 feet. After a la] ime 10 years the ease, with the particu- lars, &C, was related to a friend, a highly respected and eminent gentleman of South Carolina, and which had pass- ed from the memory of the writer, till recalled about 3 vears since bv a letter referring; to the circumstance and stating that he had a son 10 years of acre similarly afflicted; and that none of the physicians consulted seemed to under- stand either the disease or remedy, and requesting a full statement of my ease with the symptoms, prescriptions, &c, it was given with full directions: but suggesting the pro- priety, if the turpentine was resorted to, of leaving it to a phpsician to prescribe the decrease in the proportion for the child, as compared with an adult. Some two or three months afterwards a second letter was received from this friend, communicating the pleasing in- telli_ >r his having used the prescription as directed, with complete success, his son being entirely cured, and ex- pressing his grateful acknowledgements, and the belief that I had. under Providence, been the instrument in saving the life of his child. nsidering the result in this latter case us establishing the efficacy of the remedies in the two, it was determined at leisure time to make a statement of the same for the benefit of the public, waiving all apparent delicacy involved, believing that the cause of humanity demands it, that purpose has been delayed to the present onlyvby other engagements. Medical readers, as well us others, will, doubtless, make due allowance for the absence of the use of t<'clmi<-;il terms ne not versed in them. 358 Berlingkbr. Becicd Touch. [^foy> ARTICLE XT. Rectal Touch w early Pregnancy. By Martin Bellinger, M. [., Barnwell, s! 0. The diagnosis of utero-gestatiou lias drawn the attention of medical philosophers from the earliest age. Its import- ance behooves every one to investigate the signs closely, for at every step in prorfessional life occasion may call for a prompt and decisive opinion. Xot only in a medico-legal point of view is it of importance, but the moral integrity of the family circle may rest on the medical man to estab- lish, or refute the suspicion of conception, and his fiat con- signs to ignomy or restores to social purity. The suspect- ed female may traverse an humble path, may be a slave to minister to the wants of those to whom God has given her services, but her social rights must be maintained. She may be the highest lady in the land, whose hand it was an honor to touch, and yet the fell suspicion can rest heavily on her and drive her to seek companionship with degraded beings. Her own sexw^ouldbe the first to spurn, for her hyper- critical at all times towards each other, they pitilessly lash the fame of the frail sister who deviates from rectitude. More vindictive than the slouth hound, for he pauses at blood ; the shroud of female scandal often envelopes the pale remains of the fallen. The object of this paper is to call attention to an import- taut element in the physical diagnosis of pregnancy. It is presented in this crude form in the hope that some of my 'professional brethren may deem it of sufficient moment for the subject of investigation. To those of ample obstetrical practice, each day will furnish opportunity for the truth of the sign herein mentioned, and to those I look to prove its truth or falsity. I will briefly relate the circumstances which led me to its observation. Several years since, when first commencing to practice, I was requested by Mr, Andrew Dunbar, a planter of this vicinity, to ascertain if one of his negro women was pregnant, the work allotted to such being lighter 1861.] Bellinger. Rectal Tmoh 35^ than otherwise. She was said to be two months advanced, I found morning Bicknees, suppressed menses and depres- sion of the aterus with enlargement of its neck. The mamma afforded no evidence, as she was nursing a twelve months child, which, of course, roughened the nipple. In addition to these Bigns 1 could detect no evidence of dis- . nor was there any complaint made. My opinion, therefore, to the owner was that though far too early to form a positive one. in all probability the woman had con- ceived. Time proved it to he a false diagnosis the woman was not pregnant It was a ease of amenorrhea, with slight en- _e:nent of the cervix uteri. Cliarles Wot says, that he who learns truly from person- al ohscrvation, derives benefit even from his errors ; that his mistake will serve as beacons to indicate the breakers among which he was once wrecked. Bat the lesson taught here never to give an opinion till the case was sufficiently advanced to be unmistakable was of little avail. For, in a lice almost entirely of negroes, where the question of morality could never be considered, cases of amenorrhea would come and had to be discriminated from pregnancy. And frequently it is of primary importance to know the true uterine condition to avoid the detrimental use of certain drug So that whether I expressed an opinion or not, I was often compelled to form one or refrain from decisive treatment of the e: Tired of this uncertain course, I read every available work relative to the subject, but none, not even the work of the great Montgomery, afforded satisfaction. My attention er, drawn to Meigs' two recorded cases of al>- Uterus, and especially the means by which his ed. In case No. 1 he writes : "J requested the lady to lie on her back, and introducing the index finger of the right hand 360 Bellinger. Rectal Touch. [May, as far as possible into the rectum, I explored with it the ex- cavation of the pelvis, in order to discover any tumor or organ that might he contained within that cavity; hut as all the tissues were ductile and very yielding, I began to sus. pect there was no womb in the case. Therefore, laying the fingers of the left hand upon the lowest part of the hypo- gaster and pressing them firmly towards the finger that was used in exploring the internal parts, I found they could be brought so near each other as to make it perfectly clear that there was no womb in the case; otherwise I must have felt it, so near was the approximation of the fingers of the right to those of the left hand." (Meigs' Treat. Obstetrics, p. 153.) Whilst a student I read the above case, merely regarding it as a good description of lucus naturcv. Now it acquired the utmost importance, for the deduction drawn was that the same procedure by which the absence of the uterus could be noted, would determine not only its presence but condition whether enlarged or not. Since then I have in numerous instances put the idea to the test of experience and every investigation, but serves to confirm my opinion of its value. I can speak with confidence as regards the rectal touch of pregnant and unpregnanted uteri of child-bearing woman. It has never fallen to my lot to examine the virgin uterus. The normal position of the unimpregnated uterus of the child-bearing woman is with its fundus on a level with the interoseous cartilege of the first and second verteba?. This point is distant, per rectum, from the anus about 4 J inches. If the anus is pressed strongly toward the uterus the dis- tance is lessened from \ to \ inch. When conception takes place the uterus, increasing in weight, decend still lower, there to remain till a little beyond the third month, when it gradually ascends into the abdomen. When a woman is to be examined, she may be placed on her back, or what is better, on the left side in the ordinary 1861.] Bellinger, Rectal Touch. 361 obstetric position. One hand of the accoucher is placed on the hypo-gastrium and pressed firmly downwards and backwards toward the uterus. The middle (being the long- finger of the other hand is well oiled and passed into the rectum as far as the metacarpo-phalangsel joints. The finger now comes in contact with tbe uterus, situated an- teriority. If pregnant it will he found encroaching on the rectum, its characteristic pear-shaped enlargement well de- fined ; if not pregnant, the finger carried strongly fowards ascertains its size. The second and third months arc the most favorable period- tor exploration for then the uterus is fully within reach of the finger audits enlargement more plainly noted. Rut even up to the fourth month it can he examined with sufficient accuracy to form a diagnosis. It may he established as a principle that the uterus in the female can he examined per rectum with the same facility as the prostate gland in the male, and any deviation from the ordinary size as accurately detected. On this principle ts this simple means of diagnosis. Applicable only to the early months, at a time when all other symptoms are ohseure, it is of great value. As a negative sign it is abso- lutely certain, for the ahsence of uterine enlargement indi- cates its non-impregnated condition. It is not an absolutely positive sign because merely increased uterine size can never he held as pathognomonic of utero gestation. Here the method of diagnosis by exclusion must he instituted, having reference to uterine hypertrophy, tumors, &c. And when the enlargement is pear-shaped, when its progressive increase corresponds with other (per se equivocal) signs of ad where there is an ahsence of all evidence of . the woman on the contrary in blooming health, we will have woven a tissue of evidence before which all must vanish. 362 Neeson. Dislocations of [May, ARTICLE XII. A Diagnosis of the Dislocotions of the Hip Joint By Horace Neeson, M. !>., Augusta. | A s a supplement to an excellenl inaugural thesis, our iV'u'Tul Dr. Horace !N"eeson, presents the following sugges- tions on the diagnosis of dislocations of the hip joint. It is highly gratifying to us to find that the prolific idea of our distinguished colleague, Professor L. A. Dugas, has been so ingeniously extended and applied by one of his own pupils in the Medical College of Georgia. It will be remembered by our readers that I>r. Dugas presented his new method of diagnosis in a communication to the American Medical As- sociation during its session in the city of Nashville, Tenn., in the year 1857, and that it was published in the succced- ng volume of the Transactions of that body as well as in this journal, with four excellent photographic wood cut illustra- tions, showing definitely the idea of the author. Dr. Xeeson, whose ingenuity and thorough apprehension of the principle, is not the less entitled to great credit, deserves the thanks of the profession for thus adding his own valu- able quota to a, sometimes, difficult point of diagnosis. [Eds. S. M. & S. Jour.] It has ever been the desire of man to do something for the good of his fellow man, from the raising of a blade of grass to the giving up of his life for a friend, so have I ad- ded this diagnosis in my thesis with the, perhaps, presump- tuous hope of assisting my fellow students, and not with any view towards extending it over a greater space. In studying Professor Dugas' diagnosis of the dislocation of the shoulder joints, I concluded that as the mechanical ar- rangement of the glenoid cavity in the upper circle of bones resembled that of the acetabulum in the inferior circle^ that this diagnosis could he applied to the dislocations of the former, if I. could learn the principle upon which it acted. Accordingto a well known geometrical axiom, "the zadii of all circles of the same length and with the same axis will describe the same arcs." 1861.] The JI

,; {lamination, as in many cases of tetanus : and if, as is certainly the case, the tetanic symptoms are comparatively slight and fined to the back and nock, where the spinal cord is actu- ally and unmistakably Inflamed, Is it not fair to suppose thai the inflammation has had the effect of antagonizing or miti- gating the spasm \ As in the different varieties of tremor and convulsion, therefore, so in the different varieties of spasm, the facts would seem to be altogether at variance with the idea that the mus- cles are provoked to excessive contraction by excessive stim- ulation of any kind. The facts, it would seem, are at complete variance with this idea, and in as complete harmony with that theory of muscular motion which was propounded in the first lecture. It would seem, in short, that the key to the pathology is supplied by the physiology, and that the physiology is con- tinued and established by the pathology. It is the same story throughout. J I. The Therapeutics of Convulsive Diseases. Arguing from the physiological and pathological premises, it may be inferred that the fact of tremor, or convulsion, or spasm, can, in no single instance, be urged as a plea for the adoption of " lowering measures." It may be inferred, indeed, that the great desideratum in every convulsive affection is a more vig- orous circulation and a purer blood, and that the remedies to be sought after will be those which bring about these changes. 1. I know of no facts which show that a low diet is bene- ficial in epilepsy. On the contrary, I know of many instances where the patient has been undoubtedly benefitted by the abandonment of such a diet. The meals, of course, must always be regulated .-< as t<> guard the stomach from an over- load of food; but of the two evils, abstinence is more to be dreaded than repletion. It would seem, iifdeed, as if the sto- mach of a confirmed epileptic can never be allowed to remain entirely empty, without some risk of an attack. As a rule, Qulants, of one kind or another, would seem to be very serviceable, in some cases, it is true, malt Liquors may be objectionable: but in thi >s it will generally be found that unquestionable good will result from a proper allowance nerrv, weak brandy-and-Water, or, belter still; of claret. Indeed, I am satisfied that epileptics, and nervous patients rally, will have good rea overlook the shortcomings aty by which, at reasonable rates, they will substitute the light wines of France for tin- fiery wine- Mt" Spain and Portugal, and the strong ales of our own bre . would Beem to bo a more suitable 3G8 Lectures on [May* beverage than its Lees stimulating companion, tea, particularly at an early period of the day. It is, no doubt, of extreme importance to prevent the accu- mulation of effete matters in the bowels, and to remove such accumulation when it lias taken place; but whether purga- tives are the proper remedies is not quite so certain. If the bowels do not act with sufficient regularity, there is, in all probability, some error in the diet some excess of animal Food, some deficiency of culinary vegetables and fruit; and the first thing to be done is, obviously, to correct this error. And this is often all that is wanted, if care be taken to explain to the patient that his bowels can act without purgatives, and that he need not particularly if advanced or advancing in life be altogether cast down if now and then they do not act every day. Indeed, if the diet be properly regulated, and this explanation made, the patient will generally have the satis- faction of finding his tongue clean, when he remembers to look at it, and of forgetting his stomach and bowels altogether. Or if the result be not quite so satisfactory, an occasional injection of cold water or brine, on getting up in the morning, will rarely fail to set matters right, and that without disturb- ing the digestion in any way, or producing disagreeable feel- ings of depression or irritability. As to the rest, it appears to be advisable to order the habits in such a way as to save the strength as much as possible. Proper exercise is, of course, necessary ; gymnastic exercise, by which the chest is expanded, and the respiratory capacity increased, are valuable adjuvants; but it is no less certain that muscular exertion upon or beyond the verge of fatigue must be looked upon as a common cause of the epileptic attack. As a rule, also, it would seem that epileptics require more than the average amount of sleep, to enable them to recover from the multifarious fatigues of the day and night. The more strictly medical part of the treatment of epilepsy is a subject of no small difficulty. The treatment of the pres- ent day is very different from what it was when almost all disorders were referred to inflammation or over-action of one kind <>r other. Practically the lancet is new abandoned, and leeches are in a fair way of being left undisturbed in their swampy homes; practically, also, it has ceased to be the habit to distresf the Btomach and bowels by the frequent use of strong purgatives or emetics ; and this change may be appealed to as an argument that " Lowering measures" had disappoint- ed the hopes of those who had tried them so long and so pa- tiently, and who gave them up so unwillingly. Be this as it 18G1.] Coi> 369 may, cliaoge has come over the treatment of epilepsy, and the remedies at present most in vogue in this country arc f zinc, copper and silver, particularly the le of zinc, ami the ammonio-sulphate of copper. r fancy for oxide of zinc has been caught from M. Herpin, who has dei ibstantial volume to the pnr- ihat many cases of epilepsy may be cured by the vigorous and persevering use of this remedy. In this work, M. Herpin relates thirty-ei f epilepsy or epi- leptiform disease, in nearly all of which he gave the oxide <>t" zinc; but, as I have elsewhere shown, the favorable opinion of thi - I > the virtue of this medicine is by no means home ont by an analysis of those cases. It would ap- pear, liar M. Herpin himself has become less con- fident than he was in 1852, when he wrote the work in ques- a more recent statement is, "que l'oxyde de zinc, ne mt point d'etre convenable pour les enfans et les vieil- lards, echoue tres souvent chez les adults." M. Delasiauve, liese words, tells us that one reason for this change of opinion was the absolute failure of an experiment in the Bicetre, in which one of the physicians of the establishment, M. Moreau, treated eleven adult epileptics in every particular after M. Herpin's method. M. Delasiauve also tells us that M. Herpin now gives the preference to the ammonio-sulphate : in the treatment of adults. I might argue, also, that his faith is even shaken in this remedy, for I have recently ne patient, who had previously been under him, in wIioe lie abandoned the copper after a very short ble simple, of which I shall have .1 speak favorably as to the re- the trials, nine in number, in which 1 gave oxide of zinc after M. Herpin's method ; and my experience in this ct agrees fully with that of my friend and colleague Dr. Marcet, who, more perhaps than any other man in this cpun- put this ' treatment to the test of experience. At the same time, it does not follow that zinc is of no value in epilepsy. On the contrary, the probability is, that it is a lerable value in the proper case and in mod- and thi- opii a little supported by the -ult.- which Dr. Marcet has recently found to at- tend In many form- of nervous excitability. Of the rprepan zinc it is no! ak, for there ilieve that their action for good or evil is ride. It i tain any sound evidence of the value of 24 870 hires on [^ay tlir aminonio'sulphate of copper in epilepsy. Speaking of the cases recorded in his published work, M. Herpin says that, including relapses, he obtained fourteen cures in eighteen pa- tients; but when these cures are fairly analyzed, they do not turn out to be a whit more satisfactory than those which he ascribes to the oxide of zinc. Nor do I know of anything thoroughly satisfactory in the experience of others. For my- self I oughl scarcely, perhaps, to express an opinion, for I have never given the medicine a fair trial ; hut I have met with several patients who have taken it, under the advice of other physicians, and of these I have no hesitation in saying, that n<>r a few, on being asked how they were affected, have said that they felt more nervous while taking it, and that no beneficial change was produced in the fits. With respect to nitrate of silver little need be said. I have had three patients under my care whose skin, before they saw me, had been tinged of a dismal grey color, and whose fits had been worse, rather than better, during the time they were ta- king the silver ; and many cases arc on record which show that this evil may happen without any countervailing good. "Of all the metallic remedi s Dr. Watson, " I should prefer some preparation of zinc or iron ;" and I believe there are signs of change of opinion in the minds of many thought- ful men, and that before long iron maybe placed before zinc, and not after it. If, as has been said, the inferences from the premises is that the desideratum in epilepsy is a more vigo- rous circulation and a purer blood, it is to be expected that iron may not unfrequently be wanted ; and this expectation is not belied by my own experience. At the same time I must confess that there are many cases in which this remedy fails to bring about any beneficial result, and where harm rather than good may be said to attend its use. In many cases, also, another common remedy, which is not mentioned in Dr. Watson's chapter on epilepsy, and which is also overlooked by almost every other author, would seem to do good. This is quinine. But with this remedy, as with iron, it must also be confessed that there arc other cases in which, to say the least, the good done is not unequivocal. In a w exceedingly difficult, in the present state of our knowledge, to decide as to the value of these remedies in epilepsy; bur that zinc i- no specific, and that the common tonic- mentioned are not of themselves sufficient, must, I doubt not, be the c d "T every one who has had sufficient ex- perience in the matter. Where, then, must we turn for what is wanting? Is it to 1861.] 871 remedies of a directly stimulating character! Is it to reme- dies which may be supposed to purity the blood from certain matters which ought to be excreted, but which being retained produce a depressed or oppressed state of the circulation \ "It"." saysJ)r. Watson, "] were called upon to name any single drug from which, in ordinary case.- of epilepsy, I should hope for relief, I should Bay it was the oil of turpentine. And 1 find that other physicians have come to the same con- clusion. Dr. Latham, the elder, was, I believe, the first per- son who made known its efficacy in this disorder. Foville states that he has seen excellent effects from it. It is highly spoken of by Dr. Perceval in the 'Dublin Hospital Reports' It is not given in large doses, but in smaller ones frequently repeated ; from half a drachm every six hours/' And that turpentine is a valuable remedy in epilepsy, very valuable, I have no doubt whatever. Another remedy which puts in its claim for approval is valerian. This is a very favorite remedy, both in this coun- try and elsewhere, and its claims, though not equal to those of turpentine, appear to be in every way deserving of atten- tion. Recommended by Aretaeus and Dioscorides, and in use ever since, it was never other than a favorite remedy. Xow the prominent action of valerian is that of a stimulant an action depending upon the presence of a composite volatile oil, of which one portion is a volatile acid, capable of forming It with bases, and known under the name of valerianic acid : and it is a natural guestion, after what we know of tur- pentine, whether the stimulating action of the drug does not show that it may be efficacious, and explain the secret of its efficacy. It is somewhat significant ako, that the sclinuni palustre is one of the four principal remedies to which 2>I. Iierpin has pinned his faith ; and not only so, but the one to which he gives precedence. These four remedies, ranked in the posi- tion belonging to them in an ordre dt are sclinum palustre, ammonio-sulphate ot copper, oxide of zinc, and vale- rian. Now, selinum palustre is an unbelliferous plant, of which several grammes may be taken at once ; and, on ques- tion] four patients who have taken it, the answer was that they were warmed ami comforted by it. In other words, it- action would seem to be that of a feeble stimulant. circumstances, therefore believing that a more act/ of the circulation is a desideratum in epilepsy, and having these practical i ats in favor of turpentine and valerian a sufficiently natural question was whether cam- 372 Lectures on [May, phor, naphtha, or ether in its various forms, or any of the stimulant gum-resins, or musk, or castor, or some other stim- ulant would be of use in epilepsy. Nor, if I can read aright the lessons of my own experience, is the answer different from what mighl be expected. That camphor is often a very valuable remedy in epilepsy, I have no doubt in my own mind. In doses of about three grains, twice or thrice a day, for a time, I have seen such re- sults as to justify me in ascribing to champhor all the virtues belonging to turpentine, with this addition in its favor that it is not unpleasant to the taste, and that it exercises, or seems to exercise, a directly quieting influence over the generative and urinary organs. Naphtha also would seem to have the advantages without the disadvantages, of turpentine. In doses of from half a drachm to a drachm, and taken for some time, I have often had what seemed to me unequivocal evidence of its beneficial action. As a rule, also, a patient soon becomes indifferent to the taste, particularly if it has been redistilled more than once. Of the stimulant gum-resin, my experience is not very am- ple ; but I think I have seen enough to satisfy myself that, in several cases, they are of considerable value. Of musk and castor I have no experience. With respect to the different forms of ether, Hoffman's anodyne, chloric ether, spirits of nitric ether, and so on, there can, I think, be no doubt as to their great value as occasional remedies; and the same may be said of ammonia. In the majority of instances, it is only to this class of remedies we can trust for warding off a fit. In some cases, also, ammonia would seem to be of much use as an alkali in a point of view of which we have now to speak. But however beneficial stimulants may be, it is necessary to confess that they will not do all that is wanted. It would appear, indeed, as if some- thing were wanted which will carry out the second indication, and ensure what has been spoken of as a purer condition of the blood. Xor are we here altogether in the dark. " About fourteen months ago," wrote Sir Charles Locock in 1S53, "I was applied to by the parents of a lady who had had hysterical epilepsy for nine years, and had tried all the remedies that could be thought of by various medical men (myself amongst the number) without effect. This patient began to take oromidi of potassium last March twelvemonth, having just passed one of her menstrual periods, in which she had two attacks. She took ten grains three times a day foi three months; then the same dose tor a fortnight previous to v / 878 each menstrual period; and for the last three or four months she lias taken them for only a week before menstruation. The result has been that Bhe has not had an attack during the whole of the period. I haw- also tried the remedy in fourteen or fifteen cases, and it has only failed in one, and in that one the patient had tits not only at the times of menstruation, hut als.> in the intervals." In using bromide of potassium in these cases, Sir Charles Locock's object was to calm an erotic disposition, which at- tended and aggravated the epileptic symptoms, and this end may have been, and in all probability was, answered. But this is certainly not the only way in which this remedy acts beneficially. On the contrary, after trying it in scores of - during the last two year.-. I can testify that bromide of potassium is a very valuable remedy in cases where there is not the slightest sign of an erotic disposition. I can testify, indeed, that this remedy has proved more or less serviceable in cases the most dissimilar in character so serviceable that the name of Sir Charles Locock ought always to be remem- bered with gratitude by every epileptic, and by many suffer- ing from other kinds of convulsive disorder. How to explain the modi ndi of this medicine is no very easy matter ; but I am inclined to think that this in part at least, is by an alterate action upon the blood analogous to that produced by iodide of potassium and common salt an action by which, sibly, the blood may be kept free from compounds analo- gous to uric acid. And this I do, because for a long time, 1 have found decided benefit from occasional doses of a mixture containing bicarbonate of potass and iodide of potassium, with or without a drop or two of tincture of colchicum or wine of white hellebore At any rate, the alkaline character of the pound would seem to be necessary in some cases; for on looking over about thirty cases in which I tried bromide of iron, as well as bromide of potassium, I find that in the ma- jority the latter preparation had a more beneficial action than the former. At any rate there can be no doubt that a healthy action of the kidney, and of every organ by which the blood is kept in a state ofpuri ssential to the successful treatment of epih But, it may be asked, what is to be said of the thousand which have been recommended from time to time \ What, amongst others of strychnia, belladonna, conrum, coty- ledon, umbilicus, poudre de Neuchatel, tracheotomy and cau- terizatic i 374 Lectures on [May, Strychnia, as all know, was a favorite remedy with the late Dr. Marshall Hall ; but the dose was attenuated to such a de- gree as to render it somewhat difficult to believe that much good came of it. Dr. Hall, indeed, distinctly allowed that harm is done if the dose be sufficient to produce the physio- logical effects of the drug. Belladonna a remedy recommended by Stoerk, and used some years afterwards by MM. Debreyne and Bretonneau has been again brought into notice by M. Trousseau, who says he has employed this remedy for twelve years, and al- ways had under treatment from eight to ten patients. He says, further, that of 150 persons so treated, 20 have been cured, or, at any rate, that their fits have not returned; and that Mr. Blacke> who employed it during the same period in a large private practice, has met with a like proportion of suc- cesses and failures. It is a fair question, however, whether 13 per cent, of successes (which may, possibly, in part at least, be explained in a different way) can be regarded as sufficiently conclusive evidence in favor of the remedy ; and this the more, as other practitioners, M. Delasiauve among the num- ber, have been less successful. Judging from my own expe- rience, my impression would be that belladonna is of very doubtful value. JSTor is a more favorable conclusion to be drawn respecting conium. I have tried this remedy in several cases, in small and also in full doses; but the result was no more satisfactory than that which had been already arrived at by Professor Sc'hroeder Van der Kolk. With regard to cotyledon umbilicus, it is not very easy to believe in any powers beyond those which may be derived from the imagination acting upon a new and innocent medi- cine. It is very possible, also, that some part of the benefit, where there has been any benefit, may.be ascribed to the leaving off of some less innocent drug. Poudre de JS'euchatel is a remedy which has some credit in Switzerland, and which has lately been brought prominently under our notice by having been given in some of the cases recorded by M. ITerpin. And what is this remedy ? It is none other than the powder of taupe grille in plain English, fried mole. It is, indeed, a relic of the days when animal re- mains, of a more objectionable character, fried or otherwise, were offered to the unhappy epileptic, hi justice to Mr. Herpin, however, it must be said that he does not believe in this out-of-the-way remedy. lie enly tries it when other remedies have failed. And certainly it must be allowed that tracheotomy does not 1861.] 375 realize all the original hopes of Dr. Marshall Hall. It does not always, perhaps usually, make the convulsion slighter. It does not prevent danger, for (as I have shown elsewhere) of the few patients upon whom the operation was performed, three have died either in the tit, or in connection with the fit, and of the three the opening was free from all obstruction, at least in one. The first two eases, indeed, were calculated to damp the hopes of any one less sanguine than Dr. Marshall Hall. In the first case, the patient was a boatman, aged twenty-four, epileptic for seven or eight years, and whose tits were frequent and severe. The operation was performed by the late Mr. Cane, of Oxbridge, during a fit of uasphyxial coma," which had lasted nineteen hours. The relief was im mediate, and for some months afterwards the fits were absent; but unfortunately for the credit of the operation, the patient, not liking the gurgling noise and the muteness consequent upon the unnatural opening in his windpipe, had chosen to icear the tube with its opening carefully corked up. This in- formation I had from Mr. Cane himself. Very soon after- wards the man was lost sight of, having been discharged from his situation for drunkenness. In the second case, that of a woman, aged thirty-six, death happened in a jit about twenty months after the operation, and it is certain that the tube was open at the time. It is certain, also, that the fits continued after the operation, possibly a little less frequently and se- verely, but decidedly of the same. As to the value of cauterizing the larynx, it is less easy to come to a conclusion. Dr. Brown-Sequard says that a third of his epileptic guinea-pigs were cureel by this mode of treat- ment, and that all the rest, with the exception of two or three, were relieved ; and he suggests a similar mode of treatment in epilepsy. A little later, Dr. Eben Watson, of Glasgow, recommended a similar mode of treatment, and relates three cases two by himself, and one by Dr. Horace Green, of New York in which the treatment appears to have been carried out with benefit. Dr. Brown-Sequard also lays .-tress upon cauU parts, as in the nape of the neck, and especially in the neighborhood in which the aura originates, and he prefers the moxa or hot iron to milder measures. This practice, he tells us, proved wry successful in his epileptic guinea-pigs. In a word. Dr. Brown-Sequard furnishes us with some additional facts in favor of counter-irritants as a means of cure in epilepsy ; and not only so, but he gives a hint which may prove I some practical value, in pointing out the larynx, and the locality in which the aura originates, as sites 376 Lectures on [May, in which "counter-irritation" may le especially serviceable. Now, the verdict of past experience is very much in favor of counter irritants, and I can well believe that this verdict is true true because the inflammation caused by the counter- irritant may for the time rouse the sluggish circulation of the epileptic towards a pitch of safety, and because the discharge may tend to rid the blood of some impurity ; but my own ex- perience in this matter is too limited to enable me to arrive at a sound conclusion. With regard to the treatment of the epileptic lit little need be said. As a rule, it will be only necessary to take care that the patient does not injure himself ; that the head is not al- lowed to hang too low ; and that any necklace or neckerchief be loosened. If salt be at hand, a spoonful may be put into to the month ; if water be within reach, a little may be sprin- kled upon the face, though the advantages of such a practice are scarcely sufficient to compensate for disadvantages and risks arising from wetted garments. In ordinary epilepsy, it can scarcely ever be necessary to have recourse to chloroform, as it may be in some prolonged epileptiform affections ; but if the convulsive stage is unusually prolonged, no remedy would seem to be more appropriate and effectual. In concluding these brief remarks upon the therapeutics of epilepsy, we may say with Marshall Hall "There is no royal road to the cure of epilepsy. The idea of a remedj^ for the disease is unphilosophical ; and the treatment should consist in a well-advised plan, embracing every means of good, and avoiding every means of harm." 2. A single word must serve for what has to bo said upon the therapeutics of other convulsive diseases. Where these diseases are of a chronic character, whether the convulsive symptom be tremor, convulsion, or spasm, it matters not which, there appears no reason for adopting an opposite plan of treat- ment to that which has appeared to be necessary in ordinary epilepsy. Nor does the case appear to be different where the convulsive symptom is associated with disease of an acute character, inflammation, in itself, is no longer regarded as a sound argument for the adoption of lowering measures ; and if inflammation in itself does not cull for these measures, it certainly does not follow that a louder call is made by the oc- currence of tremor, or convulsion, or spasm, before or after the inflammation. On the contrary, the natural inference from the premises is, that the convulsive movement might often have been prevented by more carefully husbanding the strength" of the patient. According to the premises, indeed, mvnlsion, or spasm, would be a reason Casing blood, ratber tban for abstracting blood exccp , >erbap in one single case, and there is where, from the unn- El prolongation and severity of the asphyxia in a first atta ck 3Ua i .. t v . ... ,a+ ,n Kviin'ini nun's. And ;Ul>lVH01l'r;iUi'iianu .^^l.^. -- , ttere is danger of baemorrbage into tlie Wain and lungs. And Mainly there is no practical ob ection to bis view, or all , st know that we have no reason to be satisfied with the re- Ste of a lowering plan of treatment m acnte convulsive dis- ordci er m si Rattlesnake Bites. 3?? he Treatment of Rattlesnake Bites, with Experimental ms upon the various remedies now in use. Jiy b. Wler Mitchell, M. D. The subject of the poisons made use of by certain animals has been in all times of the utmost interest to the popular bind That it has failed to attract an equal or proportion- al amount of scientific investigation, can only be accounted for by supposing that the popular aversion to serpents as Cell as the real danger which more or less surrounds the pursuit have combined to deter toxicologists from engaging In such researches. The admirable effort in this direction bade by the Abbe Fontana, who has left us the record ol periments on viper poisoning, may also have done to prevent further study of this serpent, since his opinionshavebeen reverentially received as imaland the multitude of his experiments has caused them to be looked a as exhaustive of the subject. In other than European countries, and where the moic virulent poisonous snakes abound, observers have been wanting, or they have lacked those means of pursuing the study which only a great city affords. It has thus happened that through want of material where observers were plenty, or lack of these where material was abundant, the know- iedg pent venoms has advanced but little Bince the davs of Fontana. . JBefore the time of thai great toxicologist, viper venom had tudied by Charas, 1669, Redi, 1672 and 1675, aiul vi A multitude of others had also touched the - but on the whole, they added nothing import- rmation which came down from the Greek nan fathers of medicine; or. when they added any- tlli] tape of fanciful conjecture, and served oni, Qore difficult thetask of unraveling the united Rattlesnake Bites. [May, web and woof of popular and scientific beliefs as to venom- ous serpents. Without carefully reviewing this mass of strange opinions and superstitious conceptions, it is not possible to appreciate the services done by Fontana in clearing the ground for modern research and in setting at rest a host of minor absurdities. .Most of the definite and novel views which he put forth as the direct results of his experiments have been more or less unsettled by various partial inquiries of more modern date: but, on the other hand, some of the most valuable facts which he discovered have never been questioned; and, as a whole, his essay, or series of essays, is still a monument of industry, ingeniously directed, and of experimental sagacity of the highest order. From 17(37, the date of his essays, no contributions of any moment were made to the toxicology of venoms until the publication of Russel on the Poisonous Serpents of India, in 1787. %In 1798 and 1709 appeared in this country Dr. Barton's ys, which were rather records of his own thoughts and of popular and other opinions than of original research. In 1817, Mangili settled the question of the innocency of venom taken by the mouth ; and 1843, Prince Lucian Bonaparte analyzed the venom of the viper, and determined its albu minous nature. At various periods also appeared numer- ous papers by East Indian surgeons and European physi- cians on the therapeutics of snake bites; but with trifling exceptions, no further experimental papers were produced until Drs. Brainard and Green recorded their researches in 1853. Dr. Brainard's separate Essay, 1854, contained in- teresting observations as to the phenomona of venom poi- soning, but the main object of both ihe papers alluded to was the examination of the value of iodine used locally as an antidote. The tendency to regard the subject chiefly from a therapeutical point of view has indeed prevailed through- out nearly all of the res< made either in this country, in India, or in Europe, so that if we omit the essays of Bonaparte, Mangili, Russel,and Davy, the work of Fontana still remains without a companion no one since his time having examined any one serpent poisonas to its chemistry, toxicology, and mode of formation. Yet, as every physician musi concede, the treatment of snake bites can never be rationally understood until we retrace our steps and study anew and more profound the venom malady and its cause, II.] Rattlesnake Bit 379 in place of playing at perilous hap-hazard with its difficult therapeul Whenlfira tudy of the venom of the rattlesnake, it was with the intention of ascertaining what value Bibron's antidote possessed. To effect this single end I procured four or five snakes from th< ylvania Alleghanies and proceeded to subject animals to their fangs, and afterwards to give the supposed antidote.' After destroying many animals and attaining only nega- tive results. I began to perceive that I was working in the dark, and that it was altogether impossibe to obtain useful results without possessing definite knowledge as to the nature of the venom, the mode of its formation and ejection, and the whole natural history of the disease to which it gave rise. The information which I desired was yet to be created. It existed in none of the hooks, and even so much of it as had [uired by Fontana with regard to the viper, might rue of the rattlesnake. With a clear sense of these deficiencies in the present knowledge as to venom poisoning, I laid aside my on remedies, only to resume them after the mmers had removed from my path the im- pediments which have hitherto rendered the study of anti- dotes practically . The result of these research* riled at length in a paper recently published by the Smithsonian Institution, and to which I desire to refer the Ler for full details of my experiments, and for the con- - to which they led me.* The principal difficulty which I encountered at the outset was the want of snakes ; owii . to the ready and constant aid which I re- from the Smithsonian Institution, I was enabled to ply from the Virginia Alleghanies, and with these and such other chance supplies as I could pur- rocured for me through the kindness of :ahled to pursue ray purpose with only long to the subject. difficulties which lay in the way of one ition Wier ition. Jam: Vv> Vrk: 1) 380 Rattlesnake Bites. [^fay, studying the treatment of snake bites were among the most easily resolved of the many questions which multiplied in number and increased in perplexity as I advanced on this interesting path of study, fn fact,* I cannot but perceive that I have re-opened a field of research which promises most valuable and strange results to the toxicologist, nor can [fail to comprehend that the whole subject of venom poisoning is to be reconstructed, and that on no branch of science are we so utterly ignorant as on this one. M. Ber- nard alone, of all the recent writers, seems to be aware of our lack of knowledge in this direction, and strongly urges a re-examination of the principal animal poisons, such as the venom of toadsf and serpents. At the close of the Smithsonian Essay, just referred to, 1 have given a brief statement of my views as to antidotes, and as to the great difficulties attendant upon their thorough study, and I have appended a short discussion of the rela- tive value of various remedial means now in repute for the treatment of snake bites, as well as my own opinion on the rational method of treating these injuria The object ot this present essay is to consider all the best known antidotes by the light of the practical criticism of experiment, and, finally, to point out what means of treat- ment appear to be best calculated to relieve the sufferers from these dreaded accidents. The course of study thus laid down will involve an ex- amination of the following points, which I shall consider at such length as my space permits: 1. Fallacies in regard to the use of antidotes of all kinds, arising from want of exact knowledge as to the secretion ot venom, and the mode in which the serpent uses its fangs and ejects the poison. 2. Falacies as to antidotes, arising from want of informa- tion on the natural history of the disease caused by the venom. 3. General considerations as to antidotes, and as to the mode of conducting researches in this direction so as to avoid errors. ind Gazette, Sept. i2-.m1i. I860, p. 296. M. Bernard mak< teresting remarks on the venom Of the toad. ~S\. Gratiolel had already examined thissnbjecl mid arrived at somewhat similar con- clusions, to which, however, M. Bernard does not allude. See Gratiolet. Oomptes Rendus, vol. xxxiv. p. 732, 1851. 1.] fi / 381 Description of the ph< a of rattlesnake anal tc. :al treatment Experimental examination of tho medication most in repute. aeral or constitutional treatment. Experimental examination of the principal constitutional remedies. 7. Sketch of the author's views as to treatment, local and general. 1. Fallacies in regard to the use oi antidores oi all kinds, arising from want of exact knowledge as to the u of venom, and the mode in which the serpent uses its fangs and ejects the poison. When antidote has been given, any treatment used after a snake has bitten a man or a lower animal, it is usually taken for granted that the danger of any two bites is much the same if the subjects of the bites are alike in age or vigor. Xow, even when the serpents are themselves of equal bulk and have at disposal drop for drop the same amount of venom, it may chance, that the danger of the two bites is utterly unequal, and thus that in one an antidote might fail, and in the other appear to succeed. This arises from one of the following reasons : The snake fails to elevate its fangs sufficiently when striking, and the fang points touching the skin are driven backward toward their usual position of repose without irating the part aimed at. When this accident occurs no wound is inflicted unless the teeth of the lower jaw be- . tangled in the skin of the bitten part, in which i the small wounds thus made maybe easily mistaken for fang mark-. When experimenting with Bibroh's antidote, in duly, 1859, a large dog was scoured and placed within :h of a -make which struck it fiercely and became fasten- ed for a short time, so that I was able to perceive that the fangs were doubled backward, their anterior convexities the skin to which the Berpent was attached by the curved teeth of its lower jaw. The wounds made by -e teeth were of c and the d^'j; experienced no further inconvenience. Thie >f failure in the bite rt be difficult of detection, under ordinary circumstances the s!iak ', since it would be dangerous to ap- proa e the snake is usually entangled i'nv out a brief period. When, however, ti held by the middle, in a leathern loop at the end of a stiif, and thus allowed to bite, they not unfrequently fail to elevate triciently, and, as in experiments on antid 382 Rattlesnake Bites. [May, it is often necessary to secure the serpents in the manner described, the possibility of this occurrence should not he overlooked. 'When tin1 rattlesnake bites, whether it he at perfect free- dom or not, both fangs do not always pierce the skin of the animal stricken. I have sometimes suspected that the ser- pent does not always elevate hoth fangs. This, however, is a point which does not readily admit of direct observa- tion in snakes at liberty, and can only add, that of seven dogs bitten by serpents at freedom, four had two fang ] narks, and three had hut one. Now, as the fang, duct, and gland of one side are quite distinct from those of the other, if only one fang he used, the dose of poison adminis- tered will he hut one-half of that which would he injected were hoth fangs employed. Apart from the possibility of the snake using only one fang at will, there are other facts in this connection which may enahle us to explain the frequent occurrence of single fang marks. When, for example, the snake strikes obliquely at the Hank of an animal, one fang sometimes remains out of reach of the part penetrated by the other, and this is the more apt to occur, because, in elevating the fang teeth, at the moment of attack, their extremities are made to diverge widely.* For a like reason, when the ser- pent strikes a small limb or member, it sometimes chances that the fangs either straddle the part completely, or that entering it, the other passes it to one side without in any way injuring its tissues. Besides these cases of fang marks, many instances occur in which, although hoth fangs penetrate the opposing tis- sues, only one is in reality active, or, hoth entering the flesh for reasons to be presently detailed a part,. or perhaps in some cases the whole of the venom fails to he injecteel, and the danger of the wound is materially lessened. "When the fangs in biting arc fixed in the flesh, the lower jaw of the serpent is pressed upward against the part bitten and at the same instant the temporal muscles, and especial- ly the anterior temporal, compress the venom gland, and Tin- object of this Beemsto he to protect the lower jaw from injury in :iis< their aim and are driven downward, in which cases they would pierce the lower lip of the snake were it not that their diver- throws their points outside o\' it. 1861.] 383 urge its accumulated venom along the duct and through the !i. In most rhere both fangs have been used, the actions which bury the fangs more deeply, and inject the - 'ii, are consentaneous on both but sometimes a perceptible interval appears between the contraction of the right and left sets of muscles, so that a sudden motion of the bitten animal occasionally libera fang 1>< charge of venom lias been duly deliver* Still more curious, however, is it, that we may have both fangs deeply buried in the flesh of an animal, and yvt not a drop of venom injected. The explanation of this source of fallacy in the use of remedial means is to be found in the following facts li, in his >hes on viper venom, published in 1675, Btates that the poison } i es down alongside ol the fang, and between it and the mucous cloak which covers it when at rest, and which is now known as the vagina dentis. Fontana disproved this statement, showing that the venom passes out through the canal of the fang. If, as I presume is the case, the arraj ment of which I shall presently speak belongs to the viper ell as the rattlesnake, both were right and both were wrong. Professor Christopher Johnston, of Baltimore, and Professor Jeftries Wyman have both of them recently des- cribed the venom duct of the rattlesnake as ending in a papilla, which projects into the basal aperture at the base of the fang. Upon close inspection it can be seen that no tissues connecting these two parts together in any direct manner, the end of the duct being held in close contact with the tang by the gum, which envelopes flic tooth, and through which the extremity of the duct When the far. couched, at rest, in its mucous sheath, the apposition of the tang and duct is still kept up, but is less perfect than when the fang is erect, since then the mucous cloak is thrown off the anterior convexity of the fang, and gathered in firm folds at the base of the tooth, firmly presses the papillary end of the duct into the lower orifice of the flu h being the case, it can be seen that if the fang is not fully erected, or if, from any cause, the end of the duct is rated from the fang opening, a part or the whole of the m may escape between the fang and its mucous cloak, and tail innocuous on the skin of the bitten animal, hi a modified form this result often happens, and a part at least of the poison is cast on the skin, the larger portion travers- ing the duct, and probably the excess alone being wasted. 384 Rattlesnake Bites. [Majl In direct experiments on animals I have often noted tin escape of venom alongside of the fang, and in general, the mure serpent's motions are interfered with during the experi ment the more likely is it that the whole or apart of the poisoi will he lost in the way I have mentioned. It thus happens thai \\w most vigorous serpent may become innocent at the verj moment of the bite, and that not even the most watchful attention will enable the observer to say that the remedj given was the cause of a bite proving mild in its effects! I have here urged, this, like other sources of fallacy, is most apt to appear when the serpent is held, and when thus we endeavor to cause the bite to occur in a particular part of the body of an animal. 2. Fallacies to the value pf antidotes, arising from wan] of information in regard to the natural history of the dis- ease caused by the venom of serpents. There exists as idea, not confined to the popular mind, that the bite of the rattlesnake is an extremely fatal accident. Although wc have no full statistics which are available to settle the mat- ter, I have gathered enough information from various sources to enable me to assert with great confidence that it is fai less fatal than has been supposed. When making this statement, I do not mean to be understood as saying thai the rattlesnake is not a dangerous animal, but only that neither man nor dog need be regarded as condemned to death when wounded by it, whether remedial means arc afterward employed or not. A large rattlesnake long re- strained from biting will use his weapons no doubt with deadly effect, and'hence, when showmen have been bitten, they have rarely escaped. On the other hand, the greater number of such accidents, arising from serpents at freedom, will be apt to prove serious in their results, but not very often fatal. Of fifty-seven cases of rattlesnake bites which are given in full or merely mentioned in the journals, only five died ; and even if we make every allowance for the character of the reports, this evidence still remains sufficient- ly strong; nor have I found that it lost force in the pre- sence of such facts as my experiments on animals have brought before me. A close analysis of the table of casei in my Smithsonian essay, (p. 100,) with reference to the treatment and the result, brings us to the conclusion either that all treatment (oil, alcohol, iodine, ammonia, etc.,) is successful, or else that the greater part oi the cases must have survived under any form of medication. It can be 1861.] fi shown, moreover that most of the plana of treatment em- ployed are utterly useless. Here, then, is a malady from which at least seven-eighths of the patients recover. The mere fact of their surviving can assuredly be no test of the value of apian of treatment. . that this or that ease did not die has been thus con- strued, and this cardinal error exists in almost all of the earlier examinations of antidotes, and in some of the later ones. Authors who have reported successful cases of the treat- ment of snake hires hy various means, have been further misled by a want of knowledge as to the duration of cases not treated at all, and as to the character of the recovery. general survey of a number of cases, and a careful study of animals bitten and not treated, can alone supply this lack of information as to the average natural nistory of cases un disturbed by any therapeutic resorts. Ai the result of such study, we learn that a few cases of rattlesnake bite die, that a few linger long ere recovery is complete, and that the larger proportion get well, and that with a degree of sudden- - which is sufficiently surprising, considered with refer- to the serious character of the symptoms, and well calculated to deceive the credulous therapeutist. In many cases this abrupt departure of all serious symp- toms at remarkable ; a man is bitten, thought to be dying, treated this or that way. and on horseback or t work forty-eight hours from the time of the bite. In dofc? bitten, alike result obtains and the recovery after the mot*, urgent symptoms is usually rapid and compl Now nothing is more gratifying to the physician thai. the sudden effect of his remedies; and the speedy and favorable change of a case from an appearance o\% extreme danger to one of relief and convalescence, naturally leads him to attribute that result to his medication, which really was natural to the malady. A fuller acquaintance with the rt annihilate this source of error for any but the r incautious minds, [t will now be fitting to consider the third section of our subject, and to comprehend clearly how we avoid the of falacy above pointed out, and how the study of antic1 serpent] should be conducted. And first, what is an antidote ': The popular mind usu- ally conceives of it as a remedy having power to neutralize directly in the system a given poison, destroying its potency ".s'i Rattlesnake Bites. [May, by acting upon it chemically or otherwise, in some more mysterious way. It is possible that agents of this kind may exist, lmt thus far we are ignorant of any possessing such a relation to the venom of the rattlesnake. The pretensions of remedies supposed to he so gifted may be easily settled by mingling them with the venom, and afterward injecting the mixture into the tissues ot an animal. The more rational conception of an antidote, is of an agent which merely counteracts the effects of the poison, and which may have no chemical influence on the poison itself. Such an antidote may enjoy no power to affect the toxic activity of venom when mixed with it, and yet may prove to be an active constitutional preservative against its effects. Just this position seems to he held by one of the supposed antidotes most in repute. So far as I am aware, no great difficulty is likely to arise in the study of antidotes, owing to their nature as such, for although some of those most in esteem, such as Bibron's antidote (bromine) and the Tanjore pill, (arsenic,) are poi- sonous in a high degree, it is easy to learn how much may be given with impunity. Hence, although in one or two instances observers have actually and plainly destroyed ani- mals with the very agents which were designed to relieve them, it is not probable that errors of this kind will be per- petuated, or even occur so often as to bring into disrepute any really useful remedy. The mode in which the study of antidotes and local remedies should be conducted, so as to avoid all the fallacies to which I have alluded above, will now claim our attention. Opportunities of studying the use of remedies, local and general, in connection with cases of venom poisoning in man. are of course more or less rare, and it is scarcely pos- sible to eliminate or allow for the varied fallacies which sur- round with difficulty this method of studying the subject. Owing to this, and to the comparative ease with which the means of study may be created in animals, it is preferable to employ these, and to use only such treatment in human cases as may appear to promise enough of success to justify its usage. The larger the animal employed the better will it be for the purpose, since the symptoms are more easily studied in large animals, and since they are less likely to be injured by active antidote-. Almost all toxicologists who have; in- \ estigated this subject, have been content to submit animals, L] Rattlesnake Bit 887 as dogs, etc, to be bitten by the serpents themselves. We have seen, however, that when this course is followed, a number of fallacies interfere to prevent the observer, from drawing satisfactory conclusions, and although great care and thorough acquaintance with the anatomy and habits of the serpent may enable us to overcome this difficulty in part, some portion of the obstacles in question are in the nature of things unavoidable. In my own researches I have sought to escape from these embarrassments: first, by a fill study of the natural history of venom poisoning in - and other animals : second, by injecting into the ani- mal experimented upon known quantities of venom previ- ously removed from the ducts of active serpents. The venom to be thus employed is secured in the following man- ner : A serpent is seized by the middle, with a leathern loop at the end of a stall'; then the neck is caught and held down on a table with a notched stick, while a tube an inch and a half in diameter, and holdidga sponge soakedin chloroform, is slipped over the snake's head, and by a dexterous motion carried downward so as to include one-third of the length of the serpent, the notched stick being at the same time re- moved. About twenty minutes are required to stupefy the snake. It is then seized by the neck, and the i^d^c of a slipped under the upper jaw, so as to elevate the fangs. This is done by an assistant while the operator with his right thumb and forefinger strips forward the glands and ducts on both sides. The yellow venom runs out through the fang and along- his weapon. A known amount of this fluid may then be injected into the tissues of an animal, the instrument employed being a minute tro- car and Itmaybe objected to this method of us- ing the venom, that it is supposed by many persons that the poison i- less fatal when used artificially than when injec by the snake. Of this, however, there is no adequate proof, and Iha nothing to induce me to believe that it is at all correct. On the other hand, the advantages arising i the artificial use of the venom are manifold and obvi- . ami it is only essential to know what amount of venom troyadogifno remedial agency intervenes, a addition to this, th wr is thoroughly cognizant te ordinary phenomena of ti he will table ni< ansof insuring accuracy, which are now attainable. Antidotes mav then be used internallv 388 Rattlesnake Bites. [May, in one or two ways to be hereafter illustrated, or mingled with the venom, and injected where this mode of study is to be desired. Before stating my experiments upon the plans of treat- ment now or recently in repute, it will he proper to give the reader certain necessary information as to the nature of venom poisoning, the forms it affects, and the symptoms which characterize its varieties. These details must of ne- sity be brief, and the reader who wishes more complete information is referred to the author's previous paper. The venom of the rattlesnake is a yellow, albuminous fluid, of an acid reaction of a sp. gr. of 1044, and coagulable at a temperature of 140 to 160. Its toxic activity is un- affected, or but slightly affected by boiling, and not at all by freezing. Acids and alkalies, alcohol, etc., do not de- stroy its virulence, and when dried it retains dreaded power for an unlimited period of time. Closer qualitative analysis discovers in it at least two albuminous substances: one co- agulable by boiling, either when alone or diluted with water, and also by alcohol ; the other, also albuminoid, co- agulable by alcohol only, and constituting the active ele- ment of venom. This latter agent I have described as cro- taline. Effects of venom on man and animals. When an animal receives in any way a dose of venom, one of two things happens. If the animal is small, or at all events if relative- ly to the size of the animal the amount of venom injected is large, the animal dies very suddenly, acutely poisoned. If, on the other hand, the dose of venom is relatively small, the animal suffers to some extent with the symptoms of acute poisoning, and then passes into what I shall term the stage of chronic or secondary poisoning, which may endure for an indefinite period, and end in death or recovery. Acute poisoning in a man is rare,* and is more and more common the smaller the bulk of the animal bitten, until we arrive at cold-blooded creatures, in whom this sudden ending is the exception, and great prolongationof the mala- dy (/'. e, secondary or chronic poisoning) the rule. In dogs I ugh rare, not impossible; men have died from this cause within ty minutes of the time of the bite, although no such cases are oo rd in the journals, and arc only known to me by personal informa- tion. ;L] RaUUsnah B have rarely seen the very rapid death I speak ofj but it is not ancommoD whore the serpents are large and active and their venom abundant Let it be clearly understood then, that when man or ani- mal is poisoned by venom, a set of symptoms occur which wind up with death, or. being prolonged, pass into others of a somewhat different nature, constituting the chronic r those which survive long enough to exhibit the - which characterize the secondary poisoning. When, for instance, a pigeon is bitten, or receives in any way three or four drops of venom, it walks a few m crouches, - i'ov breath, rolls over and is dead in a few minutes, convulsed or not in the moment of agony. So sudden and speedy is this ending in some eases, that the pigeon may die within a minute. The only additional symptoms which we can percriveare the rapidly quickening and enfeebled motions of the heart, and sometimes vomiting and evacuations from the cloaca. In larger animals the same symptoms take place, but the vomiting is more com- mon and the expression of general debilitv more percept- ible. Men who have been bitten describe their symptoms much the same in kind, but, as before stated, they rarely end in death in thia t least : the power of resistance acquired by increased bulk being, I presume, the chief pro- tective agency. In some eases the more formidab of prostration do not declare themselves before some minutes or even halt* an hour has passed. In one man engaged in splitting wood was bitten ; lie picked up a stick and pursued the snake a few feet, when suddenly he :: at the stomach, complained of deadly nausea and general weakness, reeled a few steps farther, and fell on the ground. In another instance, the sufferer walked briskly for twenty minutes before the symptoms of debility ;.me very well marked. It - important to our purpose to decide th< mptoms and what organs are affected. .Ml auth s in speaking of the condition as one of debility and all describe the pale face and cold the hurried ih and (piick and feeble pulse. If we examine an ani- mal dying rapidly with these symptoms, we find absolutely no 1 ihe blood and the t. re alike healthy in app- both to the naked and I eye. of experiments, the relation of which would be misplaced )00 Rattlesnake Bites. [May, here, lias shown that the heart does really become enfeebled and that the arterial pressure is singularly diminished, and this appears to be a direct effect on the arterial system, since it is impossible long to sustain life by artificial respi- ration ; at the same time the nerve centres are attacked, and the respiratory movements failing on this account, become jerking and labored; the sensory and motor nerves seeming still to preserve their functional in- tegrity. Such, in general terms, I suppose to be the causation of death in these cases. Far different are the symptoms which arise for study when the patient sur- vives the stage of acute poisoning. The duration of this stage is indeed difficult to define; this only we know, that alter a time the debility continuing, as shown by vomiting and syncope, the blood becomes affected in a marked and singular manner, while the relations of tissue and fluid are so altered that passive hemorrhages take place ; jaundice occurs, and a variety of symptoms declare themselves as .this or that organ becomes diseased and the seat of congestion and eechymosis. Meanwhile the local symptoms assume an importance which they do not possess in the acute stage and may even become paramount influence in deciding the fate of the patient. If then the patient die very early, there are symptoms of weakness alone, and there are no perceptible lesions of 1)1 ood or tissue ; supposing life to be prolonged, the early symptoms continue, while signs of blood poisoning appear in addition, and lesions closely resembling those of yellow fever are found post-mortem. If, again, the patient success- fully resists the secondary evils here described, he may still perish from the results of the local injury, which increases in danger and importance as the case progresses. To make this matter clear, we will now examine more accurately the various symptoms and the character of the wound. Wound. The wound is usually described as very painful, but so far as my own experience informs me it is not always so in animals, nor do all men who are bitten speak of it as painful at first. Indeed, the wound has sometimes been for a while disregarded, and at all events the hooked form of the fang, the forcible injection, and the sudden with- drawal of the weapon, account sufficiently for the pain, without supposing it to be specific. The succeeding local ymptoms are rarely notable when the patient dies within a.] Eaitl make Bii 393 half an hour, except that in animals the muscles twitch most violently, of which wo hear nothing in the human ca advances, the part swells, becomes discolored and increasingly painful, and these4 changes extend np the limb involved, and, reaching the trunk, swell and bloat side, or the whole body. This swelling is not inflammatory, but arises from the gradual effusion of blood, which has lost power to coagulate and which therefore extends from the broken vessels, at the seat ot the wound. The later swelling is also due moi ma than inflammation, although it seems probable thai in man the tendency to inflammation under venom poisoning eater than in the lower animals. In dogs bitten, the local swelling is sometimes slight, sometimes enormous, and and when cut into is found to depend on a collection of blood, either fluid or semi-coagulated. The pain which ac- companies the swelling is excruciating in many cases, and - not lessen until the part becomes vesicated, loses heat and falls into gangrene. Ln man this process destroys the skin only, or the whole of the limb, but in dogs I have seen no such extensive sloughs, and the skin often escapes, so that we find only a small opening, and beneath it a cavity containing the debris of broken-down tissues, mixed with pus. I suspect that in man the swelling would occur I rapidly were it not for the constant use of the ligature about or above the wounded part. If the case be a serious one, the early constitutional .signs of prostration continue ; casional vomiting, or at least nausea, is present, frequent, syncope occurs, and the pulse continues weak and rapid. In general the bowels are constipated, unless the case be greatly prolonged, when diarrhoea, may take place as a sequel. The mind is. in most instances, clear up to the time u{' death, or at all events it is only confused, excited, or sub- ject ry delusions, while convulsions seem to be of extreme rarity in any period of the malady in man. The tall of temperature in the skin is usually described as an early symptom of the general weakness, but no accurate thermometric observation have been made in human cfl The duration of cases of rattlesnake bite is very various, although both in dogs and men the recoveries are often rapid and unex] - it is impossible for me to dwell in full detail upon the symptoms of the venom malady, and equally impossib] cribe the great variety of lesions which may occur, I 392 Rattlesuake Bites. [May, have thought best to state three typical eases of poisoning in animals, and two in men. The following arc quoted in full from the essay so often referred to : " Eperiment. The dog, a small terrier weighing about fifteen pounds, was intended to make one of a set of obser- vations on the value of Bibron's antidote. For this purpose he was placed in the snake-box, where instantly he was struck twice by a large snake, both wounds being double fang marks, and both being in the right flank. On remov- ing him I observed that from one of the wounds blood was running in a thin stream. After it had run for some time, I caught a few drops in a watch-glass, and found that it co- agulated well. Before I thought fit to use the supposed antidote, I was called away. Returning at the end of an hour I found the dog standing with his head pendant, having just vomited glarily mucus. His pulse was quick and feeble, his respiration occasionally panting. The hemorrhage had ceased. Owing to an accident which at this time deprived me of the supply of Bibron's antidote, which I had pre- pared, I was unable to employ the animal in the manner proposed, and not desiring to lose the observation altogether, I made use of the opportunity in the following way : " One hour and a half after he was bitten I drew a drachm of blood from the jugular vein. It clotted perfect- "Four and a half hours after the bite a drachm of blood from the same vein coagulated equally well. " Twenty hours from the time of the poisoning, the dog was found on his leftside, having passed slimy and bloody stools in abundance. At intervals he seemed to suffer much from tenesmus, but was so weak that he stood up with difficulty. His gums wTere bleeding, a symptom I had seen before, and his eyes were deeply injected. At this time about two or three drachms of blood were drawn. It was very dark, and formed within five minutes a clot of feeble texture. " Twenty-seven hours and a half after the time at which he was bitten, the dog was weaker. His hind legs were twitching, and the dysentery continued. Three drachms of blood were drawn as usual, but no clot formed in this speci- men although it was set aside and carefully watched for some time. While I was collecting the fluid for observation the dog suddenly discharged per anum at least four ounces of dark, grumous blood. At this time I supplied the dog 1861.] Rattlesnake 398 with water, and left him. Fifty-four hours after the bite he was seen again, and found to have drunk freely of water and to have passed fewer stools. Up to this date he de- clined all food. " From this time he improved rapidly, and took with trness whatever nutriment was offered^ On the fourth day his blood again exhibited a clot, although it was very small and of loose texture. 1 made no further examination of the blood. The dog lost flesh as he gained strength, and had profuse suppuration from an abscess in the bitten flank. At the close of two weeks he was active and well, except that the wound was still open. " The case last related is doubly valuable, as pointing out even in a single instance the time at which the blood be- came altered, and also as showing, once more, how pro- found may be this change, and how perfect the recovery. * Experiment. A dog of mongrel bull-terrier breed, weighing thirty-one pounds, was lowered into the cage, where he was struck on the outside of the right hind leg in the thigh. He drew up the leg when released, and whined for a few minutes. The wound, which was a double fang mark, bled a drop or two, and the muscles about it twitch- ed considerably at intervals for an hour, when this symptom was obscured by the swelling. His pulse, which was natur- ally about 145 and irregular, was, at the fifth minute, 140 and regular, respiration 35. At the fifteenth minute lie lay down much weakened, pulse 1G0 and feeble, respiration 40. At the twentieth minute the bowels moved loosely, with a gray discharge, and there seemed to be some tenesmus in the rectum. Twenty-fifth minute, pupils so far natural and mobile ; he could stand when urged, but lay down again at once, and was much weaker. Forty-fifth minute pulse 160, respiration 45 and laborious. Fifty-fifth minute, loss of power in the hind legs. Eightieth minute, quick and labored, and so irregular as to make it impossible longer to count the heart pulses. The eyes were natural, and follow- ed motions ; and lie wagged his tail when fondled. At this time the observation was temporarily interrupted, and, on its resumption at the third hour, the dog was found dead, lb- had no foam about his mouth, and probably died quietly. "Post-mortem section. The whole muscular and areolar tissue of the leg and thigh, lnilf way up and down the limb, was dark with infiltrated blood. About the wound the 394 Rattlesnake Bit [May, swelling was due bo a mass of blood partially coagulated. The extravasated blood extended through the limb, and on the inside it passed halfway up the sartorius and adductors, and along the Bheath of the vessels to within two inches of the femora] ring. Nearly an inch of the sheath was clear of it, but one-half inch below the ring tissues were shaded with blood, and the same appearance was ^aon around the ring itself. From this point the extravasation extended under the peritoneum, into the pelvis, and on to the inner face of the ilium. The color of the tissues thus stained was a brilliant scarlet. The abdominal viscera were healthy, ]>t that the mucous membrane of the lower bowels was somewhat congested. The lungs were sound. The heart was relaxed, the right side full, the left nearly empty. The blood on the right side was a little darker than that on the left ; on both sides and even-where else it was perfectly fluid and free from clots. Placed in a phial, it remained fluid until decomposition enusued. Two hours after death, some of the blood globules found in the heart were slightly indented ; those taken from the small vessels of the ear were perfectly normal. At the period of examination, the muscular and nervous irritability had entirely de- parted."' A third observation on a smaller animal, and also drawn from a like source, will answer my present purpose. "Experiment. In this instance the animal, a rabbit, was struck once in the back by a large snake already exhausted by frequent use. A few minutes after the bite took place, the rabbit was seized with weakness, gritting of the teeth, and rapid respiration. It passed urine and feces, and re- mained feeble during some hours. From this period the weakness abated somewhat, but the back continued to swell. On the second day the local signs were improving, but the animal had passed a very albuminous urine, and a large amount of blood mixed with The symptoms of general weakness now increased, the hind legs began to drag, the motions were uncertain, and the bloody purging grew worse. The rabbit died on the third day, during my ab- Bencj "Post-mortem section. Kigor well developed. The period of death being uncertain, the irritability of the tissues was not toted. The wound was surrounded by half an ounce or more of dark fluid blood. The vessels in the liborhood were full of a similar fluid, but there was no L] Rattlesnal ilar redness, like that of acute inflammation. The muscles in the track of the bite, which double fang mark remarkably softened and could be torn with the utin The brain was highly congested, and there was a good deal of bloody serum in the cavities of that or- gan. Similar congestion existed in the spinal canal, and at several points the white nervous tissue was Btained with small patches o( blood. The lungs were healthy. The pericardium was curiously distended with bloody serum. The heart was contracted and contained hut little blood, that dark and diffluent. Tl e intestine- were spotted at intervals with ecchymoses lour to five lines in diameter and apparently just beneath the serous covering, the cavity of which contained a little bloody serum. The intestines from the oesophagus to the rectum were dotted with ecchymoses and tilled, especially tie gut, with hlood and mucus. The right kidney was large and absolutely soaked with dark rluid blood. The left kidney was more healthy. The blad- der and ureters contained a good deal of bloody urine. How the rabbit lived so long with such a singular complication -ions it is difficult to conceive. In most cases ironic poisoning, some one or two organs may become of local extravasations, but for extent and character of lesions this case stands alone in my experience." Ti. i its given ly our own authors of the cases oi human poisoning stremely meagre and unsatisfactory the best reports being those by Sir E. Home* and M. Pih' ith of whom described cases which took place in showmen. {Dr. Homer's case is perhaps one of the best among our own reports, but like the more curious one given by Sigaud, the patient was not altogether a healthy subject. I shall quote Dr. Korni with the statement that the local vere belter illustrated in the second case quoted, that by Dr. R. Hark ol., vol. viii. i,. ains the follow] every a the bite of the 896 Rattlesnake Bites. [May, \d;iiij Lake, aged about 40, a robust, muscular man, acting in a laborious capacity, and wbo, from his own ac- count, was in the habit of drinking from half a pint to a rattlesnake cures the leprosy (lepre leontine of Alibert) without injury to the patient. Many facts would seem to show that lepers have been bit- ten without fatal results, not only by thecoroline viper, by the jararaeasu, but even by the rattlesnake. Among these tacts may be cited those which have been collected by Dr. Jacintho Pereira Reis, and by the deputy, Estevao, Rafael de Carvalho. The firsl is that of a leper of the district of Rio-das- Velhas, in the province of Minas Geraes, who having been bitten by a rattlesnake, was cured of his disease in fifteen days. The second is furnished by a negro slave of the province of Maranhao, who recovered from his leprosy in a very short time after having been bitten. >.i. de Lima assures as that being one day in the town of Saint Charles, province of Carabobo, in Colombia, he observed a man whose face was covered with a single large cicatrix, which at first he attributed to a burn, but on inquiry learned that it was the result of a radical cure of a case of leprosy, by the bite of the rattlesnake. The same observer tells us that an opinion favorable to this means of cure is entertained throughout the district of Caracas and Apure, where leprosy is common. These state- ments which, after all, are but hearsay, induced a leper to resort to this tearful mode of relief. According t< Dr. Jacintho Rodrigues Pereira Reis, another leper bad already made this experiment in this capital, (Rio de Janeiro.) This person had the courage to allow himself to be bitten at one time by the coraline viper, and at another by the jararaca pre^uicosa. Each time he was left for (lead, but notwithstanding, gradually revived without aid. After this he still had the pain to observe that his original malady continued its fearful progress. "Case. Mariano Jose Machado, born at Rio Pardo, province of Rio- Grande do Sud, aged 50, had been for six years afflicted with tubercular lepra, during 4 years he had resided at the leper hospital, at Rio de Janeiro. On third of September, he came out, resolute to put to the tot the bite of the rattlesnake, despite the prudent and wise counsels of divers physician8, who saw in the means he desired to employ a more than dubi- ous chance of SUCC6SS, and who also were aware that the patient had not exhausted all the more available and proper remedies. The patient final- ly resorted to the Louse of M. Santas, a surgeon, Rue de Vallonga, No. 61, who possessed a rattlesnake." After describing the appearance and character of the leprosy, and mentioning those who were present, M. Sigaud continues as follows: "Marianno Jose Machado, before proceeding, declared that he acted on his own responsibility, and then having signed a paper to this eifect, put his bund into the cage and twice 3eized the Berpent. The reptile at first and finally licked his hand, but, feeling itself pinched with force, turned and bit him at the metacarpal articulation ofthe little finger and ring finger. The bite took place at 10 minutes of 12, September 4th. The patient did not feel the bite, and only knew of it by the remarks of those around him. His hand wasa little swollen, but painless, and bled some- what, the pulse and respiration remaining normal, five minutes later, d a Blighl sensation of cold in the hand, with a little pain in the palm, which, in a few minutes, increased considerably. 17th 1.] Ttatllesnah pint of alcoholic liquors daily; on Friday, July 1, 1831, was in a crowd collected at Fisher's tavern, in Kensington, to witness a popular exhibition of rattlesnakes, confined in minute, pain in the wrist. 20th minute, hand swelling. 80th in., pnlse nger and fuller, mind tranquil. 55th in., sensation of swelling in sides and back of neck ; size of hand increasing; pain extends to two- thirds of the forearm. 69th m., general numbness. 1 hour and 20 min., general tremor; hyperesthesia, I h. ,,,' m., mind troubled, j>ul>e more frequent; difficulty in moving the lips; tendency to sleep; choking sensa- tion; intense pain in the hand and whole arm: hand swelling. 1 h. 45 m.. pain in tongue and pharynx, extending to the stomach; increased pain and swelling in the bitten hand; feet cold. 2 h. 5 m., difficulty Gf speech, and a little later, difficulty of swallowing; anxiety; copious sweating the chest :' h., weakness; nose bleeding; inquietude; pulse %. 3 h. 4 general sweat, and a little after, involuntary groans; pulse 100; greal pain in the arm; face injected; continual epistaxis. .'5 h. 35 m., the patient swallowing wine and water readily, and changes his shirt; a red color i- throughout the body, and a little blood leaks out of one of the pus- tules under the arm; the color deepens, especially in the bitten limb ; atrocious pains are felt incessantly in the arm-; the throat seems to be narrowed, and the breathing becomes difficult. At 4 h. 30 m., pulse 104; salivation; great heat of body. 5 h. 30 m., pulse 104; torpor; urine abun- dant: saliva thick; muscular weakness; groans from excessive pain; respi- ration tranquil; pulse lull: increased, swelling of the bitten hand. 7 h.. 'leiiee: awaking, oompls .r pain in the chest, and of a sense ttstriction in the throat; free and full urination.-; deglutition more difficult; saliva abundant; continued epistaxis; entire inability to swallow. 8 h.. inquietude; copious urination. ! h. 15 m., profound sleep. 10 h., patient took .3 teaspoonfuls infusion ofguaco; refused sugar & water which were also offered; the epistaxis ii" regular; thelep tubercles o:i the face and arms are a little depressed, and have erysipelat- ous look. 1" h. 20 m., made two ounces of clear urine: betl for a few moment-; pain in the ches i. and pain is now felt in the legs and feet, which with the bitten hand are -till cold; : liar; thirst; the patient drinks water; sitting up with facility. At 11 h., I -poonfulsot Btrong infusion ofguaco. 11 h. 45 in., urinated a col urine; continues to drink without trouble: pulse 119; arm and hand much inflamed, with excessive pain. 12 h., sleep: excitement; urination. 12 h. - face: cries of pain; the patient demands tic last of of his church, and refuses remedies. Rather later, emission of urine; jrreat heat in the limbs; the patient take- two do re half hours; symptoms as before. 14 h., -its up twice, to drink :: the difficulty of Bwallowing augmenting. 14 b. 13 m.. takes the -: pulse 110. 15 h. 30 m., mictural 15 h. 45 m.. the remedy; in voluntary movement- of the right hand ami Left leg. 16 h. 46 m.. tak aful of the remedy; repose; pulse 100; >f urine during 17th and 18th hour-; respiration being < 21 h. 45 m.. L'reat prostration; convulsive mo jaw and lower tromil ly urine. 22 h.. pulse quickened and absent at ]on;_r inter val-: increase of convulsive movement-: diminution of swelling of extremi- 398 Rattlesnake Bites. [May, a cage. hake being somewhat intoxicated, opened the door of the cage, and allowed one of the animals to creep oul and ascend his hare arm ; as it was going up, he caught the animal somewhat abruptly by the neck, it immediately struck at him, and inflicted two small wounds. In the evening he felt some itching about the bend of his arm, and he rubbed it accordingly, without thinking of the snake. The itching increasing, he was induced to examine the part, and there he found a little red spot. The recollection of the rattle- snake then occurred to him, and he began to bathe the part in salt water. This not relieving him, he called upon Dr. Elkinton, at which time the whole extremity was swollen to neatly double its size, and was very painful. Dr. Elkin- ton applied a dry cup over the part which had originally itched, and was bitten; it was near the cephalic vein at the bend of the arm; scarified cupping was also done in three or four places in the same region, and some ounces of blood were extracted by a repetition of the cups; the forearm was also rubbed with the terehinthinate tincture of canthari- des, which produced vesication. In the course of the even- ing, some doses of spirit of hartshorn were administered, and also some tablcspoonfuls of the expressed juice of plan- tain (alisma planlago,) and hoarhound, (marubium milgare.) "The next morning (July?, 1831,) the patient was brought to the almshouse, about half-past eight o'clock. He bad vomited in the conveyance, lie was sensible, and stated that the scarifications had bled much during the night; they were then bleeding freely. The arm, from the shoulder and front of the thorax to the fingers, was swollen to twice its natural size, and was very painful when moved. His pulse was almost imperceptible and thread- like, his extremities cold he was disposed to cramp in the legs, and his debility very great. His respiration was natur- al and easy. His eyes were muddyand heavy; his face was somewhat bloated. Feeling the desire to go to stool, he ties and of the dark color of the skin; deglutition very difficult: breathing labored; blisters were applied to the thighs, and the infusion of guaco givi i). 22 h. 50 in., convulsive; motionless; an inject ion of brandy given. 22 h. 55 in., oonvulsions Btopped. 23 !u same condition; an ounce of oil of 1 given by the mouth; was taken with great difficulty. Death, at ::': h, 30 in. The corpse became livid, and swelled considerably in n few hours, being mottled with violet-colored spots, The odor was such, next day. as to forbid an examination post-mortem." I.] Uattltsnak was assisted from his bed for that purpose, but was seized, while on his way, with a general spasm, without foaming at the mouth: being laid down on the floor of the ward, ii went off in a few minutes, and lie there had an involuntary evacuation from the bowels, of a dark billions color. This occurred before 1 saw him. He received from the resident physician five grains of ammonia and an ounce and a half ol. blivarum. "Sinapisms were also applied to his ankles and breast; lie was directed to take liquor volat ammonia, 5j ; sp. vin. dibit, .vs. every two hours, and intermediately use ol. oli- varum. Si - of the former prescription, he took two doses be- fore he died, and one of the oil. Another application of cups over the old scarified parts was made, and the hemorr- hage from them diminished. The extremity was then en- veloped in cloths, dipped into ice water. " The symptoms continued stationary till 11 J a. m., he then complained of violent pain in the course of the colon, and on taking his last dose oi' medicine, he said, he felt sleepy, closed his eyes, and in a few minutes died without agony or convulsion. "Dr. Harlan's case. On Monday, the 13th of Septem- ber, 1830, Daniel Steel, a showman of living animals, in this city, was severely bitten by a large male rattlesnake, im- mediately below and on the metacarpal joint of the index finger of the left hand ; the accident occurred about four o'clock, p. m., <>n a warm day, while he incautiously seized the reptile by the neck, not so close to the head but that the animal was able to turn upon him. Immediately after the bite, the blood flowed freely from both the fang punctures; the parts in the immediate vicinity of the punctures became tumid and livid, notwithstanding the efforts of the patient at suction with his mouth which faintness obliged him to relinquish. On my arrival, about half an hour after the accident. I found him extremely pale 'and faint, and was informed that he laid fainted several times, the whole of the back of the hand was puny and tumid, with infused non-coagulated blood, which appeared to have in- filtrated from t; els and forced its way through the cellular tissue; a ligature had been, previously applied on the wrist ; another was now.placed ^m the arm, the forearm having already commenced -welling. 'I'; e situation of the wound rendered the use of cups in- applicable, and the flow of blood was bo rapid as to make 400 Rattlesnake Bites. [May, their application inexpedient. The punctures were separ- ated some distance from each other, which rendered it re- quisite to excise two large portions of integument; the ex- cisions extending down to the tendinous fascia; the blood, which flowed freely after the operation, did not appear dis- posed to coagulate; cold water was now poured on the wounds in a continued streams, from the mouth of a pitcher, held at a considerable elevation, and the swollen parts in the vicinity of the wounds were forcibly passed, in order to expel the effused blood. The patient again became very taint, and was held in a recumbent posture. The wounds were next washed with spirit of hartshorn, several doses of which were administered internally ; butbeingnow inform- ed that the patient had drunk freely of sweet oil, the harts- horn was omitted, until the stomach should be evacuated by drinking warm water. A poultice of bread and water was next applied, to encourage the bleeding, and the patient was put to bed. At ten o'clock p. m., I was sent for in haste ; the patient was thought, by attendants, to be dying. The bleeding of the wounds had been extensive, the tume- faction had extended up to the arm, the inner and inferior portions of which were discolored by effused blood; the patient vomited incessantly ; he complained of insatiable thirst, and drank cold, water cve,ry few minutes ; he had pain and stricture at the pit of the stomach, great restless- ness and anxiety, cold skin, with the exception of the wounded arm, which was verypainful; add to which, there existed delirium, singultus, difficulty of breathing, and pulse at the wrist scarcely perceptible. The poultice, banda< and all ligatures were immediately removed; the back of the hand was blacker and more swollen, and the skin of the forearm was hot and tense. As a substitute for the poultice, and in order to suppress the bleeding, which ap- peared to endanger the life of the patient by the debility it occasioned, large Hat pieces of fresh meat, were bound on the wounds, hand, and forearm. Before this operation was completed, the patient exclaimed, 'That feels comfortable.' The indications arising from the present syptoms, were: 1. To allay irritation and thirst. '2. To arrest the vomiting. 3, To procure sleep, if possible. 4. To excite the sanguineous I the depres- sing power of the poison, which had so emphatically mani- fested itself on the >vtein in general. 1861.] Rattlesnake Bit 401 A mustard plaster was directed to be applied to the pit of the stomach; Bixtydrops of laudanum to be administered every half hour, until the vomiting should be arrested ; al- ter which the following bolus, to be taken every two hours until sleep should he induced : R. pulv. opii, six grains : puiv. gum. camph., 18 grains ; pulv. carb. ammonia, 30 grains. M. ft. in three holuses. Big. as directed. Of these pills he took three before the effects desired wxre manifested. On the morning of the second day, his pulse was raised : the extreme thirst and irritability of the Btomach were allayed, and re-action of the system in sever- al respects was manifested; but the tumefaction of the arm had extended to the shoulder, with broad black streaks up to the axilla: Btricture at the breast and great local pain were now the chief complaints. The application of raw meat was renewed, as it afforded comfort to the patient, and appeared to reduce the swelling of the hand, and by pres- sure, had nearly suppressed the hemorrhage. In order to allay the pain and tension of the whole arm, he was direct- ed to expose it naked to the fumes of burnt wool, in a con- venient apparatus, which was attended by BUch marked al- leviation of symptoms, that the patient himself was desirous to have the operation frequently repeated, and continued for two or three days: the swelling always dimishing after each application ; it caused the arm to perspire profusely, and covered it with blackish soot impregnated with am- monia, resulting from the decomposition of the wool. Dur- ing the intervals, the arm was rubbed with volatile liniment, raw meat having become offensive from its disposition to ferment and putrify, was omitted, and flaxseed poultices substituted: the anodyne boluses were continued in half d<-es through the day, and the quantity increased at night t<> produce Bleep. The system again became depressed and appeared to struggle with the effects of the poison ; as the patient had been somewhat addicted to intemperance, he 3 allowed milk-punch to support his strength. On the third day, a greater degree of reaction was obvious; the bowels wei lated by castor oil; the dose of the anodyne was diminished, and by carefully nursing the arm, in less than u week suppuration supervened, and the patient was able to leave his bed." ft is much to be regretted that physicians in this country Bhould have paid so little attention to the venom malady as 26 402 Operations on [May, only to report cases in which the}- supposed themselves to have been successful. Hence is it that no good history of the disease can be made out from their statements, 'and hence it is that post-mortem examinations of the lesions are almost unknown there being only three on record, of which two took place in Europe. The reader need not be surprised then at the small amount of accurate knowledge of symptoms placed at the author's disposal: fortunately the ability to create the disease in animals enabled us in some measure to fill up this gap. The information now in possession of the reader will enable him, I trust, to follow the remarks upon the use of remedies. A number of these, whether local or constitution- al, may be readily dimissed, either because their value or want of value is plain, or else because former observers have settled their therapeutic position in some conclusive man- ner. In treating of this matter, I have been obliged to deny notice to a host of herbs which enjoy repute in small sections of our country, and which, in turn, have once possessed and lost a wider reputation. The reader who calls to mind what has here been said as to the many fallacies which surround the observer, will not fail to perceive in the accounts of these remedies given by authors the reason of their apparent success and ultimate los3 of favor. North American Medico- Chirurgical jRevkw. A Statistical View of Operations on the Tongue, and more es- pecial!.}/ in reference to their danger from Hemorrhage. By Otto Just, Jr., M. D., of Zittan. Dr. Just divides the different methods of removing the tongue into the following groups : A. Operations with the knife. 1. Amputation or partial excision. 2. Amputation bv iiap-incision, or wedge-like incision. 3. Total amputa- tion or extirpation. B. Ligature. C. Ecrasement lineaire. I). Cauterization. 1. By the actual cautery, galvanocaustic. 2. By the potential cautery. A.* Operations with the knife. i. Amputation. Dr. Just has collected thirty-three cases of partial removal of the tongue for carcinoma, and sixteen for hypertrophy. To render the organs more accessible to the knife, as well as to 1861.] The Tongue. 403 ligature the vessels with more facility, it should be fixed by forceps, or by a stout ligature carried through its entire thickness. When the incisions have to extend toward the base of the tongue, on account of the small space we have to operate in, the procedure becomes more difficult and the arrest offiemorrhage is not so easy. In these cases more room can be gained by slitting open the cheek of the affect- ed bide, or by drawing out the tongue through an aperture in the neck, or by sawing through the symphysis of the lower jaw. These me thous will, however, be unnecessary if the lingual arteries he previously ligated. '2. Wedge-like excision. Under this head are mentioned 12 cases of can- cer, one of telangiectasis, and 11 of hypertrophy. 3. Extir- pation. The author considers this operation justifiable when the whole of the tongue is diseased. Ofthree cases, one recovered. Methods of stopping the hemorrhage. The following means were emploved for the arrest of hemorrhage, in 62 cases in which it is mentioned : In 20 cases, ligature of the Is in the wound : in 2, ligature en masse ; in 7, pro- phylactic ligature of the lingual artery; in 7, the actual cautery; in 6, ice and cold water ; in 7, suture of the edges of the wound after dap-incision ; in 3, styptics ; in 1, bleed- ing spontaneously stopped. Ligature of the arteries in the wound is the method, and has never been followed, when employed alone, by secondary hemorrhage. The actual cautery, cold or styptics should bo restricted to slight S ;ondary hemorrhage ensued rather frequently when the actual cautery had been applied. Suture of the - of the wound is unsafe, for in three-sevenths of the cases it was followed by secondary bleeding. Ligature of the lingual artery above the hyoid bone should be resorted to when the base of the tongue is diseased and the mouth of large size; two of these cases died of pyaemia. Period of recovery. The most rapid recoveries took place when sutures hail been used after excision of a wedge- shaped piece; in 16 of these cases, 14 united in from 6 to 14 days. After amputation in general, it required from 12 day- to 4 weeks. The cases treated by -awing through the symphysis took from l to 1 months. Result Eight of 86 cases terminated fatally, being U| per cent. In 5 cases death resulted from pyemia. B. Removal by ligature. Nineteen cases are quoted of ligature for cancer, and 7 for hypertrophy; and 2 of tic 404 Operations on the longue. [May, ended fatally, 1 from pyremia, and 1 from poisoning by the offensive discharge. This method is troublesome and disgusting from the very fetid discharge, occasioning the patient great misery. Gangrene commences in about 24 hours after the application of the ligature, and on an aver- age 11 days are required for the separation of the mass. The wound left after the detachment of the slough will heal generally in about 14 days. Hemorrhage occurred in three instances, twice from too early a separation of the ligature, and once from the wound made for the passage of the thread. C. Amputation by means of ecrasement lineaire. The ecraseur has answered an excellent purpose in removal of the tongue, hemorrhage being effectually prevented when the instrument is made to act slowly. Twenty-one cases were treated by this method, and all recovered, the period of convalescence averaging three weeks. D. Amputation by means of the cautery. 1. By the gal- vanic cautery. Eight cases come under this head, hemor- hage attending 4. The vessels required ligation in the wound twice, and once after previous ligation of the lingual artery. Secondary hemorrhage followed in about one-third of the cases. To prevent bleeding, the wire should be thick, the galvanic current weak, and the wire of the loops should not be heated beyond a black heat, 2. Extirpation of the whole tongue by means of the potential cautery. One case only is given, in which the organ was destroyed by means of chloride of zinc. The author has collected 72 cases of cancer of the tongue, in 49 of which the subjects were males, in 23 females ; the frequency in males being pretty nearly in the ratio of 5 to 2. In 63 cases the age is noted, showing that it occurs most frequently between 40 and 60 years. In 55 cases the seat of the disease was, in 7, the tip of the tongue ; in 9, the whole breadth of the organ ; in 19, the right ; and in 20 the left side. In 72 cases there were 18 recurrences ; but the num- ber is too small, as many of the cases were published soon after the operation. To sum up the different methods of treatment, we find that the knife is especially adapted for removing small por- tions near the tip of the organ; the ligature has but one ad- vantage, that of preventing hemorrhage, and the ecraseur has shown more favorable results than those of the knife. Jjondon Medical Review. 1861.] khicum. 405 Further Experiments Relating to the Dieuretic Action of Ichicum. By William A. Hammond, M. D., Professor of Anatomy and Physiology in the University of Mary- land. In the Proceedings of the Academy of Natural Sciences, of Philadelphia, for November, 1858, 1 gave the results of a series of investigations relative to the diuretic properties of digitalis, juniper, squill, and colchicum, by which it was shown that the latter alone possesses the power of increas- ing the amount of organic matter eliminated by the kid- neys. From this circumstance, the argument was adduced, that this substance, of all those experimented with, was the only one that could be regarded as a true depurator of the blood. The results obtained by earlier investigators cannot be regarded as satisfactory, owing to the .faulty manner in which their analyses were made. The urine was concentrat- ed by heat, and thus a large quantity of its organic matter underwent decomposition. Since the publication of my experiments, Dr. Garrol, of London has studied the physiological action of colchicum : but, led away by his theory of the nature of gout, he limited his researches mainly to the determination of its influence over the excretion of uric acid, which, as is well known, forms but a small proportion of the total amount of organic matter excreted by the kidneys. As the result of his inves- tigation he announced that colchicum does not increase the quantity of uric acid contained in the urine, and. that it is not by any action on the kidneys that the remedy in ques- tion exerts its curative influence in gout. His result, as relates to the uric acid, does not, so far as I know, conflict with mine, as I did not separately determine the quantity of this substance present ; but his conclusion, that colchi- cum is not a diuretic in the true sense of the term, is cer- tainly not borne out by his own experiments, and is direct- ly at variance with those which I performed. It was, therefore, obviously necessary that additional in- tdgationa should be instituted, and I accordingly under- took the task of furnishing further contribution- to the sub- ject. Before proceeding to detail these, I desire to call at- tention to the valuable memoir of Prof. Austin Flint, in the number of this journal for November, 1800, entitled "Clini- cal Researches on the Action of Diuretic Remedies." In 406 Colchicwn. [May, this essay, in addition to much other valuable matter, the conclusion at which I had arrived relative to the action of colchicum is confirmed ; Prof. Flint finding it to produce a marked increase in the amount of solid matter eliminated by the kidneys, without, however, increasing the quantity of water of the urine. The investigations to which the present paper relates consisted of experiments upon adult males, in a good con- dition of health. In all cases, the officinal tincture of the seeds of the colchicum autumnal e was given. The determinations made were the following: 1st. The quantity of urine. 2d. Its specific gravity. 3d. The total amount of solid matter. 4th. The quantity of inorganic matter. 5th. The quantity of organic matter. 6th. The amount of uric acid. The quantity of urine was determined in cubic centi- metres. The specific gravity was ascertained by means of the specific gravity bottle and a delicate balance. The tula! amount of solid matter is given in grammes, and was determined in the following manner : Ten cubic centimetres of the urine were evaporated to as complete dryness as possible in vacuo over sulphuric acid, and the residue accurately weighed. By simple proportion the amount of solids in the whole quantity of urine was easily ascertained. Although it is impossible to get rid of all the water by this process, the quantity remaining is extremely small, and the results obtained are far more accurate than those obtained by evaporating to dryness in the water-bath, as generally practiced. No matter how carefully this latter process is conducted, the loss of urea by decomposition is always an important item, and involves far more serious errors than the imperfect declaration by the former pro- cess. For the determination of the amount of organic and in- organic matter separately, the solid residue obtained as above was mixed with ten or fifteen drops of moderately strong nitric acid, and gently heated till the mass was well dried. The heat was then gradually raised till all the car- lion was consumed, and the mass, in c< nsequence, became white. It was then cooled in vacuo over sulphuric acid. 1861.] Colchicum. 407 and weighed. The inorganic matter was thus determined, and the loss showed the proportion of organic substance. The quantity of uric acid acid was determined by adding chlorhydric acid to a known volume of urine. The tirst experiments were instituted upon myself. In three days immediately preceding their commencement, the average quantity of urine for each day was 1425 cubic cen- tum specific gravity 1021.73. The average amount of solid matter was 64.28 grammes ; of which 30.18 were inorganic, 34.10 organic substances. The average amount of uric acid excreted for each period of 24 hours was 0.77 gramme. Daring the experiments with the colchicum my manner of living was not materially altered from that of the three days above referred to : i. e., I ate the same food and took the same amount of exercise, and endeavored to make all the collateral circumstances the same, so as to ascertain as nearly as possible the exact effect produced by the col- chicum. First day. Cm this day I took one fluid drachm of the tincture, three times: at 8 a. m., - p. m., and 10 p. m. The total quantity of urine excreted was 1685 cubic centimetres, o^ which the specific gravity was 1021.50. The total amount of solids was 70.15 grammes, of which 30.90 were represent- ed by inorganic, and 39.25 by organic matter. The quan- tity of uric acid was 0.81 gramme. cond day. One and a half fluid drachms ol the tincture were taken, as on the previous day. Quantity of urine. 17:20 cubic centimetres: specific gravity. 1020.87; total solids, 75.29 grammes ; inorganic solids. 32.44 grammes; organic solids, 42.85 grammes : uric acid, 0.69 gramme. Third day. Same quantity of colchicum taken ason previ- ous day. Quantity of urine. 178-1 cubic centimetres ; spe i fie gravity, 1022.57; total solids, 80. 13 grammes; inorganic solids, 35.11 grammes ; organic solids, 45.03 grammes; uric acid. 0.82 gramme. Fourth day. On this day the quantity of colchicum was reduced to half a fluid drachm, taken as before. Quantity of urine. \'Ao cubic centimetres : specific gravity, l<'ii:;.17 : total solids, 69.23 grammes; inorganic solids, 31.09; or- ganic solids, ;.;*. 14 gramme- ; uric acid. 0.78 gramme. Fifth day. On this day the quantity of colchicum was increased to 1] fluiddrachms of the tincture before mention- ed. Quantity of urine, 1698 cubic centimetres: specific 408 Colchieum. [May, gravity, 1023.08; total solids, 70.14 grammes; inorganic solids, 83.26 grammes ; organic solids, 42.88 grammes ; uric acid, 0.7(5 grammes. On this day there was some derange- ment of the genera] health, manifested by increased heat of shin, fever, and severe abdominal pains. There was also a little diarrhoea. The experiments were, therefore, discon- tinued. From an examination of the results obtained b}T the fore- going investigation, the effect of the colchieum upon the urinary excretion cannot fail to be perceived. The conclu- sions which I think may be formed are: 1st. That the colchieum increases the quantity of urine. 2d. That its increases the total amount of solid matter eliminated. 3d. That this increase is mainly due to an augmentation of the organic matter. 4th. That the amount of uric acid does not appear to be affected. These conclusions are rendered much more probable from the fact that on the fourth day, when the quantity of the tincture of colchieum taken was reduced one-third, the ef- fect upon the urine was less decidedly marked; and that when, on the fifth day, it was again augmented to a drachm and half, the urinary excretion was materially increased in quantity, and the solds, the organic especially, remarkably raised in amount. The relation of cause and effect would therefore appear to exist; and accordingly, it would be contrary to the principle of sound reasoning to assert that the change in the composition of the urine was accidental. It is doubtless true that the urine changes greatly from day to day, and even from hour to hour; but this fact is due to the other fact, that we are constantly varying our food, ex- ercise, &c. When, however, as in the investigation cited in this paper, these circumstances are tixed, and only one difference exists between the ordinary mode of living, and that practiced during the continuance of the experiments, we arc justified in attributing any change in the urine or in any other excretions to the influence produced by that difference. Tn the next series of experiments the effect is just as di- rectly shown, though, for reasons beyond my control, they were not continued as long as was desirable. The subject of these experiments was a young man 23 ra of age, and weighing about 140 pounds. Before tak- L] Cbkhkwn. 400 ing the colchicum, I examined bis urine whilst be was taking a fixed quantity of food and exercise, he being at the time an attendant in the hospital under my charge. As the results of these examinations for three consecutive davs, 1 obtained the following as the averages for each day: Quantity of urine, 989 cubic centimetres; specific gravity, 1020.14 : total solids. 51.20 grammes; inorganic solids.' 22.4.~> : organic solids, 28.75; uric acid, 0.47 gramme. First day. On this day one drachm oi the tincture of col- chieum was taken three times. The effect upon the urine was as follows : Quantity, 1021 cubit centimetres; specific gravity, l<>24.18; total solids, 64.25 grammes; inorganic solids, 23.57 grammes : organic solids, 40.68 grammes ; uric acid, 0.59 gramme. cond day. One and a half drachms oi the tincture were taken to-day three times, as previously. Quantity of iirin cubic centimetres; specific gravity, 1026.11 ; total solids. 60.25 grammes; inorganic solids, 20.38 grammes; organic solids, 30.87 grammes; uric acid, 0.51 gramme. On this day diarrhoea was produced. This was of quite a severe character, and in consequence, the colchicum was not further continued. The remarkable effect of the colchicum in increasing the amount of organic matter excreted is, however, very de- cidedly shown. This increase is so great as to render the probability of its being accidental extremely small, and wc cannot do otherwise than regard it as being directly due to the infiuence of the eolchienm. The details of the third case in which the colchicum was given have been unfortunately mislaid. I am, however, enabled to Btate with certainty, that the same well-marked er the amount of organic matter excreted by the kidi exerted as in ti the particulars of which have been in full. The experiments were continued for >ix days, with variable quantities of the tincture. What are we to infer from these investigations ? It ap- pears to me that the conclusion must 1>" admitted that col- li true deputator of the blood, and hence we have an explanation of its good effects in those blood dis- >ut and rheumatism. that no constant effect was produced upon the quantity of uric acid eliminated, and hem experi- ments do not conflict with those of Dr. Garrod* We are 410 .Delirium 'Iremens. [May, not, however, hound to admit the presence of uric acid in the blood in increased amount during a paroxysm of gout or rheumatism, is the cause of that paroxysm ; and conse- quently, because colchicum docs not increase the quantity of this substance found in the urine, we are not to srfp] that the remedy in question does not exert its influence through the kidneys. Am. Med. Monthly, The following are from Dr. O. C. Gibb's Monthly Sum- mary : Delirium Tremens treated with Digitalis. In the American Medical Times, for December 1st, is the report of two cases of delirium tremens, treated with large doses of digitalis, by the advice of Dr. Stephen Smith. In botli cases the delirium was active at the commencement of treatment. Tinct. of digitalis was ordered in two-drachm doses, and to be repeated every two hours until the patient slept. After the administration of the second dose both patients be- came quiet, and one of them slept ; the other slept after the fourth dose. In one case the pulse came down from 108 to 82. It will be remembered that, some month ago, we recom- mended veratrum viride in the stage of excitement of de- lirium tremens. The indications for the use of the digitalis are based upon the same principles. We cannot help thinking the veratrum viride is the safer of the two. Qui- nine and strychnine we would recommend after the stage of excitement is passed, to give tone to the nervous system. Though we have never used it, we cannot help thinking that from 10 to 15 grains ol quinine might be given with benciit, even in the stage of excitement : we should expect it, in connection with veratrum, to produce quiet and free perspiration. We believe that opium has been the death of many patients suffering from delirium tremens. Diphtheria. In the American Medical Times, tor Dec. 8th, Dr. Win. M. Turner has an article upon the subject of diphtheria, and more particularly its treatment. Jlis views are stated with earn- and his treatment given in de- tail, and in a tone that gives evidence of a supposition ot' novelty. His views of its pathology are doubtless correct. l.] Glycerine and Camp) 411 and bis treatment judicious : l>ut the pathology and treat- ment arc such as have been for some time advocated by the first physicians of Europe and this country. But one novel- ty is mentioned, and that will be alluded to. In regard to its nature he L think the disease Is owing to malarial influence, and that it is essentially a blood-poisoning, with sneracy and breaking down of the vital force." \\ e will not enter into detail in regard to treatment; it is thus briefly stated: "Tonic and disinfectant, (the latter in- ternally and topically,) all combined with rich diet. Best .! disinfectant, in form of gargle, Labarraque's solution ,ua pura, or any gargle in which, with other ingredi- ents, a disinfectant bears a large proportion." The novelty to which we have referred, and because of which we have referred to this paper, is in regard to local means. lie Bays, *! studiously avoid probangs ; 1 look upon them as instruments of torture and of death. I know I have seen lich died from the constant mopping to which the throat was Bubje Among the local means employed, the following is well "Equal parts of ol. olivse and spir. terebinth," * be applied with a soft rag, and touched very gently.'" In addition, a flannel irated with ol. tere- binth lied to the neck externally. -in tiie Savan- nah Journal of Medicine, for Xovember, Professor Juriah Han n article upon the influence of remedial agents in a: etion of milk in the human female. In Madonna, he says, he has ur. Swinburne, who recommends them as universal sutures. of the Leg. The treatment of this trouble- some affection is a matter of interest, and more particularly s> because surgeons of equal eminence differ in regard to it. We quote a lew opinions that have fallen under our ob- servation during the last month. In the American Medical Times, for December 1st, Prof. A. ('. Pos1 makes the fol- lowing remarks: "The treatment of varicose veins is palli- ative or radical. The radical treatment consists in obliter- ation of the diseased v. ,d the process is always at- tended with more or less danger to life ; it should theref her- . _ avated cases. The palliative treatment consists in giving a uniform support to the limb by means ot bandage-, or of elastic laced stockin. We have pre- 414 Varicose Veins of the Leg. [May, viously referred to the radical treatment of varicose veins by subcutaneous application of the metallic ligature, as prac- ticed by Dr. 1i. J. Levis. En a private letter to us, Dr. Levis says his method of cure "in always efficient, and is absolutely safe." [n the American Medical Times, for December 15th, Dr. T. C. Moffatt has a lew remarks upon the treatment of this affection by injection into the diseased vein. We quote one case in illustration. The case referred to was an unusually bad one. Dr. Maffatt says: "Placing a tourniquet upon this (themostprominently enlarged vein) above, and making pressure below, so as to isolate about two inches of the vein, I threw into it eight drops of the persulphuret of iron diluted with as much water. (Squibb.) The instrument used was the syringe commonly employed for injecting morphia into the cellular tissue. After a few minutes the pressure was removed, and a hard plug re- mained; the blood coagulated almost instantly. The in- flammation which followed was not immoderate. Cooling anodyne lotions were applied, and subsequently lead poul- tices. A very slight amount of suppuration resulted, and in just three weeks the limb was perfectly cured." Bearing upon this point, Prof. E. 8. Cooper, in the Octo- ber number of the San Francisco Medical Press, has a few remarks. He has not much confidence in the treatment by injections of Monsel's salt. That the injection will produce an immediate clot, he does not doubt ; but this clot will ar- rest the undecarbonized blood in its way back to the heart, and this arrested blood will become a great source of irri- tation. He says. "After trying the various methods of treat- ing varicose veins of the lower extremeties, we are convinced that there is none like that of free incisions, followed by keeping the wound open until granulations begin to till up the incision, in the mean time keeping a roller as tightly upon the limb as the patient can conveniently bear, com- mencing its application at the foot. By this means, blood is prevented from entering the veins to any considerable extent." Besides the objections to the injections above stated he says : "We do not believe that even a very small quantity of Monsel's salt can be introduced into a blood-vessel, with- out risk of fatal consequences." 1861.] Lectures on Diphtheria. 41f> Lecture* hfhcri'i. \ Eqyptian Disease.) Delivered at L'Hotel Dieu9 i By M. Trousseau, entlemen: For several years the reports sent to the demy of Medicine, the communications addressed to various scientific journals, have indicated that fatal epidem- ics of diphtheria prevailed in different parts of France, in- vading' all departments ; those of the south, as well as those of the north, of the west, and of the east. These epidemics also prevail abroad, in England, where for sixty years it has hardly been known ; in America, in Germany, and in the Spanish Peninsula. The attention of the public, as well as of physicians, is more than ever aroused in relation to this dreadful calamity. The cases which have lately in- creased in my service afford me the opportunity of giving you my ideas upon this important subject, and it is my duty to communicate them to you. I shall, then, in a series of lectures, consider this disease, one of the most serious which affect humanity. I do not intend to exhaust the subject, promising some day to write a treatise upon diph- theria. I shall, therefore, take up only the most practical points, illustrating them, as far as possible, by the patients we shall see together. Do not expect, gentlemen, a resume of the numerous observations which, have been made under your eyes, hi making use of them, in sustaining my pro- positions by the experience of my confreres, and that of dif- ferent authors who have written upon the subject, I shall be chary of long histories, citing only what is necessary to make everything I say clear and comprehensive to you. I shall also insist, .gentlemen, upon the necessity of a treat- ment the utility of which is to-day questioned. I shall oppose that deplorable tendency among observers of the highest order to leave the true road, which has been pe vered up to this time. Diphtheria is a specific disease, par excellence, contagious in its nature, displaying itself upon the mucous membranes and the skin, and presenting the same characteristics in both places. I say, that it shows itself upon the skin and mucous membranes, because, in fact, diphtheria has this m common with certain specific and contagious diseases eruptive f e philis ; with this difference, however, that it affects the external teguments only when it is denu- ded of its epidermis. Still, the disease which we are about to study shows a marked preference for the pharynx, for the air-, j, the larynx especially, constituting the af- 41G Lectures on Diphtheria. [May, fections commonly known under the denominations o malignant, false membranous angina, otherwise designated gangrenous sore throat, suffocating angina, and now more particularly called croup, when the angina seizes upon the larynx. Diphtheria is frequently observed to attack the nasal mucous membrane, the buccal mucous membrane, the vagina, the prepuce, the glans penis. Of all the differ- ent forms, whether pharyngeal, laryngeaul, nasal, buccal, vaginal, anal, or cutaneous, the first is by far the most common. In certain epidemics, it is this form it almost exclusively assumes, destroying those affected, by its exten- sion to the larynx and trachea, by croup, in a very different manner from malignant diphtheria, which kills by a kind <>f general poisoning like septic and pestilential diseases. To this first form the attention has always been more par- ticularly drawn, because it is the most common ; it is this which has been described by the older writers, and which served as a type for the treatise on diphtheria by M. Bre- tonneau ; it is with this that we shall commence the study we are about to undertake. Diphtheritic Angina and Croup. (Pharyngeal and Lar- yngeal Diphtheria.) A young boy, four years old, in excellent health, was suddenly taken with symptoms in the throat, which at first were so slight that they did not alarm his family. After a day or two, it was noticed that he grew pale : that he was quieter than usual, and remained indifferent to his ordinary playthings. lie coughed a little, but had no fever, and although his appetite was not as good as usual, lie still sat up all day. Accident alone revealed the disease with which lie was attacked. The family physician, who had been called to see another infant affected with epileptiform ver- tigo, was casually consulted for the boy. lie was struck with the pallor of the skin, and perceived a slight swelling in the submaxillary region. Thus, having ascertained the existence of tumefied ganglions, he examined the throat, and found the pharynx and the tonsils quite red, while the latter were increased in size, and one of them, the right, was covered with a quite thick grayish membrane. He immediately decided that the case was one of diphtheritic angina, and acting upon this belief, he instantly cauterized the diseased part with the caustic nitrate of silver, taking care to detach the false membrane by means of the nitrate. 1861.] hares on Diphtheria, 417 The cauterization was repeated the same evening, and the next day both morning and evening, and in the interval between the cauterizations he made, or had made, several insufflations of the powder of alum. The child was well fed, according to the express instructions of the physician, and took, besides, a tonic mixture, the base of which was the wine of cinchona. The disease was arrested, but the general pallor continued for some time, and a paralysis of the veil of the palate succeeded. The child was taken into the country, returning at the end of six weeks in perfect health. This, gentlemen, is an example of pharyngeal diphtherit- ic angina. The insidious maimer in which the disease began, the mildness of the general symptoms, the absence of fever at the time the physician ascertained the condition of the patient, the soberness of the child, the pallor of the skin, the tumefaction of the submaxillary ganglions, and finally, the presence upon the right tonsil of the characteristic false membrane, abundantly sustain the diagnosis. The para- - of the veil of the palate, which occurred a few days after, also confirms it, and I have no doubt the energetic treatment adopted in the early stages cut short the disease, which might have extended by degrees, and having invaded the larynx, would have produced croup. Pharyngeal diphtheritic angina is ob'served at all seasons, in all climates. It is not without a certain degree of aston- ishment that I somewhere read that, this disease was seen more especially in northern countries, in cold and moist climates, and that it was almest unknown in the south of France and Italy. Whoever advanced this singular asser- tion," must have had a very slight knowledge of the history of medicine, not to know that the cisease described by Ar- 18, and which was none other than a pseudo-membra- nous angina, was endemic in Egypl and Syria, whence the name ot Egyptian Ulcer and Syrian Ulcer, which was given to it at an epoch contemporaneous with Homer rather than Hippocrates, according to M. Bretonneau, or not to know that Carnevale, Nbla and Bgambati have given to us histo- Inopp this proposition, we recollect thai an author of the last century, Wedel, has said, that diphtheritic angina, which he called 'lis contagiosa, was more frequent in Italy than in the north of Europe. --In Italia frequenMor quam "]>>/d of development, the longer it takes for the (lis- to invade progressively the parts within sight. If it that false membranes form more rapidly in in- fants than in the adult, it is, perhaps, because the blood of former is richer in plastic materials than the latter. It I always v that in children of three, lour, five, and ix years, the two tonsils and the posterior part of the phar- ynx can ered with diphtheritic concretions within 420 Lectures on Diphtheria. [Mi thirty-six to forty-eight hours ; in the adult, and parti* larly in old persons, five, six, seven, and eight days p: before all the parts are completely covered. In patients whose pharynx can be well examined, t false membrane may be seen increasing each day by t addition of new layers which are formed underneath th( first developed. These different layers take on a stratifi arrangement. The most superficial become softened, a are easily torn ; altered in their color by the food, the drir the matters vomited, the medicines taken by the patiej by blood from the pharynx or posterior nares, these me brancs become grayish, black, and resemble the detritus gangrene. The resemblance is the greater, from the fi that, in these conditions, the false membranes putrefy a exhale a very repugnant foetid odor. This was the ca you may recollect, with the young girl twelve years old, recently had under our observation in the ward St. B nard. Her breath had an insupportable gangrenous od and when we removed the detritus which covered the t< nils and the veil of the palate, by means of a pledget charpie, we found it to be composed of a grayish matt which was very like the detritus of gangrene. And yel was not, for when the diseased surfaces were afterwai cleaned, the mucous membranes, but a short time bef< covered with false membranes, appeared red, hardly ex< riated, but showing no traces of gangrene. This appearance of gangrene which the diphtheritic p: duction assumes, is a point sufficiently important to be cc sidered more particularly. It explains to us how, for a lo time, diphtheritic angina was confounded with gangrene angina, and gave rise to the names of angina, of gangrem sore throat ; names which some physicians use even at tl time. If we study diphtheritic angina in the infant and co pare it with what occurs in the adult, we shall observe tl the disease almost never presents the gangrenous aspe which, on the contrary, is very frequently seen in the adi Should we therefore conclude that gangrene is really p sent in diphtheria of the adult? No ! These are only pearances of gangrene, and do not exist in the adult a more than in the child; there is no true gangrene, unl in exceptionally rare cases ; so rare, that, in the wh course of my medical career, I have met only three exa pies of it. I admit it is very difficult not to believe in $61.] fures on Diphtheria. 421 ven now, although I have so seldom witnessed gangrene these cases, although I know when a recovery has taken ace, or when, at the autopsy, with the pathological speci- ens in my hand, I discover no traces of sphacelus upon e tonsils or the mucous membranes, finding only some ght excoriations, and in many cases not even these; not- ithstanding this, I cannot at first, even now, disabuse keif of the idea that gangrene exists. In the young girl the ward St. Bernard, I was sure that there was no gan- ene, and you also were convinced of it; still, the extreme kidity of the breath, that grayish secretion which covered )th tonsils, could not fail to suggest to our minds a mor- ication of the mucous membrane, a sphacelus of the sub- cent cellular tissue, or even a deeper destruction of the 5sues. These are the reasons why diphtheritic angina has been nfounded with gangrenous angina; why certain physi- ;11 confound these two diseases; and why, in the scrip tion of epidemics of croupal angina, you still often ar of gangrenous sore throat, even when they were only llicular or pseudo-membranous affections. One word more, relative to the mode of circumscription the membranous exudations at the points upon which ey are developed. Sometimes they are surrounded by a lall bright-red line ; sometimes they do not appear limi- i; and. as I remarked in the beginning of my lecture, the Ise membranous concretion, growing thinner at its edges, reads out over the surrounding parts. In such a case, the dency to spread is greater and more to be feared than former. If pharyngeal diphtheritis, left to itself, does sometimes come limited to the pharynx, examples of which have en cited by M. T>retonneau, and which every one may serve in certain epidemics, it usually, however, continues ; .In some eases it passes into the oesophagus, d reaches even to the cardiac orifice. The distinguished in of Tours lias reported two instances of this char- ter, and Borsieri has instanced others; but almost inva- -bly it invades the larynx and trachea, and constitutes its ordinary course, the most common ter- nation of diphtheria. In fact, we see more persons al- ied with this disease die of croup, than from those malig- nt anginas, of which I shall speak hereafter, which the main reliance must be placed in repeated ering, both in front and behind the chest. At this stage advantage will be derived from the use of spirits of turpentine, together with simulating expectorants, as decoc- tion of seneca and syrup of squills." - local remedies, he recommends nitrate of silver, 20 i\ to the ounce of water, to be applied only once a day. We have ordered a saturated solution of common talt to be thus used, and to be repeated every hour or two, wish decided relief. It clears the mouth and throat of the adhesive and nauseous secretion better than anything else we have tried. After the removal of the diphtheritic membrane with a strong solution I prefer to apply the stick to the exudation, and a solution of ii dr. t<> surrounding mucous membrane for the early ap- plications, to be omitted or diminished as the disease begins A variety of chlorinated mixtures arc Bpoken of, lapted to the milder cases, or the convalescing Bta ral treatment, muriated tincture of iron, chlorafe quinine, turpentine, and alcoholic stimulants, are mmeuded. "Chlorate of potash has an advantage over 424 Dtphtneria. [May? the tincture of the sesquichloride of iron, as an alkali in its resolvent effect on the fibrin of the blood, and hence a proba- bility of its diminishing and arresting the exudation.'' In our experience, this statement has hardly been borne out. AVe think we have seen the most positive results from the tincture of iron. "Besides quinine, chlorine, or turpentine, diphtheria requires alcoholic stimulants. The flagging powers of life need frequently repeated excitants to sustain them against the steadily depressing influence of the disease." these, he thinks, can usually be commenced with as early as the second or third day. We have frequently commenced with them on the first manifestation of the disease, and are confident that we have seen those severe neuralgic pains, so common in the outset, yield to a full do? e of hot sling. The absence of sur- face heat he regards as an indication for the commencement of the stimulant, and adds, " but we might, without hesitation, say that the presence of the disease is alone a sufficient indication." In one regard Prof. Thayer and Dr. I' Anson are at variance. Prof. Thayer says, " I cannot avoid thinking it especially ill- judged to mercuralize v patient if wise at any stage at the somewhat advanced period at which the croupal symptoms usually appear in diphtheria, as the peculiar adynamic condi- tion also is approaching, if not already begun, which must be hastened and aggravated by a mercurial course." As in typUoid fever, so in diphtheria, he thinks a tongue dry and black requires turpentine, and not calomel. We have used the turpentine in about half of our cases, in all that were protracted, and at any time gave a dry and red, or black tongue, and always with an e idence of improvement. In an article of twenty pages upon diphtheria, by Dr. C. II. Cleveland, the subject is discussed with some novel views. As his treatment is somewhat different from any previously given, we subjoin it in substance. Dr. Cleveland thinks alhalien are of the first importance, and recommends the bi- carbonate of soda, to be given in from one to ten grains, ac- cording to the age of the patient, every half hour, or every hour. As a local application, he prefers a strong solution of common salt. We make one quotation: "A gargle, com- posed of a very Btrong solution of common table salt, if the pellicle is not ycl formed, will produce an osmotic flow of fluids through the epithelium, and thus cause the fauces and throat to be too moist to allow a pellicle to be formed. It taken early in the attack, repeated very often, at the same time that plenty of soda is taken internally, most cases of I L861.] 425 diphtheria will pass off without any appearance of the mem- branous exudation. Without doubt, By thus preventing the formation of a pellicle, many cases of genuine diphtheria have been made to remain so mild in their action, that even rvant physicians have been led to suppose the Lse was simply an ordinary pharyngitis." In the Nashville Journal of Medicine and Surgery, for January, Dr. J. 0. Calhoun lias a short article on this subject. He says that last fall the disease prevailed in an aggravated form. The first few cases he treated "in the usual manner, with alterative d mercury, an occasional emetic, and nitrate of silver to the throat," and all died. (Dr. Calhoun should know that this is not the usual treatment.) " But Bince we have adopted the following treatment, not a single has terminated fatally, so far as I have heard : It. Two table-spoonsful of fresh tar. The yolk of an egg. Spread on a piece of coarse cloth, cover it with a piece of old muslin, and apply to the throat. This plaster should be removed once in eight hours, li the subject is an adult, direct him to use a strong decoction of cayenne as a gargle, every two hour-. For children a weaker decoction should bo used, and applied to the throat with a mop. This, together with keeping the bowels in a soluble condition, will as cer- tainly cure diphtheria, as quinine will arrest intermittent :*. The efficiency of the above treatment has become so generally known in this locality, that physicians are seldom called t<> diphtheria patients." This statement, in our opinion, is quite too sweeping. We are not prepared to believe that an external application to the throat will cure a constitutional disease, of the severity which diphtheria frequently assumes, with that certainty "'if It which in the Medical ami Surgical Reporter, for January 5th and 12th, Dr. W. Pepper has lectures npon diphtheria. We sub- join the more important points of treatment. "1 am in the habit ing the muriated tincture of iron, in fifteen a day, and sulphate of quinia in that fiv all bo taken in the coin- the ne tin.' . tain the (1 water, wine whey and porter, and ration present, 1 employ itine, the ric (typhoid) mercury, lie thinks there are 420 . Diphtheria. [May, some cases of u sthenic character that may be benefitted by the use of mercury, under certain conditions ; but in adyna- mic cases, he thinks there is no doubt of its impropriety. He also uses the chlorate of potash. As to local remedies, he thinks powdered alum, or borax and sugar, preferable to nitrate of silver in substance. He thinks there are many cases, the local symptoms of which might have remained mild, but lor an aggravation by the use of the nitrate of silver. He occasionally uses the nitrate of silver, but in weak solution under twenty grains to the ounce. Where emetics are indicated, he prefers alum with ipecacuanha. In the St. Louis Medical and Surgical Journal, for January, Dr. S. T. Newman has an article upon diphtheria. He con- cludes his paper with a letter from Dr. J. W. Bright, of Lexington, Ivy., in which a slight modification from the or- dinary treatment is advised. Dr. Bright commences the treatment with a gentle purgative, and afterwards the bowels are kept soluble by means of oil and turpentine. The mem- branous exudation he removes with a fine sponge, and applies a solution of nitrate of silver, 50 grs. to the 5j., or the sulphate of copper, 3j. to 5j- of water, once a day. For general treat- ment : "I give the muriate of ammonia in full doses, say, to a child eight years old and upward, 10 grains every two hours (in solution), and ten drops of the sesquichloride of iron in the intermediate hours ; and these are not to be omitted for thirty-six hours ; then rest four or five hours, and again give them in like manner. Continue this treatment for four or five days, according to circumstances." " The cure should be completed by the uye of tonics ; I have found beeberine the best. Diet nourishing. I have treated three hundred and thirty-four cases after this method, without the loss of one" The result is quite satisfactory. In the American Medical Times, for January 19th, Dr. E. W. Spafford has a short article upon the treatment of diph- theria. He says, " I have lost none to whom I was called within Ibrty-eight hours after the attack. My first business is (if it has not been done) to relieve the stomach and bowels of their morbid contents by the use of a gentle cathartic ; apply //. iodine to the neck, three times per day, and with a sponge probang, alternately apply a solution of chlorate of potash and nitrate of silver to the ulcers in the throat ; sponge the body with diluted nitro-muriatie acid; give gum water, beef-tea, wine, quinine and iron, as the case may require. Tonics are indispensable. If neglected or too sparingly used, alarming debility may ensue, the surface of the body become colorh 1 .] Diphtheria. 427 muscular power in a very short time lost, and the patient soon - to breathe. * 1 have been much gratified at the beneficial results grow- ing out of the use of mtro-muriat ' \ the surface. It not only acts as a counter-irritant, but as a tonic. Where I have had opportunity to use it early in the disease, I have not witnessed the debility, the flabby, soft condition of the muscles, or colliquative sweats, which bo often lead us t<> an unfavorable prognosi In the American Medical Times, for January 20th, Dr. Jonathan Kneelaud has an article upon this subject. In < raondaga and vicinity diphtheria has prevailed somewhat an epidemic since July last. About eighty cases have occurred, and A. a deaths. Of these eighty cases, Dr. Knee- land lias treated seventeen, all of which have recovered. AVe shall make a few extracts from his treatment, and thus give what is peculiar. " En giving briefly the treatment I found . [ would claim no other merit but that of having somewhat early learned that we must at the onset ain our patients by specific constitutional remedies, and much on local treatment. " The bowels were first emptied, in Dr. KneelaiuFs course, and then the patient put directly upon the chlorine mixture : * R. Chlorate of potash, 5ii. Hydrochloric acid (dil.) 5ij. Water, Sviij. sweetened to the taste, giving from a dessert-spoonful to a large spoonful, according to the age of the patient." To this nail amount of morphine was added in some cases; and if muriated tincture of iron was considered advisable, it was given in connection with this mixture, in which connection he thinks it is better borne than when given alone. Quinine, in iders all-important : " In no disease have ell borne." Like almost eve rver, Dr. Kneeland found "good broths and food ^( easy assimila- tive capacity ttial service. He says, "1 have found nitro-muriatic acid (equal parts of each acid), given in doses in water, and taken atb . well borne in patients, who did not bear either the iron or chlorine mixture well." Alcoholic drinks in aid ' f quinine, general stimulants and nourishing broth-, id in some cases. But li wc found that the :i-eed better than ardent spin We have more confidence in ap- 428 Diphtheria. [May, propriate stimulants than anything else in diphtheria. Upon this subjeet we have frequently expressed our opinion. A few days since, a gentleman called upon us for advice, in re- gard to a sore throat and general prostration of the system. ( )n examination, we found the fauces soft, palate and roof of the mouth presenting that erysipelatous redness peculiar to the first stage of diphtheria. Ilis business was such as to render it important that he should keep about. I advised him to use all the rye whisky that he could and not become intoxicated; also, to use a saturated solution of potash as a mouth wash and gargle to the throat. We should have said that his tongue was swollen, so as to leave the prints of every tooth upon it, and was heavily furred, and ulcerations had appeared at various points. My directions were adhered to ; a pint and a half of whisk}' was used daily, and the patient re- covered without taking his bed at all. In regard to hard cider, we have seen many cases of typhoid fever, in which this stimulant has been almost irresistably craved ; in such cases, we have always gratified the desire, and good lias al- ways resulted from it. As an article of diet, Dr. Kneeland recommends the fol- lowing : " As an article of diet, remedial, and yet palatable, I would recommend, where they can be obtained, sour-baked apples, mixing the tender pulp with sugar, or giving them alone, if the patient so prefers them. For many years I have used apples in this way as the diet par excellence in scarlatina; and how many grateful little ones, nauseated with pap, por- ridge and panada, have risen up to call me blessed, for the grateful change to the apple diet !" As a local treatment, he has no very high opinion of nitrate of silver; "To prevent the secretion from forming after re- moval (as it often does), I would use tannin and dried alum, applied with a soft linen rag, or on the moistened linger, to parts within reach, and blown into the throat through an ivory or glass tube; or two or three quills introduced into each other answer a good purpose ; no harm follows inhaling this powder, as a short paroxysm oi' cough clears all out again.1' The pulverized burnt alum we first saw recommended in the N. 0. Medical and Surgical Journal, by Dr. Bigelow, then of Paris. We have used it often, and with satisfactory results. We prefer it to nitrate of silver. For a gargle, the loll., wing is my preference, after trying a variety: 1861.] Strangled Hernia. 42!) R. Hyd. chlo. ammonise, 5jj. Iffi niuriat., oiv. Pulv, capsici, ' jj. Yin. 5ij. And <>ne and a half pints hot water; cool, and use freely. If any is swallowed, no harm foil "::" "I apply externally, over the throat, salt pork, moistened with turpentine, and <]uiekened with pal. sem. sinapis, or capsi- cum, it' need be."' The views, of Dr. Kneeland, in regard to treatment, corre- spond very well with our own ; we conclude with the follow- ing paragraph in regard to its nature : u From what I can gather from the recorded or narrated knowledge of others, and my own knowledge of the disease as gleaned from a limited number of cases, I have concluded that diphtheria is a blood-changing disease, and that lesion of function in the spinal nerves occurs early in grave cases ; that we would not wait for sinking, but, if possible, anticipate and prevent it ; and, finally, that to oxygenate the blood, and rouse and vita- lize the nervous system, are the leading indications to be _ht.v American Medical Monthly. Strangulated Hernia. Chloroform. Unless chloroform be given to a very free extent, it does not produce perfect re- laxation of spasmodically contracted muscle, hence in ^ of strangulated hernia it must be given so as to pro- duce a perfect state of comia, as indicated by stertor. If this be produced there are but few cases of inguinal hernia which will not yield to efforts at reduction, if the case is seen sufricienty early. Success to the same extent cannot be hoped for infemoral hernia, as statistics show that this form of heri requires operation 25 per cent, more fre- quently than inguinal. Mr. T. Byraat, p. 167. Incontinence oj . In a boy of fourteen, give one- third of a grain of extract of belladonna twice a di.y in cin- namon-water, in thofi where the affection issuspe from weakness or paralysis of the sphincter of the bladder. Belladonna acts by toning or exciting the gang- lion, m, and depressing the cerebrospinal system. Dr. R. Hughes, p. 395. 430 Mitorial [May, EDITORIAL AND MISCELLANEOUS. OUR PRESENT NUMBER. We call attention to the original department of our present issue. The three short articles here presented arc, each, of much practical value to the physician. The paper on Tape Worm presents the details of a case "by a most intelligent patient and his observations, though not those of a medical man, will he found suggestive and practical. Turpentine, it is well known, has been long regarded as among our most valuable anthel- mintics, but heretofore, it has been thought more particularly adapted to the lumbricoid form of parasites the experience of the two cases re- ported in our present number, certainly appears to admit its claim as no less reliable in Tape Worm. The mode of its administration should be well considered and followed by any of our readers who may wish to ap- ply the remedy in a similar case. J)x Bellinger's paper, on the Diagnosis of Early Pregnancy by Rectal Touch, presents many points of originality and practical value. It can- not be denied that our means of the certain diagnosis of early pregnancy are deficient and though Rectal Touch may not present an unquestion- able criterion, still we are disposed to give great credit to any extension of our means of determining a matter, often, of so much importance. Dr. Bellinger deserves the thanks of the profession for this valuable contribution. No less valuable than the two foregoing is the communication of Dr Horace Neeson, on Dislocations of the Plip Joint. Wre forbear extended observation on his views, in this place, as we have already discussed their merits in our introductory remarks heading the paper. We again earnestly call on our correspondents for contributions No scientific work can be supported and kept valuable except by the joint labors of both its readers and editors. The South is teeming with knowledge and experience of the most valuable and practical kind. It requires but little industry and self-sacrifice to place all this before the profession and to render what is now but "the property of a few, attain- able by all." We say, then, to our readers, still let the Southern Medi- 1861.] Miscellaneous. 431 cal and Surgical Journal remain, as it lias ever been, an object of inter- est to (ill sections, if not for the spirit and vigor of its editorial disquisition g at least because it furnishes fully and fairly its own quota of experience to the general fund of American Medicine. Hypodermic Injections of Atropine and Cutaneous Revulsions in Sciatica. Hypodermic injections with narcotic fluids do not, as might have been expected, relieve pain in all cases of neuralgia. "When the symptoms remain unaltered after such injections, various therapeu- tical resources are left ; and it would appear in sciatica, for instance that linear cauterizations with sulphuric acid along the course of the nerve niay prove very efficacious. This was lately proved by M. Legroux, physician to the Hotel Dieu of Paris, in two cases, Both patients were men, aged 35 years. Injections of sulphate of atropine, one grain to one hundred of water, did not remove the pain, though giving rise to symptoms of Belladonna poisoning. Sulphuric acid was now applied by means of a brush rapidly carried from the origin of the sciatic nerve to the ham, the skin being thus cauterized in a linear direction. The severe pain caused by the acid not did last long; and the neuralgia gradu- ally diminished. In the two cases alluded to, several operations were necessary ; but the complaint was completely subdued in a few days. London Lancet. Obstinate Neuralgia. ElcUricity. It is well known that if an instense current of electricity be applied in the course of a nerve, its sensory power is benumbed for a time, and the same result follows if the nerve is the seat of neuralgic pain. After a time the pain returns, but on repeating the electrisation the recurrence each time at longer and longer intervals, until finally a cure is effected. Sciatica, lumbar, inter- costal, crural, and trifacial neuralgia may be thus treated successfully. Nineteen cases of scatica, many of them old standing and obstinate cases have been cured by this plan of treatment. M. Becquerel, p. 49. Atropine Strength of Solution used. When it is wished to di- late the pupil for ophthalmoscopic investigation, the strength of the so- lution used should not be more than half a grain of the sulphate to an ounce of water. This will suffice for the purpose, and the unpleasant effects of a stronger solution will be avoided. Mr. 11. Walton, p. Vaginitis. Tannin Ointment. In cases of simple vaginitis, or superficial inflammation of the neck of the uterus, an excellent local ap- plication is an ointment composed of tannin and lard. This may be smeared over a piece of wadding and introduced through a speculum, a thread being attached to it, so that the patient can remove it herself. This docs not supersede the use of constitutional remedies as well. Dr. Foucher, p. 264: 432 t/fa/ieous. Tetanus. Aconite. It is worth while to try the affect of aconite in tetanus, as from souk: cases related its employment seems to have been followed by some amelioration of the symptoms. In one case five minims of the tincture were given every two hours at first, then increased to eight minims. The improvements in the symptoms dated from the employment of the aconite. The patient was well sustained by beef-tea and brandy. This remedy must be administered very cautiously, how- ever, as though it certainly is a powerful nervine sedative, it acts much more powerfully on the heart. Death from aconite usually occurs from Byneope. It is cumulative in its action. Ed. Lancet, p. 45. Profuse Moist ruation Quinine. The periodicity of tWb menstrual process is to be referred for its cause to the ganglionic system of nerves. There is considerable analogy between each individual menstrual flow and an attack of ague. Now, when the process occurs too frequently, every fortnight or three weeks, it may generally be controlled by quinine (unless owing to severe inflammation of the neck of the womb). The quinine may be given in doses of two or three grains every night or every other night, and if nervous symptoms predominate, it may be com- bined with sedatives, or if anaemia is present, with iron. Dr. E. J. Tilt, p. 286. Pulmonary Hemorrhage. In the intercurrent haemoptysis of ph- thisis, the tincture of larch-bark, in doses of half-a-drachm to a drachm every second or third hour is a very effectual remedy, succeeding in some cases when the usual remedies (ipecacuanha, lead, tannin, and gallic acid) had failed. It is now the remedy principally used in these c in the wards of St. Vincent's Hospital. Flooding after Delivery. Inject about half a pint of very cold water (iced if it can be obtained) into the rectum ; at the same time give cold brandy and water, with otic drachm of Cnrtis's liquor secali cornuti in it. Mr. T. Ilubbcrt, p. 244. Larch Bark is also recommended in cases of purpura, hsematuria, and metorhagia. The tincture may now be obtained of most respectable chemists^ Dr. J. M. (J'Fcrrc?l, p. 77. " Solution of Gold in, the Body. By T. Wordsworth Poole, M. 1). Saving known considerable anxiety caused by the swallowing of pieces of dentists' gold plates, I was led to make a few trials on animals with solid mercury and diluted sulphuric acid, given some time after the gold was swallowed. The gold was rendered brittle and partly dissolved in the mercury, and the animals seemed to suffer no bad consequen I hope that by your permitting this suggestion to appear in the Lancet some one of more experience may undertake the matter, and form a di terminate method of treatment.'' SOUTHERN MEDICAL AND SURGICAL JOURNAL. (XEW SEKIEtf.) Vol. XVII. AUGUSTA. GEORGIA, JUNE, 1SG1. NO. I! ORIGINAL AND ECLECTIC. ARTICLE XIII. A Lecture upon Tetanus. By L. A. Dugas, M. 1)., Professor of Surgery in the Medical College of Georgia. GENTLEMEN: Having studied with you the nature and treatment of wounds in general and in particular, it remains for me to direct your attention to a very remarkable affec- tion which occasionally presents itself as an effect of injuries apparently trivial in themselves ; I allude to tetanus. This is a spasmodic affection of some or many of the muscles of voluntary motion, which usually shows itself between the nth and tenth days after an injury, and which most frequently terminates fatally in a few days. Tetanns is said to be partial or general, according to the number of muscles implicated, for it may be in its early stages, and sometimes throughout the whole case, restricted to a xavy small num- ber of muscles, whereas in other instances it will invade them extensively. Tetanus isalso said to be idiopathic and traumatic, 1 have, however, never seen a case I considered strictly idiopathic. There is occasionally some difficulty in ascer- taining the seat of the injury, for this is sometimes so trivial scaped the notice of the patient. Some patients will also pertinaciously conceal the truth, as I have had oc- casion to see in two instances in which the injuries had been BUStained under circumstances that would not be confessed, but which I fully verified. 28 j 434 Dugas. Lecture on Tetanus. [June, Most writers speak of tetanus as being either acute or chronic. This is a distinction I think calculated to mislead the inexperienced, i fwe carefully study the natural history of this disease, unmodified by ])erturbating influences, we will find that while the fatal cases terminate in a few days, those thai arc successful occupy a much longer time to run their course. As a general rule, the disease cannot be cut short by treatment, nor does it ever abruptly give way, if let alone It may terminate abruptly by death; but when this does not occur and the disease is allowed to pass through all its stages to a favorable termination, itprogress- rradually to its maximum of intensity and declines by degrees almost imperceptible from day to day, until, at the end of weeks or even months the last symptom of rigidity will disappear. What is called chronic tetanus, then, is in reality nothing but the regular course of the disease when it does not terminate fatally. It is always a matter of prim- ary importance to know the course a disease will run when left to the unaided efforts of nature, for without this know- ledge we cannot treat it judiciously. Is it not probable that much of the want of success in the management ot tetanus is attributable to a neglect of this study ? This disease is infinitely more common with the African than with the Caucasian race ; so much so, indeed, that injuries which excite little or no apprehension in a white person, are never considered without danger if sustained by a black and the danger lessens in a direct ratio with the infusion of the Caucasian element into the constitution of the individual. Among our domestic animals the horse is exceedingly liable to tins affection, especially when prick- ed in the foot. The scat of injury seems to exert a decided influence in the development of tetanus, for it unquestionably oftener follows wounds of the extremities, especially the foot and hand than those o\' the trunk. Wounds of the external ear and of the occipital region are also thought to be peculiarly apt to induce it. 1861.] Dugas. Lecture on Tetanus. 43o Suppurating wounds are less dangerous than those appar- ently more trivial. Veterinarians are so well aware of this that when a horse is pricked in the foot they lose no time in provoking active suppuration by pouring spirits of tur- pentine into the wound and searing it with a hot iron. They consider the horse comparatively safe if they can se- cure a free flow of pus, for eight or ten days. Our negroes act upon the same principle witli their children ; hut after using turpentine they paddle the sole of the foot instead of resorting to the hot iron. Tetanus is thought to he more common in hot than in temperate climates. It is certainly very common in the West Indies; hut it is not satisfactorily estahlished that white persons are more subject to it there than in the tem- per zones of Europe and America. The negro population beinii: very large in those islands will account for the fre- quency of the disease. Sudden or prolonged expose to cold will frequently induce tetanus in those who would probably have escaped it, as the records of military surgery abun- dantly testify. AVounded persons should not be allowed even in warm climates, to be exposed to cold or moist air. especially during the night. It is still worse in cold climates a> has been often painfully exemplified in the case of wounded soldiers left exposed to freezing weather without adequate protection. The intense cold of arctic regions has induced it among the explorers of those inhospitable locali- ties, probably in consequence of previous frost bites. Men are supposed to be more liable to tetanus than wo- men and children; and the young more so than the aged. This may probably result from the circumstance that men are more exposed; moreover, the statistics are chiefly derived from army practice where men are almost exclusively treat- ed. I doubt that in civil practice those positions would be sustained. In my own the number of males is only slightly n excess of that of females. Symptoms. In studying the smyptomatology of tetanus ou must bear in mind that this is essentially a spasmodic 136 Dugas. Lecture on 'lelanus. [June, affection and that its manifestations must, therefore, be sought for in the muscular system. The functions of the other organs suffer comparatively little modification until the disease has progressed considerably, as I will point out as we proceed. The inception of tetanus is not preceded by premonitory indications, and is often so insidious as to es- cape observation for sometime. Usually the first smyp- toms are a sense of stiffness in the back of the neck and the occipital region, with an inability to open the mouth widely. The rigidity extends to the temporal and masseter muscles, thus increasing the difficulty of opening the mouth, and down the back giving to the trunk a peculiar air of stiffness. The patient may be still walking about the room, under the impression that he has caught cold in the muscles or that he is rheumatic. Muscle after muscle be- comes implicated, however; those of deglutition obey the will so imperfectly as to make it difficult to swallow without being strangled; the jaws are locked; the abdominal muscles become tense and hard to the touch ; the diaphragm draws painfully upon the ensiform cartilage as it were ; the sterno-leido-mastoideus feels like a cord on each side of the neck ; and all the muscles of the face become so fixed as to give to the countenance an expression so peculiar and char- acteristic as never to be forgotten when once seen. Every feature appears immovable and sunken as though greatly emaciated. In violent cases the body may be bent in various direc- tions, constituting peculiarities designated by authors as opisthotonos, when the body is carried backwards, empros- thotonos when it is drawn forward, and pleurosthotonos when the inclination is to one side or the other. The most com- mon form is that in which the body is bent backwards, and cases are recorded in which this was so extreme that thehcad and heels were brought nearly in contact. I have never Been an instance of this degree of violence. A- tin- disease progresses all the respiratory muscles be- come more or less rigid so as to interfere materially with 1861.] Dugas. Lecture on Tetanus. 487 respiration, which is then short, and will he found, by dose observation to be tremulous. The abdominal muscles in- eluding the diaphragm are so fixed that the respiration is almost entirely thoracic, the shoulders being seen to rise and fall in each act of inspiration and expiration. Many cases proceed to a fatal termination without any serious rigidity of the limbs; but these are often found affected the lower extremities more frequently than the upper. I have thus far spoken only of the persistent rigid- ity of the muscles. I say it is persistent, because, although under the influence of sleep or of powerful medication, the tension may be temporarily lessened, it never ceases entirely. But I must now direct your attention to a peculiarity which may be regarded as characteristic dt this affection, and which has, therefore, been termed the "tetanic jerk." Every now and then, at in- tervals varying froml to 15 or 20 minutes, or even longer, thejoatient experiences a sudden and forcible contraction of the muscles implicated, resembling very much an electric shock, and which is more or less painfhl. Sometimes he will simply groan as it occurs, but in some instances he will cry out with pain. In the beginning of the attack you may have to watch the patient half an hour before you can detect one of these jerks; but as the disease progresses the intervals become shorter and shorter, until they will not exceed a few minutes ; and the violence of the shocks in- creases correspondingly. They are then induced by the slightest circumstances, such as addressing the patient, ask- ing him to move, or to show his tongue, giving him food or drink. If any one walks in, or any noise is heard, they are induced. Hence the importance of great quiet in the treat- ment. I should have mentioned that these shocks or jerks are attended with a sudden closure of the larynx, which produces a sound not unlike that of hiccough or singultus, but occurs only once at each tetanic jerk. During this dreadful perturbation of the muscles of voluntary action those of organic life seem to be entirely un- concerned. It is true that the heart may be somewhat 438 Duqas. Lecture, on Tetanus* [June, accelerated in its movements; but this seems to be only secondarily probably in consequence of the modification in the act of respiration and the pressure of the inter-mus- cular blood-vessels. There is not usually much febrile ac- tion, if any. If the bowels are slow this may be accounted for by the rigidity of the abdominal muscles and by the small quantity of food taken, rather than by any impair- ment of peristaltic action. We have, I say, no positive evi- dence of any affection of the involuntary muscles. The intellect remains unclouded almost to the last gasp. The temperature of the surface is rarely much increased; the skin feels soft and pleasant ; but as the disease advancei to a fatal termination a copious sweat breaks out and continues to the end. Such are the symptoms usually observed ; but you will find them more minutely detailed and sometimes different- ly interpreted in the books. Diagnosis. The only affection with which tetanus might possibly be confounded is hysteria, in some of its protean manifestations. But in this disease the mind is more or less distempered and the spasms instead of being marked by persistent contractions and sudden exacerbations or tetanic jerks, have more the character of convulsions, that is to say of alternate contractions and relaxations of the muscles in rapid succession. The whole history of the case will also aid in our diagnosis. Pathology. With regard to the pathology of tetanus we arc still very much in the dark. Postmortem examinations have failed to throw any light upon it, unless we give more importance than I am disposed to do to the occasional de- tection of morbid appearances in the nervous filaments in proximity with the traumatic lesion. We have seen that the danger of tetanus is by no means proportionate to the violence done to the tissues but that, on the contrary, slight injuries are more apt to induce it than severe ones. The morbid condition of some of the nerves leading from the -rut of injury should, it seems to me, rather be regarded 1861.] Dugab. Lecture on Tetanus. 439 as a mere coincidence than as the immediate cause of the dreadful developments of tetanus. The brain and spina' marrow have boon most serutinizingly inspected without revealing any condition or lesion peculiar to tetanus. We must, therefore, look to physiology, natural and experiment- al, for an explanation of the phenomena of tetanus, as well as ot other spasmodic diseases. Physiology teaches us that while strcng impressions in- duce pain and perhaps inflammatory sequelae, slight ones provoke convulsive movements at a distance and general exhaustion. Laughing, sneezing, vomiting, kc, induced by the slightest titilation of the peripheral extremity of the nerves are familiar instances of physiological convulsions and cannot be provoked by violence. Here we have a slight irritation transmitted to the nervous centres which in their turn excite contractions in muscles more or less re- mote from the seat of original impression. This is the re- flex action of modern physiologists, and this explanation is applicable alike to pathological and to physiological cases. A pin gently passed across the sole of the foot will cause con- vulsive movements in the muscles concerned in laughter ; this is physiological ; but let the loot be pricked with a pin and we may have induced all the phenomena of tetanus. In both instances we have a peripheral impression, or irri- tation, which is perhaps a better ;erm, followed by a pertur- bation of remote muscles which, the irritation could not have reached without passing through the nervous centres. We therefore arrive at the conclusion that tetanus is a morbid reflex action induced by a morbid irritation of certain nerv- ous extremities. But, you may now a-k, why it is that the same morbid irritation does not always induce this morbid action? [ answer that all persons are not equally suscep- tible; some are very easily thrown into violent tits of laughter by being tickled, whereas others bear it with im- punity. In like manner morbid inita .ions which are harm- affect other constitutions with spasmodic dis- It would seem, therefore, that the induction of 440 Duoas. Lecture on Tetanus. [June, tetanus depends in a groat degree upon a morbid suscepti- bility or irritability of the nervous system, which we cannot however, recognize before the development of the disease. We have observed that negroes arc more susceptible to tetanus than whites. Why this is so we cannot determine. Tbe persistence of this perturbation of the muscular ac- tion is exceedingly exhausting, especially when respiration is much impeded ; and if to insufficient aeration be added deficient nutrition, in consequence of' difficult deglutition, you will readily perceive that fatal exhaustion must be in- evitable. The victims die, then, from exhaustion of the vita] powers induced by excessive muscular action and in- anition. You are now prepared to appreciate what we have to say with regard to treatment. Treatment. In determining the treatment of any given disease we must take into consideration its pathology, its natural history, that is to say, the course it usually pursues when not modified by perturbating agents, and finally the teachings of experience. I ought, perhaps, to have placed the results of experience first. But while in many instances our most valuable resources have been acquired by mere accident, we have nothing to boast of under this head with regard to tetanus. We have accidently discovered that cinchona is a specific in intermittent fevers, and can, there- fore, treat this disease very well without reference to either its pathology or its history. Xow, if we knew any agent that' would act as a specific in tetanus, I would advise you to go no further. I would certainly not stop to consider whether its action accords with my pathological views. With regard to tetanus, however, we know no specific; ac- cident or empiricism has really taught us nothing valuable. We are, therefore, necessarily thrown upon first principles, and if our pathology and history be correct, we ought, assuredly, to be able to indicate the most rational treat- ment. We have here, a susceptibility of the nervous system so L861.] Dugas. Lectureon Tetanus. 441 morbid thai a trivial irritation of its periphery lias induced a most alarming perturbation of its functions so far as they relate to the muscular movements ; and history teaches us that unless the disease be arrested by death, it will occupy pal weeks in running its course to resolution. We know also that this perturbation is attended with the most exhausting effects. Is it not evident, then, that we should endeavor to remove the cause or source of irritation, to lessen the susceptibilities of the nervous system, and to sustain the vital powers by nutrition, instead of attempting by violent means to arrest the disease? You should, therefore, remove the offending cause if you can. The splinter or other foreign body may still be in the tissues : if so, take it away. You may find pus that cannot escape ; if so, let it out by a free incision, and favor its issue by lye poultices. Xervous filaments may be lacerated; you should then make a clean division of them. If the injury be to one of the small extremities, a finger or a toe for example, amputate it at once. The propriety of ampu- tating a leg or an arm must depend upon the extent of the injury. A crushing or lacerated wound of the hand or foot is a common cause of tetanus, especially in negroes, and however great may be your desire to save the limb, you should not hesitate to amputate upon the slightest manifes- tation of tetanic symptoms. Indeed I do not think that in the ease of slaves you should, under such circumstances, run the risk of waiting for such manifestations. It is better to amputate as early as possible in such cases, for the rea- sons I have urged upon a former occasion, when speaking of amputations in general. I insist that Ave have no right to risk the life of a slave for the purpose of saving a limb, be- - neither he nor his family will suffer for the necessar- f life in consequence of the maiming. His master will ide them as abundantly as if nothing had happened to impair his efficiency. We may sometimes yield t<> the so- licitations of a white man who is willing to risk his life to a limb, without which lie could support neither him- 442 Dugas, Lecture on letanus. [June, self nor his family ; but the slave is more fortunately situ- ated and our first duty is to save his life. This may be a new doctrine in surgery ; but I think it correct. I do not wish you to understand me as attaching much value to amputation after the development of the disease for experience has but too often demonstrated its inutility. I think, however, that the successful termination of one of the cases I managed was promoted by the prompt removal of a finger, in which a bit of needle was lodged, upon the first manifestations of the disease. It is true that the symp- toms were not arrested by the operation, and ran their course for several weeks, but they were mild. AVe pass now from the local to the general treatment and we should select from the materia medica those agents Ave know to be most effectual in lessening nervous irrita- bility. These are unquestionably quinine, opium, and assa- fcetida. Use these with discretion and they must be bene- ficial, but you should bear in mind that they are to be given only as palliatives, for you cannot arrest the disease except by death. If you give opiates in the enormous doses some- times recommended you may overcome the rigidity, but the case will terminate fatally. I was once called in consulta- tion to a case in which the patient had taken half a grain of morphia every hour for 24 hours, besides inhaling large quantities of chloroform and yet the attending physician was surprised at the inefficiency of such active treatment ! The patient died shortly alter I saw him. A grain of opi- um with 5 gr. of quinine and as much of assafoetida, ad- ministered twice or three times in 24 hours, might have al- lowed him to live through the disease. But these antispasmodics will do no good unless aided by nutrition. As nothing makes one so nervous as abstaining from food, so there is nothing so bracing as well digested nourishment. Let him have such as he will relish and as much as his instincts will require. Animal food is best. Brandy is an excellent adjuvant and should be prescribed. Those who are in the habit of drinking should use it liberally. 1861.] Dug as. Lecture on Tetani -443 The appartmeut should be kept dark and perfectly quiet. No visitors should be allowed admission and none buta dis- creet nurse should be in attendance. No allusion must be made to the nature of the affection and the patient should he cheered with the belief that he will gradually recover. Micturation and defecation should be attended with the least sible exertion. AVlicn the bowels become uncomfortable from the retention of feces or flatus, let them be washed out with an enema of warm water and soap, or oil. I dislike to mar the simplicity of this plan of treatment by recounting to you the numerous remedies alternately ex- tolled and repudiated by systematic writers and journal re- porters. Indeed this would consume too much of your valuable time. Blood-letting, revulsives, mercury, emetics, cathartics, tobacco, indian hemp, and finally chloroform have all been more or less lauded. I have tried most of them without any evident advantage. They are all more or destructive of the energies of the system ; whereas I wish to impress upon you the great importance of husband- ing the resources of the economy. Strive to enable your patients to live through the disease instead of endeavoring to arrest it, and you will every now and then have the satifac- tion of witnessing a recovery. Trismus Xascentium is a form of tetanus which occurs in new-born infants and is known by the people as the "ninth day fits" because of the period at which it usually shows itself. This is also much more common with negroes here than with whites. Its real cause is not known, although some think it connected with the state of the umbilicus. Some negro families are peculiarly liable to it. I have seen a striking instance of this. A negro, of apparently good constitution, married a woman who had previously had ral healthy children; but who lost, with trismus nascen- tiura, every one she had by this marriage, seven in number, then died and her husband married another woman who had likewise reared several children by her first hus- band. But the only child she had by this man died with Ml Doughty. He port of [June, trismus. I examined a number of these children and could detect nothing wrong about the nmbilicus. As the women were attended by difterent midwives, it is not probable that there was any special mismanagement of the cases. Note. Since this Lecture was delivered and written onr. I have read with much interest a valuable and suggestive paper upon the pathology of tetanus, hv W. llanna Thompson, M. I)., published last February in the American Medical Times, of \e\v York, in which the author advocates the doctrine that tetanus depends upon a morbid condition of the blood either acquired or induced by some peculiar poison. The nervous phe- nomena would then be referred to the influence of morbific agents conveyed by the blood, instead of regarding them as the mere effect of irritation upon inordinate susceptibility. The treatment lie proposes consist- of "hematic agents, such as iron, mercury, iodine and bromide of potassium'1 with such "nervine stimulants as asafoetida, musk, camphor and alcohol, to uphold the sinking nervous force, while the hematic agents are coun- teracting the toxic cause in the circulation." ARTICLE XIV. Report of Hospital Cases. By Wm. IT. Doughty, M. D., Physician to Augusta City Hospital. Opacity of the Cornea. P. G., aged 45, entered the Hos- pital April 29th, 1860, for acute catarrhal ophthalmia of both eyes. The left eye yielded kindly to treatment after a short time, but the right continued highly inflamed and painful; at present, however, the inflammation does not involve the palpebral conjunctiva. The cornea partook of the inflam- matory action, as a result of which it has been left in an opaque state, sufficient to prevent the detection of objects only a few feet from the individual. From the outer cir- cumference of the eye, two or more large capillaries are 'i extending to the centre of the cornea. The sensibility of the organ to light is at that the patient keeps it covered with a handkerchief. The following treatment was continued for two months, at the end of which time, the Stil.] Hospitm 44.") ase had improved so much that the individual could dis- 3h objects at the distance of an hundred yards, and ,t his request) waa dismissed. All inflammatory action has d, and very little obscurity of the cornea remains. Constitutional treatment was 5 grs. blue mass at night, hree times weekly ; and one teaspoonfui of the following nixture, three times daily : lv. Potass Iodid, 5ij Tr. Iodin gtts* xxx. Aqua ad Sij.m. Locally the frontal and temporal regions were sponged Veelv with cold water, and the following wash used twice laily : 1\. Argenti Xit, grs. iij. Aqua, 5ij Open the eyelids and drop in a few drops. The enlarged apillaries were also cut in several places; and occasionally i small blister applied to the temple. 'Remarks. The satisfactory results of the above treatment ias alone caused the selection of this case for publication. jfcs purely practical character will render it acceptable to the -ion. Amputation of the Leg for Ch.ro/>:, Ulceration. For four- teen years Mr. U. C. W. had been afflicted with chronic Qceration of both legs the right, however, being worse ban the left. As is common with such cases, the ulcers, rhicb were large, irritable and offensive, would occasionally ical and then spontaneously break out again. They have lot been healed foi eighteen months or more, and on the ight leg they are so extensive as to have embraced almost ire region between the tuberosity of the tibia and he malleoli. He is a printer by trade, is foud of whiskey, tnd has led an irregular life which facts are quite sufficient :o explain the permanency of the disease. Neverth< lie looks quite robust, and his general appearance is by no - that fa person whose constitutional vigor had been leriously impaired. He first entered the Hospital about 440' Doughty. Report of [June, the middle of January, and was under treatment until March. The ulcers were healed, though the eicatrices and newly-formed tissues were tender and weak. ITe returned to his trade and usual habits, against which lie was cau- tioned ; and, on April 10th, applied for re-admission, for the purpose of having the right leg amputated. The ulcers had broken out with renewed vigor, and verily the last state of thai man was worse than the first. Of course he was ad- vised against amputation, and urged to remain long enough in the institution after the healing of the ulcers to enable the tissues to acquire strength ; and also to quit his trade, which required him to stand many hours without intermis- sion, as well as all stimulating drinks. It was much easier to suffer amputation than to undergo the latter privation he thought, and further remarked that his brother printers had kindly offered to furnish him with a cork leg. A week was allowed him for reflection during which the parts improved, at the end of which, however, was as clamorous as ever for its removal. Being persuaded in our own mind that the circumstances necessary for the preservation of the limb in a permanently useful state would never be observed, we determined to gratify him by taking it oft'. Accordingly, on 17th April, the operation was performed by Dr. J. S. Coleman, of this city, in a skilful manner, at the point of election, a few inches below the tuberosity of the tibia. The circular method was adopted, and after the tying of the blood-vessels, and the application of the usual dressings, the patient was put to bed. For several days he had high fever, and much pain at intervals in the stump, for which quinine, laxatives, and opiates were given. April 21st. Patient comfortable; pulse natural in fre- quency and volume. Stump examined, and a portion of the indurated integument that was necessarily retained, found to be in a sloughing condition. The usual dressings were applied, and a nourishing diet ordered. 1861.] Hospital Cases. 447 April 25th. This is the second dressing since last ex- amination. Doing well. May 18th. Stump in tine condition. Remarks. The ulcers on the left leg are completely healed, and it is probable that by the time the artificial leg- is procured, it will be firm and strong. Before amputation was performed, a written certificate, with witnesses thereto, was required of the patient, relieving us of all legal respon- sibilities on his part, and all others interested. This was a necessary precaution in view of the peculiaries of the case. Autopsy of a Case of Phthisis Pulmonalis. This subject, K. M., was an Irishman, 75 years of age, of irregular habits, He had the general appearance of a patient far advanced in in phthisis, being pale, emaciated, &c., but when his case was fully investigated its tubercular character was not so evident. His disease dates from a severe cold contracted eighteen months ago, occasioned by wet feet, wdiich con- fined him to bed for several weeks ; since then he has been scarcely able to go about. For three months or more he was an inmate of one of the Charleston hospitals, where, according to his statement, he was treated for chronic bron- chitis. With the general appearance of a consumptive, yet he had no hectic paroxysms, and night sweats; no diarrhoea; no marked acceleration of pulse and respiration ; no chronic laryngitis. His breathing was labored and oppressive, but not increased in number, and his pulse, though feeble and irregular, was still scarcely over the standard. The only rational evidences of phthisis were cough, labored breathing, and general marasmus, and muco-purulent expectoration. Physical examination gave abundant evidence of disease, but as there are no signs dissevered from rational symp- toms that may be regarded as certainly indicative of phthi- was insufficient to establish its existence. Bronchial and broncho-vesicular respiration, bronchophony, pectoriloquy and cavernous respiration (in rare instances), as well as the adventitious rales, may exist occasionally, as fully marked in chronic dilatation of the bronchial tubes as in phthisis. 448 Doughty. Report of [Juno, The same is true of the percussion sounds, for degrees of dulness, varying from simple appreciable dulness to almost flatness; tympanic dulness and its various modifications are also incident to it. The physical signs elicited in this case were such as might he ascribed to either disease. Under these circumstances, the importance of the rational symp- toms became greatly enhanced, for upon them must turn the diagnosis. The leading rational symptoms of advanced phthisis were absent, and so far it favored the presumption of its absence. Doubtless it was this circumstance that in- duced others to regard the case as one of chronic bronchial disease. Irregular cases of phthisis are occasionally met with, and hence wc were vigilant to detect it if possible. This case was made the basis of a lecture on consumption, embracing also a brief notice of the differential diagnosis between it and bronchial dilatation, before the attending class of the Medical College of Georgia, which was after- wards published in the Southern Medical and Surgieat Journal, Nlarch 30. In it the main points were discussed, and the ir- regularities set forth. The position then assumed was, that it would be unsafe to declare that tuberculosis did not exist. It affords us pleasure to review the conservatism of that position: a post-mortem examination alone could settle the disputed point, a s}mopsis of which is hereto annexed. It should have been remarked that there was no hereditary predisposition to consumption on the part of the individual. April 20th. Autopsy one hour after death. On opening the chest, the left lung was found collapsed ; at its apex it was slightly adherent to the wall of the chest. Its upper third, particularly the apex, was occupied by aggregated tubercular masses, firm and resisting to the knife; the mid- dle and lower thirds were also filled with tubercles in a dis- seminated state, varying in size from a mustard seed to a large-sized pea. The right lung was adherent to the pa- rietes of the chest throughout, and so firm were the attach- ments that in some places the knife was necessary to sever them. The entire upper lobe was a solid tubercular mass. 1861.] Hospital Cases. 449 and iu its posterior part was an excavation of some size. Within and about this region, the structures seemed iu a transition stage approaching decomposition ; some parts of it were indeed so much softened as to render it impossible not to tear it in our efforts to break the adhesions. The lower lobe was also occupied by tubercles in small masses ; and the base of the lung was. as it were, firmly glued to the diaphragmatic pleura. Heart. Xot the least interesting was the condition of the heart. There was fatty degeneration, with ex- tensive softening. The muscular tissue when cut or torn, had a decided yellow tinge ; and so greatly softened was it, that it trembled like jelly when exposed to view. There was no firmness about it, and when held in the hand gave sensations such as would be experienced by a loose bladder partially filled with water. The valves of the pul- monary artery were slightly thickened ; and at the aortic orifice only one of them appeared at all altered. Remarks. This examination fully demonstrates the cor- rectness of the position taken in our lecture, and as satis- factorily teaches us the importance, aye, the necessity of bearing in mind the possible occurrence of cases of pul- monary tuberculosis, which may display but few of its ra- tional symptoms. And this is the more necessary, since it is one of those rare junctures in which physical examina- tion fails to discriminate, the differential diagnosis turning upon the rational evidences of the disease. This would not be so if there were any physical signs distinctive alone of phthisis ; as it is, however, the rational symptoms place, m a degree, a special interpretation upon the latter, which en- ables us, in a large majority of cases, to make a successful diagnosis. The question, so often asked, "how few physi- cal signs, taken in connection with symptoms pointing to tuberculous disease, are sufficient to establish the diagr- nosift?" has its converse in that which may be asked, " how few of the rational symptoms of the disease, in connection with abundant physical signs, can suffice for the differen- tial diagnosis?" 29 450 Cutaneovs Discolor ations. [June, t 'llnical Researches into Morbid Pigmentary Changes in the Complexion. By Thomas Laycock, M. D., &c, Professor Of the practice of Medicine and of Clinical Medicine, and Lecturer on Medical Psychology and Mental Diseases in the University of Edinburgh. It is well known that the tint of the skin in disease is an easily available, and often an excellent guide to diagnosis and treatment. This disease arises mainly from the fact that changes in it indicate any important change in the constitution of the blood, but more especially of the blood corpuscles. Its physiognomical uses are well known in showing the race or temperament of the individual, and therewith his mental and corporeal tendencies. In these and various other similar ap- plications, the tint of the skin is due to the presence or ab- sence of the animal pigment, with or without changes in the blood. Although these color characters are capable of such varied and important applications to practical uses, they arc so im- perfectly understood as to their nature and origin, that changes in the complexion in disease have had little more than an empirical value in medicine, and have, indeed, not infre- quently led the observer into error ; thus, the tint in "Addi- son's disease " has doubtless led to its being mistaken for icterus until very lately. The coincidence which Dr. Addi- son showed to occur between structural disease of the supra- renal capsules and a pigmentary deposit in the skin of wdiites (and whose conclusions have been confirmed by others) has of late years directed my attention to the clinical meaning and pathology of morbid pigment-deposits and pigmentary changes in the complexion. Although the results of my inquiries are not so definite as further delay might have no difficulty in showing very conclusively that clearer views as to the patho- logy, diagnosis, and treatment of certain related groups of constitutional diseases may be deduced as well from the ab- sence of pigment-deposit as its presence. The following are the conclusions at which I have arrived, and which I propose to illustrate : 1. That besides blue and green, of rare occurrence, there are two common and well-marked and distinct forms of morbid discoloration, due to pigment deposit the yellow or sallow, and the black or swarthy. 2. That both yellow or swarthy discloration of the skin will occur from the action of local irritants as heat, light, cutane- ous parasitic fungi, blisters, sinapisms, and the like, or in the 1861.] Cutaneous Discolorat' 4ol progress of various cutaneous diseases of the skin and its appendag 3. That the absence of pigment (leucopathia), as well as its deposit, may be caused by inflammatory and other diseases of the skin, affecting its chromatogenous function. . That morbid states of the cerebrospinal centres will in- fluence the deposit or non-deposit of pigment 5. That morbid states of the genito-urinary organs in both sexes, acting probably through the nervous system, will deter- mine the election of locality of pigment-deposit, according to the same law, by which the development of sexwil hair and pigment is regulated. 6. That structural disease of the abdominal viscera and peritoneum also exercise an influence through the nervous system upon the local deposit of pigment in the skin. 7. That in the diseases of the supra-renal capsules, the bronzing of the skin, whether swarthy or yellow, is partly nervous, and due to the direct or indirect influence of the capsules or the kidneys and nervous system ; partly haemic, and in so far due to the morbid influence of "dyscrasic" blood. x. That pigmentary changes in the skin of both whites and blacks may be the result of morbid causes, and yet may re- main after the operation of the causes has ceased, and assume a physiological character. 9. That although local morbid pigmentation of the skin may occur exclusively from local causes, or the influence of the nervous system, in the majority of cases there is a morbid condition of the blood. 10. That the morbid conditions of the blood associated Bt commonly with pigmentary changes are characterized by those changes in the blood corpuscles (leukaemia, leu- ytosis) which are observed in cachectic states of a con- stitutional character (pregnancy, chlorosis, tertiary syphilis, chronic rheumatism, cancer, &c.,) or which are intimately connected with " dyad'asic," visceral or glandular diseases (of the spleen, supra-renal capsules, lymphatic glands.) 11. That the tendency to discoloration increases {cceteru 'paribus) with age after a certain period of life. 12. That the morbid pigment-deposits proper, as distin- guished from masses of altered blood-corpuscles, are car- bonaceous excretions, and are often vicarious with the suspension or imperfect elimination of other carbonaceous excretions as the carbonic and lactic acids, and the pig- 452 Cutaneous Discolorations. [June ment constituents of both the urine and bile ; and are con- sequently associated with morbid states of assimilation, as well as of elimination (through the skin, lungs, liver, kidneys). ] 3. That amongst the morbid states of assimilation, the rheumatic and gouty are especially to be classed, as well as those coincident with anaunia. Semeiologg. Pigmentary changes in the skin, and pig- ment-deposits in the tissues, are observed clinically under the most varied conditions, and have given trivial names to groups of symptoms. Jaundice (jaune, yellow) is. the simplest illustration ot these. The deposit of black, or brown, or blue pigment in the skin of white races, has led to the various nosological terms indicative of the change as melasma, me- lanopathia, nigrities, bronzed skin, blue skin or cyanopathia, mcliceris, stearrheca, flavescens, stcarrhwa nigricans chlorois (or green sickness), melancholia, melanchlorosis, melasicterus, &c. As to the absence of pigment we have alcura, leuce, leuco- pathia, vitiligo, caniles, &c. The congenital absence known as albinism has always excited curious attention, and, as those who have treated albinos know, coincides with pecu- liar forms of disease. I need not refer to the albino forms of animals, nor to the curious ethnological doctrines and oppressive laws which have originated in the presence or absence of cutaneous pigment, except to say that a better knowledge of the pathological forms will necessarily throw much light on the physiological. Classification of Morbid Pigments. The pathological pig- ments are of two kinds. 1. The spurious, which consists either in foreign carbonaceous matters, or in direct modifi- cations of the coloring matter of the blood corpuscles after they have died ; these pigments are all some form of hse- matine, and presents all the shades of black, brown, yellow, and purple. 2. The true, being those pigments which are products of the transformation of the living blood corpus- cles, or tissues, and which must be held to differ from the preceding in the circumstance that they are the results of the action of the vital forces. They are of all colors ; cor- respond in this respect to the normal coloring matter of animals ; and are found in the cutaneous appendages and excreta, but especially in the urine and bile. Le Cat, a surgeon at Rouen, was the first to examine systematically the moioid pigmentary changes of the hu- man skin in their relation to anatomy, physiology, and 1861.] Cutaneous DSscdtoraHons. 153 organic chemistry. lie details cases of melasma and ni- grities, and distinguished evidently what was a case of "bronzed skin" from ordinary melasma and icterus.* He examined the pigment (which lie termed "^Ethiop*B mine- ral") chemically, and showed that the coloring matter of the ink of the cuttle fish was identical in nature with that of the skin of negroes, and of the choroid coat of the eye. He was also the first to observe that the encephalic tissues of the negro were of a darker tint than in whites an ob- servation subsequently confirmed by Meckel and others, and very recently by M. Gubler. Although considerable progress in observation has been made during the last cen- tury, we may still say, with Alibert, " Les lois de la colora- tion sont encore couvertes d'un voile epais.*' Modern inquiries have ascertained that black pigment is deposited morbidly in the tissues, mucous membranes, and capillaries (melanosis), as well as in the skin (melasma), and that it is sometimes present in considerable quantity in the blood (melanamia). Its nature and composition have also been carefully examined of late years. Baruel first at- tempted to show that the chemical composition of the black deposit in melanosis was identical with that of the coloring matter of the blood. Breschet founded upon this analysis and upon his own researches the conclusion that the de- posit was due to effused and modified blood with a large proportion of true coloring matter: and flcusinger, Lob- stein, Andral, Trousseau, and Leblanc, J. Vogel, Bruch, Rokitansky, Virchow and others, have theorised as to the mode in which the pigment is formed from the blood. | It is now well established that although the pigment in nu- merous cases really consists of modified lnementine, derived directly from the blood-corpuscles, the deposit in melan< melasma, and nigrites is not of this kind. The term melanosis was first used by Laenncc, who pointed out three forms of the disease. 1. Those in which the pigment is deposited in masses, whether encysted or not. 2. Free deposits of pigment in layers in serous mem- branes. 3. Infiltrations of pigment. t In ;i*21, Breschet * Traite de Couleur de la Peau Humaine. 6c., p. 158. 1765. ompare Kokitansky's Pathol. Anatomy, Sydenham Society's trans- lation, vol. i. p. 204, and Virchow's elaborate paper, li.' Pathol Pig- mente, in Arch, t Path. Anatomic and Physiologic, vol. i. art. '.'. : Bulletin de la Soc. de l'Ecole de Medccine, No. 2. 1860. 454 Cutaneous Discolor ations. [June added a fourth, the fluid form ; and in 1829, Andral asked whether certain eases of pigment-deposit in the skin should not be classed with melanosis. Andral also called attention at the same time, not only to cases of inky discloration of the intestinal mucous membrane, in which pigment ap- peared as a deposit into the tissues, hut to another class (some observed by himself), in which it appeared on the surface of that membrane as a secretion.* These deposits of pigments in the tissues, that is to say, externally to the blood-vessels, are now well established. Breschct and Oruveilhier seem to have been the first (in 1821) to detect pigment in the blood-vessels in the form of black, sharply-cut masses.f It was considered to be rather a post-mortem phenomenon than a true pigment- deposit, and what they observed was probably due to the hsematine of the altered blood-corpuscles. In 1823, Dr. Haliday published a case of melanosis, in which he found fluid black pigment in the vessels at the base of the brain, and in those of the choroid plexus. t In 1825, Billard and Bailey observed capilliaries of the brain to be obstructed by pigment. Several years subsequently, Mr. Holmes. Coote recorded a case of melanosis of the eye, in which he found a black matter present in the blood-vessels of the recti mus- cles of the globe, between the blood and lymph-corpuscles in appearance, and which moved with the blood-corpusles when pressure was made on the vessels. || Of late years, this deposit of pigment in the blood-vessels has been frequently observed and connected with the presence of free or celled pigment in the blood and certain viscera, but especially in the spleen. German observers have largely contributed to this portion of the subject, particularly Meckel, Ecker, Vir- chow, Planer, Heschl, and Frerichs. The term melancemia (first used by Frerchs) has been applied to that condition of the blood in which the pigment has been found. Seeing how readily the carbonaceous matter is deposited in the skin and tissues in melanosis, and how abundantly in the capillaries the conclusion was natural that in all cases it was a deposit made directly from PreciH (TAiiat. Path., torn. i. j>i>. 460-1, Considerations sur une Alteration Organiqne Degenerescenoe Noire. 1 82 1 . ; London Medical Repository. 1828. Lancet, Ang. 1846. 1861.] Cutaneous Discotora: 455 the blood, without the intermediate ^ ital action vf the tis- sues in which it was deposited. Now, this mechanical theory maybe admitted as to the blockade of the capillaries by pigment granules, the products probably of altered cor- puscles, but it is by no means sufficient to explain the usual phenomena of melanosis or melasma. As to the latter, it may be observed especially that the deposit takes place in a tissue, the normal function of which is at least to receive it, but perhaps to excrete it: hence the change is in one sense a physiological process; whereas in melanosis and in block- ade of the capillaries, the change is in no sense physiologi- cal, but purely pathological. As I shall have to refer to mdana-nila from time to time, T would observe here, once for all, that although the facts are so numerous and apparently so decisive as to the pres- ence of free pigment in the blood, they require confirma- tion, and have in tact been controverted. In 1852, Zeroni stated in a contribution on the Treatment of Ague by Ar- senic,* that he had examined the blood of ague-patients for the pigrneut-cells described by Ileschl, and, to his great delight, he found them at once ; but on examining the blood in other cases, and in the spleen of a fatal case, he could no longer find them, but discovered that lie had used glass covers which, under a power of 300, showed objects mar- vellously like Heschl's drawings of his pigment-cells, Pro- bably the doubts thus thrown on Heschl's researches are not altogether inapplicable to the researches of other inquirers, for Zeroni indicates a very certain source of fallacy. I have examined the blood of several individuals (certainly not fewer than 100). and am satisfied that nothing is more difficult than accurate observation of the pigment- elements. The slightest particle of dust, coal, or ash, is sufficient to give the appearances described by Planer and Ileschl. Even a microscopic particle of dried blood, re- maining on the slide, shows as brown pigment, in a freshly- drawn specimen of blood taken on the slide. So that the utmost care will hardly suffice to avoid fallacies in observa- tions at the bedside. It appeared to me that the only method by which even an approach to accuracy can be ob- tained clinically, is by examining the blood of a number o\' persons under the same conditions as to time, place, state of * Deusche Klinik. Xo. 40, 41. 4oti Cutaneous Discoloration*. [June, slides, and method of taking the blood, so that all the ob- servations are equally liable to the same class of fallacies; in this way a comparison of the differences in the pheno- mena observed could be instituted. The results of clinical examinations thus made, I shall state shortly, believing that, although not strictly accurate, they are sufficiently ap- proximative for the first steps of a clinical inquiry. Melasma considered generally. There are two forms of pigmentation observed in the skin of men and animals ; namely, those of the skin proper, and those of the appen- dages to it, as hair, quills, feathers, scales, shells. The pig- ment of the skin proper of man is contained in the soft, newly-formed cells of the epidermis, formerly termed the retemucosum, into or by which it is secreted. That of the hair, scales, and other similar appendages, has fundamen- tally the same origin ; for they are either compressed epi- dermic products (as scales), or produced from follicles which are fundamentally involuted portions of the derma proper. The function of these follicles is, however, modified by the fluid which is poured into them from the sebacceous glands. But these again are involutions of the derma. Hence the general relations to the pigment of the skin appendages are the same in both ; it is contained in cells having a common origin at the surface of the body. The skin in all men. whether white or dark, has nor- mally a function of pigmentation, although the activity of it differs greatly in extent in different races, and even in the same race, from va^'ing circumstances as to climate, food, and exposure to climatic influences. In white races this coloriferous function is almost in abeyance, especially in the clothed portions of the body, but it is easily devel- oped under certain circumstances. In all, however, the anatomical relations of the pigment to the epidermic cells appear to be the same. Thus the pigment-deposit in "bronzed skin" has been found by various observers to have the same relation to the epidermis as in sun-freckles (epheUs), and as in the colored races. The cells in which it is contained in the form of minute granules arc covered with a colorless epithelium in the ordinary cases of melas- ma, chloasma, ami the like, but in certain morbid states of the skin, in which there is rapid production of epithelial scales (desquamative or squamous diseases), the epithelium contains abundant coloring matter. This is observed clini- cally in pityriasis versicolor, in various forms of ichthyosis, 1861.] Cutaneous .Disco/orations. 457 in cases of true leprosy, known as ti black " leprosy, and in lepra nigricans. A similar rapid production of pigment may take place cither within the hair follicles or the seba- ceous glands, and be poured out on the surface of the skin. This is seen in stearrhaa nigricans and stearrhosa Jfavescens. It is probable, however, that it is poured out also as an excretion from the sudoriparous glands. Leueopathia in relation to Melasma. It is not every part of the human body which is equally dark, or has equally a tendency to become dark ; on the other hand, in colored races, and in portions of the skin or its appendages of the whites, which are naturally dark, there is sometimes a morbid defect in the pigmentation. This state has been termed white disease, or leueopathia. It is to be observed, however, that there may be a pathological leueopathia ; that is to say, white spots due to morbid changes in the skin may appear amongst colored patches of white skin due to excited action of the epidermis. This gives a mottled appearance to a bronzed skin i. e., a skin darkened by disease, and may tend to puzzle the observer. In particu- lar it may lead him to mistake a pathological tint for the dark tint of sordes of the skin. The mottling of the skin in cases of melasma, indicates a true pigment-deposit, for the white patches are due to the absence of morbid pig- ment, just as leueopathia in the negro indicates the absence of normal-pigment. Xow, as the pigment-deposit in these cases of melasma is due to morbid excitation of a normal hut suppressed function of the rete inucosum in whites, the white mottling indicates a morbid condition of the skin at the places where the skin or the hairs remain white, when all around is darkened. This morbid condition can often be traced to some eruptive disease of the skin by which the function of the rete mucosum, so far as the production of pigment is involved is interrupted. In other cases, it is due to some other cause or causes. I have seen, for example, a case of syphilis, in which the hairs of the entire surface of the body, cap-a-pie, fell off, and pigmentation therewidi ~cd. The patient was a young man of dark complexion, and when the colorless downy hairs reappeared on his pink- looking skin, he presented a curious contrast with his for- mer appearance. Again, although leueopathia may be thus traced to changes in the disease induced by locally inflani matory or constitutional causes, and the result of which is to interrupt the ehromatogenous function of that portion of 458 Cutaneous Discolorations. [June, the skin affected, there are forms of leucopathia wholly un- connected with any such structural chenges, and which are probably due to changes in the innervation. Thus, a man with renal and cardiac dropsy had broad patches of liver color (melasma) and leucopathia on his right forearm. No structural change could be traced in the site of the latter, while it was observable that the hairs of the spot were white, so that the production of pigment was suppressed in them, as well as in the rete mucosurn. Such cases as these 1 would term melasmic leucopathia. On the other hand it is to be noticed that portions of the skin, which have been the seat of considerable structural change, are the seat also of pigment-deposit. The deep cicatrices left by a severe attack of small-pox may be ob- served sometimes to be thus colored ; it is no uncommon thing to observe the same appearance in the cicatrices of old ulcers on the legs, especially of gouty old people. In these cases the pigment-deposit is manifestly due to another kind of action than that which occurs in the rete mucosurn or cutaneous glands in instances of melasma. In the latter it is a natural function of normal structures exalted by sonic special conditions; in the former the normal structures are destroyed, and the process is purely morbid. These two forms of cutaneous pigmentation are, in truth, typical forms, and correspond to what maybe termed carbonaceous excretion and carbonaceous deposit (melanosis proper.) The black, yellow and blue stains following upon bruises are, of course, wholly different, being due to the effused blood-corpuscles. Local Causes of Melasma. The conditions under which morbid pigment-deposit takes place, being so very complex, it becomes necessary to determine the more important by illustrative cases. These conditions may be classed under three heads, as they involve the blood, the nervous system, and the tissues themselves. As regards the skin and its appendages, it may be here observed generally and by way of preliminary, that any stimulation or irritation applied to the skin under certain conditions of the blood, the nervous system, or the system generally, will induce pigment- deposit. Thus, heat and light tinge the rete mucosurn of certain persons. Id old people, the Bhins get to be of a brown or liver color, from exposure to the fire ((aches dc brulure). The same thing happens in certain cachectic states, as in the syphilitic cachexia, in anaemic conditions 1861.] Cutaneous Liscoloratr 459 (chlorotic girls), and the like. In a similar class of c< the irritation of a blister suffices to cause pigment-deposit, bat the exact size and shape of the blister is indicated dusky brown or liver colored patch. Various skin - have a similar effect, as the furunculoid, eczema, psoriasis, &c. In an inveterate case of peoriarsis, treated in the clinieal wards during the session 1869-60, a man. aged about fifty-eight, after convalescence the entire surface of the back and trunk was almost wholly covered with large confluent patches of dark pigment-deposit, indicating the portions of the skin which had been the seat of the disease. And seeing this result, it was not difficult to understand how, in cases of this kind, the complexion of the individual might be indelibly changed, so that he would exactly re- semble men of the colored races, in that particular at least, just as in some cases of leucopathia in negroes, the skin has become as white as in the white races. Now, in these cases of cutaneous pigmentary change, after convalescence from skin diseases, I have observed that the patient lias been either advanced in years or cathectic (if young), or both aged and cathectic. Psoriarsis, for example, is very common in young and healthy adults, but in these cases, stains are very rarely left after cure, as in the aged and cathectic. It occurs in the ptions. I think, because the patient is of a dark com- plexion, and is therefore predisposed naturally or normally to pigment-deposit, just as a woman of such a complexion will have a darker mammary areola from pregnancy than a fair-complexioned woman : and this indicates one of the most common conditions under which pigment-deposit will vary in intensity namely, the ethnic, or conditions proper to the mee. Probably to this class of conditions may be at- tributed, in part, the difference between swarthy and yel- low bronzings in the diseases of Europeans. The mode in which the sun's rays excite freckles (ephelis or lentigo) >hows, however, that there are conditions in the skin of the face and neck which predispose it to the deve- lopment of pigment in the small patches termed freckles, otherwise the change in color weuld be uniform. Some- rimes this appearance is x^vy remarkable, as in a youth of twelve, just arrived from India, who came under my notice. and whose face, after exposure to the sun, was suddenly dotted uniformly over with round brown spots of the rgepin'fl head. In the- the deposit may be due 460 Cutaneous Discolor ations. [June, to irritation of the rete mucosum at points where a group of sudoriparous or sebaceous glands pour out their pro- ducts, or if not to this, to the same class of elective causes, by virtue of which herpes, variola, and other circumscribed inflammations of the skin, are induced. It is to be ob- served, too, that red-haired persons are more liable to this lenticular pigment-deposit (laches de rousseurs) than the dark-haired, in whom the pigmentation is more uniform. I shall, however, refer to these special forms of pigmenta- tion or leucopathia when I discuss more particularly the causes of melasma, and with these preliminary remarks will now give some illustrative cases. Caih.ectic melasma (?'. e. swarthy bronzing, as distinguished from yellow) is the most commonly observed ; it is that specially designated by the term melasma. Case 1. Mottled swarthy bronzing (melasmic leuco- pathia) of thorax and abdomen, mistaken for sordes ; ab- dominal tumor; enlarged lymphatic glands. Reid, a tailor, aged about thirty-live, was admitted into the clinical wards, 27th May, 1856. On admission it was found that he had a pulsating tumor about four inches in diameter, oc- cupying the middle line of the epigastrum, and extending thence "into the left hypoehondrium. In addition to the tumor proper, there was a supplementary enlargement caused by faecal accumulation at the left angle of the colon. Complained of constant constipation and severe shooting pains in the back and loins, extending to the left groin. rain also more particularly referred to the region of the kidney, where there was tenderness on pressure. On care- ful examination the tumor was found to be not expansile, but a loud stystolic murmur was heard over il. The skin of the trunk was universally of a darker hue than natural, but more particularly over the abdomen ; the dark surface was mottled with white spots, which, on inquiry, we found to be the sites of a previous pustular eruption. Face pallid anaemic ; axilliary and inguinal glands enlarged. In dis- cussing this case at the bedside, I pointed out the bronzing of the skin, but the appearance was so like that of sordes, that several of the class got soap and water, in the confident expectation that they could tl wash the Ethiope white." The only result was to bring out the dark and white spots more distinctly. Symmetrical Melasma. In the cast- just detailed, the change in color was limited to the trunk; it is sometimes, 1861.] Cutaneous Biscoloratlons. 461 however, symmetrical, both as to morbid whiteness and morbid dinginess ; and although it by no means follows that, beiug symmetrical, it must be due to changes in the centric nervous system, yet in the absence of any other cause, we may fairly refer it to these, as they probably were influential in the following case. Case II. Long-continued diathetic eczema and erythema; enlargement of lymphatic glands ; symmetrical pigment de- posit on the skin ; melasmic leucopathia. P S , aged sixty-two, a workman in an iron foundry near Glasgow, admitted into the clinical wards 22d July, 1860. He states that he had always enjoyed good health, with the exception that in youth he had frequent attacks of headache until six- teen years ago, when his lips became red and swollen and covered with small vesicles, accompanied with exces- sive itching. In three or four weeks he was cured by the application of a yellow ointment, but the affection recurred annually every spring, and at each recurrence extended over a wider surface. About four years ago the shoulders became affected, and for the last two or three years there has been no remission. The itching is very distressing, and the desquamation from the parts affected considerable. About three years ago, he observed that the glands of the groins were becoming large, and shortly after those of the axillse. About this time, also, three abscesses formed ; one in the right groin was opened, two others lower down in the right thigh burst. They commenced with shivering, thirst, and other febrile symptoms. Two years ago, while feeling a little weak, small brown spots began to show themselves on various parts of the skin of the groins, back, and abdomen. He cannot remember whether one patch preceded another, or whether they all appeared at the same time. He has never had rheumatic fever, but when forty years of age he suffered from three or four attacks of lum- bago. His father was rheumatic, his mother not. Examining the patient more particularly, it was found that he complained of no pain, only of a troublesome itching extending over the whole body. The skin generally is of a pinkish-red color where not discolored, showing a deficiency of pigment, gives off* abundant scales, and is universally thickened, but more especially so on the legs, where it pre- sents the appearance of ichthyosis. Symmetrical brown patches, as large as two hands, are observed over each shoulder-blade, and which extend across the median line; 4(>2 Cutaneous Discoloration*. [June, another large patch surrounds the neck, and extends sym- metrically up to the face, which is uniformly dusky, pre- senting no patches. Symmetrical patches occupy each axilla, extending forwards to each nipple; there is a simi- lar patch around the umbilicus, and also in each groin. The superficial lymphatics generally are enlarged in the groins, both above and below Poupart's ligament, in the axillee, at the elbow, and in the neck behind the sternomas- ioid. There is also an enlarged moveable gland over the left tenth rib. The head is covered with hair, which is almost uniformly white, contrasting with his dusky face. The facial and other characteristics are those of a degenerate form of the gouty or rheumatic diathesis. The lips do not exhibit any peculiar pallor. The blood was examined microscopically, and found to contain an abundance ot white corpuscles. (Leucocytosis.) A cardiac murmur is heard with the first sound, loudest at the apex; pulsation visible in the neck ; pulse G9; the appetite is good; the bowels regular; urine abundant, of a light amber color, with the normal amount of chlorides, and affording no traces of albumen or sugar. As the wards were closed for the autumn shortly after his admis- sion, the termination of the case was not observed. In this instance the symmetrical deposit of pigment in certain spots of the skin, and its absence in others, is the most striking point. It is also to be classed with Case Xo. I. in regard to the affection of the glandular system. The melasma presents resemblances to that observed in some of the recorded cases of bronzed skin. Thus, in No. G of Dr. Additon's cases,* the patches of discoloration were asso- ciated with patches of leucopathia, in which the skin pre- sented " a singularly white or blanched appearance : the hair upon these patches were also " completely white." The axillee and groins are also very commonly the seat of dis- coloration in Addison's disease, and in some of the cases B symmetrical deposit has been observed, as in this. Sym- metrical deposit is not confined, however, to these consti- tutional forms. In chronic peritonitis and chronic struc- tural diseses of the abdominal viscera ot' all kinds, it is not uncommon to find a darkened hue of the skin of the abdo- * On the Constitutional and Local E of the Supra-renal Capsules, p. 2~>. 1861.] Cutaneous Discolor ations. 4G3 men, approaching in sonic case- to a deep tint of Indian ink. In one of this class (evidently cancerous) which Dr. War- burton Begbie kindly brought under my notice at the Edinburgh Royal Infirmary, there was not only this pig. ment-deposit in the skin of the abdomen, but it extended symmetrically downwards along the groins to each thigh. " Desquamative Melasma. The desquamation in Case No. II was not pigmented. There are cases, however, in which the scales either contain or excrete abundant pigment. Schilling* mentions the ease of an infant with previous k* hyperemia " of the skin, whose entire surface was covered with a lamp-black matter, which came oft* with the linen. The following presents one of these forms of pigment- deposit. Case III. Xigrities of trunk with extensive desquama- tion (pityriasis versicolor) ; eczema ; yellow bronzing of face ; profound ameniia. Elizabeth Fleming, aged sixty-six, ad- mitted into the clinical wards May, 1856. On admission, physical signs of bronchitis, with slight consolidation of lung, blowing stystolic murmur loudest at the base, oedema of legs, recurrent headaches, and attacks of diarrhoea. On the surface of the bod}- were the remains of an ecze- matous eruption, the lips very pale, face and hands strik- ingly anaemic, but of a pale straw color (yellow bronzing), contrasting strongly with the hue of the arms, trunk and extremities. These were of various shades of bronze and black ; bronze on the forearms and legs, but deepening upwards towards the trunk, which was very dark, and, in- deed, almost black in the axillae and over the abdomen. Al she recovered her health under chalybeates, wine and generous diet, desquamation came on, and the epidermis came off in dark flakes, leaving the skin paler, but of its natural hue. Xo sporules of the pityriasis fungus (the mi- croscoporon furfur) could be detected. The skin over the abdomen and other pigmented parts was mottled over with pale spots, which had evidently been the seat of the ecze- matous eruption. This was a second attack of the kind, for the patient stated that five years previously she was simi- larly affected, and that it ended then in desquamation. This case presents an obvious point of resemblance to the two preceding in the circumstance that leucopathia, from * De Melanosi. p. 83. 464 Cutaneous Discolor ations. [June, the inflammatory affection of the skin, was associated with the nigrities. In other words, that some morbid condition of the skin caused a deposit in one portion of it, while another morbid condition prevented the deposit. In the blood condition there was also a point of resemblance. Visceral Melasma. The cutaneous pigmentation ob- served in Addison's disease has been termed melasma supra- renale. This term is "premature and objectionable, because it assumes the accuracy of the theory which connects the eutaneous pigment-deposit neccessarily with structural dis- eases of the supra-renal capsules. In some of the cases there is melanosis as well as melasma, and these two patho- logical changes are, as we have seen, very distinct in their nature. The general symptoms arc anamiia, gastric and intestinal irritation, and various neuroses, as neuralgic pains, convulsive movements, and mental despondency. The following case presented these, together with melasma : Case IV. Addison's disease ; intense swarthy bronzing; recovery. Stevenson, aged twenty-nine, a ship carpenter, from North Shields, was admitted into ward No. 1, on the 18th June, 1856. Naturally of a dark complexion, he pre- sented nothing particular in this respect until the month of August previously, when, without any serious ailment, he began to be dark and yellowish in color, and was treated for jaundice, without any alteration in his complexion. Feeling pretty well, he engaged as ship carpenter for a voyage, but hardly had been four days at sea before he was seized with most violent vomitting and purging, accom- panied with a feeling of great uneasiness in the lumbar and right iliac regions. He returned from London (where he was treated) to North Shields, and had another attack on the way. Six weeks before admission he again engaged to serve on board ship, but the first night he was seized with a rigor, which continued a quarter of an hour, and was suc- ceeded by a cold sweat. During this he became uncon- scious, and was carried ashore in that state. Again, on June 7th, he was seized with violent vomiting that con- tinued four hours, and with purging and abdominal pain, especially in the right iliac region, with great weakness, headache, and total loathing of food. Has had seven such attaeks. His complexion is absolutely that of a mulatto, so that on admission he was taken for a man of color. His hands and feet are brown, like his face ; dark patches in axilla* and groins ; conjunctiva1 and nails white; the mucous 1861.] Cutaneous Discolor -ations. 46o membrane of month and lips patched with dark inky spots; the same spots seen on the side of the tongue. Tongue clean, bowels costive, moved once in four or five days ; pulse 80. feebl i : cardiac impulse leeble, and sounds very faint. In left lung posteriorly crepitation. Hands very cold and moist; feet cold. Complains of pain in the spine at the level of the crest of the ilium. Under the mi- croscope blood showed abundance of small white corpus- cles. He was ordered the persesquinitrate of iron, wine, and a generous diet, but diarrhoea came on and he lost strength and weight, so that on 1st July he was reported to have lost one pound and a half during the preceding k. On that day he was ordered full doses of glycerine daily, and in addition to the other remedies. He now be- gan to improve rapidly in both strength and weight, so that by the 14th July he was so much better in every respect, except his complexion, that he went home convalescent. This case was in all particulars so similar to the forms of melasma accompanied with anaemia which JDr. Addison has described, that I have no difficulty in classing it with them. Of course it may be objected, that there was no proof there was disease of the supra-renal capsules, because there was no post-mortem examination to determine the fact, and that as all true examples of the disease have al- ways been fatal, the simple fact of recovery is opposed to the diagnosis. I cannot admit, however, that every case present- ing the group of symptoms known as " Addison's disease" must necessarily end fatally, or that the concurrent disease of the capsules is necessarily structural ; nor is it a legiti- mate exercise of the art to establish no diagnosis except by examination after death. The case presented all the path- ognomic symptoms of Addison's disease, and ought there- fore to be placed as such nosologically. There is one point in the history of the melasma in these cases of considerable clinical importance. The morbid con- ditions which lead to the pigment-deposit may be removed, and yet the deposit itself may remain ; or, in other words, the primary disease may be curable, but the melasma be permanent or incurable. A patient (Lawson), aged fifty- four, was admitted into clinical ward No. 1, under my care, in profound anaemia, apparently the result of starvation. His color was universally of the swarthy hue of a mulatto, but deepest in the face, lie spoke with the strongly marked Scotch accent, or he might have passed for a Las- 30 466 Cutaneous Discolor ations. [June, car just arrived. To all inquiries as to his color, he only answered that his mother told him he was white until he was four years old, when his skin changed to dark after an illness. It is possible that the maternal history may have been a myth, for Le Cat quotes a case in which the blackness of the child of a lady was attributed to her hav- ing seen a negro. A case related by Dr. Parkes of this kind, is, however, conclusive: A man, aged fifty-nine, was treated in the University College Hospital for jaundce. He left the Hospital apparently well ; but four or five months afterwards portions of the skin became gradually dark first on the face and neck, then in patches on the body, arms and thighs, until the hue was very deep. For five years afterwards no change in tint took place, when he was again admitted into the hospital (seven years after the attack of jaundice), with ascites dependent on contracted liver. At this time he was like a mulatto, there being only slight variations of tint on the face, neck, shoulders, and arms ; but over the trunk, and especially the abdomen, thighs and scrotum, there were white patches (melasma leucopathia) ; below the knees the skin Avas of its natural tint. There was a little pigment on the conjunctiva, and a dark patch on the mucous membrane of the lips. ISTo ex- cess of white corpuscles or free pigment were detected in the blood. After death pigment-deposit was found be- neath the epithelium of the peritoneum (melanosis). The supra-renal capsules were found to be perfectly healthy. JN'ow, in this case the pigmentary changes were consequent upon the attack of illness which occurred seven years before death. If they had depended upon supra-renal disease (which may have been the case), then that had evidently been of a curable character, and the organs had been restored to a healthy condition. In any case the melasma and pigment- deposit were exactly like that which occurs in "Addison's disease," as Dr. Parkes very truly observes." We may, therefore, conclude from these examples (and others might be added) that melasma may occur in whites as a permanent coloration of the skin, resembling that of the colored races in all essential particulars ; and although the result of the dis- is not itself a morbid 6tate. Yellow bronzing. 1 have hitherto described more espe- Medical Tiinesand Gazette, Dee. 11th, 1858. L861.] Cutaneous Discolor ations. 467 jially the cases of morbid pigmentation in which the discol- oration was swarthy or dark. In Case III., however, although .warthy on the trunk, it was yellow on the face. As these ?ases of yellow bronzing are little understood, yet more com- non even than the swarthy, the discoloration requires a more particular investigation than it has hitherto had. For example, in all the recorded cases of " Addison's disease," the swarthy tint has, I believe, been exclusively looked for and described, so that examples of supra-renal disease in which the discol- oration was yellow have been recorded as instances in which there was no pigmentation whatever. That yellow discolora- tion of the skin is as possible an occurrence as black discolora- tion in diseases of the white races is clear from the simple tact that the races of mankind of a yellow color, or of yellow shaded with brown, are as numerous as the swarthy or dark races. The complexions of the numerous and widely-spread Mongolian race and of its various offshoots and branches have yellow as a basis. When, however, such yellow tint (known llowness) has been observed in various morbid states as icterus, hepatic and splenic diseases, chlorosis, scrobutus, can- cer, tertiary syphilis, and the like, the change has not been connected with morbid pigment in the epidemic cells, but exclusively with morbid states of the blood. Now, that it is often due to these is certain ; but there are numerous facts which incontrovertibly show that this doctrine is wholly in- sufficient to explain all the phenomena of the discoloration, even in those of a pure case of icterus, when bile can be de- tected in the blood. Before we can form a correct diagnosis in the class of cases in which there is a morbid deposit of a yellow or xanthous pigment analogous to the swarthy, we must examine more carefully the order of the symptoms upon which our diagnosis lid be founded. Ordinary swarthy bronzing (as in " Ad- dison's disease") is easily mistaken for the tint of biliary dis- : by the inexperienced eye; now, the condition of the blood in the vessels is our guide in these cases. If the con- junctiva be white and pearly, the nails white, and the mucous nembranes very pale, it is inferred that the discoloration is ot due to biliary disease, because bile-tinted blood gives a ellowish tint to the conjunctiva, nails, and mucous surfaces. )n the other hand, a careful examination of the discoloration that the color is not in truth that of a diluted bile be- lt too dark, but rather of diluted Indian ink. Cases of me- ns may, however, present this swarthy complexion ; ut for the most part the diagnosis of the tint in " Addison's 468 Cutaneous Discolor utions. [June, disease'' from that of hepatic disease may thus be made. Now, ir is obvious the diagnosis of yellow bronzing must be made on the same principles, but more weight is necessarily given to the pallor of the conjunctiva than in swarthy bronz- ing, and less to the differences of tint, because the sallowness pigmentation differs little from the sallowness of the icteric tint. 1 would not, however, be understood to regard the color of the conjunctiva as an absolute guide in diagnosis, for it is also pigmented in the colored races as well as the skin, and there- fore there may be pigment-deposit in it in disease ; and we have seen that this occurred in Dr. Parkes' case, before quoted. It is not difficult to understand how this may be. The conjunctiva contains all the elements of the skin, for the eye itself, qua development, is a skin product. Hence, not only pigment may be deposited therein, but hairs may grow from it. My friend, Mr. A. M. Edwards, lecturer on surgery in Edinburgh, showed me an interesting illustration of this fact, in a portion of conjunctiva with the hairs attached, which he had removed from the eye of a girl, aged eighteen, in whom the deformity was congenital.* Tnese observations equally apply to the color of the buccal mucous membrane and of the tongue, as both these surfaces are normally the seat of swarthy pigment-deposit in lower animals. It may bo objected, that the presence of bile in the urine, its absence from the faeces, and other circumstances, may serve equalh well, as the color of the surfaces indicated to diagnose morbic pigmentation from biliary blood ; but in practice it happen: that the most difficult cases for diagnosis of this kind are jus those in which there is simply a bilious tint without any im portant or noteworthy change in the secretions. Yellow bronzing may pass into swarthy bronzing, or b conjoined with it in as in Case III., or it may be symmetrica Le Catf quotes cases of this kind from the Journal Encycl pedique, for March, 1744. A man had an apoplectic attad after being x^ry angry, which ended in hemiplegia of til right side ; at the same time this side of the body becarf completely yellow, without excopting the right half of t, nose Another man, addicted to drunkenness, experienced painful feeling of numbness on the right side ; when it pass! .ii account of the case, and reference to others, may he found in : er number (1800) of the Edinburgh Veterinary Review. t Ti ait de In Couleur do hi Peau Humaine, p. 108 et sc 1861.] Cutaneous Disc.olorations. 4G9 off, the face became green, the right side black, the left side yellow. The urine was sometimes black, sometimes green. Having taken salt o\' wormwood (carbonate of potash) for ral days, the color changed, the face and the right side became yellow, the left side black. h\ about twenty days a yellow tint only remained, and this gradually disappeared. These are not, by any means, solitary cases, but it is unneces- sary to multiply examples. The following illustrates yellow bronzing in a case of supra-renal disease, expressly recorded by tW reporter, as being opposed to the conclusions of Dr. Addison : Case Y. Yellow bronzing; disease of supra-renal capsules ; multiple cancer. Leclerc, a laborer, was admitted into the Hospital Beaujon, April 3d, 1S56, under "M. Gubler. His previous history could be ascertained with difficulty on ac- count of his remarkable " insouciance," but two months pre- viously he was attacked with a painful feeling of distension of the abdomen, loss of appetite, occasional vomitings, and habi- tual constipation. He became pale, and thin, and weak, the abdominal pain increased in violence, recurring in paroxysms, and for a fortnight before his admission he had been confined to bed. On his admission, the most striking characteristics were his extreme thinness, and the remarkable pallor of the surface, which also presented in a remarkable degree the yellow straw tint [feinte jaune-paitte) of the " cancerous cachexia." No icterus, the sclerotica being of a very pure white, no trace of bronzed discoloration or vitiligo ; bellows murmur in the neck ; cough, with expectoration of greyish sputa ; abdom- inal symptoms those of cancerous disease ; urine of an ochre yellow, and containing uric acid, no albumen nor sugar. As the disease advanced the yellow tint became deeper and deeper, the epigastric pain more intense and cons! ant, and ex- tending thence to the base of the thorax and the lumbar region. A little to the left, and below the umbilicus, two tumors appeared which were the seat of a powerful impulse and loud murmur. The patient died twenty days after ad- sion. The post-mortem examination showed that, although the liver was very voluminous, and the substance matter hypertro- d, bile had been freely secreted, for there was abundance it in the biliary canals; the gall bladder was large and filled with greenish bile ; and although the common duct was surrounded by cancerous masses, its calibre was rather in- creased than diminished. The stomach, pancreas, and supra- 470 Obscure Trunk Pains. [June renal capsules were the seat of cancer, as were also the mes enteric and dorso-lumbar glands. The spleen healthy and small ; the kidneys large, anaunic, but not cancerous. No examination of the blood. * In this case the post mortem condition of the liver and bile- duct was conclusive as to the correctness of the diagnosis dur- ing life namely, that as the schlerotic was of a pure white, there was no icterus. The yellow bronzing could not be due, therefore, to the presence of bile in the blood, while the ex- treme pallor showed it was not owing to change of color in the blood-corpuscles. Hence the only remaining conclusion that it was caused by pigment-deposit. The examples of yellow bronzing are so common in prac- tice that I need only leave it for further and closer observa- tion, as a true form of morbid pigmentary change. But I may remark, by way of caution, that while the coloring mat- ter of the bile will give a yellow tint, it must not be forgotten that a thin layer of blood corpuscles separated upon the der- ma, will also stimulate yellow bronzing. The most familiar illustration of this is to be found in bruises or in scorbutus ; but it also takes place in yellow fever, and, perhaps, other forms of fever not, however, to the exclusion of biliverdin. Amongst the most interesting forms of morbid pigmentary changes, are those which are associated with emotional states of the nervous system, or with peculiar conditions of the genitory-urinary organs. They may be termed the neutrose forms, but as the entire group requires special and detailed examination, I shall reserve the consideration of it for a separate paper. British and Foreign Medico- Chimrgical Review. [to be concluded in our next.] Obscure Timnk Pains ; or, Chronic Pains in the Abdominal and Thoracic Walls. By James Jago, M. D., Oxon, Prysician to the Cornwall Infirmary. The great multitude of patients who seek advice on ac- count of obstinate pains in the walls of the chest or of the abdomen, and the obscurity that frequently hangs over the M. Ferreol ; Gazette Hebdomaire. August, 185' L] Obscure Trunk Pains. 471 origin of their sufferings, must always claim the indulgence of "the physician for any attempt to throw another ray of light on their modes of production. I shall, therefore, venture a few remarks on the subject, premising that these will be of an elementary character, chiefly aiming to show that the weight of the upper portion of the frame often con- tributes to engender Bufferings in those parts, in ways not commonly suspected ; and that thus there may be simple means at hand of affording relief in cases beyond the reach of drugs. Whilst such is my main purpose, I may be tempted to illustrate the views submitted from collateral sources. It is an old remark* that rheumatism is oftener found associated with the tendinous and aponeurotic continuations muscles, especially at the junctions of these with bone, than with the muscular fibre itself. And Dr. In man, of Liver- pool, has ably maintained"}" that much of the pains expeu- enced in the structures now mentioned are due to a stretch- ing of fibrous tissue by the contraction of muscle, or by its excessive tension produced by any othermeans. He elabor- ately distinguishes between the pains thus engendered in the muscular fibre, as cramp or spasm, and those resulting from strain along the line of osseous attachment, or line of union between the muscular and tendinous fibres. And he insists that in a weakened condition of the animal system the muscles are more liable to cramp than in a robust, and pain more likely to be felt along the said lines of junc- tion. Xow, I have no further exception to" take against this doctrine, but I do not think that it embraces the whole series of such kind of pains as it aims at accounting for. I would affirm rather, in general language, that all the tissues of the body in their several degrees become painful when they are either stretched or compressed ; in other words, that there is a state of equilibrium for the structures throughout the animal frame, which is the only one in which they remain free from pain; that the amount of suf- fering consequent upon the disturbance of this balance of opposing forces depends ordinarily upon the extent of the lacement, or the time during which it is kept up, that *Copel:m are the requisites of such structures. At least. T will give a device for what 1 have concluded to be the best torm of chair as? an example. I will do >o in dimensions to fit the )f a man of middle size. The chair shall he of wood, for if it he easy in hare wood, it cannot fail to be so when cushioned. Let the seat he IS inches from the floor and of the shnpe oi" a semi-circle of a diameter of 21 inches, whoRe straight edge is the front of the seat, and let in, in a sfvle which is common, he scooped towards the back to lit the nates. ain, in the usual style of elbow chairs, let there he a horizontal semic-circular bar for the elbows to rest upon, 11 inches above the seat and of its diameter, and let this elbov - bar he supported on either hand laterally by four or five upright bars with equal intervals. In the middle of the hack let the support for the elbow- arch he a Hat plank of 5J inches' breadth or rather, let two short elbow-bars be let into such a plank rising f om the middle of the posterior border of the seat, to the height of aches, and let this plank be curved to the lateral con- tour of the loins, as may be seen in the cushions of railway carriages. Or in definite measurements let the plank, at vertical heights of 2, 5, 10, 15, 22 inches, be gradually in- clined backwards to the horizontal extent of J, J. 2$, 3J, 4 inches, respectively. Beginning at the top of the plank, let a longitudinal groove be cut afoot down the ante . ior face of the plank, of 1 inch wide .and f inch deep; let its edges be bevelled away, as also other sharp edges of the plank. Below the elbow-arch the plank may be hollowed the in h< rizontal direction to coincide in curvature with the : aeefnl appearance apart, we have here the elements of a comfortable chair. The lower portion of the hick will form a cradle for the pelvis, and prevent its weight from effecting pressure upon higher parts of the trunk; the curved portion rising therefrom will bear up the loins and lower part of the chest. The backpiec e will allow the mid- dle channel of the back to rest against it at any* and even- ts whilst its longitudinal groo\e will afford an escape from pressure for the thinly-covered vertebral spines, leav- ing this to be encountered by the bed of muscle at their a. Then any pressure that might be extended to the ribs would not affect the form of tl owing to the short leverage at the vertebral articulations of the ribs along 486 Obscure Trunk Pains. [June, the channels at the sides of the spine. The shoulders play backwards and forwards without impediment; and since the tmnk preserves its natural form as in a standing posi- tion, the respiratory muscles meet with no hindrance in their oitice. The arms, resting upon the elbow-bars, do not cast their weight on the shoulders, whilst these are steadied. But the combination of contrivances fulfils more recon- dite conditions. Not only do the ribs and abdominal sur- face ebb and flow as we breathe, but the curvature of the spine oscillates in degree. In this oscillation the backpiece allows the vertebral calumn to roll, as it were, along it it is a sort of involute, for the chain of vertebra', as the evo- lnte, to wind and unwind upon. For these reasons I have placed persons suffering from pains about the sternum, which have been acquired by pressure habitually thrown upon the shoulders, to sit against a narrow pillar or vertical plank, as may be met with in pannelling, and the ready ex- pedient has answered my expectations. People do not sit long in one posture, and this chair al- lows a considerable degree of snuffling about the sacrifice of its presumed advantages. If to change the point of chief pressure the nates be slid forwards, the backpiece will take the spine, and chiefly at another spot, so as to relieve the points of pressure along the back also ; and the semi- circular shape of the back-cradle will give the sitter a fitting support for his back, however he leans about. Though it has been laid down as a rule that the shoulders should not rest against any framework, it would not be amiss if there were such a framework forming a portion of a larger circle than the framework described, and crossing the upright bar at the top posteriorly, so that this bar be let into the upmost crosspiecein front, and that it project for an inch beyond it, Thus this extra framework, which may be partially formed by prolongations of the hinder upright bars that support the elbow-arch, would form recesses where the shoulders may be brought to bear a little to steady them laterally, and that they may take a little of the pressure of the trunk at our pleasure. I have given the above description of still-lines for the sake of being explicit and intelligible, but there is no rea- son why elegance should not be realized in the design. The elbows may be curved along their upper margin, the bara replaced by ornamental carvin 2; or wicker-work, the 1861.] Diphtheria. 487 backpiece extended in a curved fashion below, or perfor- ated for ornament, and may be undulating upwards, spread- ing over the top of the shoulders on either hand. Cushioned chairs may be so stuffed as to afford a backpiece as here in- dicated, as well as the transverse projection for the loins as they now commonly have ; and if carried as high as the head, bear a cushion projecting well forwards, to take it, without the neck being unnaturally thrown back. I have thus devoted some attention to the analysis of the conditions essential to comfort in an article in daily use by every healthy person who is not destitute or a bad-liver ; and whatever be thought of these reflections, it will not be gain- said that they treat of questions of concern to the healthy, and of vast interest to a host of invalids. Diphtheria An Unsuccessful Case of Irackeotomy, and a New Method of Treatment, Exemplified by Four Cases. By Jno. O. Brinson, M. D., late Professor of Anatomy in the Xew York Medical College. The many methods which have been followed in the treat- ment of the disease under consideration seem, as far as my observation leads me, to be possessed of no very distin- guishing characteristics one over another. The one prevailing idea is, the evident prostration and the seemingly i; tonic course to be pursued. The results which have followed my efforts in the treatment of the disease, governed by this idea, have been so unsatisfac- tory, that I have been led to mark out and pursue an entire- ly opposite course. In the case first mentioned, and in which tracheotomy was performed, the tonic course was pursued, and, as in nearly all previous cases, without a fa- vorable result. Ca-e A. Tracheotomy Performed. On Sunday, Decem- 23d, 1SG0, I was called to see one Daniel Ilorgan, set. 4 years and 7 months. He had been ailing for about a week, though running about until the day previous to the sum- mons. He had had a cold, and complained of a sore throat, ior which his mother had given usual domestic remedies, without any good effect. She therefore sought advice. The little fellow was suffering with an inflammation of the mucous membrane of the pharynx and larynx. Diph- 488 Diphtheria. [June, theritie patches were developed upon the tonsils and on the posterior wall of the pharynx. Prostration severe. Pulse 126. I prescribed tinct. ferri mur. and quinia} sulph. To the inflamed parts argent, nitras., in solution, was applied. On the following day, the little patient was not less pros- trated. The diphtheritic exudation had extended but little, if any. The treatment was continued, and wine whey or- dered. 25ih (Christmas Day.) Called at 8 A. M., in response to renewea summons. Patient much worse. Prostration ex- treme. Great obstruction to the respiration. Fauces com- pletely lined with exudation, which had undoubtedly ex- tended into, and perhaps beyond, the larynx. Pulse 146. Believing my only hope to be in tracheotomy, I proposed the operation, which was acceded to by the mother. Having obtained assistance, at ten and a half o'clock I again visited the patient, prepared to operate. The lips and countenance of the little patient, by their livid hue, beto- kened early suffocation. Assisted by Messrs. J. E. Steele and F. G. Sanley, medical students, I performed the opera- tion speedily, with but trifling loss of blood, and with im- mediate relief to the patient. A considerable quantity of false membrane found exit through the wound, and after the introduction of the tube, the child soon began to rally, and seemed better than for two days previous. Potass, chloras, quinia* sulph., and brandy were prescrib- ed. At 3, and again at 9 o'clock, observations were taken, and he had improved. Respiration easy. Expectoration of tenacious mucus very considerable. Pulse 130. 26th Morning. Slept well most of the night. Respira- tion free. Expectoration as the day previous. Pulse 126. The treatment continued. Evening Condition generally as in the morning. Ex- pectoration, however, diminished. Pulse 130. 27th Morning. Expectoration much diminished. Res- piration labored. Symptoms like those present previous to the operation appearing; pulse 140. It is evident that ex- udation has produced the fatal membrane in the bronchial tubes. Evening. Further efforts deemed unavailing. 28M,. Died at 5 a. m. Examination fourteen hours post-mortem. Rigor mortis complete. In laying open the thorax, the lungs did not collapse; pulmonary emphysema general. Larynx, and 1861.] Diphtheria. 489 portion of the trachea above the point of entrance in the operation, completely filled with false membrane. The por- tion of trachea below the above-mentioned point exhibited an ulcerated condition. The bronchial tubes, as far as into the fourth bifurcation, were lined with the characteristic exudation, at many points to the extent of entirely closing the canals. Upon making examination of the wound, there appeared to be no secondary exudation. Case B. Adult. On the second day of January, 1861, I was called to see Mrs. C, a native of this city, set oO. She had been sick for several days, and was getting worse. She was of a weak habit. I found her with a flushed face, hot skin, sore throat, and anxious expression; pulse 145. An examination of her fauces evinced the presence of diphthe- ritic membrane on both tonsils, and on the palate. Having concluded previously to institute a new method of treatment upon the presentation of the next case of the disease, I prescribed as follows : R. Tinct. aconit. rad., 5ss. Aquae pura?, giv. M. Sig. Cochl. parv. quaque hora sumendufc. R. Ammoniac mur., 5ij- Aquse pur., 5yj. M. Sig. Garg. quaque duo horis utenda. On the 3d, I found the patient improved to this extent skin cool, pain much diminished, deglutition much easier; pulse 120. Treatment continued. On the 4th, still more improved; pain but slight, skin natural. One small spot of exudation three-eighths of an inch in diameter present in the faucus; pulse 98. Treat- ment continued. On the 5th, throat clean. Inflammation entirely gone. Aconite to be taken only once every three hours; the gar- gle as before, every two hours ; pulse but 80. On the 6th, the condition of the patient such, that tonics and stimulants could be used with hopes of success. I therefore prescribed as follows: R. Quinia! sulph., >)j. Fern Sulph.. vij. Ext. nucis vom., gr. vj. M. In pil. xx. div. Sig. L'nam ter in die capiat. Wine whey, and such articles of solid fond as desired, ordered to be taken. 490 Diphtheria. [June, From this time onward, everything progressed most sat- isfactorily, and the patient was discharged in a few days. Case C. Adult. On the 17th of January, but a few days subsequent to the preceding case, I was called to sec Mrs. P., also a native of this city, set. 58. The condition ol the patient was very similar to the condition of the previ- ously cited case. She had not been so long sick, and ] found the diphtheritic exudation on the left tonsil to be less dense than elsewhere. It presented the appearance of a frosted spider's web, and seemingly was more tenacious than that fully formed. The prescription was identical with that used in the pre-' ceding case, and the result was even more perceptible. . In thirty-six hours the membrane had entirely disappeared. The pain, which at first was present in the throat, was ban- ished at an earlier period than in case B. The after-treat ment was identical in character and in result. Case D. Infant. On the sixth of February, 1861, 1 was: summoned to the bedside of a little girl, the daughter o:1 Mrs. D. The condition of the child was very similar tc Case A, but with less laryngities ; pulse 150. Hoping t( meet with like effects from the use of the same remedies used in Cases B and C, 1 prescribed the aconite, with thu modification: (the patient was but three years and sii months old, and consequently could but receive a propor tionate dose of the aconite, with any hope of success.) R. Tinct. aconit. rad., gtt. vj. Aquae, ojv. M. Sig. Cochl. parv. quaque hora capiat. The gargle was used as a lotion, by means of a probong not diluted. On the 7th, a great part of the exudation had disappear ed from the fauces. The pulse of the patient had diminish ed to 105, and in every other respect improvement was evi dent. On the 8th, the pulse had come down to 90, and tin throat was perfectly clean. A diminution of all the symp toms was present, and everything betokened a result simi lar to the preceding cases. With wine whey only as a ton ic, I was pleased to find the little patient put on its wontec strength, and assume its former health. Case E. Adult. I mention this case because it resem L861.] 491 les the cj ses marked B and C, in respect to time and the Bsappearance of the exudation. On the first of March 1 was called to young lady, et. 20, a native of France, having been in this country about ighteeu months. The genera] condition of the patient was nore extreme than that of the aforementioned cases. Skin lot, dry, and flushed: throat swollen and painful; diphthe- ritic exudation present on both tonsils, and on posterior vail of pharynx. Pulse 153. I considered the aggravation of the symptoms attributa- ble to the torpid condition of her bowels, which had exist- r some time. I prescribed ten grains of blue mass to 3e given at once, and followed in eight hours by six ounces )f tiie solution of the citrate of magnesia. As soon as the xnvels were freely emptied, the same remedies prescribed n case B were ordered. In thirty-six hours the patient's ondition was such that I felt that the remedies were almost pecitic. In forty-eight hours all exudation had disappear- d from the fauces, and the pulse, from 153, had come down '. All pain had left the throat, and one small spot lone showed signs of inflammation. On this spot I applied i piece of the sulphate of copper, simply as a stimulant. t was probably not necessary. On the following day all symptoms of anything like disease were gone. I prescribed as follows, the patient seemingly having a sufficiency of iron in her system. K. Quinifie sulph., Zinci valerianate 3j. Ext. nucis vom., gr. yj. Aloes socot., gr. v. M. In pil. xxiv. div. Big. Unam term die capiat. iVine at dinner made up the complement of directions, and q three days' time all evidences of disease or debility had lisappeared. It would afford me much pleasure to have introduced a arger experience in the treatment of infants after this mode, ret I believe that the early and agreeable change which i followed in the one be adult A iase-. is evidence of almost a uniform result. We arc all prell aware that the system bears up better under, and re- lets quicker from, a condition of depression, than of ex- citement. I deem the constitution of children poorly pre- ared to bear the stimulus and tonic remedi< ivad- 492 Diphtheria. [June ministered in the treatment of diphtheria, and if called ui on to give testimony in reference to the matter, I shoulc from my convictions, be obliged to say, that I believe man succumb to treatment rather than to disease. The following summary of experience on Diphtheria, w find in the valuable Monthly collection Dr. O. C. Gibbs, o Frew sburg, New York : Diphtheria. In the Boston Medical and Surgical Journal for Januar; 24th, Dr. L. H. Angell has an article upon this subject. W make one quotation only. "Tonics and the preparations c chlorine are indicated to arrest the febrile paroxysm, and consequently, the formation of false membrane. I have prir cipally relied upon quinine and the chlorine mixture, an have not been disappointed in a single instance." In the Cincinnati Medical and Surgical News for January Dr. W. H. Matchett, of Ohio, has an article upon this subjec; As Dr. Matchett's treatment differs somewhat from that w have previously seen recommended, we shall attempt a synop sis of it. After moving the bowels, he trusts the case, so fa as internal remedies are are concerned, to quinine and iodid f potassium, both in tolerably full doses, and frequently re peated. In addition, he adds a generous diet. As loca means, he recommends a gargle of pepper, salt, and vinegar This is also applied by means of a swab, and then the parti are dusted with finely-pulverized borax ; these local mean are frequently repeated. A tar plaster is applied to the neck Unlike Dr. Calhoun, of Georgia, referred to last month, In does not ascribe the cure to the tar plaster, but to the quinine iodide of potassium, and nourishing diet. He does not ap prove of the frequent application of nitrate of silver to the di seased parts. He says: "The frequency with which the soli" tion of nit. arg., of the strength of 20 grains to the 5, is use by some physicians, is, of itself sufficient to produce seriou difficulty." Partial paralysis, after diphtheria, is not a very uncommoi affection. In such cases, Prof. Pepper, of the University o Pennsylvania, makes the following prescription: "K. Extract of St. Ignatius' bean, 8 grains. Sulphate of quinia, 30 grains. Yallett's mass, one drachm. M. hi.] Diphtheria. 493 be made into 30 pills, of which one is to be given 3 times after meals. At the same time electricity is to be ap- ied to the throat." In the Chicago Medical Examiner, for Januaiy, Dr. T. J. 'earce has an article upon diphtheria. lie has but little con- idence in topical treatment : UI think the too frequent swah- hng has been in many cases a fruitful source of mischief." Be does not object to gargles. "As an external application, Ken there is oedema or enlargement of the parotid or cervi- |al glands, I have found nothing better than the free use of dine. .V domestic poultice of equal parts of tar and pheal bran may often prove serviceable." He, however, llaces greatest- reliance upon general remedies : "We know of lo course better than the free use of chlorate of potash, mur. pet. ferri, and sul. quinia. The mur. tinct, ferri, I think, is fenerally given too sparingly." When emetics are needed, e recommends sulphate of copper, or, in croupal cases, sul- haie of iron. As a gargle, he prefers the sulphate of copper ,ri solution. The Special Committee of the Xew Jersey State Medical Society, as per report in the Jledical and Surgical Reporter lr January 2Gth, recommend the following, which does not tfier from that usually relied upon : "The tinct. ferri sesqui- lloridi, ten to fifteen drops, in water, every three or four .Jours, with chlor. potassce and quinia, and brandy with milk, Jiloric ether. .. are the articles chieily recommended." Ts a local application, a solution ot nitrate of silver is pre- irred. 1 Before the Paris, 111., yEsculapian Society, at a recent i|ieering, the subject of diphtheria was under discussion. r. Chambers reiied upon chlorate of potask, and large doses ' quinine, with the local use of nitrate of silver, "gr. 60, the ounce of water." Dr. Tenbrook relied upon stimu- nd tonics, and the solid nitrate of silver locally. Prof. . S. Davis prefers the tincture of iodine, as a local applica- >n, believing it will stop the spread of* the disease from the roat to contiguous parts. We quote from a report in the iner, for January, the remarks of Dr. York : "Emetics should he used continuously ; of these alum, one teaspoonful every twenty minutes un- l vomiting. Avoid the too frequent application of caus- es to th :'/ it produces mischievous irritation; not tenen than once every day, or every other day. When the has extended into the larynx and trachea, stop the cal application of tincture of iodine, or nitrate of silver, 494 Surgical Miscellanies. [June, (we should have observed that lie prefers the tinct. of iodine.) It is then a useless annoyance. A vast majority of cases die in which there is complete aphonia known of only four recoveries from this condition. Here I give quinine very freely, with Dover's powder." We have thus endeavored to give a summary of the prac- tical portion of the papers, upon the above subject, that have come under observation in the journals of January. If any papers have been overlooked, their respective authors will please excuse us. Surgical Miscellanies. By Furneaux Jorday, Assistant-Sur- geon to the Queen's Hospital, Consulting Surgeon to the Birmingham Eye and Ear Dispensary, and Professor of Anatomy at Queen's College. I. An undescribed Affection of the Leg. During the last six years I have seen a few cases of a peculiar affection of the leg, any description of which lam unable to find in sur- gical literature. The cases to which I allude are undoubt- edly rare less rare, however, I think, than many surgical diseases of which we are supposed to possess an extended knowledge. It is my intention, in these miscellaneous sur- gical notes, to avoid the record of individual cases, and state merely the conclusions which they have led me to form. Let the reader test such conclusions by his own ex- perience by his own recorded and remembered cases. The disease to which I refer exists in two varieties, which may occur separately or together. In the first there is a convex enlargement or collar completely surrounding the lower part of the leg immediately above the malleoli. The second form is more common and less peculiar; it consists in a slightly irregular, rounded, or hemispherical projection seated below and behind the malleolus. The relative fre- quency of the two affections may be stated as follows: little frequent is that below and behind the outer ankle; less fre- quent is the combination of the two; least frequent is that around the tibia and fibula. The rarest form of the disease, and the most characteris- tic is a soft, elastic enlargement, occupying the entire cir- cumference of the leg. its size and shape are the same at the inner, outer, anterior, and posterior aspects. The ver- tical measurement of the collar is about three inches. Its 18G1.] Uawes. greatest thickness (an inch and a half) Is at the centre. The margins are thinner, bnt do not become imperceptibly lost in the parts above or below. The lower portions of the malleoli are not involved. At no period in the formation of the growth is there doughiness, or pitting, or pain, or tenderness, or intcgumental discoloration. Indeed, the skin is throughout perfectly healthy. The bones of the leg are not altered in size. The formation appears to be grad- ual, and unattended by noticeable constitutional phenome- na. The word k' noticeable " is nsed designedly, because the general health is certainly not good, and there are indi- cations of cardiac or circulatory derangement in greater or less degree. In the most typical case I have seen there was marked mitral regurgitation, but there was no history of acute rheumatism or any other acute disease. All the cases were in young, adult, unmarried, and childless women. In asking what the aiiection is, let us first ascertain what it is not. It is not elephantiasis arabicum; elephantiasis has a gieatiy thickened, hard, rough, nodulated, darkly colored, and partially insensible skin. The bones, areolar tissue, fat, and other structures (muscles excepted), share in the enlargement. The toes and feet are implicated, and severe pain is usually present. It is not a cutaneous outgrowth; in the cutaneous out- _ vth, as Mr. Paget remarks, all the tissues take part, and the proper tissue and appended organs of the cutis are near- ly as much exaggerated as the fibro-cellular substance. Fibro-cellular outgrowths, moreover, are usually peduculat- ed and attached to the parts in the vicinity of the vagina and rectum. It is not a fibro-cellular tumour at least if we use this term in its strict meaning for, independently of the cir- cumstance that the fibro-cellular tumour resembles in its sites the cutaneous outgrowth, the enlargement I am at- tempting to describe certainly could not be separated or enucleated from the neighbouring tissues. Erythema nodosum sometimes leaves irregular bulky masses on the leg, but its history is unmistakeable, and the enlargements which it leaves have no uniformity of config- uration or locality. The term phlegmasia alba dolens has an accuracy and significance of meaning which render any observations on white leg a superfluous task. That the enlargements in question are fibro-cellular in structure I think there can be little doubt, though differing 49G Surgical Miscellanies. [June? essentially from the cutaneous outgrowth and flbro-cellular tumour. There is probably as little doubt that one of the two following causes operates in their development. Eith- er (1) there is a peculiar fibrinous oedema arising from ex- treme obstruction (cardiac or other), of an extent so limited and a duration so temporary as to permit of the organiza- tion of the effused plastic material, or (2) there is inflamma- tion which is neither acute, nor obvious, nor lasting. The inflammatory phenomena, however, do not disappear until plastic lymph has been effused in a locality and under cir- cumstances favourable to organic development. The sec- ond causal agency appears to me the more probable. In dropsy, local or general, serum without fibrine is usually, and always at first, effused. In extreme obstruction, such as to involve exudation of fibrine, the large quantity of at- tendant serum would have a historical value too great to escape detection. But indeed fibrinous dropsy in the low- er extremity, with or without general anaserca and grave constitutional ailment, is altogether improbable. In the hydrops fibrinosus of Yogel, where the fibrine was noticed in the abdominal cavity, serious disease was certainly present. If, then, immediately above the malleoli, or beneath the outer one ? Why in those localities particularly should the inflammatory product be more susceptible of organization, and less amenable to absorption than elsewhere ? Probably from some evanescent and slight cardiac ailment, endocar- dial, or pericardial, or, which is more probable, from a tem- porary aggravation of a chronic disease, obstruction occurs in the venous system. This, for many reasous, is chiefly evident in the lower extremities. The internal and exter- nal saphenous trunks, and the network of veins which con- nects them around the lower part of the leg, are plugged with coagula, which subsequently acting as foreign bodies, cause a certain degree of inflammation attended with effu- sion of plastic lymph. The inflammation terminating quick- ly, permits the lymph to organize, probably by nucleated blastema, as in the repair of subcutaneous wounds. Xow, if the obstruction should be more permanent, or the inflam- mation more severe, we should have not development, but disintegration, in the form of ulceration, varicose or other- wise. It is possible that the inflammation may be confined to the radicles and the commencement of the external saph- enous \ "in. which runs behind the outer ankle without any 1861.] Surgical Miscellanies. 407 muscular support, and which, as wo shall presently Bee, may explain the Becond form of enlargement under considera- tion. The obstruction and coagulation of blood in the veins mnionly attributed to the hydrostatic pressure in a long column of blood, as that in the internal saphenous vein. Aparr from the fact that this hypothesis does not explain the lesion in the external saphenous vein and its radicles, it appears to me that a better explanation can be found, and that the anatomist can more easily discover it than the me- chanical philosopher. There is ample proof that muscular eontraction plays an important part in assisting the flow of blood in the veins. It is a remarkable fact that such assis- tance is almost entirely absent in the lower third of the leg and below the outer ankle. Tendons have not the slight- ontractile, and therefore no expansive power. In the lower part of the leg we find (for very good reasons too) ten- dons only. The tendons of the deeper layer of muscles at the back of the leg have muscular fibres joining them at a lower level than is the case in the superficial layer, but they are so tightly held down to the tibia and fibula by the deep fascia as to exercise no influence on the superficial veins by their contraction. Further, on each side of the tendo Achillis there are large spaces filled with loose areolar and adipose tissue, which afford the most favourable opportuni- ties f>r the inaction and dilatation of veins. In exceptional -. I may parenthetically remark, the soleus muscles send muscular fibres to the under aspect of the tendo Achillis al- most to its insertion. Such cases we may reasonably infer would be little liable to varicose or indolent ucler, still less to the peculiar enlargements under consideration. Again, a third of the tibia is subcutaneous, and the veins (the in- ternal saphenous especially) can receive no pressure from BO passive an agent. Thus, then, many circumstances con- spire to show how a lesion affecting the venous system is prone to show itself in the snpra-malleolar region and below the outer ankle. In the latter spot the external sophenous vein lies on the flat calcaneum, totally unassisted by mus- cular action. It is true that the two peroneal tendons run obliquely across the outer and anterior part of the oa calcis, but they have not the least influence in compressing the veil I have reason to think that the enlargement which I have scribed as Beated below the outer ankle has been \'\-( quent- ]y, though vaguely, referred to synevial distension of the 498 Surgical Miscellanies. [June, peroneal sheaths. On the super-mall eolar form of the di- sease I have never known an opinion given. If it be granted that I have shown sufficient grounds for the dilatation and inflammation of certain veins, with the possibility of an exudation of plastic lymph that shall, un- der certain circumstances, be capable or organization the circumstances, however, being so rare and so peculiar, that varicose and indolent ulcers must always be more common diseases than the one which forms the subject of these ob- servations it will also be granted, the lymph having been exuded, and the inflammation and other circumstances un- favorable to organization having disappeared, that the same agencies which operate against the flow of blood in the veins will operate also against the absorption of the lymph which is deposited in the areolar tissue at the lower part of the leg. Here, then, there is none of that muscular pres- sure which elsewhere is a most effective agent in the ab- sorption of inflammatory exudation. It is not improbable that the fluid exuded by the inflam- matory process should escape notice, because the so-called serum of inflammation is really liquor sanguinis, containing all the material requisite for coagulation and organization. Probably, too, the enlargements do not result from a single pathological process, but from a series, each in itself slight, painless, and unobserved. I have indirectly referred to a new pathology for indolent and varicose ulcers. At another time I hope to fill up the outline, and suggest a treatment which is more analogous to muscular pressure than any now in use, and which I have adopted in practice with great success. II. A Node on the Patella. In the 'Edinburg Medical Journal,' in 1857, I described a case of bubo occurring with- in the abdominal cavity. Last year another singular form of constitutional syphilis came under my care. A hard, in- dolent, partially tender, and nocturnally painful swelling formed on the patella. This, after a lengthened period, suppurated. A practitioner, under the impression that it was an in flamed bursa, passed a seton through it. Inveter- ate, though varying suppuration, and short, irregular sinu- ses in the superjacent tissues, followed for upwards of two years. The knee-joint was not affected, but the patella was much enlarged, and its range of motion greatly diminished. The tendon of the extensor of the thigh covers very closely the anterior surface of the patella, and presents certain an- 1.] Whiskey as a ProphylaUc in Typhoid Fever. 49(J alogies to the relation of the occipito-frontalis muscle to the cranial bones, which are so obnoxious to syphilitic disease. III. A Proposition for the Treatment of Aneurismal Yarix. The rarity, in late times, of cases of aneurismal varix must be my apology tor proposing a method of treatment before 1 have had an oppotunity of practically testing its utility. It is common to do nothing in these cases unless the symp- toms are very severe, when a ligature is applied above and below the wound in the artery. It appears to me that, in a large number of cases, especially in the extremities, very -iderable, if not complete,' relief might be afforded by on of the vein, above and below its communication with the artery, by means of a needle and twisted suture, - mie other method, as in an ordinary (and widely differ- ent) varicose vein ; perhaps in some cases a needle might - ed with advantage under the contiguous artery for a short time, as in the acupressure method of Professor Simpson. If the practicability of the principle be granted, the method of applying it admits of great variety to meet the requirements of individual cases. J J hiskey as a ProphylaUc in Typhoid Fear. By Hugh Kellv, M. D., of Iredell county, X. C. The above announcement may excite surprise, increduli- sgust in some; but all should, however, suspend their -vment until they have had an opportunity to test it ful- ly. I by no means advocate the regular or even the occa- : ardent spirits as a beverage by persona in health, for I hold that spirituous liquors arc in their proper sphere only, when used and prescribed as medicines. Consequent- ly, persons in health should not indulge, for by so doing, they tax their systems beyond what they have a right to do. Very frequently the stomach, lungs and kidneys are over worked to dispose of what is not at all congenial to health, and particularly to the natural functions of those organs. What a very short period elapses betwixt the reception into the stomach of a portion of spirits, and efforts for relief thn and kidneys, rendering it very evident that it is an intruder, all the energies of the system being called upon to dispose of this unwel sow In tin- spring and summer of 1847, there w as a great deal of typhoidlfever in the neighborhood of Gold Hill (then a 500 Whiskey as a Prophyhtic in Typhoid Fever. [June, village containing a population of some eight or nine hun- dred inhabitants, white and black.) The fever made its appearance in the latter part of April, was of a very grave type, and was quite fatal among the blacks. The appoint- ment of a nurse was almost equal to passing sentence of death on the one so appointed. Some four or live of them died. The whites suffered very much also, and a number of fatal cases occurred. In one instance, where some sixty or more negroes were employed by Barnhart Manney & Co., the number of sick was between thirty-five and forty; and, in fact, all seemed to be dispirited and languid. Nurse af- ter nurse dying, I feared that all might in a very short time be confined to bed, whites as well as blacks. A short time previous to this, I had read the history of typhoid fever in an Irish Hospital, that had continued for some time, prov- ing very fatal to nurses and physicians, and making it dif- ficult to get those who were willing to take the places made vacant by diseases. Only two or three nurses of the origi- nal corps were left, and not one physician. One of the new- ly appointed doctors, enquired of those nurses how they managed to keep clear of the fever, theii answer was that they took their whiskey three times a day, and plenty of it; hence they did not fear the fever at all. The physician act- ing upon this hint had all the nurses and doctors belonging to the house to commence the use of whiskey, and he re- ported that from that time no new case occurred in the house. Finding myself to be similarly situated, I ultimate- ly prevailed upon the company (all being temperance men) to try whiskey, by giving from half gill to a gill three times a day for an adult, and to children in proportion. I was much gratified at the happy change effected. From the day they began to give the hands, both white and black, their allowance of whiskey, not a single new case occurred, and the fever subsided in some two or three weeks, and all were up again. ! was so much pleased with this result, that I determined to try it further, and did adopt it in all the families to which I was called, where they had fever of this type, from this time, July 47, up to the time of my removal, December 54. In not one single instance did a new case occur, during that period, alter the family (I mean those that were able to be up.) had commenced the use of this remedy. Since my residence in Iredell, I have pursued this same course and with the same success. Some persons in this section of 1861.] Varicose Veins. 501 country would not make a trial of this preventative, and all or nearly all of their families were sufferers. A trial was made in this neighborhood last summer, which resulted as all the rest had done. Col. A. has a large number of ne- ts who had the fever among them in June last. It was of a malignant type, and after some three or four deaths, he procured a barrel of whiskey and commenced giving it as heretofore directed. The result was that not another case occurred on his farm. Its modus opierandi in preventing this fever, I leave for others to examine; that it is a preven- tive, I am fully satisfied from an experience of thirteen years. When called to attend on cases of this fever, I advise all the family that are on foot to use this preventive, and to con- tinue its use for sometime, at least until the sick are out and able to take exercise; or for two weeks at least after the fe- ver subsides in the family. In many instances where sever- al members of the same family were attacked at or about the same time, I have seen the remaining members of the household adopt this prophylactic, and continue to watch and nurse for several weeks in succession without one of them taking the fever, which fulty sustains the opinion formed of this agent. I suggest to all who nurse typhoid cases to use this medicine, as constant exposure to the fever, but for a very few days, may bring on an attack. That ty- phoid fever is contagious to a certain extent I presume none will doubt. Remarks on Dr. Levis Application of (he Jletalic Ligature to the Cure of Varicose Veins, with Report of 1 wo Cases. By J. M. Boisnot, M. D., of Philadelphia. It is more with the object of contributing something that may substantiate an operation that the reaeers of the Re- porter are already acquainted with, than to advance any- thing new, that the following remarks are submitted. The number of cases of varix existing, and the previous want of an operation to safely effect a radical cure, make a method likely to be followed by success, and especially one that has simplicity and freedom from danger to recommend it, of great importance. Yarix depends for its existence upon two principal causes an imperfect condition of the veins themselves, and any- thing retarding the return of the blood through them; the 502 Varicose Veins. [June, first being* clue both to constitutional and local causes ; the second mainly to mechanical. To be more explicit: in a person where the return of the circulation is unequal to the distribution, we have a cause acting upon the veins that will be followed by distention, not only in the main trunks, but also in the branches. Imperfection in the valves is what I refer to as local, and pressure the mechanical cause. Varix of the lower extremities is essentially a disease of the saphena interna; the continuous length and superficial; po- sition of this vein explain, in a measure, why this is so. A derangement of the circulation must first affect the main trunk; afterward the confluent branches. Independ- ently of the cause, therefore, we say, as it is the saphena in- terna that first suffers so must it first be treated. The veins in this disease may be compared to streams which, under ordinary circumstances, are able to drain perfectly the ad- joining land; but, hen unusually filled, suffer, not only in themselves, but by communicating the force of the flood to tributary branches, damage contiguous parts also. To ac- complish the desired end, therefore, we must force the cur- rent in a different direction, and away from the suffering parts; this the operation under consideration does most ef- fectually; and, as it is simple and productive of little or no subsequent irritation, we see no reason why it should not meet with general approbation. The success of the operation so far has been such as to leave no doubt of its efficiency, while its simplicity and free- dom from danger tend strongly to recommend it. Subse- quent irritation and inflammation seem to have been the principal sources of objection to previous operations, but this is overcome by the fact that silver wire is unirritating, and subcutaneous operations, generally, do not produce in- flammation. Nearly all the operations heretofore advised for the cure of varix have been opposed, or reluctantly performed, on account of their liability to produce fatal inflammation, and yet the idea that a certain amount of inflammation was in- dispensable to effect a cure has been embodied in all of them. Xow, it is this that is avoided by the operation un- der consideration, and yet the desired end attained, viz : obliteration of the veins ; and this we maintain is accomplish- ed, not by inflammation, but in the same manner that the umbilical vein and ductus venosus, deprived of their circu- lating current, become reduced to fibrous cords. 1861.] Varicose V< W3 Case 1. Mrs. 1\.. 8Bt 42, came under my care in the au- tumn of 1859. She was Buffering from a varicose condition of the veins oi the right leg, and an under near the exter- nal malleolus of the same. This condition had existed near- ly three years, the varix having formed during a twin preg- nancy, and the ulcer originated from a burs ted vein. From the first she had been under medical treatment, but no operation had been performed. The usual palliative measures had been employed with the usual success. I relied upon strips of adhesive plaster as the best means for exerting a constant and uniform pressure upon the part. The subcutaneous application of the metallic ligature had not been advised. As soon as I was informed of this oper- ation I resolved to try it upon the case under consideration. In Xovember last I placed a silver ligature upon the saphe- na interna, about three inches below the knee joint, and one upon the tributary branch, midway between the knee and ankle joints, in accordance with the directions already given in this journal. Xo dressing was applied to the ulcer, excepting dry lint, and at no time were the wires interfer- ed with until their removal at the time of cure, which was seven weeks from the time of operating. Case 2. AVilliam G., t 63, called me to attend him Xovember Oth, 1860. He was confined to bed by a very large ulcer, situated just above the internal malleolus of the right leg, dependent upon varicose veins. I was in- formed that the ulcer had existed since 1824, and had never been entirely healed from that date, being a duration of thirty-six years. He was feeble, anemic, and unable to go about, excepting from one room to another by the aid of crutches. The ulcer discharged a very offensive, ichorous pus, and presented an extremely indolent appearance and no disposition to heal. He had been under the care of physi- cians and surgeons of eminence, both in this city and New York, without material benefit to either the ulcer or the veins, although the latter had been subjected to the much lauded caustic treatment. I propose the operation of subcutaneous ligation, but was not allowed to perlorm it before the 28th of Xovember. The points of ligation were the same as in the previous case, the ends of the wire were covered by strips of adhesive plas- ter, a compress of dry, soft muslin was placed over the ul- cer, and a roller applied from the toes to the knee. The bandage was removed every two or three days for the first 504 Compound Fracture. [June, two weeks after the operation, and the ulcer washed with soaj) and water. This constituted the whole of the local treatment. Constitutionally he received a nourishing diet, with quinia and iron. The irritation from the wire was at no time sufficient to produce more than slight redness at the point of entrance and exit. On the forty-sixth day af- ter the operation, finding the veins, where ligated, quite solidified, and the ulcer entirely healed, I untwisted the wires and withdrew them. The cure seems perfect, and, at the present time, he is able to go about free from lame- ness and in good health. Medical $ Surgical Reporter. Compound Fracture. A Paper by Mr. Byrant, F. R. C. B. Having recognized the fact that the science of Medicine and Surgery was one purely of observation, and that its principles and practice could only be regarded as sound so long as they were based on facts, the result of recorded and carefully-observed phenomena, the author went on to state that he believed it to be the duty of every practitioner to communicate to his professional brethren any positive ma- terial he may possess, and thus to add his quota in building up the noble art and science to which we have the honor to belong. Jn conformity with such a principle he had the pleasure of presenting to the Society a brief analj'sis of up- wards of 300 cases of compound fracture of the extremities omitting only those minor examples in which the smaller bones of the hands and feet were involved, believing that the results educed were not unfruitful either of interest or instruction. The eases were all taken from the experience of Guy's Hospital within the last twenty years, the earlier ones having been collected from the records of the institu- tion, and the author's own notes having furnished him with the particulars of every case -admitted within its Avails during the last seven years. He then proceeded to the analysis of the whole number 802 eases: IT or 5-6 per cent, were of the thigh. 198 or G3-9 " " leg. 35 or 11-:. arm. 57 or 18 -8 ' " forearm. I 1 out of the 17 eases of compound fracture of the thigh 1861.] Compound Fracture. f>05 proved fatal, or 64-7 percent. 74 oi>t of 193 examples of compound fracture of the leg were fatal, or 38-3 per cent. 4 out of the 85 cases of compound fracture of the arm died, or 11-4 per cent. Ami 7 or 22-2 per cent, of the 57 cases of compound fracture oif the forearm. Of the whole num- ber, 96 were fatal, or 31-7 per cent. A table then followed showing the causes of death in these 96 cases, from which it appeared that in cases subjected to amputation pyaemia was twice as fatal as in others treated on conservative prin- ciples, and that exhaustion and gangrene were more com- mon causes of death : that in cases treated on ordinary sur- gical conservative principles delirium tremens and tetanus were more common causes of a fatal result. Analysing the 17 examples of compound fracture of the thigh 9 under- went primary amputation ; 6 died and 3 recovered. 1 un- derwent secondary primary amputation ; fatal. 7 were treated on conservative principles ; 4 died, and 3 recovered. 10 were thus treated by amputation, and 7 of these died, or 70 per cent. 7 were left to Nature's efforts for repair, and of these 4 died, or 57 per cent. Having given an out- line of the fatal cases, the author went on to remark, first, on the rarity of compound fracture of the thigh, the acci- dent bearing the proportion only of 5-6 per cent, to the other cases involving the larger bones of the extremities. This fact, he stated, was well borne out by the experience of all surgeons. The excessive mortality of these cases was the second point to which he alluded, (J4 per cent, of the whole number of cases proving fatal. In nearly 60 per cent, amputation was had recourse to, and 70 per cent, of these cases subsequently sank. The extreme severity of the majority of these cases, he remarked, rendered primary amputation absolutely essential, lie showed that more than halt' the examples died, or 57 per cent., in which at- tempts had been made to save the limb; and that in cases in which recovery had taken place were in young and healthy subjects. The author passed on to review the opinions of some military surgeons on the subject, and pointed out how Dupuytren, Ilennen, Larrey, Guthrie, and LI agreed that in compound fracture of the thigh Irom gunshot wounds, " in rejecting amputation, we lose more lives than limbs;" and also, "that in the ex- ceptional cases, which result in consolidation, the condition of the limb i> not encouraging.'' lie quoted Macleod's Crimean experie indicating the same opinion, this 506 Compound Fracture. [Juue, surgeon advising amputation in all such cases when taking place in the middle and lower third of the thigh, and hesi- tating only in a like recommendation in cases of fracture of the upper third, on account of the extreme mortality of such amputations. Malgaigne's and Bauden's experience was then quoted to prove the poor success of conservative treat- ment in these injuries, the latter surgeon saving 2 out of 25 cases, and these two retained useless and deformed limhs. The author then went on to say that the experi- ence of civil surgeons was not unlike that of their military brethren, although it was much more limited ; and ex- pressed an opinion, which he believed to be generally en- tertained, that a satisfactory result can rarelv be obtained by conservative treatment, except in the most favorable cases that is, when the subjects are young and the frac- ture uncomplicated ; when the soft parts are not materially damaged nor the bone comminuted. When the bone was comminuted and the soft parts seriously involved (such a condition being generally produced by local mechanical violence), he believed that a satisfactory termination of the case must be regarded with doubt. If the patient should be old or unhealthy, amputation should be at once per. formed ; and if there should be a doubt as to which line of treatment to adopt, the safest is to decide on amputation. But if the subject should be a young and healthy one, and not subjected to injurious hygenic influences, the author believed that a satisfactory termination might be obtained by removing at once the broken and disconnected frag- ments of bone (enlarging the wound if necessary), and by maintaining the absolute repose which is so essential. lie stated that he believed it to be bad practice to leave the broken fragments in position, with the hope of union ; and that by doing so we left a constant source of irritation, which must retard the local process of repair, as well as seriously weaken the powers of the patient, a subsequent operation being almost necessarily required to remove what will become necrosed bone. Analysis of the 193 Cases of Compound Fracture of the Leg. The author commenced by stating that these num- bers included fractures of the tibia, and tibia and fibula combined, the latter being the most numerous. Compound fracture of the fibula was comparatively a rare accident. 129 were treated on conservative principles, 35 of which died, or 55-55 per cent. 15 underwent secondary amputa- 1861.] pound Fracture. 507 tion of the leg, 10 of which died, or 66-66 per cent. G un- derwent secondary amputation of the thigh, 4 of which died, or 66-66 per cent. 74 of the whole number died, or 38-34 per cent. 27-13 of those dying which were treated on conservative principles, and 00-U per cent, of those treated by operative interference, hi 22 per cent, primary amputation was performed ; in 10 secondary ; land in 67 per cent, conservative treatment was adopted. A table was then given, showing the causes of death in the fatal examples, from which it- appeared that of the fatal cases operated on, about one-third died from pyaemia, and nearly two-thirds from exhaustion or gangrene. That of the cases treated on conservative principles, not one-sixth die from pysemia, and something less than half trom exhaustion and gangrene pysemia being evidently a more common cause of death after operation. The author then went on to ob- serve, that no comparison can be wo^l drawn between the two classes of cases in which conservative treatment and operative interference had been applied. In compound fracture of the leg, he believed that the injury should be very extensive to warrant such a practice as amputation ; for most cases, whether treated by primary or secondary amputation prove fatal to about sixty per cent. ; and when attempts to save the limb are carried out, by care and close attention good results may be anticipated. Let a free exit be made and kept for the evacuation of all pus ; let loose pieces of bone be removed as early as possible ; and limb be preserved in absolute repose by any splints which will secure such an end. Let the tendo-Achilis be divkled if the slightest difficulty is experienced in maintaining rest, and good support and nourishment freely given. Under such treatment, apparently hopeless cases often turn out well, and rewards the surgeon's attention by a successful result. The author then dwelt at some little length upon the necessity of making free incisions wdienever pus was present ; it was a practice which he had never seen followed by any other than good results, and strongly advocated its adoption in appropriate instances. Analysis of the 35 Cases of Compound Fracture of the Arm. 14 were treated on conservative principles, and all vered ; 4 were treated by primary amputation at the shoulder-joints. 2 of which died from internal complications; 13 were treated by primary amputation of the arm, and 2 died ; were treated by secondary amputation, and re- 508 Epilepsy. [June, covered ; 31 of the whole number recovered, and 4 died, or 11-4 per cent. Analysis of the 57 Cases of Compound Fracture of the Bones of the Forearm. 27 were treated on conservative principles, and all recovered. 22 were treated by primary amputation of forearm ; 2 died, or 9 per cent. 5 were were treated by secondary amputation 4 of forearm, 1 died ; 1 of arm, fatal. 3 died from internal complications. The author then drew attention to the fact of the favorable termination of these two classes of cases, which the expe- rience of all surgeons correctly indicated, lie stated that such operation as amputation should be resorted to only in the severest examples, and that in more favorable cases a good recovery might with some confidence be anticipated. lie drew attention to the fact that so large a proportion as 50 per cent, of the cases of compound fracture of the fore- arm admitted into Gkiy's Hospital were subjected to ampu- tation, and explained it by proving that the majority of the cases were caused by machinery, which was too often fol- lowed by a total destruction of the part. The author con- cluded by expressing a hope that the analysis was of some value and interest, although he was well aware that few general deductions could be drawn, as there were no cases in surgery which required to be treated more upon their individual peculiarities than those of compound fracture. Analysis of Fifty -two Cases of Epilepsy. By Dr. Edward H. Sieveking. This was the second contribution of the same character as the one admitted into the Transactions of the Society for 1S57, and the author has limited the analysis to the same number of cases, taken in the order of observation as had been subjected to analysis on the former occasion. Only those points were brought forward on which satisfactory evi- dence could be obtained. Sex. 23 were females, or 44-2 per cent. ; 20 were males, or 55 8 per cent. Taking the two series together, the ratio of females to males was as 45-2 to 54-S. Age. The following was the distribution throughout the different periods of life: Under 10 years, 13 cases ; from 11 to 20. 25 cases, from 21 to 30, 7 eases ; from 31 to 4i), 3 cases ; from 41 to 50, 2 eases ; above 51, -"> cases. The basis of tin's 1861.] Epilepsy. 509 calculation is the time when the epilepsy first showed itself. Arranged according to sex, we iind during the first decen- nium S males and i females ; during the second, 11 males and le females ; during the third. 5 males and 2 females; during the fourth, 3 males ; during the fifth, 1 male and 1 female; during the sixth, 1 males and 2 females. Causes. An hereditary taint was traceable in 11 cases, but in S only ot' these was there evidence of epilepsy having oc- curred in a near relative of the patient. The exciting causes were traced in 37 cases, as follows : Uterine derangement, 9 cases ; venereal excesses, including masturbation, 6 cases ; fright, 4 cases ; over-work, -1 cases ; anxiety, 3 cases ; dys- pepsia, 3 cases ; denition, 4 cases ; scarlet-fever poison, 2 cases (doubtful) ; meningitis, anaemia, blood-poison, and de- velopment of puberty, each 1 case. Premonitory Symptoms. Comprising under the term "aura" all symptoms indicative of a near approach of a paroxysm, the author found in 21 cases, or forty per cent., or less frequently than it was met with in the first series, where 52 per cent, of the cases exhibited premonitory signs. Headache. Headache is very commonly associated with epilepsy, but its significance varies much according to its period of occurrence ; it may be habitual, or it may be con- nected with the attacks only as a precursor or a sequela. It was constant or frequent in 0 cases, 17-3 percent. ; it occurred after the seizures only in 12 cases, or 23-0 per cent. ; it oc- curred only immediately before or after the fits in 3 cases, or 5-S per cent. Biting the Tongue. Although a large number of genuine cases of epilepsy occur in which this symptom is never met with, it is important as a corroborative symptom. In the first series it was met with only in 32-7 per cent. ; in the present, 27 patients, or 53-S per cent., exhibited this feature. It did not appear that the female sex, as might have been antici- pated, were less prone to inflicting this injury upon themselves than males; because of the 24 cases in which the tongue had not been bitten, 1G were males and S females. Urine. The author has found no constant derangement in the urin ated with epilepsy. He has always failed to discover any sugar, nor has he met with a constant or even frequent r a diminution of urea. In several ca?e.-5 he found the urine presenting a specific gravity ranging about 1030, and containing a large excess of urea. There was in the present series no case of albuminuria, ex- cept, perhaps, in one instance, in which a Bmall quantity of 510 Primitive Gangrenous Angina. [June, albumen appeared to be present for a brief period. An ex- cess of phosphates was observed twice, oxalates in one or two cases, and an excessive deposit of lithates in a small number of cases. Treatment. The author, while urging the value of treat- ment in alleviating the disease and indefinitely postponing the seizures in a large number of cases, admitted the doubt which always attached to any absolute cure of epilepsy. He advocated no specific, but the employment of all rational means indicated by the constitution and peculiar symptoms of each individual case. Above all, he considered persever- ance in a combination of moral, regimenal, and medical treat- ment essential. As many of the cases analysed had not been under the authors care permanently, he did not regard the results as to the treatment indicative of what might have effected in the whole series, lie considered that he could lay claim to eight cures, that fifteen were decidedly benefitted, while the remainder were either uninfluenced by treatment, or did not continue under observation for a sufficient period to justify any positive statement as to the result. Medical Times. Dr. Henry Musset relates a case of gangrenous disease of the back of the mouth which resisted all other remedies, but yielded to the employment of perchloride of iron. This medicine was administered in a draught at periodical intervals, and under its use the fever abated, the delirium ceased, and a large patch of ecchymosis wdiich had ap- peared on the right side of the chest began to grow pale. Broth and wine were then administered, and every day the improvement continued ; the breath was no longer foetid, the tissues became clean, and at length the patient, who had appeared moribund, was restored to life. Dr. Musset attributes the recovery entirely to the use of the perchloride, because it was the only medicine employed internally from the time when the worst symptoms appeared, and because the improvement continued regularly as soon as its admin- tration was begun. With regard to the patch of ecchy- mosis which appeared on the chest, the perchloride seems t have acted beneficially in removing it, whether this in- teratrial hemorrhage was produced by the gangrencc hav- ing destroyed some vein, or whether it was the conse- juence of an alteration of the fluids under the influence of a general cause. U Union Medicate. 1861.] Editorial 511 EDITORIAL AND MISCELLANEOUS. MEDICAL COLLEGE OF GEORGIA. Under cover of the present issue will be found the Thirteenth Annual Announcement of the Medical College of Georgia with the catalogue of its numerous alumni. By this our readers will find that the session will open, as usual, on the first Monday in November, and continue until the first of March following. The College Edifice, lately much improved by the addition of a most commodious Dissecting Room, is now undergoing thorough renovation and repair, being painted from attic to cellar, and in every way prepared to afford comfort and convenience to the class. The present political distraction on our continent, and the din of actual war. may. for the com- ing season, diminish the class, but thorough preparation and accumu- lated facilities are the best means of securing success in teaching. In these no medical institution, North or South, can surpass the Medical College of Georgia. Every means of demonstration, and every ap- pliance are accumulated within her walls, and each member of the Fa- culty, well practised in the art of teaching, will give himself with energy and devotion most earnestly to the task. Let Southern institutions of learning, like all other departments of Southern enterprize, receive now new life and additional impulse from the remodeling and regeneration which must surely follow the present national troubles and disaster, brought upon as by fanatical enemies, not only of the South, but of the whole country. The constant dripping of water has at last worn away the rock whose foundations seemed so deep and so firm that the shock of a volcano could scarce have stirred its base. Pulmonary Hemorrhage. In the intercurrent haemoptysis of phthisis, the tincture of larch-bark, in doses of half a drachm to a drachm every second or third hour is a very effectual remedy, suc- ceeding in some cases when the usual remedies (ipecacuanha, lead, tan- nin, and gallic acid) had failed. It is now the remedy principally used in t: -.in the wards of St. Vincent's Hospital. Dr. J. AC (TFerrall, p, 77. 512 Miscellaneous. Notes on Diabetic Cataract. The author has collected from dif- ferent sources about twenty cases of double cataract, occurring in patients suffering from diabetes. These cases are of no small interest in con- nection with the recent observations of Dr. Weir Mitchell* and B. W. llichardson.f which show that, in several of the lower animals, the ab- normal introduction of sugar into the system, whether by immersion of the body in syrup for a sufficient time for the osmotic process to take place freely, or by injection beneath the integument, in almost certainly followed by the development of lenticular development. John F. France. Bronchocele. The author considers this disease as the result of a perverted action of the nervous functions, at least in this country. Acting on this theory he administers strychnia in these cases, giving at first a dose of the sixteenth part of a grain three times a day ; if ac- companied by anaemia, he combines iron with the strychnia in solution. This treatment, from the cases reported, seems to be followed by good results ; the enlarged organ shrinks, the improvement commencing after taking the remedy a few weeks. Dr. Murney, of Dublin. p. 281. Chorea. Farardization of the skin in cases of chorea occasions a rapid and marked diminution of the movements, and frequently effects a rapid cure of the malady. It should be applied chiefly to the parts most convulsed, every day, or every other day. M. Briquet, p. 70. Headache, Congestive. Iu severe headache, owing apparently to congestion, give the usual doses of the extract of belladonna, This drug excites the ganglionic nerves, tones and strcngtJicns them, but depresses the cerebro-spinal system. Hence its value in congestive headache. Dr. R. Uughes, p. 300. [We should rather doubt this being the true explanation. There is just as much reason to think that the belladonna is valuable as a sedative to both the ganglionic and cerebro-spinal nerves. Editor Braithicaite's Retrospect oj Practical Medicine and Surgery. \ Neuralgia. Hypodermic Injection of Morphia. The hypo- dermic injection of morphia is of no use whatever in cases where in- flammatory disease (caries of bone) produces the pain. It was of tem- porary benefit in a case of severe pain originating in inflammation of the nerve itself, The cases best adapted to this mode of treatment are those where the pain is of a purely neuralgic character, depending upon general anocmia. Dr. J. K. Barton, p, 46. ' American Journal of the Medical Science, Jan. 1860. ; Di-. Brown-Sequard's Journal de la Physiologic, &c, July, I860. SOUTHERN MEDICAL AND SURGICAL JOURNAL T.L XVII.. AUGUSTA, GEORGIA, JULY, 1861. NO. 7 ORIGINAL AND ECLECTIC. ARTICLE XV. /'/cry. By Tilmax Douglas, M. 1)., of Alexander, I Georgia. A disease produced by so many various causes ; affecting the various ages and constitutions so differently ; involving in its course such various portions of the lower part of the canal, being sometimes simple rectitis, and then involving the whole colon, and eviii the ileum; frequently compli- cated with disturbance of the liver and febrile reaction, makes the suggestion to treat the "case and not the malady" a common sense precept. The idea which I wish to impress will be best illustrated by noticing, in their order, the classes of cases which were produced Jyv their several causes. Dysenterp from Improper Dieting. Case 1. Mr. ('., ag GO, of good character and constitution; large, tall, well formed, a man of indomitable energy, but \ery irregular in his habits of eating. Would rise before day and ride till dinner, when, tired and hungry, would sometimes indulge too freely. 1 was called in great haste to see him, Septem- ber 11, 1845. Found him with intolerable pain in the um- bilical region, coming on in paroxysms, followed by tenes- mus and passing only spoonfuls of mucus and then having to throw up. I learned that he had been riding all the mornin. >re day, looking after his stock, and that, 514 Douglas. Dysentery. [July, ou his return, he took a very hearty dinner, which was the first thing he had ate that day. Prescribed at once 10 grs. calomel and followed in short time with three drops croton oil, hot bath, counter irritants to the abdomen, but without benefit. Sent home and got a long gum elastic stomach tube, which I introduced far up into the colon and threw about a quart of warm water. He said he felt the water reach the part which seemed to be obstructed. Copious discharges of hardened foeces immediately followed, and was soon well. Case 2. During the hog-killing season otthe same year, when we of the country are so prone to indulge in "swines* flesh and broth of abominable things," a gentleman, after being cold and fatigued all day, partook too freely at night of the rich fruits of his day's labor, and was tormented for two days by paroxysmal pains throughout the abdomen, harrassing tenesmus, great difficulty in urinating and fre- quently passing small quantities of bloody mucus. Would take scarcely any medicine or submit to the use of the syringe, saying he would certainly soon be relieved, for he felt as if he would pass the disturbing matter very soon. TTas finally relieved by the hot hip bath, which brought away large, hardened matters in abundance, followed by the contents of that unfortunate supper. Dysentery from Cold and Fever. Case 3. May 2nd, 1860, called to see J. W. IT. B., Esq., aged about 30; of good habits, medium size, well formed, dark complexion and black hair ; constitution only tolerably good. His mother died of chronic bronchitis, and he was very prone to be af- fected by sudden changes of weather with cold and cough of so serious a character as to keep him apprehensive of evil. Also, subject to most distressing attacks of dyspepsia. Mr. B. had recently taken cold which, instead of affecting the lungs as cold usually does in his case, caused large, fre- quent, serous discharges from the bowels, which very soon became painful, strainiug, small, consisting of mucus and blood, and attended with intermittent fever. Prescribed oil 1861.] Douglas. Dysentery. 515 and turpentine emulsion, as used by J)r. Kobert Campbell, every lour hours, and 18 grs. quinine to intercept the next paroxysm of lever. May 3rd, Mr. 1>. had fever again. The condition of the bowels was, if anything, worse. The oil mixture seemed to have agravatcd the griping pains, and the tenesmus was intolerable. Dyspeptic symptoms also being urgent; patient was disponding. Gave an occasional dose subnitrate bismuth, continued the oil mixture in less doses, and quinine as before. Bathed the bowels with essence pepper- mint and covered them with a folded blanket which caused considerable burning and much relief. May 4th. Discharged the same bloody, straining, mucus character. Considerable fever. The oil emulsion, our favorite remedy, had to be abandoned in this case. Substi- tuted : Mucilage gum arabic, 3 oz. Cream of tartar, 1 oz. Pure sugar, j oz. Oil lavender, 4 gtt. (I have used the spirits of lavender, but think oil best for this mixture,) a tablespoonful every three hours. Quinine as before. May 5 th. Patient sitting up, reading convalescing. I had two other cases at the same time, produced by the same change of weather; so similar in character, treatment and results I need not detail them. The oil treatment in these cases was not successful from the fact that they commenced with diarrhoea, which cleared out the upper portion of the canal, and left the mucus mem- brane so sensitive that the oil excited it to action. In cases where dysentery has supervened a diarrhoea, cream of tartar, in small doses, has acted, in my practice, like a charm by making a slight renewed impression on the serous mem- brane, which relieves the mucous surface by a revulsive ac- tion. And it 18 evidently better than salts for that purpose. 516 Douglas. Dysentery. [July, because less irritating. To the next case the oil treatment was well adapted. Case 4. February, 18G0, Rev. Mr. W., aged 20 years, a young gentleman of unexceptionable character and habits. 'Fall, slender form, red complexion and sandy hair. By taut travelling and exposure to cold and inclement weather, had taken cold, bowels constipated, and had irregular paroxysms of fever every forenoon, attended with griping pains in the bowels and frequent small discharges of bloody mucus. Prescribed 16 grs. quinine early in the morning, and a tablespoonful of the oil mixture every four hours. Bathed the abdomen with essence peppermint and covered it with folded blanket, which afforded him so much comfort that he pronounced it the only thing that saved him. The next day the fever had returned and agravated the dysenteric symptoms. Continued the same treatment. Third day the disease had so abated I left him and he was >n well. Dysentery, thesequd of Measles. Case 5. May 28, 1853. A negro woman, aged 30 years, black, well formed and good canstitution, belonged to Mr. II. Was suffering- great pain low down in the abdomen, paroxysmal, attend- ed with bloody, watery, mucus discharges and painful tenes- mus. The womb was excited to action by the inflammation and continued spasmodic action of the colon and rectum, and fever of a remittent type agravated all the symptoms. She had measles a month before in which the fever was very high Nature had, as usual in such cases, abated the lever by a diarrhoea, which terminated in dysentery. That was thought but little of, and allowed to run until it became alarming. Attempts were then made by the family to cure the case with opiates and sundry astringent herbs, and then ;rge and repeated doses of calomel which brought her to the helpless state of prostration in which I found her. >on as the fever had abated a little, I covered the abdomen with a blisterto be dressed with a hot poultice, and 1861.] Douglas. Dysentery. 517 put her on 3 grs. quinine and 1 gr. opium every three hours to intercept the next rise of fever and to.quiet the action of the uterus. May -0. Had less fever and pain, but dysenti persisted. Prescribed quinine disolved with elixir vitriol in 1 gr. doses every lour hours, toast water, chicken water, etc., under which she improved till the 2nd day of June, four days from the time I first saw her, she had so far re- coved I left her. Case 0. June 12, 185G. A youth, son of Mr. II., of same family, as the above, aged about lo, that tender age of boys, had measles, and dysentery as its sequel at the same time, was not thought to be so dangerous as to require my ser- vices while I was attending the negro, hut was treated by the family with repeated doses of ealomcl and astringents and opiates. I found him completely prostrate. Tormina in parox- ysms, and most distressing tenesmus ; passing every few minutes small quantities of watery, bloody mucus. Fever had been intermittent but was now almost continued. The treatment after I saw him consisted mainly of quinine dis- solved with elixirvitriol and an occasional dose of opium which the severe pain seemed positively to demand. And copavia and gum water. .:ses T and 8. Aged about 10 and 12, were younger brothers of the above, who were taken while I was attending 6, and a milder treatment adopted from the-first, they soon recovered. Dysentery from Drunkenness. Case 0. November 1, 1 I (/ailed to see Dr. M., a young professional brother, aged about 25 years, who was universally respected for high toned honor and gentlemanly bearing. Had gr only three years previously in the Medical Col] Georgia. Was pronounced by Dr. E. L. Anthony, his ecptor, to have had the best physical constitution ' saw. But in an evil hour, while reading medicine in Waynesboro, he glided gradually and imperceptibly into 518 Douglas. Dysentery. [July? the habit of visiting the bai rooms, which so completely undermined his moral sensibilities that lie did not more than complete his education and get fairly into practice, where an honorable and useful career awaited him when he found his moral and physical energies paralized and he fell back in hopeless despair. I found my young friend in bed, emaciated, bloated face, and a countenance which indicated the most dreadful horror. Very cautious in retrospect! ng the history of his case. Had to get my information respect- ing his past course from others. It made me sad. For three years he had been in the constant habit of sending for a gallon of spirits at a time, with the intention of taking only a little as he needed it. That was, of course, when fatigued and exposed to cold and wet on his visits at night, &c. But instead of using it necessarily as he honestly in- tended, he drank each new supply sooner than the former. And being a man of means and social, liberal, friendly feel- ings, he was not alone long at a time and his comrades were not angels by any means. I found him with a supply of wine, and about the only information I could get directly from himself was that brandy made him sick and could not be retained, that wine was retained better than spirits and that it was impossible for him to do without something of the sort. It just then recurred to my mind that only a short time before that I was passing his house late at night and saw him leaning over the piazza rail heaving as though he was trying to eject the whole abdominal vicera from his mouth. At the same time had all the symptoms of the most distressing and threatening dysentery. And so debilitated was he that it was impossible for him to get down to the chamber on the floor, and had a box fixed on a level with the bedstead that he might glide off easily over the chamber. Once while sitting on his box his hands were moving the soft flabby muscles (once so plump and hard,) and while folding and doubling them, and pressing with his fingers as if to fool how near it was to flic bone, he sighed and said, spirits 1861.] Douglas. Dysentery. 610 has done all this ! and it was remarked by those who had been with him constantly that that was the first time he had over admitted that spirits was doing him any harm. Now, it was evident that the whole canal was involved. The Btomach could retain only a spoonful of anything at all and nothing stronger than wine ; the duodenum and small intestines were painful and distended ; the colon and rectum inflamed, and constantly discharging blood and water and muens and some pus, which was wasting him away. The nutritive functions were so completely destroyed he must have perished even though he could have eaten. The thought of treating such a case farther than to soothe for a few days would be absurd. Dr. E. L. Anthony, who kindly came to my assistance, suggested salts as recom- mended by Drs. O'Keefleand Dugas, but it only added to the sensitiveness of the whole canal and rendered him still more nervous. Nothing could be done but soothe with wine and opiates so long as the system was susceptible. Case 10. Called June 4, 1854, to see Mr. Q., an Irishman, farmer, about 35 years of age. An honest, energetic-, thrifty man of good constitution. Had recently great trouble with his negroes, and went to Augusta to sell one, where by drinking, exposure and improper dieting he had ;i lit, of cholera morbus. A physician gave him a dose of lauda- num and sugar of lead, which enabled him to get home. 1 found him next day with considerable fever, stomach very irritable, and passing from the bowels every 20 to 30 minutes, bloody, watery mm* us, attended with griping [tains and tenesmus ; bowels sore and distended, restless and very apprehensive of a fatal result. Prescribed small doses cream of tartar every three hours and 3 gr. doses quinine, with ] gr. doses opium between the times of giving the cream of tartar. June 5. The cream of tartar had reduced the distension of the bowels some, but the fever, dischargee arid tenesmus about as yesterday. June G. All the worst symptoms aomewhat abated and 520 Douglas. Dysentery. [July, we were somewhat encouraged. Continued the same treat- ment. June 7. Discharges larger and less bloody, but fever persisted. Dismissed the cream of tartar and continued the quinine. * June 8. Fever high, discharges frequent, painful and .-training. Continued the quinine with occasional doses of opium. June 9. All the symptoms remaining the same and the bowels being more distended, a blister was applied all over the abdomen. June 10. Fever had abated some and the passages les3 frequent and the pain had diminished very much, but now the parotid glands had swolen enormously. Dr. E. L. Anthony was called in consultation. Patient was put im- mediately on Dr. A.'s favorite remedy, sulph. magnesia, and quinine as before, and painted the parotids with tinct. iodine. June 11. The salts had caused enormous serous dis- charges, but the patient was so prostrate it had to be aban- doned. Continued the quinine dissolved in the aromatic sulphuric acid and an occasional dose of opium. June 12. Growing worse in all respects. Blister had relieved the distension but slightly, and was itself exceed- ingly troublesome and painful. The passages, frequent, painful, bloody, watery, mixed with pus, and exceedingly offensive. (If it be said he drank "rot gut whiskey," I re- ply, all spirits rot the guts if we are to judge by the charac- ter of the discharges in the last stages of drunkenness.) He was restless and unable to get out of bed. Kept him on quinine in 2 gr. doses, elixirvitriol and opiates, &c, under the use of which he lingered until the 29th, 24 days after liis return home. Dysentery from Teething, Case 11. April 25, 18G0. ( ailed to a little negro boy two years old, property of Hon. .1. A. B. Several teeth coming in a group, gums swollen, had had diarrhoea for several days, passing large quantities 1861.] Douglas. Dysentery* 521 of watery matters, sometimes white, undigested bread, &c, ed directly through him, at other times greenish. This followed by bloody mucus in small quantities with pain and tenesmus, complicated with remittent fever, and that symptom so much dreaded in such cases hot head was also very prominent. Prescribed the oil and turpentine emulsion in small doses every four hours, a liniment of olive oil, tinct. iodine and camphor for bathing the abdomen, cold water to the head and quinine in 1 gr. doses every 3 hours. April 20. Patient had more copious discharges and less blood and tenesmus, but did not urinate freely. Continued the same treatment with the addition of buchu tea. April 27. Head less hot, dysentery persisting. The same treatment was kept up with very little variation till the 1st lay, four days longer without, any permanant change for the better. The abdomen being distended, applied a blister. May 2. The benefit resulting from the blister had been onl}- temporary, all the symptoms were worse. Continued the oil emulsion, increased the doses of quinine and added small doses ipecac. May 3. Dysenteric symptoms persisting, little negro be- ginning to look quite ghastly. Made him an emulsion of Gum arabie, 2 oz. Loaf sugar, \ oz. Copavia, I dr. One teaspoonful every 3 hours ; quinine and ipecac as be- fore. May 4. Much better every way. Continued the same. May 5. Patient convalcssing left it. It bloated and got up slowly, but surely. X. B. This case commenced with diarrh rilar in some respects to < Case 12. ged about 20 months, a fine sprightly 522 Douglas. Dysentery. [July, boy, son of Mr. F., of Savannah, was unfortunately weaned while a group of teeth were just causing the gums to look red and swolen. Diarrhoea set in in April, 1860, and was checked with chalk and opiates. Dysentery soon followed of so violent a character that Dr. Young, the family physi- cian, advised its removal to the country as the only chance for its life. It did not come to this place till June, two months after, when I found it with fever, coming on late in the afternoon and lasting all night, with hot head, continual moaning, jumping, trying to get out of bed, screaming fre- quently, as if frightened, and passing from half dozen to ten bloody, mucus, greenish discharges during the night and several during the day. The abdomen was much distend- ed. Appetite sometimes entirely absent, at others voraci- ous. The oil emulsion acted finely at first. Lessened the frequency and improved the character of the discharges. But the dysenteric symptoms would soon return. Lanced the gums frequently and covered the surface of the body with olive oil morning and night. The teeth which we thought would be through in a few days remained at a stand, and all the symptoms would return suddenly and blight our hopes. I found the cream of tartar emulsion as used in the 11th Case the best means of reducing and softening the distend- ed bowels. Towards the last of June he was so emaciated, his joints appeared so very large, limbs and neck so small, had entirely quit walking and the head would hang on the shoulders, and the tired, distressed countenance made his look almost frightful. The discharges also had that rotten flesh fetor, which led me to suspicion rachitis. By the first of July the dysenteric symptoms gave way. But the discharges continued frequent, watery and offensive. And what to me was singular, a tumor appeared under the tongue, which 1 at first took to be ranula. Prescribed so- lution < him arabic, 2 oz. Pure BUgar, q. s. Cretap.pt., 3G grs. Iodide potass., 24 grs. Copavia, J drachm. I.] f the Spinel Muse onful every 4 hours, and cod liver oil twice every day. which had a most happy effect* lessened the fre- quency and offensiveness of the discharges, and made them more coi , But the tumor under the tongue continued some weeks, when he was found to bo salivated and the tumor had disappeared. The same mixture, except the iodide, was continued several weeks longer. The salivation sub- sided and the tumor returned. Iodide potash was again combined with the mixture, salivation soon appeared and the tumor again subsided. But still the general improve- ment was unsatisfactory. Sometimes feverish discharges, too frequent, watery and now and then offensive, but little improvement in appearance. About the first of August commenced the inunction with olive oil again overthe entire surface every night ; applied a flannel roller to the whole body and dusted it well with red bark. That was continued through August and September, and the above mixture, minus the iodide, every four or live hours. Last of Sept., four months from the time he came under my care he was found growing plump, lively and stronger, and re- turned home in high hopes. II13 mother writes, Xovcm- ber 1st, littl I still fattening. I have treated dysentery during the Last spring a great deal on the general principles above indicated, with the ilts with on. exception. i I By \)v. Zuradella. Of this >llowingchai tics are summed up: 1. Dull pain in the lumbar region in on long ding and dimini lying down; in some people neuralgia of the intercostal ional Lhility of the Bpine. . hi incurvation of the -pine ; in that til- on the '>. Excavi ti the yerte- 524 Lithotomy, fic.9 in Children. [July bral extremities of the ribs may be more or less easily dis- tinguished. 4. Some painful point exists on a level with a lumbar spinous apophysis, owing probably to stretching of the ligaments which have lost tonicity. "5. In advanced cases a peculiar elasticity at the level of the spinous and transverse apophyses of the vertebrae, due to tension of the aponeurosis. G. Impossibility in maintaining the erect posture without support. 7. Incomplete power of extending the trunk without fixa- tion of the upper limbs. 8. Alteration in the natural curvatures of the spine, the concavity of the cervical region being the first to disap- pear. 9. Eight declination of the whole spinal column to the right side. "lO. Incomplete straightening of the spinal column by Farardization of the muscles of the vertebral gutters. 11. Freedom of movement of the cervical muscles, ex- cepting the above-mentioned incurvation. 12. Increased mobility of the vertebra? one upon the other, owing to the relaxation of the muscles, attended by occasional noise like the crepitus of certain dislocations. On Lithotomy and IMhotrity in Children. By M. Dolbeau. M. Dolbeau, in temporary charge of M. Guersaut's wards at the Children's Hospital, has taken the occasion of the presence of two cases to make some interesting observations upon the operations best suited for the relief of stone in the child. One of these patients, lour years of age, had been submitted to bilateral lithotomy by ]\f. Guersaut, and did very well, except that, a month after the operation, a fistula remained, which will require surgical interference. The other child, seven years old, had a very hard calculus, measuring three centimetres in one direction by two and a half in another. M. Dolbeau Liberated him of this by means lithotrity, eleven seances, each of about a quarter of an hour's duration being required between the 11th July and the L'Oth of A.ugust Chloroform was employed, and hut very ^861.] I little local irritation was produced. The bladder, p< but little power, discharged the fragments very imperfectly, and considerable difficulty was often experienced in their val. In estimating the comparative value of the two operations for children, in 1849 M. Guersaut gave the decided prefer- ence to lithotomy, except in those cases in which the stone admitted of being crushed in a single seance : but, although this surgeon has published no statement since that time, AT. Dolbeau now states that he performs lithotrity much more frequently than he did, by no means limiting its application to cases which can be disposed of in a single seance, and that his success is tar more considerable than heretofore. Several of the circumstances which have been objected to lithotrity are really due to the want of skill on the part of the surgeon. A serious inconvenience, however, is the engagement of the fragments in the uretha a complication far more common in children than in the adult. In place of moderating the efforts at micturition, performing them in the horizontal posture, and using various other precautions, they expel all the fragments through the dilatable neck of the bladder into the uretha. Other inconveniences of urine, and sometimes a very notable diminution in the contractile power of the bladder, are in general of no long duration. In M. Dolbeau's opinion, the two operations may be thus compared : lithotomy is applicable in all cases. It very fre- quently succeeds, but it exposes to accidents, such as inflam- mation and the establishment of fistula, which are difficult of cure. As a general rule, the operation is simple and easy of execution. Lithotrity is not applicable to all patients, but in rminate cases its results are excellent. Its execution ne- gates a special dexterity, as it presents greater difficulties than does lithotomy. It may also give ri accidents, as urethal fever, which may carry the patient off, the engage- ment of fragments in the uretha (a omplica- tion), and incontinence or retention of urine. As the opera- ithotrity may. have to be extended <>. er a long period (a child nine years of age, a patient of M. Civiale, required . the health should be good, and the bladder healthy and of good capacity. Nor must the calculus be too too hard; its volume maybe considerable if if is only friable, but in the case of a large stone, th] is an extreme size. In spite of the success of lithotomy, it is an ration that should not be performed except when lithotrity ble. A seance of lithotrity may always be first 526 Fracture of tJie Scr alum. [Jul}*, tried in doubtful cases, in order to judge whether this can be borne, and that without any prejudice to the ultimate success of lithotomy. Chloroform should always be had recourse to, its advantages far outbalancing any inconvenience which may result from its use. As none but small instruments will enter an nretha of the amount of development in a child, the habit of manipulating witli such must be acquired. The seizure of the stone is a matter of difficulty, and that not so much from the want of capacity in the bladder as from its form and situa- tion. In place of being comprised within the pelvis, it occu- pies a part of the abdomen, while the absence of the prostrate prevents the formation of the depressed part termed the basfo?icl, where in the adult the stone is so frequently found. The bladder is large, since it mounts up into the abdomen, and the very moveable stone has no fixed situation. In the author's opinion, the manipulation is facilitated by leaving only a little fluid in the bladder, and by raising the buttocks so as to keep the buttocks so as to keep the stone in the most dependent part of the bladder. "When the stone is hard and large, owing to smallness in size of the instrument, it is held and broken up with difficulty. When the stone has been broken up, it is the engagement in the deep portion of the uretha to be most feared. We must especially endeavor to reduce the smaller fragments to powder, or they may some- times be gently removed in the grasp of the instrument. Fever seldom follows either catheterism or lithotrity opera- tions in the young, and in consequence of the little reaction which takes place, the seances may be longer or sooner re- peated (every two or three days at most) than in tbe adult. Monitewr des Hopitm Cases of Fracture of the Scrotum. By MM. Hamon and Mercer. As this accident is of such rare occurrence, and is so con- cisely treated of by writers on surgery, M. Hamon supplies the details of a case which occurred in his practice. A woman, aged twenty-eight, July, 1S56, fell upon her seat from a height of about ten feet. On examination, the lower part of the scratum, at nine centimetres above the point of the coccyx, was found flattened and carried forwards, free movement being imparted to the fractured portion, with- 1861.] Fracture of the Scrotum. 527 out any pain being induced when the linger was passed into the rectum. The bladder and rectum were paralyzed, both requiring aid for the removal of their contents. While nothing remarkable was observed with regard to the thighs, the legs were paralyzed. Seen two years afterwards; the rectum had recovered its power, but the catheter still had frequently to he used, while the paralysis was s< far amended as to admit ot' the patient walking, although with difficulty and with the aid of crutches. M. Hamon saw the patient last early in the past year, and nearly four years after the accident, lie found that menstruation, defalcation, and the discharge of urine, all took place in a normal manner. A very projecting angle could be felt at the seat of fracture. While the thighs were of their normal size, the muscles of the legs had underwent consider- able atrophy. The motors of the legs were only enfeebled ; and although all movements of the foot were found to be im- sible when it was held free in space, these became execut- able as soon as the heel rested on the ground. All the motors of the toes were completely paralyzed. Imperfect perambu- lation by means of a crutch and stick was alone possible. In reporting upon this case, which was read at the Paris Medico-Practical Society, M. Mercer relates another example of the accident, which occurred during his interned at the Hotel Dieu : A young mason fell from a height on to a stone in the sitting posture, and a compound fracture of the sacrum was the result ; the fracture extending obliquely from one side to the other, at three inches above the point of the coccyx, and the detached portion being carried to the right. The rectum, seen at the bottom of the wound, remained in- tact. Ths skin covering the middle portion of the posterior surface of the pelvis had lost its sensibility to the extent of three or four inches transversely. Beyond this the sensibility was preserved, and the lower limbs were not paralyzed. The expulsion of neither urine nor faeces took place without aid, hut after some days loose stools were discharged involuntarily. The patient sank exhausted twelve days after the accident, ge portions of the sacrum were found inseparable, and bathed in pus. The cauda equina was destroyed, the inflam- mation and suppuration invading the portion occupying the the lumbar spine as high as the third vertebra. All the roots of the sacral plexus, excepting the last lumbar and first sacral pair, were destroyed. M. Mercer concludes from these two c at the para- plegia is much less the effect of the rapture of the nervous Is compromised by the fracture, than of the itive 528 Ox- Gall in Frost-BUc. [July, compression and inflammation of the nervous plexus of the pelvis ; and he suspects that the prevalence of the paraplegia in the slighter case, and its absence in the severer one (al- though in this last any difference which might prevail between the condition of the thighs and the legs was not sought for), may depend upon the effused blood not obtaining the outward issue in the one. case which it did in the other. M. Mercer further draws attention to this question. Why, in any case of paraplegia coining on rapidly, does the paraly- sis of the rectum, and especially that of the bladder, habitually commence with the retention of the contents, incontinence manifesting itself only at a more or less distant period ? So complete is this retention in some cases of lesion of the spinal marrow, that the bladder would burst rather than allow a few drops of urine to escape. Supposing there to exist an equal inertia of the body and the sphincter ot the organ, the slightest repletion ought to lead to a continuous discharge ; and ad- mitting, what seems to be the fact, that the sphincter is more under the influence of the spinal cord than the body of the reservoir, it ought to be the first effected by such lesions, and incontinence should at once appear ; while it is just the con- trary which is observed to take place. The neck of the blad- der, in fact, is not closed by a simple wrinkling, as is generally supposed. The muscle, acting as the occluding agent, gives rise to a true valve, which the tonicity of this muscle is en- abled to keep closed until the distension of the organ and the passage of instruments at last have destroyed the last remains of the contractility of tissue. Then, not only is there regorge- ment of urine, but a true incontinence. M. Mercier has ex- pressed his views at length in the Gazette Medicale for 1854. The remarks made on the tonicity of the sphincter of the bladder may be applied to the anal sphincter. And, although the functional mechanism of the latter is not so favorably disposed', this is the less necessary, in consequence of its strength, and the compact nature of the matters it has to retain. L1 Union Medicale. Ox-Gall in Frost-Bile . jistant burgeon Moore, of the United States Army in CTtah, states that he has employed in si i ox-gall in frost-bite with great benefit, when the injury is superficial. It is ap- plied as a liniment or on pieces of lint saturated with it. m Med. Tim . 1.] mischief among the French, causing serious mortali- ither directly or indirectly, besides disqualifying large numbers for service. orvy was another dreadful enemy which the British ami French troops were compelled to encounter in the Crimea. It prevailed more or less extensively for a long time and served to impart its livery to the other diseases of the soldiery, masking their character, and remarkably aug- menting their virule: Considering, then, the frequency of the occurrence ot 5C disease-, and their excessive fatality, it behooves the military surgeon to use every means in his power to guard, in the first place, against their outbreak, by the employ- ment of proper hygienic or sanitary measures, and in the next, to treat them with all possible diligence and judg- ment when their development is unavoidable. It is, of course, impossible, in a work of this description, to enter into any details upon the subject; but there are several points which cannot, I conceive, be too forcibly impressed upon the mind of the military practitioner. I refer to the r. the paramount importance of 1st, proper isolation of the sick, or, what is the same thing, the importance of not crowding them together : 2dly, free ventilation; 3dly, bodily cleanliness; 4thly, little medicine; 5thly, a good supply of fresh vegetables and fruits, especially oral and lemons; thly, careful and tender nursing. Painful experience has shown in all parts of the world, that the crowding together of the sick and wounded is one of the worst calamities that can befall them. For want of precaution. 3, otherwise easily manageable, often Lme an epidemic character, or, in the absence of this character, often battle the best directed efforts for their re- lief. When the wounded are crowded together they fre- quently become the victims of erysipelas, hospital gan- grene, pyemia, and phlebitis ; occurrences which, under better regulations, might in many cases be entirely pre- vented. Of the proprie instant and thorough , it IS unnecessary t< speak. It pure air is so essential in health, it is easy enough to Bee how important it must be in sick: 88 of body Bhonld be regarded as a relig duty; it may be effected with V je and tepid, cool or cold water, according to the exigencies of the case, and can- :J7 578 Military Surgery. [July, not be performed too frequently or too thoroughly, care heing, of course, taken not to worry or fatigue the patient. In some instances the water may be medicated with com- mon salt, potassa, vinegar, or Labarraque's solution. Noth- ing is generally more grateful to the sufferer, in the differ- ent kinds of fevers, than frequent sponging of the surface with cool or tepid water. The use of heroic medicines, or of any medicines in large doses, in these diseases, and also incases of severe wounds, cannot be too severely reprobated. More men, there is reason to believe, have been killed in this manner in the armies and navies of the world than by the sword and the cannon. Let medicines, then, be administered sparingly. Let the secretions be well seen to ; but purge little, and use depressants with all possible weariness. Give iced water but not too freely, and lumps of ice when there is much thirst with gastric irritability and excessive restlessness. Mild diaphoretics and anodynes, will, as a general rule, be highly efficacious, but the latter should be exhibited with great caution when there is cerebral oppression. Lemon- juice and potassa are indispensable in scurvy, or where there is a marked tendency to scorbutic disease. Quinine is one of the great remedies in most, if not in all, of these diseases, especially when, as is so often the case, they are associated with a malarious origin. The good average dose is from two to five grains, repeated from three to five times in the twenty-four hours. When marked debility prevails, the best stimulants are brandy, in the form of milk-punch or toddy, and Madeira, Port, or Sherry wine. Immense suffering and loss of life are often occasioned for the want of fresh vegetables and fruits in military oper- ations, as well as in the garrison and the hospital. A daily supply of these articles should, therefore, be provided at almost any hazard and expense. In all low states of the system, however induced, the strength can never be rapid- ly brought up without a diet which partakes more or less of this character. There is a form of dysentery, very common in India, which is exceedingly apt, when large masses of troops are habitually c together, to assume an epidemic character ; and it is for this reason that it has often been supposed to be contagious. For sncli an opinion, hewever, there does not seem to be any valid reason. Ballingall, 1861.] Mititor ry. 579 who witnessed at least 2 oi this disei serts that he never once met with a circumstance tending to create such a suspicion : and the views advanced by this eminent Burgeon are those now pretty generally, if not universally, entertained by the British practitioners in India. The remote causes ot dysentery in India arc conceived to be heat, particularly when combined with moisture; the immediate and indiscriminate use of fruits ; the abuse of spirituous liquors, and exposure to currents of wind and to noxious night-dews." Troops recently arrived from Eu- rope are particularly prone to the disease. Tropical dysentery presents itself in two varieties or form. tl. and the chronic. The first, which is an ex- tremely fatal disease, is seated in the rectum and colon, the latter being often involved through nearly its entire extent, and it frequently commits very serious, if not irreparable, mischief in these structures before the patient and the at- tendant are aware of its true character, owing to the ab- e of urgent pain and pyrexia. In general the attack is ushered in by the ordinary symptoms of diarrhoea, such piping pain in the bowels and frequent calls to stool inin-g, the evacuations being, at first, thin and copious but without fetor and but little streaked with blood. The tongue skin, and pulse are nearly, per- haps entirely normal. Gradually the pain becomes more violent, as well as more fixed, and is felt in both iliac re- >r even along the whole track of the colon ; the dis- chai i sists chiefly of blood and mucus, or of a fluid cabling water in which fresh beef has been macerated ; ivered with a white coat; the skin is either ho1 and dry. or bathed with clammy perspiration : and the straining is so e as to occasion prolapsus of the The pulse is, n at this stage, often but little affected, being perhaps, only somewhat increased in qui P, if is very full, bounding, and vibi ity, and when this ia I ccording to Ballingall, forebodes evil. Toward the . the pass are frequently invol- untary and intolerably fetid, gangrenous portions oi" the mucous coat of the bowel are sometimes extruded, and juliar cadaverous smell. Tl. I at which death 0 about one week, but many cases linger on much iong< 580 Military Surgery. [July, The remedies upon whiclithe India practitioners mainly rely in the treatment of this horrible form of dysentery are venesection, mercury, and opium, leeches, purgatives, diaphoretics, warm bathing, blisters, and enemata, being employed as auxiliaries, venesection is always practiced early, and, even when the patient is not very robust, bold- ly, it being, apparently, regarded as the sheet anchor of the physician's hope. Calomel is administered in doses of from ten to twenty grains, along with two or three grains of opium, twice or thrice in the twenty-four hours ; and, while profuse salivation is discountenanced, production of slight ptyalism is generally aimed at. Such treatment as this seems altogether frightful to the modern American practitioner ; it strikes him as unneces- sarily harsh, and as well calculated to augment the mortal- ity of the disease. "We might, in this country, perhaps bleed, and that pretty freely, at the very commencement of an attack of dysentery; at all events, leech very copiously, but we would certainly draw blood sparingly if the attack had already made serious constitutional inroads, or if it was of an epidemic character, and, as to giving mercury with a view to ptyalism, however slight, few men would, I presume, be so fool-hardy. The India practitioners do not, it ap- pears, employ quinine in the treatment of this form of dys- entery ; a remedy so extremely needful in many cases of this disease as it prevails in this country, especially in our Southern latitudes, where it is not unfrequently of a malar- ious origin. The ehronic form of India dysentery, termed hepatic flux, more frequently attacks persons who have been for some time inured to the climate of that country, and is always associated with biliary derangement. "This flux, like the other, often assumes at its commencement the appearance of a common diarrhoea, and becomes afterward character- ized by frequent and severe fits of griping, resembling colic pains, partieulary urgent about the umbilical region. Each attack of griping is generally succeeded by a call to stool, and the evacuations are always unnatural in color and con- nce, free from any admixture of blood, but generally of a yeasty or frothy appearance, and accompanied with rges of flatus ; while in passing they are attend- ed with a sense of scalding about the anus. The patient, after each evacuation, lecls considerably relieved, andhopes to enjoy an interval of ease,' but the recurrence of the 1861.] 'Hilary S griping, accompanied with a ton of air passing through the I and succeeded again by a call to stool, give him little . From the commencement of the attack, the patient complains of nausea, want of relish for his food, and preternatural thirst, attended often with a disagreeable taste in the month. The tongue is furred or loaded, and not unfrequently covered with a yellow bilious coat. The pulse is quickened and the skin parche 1. C / i must, necessarily, in this country, especially in our Southern latitudes, and during the hot summer months, be a more or k iient attendant upon camp life, although much may be done, by a proper observance of hygienic laws, to prevent it. When the disease breaks out it cannot be arrested too speedily. The most appropriate remedies, particularly in its earlier stages, are perfect quie- tude, abstinence from drink, sinapisms to the epigastrium, and an efficient dose of morphia and camphor, or even mor- phia alone. If torpor of the liver exists, blue mass or a few grains of calomel may be advantageously combined with the anodyne. The swallowing of small lumps of ice will greatly assist in allaying the gastric irritability. A mustard and salt emetic will be indicated if the stomach is loaded withingesta. The bowels arc quieted with an ano- dyne enema; and to relieve thirst, and reduce heat of skin, the surface is frequently sponged with cool or tepid water. A combination of carbonate of potossa and acetated tinc- ture of opium, with fresh lemon-juice, in peppermint or camphor water, will often act like a charm in relieving the trie and intestinal irritability, the cramps, and other dis- :ng symptoms. The exposure of the soldier, both in the tent and on the field, renders him extremely prone to rh n, frequent- ly attended, with high inflammatory excitement and severe pain. Such an attack is often effectually put to flight if, at its inception, it be treated with a large anodyne and retic mixture, as fifteen grains of Dover's powder, a third to half a gram of sulphate of morphi with a fourth i i of tartar emetic, or, what is perhaps still better, a hm of the wine of colchicum in union with a full : of morphia or black drop. When I mad , an active purgative should precede exhibition oi medicin< *Ballingair.s Military Surgery, p. ."511, I 582 Military Surgery. [July? Sore throat, tonsilitis, and catarrhal affections, or, what in common Language arc called colds, are very common among soldiers, especially the raw troops just mustered into service, ill clothed, inexperienced, and unaccustomed to camp life. The moment such disease sets in, no matter how Lightit may he, the person should be compelled to re port himself at the surgeon's quarters, in order that he may receive the necessary attention and advice. Generally an attack of this kind will promptly yield to a trifling pre- scription, as a little hot drink, a mild aperient, or, "better still, a quarter of a grain of morphia, a grain of opium, or a large dose of Dover's powder. In an army not under strict discipline, or where proper care is not observed in enlisting,maraa apolu is very apt to show itself, much to the annoyance of the nurses and the physicians. If, in such a case, the patient he not well se- cured, he may, in his perverted military ardor, do serious mischief to himself and to his attendants. A moderately active mercurial purge at the outset of the disease will often go far in quieting the system and in abridging the attack. After the medicine has operated, a mild opiate and seda- tive treatment will generally be the most soothing. Al coholic stimulants are, in general, to be witheld. Nostalgia is another complaint liable to assail the soldier, even the hardiest, especially if he is a person of strong do- mestic attachments, or engaged in an "affaire du coeur." It is more apt to show itself in soldiers enlisting for the for- eign service, or in those who are forcibly expatriated, and is often attended with great suffering, terminating in con- firmed melancholy. It is characterized by a love of soli- tude, a vacant, stultified expression of the countenance, a morose, peevish disposition, absence of mind, pallor of the cheeks, and progressive emaciation. Many of Bonaparte's troops, during the campaign in Egypt, suffered from this complaint ; some in a very distressing degree. In this country, nostalgia will not be likely to occur, at least not to any extent, as our people are essentially of a roving habit, and ol an eminently social disposition. The treatment is rather moral than medical;- agreeable amusements, kind- ness, gentle but incessant occupation, and the promise of an early return to home and friends constituting the most important means of relief. It is impossible, even under the most rigid discipline, to prevent gonorrhoea among soldiers. They will expose them- 1861.] Military Surgery. solves, in Spite of all that can be done to prevent it, and they often pay a heavy penalty i'or their indulgence, not only from the Buffering entailed by the primary disease, but its different complications, especially chordee, cystitis, and orchitis. The symptoms of gonorrhoea are too well under- stood to require enumeration here. The treatment should, from the start, be rigidly antiphlogistic : by rest, low diet, active purgation, and Uie antimonial and saline mixture, with the addition of a small quantity of copaiba. The penis and scrotum are well supported, and covered with warm water-dressing, the former organ being bathed in tepid salt water, at least thrice daily, for twenty minutes at a time. When the discharge is greatly lessened, but not till then, recourse is had to injections of lead, sulphate of zinc, or nitrate of silver, at first very mild and gradually increased in strength, repeated every six, eight or twelve hours. The treatment is continued, in a modified form, for about five days after all the specific symptoms have van- ished. Chordee is best relieved by a full anodyne, as half a grain of morphia, in union with the fourth of a grain of tartar emetic, given toward bedtime, or by a large enema of lau- danum : with warm water-dressings to the genitals. >r the relief of cystitis the most appropriate remedies are anodyne diaphoretics, in the form of Dover's powder, or a solution of morphia and tartar emetic, ^aided by the free use of bicarbonate of soda and moderate quantities of diluents. Or treated by suspension of the affected organ, with strong lead and anodyne lotions, and the judicious hibition of antimony, in union with morphia or black drop. CI- must be thoroughly cauterized at tin; beginning, either with nitrate of silver, nitric acid, or acid nitral mercury; and subsequently, or after the disease 1: . like any common sore, with mild measui '\\(^ studiously withheld, except in the hard form of the ai but not even then while there is much in- flammation or inordinal rational en t. In a measures must be avoided. 'Thepati will g lydoatl ithout than with mercury. ton must be paid to cleanliness, and for this purpose the parts should be fre- quently bathed in tepid salt water, aid<'d by the Byring there be a tight 584 Military Surgery. [July, warm water-dressing, covering in the entire genitals ; if much swelling and pain are present, it may be advanta- geously medicated with lead and opium. As the inflam- mation subsides, the sore may be dressed with some gently stimulating lotion, as two grains of tannin, the eighth of a grain of sulphate of copper, and half a drachm of laudanum to the ounce of water, a weak mixture of sherry and water, or a solution of nitrate of silver, zinc or iodide of iron. If the ulcer is disposed to spread, or presents a sloughy or un- healthy aspect, it will be proper to touch it lightly twice1 a day with the solid nitrate of silver, or a solution of one part of acid nitrate of mercury to four parts of water. The constitutional treatment is rigidly antiphlogistic, or tonic and supporting, according to the particular nature of the case. The bowels should receive early attention ; the skin be kept moist ; and pain be allayed by anodynes. Per- fect recumbency should be observed until the parts are near- ly healed. If mercury be required, the best forms will be calomel and blue mass, in small doses twice a day, with a vigilant eye to their effects, ptyalism being studiously avoided in every case. If bubo supervene, the treatment must be prompt and ef- ficient, with a view to the prevention of further mischief. Recumbency, the topical use of iodine with warm water- dressing medicated with lead and opium, light diet, and the antimonial and saline mixture constitute the most appropri- ate measures. If matter form, an early and free incision is made, and the part afterward treated as a common sore, the granulating process being promoted by mild means. Mer- cury is carefully withheld, at all events in the early stage of the disease. The army is no place for soldiers laboring under seconda- ry or tertiary syphilis ; the sooner they are dismissed from the service the better, especially if they are volunteers. Ophthalmia is one of the annoyances of the soldier's life. Liable to be caused by cold, it is capable of assuming seve- ral varieties of form, and sometimes prevails extensively as an epidemic. The granular and purulent, in particular, are to be feared, as they frequently destroy the sight, and even the eye, in a few days, occasioning intense suffering. To ascertain the condition of the parts, the lids muSt always be gently everted with a probe or the finger. The greatest cleanliness should be observed in these affections ; the pa- tients should, if possible, be sequestered, at all events not L] Military Surgery. 585 be permitted to use the same basins and towels ; the light should be excluded from the apartment ; and the general and local treatment should either he strictly antiphlogistic or of a mixed character, partly antiphlogistic and partly stimulant. The applications should he of the mildest des- tion, especially those intended for the inflamed surface. The Byringe is frequently used to wash away the secretions. >ng collyria generally do immense harm in all forms and stages of ophthalmia. Blood may he taken from the arm, or by cups or leeches from the temples, if the symptoms are unusually urgent and the patient plethoric. In rheumatic inflammation of the eye, colchicum and morphia, given freely at bedtime, will he of immense service. When foreign matter gets into the eye, or becomes imbed- ded in the cornea, speedy removal must be effected, and the parts afterward treated with rest, cold or tepid bathing," gentle aperients, and seclusion from light. Particles of 1 and other sharp bodies are picked out with the point of a delicate bistoury, or cataract needle. The effects of lime and oth^er alkalies are neutralized by syringiug the eye freely with a weak solution of vinegar ; those of nitrate of silver, with a weak solution of common salt, a thorough coating of olive oil being afterward applied. boils, and aba which are of frequent irrence in army practice, demand prompt attention, both on account of the suffering they induce and the disqualifi- cation they may entail for temporary duty. They should be opened early and freely, and no time be lost in amending the general health by gentle mercurial and other purgatives, alterants, and tonics, particularly quinine aud iron. The most appropriate topical remedies are tincture of iodine and warm water-dressings. In carbuncles the affected structures, after free division, will generally require the thorough application of some .arotic or detergent stimulant, as Vienna paste, nitric acid, nitrate of silver, or acid nitrate of mercury. Continued in -V 586 Health in the Camp. [July, Health in the Camp. By Paul F. Eve, M.D., Nashville, Tenn. The science of medicine lias an intimate connection with the movements of armies and navies, and in all civilized nations is an important element in their organization. As surgeons and physicians, our peculiar province is to miti- gate the sufferings incident to warfare hy stanching the bleeding, binding up the wounded, relieving pain, prevent- ing disease, healing the sick. The high office of our noble calling is to cure the millions, who for want of timely care, would die of medicable wounds and remedial affec- tions. In all well regulated armies and navies, each detachment or separate command and each vessel, however small, is entitled to have a medical officer. Four or five companies, each of from fifty to one hundred men, compose a battalion, and two of these constitute a regiment. Each battalion has its medical officer, so that in a regiment there are two, known as the surgeon and the assistant surgeon, who are also called the regimental surgeons. It is a part of their duty to enter into battle with their battalions, so that all soldiers slightly wounded may at once be attended to, and that thus the combatants may not be reduced in the ranks during an engagement. Two or more regiments form a brigade commanded by a brigadier-general, and two or more brig- ades a division, whose commander has the title of major- general. Kow each general appoints in his staff his surgeon or surgeons, to whom are committed the arrangement of hospitals for the sick, and ambulances for those severely wounded on the field. These constitute the staff surgeons whose position is usually in the rear of the line of battle where capital operations, &c, may be safely performed. There are men enlisted as stewards and nurses for the spe- cial purpose, in order that while the wounded may be pro- perly cared for, at the same time, nothing, not even the calls of humanity, may interrupt the conflict carried on by the contending forces. In the army of the United States as the wars have been- few and no large assemblage of troops been required, the appointment of medical officers has been restricted to r il surgeons, and in it there are no staff surgeons. The senior medical officer of a division or of an independent command of a general sometimes has the the title of medi- cal inspector or (/''rector ; and of a commodore's command at 1.] Health in the Gimp. . that of fleet surgeon. The highest medical officer known in our service is th< /v/, who, as the medical purveyor, &c, lias the entire direction of this department in the army. A requisition for medicines, lint, bandages, other materials for any number of men, a battalion, or division, is at once supplied by Lim. The acting surgeon- Leral of the Confederate army said to me in Richmond, had purchased 4000 ounces of quinine at ^2 25, and could get as much more at $'2 50: and that nor. ematized is the service, all lie required in for- warding supplies to any given point, was the number of ops to be stationed there. In the organization of the volunteer forces in the sepa- rate . that of the regular army is assumed as the model. To insure well qualified medical officers, a hoard of examiners is established to assemble once a year for a iks, before which all applicants must undergo a rigid examination to obtain an appointment. Tennessee, however, lias three surgeon-generals, besides a medical purveyor, who if . lull surgeon; and they, I under- star - the medical board, which was no doubt design- ed to i ated by her legislature. Tin- \clusively employed in the army and navy medical appointments, because it implies the qualifications for the discharge of professional du- p no one can be a good surgeon who is not capable ^of maki d physician, but one may be a good physi- and yet never become a surgeon at all. Hygiene in the tented field, or the preservation of health in the military is just now of deep interest to our pie. To array his forces in the best possible physical - the grand object of every commander; and to do this lie b lit, and must rely chiefly upon his medical advisers. The prevention of d: is the nig] ign and end of medical scien may not cure, cannot under certain circumstances and in many >. but from a kn icinghuman rtainly indi- cati . may I camp, and of habits and mode of living, [j may do the recruit some good to make known those thing-, the i oravoid- :e of which may best pr arduous 588 Health in the Camp. [Ju , duties: and the maintenance of health and strength is now the more necessary since in carrying on modern warfare greater bodily activity is required than formerly. The Zouave drill demands greater personal vigor, more rapid movement and quicker evolution on the part of troops than ever exhibited before. Battles are now decided by rifle cannon and musket at long range, and then with the rush of the bayonet. Our armies should therefore not only be well equipped, but every man in them fully able to handle his weapon in the most efficient manner, and each one kept constantly vigilant and active. Age, The first remark I make in regard to the physical condition of the soldier is in reference to his age. To be prepared to endure the fatigue and exposure of a campaign, the human system should be fully developed. Males are liable to military duty from eighteen to forty-five years of age ; but no one under twenty-one, the period of maturity, ought to be required to do full duty. The best soldiers Napoleon ever had were those drilled two years at Bou- logne in 1805. The youngest among them was twenty-two, and when suddenly ordered to Austria, they traversed a distance of over a thousand miles without scarcely leaving a sick man on the route ; but when in 1809, this great captain led his army again to Vienna from Strasburg, the nearest point from France, his young conscripts of twenty years filled numerous hospitals by the way. For the elan, a desperate reckless charge, or the forlorn hope, the young unmarried man, as he has fewer cares and everything to gain might be best ; but for the regular service, the steady, continuous hard work in the line, those between twenty- five and forty will be found the most efficient. The life of a soldier and sailor is undoubtedly the most trying to the constitution of man, and no one ought to enter upon it be- fore attaining a suitable age to sustain the hardship. Habits. These of course ought to be regular and syste- matic, and nothing indulged in to impair the full vigor of the constitution or prevent the perfect development of the system. Early hours are best that sleep may be obtained at night. The^ instinct of nature in this respect is no doubt right, approved as it is by reason and experience, that night is the proper time for rest. To recover from the fatigue of the day, for the system to recuperate from hard labor or a long march, the soldier requires at least eight hours repose. I know it is published, that Pichegru, one of the republican 186L] Uh in (he C 580 generals of France, passed through a campaign with only one hours Bleep in the twenty- four, and that Napoleon slept but four or live hours: these were, however, extraordinary instances. Gen. Taylor ar the council of war held by the field officers alter the battle of Palo Alto, made one general reply to the many anxious inquiries what was to he done, which was let the men sleep. The result at Resaca on the morrow plainly demonstrated how he estimated the value of rest to the weary soldier. To preserve health in the camp plenty of sleep is required; and the opposite to this, all irregular hours, sitting up late, excursions or exposures during the night ; wet, uncomfortable places of repose are obnoxious, and should be carefully avoided. Dr. Winship, who lifts eleven hundred pounds, says one condition to exert this immense power is plenty of sleep. After the treaty of Tilsit, the French Emperor, who, we have stated, was always so very wakeful, slept nine con- secutive hours. It is not rest or repose alone, but to be refreshing it must be quiet, undisturbed sleep. Great cleanliness is essential to the preservation of health at all times and particularly in crowded collections of men. Daily ablution of the whole person, when at all convenient, and throughout the year, is recommended. This greatly fortifies the system and enables it to resist the impression of cold, kc. The best time to bathe is in the morning, rising from bed, or before dinner; and where water is not abundant, a wetted sponge or towel freely applied to the body, followed by friction, may be substituted. After great fatigue or exposure the warm bath or bathing the feet in warm water is best. The nails, hair and beard, it scarcely need be observed, so obvious are the reasons, ought to be worn quite short on the tented field. Habit may become second nature, so that man can accus- tom himself to almost anything. The human will too is almost omnipotent. The veriest poisons may not only be daily used but even en; luxuries. I leel this is not the time or place to offer arguments against tl; ardent spirits and tobacco, or to attempt [fy them with opium and arsenic in their effects upon man ; still the almost universal and incessant practice of drinking, chew- ifi unqualifiedly condemned. Wnafc ojurious to " -'em, or weakens the power of its -ce to disease, ought to be abandoned ; hence daily 590 Health in the Camp. [July, rations of brandy or whiskey are no longer issued in the army or navy, but very wisely coffee and tea substituted instead. Chemistry in the nineteenth century has obtained two essential elements extracted from coffee and tea, known as caffeine and theine, having a remarkable affinity for the human system ; thus confirming or legalizing as it were by science these excellent beverages which had been employed extensively for the three previous centuries. But the con- stituent principle from tobacco, nieotine, is a deadly poison ; so that the sickness produced in first using it, the habitual furred tongue, loetid breath, tremor of muscles, nervous- ness, &c, in all those who smoke or chew, but ratify the truth revealed by the chemical analysis of it. The recent demonstrations too in a school in France is mathematical proof that the use of this article does obtund intellect and diminishes the vigor of young persons. While I would not curtail one comfort from the very small number enjoyed by the soldier in the toil and privation of a campaign, but would most willingly add to his pleasures and happiness ; yet as a medical man I must denounce the constant habit of smoking and chewing, as 1 do that of drinking, because it renders him more liable to sickness, and when sick makes him more difficult to be recovered. And I know full well how such an unpalatable truth, for truth it is, will be re- ceived and how little heeded. I have but done a duty in pointing out how health may be secured by raising a warn- ing voice, especially to the rising generation, against a fashionable habit injurious to the constitution of man, physically, mentally and morally. I would substitute coffee for the tobacco offered by your general in a recent order, and should not value the advice of your surgeon if found interested in a practice so unprofessional. Diet. The food of the soldier should be of the best mate- rial and properly prepared for easy digestion. To prevent exhaustion from the great and constant waste going on in the system the supply ought to be good and abundant. The com- missary department is one of the most important. Troops to light well must be fully provided and cared for, well fed, and well clothed. Without doubt the best organized army in the world, in all its appointments, is that of France. The French soldier has soup twice a day with vegetables and bread, he- sides his coffee. I believe that it is no caricature to say that ours are fed almost exclusively upon very fat bacon, poorly cooked bread and strong coffee, three times a day. With the I.] Health in the G . 591 very aterials on the earth, yet in no country is the pre- paration for the table so lamentably deficient. Our mothers who did know how to cook are last passing away; and alas! the art is now ignored, and we are rapidly becoming a nation of dyspeptics. The coffee drank in the camp is too strong, much fat bacon is consumed, and the bread is not well baked. No work should he done on an empty stomach ; the breakfast may be made to consist of coffee or tea largely di- luted, it possible, with milk, a little meat, fresh if obtainable, and bread made ot' unbolted Hour, or corn or rye meal. AVj^ have sacrificed the host properties of the wheat in its fineness mv\ whit^n^s Th. ancient Greeks and Romans, those re- nowned warriors, used no bolting cloths. Soup, whenever practicable, or stews with vegetables, some meat, bread, and no coffee for dinner ; and for supper a light meal with tea, are best. Ripe fruits and vegetables in seaaou, dried fruit cooked, -. butter, sugar, molasses, vinegar, ecc, are all promotive of health, and are by no means to be omitted in the supply for the camp. Clothing. ^Ye live in a climate ot great variability at all seasons, and it becomes us to guard against the frequent, great and sudden changes. Flannel next the skin at all times, when it can be endured, should be worn. Silk or cotton is prefera- ble to linen for this purpose. I can recommend the flannel belt, particularly during the spring and summer months, as a preventive to bowel affections. The military cap is unsuitable to the Southern State- ; ought to be rejected entirely for the warm weather, and the broad brim hat worn during this pe- riod of the year. So too in regard to high collars, padded coal stocks, and tight clothes : a soldier or an officer on the battle field has no use for brass buttons, gold lace, cocked hats; corded tassels or epaulettes. While I admit a uniform roper in all military men, I would have it exceedingly plain, presenting no contrasts in colors, and fitting easy about the | perience has proven that a lighl less frequently struck by balls in an engagement than any other, and is t. suitable under the fire even of the Minnie rifle. In addition to the clothing, the thickness of which must vary according to the weather, an overcoat and blanket, made water-proof, and a knapsack secured too, against rain, are to be provided. r] to have thick sole.-. ; water-tight by being well oiled, ami the i to pre- vent blistering or chafing. The clothing should be frequently changed, washed and 592 Health in the Camp. [July, dried, and no one ever allowed to go to sleep in them when wet. I would advise the soldier to avoid tampering with medi- cines, indulging his appetites or passions, never to drink spirituous liquors, but to live temperate in all things. Dis- cipline iu the army implies a life of self-denial as well as of great exposure and hard service ; and good health is an abso- lute requisite to discharge its duties. Though sentence against moral sin may not be speedily executed, yet every infraction of hygienic rules is immediately visited with suffering. In this respect be sure your sin will find you out, for it is an inflexible law of nature, without variableness or shadow of turning, that all her violators shall individually and peremp- torily be punished. All military men ought especially to be vaccinated. Cheerfulness, too, is a great promoter of health, as a con- sciousness of right is to courage. As the camp is no place for the sick, the sanitary question is the all important one with the surgeons. Five to ten per cent more die from diseases contracted during a campaign than in battle, and whenever possible, hospitals or barracks should be provided for the sick, particularly during epidemics. We are to recollect too that our volunteers are gentlemen, and not drafted or mercenary troops ; and in their treatment, if a distinction is made in favor of any class in the army, it should be the soldier in the ranks, who, in every sense, bears the heat and burden of the day. Nashville Journal of Medicine and Surgery, July 18G1. In view of the great want of some convenient work on Military Sur- gery, we present in the present number the first portion of a valuable little Treatise recently published by Dr. S. D. Gross, of Philadelphia, *Thc book trade between the two sections of the continent having been interrupted, it has rendered it impossible for the publishers to furnish the work. We do not consider that their rights or those of the distin- guished author are in the least violated by giving the work to the Profession, serially, to the extent of the circulation of a single Medical periodical. M 5 trgery. A Manual of Military &ur$ the Emergen Camp, a . By B. D. Gross, \[. J). Professor ot% Surgery in the Jefferson Medical College of Philadelphia. CHAPTER 1. HISTORICAL SKETCH OF MILITARY SURGERY. The duties and requirements of military are essentially similar to those of civil surgery. It is founded upon the same knowledge of anatomy, medicine, and the associate sciences ; it demands the same qualifications, physical, moral, and intellectual. The difference consists in the application of our knowledge rather than in its range or depth. The civil surgeon remains at home ; the military follows the army, examines recruits for the public service, and superintends the health of the troops. If the former ;- well educated, he will be quite as competent, at any time, as the latter to perform these duties ; for the emer- gencies of civil are often not less trying than those of mili- tary practice, although they may not he on so large a scale. The best civil have often also been the best military sur- geons. In proof of th ion it is necessary only to r to the names of Pare, Wiseman, Schmucker, Kern, Larrey, Guthrie, Charles Bell, Alcoek, Thomson, Ballin- gall, and Macleod, of Europe ; or to those of Rush, Jones, icher, Mann, and Horner of our own country. Military surgery occupies, at the present day, a deserved- ly high rank in the estimation both of the profession and of the public. The war in the Crimea, the mutiny in India, and the recent convulsions in Italy, ail attended with iUeh waste of blood and life, have attracted to it t\ic uui- ud attention of the profession ; and the revolutionary movements now in progress in our own country invest it with a new and feartul interest to every American phj ciau. Its praises have bee: by Homer, ami, in all - of the world, governments have extended to it a fos- and. As a distinct branch, however, of the heal- ing art, it dates back no further than the early part of the enth century, when it was inaugurated by Ambrose Pare, by the publication of his treatise on "Gunshot 530 Military Surgery. [July? Wound-." the fruits of his observations in the French army in [taly. This man, who was surgeon to four successive kings, was an eye-witness of the numerous French cam- paigns, from L536, down to the battle of Moncontour, in L569, a period of thirty-three years* His popularity, both aa a civil and military surgeon, was, up to that time, with- out a. parallel. The soldiers worshiped him ; and the suc- cess of more than one siege, aswell as of one battle, wasdue almosl exclusively to the wonderful influence of his pres- ence. His treatise on "Gunshot Wounds" appeared to- ward, the middle of the sixteenth century, and, after hav- ing passed through various editions, was ultimately incor- porated in his surgical writings, published nearly a quarter of a century later. In England, the earliest work on military surgery was that of Thomas Gale, entitled a " Treatise on Gunshot Wounds." designed chiefly to confute the errors of some of his contemporaries, respecting the supposed poisonous nature of these lesions. Gale was horn in 1507, and after having served in the army of King Henry YIIL, at Mon- trieul, and also in that of King Philip, at St. Quintin, tin ally settled at London, where he acquired great distinc- tion in his profession. In 1G39 appeared the work of J. Woodall, "The Suigeon's Mate; or, Military and Domestic Surgery."' lie was surgeon under Queen Elizabeth, by whom he was sent to France, along with the troops that were dispatched to the assistance of Henry IV. and Lord Willoughby. In 1676, Richard "Wiseman, sergeant-surgeon to King Charles 11., published his famous "Chirurgical Treatises," one of which was expressly devoted to the con- sideration of gunshot wounds. Two years after this a treatise on gunshot wounds was published at London, by John lb-own, also surgeon to Charles. He was a man of eminence, and served with much credit in the Dutch war of 1665. The next English work on military surgery ap- peared in 1744, from the pen of John Ranby, sergeant- surgeon to George li., under the title of "The Method of r Gunshol Wounds." After Ranby came the im- shable work of John Hunter, familiar to every reader English surgical literature. The part relating to gun- shot WOunds was founded upon his observations made while serving as staff-surgeon at Belleisle and in Portugal, and is one of the most precious legacies of the last cen- tnrv, near the close of which if appeared. L861.] MUitary Surgery. 631 The present century has supplied quite a number of works on military surgery, as is shown by the valuable publications of La r rev, Bennen, Becker, Angustin, Guth- rie, Thomson, Hutchinson, Ballingall, Baudens, and others, which have contributed BO much to the elevation of this department of the healing art. Some of these works have been re-issned in this country, and have acquired a wide celebrity. We must not forget, in this rapid enumeration of works on military surgery, the "Manuel de Chirurgien d'Armee" of Baron Percy, published at the commencement of the revolutionary war in France. It is a model of what such a treatise ought to be. The ouly work on this department of science yet fur- nished in this country, is that of the late Dr. James Mann, published at Dedham, Massachusetts, in 181ri. It is enti- tled " Medical Sketches of the Campaigns of 1812, '13, and '14,'' and forms a closely-printed volume of upwards of three hundred octavo pages. The latest treatise on this subject in the English language is that of Dr. George II. D. Macleod, now Professor of Surgery at Glasgow, entitled "Notes on the Surgery of the "War in the Crimea; with remarks on the Treatment of Gunshot Wounds." Jt is a work of intense interest, writ- ten with great ability by an accurate and diligent observer, and is worthy of a place in every medical library. To this work frequent reference will be made in the following pages. To Dr. Lewis Stromeyer, Physician of the Royal Han- overian Army, we are indebted for the most recent German work on military surgery, it was issued in 18o8, under the title of "Maximen der Krieg&heilkunst," in two duo- imo volumes, to which a Supplement was added in the early part of the present year. A more valuable contribu- tion to this department of surgery could hardly be im- agined. Besides the above more recent work-, the reader should carefully study the "Principle- of Military Surgery," by the late Dr. John llennen, one of the m08l zealous and distinguished military surgeons that Great Britain has yet produced; a man of vast experience and of tin- most en- lightened views upon everything he has touched with his pen. Perhaps the most systematic work on the subject in the English language is that of Sir George Ballingall, entitled ,")3^ Military Surgery. [July, "Outlines of Military Surgery," the last edition of which. the fourth, appeared only recently at Edinburgh, where the author held for many years the chair ot military surgery, for a long time, we believe, the only one in Great Britain. It is a production of much merit, and is destined to main- tain a very high rank in this species of literature. The works of the late Mr. George Guthrie also deserve attentive study ; they are written with great clearness and ability, and embody the results of an immense experience, acquired during many years of arduous and faithful labor and observation in the British army. I have always re- garded the works of this great man as among the most valuable contributions, not only to military surgery, but to surgery in general, in the English language. With these works before him, the student of military surgery cannot tail to make himself in a short time per- fectly familiar with everything pertaining to the subjects of which they treat. He should also provide himself with a ropy of the excellent little volume entitled " Hints on the Medical Examination of Recruits for the Army," by the late Dr. Thomas Henderson, formerly Professor of Medicine in Columbia College, Washington City. A new edition of it was published a few years ago by Br. Richard IT. Coolidge. of the 'United States army. Although we have long had one of the most respectable and thoroughly organized army and navy medical staffs in the world, our country has, neverlheloss, not produced one great military surgeon ; simply, it may be presumed, be- cause no opportunity has occurred since the establishment of our government in which the men iu the public service could distinguish themselves. Their aid has been required in the duello and in skirmishes rather than in great battles, such as have so often characterized the movements of the armies of the Old World. We make no exception in this remark in favor even of the battles that were fought during the Revolution, and during our Late War, as it has usually been designated, with Great Britain. Those engagements were, for "the most part, comparatively bloodless. Happily living under a Hag which, until recently, commanded alike the respect and the admiration of all nations, belonging to a government which was at peace with all foreign powers, the medical and surgical staffs of the public service had little else to do than to prescribe for such diseases as are incident to civil practice. America has never witnessed. 1861.] MUtiary Surgery. and we trust in Grod she never may witness, such ear naff c as that which attended the footsteps of Napoleon at the bridge of Lodi, at Leipzig, at Dresden, and at Waterloo ; or which, more recently, characterized the exploits, of the English, French, and Russian forces in the Crimea; or of the French, Italian, and Austrian armies in Italy; or of the English soldiers during ihe late rebellion in India. No** has she ever been engaged in one great naval battle similar to that of La Hogue, Toulon, Trafalgar, or Aboukir. A number of highly respectable physicians accompanied our army to Mexico, but they returned without any special laurels, and without any substantial contributions to mili- tary medicine and surgery. CHAPTER II. [IMPORTANCE OF MILITARY SUROERY. It is impossible for any civilized nation to place too high an estimate upon this branch of the public service. With- out the aid of a properly organized medical staif, no army, however well disciplined, could successfully carry on any war, even when it is one, as that which is now impending over us, of a civil character. Xo men of any sober reflection would enlist in the service of their country, if they were not positively certain that competent physicians and sur- geons would accompany them in their marches and on the tield of battle, ready to attend to their diseases and acci- dents. Hence military surgery, or, more correctly speak- ing, military medicine and surgery, has always occupied a deservedly high rank in public estimation. Dionis, a surgeon far in advance of his age, in referring to the value of medical services to soldiers, exclaims, with a burst of eloquence : k'Wo must then allow the necessity of chirurgery, which daily raises many persons jrom the brink of the grave. How many men has it cured in the. army ! How many great commanders would have died of their ghastly wounds without its assistance ! Chirurgery triumphs in armies and in sieges. Tis true that its empire is owned: 'tis there that its effects, and not words, cxpi uloguim." The confidence reposed by soldiers in the skill and hu- manity o^ their sunreon ha? often been of signal service in 534 Military Surgery. [July, supporting them, when exhausted by hunger and fatigue, in their strugles to repel the advancing foe, or in success- fully maintaining a siege when the prospect of speedy sur- render was at hand. Who that is versed in the history of our art does not remember with what enthusiasm and re- solve Ambrose Pare, the father of French surgery, in- spired the souls of the half-starved and desponding garri- son at Metz, in 1552, when besieged by 100,000 men under the personal command of Charles V. ? Sent thither by his sovereign, he was introduced into the city during the night by an Italian captain ; and the next morning, when he showed himself upon the breach, he was received with shouts of welcome. "We shall not die," the soldiers, exclaimed, "even though wounded; Pare is among us." The defense from this time was conducted with renewed vigor, and the French army ultimately completely triumph- ed, through the sole influence of this illustrious surgeon. No man in the French army under Napoleon rendered so many and such important services to the French nation as Larrey, the illustrious surgeon who accompanied that mighty warrior in his various campaigns, everywhere ani- mating the troops and doing all in his power to save'them from the destructive effects of disease and injury. His humanity and tenderness was sublime ; and so highly was his conduct, as an honest, brave, and skillful surgeon, ap- preciated by Xapoleon, that he bequeathed him a large sum, with the remark that "Larrey was the most virtuous man he had ever known." CIIAPTEPv HI. QUALIFICATIONS AND DUTIES OF MILITARY SURGEONS. It is of paramount importance that none but men of the best talent and of the highest education should be received into the public service. Rigid as the examination of the army and navy medical boards already are, there is need of increased rigor, in order that none may be admitted who arc not thoroughly prepared for the discharge of their re- sponsible duties. Equal vigilance should be exercised in regard to the introduction of physicians and surgeons into the volunteer service. Every regiment should be provided with an able medical head, a man ready for every emer- 1 1. "] Military Surg* \ >''> agency, however trying or unexpected ; a man skilled in the diagnosis and treatment of diseases, and competent to form any operation, whether small or largo, on the spin* of the moment. To do this, he must be hiorc than a mete physician; he must be both a physician and surgeon, in the true sense of the terms, otherwise he will he unfit, totally unlit, for his position. He must have heen educated in the modern schools; be of undoubted courage, prompl willing to assume responsibility, humane and sympathizing, urbane and courteous in his manners ; in short, a medical gentleman, as well as a medical philosopher, not hesitating, if need be. to perform the most menial services, and to do all he can to preserve the health and the lives of the sol- diers committed to his. care. The white-gloved such as figured in some of the regiments that went to Mexico, have no business in the service; their time can be much better spent in the discharge of their domestic du1 in the practice of their neighborhood, and in the contem- plation, at a distance, of the miseries of war. It i- much to be feared that, from the rapid man: which our volunteers have been hurried together, many medical men, old as well as young, have already been ad- mitted into the g utterly unfit for the ofii fthis be the case, let our authorities, warned by the past, bo more circum gard to the future. Above all, them sec that the medical staffs of the bin'/.- volunl the country be notdefiled by charlatans and unworthy men, between whom and the regular practitioners there possibly be any professional, much less social intercourse, cither in civil or military practice. Th< al men should be on the b< ible terms with each other; all f discord aud bickering among th< mid studiously obviated, and speedily suppressed, if, unfor- tunately, they should a> ' :t of action on the part of the medi<-al corps is in\ the courtesy of the gentleman, not the asperity of the enemy. They should not forget that they are brethren of the same noble profession, acting in the capacity of minis- tering angels to the sick and dying. Country and cause alike should be forgotten in generous deeds. By the usages of war in all civilized countries, the sur- qs are always respected by the enemy if, during an en- ment, they happen to fall accidentally into their hands. Their lives arc regarded as sacred, the more so, as they are comparatively defenseless. They are not, however, during the rage and smoke of the battle-field, always easily distin- guishable from the other officers, or even the common sol- diers. The green sash, their distinctive badges of office, does not always afford them immunity, because it is not always recognized ; and it is worthy of consideration whether, as an additional safeguard, the word "surgeon' should not be embroidered in legible characters upon a piece of cloth, to be thrown across the chest in time of battle. The significance of such a badge could not be mis- taken by friend or foe, and would be the means of saving many valuable lives. I ilAPTEJi IV. MEDICAL EQUIPMENT AND HOSPITALS. Every regiment, or body of military men, should be am- ply provided, in time of war, with the means of conveying the wounded and disabled from the field of battle. For this purpose suitable carriages and litters should constantly be in readiness. The carriages should be built in the form of light wagons, drawm each by two horses; with low wheels, easy springs, and a large wide body, furnished with a soft mattress and pillows, and capable of accommodating not less than eight or ten persons, while arrangerm might be made atti for seating a number more, in the French A ;, I ;in>r the sun and the rain, it should have a light cover of oil- cloth or cam, . reat number of Uttei'8, or bearers, will be found de- scribed in ( on military surj at 1 am not ac- quainted with any which combine so much simplicity and Military Surgery. [July. cheapness, with lightness and convenience, as one which, after a good deal of reflection, I have just devised. It con- sist of two equal parts, conducted at the ends hy stout hinges, the arrangement being such as to permit of their being folded for the more easy transportation on the held of battle. Each part has a side piece of wood, three feet four inches long, by two inches in depth, and an inch and a half in thickness, the free extremity terminating in a slightly curved handle. The side pieces are united by four traverses, and the entire frame is covered with ducking, twenty-four inches in width. Thus constructed, the'appa- ratus is not only very light, so that any one may easily carry it, or, indeed, even three or four at a time, but re- markably convenient both for the transportation of patients, and for lifting them in and out of the wagons, which should always be at hand during and engagement. Moreover, by means of side straps, provided with buckles, it will answer extremely well for a bed-chair, so necessary in sickness and during convalescence, the angle of flexion of the two pieces thus admitting of ready regulation. In carrying the wounded off the field, the labor may easily be performed by two men, especially if they use shoulder-straps to diffuse the weight of the burden. The body, in hot weather, might be protected with an oil-cloth, while the face might be shielded from the sun with a veil or handkerchief. A pillow for the head can be made with the coat of one of the carriers. Besides these means, every regiment should be furnish- ed with an ambulance, or, as the term literally implies, a movable hospital, that is, a place for the temporary accom- modation and treatment of the wounded on the held of battle. It should be arranged in the form of a tent, and be provided with all the means and appliances necessary for the prompt succor of the sufferers. The materials of which it consists should be as light as possible, possess every facility for rapid packing and erection, and be conveyed from point to point by a wagon sot apart for this object. The ambulance, for the invention and improvement of which we are indebted lo two emineul French military sur- geons, Percy and Larrey, is indispensable in every well- regulated army. Tl lis temporary hospital should be placed in an open pace, convenient to water, mid upon dry ground, with ar- for the free admission of air and li^ht, which, 1861.] Military Surgery. 539 next to pure air. is one of the most powerful stimulants in all eases of accident attended with excessive prostration. The direct rays of the sun, in hot weather, must of course be excluded, and it may even he necessary, as in injuries of the head and eye, to wrap the patient in complete darkn< A properly regulated temperature is also to be maintained, a good average being about G8 of Fahrenheit's ther- mometer. As engagements are sometimes begun after dark, or are continued into the night, an adequate supply of wax can- dles should be provided, as the}' will be found indispensa- ble both in fielc^and hospital practice, in performing opera- tions and dressing wounds and fractures. Torches, too, will frequently be needed, especially in collecting and trans- porting the wounded. Bed-pans, feeding-cups, spoons, syringes, and other appliances usually found in the sick chamber, will form a necessary part of the furniture of such an establishment. The object of the ambulance is, as already stated, to afford prompt succor to the wounded. Here their lighter injuries are speedily dressed, and the more grave subjected to the operations necessary for their cure. In due time, the former are sent back to the ranks, while the rest are conveyed to suitable lodgings or to permanent hospitals. As soon as practicable, after the hurry and confusion attendant upon a combat are over, the surgeon should clas- sify the wounded and disabled, taking care that those laboring under similar lesions are not brought in close con- tact; lest, witnessing each other's sufferings, they should be seized with fatal despondency. Larrcy, in order to meet the exigencies of the grand army in Italy, constructed a flying arnJndanct ; an immense, and, at first sight, a very cumbersome establishment. It listed of twelve light wagons, on easy springs, for the transportation of the wounded ; some with two, others with four wheels. The frame of the former, which wore design- ed for flat, level countries, resembled an elongated cube. curved on the top ; it had two small windows on each side, with a folding door in front and behind. The floor of the body, separable and movable on rollers, was covered with a mattress and bolster. Uandl curedtoit laterally, through which the sa-lie^ . Depressants : tartrate of antimony and i ipe- cacuanha, and tincture of veratrum. viride. 4. Diaphoretics: antimony, ipecacuanha, nitrate ofpo- . morphia, and Dover's powder. >. Diuretics: nitrate and carbonate ofpotassa, and col- chicum. 6. Antiperiodics : quinine and arsenic. 7. Anaesthetics: chloroform and ether. Simulants : brandy, gin, wine, and aromatic spirits of ammonia. Astringents: acetate of lead, perchloride of iron and alum, tannin, gallic acid, and nitrate of sih 10. Escharotics: nitric acid, acid nitrate of mercury, (Bennett's formula,) and Vienna pa 2d. The surgical armamentarium should ah aple as possible. It should embrace a small po with tcw catheter; a full amputating case, with at least three tourniquets, tw of different ,id several I; bone-nippers ; and, lastly, a trephining i Several silver 'athoter- of different Bizes, a stomach pump, small rind 542 Military Surgery. [July, large syringes, feeding-caps and bed-pans should also he put up. 3d. Under the head of apparatus may he included "banda- ges, lint, linen, adhesive plaster, splints, cushions, wadding, and oiled Bilk. The bandages, composed of tolerably stout muslin, should be free from starch and selvage, well rolled, on an average, from two inches and a quarter to two inches and a half in width by eight yards in length. The bandage of Scultetus, very serviceable in compound factures, can easily be made, as occasion may require, out of pieces of the common roller. Of lint, the patent, or apothecary's, as it is termed, is the the best, as it is soft and easily adapted to the parts to which it is intended to be applied. Old linen or muslin also an- swers sufficiently well. Charpie is now seldom used. An abundance of adhesive plaster, put up in small cases, should be provided. Collodion will not be necessary. Splints, of binders or trunk-maker's board, and ot light wood, should find a place in every medical store, as fre quent occasions occur for their use. In fractures of the lower extremity special apparatus may be required, which, however, as it is cumbrous and inconvenient to carry, may generally be prepared as it is needed. Cushions are made of muslin, sewed in the form of bags, of variable size and shape, and filled with cotton, tow, saw- dust or sand. They are designed to equalize and ward off pressure in the treatment of fractures of the lower ex- tremities. Wadding is a most valuable article in surgical practice, both for lining splints and making pads, as well as in the treatment of burns and scalds, and cannot be dispensed with. Oiled Silk is a prominent article in the dressings of the present day ; it preserves the heat and moisture of poultices and of warm water-dressings, at the same time that it protects the bed and body-clothes of the patient. Oil-cloth, soft and smooth, is required in all cases of severe wounds and fractures, attended with much discharge. Air-cushions should be put up in considerable numbers, as their use will be indispensable in all cases of disease and injury involving protracted confinement. Bran and saw-dust will be found of great value in the treatment of compound fractures, ulcers, gangrene, and L86L] Mil* l>i.i 548 suppurating wounds, as an easy support for the injured limb and a means of excluding flies. Medical t should be put up along with the other articles, for the accurate registration of the names of the sick and wounded, the nature ul' their lesions, and the re- sults of treatment. The medical officers should also keep a faithful record of the state of the weather, the tempera- ture of the air, the nature oi' the climate, the products of the soil, and the botany oi' the country through which they or in which they sojourn, together with such matters as may be of professional or scientific interest. The knowl- edge thus acquired should he disseminated alter their re- turn for the benefit of their professional brethren. Finally, in order to complete hospital equipments, well- trained nurses should be provided ; for good nursing is in- dispensable in every case of serious disease, whatever may be its character. The importance of this subject, however, is now so well appreciated as not to require any special comments here. The question as to whether this duty should be perform- ed by men or women is of no material consequence, pro- vided it be well done. The eligibility of women for this task was thoroughly tested in the Crimea, through the agen- cy of that noble-hearted female, Florence Xightingale ; and hundreds of the daughters of our land have already tendered their services to the government for this object. Xo large and well regulated hospital can get on without some male nurses, and they are indispensable in camp and tield practice. It is not my purpose here to point out the qualities which constitute a good female nurse. It will suffice to say that she should be keenly alive to her duties, and perform them, however menial or distasteful, with promptness and alacrity. She must be tidy in her appearance, with a cheerful countenance, light in her step, noiseless, un- der and thoughtful in tier manners, perfect mistress her feelings, healthy, able to bear fatigue, and at l< twenty-: f age. Neither the crinoline nor the silk dress must enter into her wardrobe; the former is too cumbrous, while the latter by its rustling is sure to fret the patient and disturb his sleep. Whispering and wal king- in on ti] has been truly observed by Florence X: a ingale, are an abomination in the sick chamber. Finally, a good nurse never fails to anticipate all, or nearly all, the more important wants of the Bunerer. Among other things t<> be specially attended to in nurs- 544 Military Surgery. [July. \S\s^r^r^/ ing is ventilation. Persons visiting the sick must at once be struck with the difference of pure air in those chambers where a proper ventilation exists and those where the re- verse is the case. To insure this the fresh air should always be admitted from a window not open directly on the bed, or causing the patient to be in a draught. Even in winter it is highly proper that fresh air should be admitted some time during the day when there is a good fire and the patient well protected by covering. The pillows, bedding, and bedclothes should be well aired and often changed, as also the flannel, under-gar- mcnt8, and night-dress. To facilitate this, it is well, when the patient is very ill and unable to help himself, to have the shirt open all the way down in front, and buttoned up. The patient often escapes great suffering and annoyance by this simple method. Where there is a discharge from the sores, or when water-dressing arc applied to a limb, it is advisa- ble to place the latter upon a folded sheet with a thin, soft oil-cloth underneath. Great tenderness and cleanliness should be used in dressing wrounds or sores. Old linen, muslin, and lint should always be had in readiness for this purpose. A great prejudice exists against the use of mus- lin, the preference being generally given to linen, but the former is really quite as goed as the other, if it is soft and old. In regaid to the cleanliness of a sick-room, it is advisable to use a mop occasionally for the removal of flue from un- der the bed ; when, however, the patient is in too" critical a situation for dampness, a few tea-leaves scattered over the apartment will absorb the dust, and can be quietly taken up with a hand-brush. A frequent change of bed linen is very beneficial when practicable, and the clothes must al- ways be folded smoothly under the patient. Great clean- liness should be observed in all the surroundings of the sick-room, and particular attention must be paid to the glasses in which medicine is given, in order to render the doses as palatable as possible. The patient should be washed whenever able, and his teeth and hair w7ell attend- ed to. The body seems infused with new vigor after such ablutions. A frequent change of posture is immensely conducive to the comfort and well-being of a sick person, if performed with a careful eye to his particular condition. Severe pain, los of sleep, excessive constitutional irritation, and dread- [861. | Military Surgery. 54o tal bed-sores are Bure to follow, in all low states of the jin, if this precaution be not duly heeded. No patient must have his head suddenly raised, or be permitted to Lie high, when he is exhausted from shock, hemorrhage, or sickness. Many lives have been lost by this indiscretion. The apartment must be free from noise, the light should neither be too freely admitted nor too much excluded, ex- cept in head and eye affections, and the temperature must be regulated by the thermometer, from 65 to 68 of Fahrenheit being a proper average. As the patient acquires strength, he may gradually sit up in bed, propped up at first by pillows, and afterward by a bed-chair. His food and drink, and also, at times, his medicine, must be given from a feeding-cup during the height of his and a good general rule is to administer them with great regularity, provided this does not interfere too much with his repose. If he is very weak, and sleeps very long, it will be necessary to wake him in order to give him nourishment ; but, in general, sleep is more refreshing than food, and more beneficial than medicine. The bed- pan and urinal of course find their appropriate sphere un- der such circunistan* As the appetite and strength increase, the patient is per- mitted to resume, though very gradually, his accustomed diet and to exercise about the room, if not in the open air. After severe accidents and protracted sickness, a wise man will not bestir himself too soon or too much, but court the tickle goddess of health with becoming caution. Dying patients >hould be carefully screened from their neighbors, placed in the easiest posture, have free access air, and be not disturbed by noise, loud talking, or the presence of persons not needed for their comfort, A - soon as the mortal struggle i< over, the body must he re- ed. should be removed a8 speedily as possible from the apartment, and the vessels in which they are ceived immediately well scalded, the air being at the same tim< tly purified by ventilation, or ventilation and disinfectants. Finally, the nurse must tak '.'.'. She must, have re.-,t, or she will soon break down. If she i obliged to be up all night, .-ho should be spared in the daw In' Military Surgery. [July, OHAPTEB V. WOUNPy AM nrin;i; | .\.| [' R \\'<. The injuries inflicted in Avar are, in every respect, similar to those received in civil life. The most common and impor- tant are fractures, dislocations, bruises, sprains, hurnsand the different kinds of wounds, as the incised, punctured, lacer- ated, and gunshot! With the nature, diagnosis, and mode of treatment of these lesions every army surgeon must, of course, he supposed to be familiar; and I shall therefore limit myself, in the remarks which J am about to offer upon these subjects, to a few practical hints respecting their management on the Held of battle and in the ambulance. Most of the cases of fractures occurring on the field of battle are the result of gunshot injury, and are frequently, if not generally, attended by such an amount of injury to the soft parts and also to the bone as to demand amputa- tion. The bone is often dreadfully comminuted, and con- sequently utterly unfit for preservation. The more simple fractures, on the contrary, readily admit oi' the retention of the limb, without risk to life. In transporting persons affected with fractures, whether simple or complicated, the utmost care should be used to render them as comfortable as possible, by placing the in- jured limb in an easy position, and applying, if need be, on account of the distance to which they have to he carried. of the mode of conveyance, short side splints of binders' board, thin wood, as a shingle, or junks of straw, gently confined by a roller. For want of due precaution the dan- ger to limb and life may be materially augmented. Per- manent dressings should be applied at the earliest moment after the patient reaches the hospital. If the fracture be attended with splintering of the bone, all loose or detached pieces should at once be extracted ; a proceeding which always wonderfully simplifies the case, inasmuch as it pre- vents, in a great measure, the frightful irritation and sup- puration which are sure to follow their retention. When this point has been properly attended to, the parts should be neatly brought together "by suture, and covered with a compress wet with blood. As soon as inflammation arises not before water-dressings are employed. A suitable opening, or bracket, should bo made in the apparatus to facilitate < Ira in age and dressing. >61.] Military <>V/'7< /;>/. 547 HxUious, accidents by no moans common in military' erations, arc treated according- to the general rules ot actice; they should be speedily reduced, without the aid ' chloroform, if the patieni is faint or exhausted: with doroform, it' he is strong or reaction has been fully estab- ihed. The operation may generally l^e successfully per- rmed by simple manipulation ; it, however, the case ih >stinate, pulleys may he necessary, or extension and oonn- r-extension made by judicious assistants. or contusions, unless attended with pulpiticatiotn soiganization, or destruction of the tissues, are best treat- 1, at first, until the pain subsides with tepid water impreg- ited with laudanum and sugar of lead, or some tepid urituous lotion, and afterward, especially if the patient )><> rong and robust, with cold water, or cold astringent fluids, the injury be deep seated, extensive, and attended with sion ot very importaut structures, the case will be a seri- is one, liable to be followed by the worst consequences, squiring, perhaps, amputation. are often accompanied with excessive pain and re constitutional symptoms. They should be gated with the free use of anodynes and with warnmvater- -essings medicated with laudanum, or laudanum and lead, he joint must be elevated and kept at rest in an easy :>sition. Leeches may be applied, if they can be obtained ; :her\vi>e. if plethora exisf, blood may be taken from the le arm. By-and-by sorbefacient liniments and friction jinein play. Passive motion should not be instituted too on. Among the accidents of Avar arc barns, and, occasionally, ilds. The former may be produced by ordinary tire by the explosion of gunpowder, either casual or from the owing up of redoubts, bridge-, houses, or arsenals, and rv irom the trivial to the mosl serious lesions, involving peal extent of surface or of tissue, and liable to be follow- by the worst consequences. Such injuries always re- tire prompt attention ; for, apart from the excessive pain A collapse which so often accompanv them, the longer ev remain uneared for the more likely will they be to end idly. Various remedies have been proposetl for these injuries, lave myself always found white-lead paint, such as that nployed in the arts, mixed with linseed oil to the consist- ice of very thick cream, and applied so ;t< t<> form ;< com- .")4S Military Surgery. [July? plete coating, the most soothing and efficient means. The dressing is finished by enveloping the parts in wadding, con- fined by a moderately tight roller. It should not be re- moved, unless there is much discharge or swelling, foi several days. If vesicles exist, they should previously be opened with a needle or trie point of a bistoury. A lini- ment or ointment of glycerin, lard or simple cerate, and subnitrate of bismuth, as suggested by my friend, Profes- sor T. (i. Richardson, of New Orleans, is also an excellent remedy, and may be used in the same manner as the white lead paint. In the milder cases, carded cotton, cold water, and alcohol, water and laudanum, generally afford prompt relief. Amputation will be necessary when there is exten- sive destruction of the muscles, bones or joints. Reaction must be promoted by the cautious use of stimulants; while pain is allayed by morphia or laudanum given with more than ordinary circumspection, lest it induce fatal op- pression of the brain. En burns from the explosion of gunpowder, particles of this substance are often buried in the skin, where, if it be not removed, they leave disfiguring marks. The best way to get rid of them is to pick out grain after grain with the point of a narrow-bladed bistoury or cataract needle. The subject of wounds is a most important one in regard to field practice, as these lesions are not only of frequent occurrence, but present themselves in every variety of form arid extent! Their gravity is influenced by numerous cir- cumstances which our space does not permit us to specify but which the intelligent reader can readily appreciate. 1 many cases death is instantaneous, owing to shock, or shoe and hemorrhage ; in others it occurs gradually with or without reaction, at a period of several hours, or, it may be, not under several days. Sometimes men arc destroyed by shock, by, apparently, the most insignificant wound 01 injury, owing, not to want of courage, butto some idiosynj 'v:\cy. Tne indications presented in all wounds, of whatever na- ture, are 1st, to relieve shock ; 2dly, to arrest hemorrhage: ;>dly, to remove foreign matter: 4thly, to approximate anc retain the parts: and, ^pthly, to limit the resulting infiam nmtion. 1. It is not necessary to describe minutely the symptoms of shock', :\< the nature of the case is sufficiently obvious i tiral sight, from the excessive pallor of the countenance, tin I8t>l,] Military .wwallow; aided, it'tlie ease be urgent, by sinapisms t<> the region of the heart, the inside of thighs and the spine, and stimulating injections, as brandy, turpentine, mustard, or ammonia, in a few ounces of water. Xo fluid must he put into the mouth so long as the power of deglutition i- gone, lest some of it should enter the windpipe, and bo occasion suffocation. Whatever the cause of the shock may have been, let the medical attendant not tail to encourage the sufferer by a kind and soothing expression, whieh is often of more value in recalling animation than the best cordials. I hiring an actual engagement, the medical officers, as well as their servants, should carry in their pockets such articles as the wounded will be most likely to need on the Held of battle, as brandy, aromatic spirits of hartshorn, and morphia, put up in suitable doses. -. The / /-: may he arterial or veiious. Or both arterial and venous, -light or profuse, primary or ndary, external or internal. The scarlet color and sal- tatory jet will inform us when it is arterial: the purple hue and steady flow, when it is venous. When the wound is ire, or involving a large artery or vein, or even middle- sized vessels, the bleeding may prove laud in a few minute- unless immediate assistance is rendered. Hundreds of her- etic on the Held of battle from 1 his cause. Tliey allow their life current to run out. as water pours from a hydrant, without an attempt to .-top it by thrusting the finger in tie wound, or compressing the mam artery of the injured limb. They perish simply from their ignorance, because the I mental Burgeon has failed to give the proper instructibn. h ary that the common soldier should carry a Petit* s tourniquet, but every one may put into his pocke stick ;. Bix inches lung, and a handkerchief orpieceof r, with a thick com] id be advised how, where, and when they arc to be used. By casting the handk chief round the limb, and placing the compress over its main artery, he can, by means or the stick, produce sncli V<) Military Surgery. [July* ail amount of compression as to put at once an effectual stop to the hemorrhage. This simple contrivance, which lias been instrumental in saving thousands of lives, consti- tutes what is called the field tourniquet. A fife, drum-stick, knife or ramrod may be used, if no special piece of wood is at hand, The most reliable means for arresting hemorrhage per-, manentlv is the ligature, of strong, delicate, well-waxed silk, well applied, with one end cut off close to the knot. Acu- pressure is hardly a proper expedient upon the battle-field, or in the ambulance, especially when the number of wound- ed is considerable. The rule invariablyis to tie a wounded artery both above and below the seat of injury, lest recur- rent bleeding should arise. Another equally obligatory precept is to ligature the vessels, if practicable, at the place whence the blood issues, by enlarging, if need be, the original wound. The main trunk ot the artery should be secured on lv when it cannot be taken up at the point just mentioned. Lastly, it is hardly requisite to add that the operation should be performed, with the aid of the tourni- quet, as early as possible, before the supervention of inflam- mation and swelling, which must necessarily obscure the parts and increase the surgeon's embarrassment, as well as the patient's pain and risk. Venous hemorrhage usually stops spontaneously, or readi- ly yields to compression, even when a large vein is impli- cated. The ligature should be employed only in the event ofabsplute necessity, for fear of inducing undue inflaniraa- tion. Torsion is unworthy of confidence in field practice, and the same is true of styptics, except when the hemorrhage is capillary, or the blood oozes from numerous points. The most approved articles of this kind are Monsel's salt, or the persulphate of iron and the perchloride of iron ; the latter deserving the preference, on account, of the superiority of it hemostatic properties. Alum and lead are inferior styp- tics. Temporary compression may be made with the tourniquet, M- ;i compress and a roller. It; may be direct, as when the compress is applied to the orifice of the bleeding vessel, or indirect, as when it is applied to the trunk of the vessel, at some distance from the wound. Constitutional treatment in hemorrhage i< of paramount importance. It comprises perfect tranquility of mind and L86L] MilUary Surgery. 551 body, cooling drinks, t mild, concenrated nourishing diet, icially when there has been 9 loss of blood, ano- dynea to allay pain, induce sleep, and allay the heart's inor- dinate action, fresh air. and a properly regulated light, internal hemorrhage in more dangerous than external. ause it is generally inaeessible. The chief remedies arc lous venesection, elevated position, opium and acetate ot ol air, and eool drinks. Exhaustion from hemorrhage should be treated accord- ing to the principles which guide the practitioner in < severe shock. Opium should be given freely as soon af reaction begins to quiet the tremulous movements of the heart and tranquilize the mind. When the bleeding is in- ternal, the reaction should he brought about gradually, not hurriedly, lest we thus become instrumental in promoting Eciungthe hemorrhage. clary hemorrhage comes on at a variable period, from a few hours to a number oi days; if may depend upon imperfect ligation of the arteries, ulceration, softening a of these vessels, or upon undue striction ^t' the tissues by tight bandage-. In some cases it i- venous, and may then be owing to inadequate support of the parts, Whatever the cause maybe, it should bo promptly searched out, and removed. The third indication is to remove alt fan This should lc done at once and effectually; with spo and water, pressed upon the parts, with linger, or finger forceps. X<>t a particle of matter, not ahair, or the smallest riot of blood must be let! behind, otherwise it will be sure I-) produce and keep up irritation. 4. A- tin.' bleeding has been checked and ii-aueous matter cleared away, the e4ges -i' the tlyand even'; ximated and permanently retained plaster, bandage. The best suture, irritating, i- silver wire ; but if this material i- not i _. thiu, well-waxed silk is used. The adhe applied in such a manner as to admit, ot five drains required chiefly in injuries extending 'u this is the ease, it- use should the : the wound. ">. When the wound In next diitv of the Btir- to moderate th<- resulting mfarmnation. For this 562 Military Surgery. [July, purpose the ordinary antiphiogastic moans arc employed. tn general, very little medicine mil be required, except a full anodyne, as half a grain of morphia, immediately after the patient hits sufficiently recovered from the effects of his shock, and perhaps a mild aperient the ensuing morning, especially if there be constipation with a tendency to exces- sive reaction. The drinks must be cooling, and the diet light and nutritious, or Otherwise, according to the amount of depression and loss of blood. In the latter event, a rich diet and milk-punch may be required from the beginning. A diaphoretic draught will be needed if the skin is hot and arid, aided by frequent sponging of the surface with cool or tepid water. General bleeding will rarely, if ever, be re- quired ; certainly not if the injury is at all severe, or if there lias already been any considerable waste of blood and nerv- ous power. Much trouble is, at times, experienced both in civil and military practice, especially in very hot weather, in prevent- ing the access of flies to our dressing. The larvae which they deposit are rapidly developed into immense maggots, which, creeping over the wounds and sores of the patient, and gnaw- ing the parts, cause the most horrible distress. The soldiers in Syria, under Larrey, were greatly annoyed by these insects, and our wounded in Mexico also suffered not a little from them. The best prevention is bran, or light saw-dust, with which the injured parts should be carefully covered. The use of cotton must be avoided, inasmuch as it soon becomes hot and wet ; two circumstances highly favorable to incuba- tion. The best local applications are the water-dressings, either tepid, cool, or cold, according to the temperament of the patient, the tolerance of the parts, and the season of the year. Union by the first intention is, in all the more simple cases, the thing aimed at and steadily kept in view, and hence the less the parts are encumbered, moved or fretted, the more likely shall we be to attain the object. The medical attendant should have a constant eye to the condition of the bladder after all severe injuries, of whatever character, as retention of urine is an extremely common occur- rence, and should always be promptly remedied. Attention to this point is the more necessary, because the poor patient, in his comatose or insensible condition, is frequently unable to make known his wants. Such, in a few words, are the general principles of treat- 1861.] MUUary Surgery, ment to be followed in all wounds; but there are boiuo wounds which are characterized by peculiarities, and these peculiarities are of such practical importance as to require separate consideration. Of tins nature are punctured, lacer- ated, and gunshot wound-. Puneturediooands are inflicted by various kinds of weapons, as the lance, sabre, sword, or bayonet. In civil practice, they are most generally met with as the result of injur- ies inflicted by nails, needles, splinters, fragments of bone. They often extend into the visceral cavities, joints, vessels, and nerves; and are liable to be followed by excessive pain, erysipelas, and tetanus; seldom heal by adhesive action; and often cause death by shock or hemorrhage. When the vulnerating body is broken off and buried, it may be difficult to find and extract it, especially when small and deep seat- ed. When this is the case, the wound must be freely di- lated, an eye being had to the situation of the more import- iant vessels and nerves. In other respects, the general prin- ciples of treatment are similar to those of incised wounds. ( )pium should be administered largely ; and, if much ten- sion supervene, or matter form, free, incisions will be neces- sary; In I wowulSj the edges should be tacked together very gently, and large interspaces left for drainage. A small portion will probably unite by the first intention; the remainder, by the granulating process. Such wounds nearly always suppurate more or less profusely, and some of the torn andbruisedtissues not infrequently perish. The same bad consequences are apt to follow them as in punc- tured wounds. 'Warm water constitutes the best dressing, either alone or with the addition of a little spirits of camphor, opium should be used freely internally, and the diet must be supporting. mhot wounds, in their general character, partake the nature of lacerated and contused wounds. They are, of course, the most common and dangerous lesions met with in military practice ; often killing instantly, or, at all events, so mutilating the patient as to destroy him within a few hours or days after their receipt. The most formid- able wounds of the kind arc made by lie conical rifle and musket balls and by cannon balls, the hitter often carrying away the greater portion of a limb, or mashing and pulpiiy- ingthei and viscera in the most frightful and -1 tractive manner ; while the former commit terrible ravai 556 Military Surgery. ['July, violent inflammation in the soft parts, and caries or necro- sis in the hone, ultimately necessitating amputation, if not causing death. Gunshot wounds of the knee-joint are among the most dangerous of accidents, and no attempt should be made to save the limb when the injury is at all extensive, especial 1 v if it involves fracture of the head of the tibia or condyles of the femur. Even extensive laceration of the ligament of the patella should, I think, as a general rule, be regarded as a sufficient cause of amputation. In 1854, Macleod saw up- wards of forty cases of gunshot wounds of the knee in the French hospitals in the Crimea, and all, except one, in which an attempt was made to save the limb, proved fatal. Of nine cases which occurred in India, not one was saved. Guthrie never saw a patient recover from a gunshot wound of the knee-joint; and'Esmarch, who served in the Schles- wig-IIolstein wars, expressly declares that all lesions of this kind demand immediate amputation of the thigh. When, in bad cases of these articular injuries, an attempt is made to save the limb, the patient often perishes within the first three or four days, from the conjoined effects o! shock, hemorrhage, and traumatic fever. If he survives for any length of time, large abscesses are apt to form in and around the joint, the matter burrowing extensively among the muscles, and causing detachment of the periosteum with caries and necrosis of the bones. Muscles, badly injured by bullets, generally suppurate, and are very apt to become permanently useless. Special pains should therefore be taken to counteract this tendency during the cure. Large shot and other foreign bodies sometimes lodge among these structures, where their presence may re- main for a long time unsuspected. Cannon balls often do immense mischief by striking the surface of the body obliquely, pulpifying the soft structures, crushing the bones, lacerating the large vessels and nerves, and tearing open the joints, without, perhaps, materially in- juring the skin. A very terrible form of contusion is often inflicted upon the upper extremity of artillerymen- by the premature explo- sion of the gun while in the act of loading ; causing excessive commotion of the entire limb, laceration of the soft parts, and most extensive infiltration of blood, accompanied, in many cases, by comminuted fracture, and penetration of the wrist and elbow joints. The constitutional shock is frequent- 1861.] Military Swrgerff. 567 ly great. If an attempt be made to save the parts, diffusive suppuration, and more or less gangrene, will be sure to follow, bringing life into imminent jeopardy. An attempt in such a case to save the limb would be worse than useless, if, indeed, not criminal ; amputation must be promptly performed, and that at a considerable distance above the apparent seat of the injury, otherwise mortification might seize upon the stump. In the treatment oi this class of injuries, the first thing to be done, after arresting the hemorrhage and relieving shock, is to extract the ball and any other foreign substance that may have entered along with it, the next being to guard against inflammation and other bad consequences. In order to ascertain where the ball is, the limb should be placed as nearly as possible in the position it was supposed to have been at the moment of the accident. A long, stout, flexible, blunt-pointed probe, or a straight silver catheter, is then passed along the track and gently moved about until it strikes the ball. In many cases the best probe is the surgeon's finger. Valuable information may often be obtained by the process of pinching or digital compression, the ends of the fin- gers being firmly and regularly pressed against the wounded structures, bones as well as muscles, tendons, and aponeuroses. Occasionally, again, as when a ball is lodged in an extremity, its presence is easily detected by the patient, who may make such an examination as he lies in bed. The situation of the foreign body having been ascertained, the bullet-forceps take the place of the probe, the blades, which should be long and slender, being closed until they come in contact with the ball, when they are expanded so as to grasp it, care being taken not to include any of the soft tissues. If there be any loose or detached splinters of bone, wadding, or other foreign material, it should now also be re- moved ; it being constantly borne in mind that, while a ball may occasionally become encysted, and is at all times, if smooth, a comparatively harmless tenant, such substances always keep up irritation, and should, therefore, if possible, be got rid of without delay. Although preference is commonly given to the bullet-for- ceps, properly so called, as an extractor, the polypus and dres- sing-forceps, generally answer quite as well, especially the former, the latter being adapted only to cases where the for- eign body is situated a short distance below the surface, or where the wound is of unusual dimensions, admitting of tin', free play of the instrument. I )urinir the extraction, the parts should bo properly sup 558 Military Surgery. [July. ported, and if the wound is not large enough for the expan- sion of the instrument, it must be suitably enlarged. When the ball is lodged a short distance from the skin, it may often be readily reached by a counter-opening. When a bnllet is embedded in a bone, as in the head of the tibia, or in the condyles of the femur, and the parts are not so much injured as to demand amputation, extraction may bo effected with the aid of the trephine and elevator. Sometimes a bullet-worm, as it is termed, an instrument similar to that usec{ in drawing a ball from a gnu. will be very convenient lor its removal. The operation being completed, the parts are placed in an easy, elevated position, and enveloped in tepid, cool or cold water-dressings, as may be most agreeable to them and to the system. The best plan, almost always, is to leave the opening or openings, made by the ball, free, to favor drainage ana prevent pain and tension. If the track be very narrow, it may heal by the first intention, but in general it will suppur- ate, and portions of tissue may even mortify. Erysipelas, pyemia, and secondary hemorrhage are some of the bad con sequences after gunshot injuries, the latter usually coming on between the fifth and ninth day, the period of the separation of the sloughs. GIIAPTEE VI. AM CITATIONS AX1) EKSKCTIOjSs. hi endeavoring to decide so important a question as the loss of a limb, various circumstances are to be considered, a? the age, habits and previous health of the patient, the kinds of injury, and the number, nature, and importance of the tis- sues involved.' In military practice amputation must often be performed in cases where in civil practice it might be avoided. It may be assumed, as a rule, that young adults bear up under severe accidents and operations, other things being equal, much better than children and elderly subjects; the strong than the feeble ; the temperate than the intemperate: the residents of the country than the inhabitants of the crowded city. The following circumstances may be enumerated as justify- ing, if not imperatively demanding, amputation in cases of wounds, whatever may be their nature: 1861.] Military Surgery. 559 L-t. When a limb has been -truck by a cannon ball or run over by a railroad car, fracturing the bones, and tearing open the soft parts, amputation should, as a general rule, be per- formed, even when the injury done to the skin and vessels is apparently very slight, experience having shown that such accidents seldom do well, it' an attempt is made to save the limb, the patient soon dying of gangrene, pyemia, or typhoid irritation. The danger of an unfavorable termination in such a case is always greater when the lesion affects the lower ex- tremity than when it involves the superior. '2d. No attempt should be made to save a limb when, in addition to serious injury done to the integuments, muscles or bones, its principal artery, vein or nerve has been extensively lacerated, or violently contused, as the re=nlt will be likely to be gangrene, followed by death. 3d. A lacerated or gunshot wound penetrating a large joint. as. that of the knee or ankle, and accompanied by comminu- ted fracture, or extensive laceration of the ligaments of the articulation, will, if left to itself, be very prone to terminate in mortification, and is therefore a proper case for early am- putation. 4th. Gunshot wounds attended with severe comminution of the bones, the fragments being sent widely around among the -oft parts, lacerating and bruising them severely, generally require amputation, especially in naval and military practice. 5th. Extensive laceration, contusion, and stripping oft* of the integuments, conjoined with fracture, dislocation, or com- pression and publication of the muscles, will, in general, be a proper cause for the removal of a limb,* Amputation i^ not to be performed, in any case, until sufti- eient reaction has taken place to enable the patient to bear the additional shock and loss of blood. As long as he is dead- ly pale, the puke small and thready, the surface cold, and the thirst, restlessness, and jactitation exc it is obvious that recourse to the knife must be wholly out of the question. The proper treatment is recumbency, with mild stimulants, dnapisms to the extremities, and other means calculated to re-excite the action of the heart and brain. Power being re- stored, the operation, if deemed necessary, is proceeded with, due regard being had to the prevention of shock and hemorr- hage, the two things now mainly to be dreaded. One of the great obstacles about immediate amputation i- the difficulty which the surgeon so often experiences in res- \ vol. i. p. 895. <~> Military Burgqry. [July? pect to the cases demanding the operation, and the uncertain- ty that none of the internal organs have sustained fatal in- jury; a circumstance which would, of course, contra-indicate the propriety of such interference. Cases occur, although rarely, where, notwithstanding the most violent injury, or perhaps, even the loss of a limb, there is hardly any appreciable shock, and, in such an event, the operation should be performed on the spot. The results of the military surgery in the Crimea show that the success of amputations was very fair when performed ear- ly, but most unfortunate when they were put off for any length of time. This was the case, it would seem, both in the English and French armies. Should amputation ever be performed in spreading gan- grene ? The answer to this question must depend upon cir- cumstances. We may give our sanction when the disease, although rapid, is still limited, and when the patient, compar- atively stout and robust, has a good pulse, with no serious lesion of a vital organ and no despair of his recovery, but a cheerful, buoyant mind, hopeful of unfavorable issue. No op- eration is to be done when the reverse is the case ; if it be, the patient will either perish on the table, from shock and hem- orrhage, or from a recurrence of mortification in the stum]). Lacerated, contused and gunshot wounds are often of so i rightful a nature as to render it perfectly certain, even at a glance, that the limb wili be obliged to be sacrificed in order that a better chance may be afforded for preserving the pa- tient's life. At other times, the injury, although severe, may yet, apparently, not be so desperate as to preclude, in tin1 opinion of the practitioner, the possibility ot saving the parts, or, at all events, the propriety of making an attempt to that effect. The cases which may reasonably require and those which may not require interference with the knife, are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious and unpleasant ap- prehension, lest we should be guilty, on the one hand, of the sin of commission, and, on the other, of that of omission ; or, in other, and more comprehensive terms, that while the sur- geon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have1 been promptly "amputated. It is not every man, however large his skill" and experience, that is always able to satisfy himself, even after the most profound deliberation, what line <>f conduct should be pursued in these trying circumstances : 1861.] Military Surycnj. 561 hence the safest plan for him generally is to procure the best counsel that the emergencies of the case may admit of. But in doing this, he must be careful to guard against procrastina- tion ; the case must be met promptly and courageously ; de- lay even o\' a few hours may be fatal, or at all events, place limb and life in imminent jeopardy. Above all, let proper caution be used if the patient is obliged to be transported to some hospital, or to a distant home, that he may not be sub- jected to unnecessary pain, exposed to loss of blood, or carried in a position incompatible with his exhausted condi tion. Vast injury is often done in this way, by ignorant per- sons having charge of the case, and occasionally even by practitioners whose education and common sense should be a sufficient guarantee against such conduct. Little need be said here about the methods of amputation. In cases of emergency, where time is precious, and the num- ber of surgeous inadequate, the flap operation deserves, in my opinion, a decided preference over the circular, and, in fact, every other. The rapidity with which it may be executed, the abundant covering which it affords for. the bone, and the facility with which the parts unite are qualities which strong- ly recommend it to the judgment of the military surgeon. The flaps should be long and well shaped, and care taken to cut off the larger nerves on a level with the bone, in order to guard against the occurrence of neuralgia after the wound is healed. Whatever method be adopted, a long stump should be aimed at, that it may afford a good leverage for the artifi- ial substitute. No blood should be lost during or after the operation, and hence the main artery of the limb should always be thoroughly compressed by a tourniquet, not by the fingers of assistants, who are seldom, if ever, trustworthy on sucli occasions. Anesthetics should be given only in the event of thorough reaction ; so long as the vital powers are depressed and the mind is bewildered by shock, or loss of blood, their adminis- tration will hardly be safe, unless the greatest vigilance be employed, and this is not always possible on the field of bat- tle, or even in the hospital. Moreover, it is astonishing what little suffering the patient generally experiences, when in this condition, even from a severe wound or operation. In the war in the Crimea, the British used chloroform al- most universally in their operations; the French also exhibi- ted it very extensively, and Baudens, one of their leading military surgical authorities, declares that they did not meet with one fatal accident from it, although it was given by 36 Military Surgery. [July* them, during the Eastern campaign, thirty thousand times at least. The administration of chloroform is stated by Macleod to have contributed immensely to the success of primary am- putations. The dressings should be applied according to the principles laid down under the head of wounds. The sutures, made with silver wire or tine silk, should not be too numerous, and the adhesive strips must be so arranged as to admit of thor- ough drainage. A bandage should be applied from above downward, to control muscular action and afford support to the vessels ; the stump rest upon a pillow covered with oil- cloth, and the water-dressing be used if there is danger of overaction. Pain and spasm are allayed by anodynes ; trau- matic fever, by mild diaphoretics. Copious purging is avoid- ed ; the drink is cooling; and the diet must be in strict confor- mity with the condition of the patient's system. The first dressings are removed about the end of the third clay ; after that once or even twice a day, according to the nature and quantity of the discharges, accumulation and bagging being faithfully guarded against. The following statistics of amputations, both in the contin- uity of the limbs and of the articulations, possess peculiar interest for the military surgeon. They are derived chiefly trom a review which I published of Mr. Macieod's "Notes of the Surgery in the Crimea," in the North American Medico- Chirurgical Review for January, 1860. The number of cases given by Macleod is 732, with a mor- tality of 201. Of these, 654 were primary, with 165 deaths, or 26-22 per cent.; and 78 secondary, with 36 deaths, or in the ratio of -6*1. The mortality of the greater amputations as those of the shoulder, arm, and forearm, and the hip, thigh, knee, and leg was 39*8 per cent, for the primary operations, and 60 per cent, for the secondary. The increase of mortality from amputations as we approach the trunk, has long been familiar to surgeons, and the results in the Crimea have not changed our previous knowledge. Thus the ratio of mortality of amputations of the fingers was >: ; of the forearm and wrist, 1*8; of the arm, 22'9 ; of the phoulder, 27*2 ;' of the tarsus, 14*2; of the ankle-joint, 22*2; of the leg, 30*3; of the knee-joint, 50-0; of the thigh, in iis ]>\ver third, 50'0, at its middle, 55*3, at the upper part, 86*8, ami at the hip, lOO'O. The limb was removed at the latter joint in LO^cases, all of which rapidly proved fatal. The French had 13 cases, primary and secondary, with no better luck. 1861.] Military Surgery. 568 Legouest has published u table of most of the recorded Bof amputation at the hip-joint, for gunshot wounds. Of these 80 were primary, and all ended fatally; of 11 interme- diate, or early secondary, 3 recovered; and of 3 remote, 1 re- covered, "thus," says Macleod, "if we sum up the whole, we have -1 recoveries in 44 cases, or a mortality of 90*9 per rent. " Some of the primary cases died on the table ; and all the rest, except two, before the tenth day. In the Schles- wig-IIolstein war, amputation at the hip joint was performed seven times, with one cure. Mr. Sands Cox, recording the experience of civil and military hospitals up to 1846, gives 84 cases, most of them for injury, with 26 recoveries. Dr. Stephen Smith, of New York, has published tables of 98 cases showing a ratio of mortality of 1 in 2 2-3. In 62 of these cases, the operation was performed in 30 for injury, with a mortality of 60 per cent. Amputation in the upper third of the thigh was performed 39 times, with a fatal result in 34 Of these cases only one was secondary, and that perished. Amputation of the mid- dle third of the limb was performed in 65 cases, of which 3S died. Of these cases 56 were primary, with 31 deaths, giving thus a mortality of 53*3 per cent.; 9 cases were operated upon at a later period, and of these, 7 died, or 77'7 per cent. Am- putation of the lower third of the thigh was performed 60 times, 16 being primary, with a mortality of 50 per cent., and 11 secondary, with a mortality of 714 per cent. . Amputation at the knee wras performed primarily in 6 cases of which 3 died, and once secondarily, with a fatal result. Chelius refers to 37 cases of amputation of the knee, collected by Jreger, of which 22 were favorable ; and of 18 cases re- corded by Dr. Markoe, of KewT York, as having occurred in the practice of American surgeons, 13 got well. These cases added together, afford an aggregate of 61, with a mortality of 21, or 314 percent. The leg was amputated 101 times, with 36 deaths, or a mor- tality of 35'6 per cent. Of these cases 89 were primary, with 28 deaths, and 12 secondary, with 8 deaths. Amputation at the ankle-joint was performed in 12 cases, death following in 2. Of these cases 3 were secondary, and all favorable. The arm was removed at the shoulder joint in 39 cases, with a fatal issue in 13, or 33*3 per cent, 33 being primary, with 9 deaths, and 6 secondary, with a fatal issue in 4. If we couple these cases with 21 that occurred during the previous period of the war, we shall have an aggregate f>f 60 <;. with 19 deaths, or a mortality of 31.6 per cent. The advan- oG4 Military Surgery. [July, tage of primary over secondary amputation of the shoulder has long been known to military surgeons. Thus, of 19 pri- mary cases mentioned by Mr. Guthrie as having occurred be- tween June and September, 1813, IS recovered, while of 10 secondary cases, 15 died. The experience of the late Dr. Thomson, in Belgium, is equally decisive. Amputation of the upper arm was performed 102 times, with death in 25 cases, or a mortality of 24*5 ; 96 of the cases being primary. Of the secondary cases one-half proved fatal. The forearm was amputated primarily 52 times, and the hand at the wrist once, with only 1 death ; while of 7 second- ary operations upon the same parts, 2 died. Resection is one of the aids of conservative surgery, and military practice affords numerous occasions for its employ- ment. " The operation, however, is not equally applicable to all the articulations. Resection of the shoulder-joint has hitherto afforded the most flattering results. It is more es- pecially applicable in cases of gunshot injuries, unattended by serious lesion of the vessels and nerves of the limb, or se- vere laceration of the muscles and integuments. A portion of the humerus, embracing, if necessary, from four to five inches in length, together with a part or even the whole of the glenoid cavity of the scapula, may be safely and expe- ditiously removed under such' circumstances, and yet the pa- tient have an excellent use of his arm. Williams mentions 19 cases of gunshot wounds of the shoulder-joint in which resection was performed, and of which 3 proved fatal. Eaudcns saved 13 out of 14 cases, and the British surgeons in the Crimea lost 2 patients out of 27. Resection of the elbow has of late engaged much attention among military men, and although the results arc less flatter- ing than in the operation upon the shoulder, they are, never- theless, highly encouraging. Of 82 cases which occurred in the Schleswig-Holstein and in the Crimean campaigns, only 10 died, or 1 in about 5. The ivrist joint has seldom been the subject of excision ; doubtless, cases not unfrcquently occur in which it might be resorted to with advantage. Dr. George "Williams has collected the history of 11 cases oft excision of the hip-joint for gunshot injury, G of which oc- curred in the Crimea. ' Of this number 10 died. Of 23 am- putations at the hip joint by the English and French surgeons in the East; all died. Excision of the In ((-joint for gunshot injury holds out no peel oj advantage, experience having shewn that, when 1.] .1/ ///. the articulating extremities of the femur and tibia are true tared by a ball, the proper remedy is amputation. The ankle-joint has been resected in a tew instances only i'or gunshot injuries, and the results have thus far been by no means flattering. When the joint is seriously implicated, am- putation will undoubtedly be the more judicious procedure. Resection of the bones in their continuity is seldom prac- ticed in this class of injuries, and experience has offered nothing in its favor. The operation was performed several times in the Crimea, but proved invariably fatal. The after-treatment in resection must be conducted upon the same principles as in amputation. The measures must, for the most part, be of a corroborating nature. The limb must be placed in an easy position, and be well supported by a splint or fracture-box, to prevent motion. The operation is liable to be followed by the same bad eilects as amputations. CHAPTER VII. ILL roxSLQUKXCES OF WOUNDS AND OPERATIONS. The bad consequences to be apprehended after wounds, amputations, and other operations, are traumatic fever, hem- orrhage, excessive suppuration, spasms, erysipelas, gangrene, pyemia, and tetanus. a. Traumatic fever usually sets in within the first few hours after the injury, or soon after reaction has been fairly estab- lished. In camp practice its tendency generally is to assume a low typhoid character, especially if there is much crowding of the sick, with imperfect ventilation and want of cleanli; Not unfrequently it displays an endemic or epidemic dispo- sition. The treatment must be exceedingly mild ; the patient will not bear depletion, but will notwithstanding his fever, pi bly require stimulants and tonics, with nutritious \'<">i\ and drink from the very commencement. A gentle anodyne and diaphoretic mixture, as morphia and antimony in camphor- water, may be needful, in the early stage, to quell the ficti- cious excitement or attempt at overaction. J I. The likelihood of secondary hemorrhagt must be steadi- ly kept in view in these cases ; much may be done to pre it by the proper use of the ligature at the time of the o] . but it is often unavoidable, especially in g shot won Ing to the injury sustained by tho> coats of sels by the grazing of the ball. However induced, it 566 Military Surgery. [July, should receive the most prompt attention, inasmuch as the loss even of a few ounces of blood may prove destructive to the already exhausted system. c. Spasms of the muscles is not peculiar to amputations ; it often exists in a most severe degree in cases of fractures and gunshot wounds. Anodynes in full doses, with a little antimony, the use of a moderately-tight bandage, and warm water-dressing, medicated with laudanum and acetate of lead, arc the most appropriate measures. d. Profuse suppuration may be looked for in nearly all bad wounds, whatever their character, and also in many of the amputations performed on the field of battle. The exhaust- ing effects must be counteracted by supporting remedies, as quinine, iron, cod-liver oil, and brandy, with frequent change of dressing, cleanliness, and ventilation. Bagging is pre- vented by counter-openings and careful bandaging. e. Erysipelas usually manifests itself within the first thirty- six hours after the injury or operation ; often assumes an en- demic or epidemic character ; is easily distinguished by the peculiar reddish blush rapidly spreading over the surface, to- gether with the stinging or smarting pain and increased swel- ling; and should be treated with dilute tincture of iodine, or anodyne and saturnine lotions, quinine and tincture of iron, with nutritious food and drinks. f. Gangrene is sufficiently common after severe lesions on the battle-field, especially that variety of it denominated hos- pital gangrene. During the Crimean war, this form of gan- grene raged with extraordinary virulence and fatality among the French in the hospitals on the Bosphorus. It also pre- vailed about the same period within some of the hospitals in the south of France, and it is asserted that the "Euphrate," a transport ship, in her voyage to the Mediterranean was obliged, from this cause alone, to throw sixty of her men over- board within thirty-six hours! After the taking of the Quarries and the assault upon the Redan, during the heat of summer, in 1855, the English surgeons lost a number of their cases of amputation of the thigh from moist gangrene of a most rapid character, the system having been literally over- whelmed by the poison. When hospital gangrene is endemic, it attacks not only open wounds and sores, but also the slight- esl scratches, cicatrices, and stumps. Persons laboring under diarrhoea, dysentery, and scurvy are most obnoxious to it. The proper remedies are sequestration of the patients, the free use of the nitric acid lotion, iodine to the inflamed skin, charcoal, port wine, or yeast cataplasms, and frequent ablu- 1861.] Military Surgery. 567 tions with disinfecting fluids, aided by opium, quinine, tinc- ture of iron, lemon-juice, and other supporting means. Mop ping the affected surface lively with strong nitric acid often answers an excellent purpose. The favorite remedy of Pou- teau was the actual cautery. ;/. Pyemia, the purulent infection of the French writers. is one o( the chief dangers after severe wounds and operations. It was the great source of the mortality after amputation- . pecially secondary, during the war in the Crimea. It usually comes on within from three to eight days after the injury, and is nearly always fatal. Its characteristic symptoms are rigors, followed by copious sweats, rapid failure of the vital power.-, delirium, and a withered appearance of the countenance, fre- quently conjoined with an ictorode tinge of the eye and skin. On dissection, 'the large veins leading from the stump or wound are found tilled with pus, with redness of the lining membrane: and abscesses, usually small and filled with un- healthy fluid, are seen scattered through the lungs, muscles, and cellular substance, matter also occasionally existing in the joints. The treatment is essentially the same as in erysipelas. h. Traumatic t tanus is not very common in military prac- tice. It is most liable to show itself in tropical countries, in hot, damp weather, and in persons of a nervous, irritable tem- perament, occasionally supervening upon the most insignifi- cant injuries, as, f wet. Larrey had repeated opportunities of observing the development of the disease under such circumstan both in Egypt and Germany. After the battle of Bautzen, the exposure of the wounded to the cold night air produced r a hundred cases of tetanus, and a largo number Buffered from a similar cause after the battle of JDresden. Like fects were witnessed at Ferozepore and Chillianwallah. Bau- unehot wounds, states that the in- fluence of cold and moisture in developing the disease, during the French campaigns in Africa, was most striking. ( )f I I men, placed in a gallery on >und floor, during the prevalence of a northea were speedily attacked with tetanus. Similar i 568 Military Surgery. [July* several times been noticed in this country. Thus, after the battle of Ticonderoga, in 1758, nine of the wounded who were exposed the whole night after the action, in open boats upon Lake George, died of lock-jaw ; and during our war with Great Briiain, most of those who suffered on board the Amazon, in the engagement before Charleston, were attacked with this disease a fortnight after, in consequence of a very sudden change of weather, the wind blowing cold and wet. The extremes of heat and cold both favor the production of tetanus. In the East and West Indies, the slightest prick of the linger or toe is often sufficient to induce the disease, and the inhabitants of the Arctic regions not unfrequently suffer in a similar manner. Dr. Kane, in his memorable ex- pedition, lost two of his men from this affection, and he adds that all his dogs perished from a like cause. The mortality from traumatic tetanus is notorious. Hardly one recovers. Nearly all perish in two or three days from the attack. The most reliable remedies are opium, in the form of mor- phia or acetated tincture, in large doses, in union with cam- phor and antimony. The effects of Indian hemp arc uncer- tain. Chloroform will mitigate pain and spasms. Amputa- tion, except, perhaps, when the wound affects a finger or toe, will be worse than useless, as will also be counter-irrita- tion along the spine. To prevent the disease should be our business, and to do this no wounded person should ever be exposed to the cold night air, or to currents of air at any time. After all amputations, however trifling, special directions should he given upon this point CHAPTER VIII. INJURIES OF THE HEAD, CHEST, AND ABDOMEN. The immediate effects of concussion of the brain are those of fainting or collapse, and must be treated accordingly ; by recumbency, access of cold air, the use of the fan, dashing ot cold water upon the face and chest, and sinapisms to the precordial region, thighs, feet, and spine, aided, in the more severe cases, by stimulating injections. If the patient can swallow, he may take a little wine or brandy. A smelling- bottle may be held near, not to, the nose. Reaction is not promoted too rapidly, for fear of secondary consequences. 18GL] Military Surgery. 509 The period of danger from collapse being over, the patient is sedulously watched, that ovcraction may not oc- cur, the risk now being from inflammation ; or, the stage of excitement being happily passed, from the remote effects of the injury, If the concussion was at all severe, all bodily and mental excitement must be for a long time avoided. Compression of the brain arises, surgically speaking, from two causes only : effusion of blood and depressed bone. In the former case, the characteristic symptoms insensibility and coma, dilated and fixed pupil, stertorous breathing, and paralysis frequently do not come until some time after the receipt of the injury. The first symptoms will probably be those of concussion, or exhaustion. By-and-by the patient regains his strength, gets up, talks, or walks, and then sud- denly drops down, as if he had been shot, in a state of ut- ter unconsciousness. The effusion of blood, kept in abey- ance during the collapse, has had full play, filling empty places, and causing unmistakable effects. Such an occur- rence will be most apt to happen when there has been ex- tensive separation of the dura mater, or rupture of the middle meningeal artery. If, on the other hand, the com- pression is due to depression of the skull, the symptoms are nearly always immediate. When the case is one of sanguineous compressiou, it must be treated very much as one of ordinary apoplexy ; at first, by efforts at gradual reaction, and afterward by purgatives, bleeding, and means to favor cerebral accommodation and prevent inflammation. The trephine is not thought of unless the unconsciousness obstinately persists, and there is reason to believe, from the nature of the phenomena, especially the existence of a wound or contusion on the head, that the blood may be reached by the instrument. Gunshot injuries of the skull, with or without lodgment of the ball, may be productive merely of concussion of the brain, or of concussion and compression. When the missile penetrates the bone, and tears up the cerebral tissues and membranes, death usually occurs instantly, or within a short time after the receipt of the accident, without, perhaps, any attempt at reaction. Nevertheless, a number of cases of injury of this nature, in which the patient either partially or completely recovered, have been recorded by military surgeons. In some instances the ball merely penetrates the skull, with no apparent depression, and in this event the treatment should evidently be very simple, being limited, 570 Military Surgery. [July, in great degree, after the occurrence of reaction, to the pre- vention of inflammation of the brain. A similar course should he adopted when the hone is broken and only slightly depressed, especially if there be no urgent or obstinate symptoms of compression. "When, on the contrary, the bone is badly fractured, comminuted, or forced greatly beyond the natural level, the proper plan is to trephine whether there be any external wound or evidences of com- pression or not. If the operation be neglected, loss of life from inflammation will be sure to arise within the first six or ten days after the receipt of the injury. In the punctur- ed fracture, as it is named, the trephine is invariably em- ployed at the earliest moment, however flattering, appar- ently, the head symptoms may be. If the instrument be withheld, fatal cerebritis or arachinitis will be no less cer- tain than when the bone is shattered and driven down upon the brain. Fracture of the skull by contre-coup, so common in civil practice, is seldom met with on the field of battle; doubt- less for the reason that the injury is hardly ever inflicted upon the top or the base of the cranium, as it is when a per- son is struck upon the vertex or falls upon his nates. The most frequent fracture among soldiers is the punctured. A ball has been known to break the internal table of the skull without the external. The skull is sometimes frightfully injured without any serious lesion of the scalp. Macleod refers to a case, which occurred at the Alma, where it was completely destroyed by a glancing shot, without any material implication of the soft parts. A round shot ("en ricochet") struck the scale from an officer's shoulder, and merely grazed his head as it ascended. The result was instant death. The skull was so completely mashed that its fragments rattled under its scalp as if loose in a bag. The condition of the brain was, unfortunately, not ascertained. In the more simple forms of fractures of the skull, how- ever induced, the practice of trephining is now much less common than, formerly, and there is no doubt that the patient often makes a good recovery, though it is by no means certain that such a person may not suffer seriously, at a more or less remote period from epileptic and other af- fections. I am convinced from my own observation that this happens not unfrequently. Dr. Stromeycr, surgeon-in- chief in the Schleswig-Holstein campaign in 1849, express 1861.] MUitary Surgery 57] strong opposition to the use of the trephine in gunshot and other fractures of the skull, oven with depression, .on the ground that, independently of the mischief inflicted in the operation upon the tissues, admission of air to the contused portion of the brain greatly augments the danger of inflam- mation. Of 41 cases of gunshot fractures of the skull with depression, reported by him, 34 were cured, and of these 1 only had been trephined. When operative interference is deemed improper, the most simple treatment should be enforced. Any probing that may be necessary should, if practicable, be performed with the finger, and the wound should not be enlarged, ex- cept when we are compelled to elevate depressed or remove loose bone. "When trephining is required, it should be done as early as rible, and without chloroform or ether, unless the patient is very unruly, as the anaesthetic might tend to provoke in- ilammation of the brain. Every particle of depressed bone should be elevated, and such portions as are loose, detached, or driven into the brain, and easily accessible, removed. All bleeding vessels are tied, the edges of the wound arc gently approximated with silver sutures, and the head, well shaved and raised, wrapped in warm or cold water-dressing, as may be most grateful to part and system. The great danger after all severe injuries and operations upon the skull is inflammtion of the brain and of its membranes, and to the prevention of this, therefore, the surgeon should di- rect his most zealous efforts. The patient must be frequent- ly visited, and every untoward symptom promptly met by appropriate measures, of which active purgation, loss of blood by venesection, leeching or cupping, a restricted diet, andjexclusion of light and noise from the apartment, with perfect rest, are the most reliable. Wounds of the brain must be managed upon general principles; all foreign matter is at once removed, and the parts being restored as nearly as may be to their normal relations, the surgeon endeavors to keep the resulting in- flammation within proper limits. Most of such lesions prove fatal within the first week from their receipt. If the patient survive for any length of time, death will generally e at last from exhaustion, cerebritis, or fungus. rtions of the 8hMy sliced off by the sabre or sword, should be replaced and secured by wire sutures, even if they are attached merely by small shreds of the scalp. 572 Military Surgery. [July, Scalp wounds of every description, but in particular the contused, lacerated, punctured, and gunshot, are extremely prone to be followed by erysipelas ; death may also occur from cerebritis, arachnitis, and pyemia. The slightest lesion, then, of this region of the body should be zealously watched. Wounds of the face must be treated with an eye to the avoidance of disfiguring scars, by wire sutures and cold water-dressing. When a large portion of the lower jaw is shot away, the tongue will be apt to fall back upon the glottis, causing suffocation. The organ should be drawn forward with the finger or tenaculum, and the patient ob- serve the prone position until the tendency is lost. One of the great sources of annoyance and danger, in gunshot wounds of the face, is secondary hemorrhage. It frequently appears soon after the accident, and, although it often ceases spontaneously, it is sometimes controlled with much difficulty. Paralysis, partial or complete, is not un- common, owing to injury of the branches of the facial nerve. In the management of wounds about the mouth, throat, and face, great care must be taken not to allow the offensive mucous and salivary secretions to pass into the stomach. The neglect of this precaution is apt to be follow- ed by a low typhoid state of the system, very similar to what occurs in pyemia, or blood poisoning. I have repeat- edly witnessed these effects after operations upon the jaws, mouth, and even the nose. In fractures of the bones of the face from gunshot an ex- ception should be made to the general rule of removing fragments which are nearly detached, observation having shown, says Mr. Macleod, that the large supply of blood in this region will enable them to resume their connection with the other tissues, in a way that would be fatal to similarly placed portions in other situations. Gunshot and other wounds of the chest are, as stated else- where, extremely fatal ; death, if the lesion be at all severe, being usually speedily caused by shock, hemorrhage, or asphyxia ; or, at a more or less remote period, by inflam- mation and effusion. When the lungs are wounded, the characteristic symptoms will be hemoptysis, with suffocative cough, great prostration, and excessive alarm. A copious flow of blood may take place in the thoracic cavity from a wound of one of the intercostal arteries. 1861.] Military Surgery. 573 Any foreign matter that is easily accessible is at once removed, but officious probing is out of the question. The wound, if small and unaccompanied by serious hemorrhage, is closed in the usual manner, the chest being firmly en- circled by a broad bandage, to compel diaphragmatic res- piration. Under opposite circumstances, it is kept open, the patient lying upon the affected side to favor the escape of blood with as much elevation of the head as the case may admit of. The main reliance for arresting pulmonary bleeding is upon venesection, copious, and frequently repeated, unless the ex- haustion amounts to absolute collapse. Sugarof lead, opium, and veratrum viride are frequently exhibited, sinapisms are applied to the extremities, and, in short, everything is done to control cardiac action. Inflammatory symptoms are counteracted in the usual manner, and effused fluids, caus- ing oppression, and resisting ordinary measures, are, un- hesitatingly, evacuated by puncture, as the only chance of escape. Wounds of the heart and aorta, of whatever nature, arc usually fatal; now and then, however, an astonishing ex- ception occurs. Wounds of the abdomen, merely penetrating its walls, but not its contents, are brought together by sutures, extending down nearly to the peritoneum, otherwise they will be fol- lowed by hernia. When they involve the intestine, and are incised, they arc sewed up with a fine needle and silk thread, either interruptedly or continuously, the ends ot the ligature being cut oft" close. Contusions of the walls of the abdomen by round shot arc among the most dangerous injuries to which the body is exposed, often rupturing both the hollow and solid viscera, and rapidly causing death, without much apparent sign of so severe an accident. The most important symp- toms of these contusions arc vomiting, and pain in the abdomen; and the great object of the treatment, in the event the patient survives their immediate effects, is the prevention of peritonitis, which often comes on in the most stealthy manner. Laceration of an internal organ is near- ly always promptly fatal. Shell wounds of the walls of the abdomen are generally followed by extensive sloughing. Abscesses among the muscles of the abdomen are not un- common after gunshot injuries. Balls often traverse the walla of the abdomen for a con- siderable distance without entering its cavity, or they pass in without injuring any of the contained viscera. Military Surgery. [Julj'j "The fatality of penetrating wounds of the belly," ob- serves Macleod, "will depend much on the point of their infliction. Balls entering the liver, kidneys, or spleen are well known to be usually mortal, although exceptional cases are not rare. "Wounds of the great gut are also always recognized as much less formidable than those which im- plicate the small. Thomson saw only two cases of wounds of the small gut, after Waterloo, in the way of recovery ; but Larrey reports several. Gunshot wounds of the stomach are also exceedingly fatal. Baudens records a remarkable case of recovery, although complicated with severe head injuries. The syncope which followed the severe hemorr- hage in this case lasted for ten hours, and doubtless assisted along with the empty state of the* stomach at the moment of injury, in preventing a fatal issue." Gunshot wounds of the bladder occasionally occur ; the ball may penetrate the organ in any direction, and at the same time commit extensive havoc in the neighboring parts, both soft and osseous. Such lesions are generally fatal. Simple gunshot wounds, on the contrary, are some- times recovered from, especially when they are treated by the retention of the catheter, thus allowing the urine to flow off as fast as it descends from the kidneys. The operation of laying open the wounded viscus through the perineum, as originally proposed by Dr. Walker, of Massachusetts, might be performed in such a contingency. Such a procedure would be much more likely to prevent urinary infiltration than the catheter, however carefully retained, during the detachment of the sloughs, as well as before the contiguous structures have been glazed with lymph. Balls, pieces of cloth, fragments of bone, and other foreign bodies, if retained in the bladder, generally serve as nuclei calculi, and should, therefore, be as speedily extracted as possible, either through the perineum, or by means of the forceps or lithotriptor. Quite a number of cases, in which the operation of lithotomy was successfully performed for the purpose of effecting the riddance of balls and other ex- traneous substances, have been reported by different writers, as Morand, Larrey, Baudens, Langenbeck, Guthrie, and 1 lutin. CHAPTER IX. DISEASES INCIDENT TO TROOPS. The discuses which attend armies, or molest soldiers in amps, garrisons, and hospitals, and which so often deci- 18G1.] Military Surgery, 5t5 mate their ranks, and even, at times, almost annihilate whole regiments, are the different kinds of fever.-, especial- ly typhus and typhoid, dysentery, diarrhoea, and scurvy. These are. emphatically, the enemies of military life, doing infinitely more execution than all the weapons of war, how- ever adroitly or efficiently wielded, put together. Pneu- monia, pleurisy, and hepatitis, of course, slay their thousands, and various epidemics, especially cholera, not unfrcquently commit the most frightful ravages. "War," says Johnson, "has means of destruction more formidable than the cannon and the sword. Of the thousands and tens of thousands that have perished, how small a proportion ever felt the stroke of an enemy I" Frederick the Great used to say that fever cost him more men than seven pitched battles, and it has long been a matter of history that more campaigns arc decided by sickness than by the sword. The great mortal- ity which attended our armies in Mexico was occasioned, not by wounds received in battle, but by the diseases inci- dent to men carrying on their military operations in an in- hospitable climate, badly fed, subjected to fatiguing marches, and obliged to use unwholesome water. Thousands perish- ed, during their absence, from fever, dysentery, and diarrhoea, and a still greater number from the effects of these diseases, after the return of the troops to their native soil. The latter affection, in particular, pursued many, like a relentless foe, to their graves long after they had been cheered by the sight of their homes and friends. In the war in the Crimea disease destroyed incomparably more soldiers than the sword, the musket, and the cannon. Typhus and typhoid fever, dysentery, diarrhoea, scurvy, and, lastly, malignant cholera, annihilated vast numbers, both in the British, French, and Russian ranks. According to Dr. leod, whose "Xotes on the Surgery of the War in the Crimea," are so well known to the profession, the propor- tion of those lost among the British by sickness to those by gunshot and other injuries, was, during the entire campaign, as 1G,211 to 1761, exclusive of those killed in action. The difference he supposed to have been still ater among the French and Russian forces. In Decem- ber, 1*54, and in January, 1 *">">, not less than 14,000 French soldiers were admitted into the Crimean ambulances on 'iint of disease, whereas, during the same period, only I were admitted on account of wounds. Of the whole number nearly 2000 died. During the lasl six month 576 Military Surgery. [July, the campaign, in which the city was stormed and taken, the French had 21,957 wounded as an offset against 101,128 cases of Disease.* At Walcheren, in 1809, the British lost one-third of their troops by disease, and only 16 per cent, by wounds^ In the Peninsular war, from January, 1811, to May, 18l4, out of an effective force of 61,500 men only 42*4 per 1000, says Macleod, were lost by wounds, while 118-6 were lost by disease. The number of sick that may be expected to be constant- ly on hand during any given campaign is estimated, on an average, at 10 per cent.; but this proportion must necessar- ily be exceeded, especially in an invading army, with raw, undisciplined, and unacclimated troops. This was eminent- ly true even in the Crimea, in a climate comparatively healthy, within a few miles of the sea. We may well im- agine what would be the effects of the climate of the South upon the Northern troops, if they were to pass far, during the hot season, beyond Mason and Dixon's line. Disease in its worst form, would be sure to invade and thin their ranks at every step. Fever typhoid, typhous, remittent, intermittent, and yellow dysentery, diarrhoea, scurvy, pneu- monia, and inflammation of the liver would accomplish more, infinitely more, for the Southern cause than all the weapons of war that ceuld be placed in the hands of the Southern people. Typhoid, typhus, and yellow fever, dys- entery, diarrhoea, and scurvy would, in all human proba- bility, soon become epidemic, and occasion a mortality truly appalling. The Southern soldier, on the contrary, thor- oughly acclimated as he is, would suffer comparatively little. The British in the Crimean war lost 5,910 men from diar- rhoea and dysentery, the whole number of cases having been 52,442, affording thus a mortality of 11*26 per cent. Cholera, of which there were 7,575 cases altogether, de- stroyed 4,513 or in the ratio of 59-57 per cent. Typhus fever killed 285 out of 828 cases ; fever not typhus, 3,161, out of 30,376. The French and Russian troops suffered in still larger numbers from these diseases. Macleod asserts that the former lost their men by typhus fever by thousands, and the latter by tens of thousands. The British suffered but little from intermittent fever, whereas this disease did Macleod, op. fit,, p. C7 SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol Wll AUGUSTA, GEORGIA, AUGUST, ML NO. ORIGINAL AND ECLECTIC. ARTICLE XV F. 'hate of Quinia administered in small doses during alth, the best means of preventing Chill and Fever, and Bilious Fever, and Congestive Fever, in those exposed to the unhealthy climate of the richlow lands and swamps of the Southern Confederacy. By Joseph Jones, M. D., Professor of Medical Chemistry in the Medical College of Georgia. Chemist of the Cotton Planters' Convention of Georgia. SUMMARY. Importance of protecting the troops of the Southern Confederacy by all passible means, from the effects of the climatorial fever of the South, illustrated by the records of Midway Congregation, of Liberty Co.. Ga., situated in the low plain bordering the Atlantic ocean : by the mortality of the Bcrmudans who emigrated to Snnbury on the coast of Georgia ; by the groat mortality of Piice Plantations ; and by the mor- tality of Savannah during the wet culture system in the lands surround- ing the city; and by the sickness and mortality of Oglethorpe Barracks and the Augusta Arsenal. Testimony to the value of Quinine in pre- ing climate fever in the Southern States. The value of Quinine in warding off climate lover, still farther demonstrated by the experience of the Surgeons ol the British Navy on the ooastpf Africa. Facts proving the unhealthy nature of the climate of Africa the malarial fever of Africa similar in all respects to the malarial fever of the low-grounds, swamps and rice fields of the Suuthern Confederacy. Comparison of the mortality in the British Navy before and after tin1 use of Quinine as a preventive of African fever. 38 594 Joseph Jones, on Quinine [August The climate of the rich low plain, clothed with a luxuri- ant sub-tropical vegetation, which forms a belt along the Atlantic ocean and Gulf of Mexico, of varying width, from 30 to 100 miles, and which is intersected with numerous swamps which discharge their waters into sluggish, muddy streams, surrounded on all sides by extensive swamps and marshes, is necessarily hostile to the white race. To the pestilential exhalation of stagnant swamps and rich river deposits, excited and disseminated by the burning rays of the sun in this hot climate during the summer and fall months, no process of acclimation has ever accustomed the white man. In the early settlement of South Carolina and Georgia, the inhabitants in most instances resided the whole year upon their rich rice and Indigo plantations ; many however soon fell victims to the climate, or dragged out a miserable existence, with constitutions broken down and rendered prematurely old, by repeated attacks of cli- mate fever. The clearing of the forests, of the swamps and rich low-lands, and the consequent exposure to the sun of the vegetable matter which had been accumulating for ages, rendered the climate so deleterious to the white race, that the planters were compelled to seek health during the summer and fall months, in sea island, or in pine barren, or mountainous retreats ; and even with the most efficient precautions, the mortality of these regions is far greater than in the more elevated portions of the Southern Con- federacy. The following facts will illustrate the effects of the climate of the swamps, rice fields and river bottoms, upon the mor- tality of the white race. In the Midway Congregational Church, of Liberty co., < la., (formerly St. John's Parish) the number of births from 1754 to 1804, was 600, whilst the number of deaths during this period was (328, thus showing an actual decrease during 50 years of 28. In 1817 there were 49 deaths in this con- gregation, which did not number more than 340 whites, showing a mortality of one in every seven of the inhabi- 18G1.] Asa Preventative of Malarial Fed r. tants (14-4 per cent. ;) of these 49 deaths, 34 occurred in four mouths, 'July, August, September arid October, and in almost every case the effects of climate fever : and other years might be cited in which, if the mortality did not rise to so high a figure, it still rose to such alarming figures as from one in qvcvy ten, to one in every seventeen inhabitants. This heavy mortality was clearly referable to climate, ior it is believed that no body of citizens in the Southern coun- try excels this congregation in intelligence and virtue, or in the careful regard for the substantial comfort and health of its families. Before the Revolutionary war, whilst Sunbury on the coast of Georgia, was in a highly prosperous condition, TO emigrants came from the Bermuda Islands : of this number 50 died the first year from climate fever. Savannah, situated on a sandy plain, termini' ted on the north by a turbid sluggish stream, and flanked on the cast and west by extensive tide swamps, afforded during the period that these low lands were cultivated in rice, a good field for the determination of the probable mortality of troops exposed to the climate of rich river-bottoms and inland swamps. The dry culture system was commenced with the lands surrounding Savannah, in 1818; we shall therefore for our present purpose, deal with the mortuary records of the city, and during the wet culture system, as far as they extend back from 1818 : premising however, that after the institution of the dry culture system, the health of Savannah, excepting the years when the yellow fever prevailed, has progressively improved, and will now compare favorably with cities situated in the same latitudes, and surrounded by similar alluvial deposits. After a c ful examination of the records of the city, I have been able to discover no record of deaths with a date earlier than 1804. The deaths of the blacks are excluded from the following statistics. The sum of the deaths of the foreigners and an 596 Joseph m.nks, on Quinine [August, tives, does not always c< *e ;pond with the total deaths from climate fever, because in some instances, the nativities are not given in the record. Deaths amongst the Whites in Savannah from 1804 to 1818. 4 ft.* ? srgl ill si - : * : 2 : s p : S o * Eg" Go ii 2. n a S ^3 si ri *S : =? o : 3 H ft. 2. ff if t 1804 118 77 63 14 207 1805 141 112 78 22 238 1806 120 52 43 9 159 1807 124 80 71 9 230 1808 103 77 67 8 219 1809 98 63 52 9 183 1810 79 46 38 8 163 1811 114 87 73 13 212 1812 132 120 92 24 226 1813 109 64 45 19 214 1814 185 166 138 23 300 1815 140 130 104 18 233 1816 161 146 91 38 272 1817 283 313 236 57 461 The population of Savannah in 1800 was 5,166 ; of these 2,799 were whites and 2,367 slaves. In 1808 the population was 6,4C4; of these 3,010 were whites and 3,454 slaves. In 1810, the entire population was 5,215 ; in 1820, entire population 7,523. Whilst the records of the population of Savannah at % different periods are not as full and explicit as could be wished, still from the data now presented we may institute comparisons, and determine the average mortality for each year with a very close approximation to the absolute num- bers : thus in 1804, the proportion of deaths in round num- bers of the whites to the white population, was 1 in 13 1805, 1 in 12; 1806, 1 in 18; 1807, 1 in 12; 1808, 1 in 13 1809, 1 in 16; 1810, 1 in 18 ; 1611, 1 in 14 ; 1812, 1 in 13 1813, 1 in 14; 1814, 1 in 10; 1815, 1 in 14; 1816, 1 in 18 1817, lin9. 1S61.] As a Preceitlativc of Jlahm'al Jfbk r. 597 It we compare the mortality from climate fever, of the strangers ami foreigners, under which class we include the seamen, who form a large part of the transient population of Savannah, we will see that that the deaths amongst this - wore more than four times as numerous as the deaths of the natives. This fact illustrates still more strongly the groat risks and siokness, if not heavy mortality, which must attend the transportation of troops from Middle Geor- gia, and from any part of the high mountainous tracts of the Southern Confederacy to the swamps and rich rice grounds, during the months of July, August, September and October; for without doubt the observation was made by the reader as he reviewed the preceding figures, that the rate of mortality id Savannah during the wet culture sys- tem, frequently rose to a figure which in healthy re- gions would have been considered as the results of pes- tilence ; and the correctness of this observation is placed in the clearest light, when it is known that the annual mor- tality in England (1) is one in every 45 of the living ; in France, 1 in every 42; in the New England States, 1 in 64 ; in the Middle States, 1 in 73 ; Coast planting States, 1 in 73 ; Northern States, 1 in 80. (2. | Whilst we will readily grant that the improved method of medical treatment of the present day would greatly di- minish the rates of mortality, we would on the other hand affirm that these improvements in practice would have lit- tle to do with the prevention of disease. We have there- fore presented these views of tin- rates of mortality in these localities, rather to demonstra e the liability of men ex- d in this climate to disease, and thus to establish the importance of the present inn 'ry; for an army may be rendered almost as ineffective ' siokness as by death. 1 Report of the I \ par General of Engl . (2) Census of United States, 1 - 598L Joseph Jones, on Quinine [August, Tho medical statistics of Oglethorpe Barracks during the period they were situated one mile south of the city of Savannah, just back of the present jail, illustrates still more forcibly the sickness and mortality of troops encamped in localities surrounded with rice fields and marshes. In 1828 during the months of July, August and September, there occurred 23 deaths in a command of 95 men ; and during the months of October, Xovember and December, 18 deaths in a strength of 85 men : the total deaths for the year was 52, besides 19 women and children Remittent fever and dysentery were the fatal diseases which caused the high mortality. During 10 years, from 1829 to 1839, the annual ratio of mortality was 5.5-10 per cent; the annual ratio of Intermittent^ was 07 per cent, and that of Remittents 22 per cent ; and every man was on an average during this period, reported sick in a little less than every five months. So prevalent and fatal were the diseases in the summer and fall seasons, that this post was finally abandoned. The Medical statistics of the Augusta ArsenaL whilst it was situated on the Savannah river, correspond with those of the Oglethorpe Barracks ; disease prevailed to so great an extent that it wan necessary to abandon the post in tho summer season, and encamp on the Sand Hills. These observations might be still farther strengthened by \\\a presentation of the rates of mortality of rice planta- tions, this subject however will be treated more fully, in subsequent numbers of this journal, and we will merely state the result of an extended personal examination of the mortuary statistics of rice plantations ; the number of births in proportion to inhabitants does not differ materially from the number in the healthiest regions, but the mortality Bcially amongst the young is for greater in fact so great daring many years instead of an increase, there is r a stationary condition, or an actual decrease. The facts which have now been presented are sufficient to justify the attempt to devise some means to ward off the climate fever. L] Asa Prevet Duringthe study of the relatio i of climate and soil to disease, the collection of the ry statistics and the investigation of the causes of disease apon rice and cotton plantations ; and during the discharge of the duties of Chemist to the Cotton Planter's Convention of Georgia, the author lias necessarily greatly exposed to the agents which produce climate fev t, and the results of his experience now presented, cannot there Tore be Baid to be wanting the test of actual experiment. Under these exposures I have found that Sulphate of Qainia taken in from 3 to 5 grains twice during the day would in most cases prevent the occurrence of Malarial Fever, and if it failed to ward it off entirely, the attack would be of a very slight character. I have still farther observed that when the climate fever first appeared, with a se of lassitude, headache and excitement of the pulse, with alternate flushings, it might be arrested bv a dose of from five to ten grains of Sulphate of Quinia, in combina- tion with Bicarbonate of Potassa and Hoffman's Anodyne. From 5 to 15 grains of the Sulphate of Quinia may be given according to the urgency of the symptoms, united with 15 grains of Bicarbonate of Potassa and f 5ii of Hoffman's Anodyne and 5 grains of Gum Camphor; the whole to be dissolved in fjvi i I water. The feet should be placed in hot water, immediately after, or before, the administration of the remedies, and the patient after this bath Bhould cove in bed. so as to promote free perspiration ami induce quiet sleep. I have frequently gone to bed in a feverish, restless -rate, with a severe h< 1 pulse, and pain in the limbs, and dry, warm -kin. and under the action of these remedi in the morning id and able to resume operati Jarbonate oi Ofthe I' i, (Salts of Tartar,) which is fever, ii . be- cause it is far less active in iqn. n the stomach, and may be taken in much la: 600 Joseph Jones, on Quinine [August, more effectually the neutralization of the acid which is so oiten abundant in the stomach at the commencement of malarial fever, and more effectually acts upon the liver and the kidneys, and promotes the removal of all offending matters from the blood. The late lamented Dr. Charles West, of Savannah, in- formed me that during his practice in Burke County, it was his custom to arrest attacks of climate fever, at the outstep, when the first symptoms were manifested, by Sul- phate of Qumia; my respected colleague, Dr. Dugas, Pro- fessor of Surgery in the Medical College of Georgia, informs me that he has used this medicine in a similar manner; and we have been informed that the energetic Superintendent of the Savannah & Charleston Eoad which passes through a most sickly region of country, preserved the health of his white laborers by the daily use of small doses of Sulphate of Quinia. We would recommend the use of Quinia as a preventa- tive of Climate fever, in the following manner : If. Sulphate of Quinia, - - grains, iii. Dilute Aromatic Sulphuric Acid, drops, v. Brandy, - tablespoonful, 1. Water, ----- wineglassfuls, ii. Drop the diluted Aromatic Sulphuric Acid upon the Sulphite of Quinia, and then add the brandy and water. Administer twice during the day, after rising in the morn- ing, and just before bed-time. To render the value of this means of warding off climate fever, still more evident, we will cite the practice and suc- cess of the British Surgeons upon the coast of Africa, pre- mising at the outset, that the endemic climate fever of Africa does not differ in any essential manner, except, per- haps, in its severity, either in its causes, symptoms or effects, from the malarial fever of North America. The value of Sulphate of Quinia in warding off the climate I'cvw of Africa, can be determined only by insti- tuting a comparison between the effects of the disease I.] 601 before and after the use of this medicine as a prophyla* Tho celebrated traveller, Mungo Park, suffered from two pe attacks oi* lever, upon t tour through the interior of Africa, and at the conclusion of his journey the color of his skin was so altered by the disordered state of his liver induced by Afri . that he could scarcely be distinguished from a Moor; and upon his second visit to Africa, not only was he brought to the borders of the grave by climate fever, but 32 out of the 38 men who left witli him the banks of the Gambia, fell victims to African fever in less than two months. The vi at out in 1G18, to relieve the English Ex- plorer. Thompson, on the banks of the Gambia, lost almost the entire crew with fever, and at the very outstep, failed to accomplish the desired object. The enterprising traveller, Ledyard, who had spent his life in travelling, and had sailed around the world with Captain Cook, had lived for several years with the Xorth American Indians, and had travelled from Stockholm, round the Gulf of Bothnia, and thence to the remotest parts of Asiatic died of African fever, in the very commencement of his journey to explore this continent. Numerous other travellers might be mentioned, as NTicholls. Morrison, Pearce, Clapperton, and the active, athletic and temperate Frederic Horneman, who fell vic- tims to the endemic climate fever of Africa. The splendid expedition to the Congo, under command . provided with a crew of fifty active individuals, and with a Botanist, Zoologist, comparative aost competent Physician, melted a. under the influence of I id burning c and Led with the loss of the Captain, all the officers and . imilar termination closed the expedition of Major Peddie, fur t; .cry of the Xiger. The average mortality amongst the better i ic, according to the testimony of Dr. Xichol, Deputy Inspector of U rly about one in twelve, or very nearly nine per cent. 002 Joseph Jonbs, on Quinine [August, According to Mr. Tidlie, acting Staff Surgeon at Cape Coast Castle in 1819, all the new-comers from England were seized with fever, and one-half died, more than one- third of the resident Europeans who had been there more than one year were seized with the fever, and one eighth died ; in 1820 all the new comers were saized with the fever, and one half of them died, and of the older residents one ninth died; in 1821 all the new comers were seized, with fever, and one third died, whilst of the older residents near one sixth died ; thus making an average of one death out of every two and two thirds, of new comers during the the first twelve months after their arrival, and one death out of every eight of the resident Europeans who had been there more than one year. From the Report of Dr. Barry, Deputy Inspector of Hos- pitals in 1822, we learn that twelve white sergeants from the Isle of Wight, selected as good and healthy men of regular habits, were attacked with fever, upon their arrival upon the coast of Africa, and within a few months after their arrival, eight paid the debt of nature, and the constitutions of three of the remaining four were permanently injured, whilst the sickness and mortality amongst their wives and children were nearly in the same proportion. According to Mr. William Ferguson surgeon to the Royal African Colonial Corps, in the third quarter of 1824, the mean strength of British soldiers at Sierra Leone, was 585, of this number 38G were attacked with this African climate fever; 161 died, showing one death to 3.63 of the strength, and one death to 2-39 cases treated; at Gambia during the same period, the strength was 108, cases of Malarial fever 02, deaths 7-4, giving a proportion of 1 death to 1-45 of the original strength, and 1 death to 1-24 of the cases treated : O CD J at the Isles de Los, during the same period the mean strength was 103, cases of Malarial fever 00, deaths 23, showing 1 death in 4-47 of the strength, and 1 death in 4-3 of the cases treated. Captain W. F. Owen of the al Navy, in his attempt in 1827 to found a settlement 1861.] As ''//(// Ft G03 at Fernando, Po., lost almost his entire colony from the End f Africa ; and Colonel Nicholls who follow- ed him in a similar attempt had one attack of Remittent fever, and eleven attacks of Intermittent fever, and lost twe: out of thirty individuals who composed the .pany. Numerous other examples might he brought forward to show the dreadful effects of the climate of Africa upon ;-s, unprotected by the sulphate of quinia ; we will however allude to but one more the expedition of H. B. s AVilberforce, Albert and Soudan, during the year 1841 and 1*4:2. np the Niger with the leading object of pro- moting the abolition of the slave trade. When the expedi- tion entered the Nun branch of the Niger, on 13th of Au- complement of men and officers consisted of, offi- inelnding civilians and engineers 53, white seamen 63, marines and Bappers 29, total number of whites 145 ; men of color entered in England 25, Kroomen and liberated African I on the coast 110 : blacks for model farm total bL and total 303. The health of the edition continued good until the ships had proceeded two hundred and fifty miles from the mouth of the river, ruber, when a most malignant fever ap- red in all the v and spread with great rapidity. The ath took place on the 9th; and on the 17th there v. I of whom were whites ; and seven whites had died. The expedition was now so disabled that it v. . id advisable to send two of the .-hips back to I the 19th the Soudan started for the mouth of the r with forty eases of fever, and was followed by the force, with nearly an equal number of sick, on the . The Albert continued up the river, the officers be- ing that the violence of the fever was in a measure hansted, and that the climate of the more open country, found I J thy. The dt proved otherwise when the ship had arrived at Egga, 340 miles from t: ban twenty more or 604 Joseph Jones, on Quinine [August, the crew had been attacked, of whom two had died ; and on the 3d of October there remained, capable of doing any duty, only one white seaman, the sergeant and one private of marines, the geologist, the mate, one hospital attendant, and the surgeon Dr. Mc William: the entire enterprise was now abandoned, and the Albert steamed down the river to Fernando Po. Of the 145 whites who entered the Niger in good health. 130 were attacked with fever, and 42 died ; of the 158 blacks, only 11 had the fever, and that in its mildest forms, and not one died. The ratio of the men attacked by fever in the Albert was 1 in 1.127, the ratio of deaths in total number victualled was 1 in 2.606, and in the number of cases, 1 in 2.391 ; the ratio of the men attacked by fever in the "Wilberforce was 1 in 1.666, ratio of deaihs in number victualled, 1 in 8 ; ratio of deaths in number of cases, 1 in 6.857; the entire crew of the Soudan were attacked with fever; the ratio of deaths in total number victualled was 1 in 2.7. We will now compare these facts and rates of mortality with the health of the British Squadron, employed for the suppression of the slave trade on the west coast of Africa, since the systematic employment of the Sulphate of Quinia as a prophylactic. The observations which we will now present, are from the most reliable of all sources : the "Statistical Report of the Health of the Royal Navy," and we shall refer especially to the reports for 1856 and 1857, printed by the House of Commons, July, 1858, and August, 1859. In 1856, the squadron employed for the suppression of the slave trade on the west coast of Africa, consisted of twenty-one vessels, with a mean force, including Kroomen and African boys, of 1630 men of all ranks and ratings. The number of men daily inefficient from wounds and sick- ness on the west coast of Africa, averaged about 55 per 1,000 of mean force. 1 861.] As a Prmevtativc of Malarial Fever. 605 The following summary taken from the nosological re. turns, will not only show that the great source of malarial fever in the squadron is exposure to effluvia or miasmata, while on shore, in boats near the shore, or by the entrance of the cruisers into the large tidal rivers, but also that the great means of warding off the endemic climate fever, and of moderating its violence and duration, was the daily ad- ministration of the Sulphate of Quinia to the men during exposure to the noxious miasmata. The Bloodhound remained during the entire year on the northern division of the station. In March she steamed about 300 miles up the Benin river; while in the river, and for fourteen days afterwards, from three to six grains of the disulphate of Quinine were given to each of the ship's company as a preventative of fever, and although they were exposed to the emanations from the mangrove swamps for twenty-seven days, only six suffered slightly from fever. Some time aiterwards they were again exposed to mias- mata in the Bonny, New Calabar, and in the Sherhro, the last, one of the most dangerous rivers for Europeans on the whole station ; but Quinine in solution was invariably used, as a prophylactic, and with good effect, as only one case occurred after the vessel had been for a week in the Sherbro and the patient was the only person who did not take the quinine regularly. Xo death occurred in this vessel from fever, but one man was invalided for its sequela. The Guilders was employed almost constantly cruising, for the first six months of the year off the coast, in the Gulf of Guinea, and during the remaining months, off the coast, between Loango and Benguela. With the exception of a few unimportant cases, her crew entirely escaped fever, until three hoats were sent on detached service up the Lagos River ; in these there were twenty-seven white men and five officers. They remained absent for two nights, one of which was spent at anchor, off' the town of Lagos. The surgeon accompanied the expedition and gave quinine-wine, which was continued after they returned on board; still, 606 JosEPn Jones, on Quinine [August, notwithstanding, nine of the thirty-two persons who formed, the party, were attacked with fever; two in five days after their return to the ship, one on the sixth day, one on the eighth, one on the ninth, one on the thirteenth, two on the sixteenth, and one on the seventeenth. The disease in all was the same, differing only in its degree of intensity ; some were convalescent on the eighth or ninth day, and others not before the twenty-eighth ; one had a jaundiced appearance. The surgeon thought the fever would have assumed a worse form, but for the quinine-wine which had been taken as a preventative. Xo other febrile disease of any consequence occurred in the Guilders for several months subsequently, nor in fact until she had been for some time stationed on the southern division of the command, when four cases took place, after she had been eight days at an- chor in the river Congo. The Firefly did not arrive on the station until August. Shortly afterwards she proceeded on a' cruise off the river Pongas, while her boats, armed with white men, were sent up the river. They took Quinine wine night and morning while absent, and continued its use for ten days after they returned, and all escaped fever. Subsequently a few cases were contracted from long contin- ued exposure to the miasmatous exhalations in the river Lagos. Eighteen cases of remitting and fourteen of inter- mitting fever occurred in the Hecate the majority of the former were contracted on shore ; two ended in death. The subject of one of the latter was a marine, who accident- ally drifted away in the life-boat over the bar at Lagos ; he slept one night on shore, and was not attacked until four- teen days afterwards. In the other case, the patient, an officer, slept two nights on shore, and exposed himself to the full glare of the sun during the day time, by rowing about in a boat, without an awning, in the lagoon off Lagos ; he declined taking Quinine as a preventative, and was attacked about fourteen days after he returned on board. 1 .61.] As a Preventative of Malarial Fever, 607 The Merlin arrived on the station about the middle of July, and after cruising a short while off the rivers Nunez and Congas, proceeded to the Bight of Biafra. She was then ordered on special service up the rivers Bonny, New Calabar and Brass ; while thus employed, the following autionary measures were adopted against fever : The crew were turned up at ">.o0 a. m., and after dressing, took half a wineglassfull of quinine wine ; they breakfasted at 6. The decks were washed with water (warm) from the boilers at 0.30 ; they took dinner at noon, and supped at 5 p. m. No white men were sent away in the boats. Serge frocks and white trousers were worn during the day, and blanket dresses during the night. Xo water was allowed to be drawn from alongside for any purpose whatever. Quinine wine was administered to the whole crew for fourteen days after leaving the rivers, in which they remained altogether twelve days. Whether it was owing to the above measures it is impossible to state, but no sickness of any kind follow- ed the several expeditions into these notoriously unhealthy localities. Although twenty-three cases occurred in this j1, only one out of the whole number was of a severe character, and it was the result of intemperance and expo- sure on shore on the Isles de Los. The records of the other vessels all substantiated the great value of Quinine as a prophylactic. It thus appears, that in all these vessels, with a mean force of about 1,680 men, there were only seven deaths from fever, being in the ratio of about a little more than four to the thousand, a mortality so small, compared with that of former ;. ems almost incredible, and might well lead to the belief that the coast, like some of the cleared por- tions of the North American Continent, is becoming more healthy: but, with the exception of the non- appearand yell p, which does not depend on terrestrial emana- tions . the climate has undergone no salutary change. The seemingly interminable forests which fringe the estuari' iy tidal river, are still as prolific of the fever 608 Joseph Jones, on Quinine [August, poison as i hey were in times gone by, when the death-rate in the squadron was ten times greater. How then, it may be asked, are we to account for this improvement ? Simply by the change which has taken place in the mode of con- ducting the duties of the station. By a wise and humane regulation, the deadly practice of sending boats away on detached service, to watch or intercept slavers, has been interdicted, or at all events, greatly restricted. Prize crews are no longer turned adrift to wander through the streets of Sierra Leone, when the vessels they navigate from distant parts of the station are delivered up to the authori- ties of the Mixed Commission Court ; the orgies of " the barn," which lowered the character of the white man in the eyes of the black, have long since ceased; and last, though not least, the introduction of quinine ivine as a preventative of fever has not only reduced the number of febrile attacks, but has lessened the severity of those which do occur, and thus the mor- tality has also been reduced to a level ivhich does not materially exceed the death-rate from fever on some of the more healthy stations. There has also been a great change in the medical treat- ment of febrile disease: the so-called active measures which were in vogue but a few years since, have given place to others of a more rational character Blood-letting is no longer carried to an extent which leaves the patient but little chance of recovery when the fever terminates, and the rash and empirical use of calomel in large and fre- quently repeated doses, to produce ptyalism, has been abandoned not only on account of the impossibility of producing ptyalism white the fever lasts, but because mer- cury, given to excess in any form, has a most injurious effect on the constitution. If these changes have had no effect in reducing the mortality, they, at all events, have lessened the sufferings and misery entailed on patients, who though they survived the fever, lingered long in a state of debility from the effects of blood-letting and mercury. Statistical Beport of the Health of the Royal Nov g for the year 1861.] Asa Preventative of Malarial Fe\ . 1856, ordered by the House of Commons to be printed 26th J 1858: pp. 110-116. In 1857 there were nineteen vessels employed on the African station, with a mean force, corrected for time, of about 1620 men, including Kroomen and liberated Afri- cans. The number daily ineffective from wounds and sick- ness averaged 112, or in the ratio of 69.3 to the 1,000 of mean force, which exceeds the ratio of the preceding ;. seven. The total number of dead, exclusive of those lost by shipwreck, amounted to thirty-six twenty-seven from disease, one from poison and eight from accidental on the whole, therefore, the mortality was some- what greater than in 1856. Daring the year, eleven a of endemic fever terminated in death: the ratio per 1,000, 6.7, and although nearly a third greater than in In- still not greater than the mortality of some of the healthiest ions, and incomparably less than the mortality upoiftlie African station, before the use of Quinine wine. The following summary, taken from the medical journals of the squadron, affords additional proof of the useful: of Quinine as a prophylactic. In the Trident there were forty cases of lever, but no death occurred : the greater number of these contracted in the rivers which enter the sea in the Light of Biafra. Quinine wine was freely used/as a preventative. On two occasions when boats were sent up the . the white men took quinine wine while in the river, and fourteen days after they left it, and no fever of any quencc followed. Fourteen cases occurred in the Sappho: they were near- ly all contracted in boating expeditions up the river Coi Quinine wine was admii : to the men on these o as, but several who did not take it regularly were :ed. Twenty men were employed off and on between the 30th of April and the 11th May, on this tell- ing a sui el in the Congo. The medicated wine administered carefully according to the printed circu- 39 610 Joseph Jones, on Quinine [August, lar. Only four men were attacked by fever, the disease Blowing itself about three weeks after they ceased taking the wine. In the Myrmidon and Pluto there were but few cases of lever, though they were employed on some of the most unhealthy places on the station : the former was laid on the beach at Sierra Leone, to be repaired, meanwhile her crew took up their abode in an old hulk which lay in the harbor. Some of the men, however, together with several of the Pluto's crew, were employed, both by day and nigl it, as their work depended on the tide, in patching up the hull of the vessel. To these men quinine wine was ad- ministered twice daily, and the executive officers took care that they did not straggle into the town or bush ; conse- quently no case of serious illness followed. The gig and pinnace of the Alecto, manned by fourteen white men and six Kroomen, were sent about 150 miles up the Congo, late in December, with presents for one of the petty chiefs ; they returned on the 6th of January, and be- tween the 12th and the 18th every white man, with two exceptions, was attacked with fever. The same boats were again sent up the river to the same place, on the 14th, when the two persons who had escaped fever formerly were now attacked, though one of them was not taken ill until thirty days afterwards. With the exception of these two persons the boat's crew on the second expedition were made up of Kroomen, who, as usual, entirely escaped. On these expe- ditions, an ounce of quinine wine was given to the white men daily during their absence from the ship ; but it ap- pears to have been discontinued on their return. In Janu- ary the boats of this vessel were again detached to cruise in the Congo, but did not proceed more than 40 miles up the river. Quinine was given to the men during their absence and for 14 days after tbeir return. The same precaution was adopted after any subsequent exposure to malaria in the river, and no cases of fever followed. The Bloodhound was employed in January in the River Benin, and during July in the Congo; as long as she remained within these 1861.] I 611 rivers, and for ten days afterwards, lour grains of quinine in a quarter of a gill of rum. was administered to every white man on hoard. One case only resulted from th two expeditions ; and in that Instance, the person attacked had exposed himself in a most imprudent manner while shooting wild fowl amidst the slimy ooze in the mangrove thickets on the hanks of the Benin ; whether the patient took quinine as a preventative is not mentioned. Three boats from the Childers went up the Congo, as far as Punto da Linha, and were absent for several days ; qui- nine was administered to the white men, and no fever resulted. In May, two hoats were sent from the Ilecla up the river Xunez, and returned on the following day. Quinine wine was issued in the usual manner, and no febrile disease fol- lowed. In July, the same vessel entered the Sherbro, and subse- quently her hoats, containing fifty-six seamen and marines, with the usual number of officers, ascended the river to the village Victoria they returned the same evening . rejoined the vessel, which remained in the river for a few days longer. Quinine in rum (the quinine wine having been all used,) was given to the crew while she remained in the river, and for fourteen days after she went to sea. s of intermitting fever," the surgeon remarks, "were added to the sick list a few days after our departure ; they were, however, all mild, and terminated favorably, alter an average of seven days' treatment. To the regular and timely administration of quinine, I think our immunity from fever may be fairly ascribed ; the cases that did occur were no doubt modified by the prophylactic. That this was the case, the mortality amongst the crews of tin* merchant 5 rrequenting the river, and by whom n<> i tive is used, bears ample testimony On the 23d of May, three officers landed at Lagos from the Hecate, intending to return on board tin- following reqm ntly happens on tliis coast, the surf 612 Joseph , ' oh es, on Quinine [August, rose suddenly, and contimn d so long, that they could not return to the vessel until the 29th. Again, on the 2d of August, the pinnace, with e ..on white men in it, was de- tached, to cruise in-shore between Little Popoe and Why- dah, where she remained until the 8th. Quinine was given on both these occasions, and no fever resulted. On the evening of the 27th of November, the same boat and a gig. with nine white men on board, were left off' Shark's Point, to guard the entrance to the Congo. An ounce of quinine wine was given to the men each morning. The boats remained in the same position until the morning of 30th, when they took advantage of a sea breeze, and pro- ceeded up the river to Punto da Linha. The gig, with one officer and two white men, returned on the 2d, and the other boat on the 5th of December. During their absence they had fine weather, and all returned apparently in good health. Quinine was now substituted for the quinine wine ; four grains were given daily to each person at seven in the morning ; but, notwithstanding this, nine out of the eleven were attacked bv remitting fever. The Merlin, between the 1st of January and the 30th of September entered the rivers Oalebar and Cameroons, in the Bight of Biafra ; she also entered the Nunez several times while on the northern division of the station. During the time she was in these rivers, and for some time after she had left them, quinine wine was duly administered to the white men on board, and no febrile disease of much impor- tance took place ; but in November,'; after having entered the Nunez and Pongas for the purpose of communicating with the native chiefs, her crew suffered most severely from remitting fever. Quinine wine was given to the crew for some time, but the supply being exhausted, quinine in rum was substituted. When the change took place is not speci- fied ; but in connexion with the substitution of quinine purchased on the coast, and :ssued in the same manner in the llccla, the quality of the alkaloid in both instances may he doubted. The Myrmidon was employed in the River 1861.] As a Preventative of Malarial Fcctr. 618 Bonny, and afterwards lay a long time in Clearance Cove, Fernando Po ; during the entire period quinine wine was given in the prescribed form : only one slight case of clima- torial fever occurred. At Sierra Leone, while the vessel was under repairs, the whole crew took quinine once a day, and those who were engaged on shore, twice ; still, though the latter were at work both night and day, only one case of remitting fever resulted. In the same manner, the Plato was laid in the beach at Sierra Leone early in March tor repairs. The carpenters, together with the carpenters of the Hecla, and a number of blue-jackets who were em- ployed on her, took the prescribed measure of quinine wine before going to work, and another on leaving off ; but the men who remained on the hulk took one measure only every morning until the 28th. Two men who had not been out of the ship were subsequently attacked with fever, but so long after the vessel had gone to sea, that the disease can hardly be ascribed to miasmata from the land at Sierra Leone. It is worthy notice that in the preceding instances, when quinine wine was administered according to the instruc- tions issued with it, no fever of any consequence followed exposure to land or swamp miasmata ; but on two occasions, when quinine purchased on the coast was substituted, and once when the wine was suddenly discontinued after the exposure, a considerable number of the men were attacked, owing, it is to be supposed, to the discontinuance of the qui- nine wine in one instance, and to its bad quality in the other, for it is well known that, like other high priced remedies, ir does not escape adulteration when it falls into the hands of dishonest traders. /Statistical He/port of the Health of the Royal Navy ', for the year 185" Ordered by the Hou to !> printed^ 2d Aug f, L859,^?. 7* A comparison of these facl the great sickness and mortality of the white explor and resident.-- and sailors of the African coast and rivers, < inclusively: 6J4 Fobd. Bcport of Surgical Cascc. [August, 1st. Quinine taken during exposure to the exhalations of miasmatic regions will, in most cases, ward off fever entirely 2d. If fever attacks those to whom the quinine has been regularly administered, its severity and duration will be far less than in those who have not taken the quinine; it therefore not merely wards off disease but renders it less powerful and destructive when present. 3d. To be entirely efficient the quinine must be administered for some time, at least ten days, after exposure to the causes of fever. ARTICLE XVII. Report of Surgical Cases from Case Boole. By DeSaussure Ford, M. D., Demonstrator of Anatomy, &c, in Medical College of Georgia. March 4th, 1SG1, master C. aged 11, was kicked by a horse on the posterior surface of the ulna, at the junction of its middle with superior third, fracturing it obliquely upwards and inwards, through its articlatiug surface, the sharp spicula of the iipper end of the fracture destroying the continuity of the soft parts, thus making the fracture compound. The same force dislocated the radius, forwards and upwards, upon the anterior face of the external condyle of the humerus. With an assistant firmly grasping the arm above the con- dyles, I made such extension as to reduce the dislocation, and, at the same time, approximate the ends of the fractured bone ; then applied an adhesive strip over the wound in the soft parts and kept the arm extended by a splint upon the entire anterior surface of the arm and forearm to the tips of the fin- gers ; this splint confined with a many-tailed bandage cold cloths were kept upon the joint, apprehending swelling, which then was not extensive as the patient was seen immediately p the injury. March 5th. The swelling very extensive; loosened the bandage; continuing the cold applications. 615 Ford. Report of & I Gases. [August, March 6th. Swelling still very extensive ; find the arm semiflexed, the bandage having been loosed during the night ; removed the dressings and endeavored to extend the arm but could not succeed ; very painful ; the wound in soft parts healing ; applying the splint and tightening the bandage around the elbow ; it was nearly extended. March 19th. Since the 6th the swelling has subsided, the arm, however, still remaining semi-flexed. Removing the splint to make passive motion, I was surprised and disappointed to discover the radius still dislocated. Jarvis' apparatus was applied, pushing the force as far as safety to the recently uni- ted fracture would permit ; failed in reducing the dislocation. The splint was replaced and allowed to remain a week longer. The young man has a partial stiffness of the elbow, caused by the dislocated radius, and not the fracture, as extension is per- fect. This stiffness does not incapacitate the arm for service, and will, doubtless, be flexed more and more as the radius is shortened by continually coming in forcible contact with the external condyle. This result of the case compensates for the oversight in allowing the dislocation to exist without discov- ery, until too late to be reduced, which dislocation must have been indicated by the semi-flexed condition of the arm the second day after the injury. It will be noted that the position most advantageous for the treatment of such a fracture the extension of the arm is most disadvantageous for such a dislocation, which explains the tendency of the radius assuming the abnormal position, so readily, after reduction. March 12th, 1861. Was called in consultation with Drs. Wm. Jones and Hatton to see Mr. B. aged 30, laborer, who had been stricken upon the head by a rough stone, which fractured both tables of the skull, wounding the soft parts im- mediately above the left eye, the fractured bone depree upon the dura mater. This was 12 o'clock at night, the acci- dent occurred at 8 P. M. immediately after which lie walked three squares, and soon after returning home, had a convul- 1SG1.] Ford. Report of Surgical Cases. GIG sion ; up to my visit had bad three. It was deemed necessary o trepan, as all efforts to elevate the bone were unavailing, and as convulsions would recur from meningeal irritation. I made a semi lunar incision with scalpel, the concavity presenting upwards, then applied the trefine above the de- pressed bone, cutting the sound bone about the middle of the left lateral half of the frontal bone ; removing the piece em- braced by the trefine, the fractured portion was elevated and taken out. There was no hemorrhage, except from the inci- sion of the soft parts. The flap was united with five sutures and slight compress dipped in cold water applied. During the operation the patient was partly conscious. Left at 2 A. M.; perfectly conscious, with pulse 80, (soft.) He had taken large doses of opium before my visit. 13th, 9 A. M. Pulse 80, skin moist, tongue soft and nat- ural color, pupils much dilated, complains of pains through- out the head and in the bowels. Bladder acted four or five times last night ; rested comfortably ; conscious. 3 P. M. Pulse 85. Complains of pain in the head, though not local and insomnia: pupil dilated; dressed the wound, which discharged bloody serum; looking healthy ; conscious. 10 P.M. Pulse 80. Tongue more dry and coated. Com- plains still of insomnia. Prescribed one-fourth grain mor- phine, to be repeated every four hours, if restless; has had no action from bowels since accident ; conscious. 14th, 10 A. M. Pulse 75. Pain in head better ; pupil a little dilated ; eyes looking better in expression; took only 1 dose of morphine last night, resting four or five hours; con- scious ; no operation from bowels; ordered light nourish- ment. 4 P. M. Pulse 75. Not much pain ; dressed the wound; removing sutures and applying adhesive strips ; it had healed by primary union, except at one point, out of which dis- charged a small quantity of bloody serum; wound looked healthy and no tumefaction of the parts; ordered one soft I egg with tea and (oast. '> P. o\[. Having no watch did not count the pulse, which 617 Ford. Report of Sur< sea. [August, ever is perceptibly Blower, say 60 ; speaks of getting up in three or four days, he tods so comfortable; morphine to "be repeated as usual; nourishment in the morning, an egg and tea and t 15th, 9 A.M. Pulse CO. No urgent pain, either general or local ; rested well last night, taking only one dose of mor- phine ; nourishment the same. 8 P.M. Pulse 44. More feeble ; cannot interpret this sudden change, with the healthy appearance of wound, which I inspected, and the absence of any symptoms of compression) complains of local pain, though not urgent ; ordered morphine as usual ; has taken for nourishment to-day, two eggs, tea and a little chicken broth, 10th, 9 A. ]\r. Pulse 41 ; not as feeble as last night ; soft and natural in force ; removed adhesive strips from wound, and it with simple cerate ; wound looking well ; did not well last night ; took two doses morphine > local pain; pupils very little dilated; nourishment only tea and 4 P. M. Had gotten up and walked across the room a few moments before visit, but is comfortable. 10 P. M. Pulse 55. Pupils contract and dilate naturally; more comfortable; same directions for the night; tea and in the morning. 17th, (.i A. M. Pi,. Skin moist and pleasant ; re well last night ; same diet, with addition of one <. :; P. M. Pulse 60. Very comfortable. 5 P. M. Pulse 56. Suspect accumulation of pus beneath flap; complains of slight, dull, local pain; same directions for the night. 3th, 11 A. M. Pulse 50. Think there is pus beneath the ilan, but have no instruments ; state comfortable; rested well last night, without morphine p for dinner. '. M. I' 1 the wound with a probe, g up the recent adhesions; healthy pus discharged ; put in a Bmall tent into the wound; same diel for the morning. 1861.] Ford. Report of Surgical Cases. G18 19th, 12 M. Pulse 50. Skin warm, but moist and pleas- ant ; the wound discharging, moderately, a healthy pus ; did not rest well last night. Same diet. 0 P. M. Pulse 60. Comfortable ; same directions. 20th, 12 M. Pulse 50. The wound discharged very freely, through the night, disturbing his rest ; comfortable. 10 P. M. Pulse 57. Wound discharging ; comfortable; same diet. 21st, 11 A. M. Pulse 55. Rested well last night. Com- fortable. 9 P. M. Pulse 60. Same uneasiness in bowels. Note He has had no action since accident ; ordered an enema of warm water in the morning, with same diet. 22d, 12 M. Pulse 57. Had an action after enema ; com- fortable. 7 P. M. Pulse 60. Comfortable ; nourishing diet ; beef steak in the morning. 23d, 12 H. Pulse 57. Some local pain, on account of the formation of a scab, preventing the escape of pus from the wound ; let out the pus ; comfortable ; no operation since yesterday this hour. 24thj 12 M. Pulse Go. Had a comfortable night ; wound discharging freely ; no operation from bowels. 7 P. M. Pulse 75. Applied a compress over the flap to invite the union of the inner walls of the abscess ; no opera- tion ; comfortable. 25th, 11 A. M. Pulse 45. Comfortable and wound not discharging so freely; able to sit up in bed ; ordered enema of warm water in the morning ; is taking strong, nourishing food. 26th, 12 M. Pulse 15. Comfortable; dressed the wound ; lias had a large operation. 27th, 12 M. Pulse 55. Had a restless night, with much general pain in head. This probably was from over exertion and excitement induced by smoking a pipe. 0 P. M. Pulse 60. Very comfortable ; not so much pain as this morning; discharge has sensibly diminished since ap- II.] Military Surgery. 619 plication of the compress ; is walking about the room and feels perfectly well, except the Blight general pain in the head. April 3d. Has been doing well since 27th of March ; dis- charged the case as having recovered. Remarks After the depressed fragment of hone was re- moved, it was obvious why it could not have been elevated and why the operation of trepanning was necessary. The internal table of the bone was more extensively fractured than the external, this internal surface being too large to pass out of the opening made in the external plate, which inner surface with its sharp spiculated edges caused the irritation of the dura mater, which brought on the three convulsions which the patient had before the operation. From the beginning there were no symptoms of compression, as paralysis, &c. I confess the slowness of the pulse, viz. 45 its minimum, embar- 1 my prognosis, nor can I now explain it, since the patient in health, has the normal average pulse. In the treatment of the case it will be noted that his bowels were not acted on for fourteen daj enjoined and nature allowed to take her course as much ible. After the abscess formed beneath the flap had assumed a chronic form, the pus becoming more thin and watery, compresses were used with a happy effect, inducing the adhesion of its internal surfaces. At this date July lGth, Mr. B. is well, but suffers dizziness whenever exposed to the sun for any length of time. MILITARY SURGERY. [Continued from .July M xtrcmely common among soldiers during the cold, wet weather of winter. Thousands of the French troo; bed from thi Russia, during Napole- on's retreat from Moscow. Frost-bite was very prevalent among the English during their first winter in the Crimea, and the French suffered in ^till greater number . il as mo; !v. The .habit which the men had aping in their wet (most universal, contributed G20 Military Surgery. [August, greatly to its production, wet and cold combined diminish- ing the circulation and vitality of the feet and toes. On the 21st of January, 1855, when the thermometer stood at 5, not less than 2500 cases of frost-bite were admitted into the French ambulance, and of these 800 died, death in many having no doubt been expedited by the effects of erysipelas, pyemia, and hospital gangrene. "Weak and in- temperate persons are most apt to have frost-bite and to perish from its effect*. In the treatment, in incipient cases, cloths, wrung out of cold water impregnated with a little spirits of camphor or alcohol, should be applied, or the parts be covered for a few minutes with snow, or immersed in cold water. On no account must they be exposed to warmth, either moist or dry. Excessive reaction is controlled by lead and lauda- num lotions, or dilute tincture of iodine. If gangrene occurs, the ordinary measures, local and general, are indi- cated. All rude manipulation in dressing the injured part greatly aggravates the disease. In general, spontaneous amputation is waited for, experience having shown that operative interference, even when the partis perfectly black, and attached only by a few living shreds, is extremely prone to be productive of excessive pain and constitutional irrita- tion, often proceeding to an alarming extent. Among the great evils, both of civil and military prac- tice, are bed-sores, which, unless the greatest possible pre- caution be used, are sure to arise during the progress of acute diseases and of severe accidents, necessitating pro- tracted recumbency. The hips and sacral region are their most common sites, with the heel in cases of fractures of the leg. The earlier symptoms are a sense of prickling, as if the part were rubbed with coarse salt, or a burning, itching or smarting pain, with a brownish or livkl discolo- ration of the skin, and slight swelling. Then gangrene ensues, followed by horrible suffering. To prevent these sores, which otten prove destructive to life, when there is already much exhaustion from previous suffering, the posterior surface of the body should be fre- quently examined, particularly if the patient is in a state of mental torpor, and pains taken to ward off pressure by tlie use of air cushions and other means. The parts should be sponged several times a day with some alcoholic lotion containing alum, or painted with a weak solution ot iodine. If gangrene or ulceration occurs, a yeast or port wine poul- 1861.] MUUary Surgery. 621 tice is used, the separation of the slough is aided with the knife, while the granulating process is promoted by the usual remedies. Ulcers of the leg are causea oi' disqualification in enlist- ing, but they sometimes occur after the soldier has entered the serviee. from fatigue, injury, or undue constriction of the limb. However induced, they should be managed as any other forms of inflammation, recumbency with eleva- tion of the affected parts, tepid water-dressings, a restricted diet, and cooling purgatives constituting the most import- ant elements of the treatment. When the healing process has fairly commenced, the leg should be supported with the roller, or adhesive strii Aa preventive of ulcers of the legs, the limbs should be daily washed in cold water with Castile soap, and no soldier ould be permitted to wear garters. CHAPTER X. MILITARY HYGIENE. Much disease and suffering maybe prevented, and many lives saved, by a careful observance of hygienic regulations. There is no question whatever that immense numbers of soldiers everywhere fall victims to their recklessness and the indulgence of their appetites and passions. We would not advocate too much restraint ; men are but men every- where, and soldiers form no exception to the general law. They, like civilians, must have their amusements and re- creations. The bow cannot last long, if kept too constant- ly and too tightly on the stretch. I ial relaxation is indispensable to health. Indolence, however, should never be countenanced in any army. Its demoralizing effects, and its influence upon the health of the soldier, have been noticed and commented upon in all ages. "The efficacy," say- an eminent military surgeon, in speaking on this subject, "of due attention to the occupation of the mind mu rer be Lost sight of. :y illustrations of its powerful inline!!'-", whether for good or evil, whether in r< U rating the in- roads of disease, may be found both in ancient and in modern times, from the retreat of the ten thousand Greeks 022 Military Surgery. [August, under Xenoplion down to the present day. It may be ob- served that disease goes hand in hand with indolence and inactivity, whether of body or of mind; and that, on the contrary, where the minds of soldiers are agreeably occu- pied, and their bodies energetically employed, as in the at- tainment or pursuit of victory, disease is kept in abeyance." It was the observation of another experienced authority in military medical affairs, Mr. Alcock, that "the period of the smallest loss to an army is a victorious and vigorously prosecuted campaign, with frequent battles and much marching;" an assertion corroborative of the facts, long since so painfully realized, that sickness, however induced, destroys incomparably more soldiers than the sword and the musket. Xo intemperance, either in eating or drinking, should be tolerated in an army ; both are demoralizing, and both pre- dispose to, if not actually provoke, disease. Alcoholic li- quors should not be permitted to be used except as medi- cine, and then only under the immediate direction of the medical officer. The ordinary drink and food should be selected with special reference to their healthful properties. The use of bad water, even for a short time, is invariably productive of mischief. The tea and coffee should be of good quality, and well prepared, to preserve their agreeable flavor and their soothing and refreshing effects. Lager beer, ale, and porter, if sound, are both nourishing and wholesome, if consumed within judicious limits. The practice of allowing soldiers spiritous liquors, as a portion of their daily rations, has, I believe, been pretty generally, if not entirely, abandoned in the European ser- vice. Its injurious effects upon the health and morals of troops have long been deprecated. In the British army in India, the use of alcoholic liquors was, at onetime, univer- sal, on the supposition that it had a tendency to counteract the depressing influences of a tropical climate ; the men took their spirits regularly before breakfast, and not un- frequently several times during the day, especially if on active duty; but it was soon found that it produced quite a contrary impression, causing instead of preventing debility, and affording a temptation to general drunkenness, which was followed by insubordination and crime. The result was that the government abolished the alcoholic ration tern altogether, substituting coffee and tea, which are now regularly served once, and often twice a <\i\y. 1861.] Military Surgery. 02:5 The condition of the L3th Regiment of Light Infantry, stationed at Jellalahad, during the late insurrection in India, affords a happy illustration of the salutary effects of absti- nence from spiritous liquors. While the siege was pro- gressing, the men, during a period of five mouths, were entirely debarred from drinking, and yet their health and courage were most excellent. As soon, however, as the garrison was relieved, and they began to indulge in spirits, many of them in a short time became sick and riotous. The experience of Major-General Wylie, of the Bombay army, was precisely similar. When the soldiers under his command were quartered in districts where no liquor could be obtained, their health, discipline, and morals were all that could be desired ; whereas, under opposite circumstan- ces, insubordination and disease prevailed to a frightful extent. During the Crimean war, coffee and tea were found to be eminently wnolcsome and invigorating, enabling the troops to sustain fatigue and to resist disease. When the men were in the trenches, and could not obtain their usual sup- plies of these articles, they became languid, and suffered trom dysentery and diarrhoea. To produce their peculiar sustaining and exhilarating effects, coffee and tea should be taken hot and moderately strong, with sugar, if not also with cream. Fresh meats are always preferable to salt, though good ham and smoked beef may be taken once a day with ad- vantage as an agreeable change. Fresh fish are always ac- ceptable. Pickled pork and beef are fai from being good articles as a portion of the daily rations. The frequent use of fresh vegetables is indispensable to the health of the soldiery. Pipe fruits are nearly equally so. Without a proper admixture of this kind, d}\spepsia, bowel complaints, and scurvy will, sooner or later, inevitably ensue ; and woe to the man that is assailed by them! The acids and other properties contained in these substances are indispensable to the healthy condition of the blood and solid-, and the importance of such a diet cannot be too deeply or too fre- quently impressed upon the attention of every commi riat. Potatoes, rice, hominy, bean spinach, lettuce, asparagus, radishes, horse-radish, water- dried peaches and apples, and the different kind- of fruits as they come into season, should be constantly on hand. Soups, both animal and vegetable, are generally grateful to G2I Military Surgery. [August, the palate, as well as useful to the system, and should be used whenever the occasion is favorable for their prepara- tion. Eggs, butter, milk, and butter-milk should be freely in- dulged in whenever they can be procured. Serious disease is often engendered by bad bread and biscuit, and it should therefore be made a part of the duty of every medical offi- cer to see that no articles of this kind are brought into camp. When in the camp or barracks, the soldier should take his meals with the same regularity as the ordinary citizen at his home. Neglect of this precaution must necessarily lead to great bodily inconvenience, and, if long persisted in, may ultimately lead to serious disease, especially dys- pepsia and other disorders of the digestive apparatus. He should not disregard regularity even with respect to his alvine evacuations ; for there are few tilings more conducive to the preservation of the health. The soldier's dress should be in strict conformity with the season of the year and the vicissitudes of the weather. He should, at no time, be either too hot or too cold, but always comfortable, changing his apparel with the alterations of the temperature. Flannel should be worn next the surface both winter and summer. The shoes must be thick and warm, with broad soles ; and woolen stockings will be more comfortable, especially when the troops arc marching, than cotton. A thin woolen cap-cover, found so useful in India, will protect the neck from the hot sun, and an oil-silk cap- cover, from the rain. In very wet weather the shoulders might be defended with a cape of oil-cloth. Frequent ablations will largely contribute to the comfort of the soldier and the preservation of his health. They should be performed at least once a day, the best time be- ing late in the afternoon or in the evening just before re- tiring. The feet, in particular, should be often washed, especially in marching, for reasons which need not be dwelt upon here. The under-shirt should be changed every night, and frequently washed, to promote the healthy state of the skin. Exposure to the hot sun, to cold and wet, must alike be avoided. Sojourning in malarious regions will be certain to be punished by an attack of neuralgia or intermittent fever. All offals should be promptly removed from the camp, 1861.] Military Surgery. G25 and carried to a distance of several miles, or be well buried. The privies should be in the most favorable location ; respects ventilation, and be closed at least every three or four davs ; or, what is worthy of consideration, every man should be compelled to bury his alvine excretions, as was the custom, in time of war, among the ancient Hebrews, each man being obliged to carry a paddle for that purpose. The emanations from these sources cannot receive too much attention, especially when large masses of men are crowded together, as they are then extremely prone to induce dis* ease. Finally the medical officer should make it his special duty to see that every recruit is vaccinated, or, if the opera- tion was performed prior to his enlistment, at a diatant period, matter should again be inserted, experience having shown that the effects of the virus are, in time, in many instances, totally eradicated from the system. In most of the European armies revaccination is extensively practiced; and it is asserted by Stromeyer that during the Schleswig- Holstein war, on an average, 38 operations out of 1000 were successful. It is impossible to bestow too much care and attention upon the selection of the camp ground, and the arrange- ment of the tents, as a vast deal of the comfort and health of the soldiers must necessarily depend upon them. The following judicious remarks upon this subject arc from the pen of an eminent military surgeon, the late Dr. Ballingall, who served in various campaigns, and who was for many years, as stated elsewhere, Piofessor of Military Surgery in the University of Edinburgh. "A camp," says Ballingall, "is most advantageously sit- uated on a gentle declivity, on a dry soil, and in the vicinity of a running stream. In order to ascertain the state of ground it may sometimes be necessary to dig into it to some extent ; for, although apparently dry on the surface, it may be found sufficiently wet at the depth of a few feet ; and if so, ought, if possible, to be changed, particularly if an en- campment is to be stationary. A camp should never be formed on ground recently occupied, nor on a field of bat- tle where much carnage has itly occurred. Many fa- vorable re to be found on the banks of rivers, which, perhaps, upon the whole, afford the mosteligibl* must yet bear in mind that, when the banks of tie' rivers are low, or the country suhject to periodical rains or sudden 40 G2.Q Military Surgery. [August' inundations from the melting of snow on contiguous moun- tains, there may be a very serious danger from this cause. Against the danger of such a position, we are cautioned in Mezerey's 'Medecine d'Armce,' which states a casein which the Austrian army lost 500 men and 200 horse from a sud- den inundation of this kind." When damp ground or a low situation is unavoidable, it should be abandoned as soon as possible for a better, and, in the meantime, the greatest care should be taken to pro- tect the soldiers from damp or wet with straw or other suit- able means. An army has been known to suffer severely from disease contracted in a malarious region. Against such a calamity useful information may often be elicited from the people of the neighborhood, especially physicians conversant with insalubrious sites. When an army is obliged to remain for a long time sta- tionary, an occasional change of camp will be greatly con- ducive to health, although such change should involve a good deal of labor and temporary inconvenience. A camp under such circumstances should, at all events, be frequently ventilated, and kept constantly clean, a pure atmosphere being of paramount importance to health and comfort. It may often be difficult to do this, but it must, nevertheless, be done; the welfare of the service absolutely demands it, and no medical officer honestly performs his duty unless he interests himself personally in these matters. "The most obvious and perfect way," says Ballingall, uof thoroughly airing the tents is by shifting them occasionally, and ex- posing the straw, blankets, and soldier's clothing to the open air; the necessity of frequently changing the straw, and enforcing cleanliness in camp in every possible way, are circumstances too obvious to require any effort of rea-^ soni ng to enforce. With this view the slaughtering of cattle, and everything likely to create noxious or putrid effluvia, ought to be conducted without the camp, and on the side of it opposite to that from which the wind gene- rally blows." The demoralizing influence of a campjife is well known, and I am convinced that there is nothing so well calculated to counteract this influence as rigid discip- line, reasonable activity of mind and body, strict temper- ance, both in eating and drinking, and- frequent religious worship. Every regiment should have its chaplains, not less than its medical officers, not only with a view of re- straining vice and promoting morality, but of affording to the poor soldier, away from Lome and friends, in the hour of his morta mity, th< eolations which the min- of the gospel alone know- how to impart. The miti- ;' the horrors and miseries of war, not less than the tendencies of the age in which we live, absolutely dera such a provision. CHAPTER XI. DISQt &XIFYIKG DISEASES. Trocps, whether regulars or volunteers, should include no men that are not perfectly qualified, both physically and mentally, for the hardships of the public service. They Bbould, in a word, he perfectly sound, or, what is the si thing, free from all defects, congenital or acquired. It is for this reason that the} are always subjected to a most thorough examination by the recruiting or regimental e geon. This examination is, as a generi I rule, a great d more rigid in the regular than in the volunteer service. In the former, the regulations are such that, if the recruit is not found to be sound after he has be- regular army surgeon, the at to hi ment and transportation falls upon the committed the oversight. ;i examination of th here mentioned <1 both time, patience, a. id skill In order to make it thorough, the candidate must be completely stripped, so that if any or delect in the exterior of the body exist it may he nee rendered apparent The examination, 1. must not be limited to the exterior: it mu the interior. The disqualifying affections may be arrai rding to the organs and regions in which seated, under separate head-: 1. : and ear. 2. 1 lect. 8. The lungs and heart. 4. Th ana thra. 0. Tl 7. Th aen. 8. The limbs, including the join The unlit a man for I e are defi ught, of hearing, and of s] iieet; ] ysi8; rnia; h ; -ai-i- 628 Military Surgery. [August, cocele; imperfect development or absence of the testes; hemorrhoid, anal fistule, and iissure of the anus; unusual protuberance of the abdomen ; organic lesion of the internal organs: large tumors; aneurism ; varix of the extremities; ulcers, or large scars indicative of their former existence; bad corns; bunions; overlapping toes ; flatfootedness ; de- formity of the hands and lingers; contractions from burns or other causes ; badly united fractures ; unreduced dislo- cations ; diseased joints ; loss of the incisor and canine teeth; serious disfigurement of the features; spinal curvature; ill- formed shoulders; habits of intemperance; diminutive stature or excessive overgrowth. In the regular army no man is enlisted under the age of eighteen or over that of forty-five. In the volunteer service, similar regulations obtain, although they are not so rigidly enforced. Recruiting surgeons, after having examined a candidate for enlistment, are obliged to certify, on honor, that they consider him, in their opinion, to be free from all bodily defects, and mental infirmity, which would, in any way, disqualify him for performing the duties of a soldier. When men become disqualified for service, in conse- quence of disease or accident, a surgeon's certificate is also required, in order to aid them afterward in procuring a pen- sion and exemption from ordinary military duties. The affections which may justify a soldier in applying for a re- lease from further service are oiganic visceral lesions, deaf- ness, blindness, mental imbecility, lameness, large hernia?, and such mutilations as interfere with the proper handling of the sword and musket. CHAPTER XII. FEIGNED DISEASES. Soldiers, influenced by a desire to quit the service, to re- visit their homes, or evade active duty, will not hesitate, at times, to play the part of impostors, feigning diseases, or even inflicting upon themselves more or less serious inju- ries, with the" hope of accomplishing their designs. This deception, technically called malingering, would be of comparatively little consequence if it were always, or even generally, confined to a few members of a regiment; but 1861.] Military Surgery. 629 when it is remembered that it is liable to become epidemic, spreading from individual to individual, it assumes a d< importance, well calculated to arouse the attention both of the medical officer and of the military commander. Its effects, then, become eminently demoralizing to the service, which, if proper care be not employed to detect and punish it, might seriously sutler, especially when such an outbreak occurs on the eve of a battle. Great ingenuity is often displayed by malingerers, requiring no little vigilance and skill on the part of the surgeon for its successful exposure, and yet it is not less necessary for his own credit than for the honor of the service that he should not permit himself to be deceived. The number of diseases, imitated by this class of dis- semblers, is surprisingly great, and there is also quite a list of self-inflicted injuries. Among the former are various mental diseases, as mania and. imbecility; deafness; amau- rosis ; epilepsy; paralysis; hsematemesis ; haemoptysis; tritis; dysentery and diarrhoea; affections of the heart; rheumatism ; lumbago ; wry-neck ; contractions of the joints ; incontinence of urine; bloody urine ; and stone in the bladder : among the latter opthalmia, opacity of the cornea, oedema of the limbs, wounds, and amputations of the lingers. Space will not permit me to enter into any details re- specting this important subject. I shall, therefore, content myself with a presentation of such facts as may be sup- posed to be of special practical interest. First of all, the medical officer should weigh well in his own mind the nature of the disease for which a soldier ap- plies for a certificate of discharge, or inability to perform duty. If the case is one of recent standing, it will be well not to come to too hasty a conclusion as to its diagnosis; it should be examined and re-examined before any definite opinion is given. Day by day facts may be developed, revealing the true character of the affection. If the patient affected with sonieserious chronic disor. eral appearance will hardly fail to afford some evi- dence of its existence. The pal tor of the countenance, the functional disturbance of the Buffering organ, the bodily atration, the want of appetite, and the gradual emacia- tion will almost unerringly point to the nature and seat of the .. on the other hand, the malady is simulated, all, or nearly all, the usual phenomena of disi 630 Military Surgery. [August, will be absent. Impostors, moreover, are generally very zealous in talking about their disorders, or in obtruding a upon tha notice of their surgeons, whereas those who are really Bick and suffering fliake comparatively little com- plaint. A malingerer may often be detected by carefully watching his movements, coming suddenly upon him when he is asleep, or when his attention is directed to some one else, tickling his foot when he feigns paralysis, or pricking his back when lie pretends to be laboring under lumbago. Sometimes a determined threat will promptly restore him to a sense of his duty, as the application of the actual cautery in incontinence of urine, rheumatism of the joints, or mental imbecility. Now and then the exhibition, in rapidly repeated doses, of a nauseous draught, answers the purpose. Whatever expedients be employed the surgeon cannot exercise too much address, otherwise he will be almost sure to be baffled. Mental alienation, or mania, unless the result of inebria- tion and of acute disease, generally comes on gradually, being preceded by a marked change in the moral character of the individual, loss of appetite and sleep, and other evidences of general disorder. Genuine deafness is also gradual in its approaches, and, when fully established, is invariably attended by a peculiar listless state of the countenance with more or less change of the voice. Before a final decision is given, a careful inspection of the ears should be made, to ascertain whether there is any obstruction or appearance of matter. The un- expected discharge of a pistol, in a case of feigned deafness, might suddenly decide the diagnosis. Amaurosis may be simulated by the internal use of bella- donna, or by the direct application of this article to the eye, causing dilatation and immobility of the pupil. These effects are often accompanied by unnatural vascularity of the conjunctiva, and they generally disappear spontaneously in a few days. In genuine amaurosis, too, there is always a dilated condition of the vessels of the eye. Feigned epilepsy differs from the real in the absence of lividity of the countenance', the want of froth at the mouth, and t\\<> partial character of the convulsions. The pupil does not contract, as in the genuine disease, the general jibility is unimpaired, the tongue is not injured, the nails are not discolored, the hand, if opened, is again firmly .shut, and the individual often watches with, his eye the II.] Military Surgery. 631 impression ; 3 making upon the by-standers. The application of a boated case-knife, or of a cloth wrung out of hot water, often speedily reveals the imposition. frequently imitated, but is generally easily detected, simply by watching the patient, tickling his feet or threatening him with the hot iron. The disease, when it attacks the lower extremity, is nearly always caused by apoplexy, and is then generally associated with mental weakness and difficulty of articulation. Partial paralysis of the upper extremity is frequently induced by lying upon the arm, by suppression of the cutaneous per- spiration, and disease of the spinal cord. s may be simulated by swallowing blood, or an infusion of logwood, and ejecting the fluid afterward by vomiting. It should be recollected that the real disease is almost invariably connected with serious organic lesion, as ulceration of the stomach, induration and enlargement of the liver, or visceral obstruction, and that the patient, con- sequently, will exhibit all the characteristic of a sick per- son. Soldiers sometimes counterfieit haemoptysis, by cutting the gums, or chewing substances impregnated with coloring matter. A case is related by Guthrie, in which a man, for this purpose, swallowed a piece of cork full of pins. The immediate effect was haemoptysis, and the remote one death by wounding the carotid artery. Gastritis may be simulated by spontaneous vomiting, a faculty possessed by some persons, and by pretended pain in the epigastric region. The attack in general speedily yields to a large sinapism and a brisk emetic. Dysentery and diarrhoea are occasionally leigned by ex- citing, artificially, irritation of the rectum, by mixing blood with the alvine evacuations, or by borrowing the discharges of ] actually affected with these diseases. In gen- uine dysentery and diarrhoea there arc always well-marked constitutional phenomena, which are of course absent in the spurious. Careful watching of the patient and com- pelling him to use a close stool will soon remove any doubt that may exist respecting the nature of the case. Disease of the heart, in the form of palpitation, may, it is Inced by the use of hellebore. Mr. Hutchinson, of England, refers to an epidemic of this kind among thnful ot' each to half a pint of tepid water, one-half to be taken at once, the remainder, it* necessary, in fifteen mini >per or zinc will afford the must prompt emetic effect h at urgen ing. The following formula will be found very BCrvicable in the earlier stages of most inflammatory affections, especially the 634 Military Surgery. [August, cutaneous, articular, and traumatic, unaccompanied "by dis- ease of the alimentary canal : 1>\ Ant. et Potass. Tart. gr. iss ; nesias Sulph. gi ; Morphiee Sulph. gr. ss; Sacch. Albi. 5ii. Aquse Destil. gvi. M. This is the antimonial and saline mixture, of which repeated mention, ocenrs in the preceding pages, and which I am in the daily habit of prescribing in my surgical as well as medical practice. Lt may be rendered depressant by the addition, to each dose, which is half an ounce, repeated every two or three hours, of from three to eight drops of the tincture of veratrum viride ; anodyne, or diaphoretic, by laudanum, or morphia; anti-periodic, by quinine; anti-gonorrhceal, by copaiba, gum-arabic being used, in the latter case, as one of the ingredients ; and anti-rheumatic, by colchicum. If qui- nine be used, the addition of aromatic sulphuric acid will be required, which is also an excellent solvent of the salts. IJ. Yini Colchici Sem. 5i ; Morphias Sulph. gr. ss ; Potassas Carbon, gr. x ; Aquas Destil. gss. M. In rheumatic and gouty affections, taken at bedtime, and fol- lowed by a mild aperient next morning. The following will be found to be pleasant and efficient diaphoretics : ]J. Spirit, Mindereri, giv ; Sp. ^Ether. Nitrici. 5ii ; Morphias Acet. gr. i. M. S. Tablespoonful every two or three hours. If there be much heat of surface, we may add to each dose the eighth, twelfth or fifteenth of a grain of tartar emetic. IJ\ Potassas Carbon. 5i ; Morphias Sulph. gr. i ; Sacch. Albi. 5h ; Sue. Limonis recent, gii ; Aquas Menth. v. Destil. giiiss; Sp. JEther. Nitrici. gss. M. S. Tablespoonful every hour or two. The effervescing draught, so valuable in irritability of the stomach, is composed as follows : ]$. Sue. Limonis recent, gji: Sacch. Albi. 5jiss; 11.] 7. G35 til. 5ji. M. ft. P >n. ,li : a. sji. m. Pat two tabic ill of the lei of the alka- line solution, ami lor the mixture be drunk while effervescing, rig the dose at pleasure. A- anti} , l di s quinine aud arsenic are the main reliance lie modern practitioner. The former may be given by itself, in pill or solution, in doses varying from two to ten ins, according to the urgency of the case or the state of the My usual dose is ten grains every eight ten, or twelve hours, until the paroxysm is arrested. If the symptoms are unusually violent, we need not hesitate to administer fifteen or even twenty grains at a dose, being of course careful to watch the effects, which will generally be more pleasant if a little morphia be combined with the quinine. In chronic, or frequently-recurring intermittent and neural- gic affections, arsenic forms a valuable, and, indeed, in many cases, an indispensable addition ; also iron, if there be evi- deuces of anaemia. I prefer myself the arsenious acid to Fowler's solution, convinced that it is much more efficacious and at the same time less apt to cause nausea and anasarca. The following formula will be found advantageous: ft. Acid. Arseniosi, gr. iss ; inioe S ul ph. Ferri Sulph. aa 5i ; Morphias Sulph. gr. i ; Extr. Xucis Vomicae, 3i. M. ft. pil. xxx. S. One every live, six, or eight hours. Quinine is also one of the best tomes, and it may always be beneficially combined with other articles, as iron, gentian, quassia, mix vomica, aud capsicum. The fluid extracts and aromatic tinctures of bark and gentian will also be found useful. One of the best chalybeate preparations is the tinc- ture of the chloride of iron, in doses of from twenty to twenty- five drops three or four times daily. institute a large class of remedial agents, but they nearly all derive their active principles from the admix- ture of tartar emetic, ipecacuanha, or squills. They may rally be usefully combined with potassa and anodynes, being rendered palatable by Byrup or sugar. Nurses should be familiar with the manner of administering .idta or injections, as frequent occasions arise for their cm- 636 Military Surgery. [August, ployment. They may be cathartic, as when they are designed to empty the lower bowel, or to promote the action of oh er remedies; stimulant, as in case of excessive exhaustion; nu- tritive, as when food cannot be taken by the mouth; anodyne, when it is wished to allay pain and induce sleep. A cathartic effect may readily be induced by an injection of a pint and a half of cold water, or water in which a little ground mustard or common salt has been stirred, a mixture of warm water and castor oil; or an infusion of senna, or senna and Epsom salts. Turpentine is particularly indicated when the bowels are distended with flatus. Stimulating injections may be made of brandy, alcohol, mustard, salt, or spirits of camphor or turpentine, mixed with more or less water ; and they are often extremely serviceable in promoting reaction. Nutritive enemata may be necessary in the low stages of fever, and in gunshot and other injuries attended with lesion of the gullet. The best ingredients are essence of beef, strong beef-tea, brandy, or brandy and milk, introduced in Bmall quantity so as not to oppress and irritate the rectum. Anodyne injections may consist of laudanum, black drop, morphia, hyoscyamus, or belladonna, either alone, or various- ly combined, and administered with about two ounces of tepid water, or some demulcent fluid. Tiie best syringe now in use is the gutta-percha, which is not liable to be deranged, and which has the additional ad- vantage of durability. It should be of various capacities, from eight to sixteen ounces, according to the intention to be fulfilled by it. The nozzle must be well oiled previously to its introduction, and care taken that no air be pushed into the bowel. 2. Topical Remedies. JJ. Tinct. Ioclina?, Sp. Vini Eectific. aa Sj. M. To be applied with a large camel-hair pencil, or cloth mop. I hardly ever use the pure tincture of iodine for local pur- poses. I\ Plumbi Subacet. 5j ; Pulv. Opii, 5j. M. To be put in half a gallon of hot water, and the solution to be used warm or cold, as may be deemed best. Laudanum may be substituted for the opium. lv. Pulv. Ammonise Hydrochior. gj ; " Potass Kit rat. 5'j ; " Opii,5j. M. 1861.] MUHary Surgery. 637 To be used as the preceding; being particularly valuable in inflammation of thejoints, on unbroken surfaces. The warm water-aressing consists of warm water, simple or medicated with laudanum, acetate of lead, or any other ingredient that may he desired, applied upon flannel or mus- lin cloths, properly folded, and covered with oiled silk, to confine heat and moisture. The cold water-dressing is composed of cold water, also simple or medicated, applied with cloths, the parts being con- .;ly exposed to the air to promote evaporation. The cloths are to be wet whenever they become heated or dryish, the water being pressed upon them from a sponge. Water-dressings, if long continued, will occasionally cause irritation, itching, and pustulation of the skin, rendering it nec\ replace them with cataplasms, or other soothing remedies. Among poultices decidedly the best, for ordinary purposes, are the flaxseed and slippery elm. The former is made by mixing a suitable quantity of linseed meal with hot, or, what is still better, boiling water, and rapidly stirring it into a thick mush-like consistence. The mixture is then spread upon a fold of cloth, in a layer a third of an inch thick, Avhen it is covered with bobinet or gauze to prevent it from adhering to the parts. A piece of oiled silk, larger than the poultice, is placed upon its outer surface, to retain heat and moisture. The elm, and, in fact, all other cataplasms, are prepared and used upon the same principles as the linseed. Like water- deessings, poultices may be simple or medicated, according to the object proposed. They should be changed at least twice, or, in warm weather, even three or four times in the twenty-four hours. J plaster is cut, in the direction of its length, into strips of suitable length and breadth, warmed by holding the backs against a smooth vessel, as a pitcher or tin case, and .led in such a manner as to bring the middle of each piece over the wound, the edges of which are, meanwhile, carefully supported by an assistant. A suitable >p;iec is left between the strip- for drainage. If things progress favorably, substi- tution need not be made under three or four days. If the wound be large, only a few of the strips are taken oft* at a time, lest, all support being lost, the edges should be forcibly separated. re the soiled dressings are removed, everything intend- ded for the new should be prepared, or put in its proper place. The strips of plaster must be removed with great gentleness. 638 Military Surgery. [August, If the injured parts are covered with hair, the surface must always be shaved before the application of the dressings. Proper material for sutures should always be kept on hand, read}' for use. The silver wire is the best, as it is less : ting than any other. Silk, however, answers exc well; J(he thread should be rather thin, and be well waxed. Saddler's silk is the article used for the ligation of large ar- teries. Among the more common and useful unguents for dressing wounds, burns, abraded surfaces, or fissui es, are the follow- ing: B\ Fulv. Opii, oss ; Pulv. Ehei, $i ; ling. Cetacei, Si- M. To these ingredients may advantageously be added, in many cases of healing sores, or eruptions, requiring a mild stimulus,. a drachm of the ointment of the nitrate of mercury, a few drops of nitric acid, two drachms of ointment of acetate of lead, a small quantity of myrrh, or of balsam of Peru, or from six to eight grains of sulphate of quinine. Jfc. Ung. Cetacei, i ; Bismuth. Subnitr. ?ij. M. Extremely soothing and valuable in superficial excoriations, slight burns, and eczematous affections. Turner's cerate may be employed for similar purposes, but should always be con- siderably diluted. The best disinfectants are the chloride of soda, chloride of lime, Labarraque's solution, and the hypermanganate of po- tassa, of which an abundant supply should always be on hand in every hospital, free use of it being made, by sprinkling and otherwise, upon the dressings, as well as upon the bedding and the rooms. The sponges about a hospital should be of the softest kind, perfectly clean, and always ready for use. The same articles should never be employed upon different persons, especially where there are foul or specific sores, as contagion might thus be communicated by direct inoculation, as has, for example, so often happened during the prevalence of hospital gangrene, 3. DieU. tie Preparations. The diet of the sick-room has slain its thousands and tens of thousands. Broths, and Blops, and jollies, and custards, and ptisans arc usually as disgusting as they are pernicious. Men worn out by disease and injury must have nutritious and concentrated food. The ordinary preparations for the sick are, 1.] Mitiiary Surgery. 039 meral, not only not nutritious, but insipid and flatulent food is what is needed, even if the quantity taken Buiall. Animal soups are among the most efficient supporters of the exhausted system, and every medical man should know how to give directions for their preparation. The if a man is his food. Solid articles are of course with- held in acute diseases, in their earlier stages, but when the . nsto convalesce they are frequently borne with impunity, and greatly promote recovery. All animal soups should be made of lean meat ; and their nutritious properties, well as their flavor, may be much increased by the addi- tion of some vegetable substance, as rice or barley. If the Btomach is very weak, they may be diluted, or seasoned with pepper. Est fe*fi so frequently given in the low stages of iVxcv. and in the exhaustion consequent upon severe injuries and operations, is prepared by cutting fro: l a quarter to half a pound of lean beef into thin pieces, and putting it into a wide-mouthed porter bottle, corked tightly, and placed in a kettle of cold water, which is then heated till it bcils. After it lias been digested in this way for a few hours, the juice is decanted, and seasoned with salt and pepper, wine or brandy. B ouch Jess nourishing than beef essence, is made by putting a quarter of a pound of lean beef in a pint and a of water, and boiling it for fifteen minutes, a few blades of mace being added du:ing the process, and the fluid well skimmed. To make chicken broth requires half a young chicken and a quart of cold water, with .. teaspoonful 01 rice or barley, tk whole being slowly boiled for two hours under cover, with proper skimming. Oh Uy is prepared by putting a chicken, cut up and all the bones broken, in a stone jur, closely covered, and re- d in boiling water for three hours and a half. The liquor is then strained, and seasoned with salt and mace. composed of two Irish potatoes, one i and a piece of bread, with a quart of water, boiled down to a pint in a closely-covered vessel, a little celery or parsley I near : of the operation. Salt and at pleas y a quarter of a pound of rice flour and e that quantity of loaf sugar are boiled in a quart of water, until the whole becomes a glutinous mafiSj when the jelly is strained off and flavored. Sago jetty is composed of four tablespoonful of sago, one 640 Military Surgery. [Angus quart of water, juice and rind of one lemon, and enough sugar to render it agreeable. After the mixture has stood half an hour, it is boiled until all the particles are entirely dissolved, the mass being constantly stirred. Oatmeal gruel is composed of two large spoonsful of oat- meal and half a pint of milk, stirred into one pint of boiling water, and allowed to simmer for thirty minutes, when it is strained through a hair sieve. Cornmeal gruel is prepared in a similar manner. t Arrow-root pcq) consists of a large tablespoonful of this substance made into a paste with a little cold water, which is then stirred into a pint of boiling water, and kept on the tire for five minutes. The nourishing properties oi arrow-root pap may be heightened by using milk instead of water in its preparation. Milk toast is often much relished by the sick ; and there h a very excellent jelly for invalids made of a thinly sliced and slightly toasted penny roll, boiled in a quart of water until it becomes a glutinous mass, when it should be strained upon a few shavings of lemon-peel. The flavor and efficacy of the various dietetic preparations here described may be greatly increased by the addition of mace, lemon, wine, or brandy. When salt, or salt and pepper are used, the patient's own taste should be consulted. Great care should be employed in making these compounds that they are not scorched. To prevent this a double boiler should be used. Milk-punch, an excellent article when a stimulant is re- quired in conjunction with a nutrient, is made by mixinggood brandy with cold, fresh milk, in the proportion of about one ounce of the former to half a pint of the latter. Sugar and nutmeg may be added to make the mixture palatable. Wine-whey, well made, may be rendered of great service to the sick. It is prepared by adding to a pint of fresh milk, as soon as it reaches the boiling point, as much good Madeira or Sherry as will coagulate it. The mixture is then strained, and sweetened or flavored tor use. The best wines for the sick are Madeira, port, and sherry. Incases of gastric irritation, champagne sometimes produces an excellent effect, quieting the stomach as well as the system at large. Jigg-nog consists of an egg, the white and yolk of which are beaten up separately; half a pint of cold water with a little loaf-sugar is then added, together with two tablespoons- ful of brandy. 1.] Syphft* of New-Bmx ChM 641 Sqp' n Chikirca. By J. 13. Hughes, of M. D., ' Kewbern, X. C. To whateverepoch or circumstance the origin of Syphilis may be assigned, it has probably existed, though in modi- fied form, since the transgression of moral laws has been nded by subsequent evil It was not till at the close of the fifteenth century, however, that it assumed the charac- ter, with which we have novi me so familiar, when it exhibited itself in continentel Europe, and startled the world with the terrors of its contagion, and ifs fearful rav- ages. Much had been written on the subject, but Hunter is the author who has given the first systematic treatise, to which we usually refer for his own, and the previous ii of its nature and treatment. lie availed himself of all the information which three centuries had furnished, and made great progress in the study of the disease gave an urimis- takeable diagnosis of the indurated chancre, but arrived at the conclusion that gonorrhea and syphilis proceeded from the same virus. It is to the French School with Ricord leading the avant garde, that we owe so much for the light which has been thrown upon this disease within the last fifty years. Ri- cord, whose genius would rest with nothing less than ac- tual experiment, inaugurated syphilography, and explo- ded the dogma that gonorrhea and syphilis had th origin, and established the contrary fact beyond the per- nture of a doubt. With mathematical ] he arranged the laws which govern syphilis; the domain and feach kind of - . and apparently left no tureofthe d unexamined; and us far as he could can- [periments, established his doctrine in each par- ticular*. Inspired by the enthusiasm of their leader, some of his ad former pupils, and especially M. Diday of Lyons have pushed their investi still fip and ubts in the minds of physicians in regard dea of the unity of syphilitic \ confirmed by Ri . ' the non-contag of the secondary manifestations of the di Ricord himself proved, that the soft chancre was almost local in *Lettres Sur la Sv;.liiiis. Ricord. 41 642 Syphilis of New-Born Children. [August, its effects ; exciting bubo, but leaving the constitution im- contaminated ; while the indurated chancre was followed, as by fatality, with constitutional infection; but insisted that both chancres had their origin in the same virus. M. Diday at the head of the dual School, said on the contrary, that the soft chancre always proceeds from the soft chancre, and the indurated chancre had as invariably an indurated chancre for its source. M. Fournier has given an ad- mirable synopsisf of the actual state of knowledge on this question, and of the result of the experimentation of MM. Buzenet and Nadau. While the advocates of the dual School seemed to be gaining ground in public belief, M. Ricord announced the new idea, that all cephalic chan- cres (of tongue, lips, face and scalp,)! were of the indurat- ed kind, and consequently followed b}^ constitutional in- fection. At the clinique of hopital du Midi, where Ricord presided, the soft chancre of the body presented itself in the preponderance in favor of the former variety, why should these cephalic chancres always be of the latter ? Unquestionably, M. Ricord has said, because the virus is the same, but the cephalic region is the peculiar soil for syphilis, and its anatomical characters convert the soft into the indurated chancre. Those of the dual School on the contrary, maintained that this region while it would resist the contagion of the soft, had a peculiar election for the indurated chancre, and that this election was not singular, but an analogy could be found in other diseases ; as the pericardium showing a great election for rheumatism, while the peritoneum enjoyed almost an immunity from it; the hands being peculiarly liable to itch, while the face, back, &c, were almost never attacked by it, though it could be forced into these regions ; and so on with other diseases. To settle the disputed points, MM. Buzenat and Xadau had the courage to attempt inoculation on a great number and variety of patients ; and their expeiiments are peculiar- ly interesting, as they belonged to the opposite doctrinal schools, and lead us inevitably to the same conclusion M.Tnion Medicale Tonic xii. Nos. 19. 22. 25. 28. 35. 1:15. (Lithe United States, these points are almost never visited by the primary sore, hut the patients who present themselves at the hospitals o\' Paris Beem to consider no points of the body sacred from its contact. 1861.] Syphilis of New-Born Chihlrca. 643 that the virus of syphilis is dual. The pus of a soft chancre was inoculated upon the lip, and at the same time upon the thigh of a healthy subject; in both places a soft chancre resulted, and so on to each point of the disputed territory, face, scalp and all. But in every instance the thigh was similarly inoculated, with the uniform result of the re-pro- duction of the soft chancre, thus establishing the fact that a soft chancre could exist in these points as elsewhere. As if in verification, however, of their pre-conceived ideas, while the soft chancre was known generally to heal with much greater difficulty than the indurated variety, it was found uniformly that the soft of the head healed very rapid- ly, while that of the thigh run the ordinary course where it was not prematurely destroyed by caustic. Farther, Ricord's idea that constitutional syphilis was like variola, in thefact of one attack freeing its victims from a repetition of it, has been strengthened by their experiments. Patients who were suffering from constitutional syphilis from indu- rated chancre, were inoculated with pus from a similar chancre, and the result was uniformly negative. The same individuals were inoculated with the pus of soft chancre, with the invariable reproduction of soft chancre, which ran the ordinary course without aggravating the constitutional malady. The followers of the dual school, then offered as their solution of the experiments, that the cephalic region enjoys a peculiar immunity from the virus of soft chancre; and that while a soft chancre will uniformly follow the in- oculation of pus from asimilarsourse, this region will resist the virus, so far as contagion is concerned. The experi- ments would seem to justify this conclusion, and when we have it more firmly established by additional investigations, its announcement will excite no more surprise than we now feel when gravely told that syphilis and gonorrhea have not the same origin. I have thought it necessary to introduce this expose of the disputed points in syphilis, which have been fully discussed in the French Medical Journals, as they affect to a gnat extent, the transmission of syphilis by inheritance the soft chancre not being transmissible, while the constitutional af- fection resulting from indurated chancre is almost invari- ably so conveyed. And also that while much is known in regard to the syphilis of new-born children, it will require some enthusiast with courage and hardihood to make actual experiments to decide other points now in dispute. The 044: Syphilis of New-Born Children. [August, following cases of syphilis in new-born children have, with- in the past three years, come under the care of my father, Dr. I. W. Hughes, and myself: Case No. 1. June 11th, 1858. Bright mulatto child, girl, four month old. The history given of it was, that it was born at term, of full size, apparently healthy, nursed well, and gave no indication of disease till it was two months old, when its nose and mouth became sore, an eruption showed itself on its body, and it began to lose flesh. When pre- sented to us, it wa3 greatly emaciated, breathed with diffi- culty through its nose ; its lips, mouth and nose filled with condylomata (mucous papules) ; on its forehead and scalp was an erythema of copperish color, while on the scalp there were also several ulcers. Condylomata were in the vagina, and associated with an ugly ulcer at anal orifice. The string of lymphatics along the inner border of the thighs was a series of abscesses. The hands and feet bore the characteristic erythema, and several pustules ; while the buttock was filled with pustules and tubercles, the spaces intervening between the eruptions being of copperish- brown color. The lymphatics at the back of the neck and behind the ears were hard and swollen. Our inquiries elicited no information of venereal taint from the mother, but the child was put upon anti-syphilitic treatment witli the happiest results. ! Hydrarg. Protiod. grs. ii to be divided into 24 powders, one to be given each morning. August 1st Child greatly improved the abscesses along the thighs had been opened from day to day as necessity required, some of them had healed entirely, and those which had at first degenerated into ulcers, assumed a heal- thy appearance with diminished discharge. The erythem- atous eruption which had in a great measure disappeared, left in many places a border of thin, whitish scales. A slight iritis which had supervened soon after treatment wa3 commenced, giving great annoyance to the child, at this time was entirely relieved. The Hydrarg. Protiod. which had purged a little, was modified by the addition of a small quantity of opium, and continued as before; a solution of Nitrat Argent, gr. i. to Aqua f 5 i. was applied to the ulcers. Nov. 1st. All signs of eruption disappeared, the enlarged lymphatics were reduced to nearly their normal size, &esh Increasing, skin clear and healthy, and the ulcer ;u ana! orifice, and one on the scalp were ail that remained of the disease. Same treatment continued. Dec. 1. Child I.J Syphilis of New-Born Children. 645 perfectly cured, and is at this time, three years old, vigor- ous, intelligent, and in the enjoyment of perfect health, having never exhibited any symptoms of the disease. As a necessary explanation to this ease, I must mention that, although the father of the child did not come under our care, I saw him and he was suffering from constitutional syphilis in the fullest sense of the phrase. Case No. *2, Oft. 1859. Negro child, boy, three months old. Born at term, with all the indications of health. At the sixth week its mouth became sore, diarrhea set in, lost flesh, and an eruption showed itself, which had been treated by its mother without etfect. When presented to us. its nose and mouth were filled with the condylomata ; on its legs, feet and arms was an erythema, associated with pustules in the accustomed crescentic order. The aspect of the child was pinched and wearied, and its scalp bore a pap- ular eruption of copperish color. We could get no fact from the mother in regard to syphilitic infection. Pre- scribed for child, Ilydrarg. Protiod. grs. ii. to be divided 24 powders, one to be given each morning. In four weeks every symptom of syphilis had disappeared, it regained flesh and was perfectly cured. It has not since had any return of the disease in any form, and is a fine, healthy child. Ca&i No. 3, August 1860. Negro child, girl, two months old. Born at Term, with somewhat pinched and aged fea- tures, but otherwise exhibiting no evidence of disease. At its fourth week Vuq inner border of legs and soles of the feet showed a pustular eruption. When seen by us all the natural orifices, nose, mouth, anus, &c. were covered with condylomata, with the lymphatics of the neck, and behind the ears hard and swollen ; its face bore patches of erythe- ma mixed with pustules, which had, in some places, broke, and been converted into ulcers, its scalp was foul with scabs. The parents of this child had been under our care in July, 1858, for gonorrhea, asscciated with indurated - hancre. In September, the expected secondary symptoms exhibited themselves, which were apparently entirely re- l in May, 1 ime in": rwards, the mother became pregnant, and in July, 1860, was delivered of the child above des- cribed. The child was nut upon the same treatment as the previous ca^es, hut gave us no symptom of decided im- provement for two weeks. In this space of time, the dis- 646 Syphilis of New-Born Children. [August, ease had reappeared upon the mother. Her occupations had prevented her realising the necessity of taking medi- cine anterior to the eruption. She was now given iodide of potash, gr. v. three times a day, and the mecury contin- ued with the child. Both mother and child soon began to improve, and in November there was no vestige of the dis- ease in either, and it has not since reappeared. The child is healthy and growing rapidly. Case No. 4, June, 1860. I was called accidentally to see patient, mulatto child, eight months old. Had been sick ever since it was two months old, when it began to lose flesh, and an eruption commenced to spread itself over the body. When seen, it was in the last stage of syphilitic marasm. On its face and scalp was an erythematous erup- tion with pustules and ulcers. The glands of neck and behind the ears were swollen ; its body aud limbs well marked with papules and pustules which assumed more or less the crescentic form. The inguinal glands had degen- erated into foul ulcers; its body wasted almost to a skele- ton. The liver was much swollen, and alternate diarrhea and constipation had prevailed ; its life was nearly worn out. Prescribed Liq. Amon, Acet. in closes of ten drops every two hours. Hyd. C. Mite, Pulv. Doveri, aa. grs. iv. to be made into twelve powders, one to be taken morning, noon and night. The child died two days afterwards . could learn nothing of the history of the case, so far as re- lated to syphilis of parents. Case No. 5, December 1860. Negro child, girl, seven months old. Had been born healthy and continued to thrive till its third month, when its skin assumed a dryish', scaly appearance, without characteristic eruption, and it lost flesh rapidly. When seen by us, the skin presented this dryish, scaly appearance very forcibly, and the expression of face was like that of an old person, with muscles of the body greatly wasted ; its bowels sometimes irritable, but generally regular, the appetite generally good, the lymph- atics of neck and groin, and the tonsils were swollen. The symptoms presented gave no such unmistakable evi- dence of syphilis, as the history of the mother. She had borne three children previously by the same husband. Neither he nor she confessed to a syyhilitic taint. Each of the previous children had between the fourth and tenth weeks, broken out with an eruption of nose, mouth, and anus, and the limbs hfed become filled with erythema and 1861.] Syphilis in Xnc-Bom Children. 647 pustules. The iirst child had had large abscesses in the groin, and though each succeeding child had manifested less of the disease it was the same in all. Each child had wasted and died before it was six months old. The child rented to us, was placed upon the same mercurial treat- ment as the cases mentioned above. January, 18G1. While the child seemed to be improving it at this time had an attack of measles, which greatly taxed its strength, but left no bad symptom behind it, As soon as it was better the mercurial treatment was resumed ; and at this time although the child is not entirely cured, it bears nearly the aspect of health its skin has become clear appetite good swollen glands disappearing flesh increas- ing and strength restored. The treatment is still continued but will not be much longer necessary. Case Xo. G, March 1, 1861. ^Tegro child, boy, three months old. Born at term, good size and healthy. He presented the following symptoms a papular squamous eruption when it was five weeks old, existed on its scalp ; at the inner border of limbs, and flexures of joints were occasional patches of erythema which had given place ii\ some points to thin whitish scales; on the face and eyelids were pustules, and the scrotum and anus were tilled with condylomata, and at the anal orifice an ulcer. The buttock was a mass of tubercles and pustules, some of which had degenerated into ulcers. Every inquiry in regard to syph- ilis was denied by parents ; but a few days before I saw the child, the mother came to me for a sorethroat which was palpably syphilitic, both nipples were sore and fissured, and one of them had several mucous papules. She told me that the throat had become sore one week after the birth of infant, then the nipples in a few days afterwards. Soon the mouth of the child was likewise affected, and then followed the general eruption of the body. The mother was given iodide of Potash, grs. v. three times a day, but no medicine Was given to the child, letting it receive its cure through the milk. This treatment is still pursued, and 1 saw both the patients yesterday. They are already nearly well. The throat of the mother gives her but little trouble, and the eruption of the child is greatly improved, having disappear- ed entirely from some parts of the body, and rapidly heal- ing in the ret The history of these cases illustrates the great difficulty in deciding many doctrinal points in syphilis of new-born 648 Syphilis in New-Bom Children, [August, children. The parents in some instances, from ignorance or carelessness in noticing the primary sore, in others, from an unwillingness to acknowledge any improper conduct, deny every inquiry which would enlighten us in the ways of diagnosis ; and if any confession is made, it is rather through accident, or ignorance of the direction to which our questions tend. The cases presented for treatment constitute hut a small proportion of those which have been infected, for a syphil- itic mother may and generally does abort a great many times, and at various periods of pregnancy, before a child is delivered at term. Observers have detected external manifestations of the disase as early as the second month of intra-uterine life, and there are many observations of this manifestation at the fifth and sixth months. This is a feature of the force of the disease, when it seems to exhibit itself with such violence as to prevent the foetus from arri- ving at term, while in the cases reported in this article which agree with other observation, the disease never exhibit itself till the third, fourth and up to the tenth week of extra uterine life. We may then say of syphilitic children born at or near term, first, that some present a pinched cachectic look, which ought to excite suspicion of the disease at time of birth ; that this cachexia may constitute the only prom- inent feature; while from mal-assimilation of nutritive matter the muscles waste, the skin becomes dry, and the child may die with or without any cutaneous eruption; or if subjected to treatment may recover without the disease ever having manifested itself externally. Second, that the ma- jority of cases presented, are reported to have nursed and looked wrell tiil the first or second month, when appetite may or may not begin to fail, child grow feeble or emacia- ted, and eruption show itself. With regard to the period at which eruptions show them- selves, we must say that pemphigus both in this particular and in result makes a class of cases for itself. Sometimes at birth generally a few days after, it manifests itself, and other things ig equal, the victims of it die very rapidly. M. Bouchut has quoted the investigations of MST. Paul Dubois, Deville and -I liers in their autopsies of syphilitic children, which have n made from the foetus of touv months up to child deliv- ered at term. The thymus gland, the lungs, brain and liver, have exhibited together or e 'y in each case, peculiar changes. In the first stage there were mere points of conges- L] en. G49 ; farther bad degen- erated into absc The thymus gland, especially, and more aniformly has exhibited those changes. In the lungs, 1 Dubois has found many abscesses, nut in one case to which da] value has been attached a child delivered at term and tilled with pemphigus the Lungs were found without -, but had disseminated all through them patches of eruption which corresponded to that manifested externally. The question which now pi tself is. what is the source of syphilis in new horn children I M. Ricord says, u there cannot be constitutional syphilis without a chancre or syphil- itic mother or father." The first part of the proposition that re is not C"HMl:!' us, as it will affect another ich >f our subject, we will leave for the present, to revert to it farther on. The second part means, that syphilis is transmissible by inheritance, and I suppose there are fewper- at the present day to contradict the fact. But the father and mother seem to po>^-ss different powers in this agency. In order to transmit syphilis to offspring, it is necessary that one parents should be suffering from con itional sy- phili unary sore not sufficient to cause such ..result. In regard to the father j ir app rt that when suffering from ititutional syphilis, the ovum is infected by him at the moment of c Q, and though the foetus may be deliv- ered, ut t 1 not exhibit the eight weeks after birth, it has really from the very first moment been dis- by father after conception, if the mother does not become affec is harmless ar as the offspring is concerned. But a child u crea- ted syphilitic by the father can infect the mother during ges- tation." The force of the disease is here brought in question M to the relative power of father affecting the offspring. Erichsen in his Surgery relates a case of Ids own, where a leman suffering from constitutional syphilis, married and a large family none of whom exhibited any symptom of the disease But this case is exceptional, and although we may beli- ffspring than the mother, still when he is Buffering from constitutional bilis the result will be, as a rule, t; iildren will e world syphilitic. In n >ther c from a con- syphilis anterior I o to an indurated chancre contracted daring on." Thus the from mother ex* the period of preg- nancy, except perhaps as M. Bouclmthas expressed a doubt 650 Syphilis in New- Bom Children. [August, towards the eighth or ninth month. The only thing requi" site is constitutional infection, for the mother to affect in fants ; and we may now ask, is a constitutional syphilitic mother who is carrying a syphilitic foetus apt to infect hus- hand? The mass of evidence is against the supposition, and M. Bouchut relates a case, where a woman who had been under his care for indurated chancre, married in a few months against his advice. She conceived, and a syphilitic child was born at its sixth month, but the husband did not contract the disease. Here arises the important question of the power of con- tagion of secondary syphilis. M. Ricord has asserted that it is not contagious ; but that in those cases where this has appeared to be the fact, there has been error in diagnosis, and that what appeared to be a secondary manifestation was really an indurated chancre transformed "in situ," into an ecthymatous pustule or mucous papule. Melchior Robert whose treatise (Maladies Veneriegnes,) is drawn from the lessons >f Ricord says in relation to this point : " It did not suffice to attribute to every primtive chancre the property of infecting the economy ; it was necessary still to multiply the propagating means of syphilis in ex- tending this power to secondary accidents. The bodies of unfortunate patients have been sown to profusion with the secretion of every variety of syphilides ; they have inocu- lated one patient from another, from patient to healthy in- dividuals ; sometimes from mucous papule, sometimes from ecthyma; again from tertiary manifestations, and finally from the blood of syphilitica; and all that to arrive at the means of contradicting an opinion, which experimentation has a thousand times confirmed." There could be no more positive assertion than this, and yet, in 1857, M. Ricord, in his Oral lectures, expressed a doubt of this very point. The frequency of reports of syphilitic child infecting healthy nurse, and vice versa, and the medico-legal importance o: the question have created much opposition to the belief oj the non-contagion of the disease in this form. "Without contradicting the theory entirely, it is certain that some modification of it is necessary ; for a healthy mother car- rying a foetus infected disease by the father, which has it in secondary form, is in her turn affected, and perhaps in an exaggerated degree, sometimes exhibiting it anterior, but generally consecutive to accouchment. The question of mother and child infecting each other when only secondary 61.] Syphilis -Born Children. 651 yjifestations have existed, have been the principal obsta- to assent io this maxim of Ivicord, for the great major- pf adults with constitutional syphilis have failed to com- micate it by contact. ran a syphilitic child infect a healthy nurse ? The pro- bility is that it can ; hut to do so it is necessary that the shall he developed into eruption. M. Bouchut re- ;es the case of an infant Baffle ring in this way, who cora- Inicated the disease to three nurses consecutively, neither whom had ever given any evidence of the disease ante- >rly : of another nurse, who had a healthy child of her jn but contracting syphilis from a child which she was rsing, actually communicated it to her own child. The means of transmission is generally thus : the child s mucous papules or ulcers on the lips, in frequent con- ?t with the nipple of the nurse ; soon upon it a similar aption, or it may be a fissure, is developed, and then fol- vs constitutional infection. Aud in some instance, the Dple is actually lost by the amount of fissure which sur- .mds it. Can a syphilitic nurse impart the disease to a althy child ? M. Ricord has denied this communication In nurse to child, except when the former is suffering mi primary syphilis, and she by accident inoculates the .rsling with the pus from primary sore, when secondary pptoms follow as a natural consequence. M. Bouchut lile citing some cases to the contrary of this doctrine, is clined to adopt somewhat the same views especially so p as infection through the milk is concerned. In the dif- rent analyses of the milk, it is pronounced " a perfect Lment elaborated from the blood," and while the different festa, excitement from rage, venereal desire, the men- ual How, lVc. &c. may affect its character in the propor- >n of fat globules, salts, &c. to a limited extent and ' affecting the nursling, yet there is no consistent viation from the average standard from these causes. So us with phthisis, scrofula, syphilis, cancer, rickets, I the milk shows no consistent change so far as chem- r will detect. Yet no one will rationally doubt at the milk elaborated from the blood of such persons, nourishes the blood, muscles, hoi, of nurs- iu some wise differ from that of perfectly Vo one would knowingly < ogage a 1 r their child who had syphili .iu>e her ilk exhibited by chemical test no derangement. In re- 652 Syphilis in New Born Children. [Auguij gard to syphilis, we sec that in the father the spermat fluid is so contaminated that it infects the ovum at th very moment of conception, and also, that a mother coi trading syphilis after the child is conceived in health wi infect it through the placental circulation. And why cai not the milk of a syphilitic nurse, whose every secretion affected b}T her syphilitic blood, convey the disease to child which is nourished by it ? There may be such vigc of constitution in some cases as to resist it, but in the gnl majority of cases the infant must suffer. We ourselvc know a gentleman, born of healthy parents, all of whos brothers were healthy ; but he was "put to nurse" to woman who was afterwards discovered to be syphilitic, an he has all of his life suffered from rheumatism, and occ* sional syphilitic eruption, which would disappear unfl good health, but manifested itself again when attacked I) any acute disease. That the milk should give no evidence of the particul malady, ought to excite no surprise when we reflect thi the syphilitic pus differs so little from healthy pus, that v have no certain means of distinguishing them, but by ii, oculation ; and farther, that in the majority of cases wbH the mother is put under treatment, and the milk is freigh ed with the remedy for diseased child, chemical test wi rai v detect any change in it. We have thus far conside ed syphilis in its secondary form, and it will be necessai now to examine its influence when passed into the tertiar In. this 3tage, the sub-cutaneous, sub-mucous, fibro-osseoi and muscular tissues, the testicle, liver, &c, have been i vade<; ; that is, the poison has passed from the external the deeper pai fca and taken firmer hold of the victim. II its power of translation increased with its progress ? N M. Ricord has said, that the disease passed into the tertiai stage is not transmissible by inheritance, but whatev manifestation may be made in a child born under such i fluence will be scrofulous. M. Devil le has observed tli children born of fathers suffering from tertiary syphilis c not exhibit the disease, and while he believes the same regard to mothers under similar circumstances, his obfll vationa have not been so satisfactorv as to allow him to i sert positive belief. The force of the disease is brought in question here, and it must be confessed tli grave doubts exist of the truthfulness of these observatioi There is no doubt that secondary syphilis and scrofula !61.] Dislocation of (he Crystalline Lens. G53 mewhat analogous in their manner of manifestation, and ten extremely difficult to distinguish one from the her; but their nature is bo different, that it will require I much stronger proof to convince us, that though rolulous parents do not give birth to syphilitic children, I parents in the tertiary stage of syphilis will bring into e world scrofulous children. This question is important a therapeutical point of view, for a remedy which is of eat benefit in a case of syphilis may be positively detri- ental in one of scrofula. With regard to the treatment, it has become an estab- Hied fact, that however much the non-mercurial school ay cavil about the use of mercury in this disease in the pit, it is at least a specific in syphilis of new-born chil- en. The iodide is the best preparation of mercury, and ay be given to infants in doses from twelfth to twentieth ain once a day ; if no benefit is derived in the course the day. the dose maybe repeated twice a day. If ad- pistered to mother, it is best to begin with one grain, to \ increased if necessary to three grains per .Uem, this will feet the mother, and through the milk, the child. Mer- ry may also be used by inunction. Where it is not de- to give mercury, the iodide of p< tash may be used 9 of five grains three times a day. if the disease is ken in time, when the child is not worn out, the proguo- i is always favorable, but when it is in an advanced stage marasm, its exhaustion and not the disease is the first combat. It this can be overcome, the syphilis will :i age able. iry Dislocation of the Crystalline Lens. exhibited a patient to the Paris So< 'Surgery who had the power ol producing a dislocation voluntarily. Paralysis of the iria . and the oabled to cause the passage of the Lens from one lamber to the oth< ransparency being completely re- ined. Some ace M. Larrey also presented & child pibiting a similar peculiarity the lens in that in- did not become opaque until three or four years af- 654 Hemorrhage. [Angus On the Arrest of Venous Haemorrhage. By Professor Lah gf.xeeck. (Archiv fur Klinische Chirurgie, Band i. p. M3 In the course of an interesting paper by Professor LangeE beck on the " Surgical Pathology of Veins," illustrated by nn nierous cases, he observes that styptics are not suitable forth arrest of venous haemorrhage. The best of these, the liquk ferri sesquichlorati, is dangerous, owing to the extensive thrombus formations and subsequent irritating effects it g rise to. In all cases, when obstinate venous bleeding proceec from several small veins, he gives decided preference to the actual cautery, as most certainly guarding against the break ing up thrombi and pyaemia. When the bleeding proceec from a large vessel, compression, ligature of the vein, or liga ture of the corresponding artery, should be resorted to. wounds of the large veins of the extremities, compression o1 the peripheric ends by means of the finger will usually suffice and in wounds of the jugulars, we should at once apply the finger to the central end to prevent the entrance of air, anc then to the peripheric end to arrest the bleeding. In the cast of a large wound of the jugular, the finger can only act pro visionally, and the best means of proceeding consists in closing the lips of the outward wound by strips of plaster, (which must not extend to the uninjured side of the neck, where they would compress the opposite jugular), so applied as to exert the most equable compression around the wound without impeding the circulation. In the case of the veins of the extremities, band- ages may also be exactly applied, commencing at the toes or fingers. When the injured vein is at the bottom of the wound, the author places somecerated linen in contact with it, fills the wound with charpie, and then brings its edges together with plaster. Ligature of the Vein. In general, tying the peripheric end of a wounded vein of the extremities suffices; but a ligature both above and below the wound may be required when a considerable branch enters just above the central end. To avoid the loss of blood during the removal of large tumors, the provisional ligature of several large subcutaneous veins, which sometimes acquire the size of the finger, may be requisite ; and in such cases the author always applies a double ligature, and divides the vein between, removing the ligatures after the completion of the operation. The practice is the more to be recommended from our ignorance of the conditions under which air gains entrance by dilated subcutaneous veins. In woun of the external jugular, the central end should always be tie as it should be prior to operations likely to lead to its bein .801.] Dislocation of the Shoulder. 655 pened. Under other circumstances, the ligature of large eins should be avoided as much as possible, especially in hos- itals, where the danger from thrombosis and pyaemia is in- roased. The internal coat of a large vein is not divided by be ligature, as in the case of an artery; and the inner walls pproximated by the ligature may unite before the separa- ion of the latter the vessel remaining pervious, though some- what narrower, up to the very seat of the ligature. "When in- lammation follows a wound or a ligature, more or less exten- ive thrombosis may succeed, which may lead to detachment I coagula or pyeemia. When this is not the case, the vein gradually becomes pervious again ; and so great is the regen- irative capacity of veins, that, even when large portions have men removed, these may be reproduced, effecting a junction etween the separated ends of the still pervious vessel. hi the Diagnosis of Dislocations of the Shoulder. By AT. Maisonneuve. It very often happens, M. Maissonneuve observed in a re- ent clinical lecture, that even experienced surgeons may lesitate respecting the existence of a luxation of the shoulder ; ,nd you are aware of the learned dissertations to which the lilfercntial diagnosis of these luxations, fractures of the neck tf the humerus, and even simple contusion, has given rise to. Numerous are the pages, even in the most recent works, de- roted to this important discussion; and certainly after reading rad meditating upon them, one can be persuaded that this -is is one of the most delicate and difficult in surgery. cs not arise from the enumeration of the characteristic ymptoms of each lesion being incomplete. Far from it ; for :eal and doubttul symptoms, vague and precise symptoms, ire bo accumulated that even the most skilful can scarcely pake them out, while the simple practitioner is utterly at a WL Still there is a simple and easily-discovered symptom, jdiieh will always enable you to recognize with certainty not nly this but any other dislocation, whatever swelling of the rounding soft parts may exist. This symptom is based ipon the fact that in all dislocations the normal movements peded or abolished, while in simple contusion these rients persist, and in fractures others of an unusual na- ure are added to them. Take hold of the arm, and endeavor to make it execute the movements proper to the articulation, f these are found to be impossible, or very limited, there is G56 Prominent Eyeballs. [August without doubt dislocation ; while if these remain intact, no luxation exists, and the presence or absence of shortening and crepitation will determine whether the accident is a fracture or a mere contusion. This sign alone will enable the diagnosis of the dislocation to be^ made. The at idy of the symptoms may be carried further, and analyzed in le- tail. We may verity the flattening and the depressibility of the shoulder, the projection of the head of the humerus, the elongation of the limb, and the various circumstances which determine the variety of the dislocation. But the mere fact of the abolition of the movements of the joint had already placed the fact of the dislocation beyond doubt. Moniteur des Sciences Medicate. Prominent Eyeballs. " Exophthalmic Goitre." At a recent meeting of the Academy of Medicine, in Paris, M. Aran, Physician to the Saint Antoine Hospital, read a paper upon the nature and treatment of the affection known under the name of exophthalmic goitre, exophthalmic cac- hexia, &c. The conclusions at which that writer has arrived are the following: That the disease known under the various names referred to above is not essentially constituted either by exophthalmos (protrusion of the eyeball) or by a swelling of the thyroid body, but rather by an irrirable condition of the heart and the arteries of the neck, with which it is, at times, closely connected; it is impossible to fix definitely, the interval wl ich separates the production of these two series of facto, a dilatation with hypertrophy of heart, and of the large vessels of the neck. Neither this dilatation with hyperthrophy nor the increased irritability cf the circulatory system, which would appear to govern it, can be considered as the base or point of origin of the malady. Preceding these phenomena, or coin< dent with them, there exists various derangements iu the digestive system, the secretory apparatus, and the n-rvous system, which do not leave any doubts concerning the com Dion tie which unites, and which generalizes them; this lie would seem to be a morbid condition of the great sympa- thetic system. The existence of this morbid condition of the sympathetic nerves is further shown by the production of ex ophthalmos which, although inexplicable on the ground ot vascular dilatation, and equally inexplicable by the hypo- 1S61.] Epileptiform Convulsions. 657 thesis of an hypertrophy of the cellulo-fatty tissue 6ontained in the orbit, (au hypothesis which is itself irreconcilable with the rapid production of this phenomenon in certain ca with it- ;: in others, and with its inure striking mani- ition in one eye than the other), is, on the contrary, fully explained by the influence of the sympathetic system, as demonstrated by the investigations of Claude Bernard and Muller. The nervous affection which we have described is curable by a plan of treatment continued for a sufficient length of time, which has for its object to excite the contractibility of the walls y^t' the heart and of the arteries, to lessen the exaggerated irritability of the heart and of the vessels of the neck, and to combat the general neuropahtic condition, which serves as a base for it, at the same time as the al- l condition of the blood when its exists. Amongst the therapeutic measures, those upon which we can place most reliance are the application of cold to the region of the heart, the administration of increasing doses of veratria, or of digitalis, repeated affusion with water, removal of the :nt into the country, and, at a certain stage of the malady, ferruginous prepan .ions, especially the perchloride of iron. London Medical Review. and Origin of Epileptiform Convulsions caused by I 1 Epilepsy. By lolf Kussmaul and Adolf Tenner, M. J). Translated by Edward Bronner, M. D. The chief results obtained from these careful researches may be con- ouped under the following beads: 1. The convulsions appearing in profuse hemorrhage of a blooded animals (including man,) resemble those ob- served in epileps 2. When the brain i- suddenly deprived of its red blood, fconvulsi cription as those occur- ent to ligature of the great i of the neck. Epileptic convulsions are likewise brought on when arterial blood rapidly as3um rioua color, as for ex- knpli . a ligature is applied to the trachea. 4. It i- highly probable that in these cases the attack of 4J 658 Epileptiform Convulsions. [August, spasms depends upon the suddenly-interrupted nutrition of the brain. It is not caused by the altered pressure which the brain undergoes. 5. Epileptic convulsions in hemorrhage do not proceed from the spinal cord, nor from the cerebrum ; tbeir central seat is to be sought for in the excitable districts of the brain lying behind the thalami optici. 6. Ancemia of those parts of the brain situated before the crura cerebri produces unconsciousness, insensibility, and paralysis in human beings ; if spasms occur with these symptoms, some excitable parts behind the thalami optici must have likewise undergone some change. 7. Anaemia of the spinal cord produces paralysis of the limbs, of the muscles, of the trunk, and of respiration. When the anaemia suddenly attains its greatest intensity, then only, and even then but rarely, do slight trembling movements of the limbs precede paralysis. The sphincter ani acts analogously to the constrictor muscles of the face in anaemia of the brain, that is, it contracts spasmodically before it relaxes. 8. Convulsions from hemorrhage are neither physical nor reflective ; they do not ensue a. In cold-blood animals, at least not in the frog. b. When the hemorrhage is slow, so that the vital power is only gradually consumed. c. When the animals are very much debilitated. d. When the nutrition of the spinal cord has suffered. e. When large pieces of the excitable districts of the brain have been removed. /. In animals subject to etherization. g. Doubtless, also, when excitable districis of the brain have undergone certain pathological alterations. 9. As suffocation brings on convulsions, and etherization averts them, it is evident that etherization and asphyxia are two different conditions. 10. The brain of warm-blooded animals can only be de- prived ot red blood for a short time ; otherwise it loses its capability of resuming its functions when again supplied with the nutritive fluid, and the appearance of death he- comes a reality. The brain of some rabbits presented this capability for two minutes. 11. It is sometimes observed, after the arteries of the neck have been tied, that the muscles of the trunk perish and take on the rigor mortis before the action of the left 1861.] Epileptiform Convulsions. G59 heart is extinct Hence the left heart is not always the im moriens among the muscular organs. 12. Contraction and subsequent extreme dilatation of the pupils in the agonies of death is no certain sign of real death, and of the incapability of being revived, as main- tained by Bouchut. 13. To cure epileptic attacks caused by anaemia, there is no better method than that of renewing the supply of red blood. The debilitating method of treating epilepsy, espe- cially by abstracting blood, should almost always be re- jected. 14. The, quantity of blood in the cranial cavity can, by way of experiment on the living subject, be considerably increased or diminished. Hyperemia in the cranial cavity used by releasing the stoppage of circulation in the cervical arteries, by tying the cervical veins, especially by simultaneously dividing the cervical branches of the symp- athetic nerve, and lastly by tying the trachea, during inspi- ration. Anremia in the cranial cavity is produced by hem- orrhage and by tying the cervical arteries, as well as by electric excitation of the vaso-motor nerves of the head. 15. The quantity of bloocFcontained in the cranial cavity after the application of a ligature to the arteries is greater Kan after hemorrhage: the amemia as regards small arte- ries, the capillaries, and the smallest veins being always nt to a greater extent. 16. From the quantity of blood contained in the skull after death, it is seldom possible to draw certain conclusions with respect to the quantity contained during life. The death-struggle brings on numerous conditions altering the circulation of the blood in the skull, and even in the corpse the quantity of blood may still undergo alterations. 17. The phenomena of the incomplete epileptic attack be explained by alterations occurring in the cerebrum : while the phenomena of the complete attack presup- )ose an alteration of the whole brain. Convulsions in epi- epsy are justly styled cerebral ones, and the spinal cord wobably plays only the part of a conductor, transferring ives from the brain to the muscles. 18. Circumscribed anatomical alterations of the brain, or ilterationa of protracted duration, cannot be regarded as the proximate cause of epileptic attacks, but may cause epileptic 19. Pathological anatomy cannot give any explanation 660 On Vrcemic Intoxication. [ August as to the nature of epilepsy. Suddenly-withheld nutrition i3 only one of the causes by which the brain is brought in- to that peculiar internal condition which is manifested in the form of an epileptic attack. Arterial congestion of the brain does not seem to be capable of producing any other symptom than those of paralysis. Venous congestion of the brain, as well as arterio-venous congestion, brings about conditions which belong more to those of apoplexy than to those of epilepsy and are characterized by paralysis of the glottis, together with a slower respiration and slight spasmodic symptoms. 20. Marshall Hall's sphagiamus and trachelismus are not to be regarded as a source of epileptic attacks, but the latter will produce them. All theories are false which assert the epileptic attack to be derived from a sudden determination of blood, whether active, passive or mixed. It is probable that certain forms of epilepsy result from a spasm of the muscular coats of the cerebral arteries. 21. The epileptic affection which disposes to the attacks occupies either the whole of the brain or some districts on- ly, and by it the brain is brought into that altered state on which the epileptic attack is based. The medulla oblongata as being the part whence the nerves causing the constriction of the glottis and the vaso-motor nerves take their rise, seems frequently to be the spot from which eclamptic and epileptic attacks proceed. N. A. Med. Chir. Rev. On Urocmic Intoxication. By m, A. Hammond, M. D. Professor of Physiology and Anatomy in the University of Maryland. In the memoir entitled as above, Dr. Hammond relates " an elaborate series of experimental researches designed to clear up some of the unsettled questions as to the effect of the accumulation of certain of the urinary elements in the blood. Dr. Hammond considers that the most important of these mooted points is, whether carbonate of ammonia from the decomposing urea, as Frerich has urged, is the cause of the condition now known as nrremia. After cri- ticising French's views, by means of a succession of well planned and ingenious experiments, Dr. Hammond exam- 1861. "I mic Into (361 inod the whole subject anew, in an additional series of ex- periments, and by their aid, arrives at the following eon- elusions : 1. That the injection of urea, in limited quantity, into the blood of animals produces a certain amount of disturb- ance in the nervous system, similar in its symptoms to the first stages of uremia, but that this condition disappears, if the kidneys arc capable of so depurating the blood as to eliminate the toxic substance. -. That urea when introduced into the circulation in larger quantity than can in a limited period be excreted by kidneys, induces death by uremia. & That by ligature of the renal arteries, or removal of the kidneys, the elemeets of the urine being retained in the blood, render this fluid unsuitable to the requirements of the organism, and consequently induce a condition of sys- tem not essentially distinguishable from the uremic intoxi- cation of Bright's disease, or that caused by the direct in- troduction of the blood. As, however, was pointed out by Bernard and Barreswil, so long as the urea or the products of its metamorphosis are discharged by the stomach or in- testines, uremia does not take place, but that when these channels become closed, convulsions and coma are produced and deatlr soon follows ; 4. That the introduction of urea or urine into the circu lation of animals, the kidneys of which have been ablated, shortens the life of such animals as Frcrichs and others have already shown. There is reason to believe that the urine, as a whole, ;ore poisonous than a simple solution of urea, for in :i which urine was injected into the blood, the int of urea thus introduced was much smaller than that sly thrown in, in a pure state, and yet symptoms of at intensity followed. That urea or the elements of urine, as a whole, induce such a condition of the nervous agly to pre- i and inflammation of the viscera, e cially the lun_ ardium and spleen. That urea, when directly injected into the blood. red to accumulate in this fluid bj ition of I kidn _ some manner the ) as to disturb the normal relation of t rpportion bite and red corpuscles, and either to hasten the de< these latter, or t 0 iuterfi 662 Placenta Prcevia. [August, with the due removal from the blood of such as are broken down and effete. 8. That there is no reason to suppose that, under the cir- cumstances specified, urea undergoes conversion into carbo- nate of ammonia, but that on the contrary, there is suffi- cient evidence to warrant the conclusion that no such pro- cess ensues. The fact that in the foregoing experiments a larger amount of urea was generally found in the blood taken from the body after death than in that abstracted daring life is, of itself, conclusive against any such hypo- thesis. Ibid. Placenta Prcevia; Treatment by the Caoutchouc Water Pessary. By E. J. Fountain, M. D. Davenport, Iowa. Mrs. I\ aged twenty, at seven and a half months of her pregnancy, began to have hemorrhage, but without labor pains or dilatation of the os. This ceased partly under the use of rest, cold water, enemata, opium, and acetate of lead. At the end of two weeks, it recurred with greater violence and some pain. Dilatation was sufficient to allow the finger to enter, and the placenta was ascertained to be in front. To check the alarming discharge, a caoutchouc bag was in- troduced and filled full of cold water, which at once arrested the flow. In half an hour it again commenced moderately the water now quite warm was allowed to escape and the bag refilled. By the continuance of this process through the day and night, the patient was kept safe. "When the contents were changed, an examination could be made with out removing the instrument. After twenty-four hours, as the os was becoming well dilated, and the pains more regu- lar, turning was thought of, but finally rejected, and the former plan continued." Finally, the head pressed down on the placenta, thus perfectly controlling the hemorrhage, and the child was soon born in good condition about thirty hours after the commencement of the treatment. Thevda* cent a was found loose in the vagina, Therapeutic uth. On the Therapeutic Acli '/A. By J. i>. M'Caw, M. D. Having concluded my remarks on bismuth and its com- binations, I call your attention for a few moments to their value in the treatment of disease. I think you will how much the curative virtues of these compounds depend upon the physical and chemical properties, already explain- ed to you. First, then, remember the physical properties of the bis- muth compounds and especially of the basic Bubnitrate, the usual form in which this agent is administered by the phy- Bician. This Bait, as I have told you, is the result of the action of water on the ternitrate, causing a white, almost insoluble semi-unctuous precipitate, which is the subnifrate of the pharmacopoeia. Known as the magistery of bismuth, this powder was much prized by the ladies, long ago, as a cosmetic, because of its emollient influence on the skin, concealing pimples, freckles and other deformities to which even the fair sex is sometimes liable, and leaving a beautiful white gloss much to be admired. Xot only did its external applieation act soothingly to the excoriated or irritated integument, but it was also used as a drying powder, checking a too profuse perspiration, by coating over, with its delicate varnish, the exuding membrane. then, you have a patient with dyspepsia, an irritable mucous membrane, painfully excited during the act of digestion, by the excessive flow of the gastric juice and the mechanical efforts of the muscular coat, can you not, with great propriety, appeal to the inocuous and emol- lient subnitrate of bismuth, which coats over the angry membrane with its soft white precipitate, shields it from all -os of irritation, and gives to the digestive function a great amount of comfort ? Recollecting, also, its mechanical effect upon the trans- piration of the skin, you can see why the subnitrate should be i: of in the treatment of serous diarrheal cially those not the result of organic disease ; in the "sum- " of teething children, and in the irritable form of disordered b< 'lowing measles ai i fever. Here, as we have to act upon ;i great extent of surface, it is give the remedy in large pi , and in such one ounce in twenty-! hours with great advantage. G64 Therapeutic Action of Bismuth. [August, So much for the mechanical influences of this agent on the mucous membrane, explaining, to some extent, its the- rapeutic action; but I think by observing its chemical at- tributes you may also derive some hints of practical impor- tance. I have shown you that the presence of bismuth or any of its compounds can be detected by the agency of sulphuret- ted hydrogen, when a precipitate of the brown-black sul- phide of bismuth will at once appear. So sensitive is the subnitrate to the presence of this agent that its use as a cosmetic has also been abandoned since the iutrod action of the coal gas as an illuminating agent, which, when impure, often sets sulphuretted hydrogen free. The pearly cheeks of a cluster of beauties decked for the ball would soon, under the action of this unerring detector, even rival the sootty complexion of Christy's Minstrels. If you have to treat hereafter cases of gastric or enteric disorder accompanied by disengagements of sulphuretted hydrogen, as, for instance that distressing condition of sto- mach called ue^g belch," or the windy colic of defective digestion and torpid liver, remember that subnitrate of bis- muth may be relied on to neutralize the offending and of- fensive gas, by the formation of a sulphide which is entirely innocuous, if not positively curative. The dark color of the stools after the administration of this remedy proves the truth of this statement, as there is not always sulphu- retted hydrogen to give the characteristic precipitate. The surgeon as well as the physician may gain some use- ful ideas from a study of the physical and chemical proper- ties of bismuth. As an application to burns, or diseases of the skin, such as erysipelas, the subnitrate, with its soothing influence, will be found very valuable; also in excoriations of the skin, and the chafing of infants, the result of acrid discharges. As a disinfectant, I would advise you to use this harmless salt freely, being equally effective and greatly more convenient than the tar and plaster of Velpeau, or the permanganates of Girdwood a foetid ulcer, a sinus con- nected with a carious bone, or a malignant sore, pouring out its putrid odors, will be greatly unproved under the Iree application of the agent under discussion. Before closing these remarks, which arc not intended to- infringe upon the prerogatives of our colleagues of surgery and the practice, but rather to show you the value of chem- istry even in the mote practical departments of medicine, 1861.] Chronic G G65 I will mention that as arsenic is not unfrequently found in . with biamuth in a native state it would be well re using the aubnitrate, in the Large quantities I have .amended, to make aure that your preparation is pure. The usual mode of manufacturing the article, I should think, would preclude the poaaibility of much danger from this source, hue we have the high authority of Prof. R. E. of Philadelphia, to justify ua in giving you this caution. In experiments made by him some years ago, he 3 of ar enic in many of the samples of subnitrate of bismuth collected by him from the druggists of Phila- ,ia. Aa far as my own observations go, however, I have never detected arsenic in the subnitrate in any appre- ciable quantity, and never heard, after an experience of many years, of its producing the symptoms of arsenical poisoning in a single instance. Maryland Yirg. 2IaL Jour. On Ghr \ Post-Mortem Appearance, Inflammation of I By X. S. Davis, M. D. Gentlemen : At the last clinic hour, your attention was occupied chiefly with a case of chronic inflammation of the mucoufl membrane of the stomach, coupled with indications of incipient tuberculosis. "We then not only stated the ptoms of the as illustrated in the patient brought you, but we alluded also, briefly, to the diagnosis between it and the different varieties of cancer on the one hand, a: functional derangement of the stomach on the other. We reminded you that chronic gastritis is S iterized by a distinct burning, Bmarting pain, inci >d ; frequently the rejection of the latter by vui:. : a sour or acrid condition, or mixed with mu- ration of the pulse; some tenderness of the ; the tong mooth and ;) its 8ui ared and tender; the bowels gene sometimes relaxed, with urine ia in most cases .ty and emaciation dve. m those '.rnple functional dci. :it of the .stomach in several 666 Chronic Gastritis. [August respects. They are more constant or uniform from day to day, while functional derangement is seldom accompanied by either redness of the tongue, acceleration of the pulse, or any considerable emaciation : and it tenderness of the epigastrium exists, it is only for a day at a time, while the distress from food is rather a load or weight with gaseous eructations, instead of burning, smarting and vomiting, as in inflammation. The differential diagnosis between chronic inflammation of the stomach and cancer was ad- mitted to be more obscure and difficult to define ; so diffi- cult indeed that the experienced arc sometimes left in doubt. We reminded you, however, that the symptoms of cancel usually commence much more gradually and ob- scurely than those of chronic inflammation. There is for a long time less alteration of the pulse, less redness of the tongue, less thirst, while the emaciation is accompanied by that mixture of the sallow and anaemic hue of the skin peculiar to the cancer cachexia ; and the abdo- men is almost constantly sunken or empty, and the bowels costive. We have briefly recalled these symptoms which were dwelt upon much more minutely in the preceding lecture, for the purpose of introducing to your notice some pathological specimens obtained by a recent post mortem examination. We were called directly from the clinic, to which we have alluded, to the bedside of a patient whom we found dying. He had the appearance of one decidedly anaemic, but was only moderately emaciated, with some anasarcous swelling of the extremities. His pulse was feeble and thread-like, extremities cold, breathing oppressed, in fact he seemed apparently in articulo mortis. From his wife and friends we learned that about one year since he had an attack of fever, and during his treat- ment, he was severely salivated with mercurials. His gen- eral health had not been good since that time. He had been constantly more or less anaemic and troubled with in- digestion. Still he had continued to attend to his ordinary duties until about six weeks since, when his food began to give him more distress, and much of it was rejected by vomiting. His strength, of course, rapidly failed, and du- ring the last three weeks he retained neither food nor drink. He had some pains in his back and head, and oedema of the extremities. The condition of the urine could not be ascertained as no attention had been paid to 1861.] Chronic Gastritis. 667 that subject The medical attendant, who was not a regu- lar member of the profession, had pronounced the disease to b< ' of the stomach. But its evident beginning after the attack of fever and salivation, the persistent and active vomiting during the last three weeks, together with the oedema of the extremities and paroxysms of headache, led us to doubt the existence of cancer, and to express the opinion that the disease was chronic gastritis, complicated with some morbid condition of the kidneys. In about an hour after this visit the patient died, and the next day we were requested to make a post-mortem examination. We complied with this request, assisted by Dr. M. O. Hey clock of this city. The cavity of the abdomen was opened in the usual manner, and its viscera carefully examined. The liver was perfectly natural in size, color and structure, and the gall-bladder was moderately full of yellow bile. The spleen was natural in color, but about one-third larger than the normal size, unusually firm and dense in its structure, and on its outer or costal surface there was a spot about one inch in diameter, where, on cutting into it, the investing membrane was found to contain a true bony de- posit, so firm as to resist the scalpel. Here is a portion of that part of the spleen, and by passing it from one to the m can see the change of stricture, and you will observe also that the hard or bony deposit is limited strictly to the surface. The whole exterior of the intestines and mesentery appeared healthy. The only evidences of found in these organs were in the mucous mem- brane of the stomach, which is here exhibited for your ex- amination. That part lining the lesser curvature of the stomach is intensely red, with here and there a dark spot, moderat id'; and on close examination two or thiv ;ill be ^Qon abraded or deprived of epithelium. An unnatural degree of redness is also seen over that part lining the left portion and larger curvature of the stomach, but less than in the part just described. A- we approach the pylorus the membrane appears more natural, and the pylorus tly healthy. Thus, all the morbid appearances in the stomach are such idicate the existence of simple chronic or sub-acute infls nofthemucou8mem.br! it the l< pliant o The bladder was found moderately d ith urine, and the left kidney entirely natural. On Lifting the right kidney from 668 Chronic Gastritis. [August, its place, it was found slightly larger and a darker red than the left; and on laying it open, its whole texture was in- tensely injected with blood, forming a strong contrast when compared with the other. The specimen is here before yon, and though faded some by maceraticn during the last forty- eight hours, yet the morbid redness is still easily recog- nized. The further progress of the post-mortem revealed no other evidences of disease. It is thus seen that the opinion expressed by the attending physician, that the pa- tient was laboring under cancer of the stomach was entirely erroneous. The morbid condition of the spleen had undoubtedly existed a considerable length of time, probably since the attack of fever one year since. As the function of the spleen evidently exerts some influence, either direct or in- direct, over the formation of red corpuscles of the blood, its morbid condition might explain the anaemic appearance exhibited by the patient during the last six or eight months. This was also accompanied by sufficient gastric derange- ment to occasion imperfect and sometimes painful digestion. These embarrassments, however, were not sufficient to prevent him from attending to his duties: in an active out- door occupation until four or live weeks since, when the active and persistent vomiting commenced and continued until death. This symptom doubtless marked the com- mencement of the inflammation which you have seen in the mucous membrane of the stomach, and the parenchyma of the right kidney. Whether the inflammation in these localities commenced simultaneously from the same general causes or not cannot be determined with certainty by the post-mortem appearances. But I wish to remind 3*011 that there is a close relation in many cases between a morbid condition of the kidneys and gastric irritation. A case came under our care a year or two since, in which the uri- nary secretion was very scanty, amounting to not more than four ounces in the twenty-four hours, and highly albumi- nous, with general anasarca, and a profuse watery diarrhoea. These symptoms had supervened during the period of con- valescence from an attack of remittent fever. Fearing the occurrence of extreme exhaustion from the continuance of diarrhoea, remedies were administered for the purpose of restraining it. and at the same time favoring the increased secretion of urine; But it was soon found that whenever the intestinal discharges were restrained for 1881.] Ma *< I Icterus. 669 twenty-four hours, either active vomiting ensued or symp- shing coma. This led to the suspicion that the diarrhoea was purely vicarious or the result of urcemic irritation ; and on applying the teste, area was readily de- ed in the intestinal discharges. The patient ultimately ivered under the influence of treatment for inflamma- tory congestion of the kidne If you make the necessary inquiries yen will find many > in practice, illustrating the effects of urinary disorder on the gastric and cerebral functions. It is now well known that a large proportion of the convulsive affections, not only of puerperal women, but of children also, arise from the retention of urea in the blood. We have found many cases of that distressing affection called '-sick headache," which had recurred again and again for a long period of time, permanently relieved by estab- lishing and maintaining a full healthy action of the kidneys. In the case immediately before us, whether the inflamma- tion of the kidney preceded that of the stomach, or merely accompanied it, there canhe no doubt but that it contributed much to increase the gastric irritability and advance the patient towards a 1 suit. Yet its existence appears not to have been suspected during life. Such cases should admonish you to acquire the habit of examining all patients carefully in reference to every important function, instead of allowing the attention to be wholly engrossed with the more prominent symptoms, as is too often the case. We shall allow you to occupy the remainder of the pre- sent clinic hour in examining the physical signs of pneu- monia com] tlicating a case of extensive tuberculosis. Chi- cago j ked Icterus villi Fatty Ik 'on of the Liver > hieys. By Dr. Yon Plazer. Marie St. -, ag< I tv an unmarried servant union, cume m in Octo- had sufl two ot three months with ition and digestive disorder, panied with col- lick in the abdomen, particularly in rium they earnc on in periodical accessions. Two days before applied for medical advice she had observed thai she G70 Marked Icterus. [August, was jaundiced, and began to be troubled with malaise. headache, heat and vertigo, obliging her to give up work. Her skin and conjunctive were moderately tinged yellow; her tongue foul, and her abdomen slightly meteoric ; the spleen was swollen, the skin hot and dry, pulse and respi- ration a little quick, the urine scanty, brownish yellow, cloudy and albuminous ; stools pale brown and pasty. The chief subjective symptoms present wTere somnolence, dull- ness, vertigo, sensitiveness of the liver and stomach upon pressure, nausea, thirst, and loss of appetite. All these symptoms were aggravated on the next day, when she passed into a state of alternating coma and delirium. On the third day of the treatment she died. Autopsy. The skin was tinged yellow, and the abdomen meteoric. The cerebral meninges were edematous, the brain swollen, congested, infiltrated with serum ; at its base were about two ounces of bloody serum. The lungs wrere somewhat edematous ; the heart was flaccid, and numerous ecchymoses existed beneath the endocardium and peri- cardium. The liver was swollen and heavy, its left lobe and the left half of its right lobe colored deep yellow, the remainder of it pale brown ; its substance was soft and friable, anemic, greasy to the knife ; the lobuli were indistinct. The gall- bladder was small, containing a little clear yellow bile, the ducts pervious. The spleen was enlarged one-half, its capsule tense, its parenchyma soft and deep red. The stomach and intestines were a good deal distended with gas, the mucous membrane puny, dotted with ecchymoses of the size of a pin's head, and covered with deep brown thick mucus. The kidneys were large, flaccid, somewhat yellow, moderately injected ; the cortical part pale yellow, here and there streaked with red, the medullary part brownish red. The urinary bladder was small, and contained three or four ounces of cloudy, icteric urine. On microscopical examination, the liver was found in a state of extreme fatty degeneration. The kidneys were in a less advanced stage of a similar condition. M. Yon Plazer is disposed to regard this case as one of acute atrophy, the fatty change becoming rapidly developed. lie quotes similar cases published by Rokitansky in the Zeitechrift der Wiener Aerzte for I860, but objects to an idea suggested by this observer, that uremic poisoning may be the proximate cause of death. Gazette Hebdomaaaire, Dec. 1861.] Miscellaneous. 671 EDITORIAL AND MISCELLANEOUS. The editor being at the seat of war, will account for the lack of matter under the editorial head. We are requested to call attention to the following announcement : In consequence of the existing war between the governments of the Confederate States of America and the United States of America the proximity of this point to the territorial lino dividing the combatants the possibility that this vicinity may, in the course of the ensuing six or twelve months, become the theatre of hostile operations, the excited condition of the public mind generally, and especially among that class of the community yielding pupils to institutions of medical learning the unfitness for receiving instruction, either satisfactory or profitable, which necessarily results from this state of mind, the large number of the youth of the country who are already in the military service the gency everywhere prevailing in regard to pecuniary matters caused be posture of affairs above described, and the fact that four of our corps of teachers are employed in professional positions connected with the army, the Faculty of Shelby Medical College have doomed it pro- per to announce that the winter course of Lectures for 18Gl-'G2 will not be opened, and that this suspension of exercises will be continued until further notice. John II. Callender, M.D. Prof. Therapeutics, etc. Thomas L. Maddin, M.D. Prof. Surgery, Daniel IS. Ciiffe, M.D. Prof. Anatomy, J. J. Abernathy, M D. Prof. Theory and Practice, Daniel F. Wright, M.D. Prof. Physiology and Pathology, Henri Erni, M.D. Prof. Chemistry, John P. Ford, M.D. Prof. Obstetrics, and Dean of Faculty U, M. Compton, M.D. Demonstrator of Anatomy. shvillc, August 22, 1861. ClILOROFORMIC SOLUTION OF GuTTA PERCHA. TaliC of GuttB Percha, in Bma and a half; Chloroform, twelve fluid ounces ; Carbonate of Lead, in 1 r, two ounces. To eight fluid ounces of the chloroform contained in a bottle, add the gutta percha. and shale occasionally till it is dissolved, then add thecar- : lead, previously mixed smoothly with the remainder of the 672 Miscellaneous. chloroform, and Laving shaken the whole thoroughly together, several times, at intervals of half an hour, set the mixture aside and let it stand for ten days, or until the insoluble matter has subsided, and the solution has become limpid, and either colorless or of a light straw color. Lastly decant, and keep the solution in a glass stopped bottle .-Am.Jour.Phar Prescription for Irritable Stomach. By Dr. Blackwell, of New Jersey. Creasoti, gtt. j. Aq. calcis f.zj. M. S. Five drops every ten minutes; failing with this, one drop every three minutes. Stomach irritation, transmitted from the pelvic viscera, in pregnant women, being paroxysmal, may be successfully treated in the interval by medicines which strengthen the stomach and general system to resist its attacks. 11. Ferri, lactatis, vel. Ferri et strychnise citratis, Quinias sulph. aa gr. xii. . M. Divide into twelve powders giving one every four hours. M.fyS.Rep. A Pathognomonic Sign of Scarlatina. For some years past, M. Bouehut (Journal Practical Medicine and Surgery) has been in (he habit of pointing out in his wards a curious sign which assists in the dis- crimination of scarlatina from measles, erythema, erysipelas, etc. It consists in a vascular phenomenon, proportionate ir. intensity to the ex- treme contra ctibility of the capillaries ; we refer to the enduring while stripe produced at will by drawing the back of the nail over the part of the skin in which the eruption exists. Pressure with the nail or any other hard substance upon the exanthematous surface, produces a white streak, which lasts one or two minutes, and sometimes more. Figures may thus be traced upon the skin, the lines of which are conspicuous from their whiteness. With a blunt probe or pen-holder, the diagnosis of the disease may be distinctly inscribed on the integument, and after a minute Or two the word scarlatina disappears, when the uniform tinge of the eruption again invades the written surface. This phenomenon is observable in scarlatina only. The scarlet hue of measles id not uniform, the eruption consisting of mottled patches, with very slight elevations separated by interstices of healthy skin In measles the procedure we have described would produce an alternately red and white streak, enduring a much shorter time than in scarlatina. in erysipelas, in the redness induced by a mustard poultice, in solar erythema, the white line we allude to is not visible ; and without attribu- ting to this sign an undue degree of importance, it may be said to supply one more element in the determination of the characters of the eruption of scarlatina. Ibid. SOUTHERN MEDICAL AND SURGICAL JOURNAL Vol. XVII. AUGLSTA, GEORGIA, SEI'IEPER, ISM. NO. 9 ORIGINAL AND ECLECTIC. ARTICLE XVIII. Indigenous Remedies of the Southern Confederacy which may be Employed in the Treatment of Malarial Fever. By Joseph Jones, M. D., Professor of Medical Chemistry in the Medical College of Georgia, and Chemist to the Cotton Planters' Convention of Georgia. No. 1. Summary. Necessity for the use of indigenous remedies at the pre- sent time. Georgia Bark, (Pinckneya puoens) its affinities with Peruvian Bark geographical distribution active alkaloid principle medicinal properties use of by the inhabitants of Georgia in the treat- ment of Intermittent Fever Testimony of Dr, John Stevens Law, of Sunbury, to its efficacy as an an anti-periodic : method of using it. Dogwood, (Comas Florida) botanical description geographical distribution chemical composition examination of Dr. Walker, of Virginia, 180-'] ; Dr. "Walker's receipt for making ink from the bark examination of Mr. Carpenter, of Philadelphia Cornine examination of Drs. Staple^, S. Jackson, James Cockburn and D. C. O'Keeffe medi- cinal properties and uses testimony of Dr. Walkt.-r, of Yirgiuia, to the medicinal properties of Dogwood ; of Dr. Gregg, cf Bristol; of Dr.-. Jacob Bigslow, 8. G. Morton, R, Coates, D. (J. O'Keeffe and others- - niethd of preparing the extract dose. Cornus Circinata (Round-leaved Dogwood) testimony of Mori m and Ives to its medicinal value. Poplar or Tulip Tree, (Lirwdcndron Tulipifera) Botanical character examination by Dr. Roger*, 1802 ; by Dr. J. P.Emmet, 1832 discovery of Liriodendrine chemical and physical properties medical properties and uses of Poplar Bark testimony of Michaux, of 43 GT4 Joseph Jones, on the Indigenous [September, Dr. Benjamin Rush, of Dr. I. T. Young, of Governor Clayton, of Drs. Barton, Bigelow arid Bberlie great value as an antipcriodic. Small Magnolia or Sivect Bay {Magnolia glauca) botanical characters geographical distribution chemical composition examina- tion of Dr. Jacob Bigelow medical properties and uses known to the Indians testimony of Dr. Bigelow a domestic remedy in chill and fever dose. Cucumber Tree, (Magnolia acuminata,) Big Laurel, (Magnolia grandiflora.) Umbrella Tree (Magnolia tripetala.) Persimmon, (Diospyros Virginiana.) Catalpa, (Bignonia Catalpa.) Virginia Sna/celioot, ( Aristolochia serpentaria) Botanical descrip- tion geographical distribution chemical constitution analyses of Bu- cholz, Chevallier, Dr. Jacob Bigelow, Conwell medical properties and uses experiments of Jorg on Virginia Snake Root used by the Indians and early settlers of America employed and extolled by numerous physicians testimony of Dr. Nathaniel Chapman, of Sydenham, of Dr. John Eberle, of Dr. Jacob Bigelow, of Dr. George B. Wood, and others. Dose, and mode of administration. Indian Quinine or Ague Weed, (Gentiana quinquifolia.) Thorough Wort. (Eupatorium perforatum) Botanical description geographical distribution chemical composition examination of Drs. Anderson and Bigelow discovery of a salifiable base in, by Mr. J. Scattergood. Medical properties and uses the Indians acquainted with its uses use of by early settlers testimony of Drs. Chapman, Wood, Anderson, Hosack, Baird, Eberle, Ives, Bigelow and others. Dose, and mode of administration. With our ports blockaded, and all commercial intercourse cut off with those foreign countries and American States from whence the South has received her supplies of medicine, it is important, and we may say absolutely necessary that the in- digenous remedies of the Southern Confederacy should be carefully examined and employed. This examination and employment of Southern remedies should be commenced by the physicians not as a temporary expedient, but as a perma- nent advance in the establishment of our absolute indepen- dence. To facilitate this important object, we propose to pass in review the various remedies which may be employed in the treatment of the most common and important of South- ern i . reserving the chemical analyses, physiological and therapeutic experiments, with these and other remedies, for subsequent papers. 1861.] Remedies of ih OD, (CORPUS FLORIDA.) L1X Botanical Characters. Arborescent ; leaves ovate, acuminate ; involucrum large, cbcordate ; drupes ovate. A tree 15-25 feet high, the trunk 8-10 inches diameter, with expand- ing brandies, the smaller crowded at the extremities of the older. Wood fine grained, hard, durable. Leaves opposite^deciduaus, c lanceolate, acuminate, entire, ribbed ; the younger oi ; tibcscent, almost villous en the under surface. Flowers in terminal beads. Invol- ucrum four-leaved ; leaves large, oboordate, nerved, white : the callous, sessile s o? each ; efore the time of flowering. Calyx one-leaved, small, tubular, left; seg- ments erect, obtuse-,, shorter than the. tube. Petals 4, linear-lanceolate, inserted into the summit of the germ, yellowish. Filaments 4, as long corolla, alternating with the petal rs incumbent, two-1 Germ inferior, slightly angled. Style shorter than the stamens, sur- rounded at has- by a glandular ring, around which the petals and fila- "Xorth American, Sylvo, vol 1. ]>. 181, PhOad. 678 Joseph Jones, on the Indigenous [September, merits are inserted. Stigma capitate. Drupe red. Flowers March. April. Elliott. Sketch of Botany of South-Carolina and Georgia, vol 1, pp. 207-208. Geographical Distribution. The Cornus Florida is first seen in Massachusetts, between the 42d and 43d degiees of latitude, and extends uninterruptedly throughout the east- ern, southern and western states to the banks of the Missis- sippi. Although abounding especially in the Middle States, it is, nevertheless, one of the most common trees over this vast extent of country. In New-Jersey, Pennsylvania, Ma- ryland and Virginia, it abounds upon moist, gravelly, and uneven soil ; in North Carolina, South Carolina, Georgia, Florida and Alabama, it is generally found most abundant and most luxuriant on the borders of swamps and low- grounds, and scarcely ever in the pine barrens, where the soil is too dry and sandy to sustain any trees but the long leaf Pine, (Pinus Australis,) the Barrens Scrub Oak (Quer- cus Catesbiei,) Upland Willow Oak, (Quercus cinerea,) Black Jack Oak, (Quercus ferruginea,) and Running Oak, (Quercus pumila.) In the most fertile districts of West Tennessee and Ken- tucky it is said not to appear in the forests, except where the soil is gravelly and of middling quality. Chemical Composition. The bark of the root, stem and branches of the Comas Florida is a powerful bitter, posses- sing a bitter astringent and slightly aromatic tae^a. The chemical composition of this ba^k appears to have been first investigated by Dr. Walker, of Virginia, who publish- ed his observations in 1303 in Philadelphia.* He found that water distilled from the bark in powder had a transpa- rent, whitish appearance, with a slight aromatic odor, and Experimental inquiry into the similarity in nature between the Cornus ad Sericea, and the Cinchona Officinalis of Linncous, &c. &c. by U. Walker. Philadelphia, 1803. 1861.] Remedies of the Southern Confederacy, 679 no perceptible taste ; when the heat was. increased the fluid a lemon color, with an unpleasant smell, and an acerb taste^ effects which were probably produced by the volatil- ization and partial decomposition of portions of the bark in consequence of the continuance of the heat until the mixture was evaporated nearly to dryness. Dr. Walker also endeavored to ascertain the effects of dif- ferent menstrua upon the extract furnished by evaporating a decoction of the root of Cornus Florida. Strong alcohol tlved from the extract, three-fourths of the entire quan- tity : the part which remained undissolved was destitute of . and underwent no change of color on adding the test of iron ; the alcohol which contained the dissolved portion of the extract possessed an intensely hitter taste with as- tringency, presented a clear red color, and turned to a deep black on the addition of a salt of iron. When the alcoho- xtract was macerated in repeated portions ot sulphuric r, with a view to ascertain the quantity of resin, the uired a dark color and a bitter taste, and dissolved quarters of the extract. When tested with iron, it found that the remaining quarter, only, waa changed to a black coJ' Upon this examination Dr. Walker announced that the Dogwood contained gum, resin, tannin and gallic acid. Mr. G. W. Carpenter, of Philadelphia, t subsequently announced the discovery of a peculiar bitter principle for which he proposed the name Cornine, and which he assert- ed to he the active alkaloid principle of the Cornus Florida, *Dr. Walker gives t for makii client ink, in which bark of gall nuts. * halt an ounce of Dogwood bark, two Bcruples of Su] hon and two scrupl the inlV, tK- of the mos By G. w. Carpenter. Philadelp] p. 202. 680 Joseph Jones, on the Indigenous [September, and to be fully equal, if not superior to Quinine in its tonic and febrifuge properties. In consequence, however, of yielding this salt in so very minute comparative proportion to what the Quinine is yielded by the Cinchona, it is even more expensive than the latter. It is greatly to be regretted that Mr. Carpenter did not publish the method by which he extracted the alka- loid principle. Some nave gone so far as to affirm that he did not discover any alkaloid principle at all, because sub- sequent investigations have failed to detect Cornine. "We consider this criticism severe, for three reasons. 1st. ISiO absolutely accurate and complete examination of the bark of the Cornus Florida has yet been made. 2d. As Mr. Carpenter did not state his method of obtain- ing the active principle, it might be supposed that the agents used exerted some influence in the transformation as well as the separation of the alkaloid principle. 3d. Mr. Carpenter affirms that he submitted Cor- nine to the examination of several physicians. This subject is of so much interest and importance that we quote the entire passage from the work of Mr. Carpenter : "It gives me much pleasure to announce the discovery which I made of an alkaline base in the Cornus Florida, which I have denominated Cornine, and which with acids, forms neutral salts, the sulphate of which has proved a highly valuable tonic and febrifuge. This article has been very carefully and accurately described by Dr. Samuel G. Morton, of this city, in the Philadelphia Journal of the Medical and Physical Sciences, and from the most respect- able sources in the medical profession, from various parts of the United States, where this article has been sent, the most corroborating evidences have been received of the un- equivocal success of the Cornine in the treatment of remit- tent and intermittent fevers, in the same doses as the Qui- nine, and the only circumstance which precludes its com- petition with that substance, is the minute comparative 1861.] Remedies of the Southern Confederacy. 681 proportion of Cornine yielded by the Cornus Florida. If, however, at any time, we should fail in our supplies of Cin- chona, which is not impossible, or even improbable, we shall then be able to supply its place by this principle of the Cornus Florida/' Essays on the most important articles of the Materia Medica, kc. p. 203. Dr. S. G. Morton,* of Philadelphia, described Cornine as a greyish-white powder, extremely bitter and deliquesent when exposed to the air, and affirmed that he had exhibit- ed it in some cases of intermittent fever with much success. Dr. Morton considered it to be in no respect inferior to Quinine. Dr. K. Coates, and several other practitioners, exhibited this salt in the same cases in which Quinine is employed, and with decided success. Cornia, according to Mr. Carpenter, does not crystallize but forms on evaporation a viscid mass. It is of a pale, straw color, attracts the moisture of the atmosphere, and dissolves in alcohol, and in sulphuric, acetic and muriatic acids, with which it forms crystallizable, neutral salts. The Sulphate crystallizes in acicular or needle-like cystals, deli- quescent, and consequently soluble in water, of a greyish- white color, and its taste is intensely bitter. According to the testimony of Joseph Tongo,f M.D. and E. Durand. of Philadelphia, Dr. Staples obtained it by digesting the bark of the root of the Cornus Florida in alcohol of 30 deg. of Baume's areometer. After several days had elapsed, the latter was filtered and concentrated by distillation in a water bath. On cooling, a granular extract was obtained, of a light pink color, of a very bitter and astringent taste ; when treated with diluted sulphuric acid, afforded a very small * Philadelphia. Journal Medical and Physical Sciences, xl. + A Manual of Materia Medica and Pharmacy, comprising a concise description of the articles used in Medicine by II. M. Edwards M. D. and P. V M. J), "translated from the French by Joseph Tongo, M. D. and E. Durand. I' 399. G82 Joseph Jones, on the Indigenous [September, quantity of cystals of Sulphate of Cornia, without having been exhausted of all its bitterness and astringency. Mr. Ellis states that Dr. S. Jackson, lately of Northum- berland, Pa. informed him that he had subjected the bark to Henri's process for obtaining Quinia from Cinchona, and that without carrying the process so far as to obtain a cys- talline salt, he used the concentrated alcoholic solution with the most decisive results, and was satisfied that it contained a principle analogous to Quinia. Mr. James Cockburn examined the Cornus Florida in 1835, with the following results : The decoction, which was of a bright red color, and slight mucilaginous appearance, formed a precipitate with a solu- tion of subacetate of lead, which consisted of gum, color- ing matter, and other foreign substances. A precipitate was also formed with pure alcohol. Upon the addition of water to the tincture, concentrated by evaporation, it threw down a curdy precipitate, which upon examination, was found to be resin. The decoction and tincture, redden litmus paper, and cause a yellowish precipitate in a solution of gelatine, and one of a dark olive green in a solution of sulphate of iron. They also afford precipitates with sulphuric and muriatic acids, lime water, alumina, the carbonates of ammonia and potassa tartrate of antimony and potassa. The color be- comes lighter on the addition of nitric acid ; milky by the corrosive chloride of mercury, and has its color deepened by ammonia. A portion of the bark was digested in sulphuric ether for a few days and filtered. The etherial tincture was of a lemon color and reddened litmus paper, and on evaporation deposited on the sides of the vessel a fatty matter, insoluble in water, but soluble in alcohol, leaving a greasy stain on paper; besides this there was a compound of oil and resin combined with colouring matter, and a substance of a light brown color, very bitter taste, friable and very regular appearance, supposed to be a 1861.] s of the Southern Confederacy. 683 compound of a peculiar bitter principle, mixed with tannin and other mutters. This was dissolved in alcohol and formed a beautiful red colored tincture, which reddened litmus paper. Lime was then added, boiled, filtered and evaporated ; a substance resembling the etherial residue, remained interspersed with small, shining acicular crystals of a bitter taste, which property I am disposed to believe they owed to the bitter extract with which they were asso- ciated. The bark used in the last experiment was submit- ted to the action of boiling ether, which on cooling depos- ited a substance of the consistence of wax, which it resem- bled in all its properties. Two ounces of the bark coarsely powdered were intro- duced into Jviij of alcohol and exposed to a temperature of from 105 to 120 decrees F. The alcohol was then decanted and a fresh portion added and treated as before. The liq- uors were then united and a solution of sub-acetate of lead added to separate the coloring matter ; after the insoluble portion subsided, the clear liquor was separated, a little sulphuric acid was then added to the solution to separate any excess of sub-acetate of lead. This was filtered, and the alcohol distilled off. There remained in the retort an oily like substance, together with a principle of a dirty, white color, curdled appearance, resembling the residue of the etherial tincture. Ammonia was then added to the liquor to precipitate any principle remaining in solution. residue was then treated with a little sulphuric acid, water and animal charcoal, (previously treated with muri- atic acid,) which, upon evaporation, deposited an abuudant ralline mas* of a flaky appearance, resembling at first sulphate of quinine, but on coolin;:, assumed a feathery ap- pearance, with a sharp saline taste, soluble in hot and cold water, insoluble in alcohol and ether, soluble in nitric acid, and resembled sulphate of ammonia in all its properties. One pound of coarsely | 1 bark was boiled for half an hour in one gallon of water, acidulated with 5iss sulphuric acid. The tincture was poured oil', and treated 684 Joseph Jones, on the Indigenous [September, with animal charcoal, and when evaporated, left a brown extract of a resinous, waxy appearance, and very bitter taste, which appeared to have very much the flavor of Peruvian bark ; this was again treated with animal charcoal, and left on evaporation, a crystalline mass in an impure form, which was slightly soluble in alcohol, almost insoluble in ether, but voiy soluble in nitric acid. The alcoholic solution was evaporated, and left crystals of a very line, long, flexible and silky appearance: which crystals decomposed when thrown upon red coals, and did not form a precipitate with oxalate of ammonia, but were without taste. The bitterness was entirely owing to the bitter extract, which was slightly soluble in water; soluble in alcohol, but nearly insoluble in ether. This I propose to call bitter ex- tractive, and in this I am inclined to believe the active principle resides. A concentrated tincture yielded by evaporation a dark brown extract, slightly soluble in water, soluble in alcohol and ether, bitter aromatic taste, possessing the properties of resin. Both this and the watery extract possess the sensi- ble properties of the bark in a concentrated form. There is a red coloring principle in this bark, taken up very feebly by alcohol and ether, but less so by water, and has its color rendered deeper by an alkali. One thousand grains of the bark yielded by incineration a product weighing sixty-five grains : this residue was sub- mitted to the action of boiling water, and concentrated by evaporation; it then had an alkaline taste, effervesced strongly with acids, and restored the blue color to litmus, previously reddened by an acid ; it was then neutralized with nitric acid, and upon evaporation yielded cystals of nitrate of potassa. The insoluble residue of the preceding experiment was dissolved by nitric acid, (with the exception of a minute portion of carbonaceous matter) with violent effervescence ; the colorless solution thus obtained, threw down a white precipitate, on the addition of oxalate of ammonia, and a 1861.] Remedies of the Southern. Confederacy. 685 deep blue one with ferrocyanate of potassa. It produced also a dark green or black, with tincture of galls. Carbon- ate of soda when added to the solution, caused a white flocculent precipitate. On adding a solution of phosphate of soda, no change was immediately produced, which led to the belief that a salt of magnesia was present. From the result of these few and imperfect experiments, we may venture to enumerate the following as among the principal constituents of the Cornus Florida. 1, Gum; 2, Resin; 3, Tannin; 4, Gallic Acid; 5, Oil 6, Fatty Matter ; T, a Crstalline substance ; 8, Bitter Ex tractive; 9, AVax; 10, red coloring matter; 11, Lignin 12, Potassa; 13, lion. To which may be added, Salts of Lime and Magnesia. Cornus Florida, by James Cock burn, Jr. Extract from Thesis. Phil. Coll. of Pharm American Journal of Pharmacy, July 1835, new series, vol 1, pp. 109-114. Dr. D. C. O'KeefTe, whilst a student of medicine in the Medical College of Georgia, published a valuable article on the chemical constitution and febrifuge properties of Dog- wood Bark ; in which he states that with the assistance of Dr. Robert Campbell, he had determined upon and con- ducted the following process for obtaining Comine: Pulverize two lbs. of the well-dried bark of the root; separate its tannin with sulphuric ether, and filter. Mace- rate the separated bark in alcohol for two days, to extract its resin and comine. Pour off the alcohol, and precipitate the resin with water. Filter off the resin, and precipitate the comine from the liquor with a solution of sub-acetate of lead. Separate the sub-acetate of lead from the solution by passing a current of sulphuretted-hydrogen gas through it. Filter and evaporate the fluid down to the comine. This substance is possessed of decided acid properties, having a well-marked acid reaction ; it is of a dark straw color, very bitter and astringent. Southern Medical and Surgical Journal, January, 1849, p. 0-7. Dr. O'Keeffe cites the testimony of Prof. Geiger, of Hei- 686 Joseph Jonfs, on the Indigenous [September, dleberg, as confirmatory of the results of his examination of the acid properties of comma. It is evident from the discrepancies in the statements and views of these various observers, that the analyses of Dog- wood, thus far published, are not sufficiently thorough and accurate, and that the profession needs more extended and definite information with reference to the chemical and physical properties of this valuable indigenous plant. Medical Properties and Uses. The bark of the Dogwood has been known and successfully used in the treatment of intermittent fever for more than one hundred years. Upon the human body the bark of the Cornus Florida acts as atonic, astringent and antiperiodic, and resembles in its general effects Peruvian Bark. Dr. Walker, by nume- rous experiments with it upon the healthy system, deter- mined that it uniformly increased the force and frequency of the pulse, and augmented the heat of the body. He in- stituted collateral experiments with the Peruvian bark, and found that both its internal and external effects agreed with those of the Cornus. Dr. Gregg, of Bristol, Pennsylvania, states that after em- ploying the Cornus Florida for nearly twenty-three years in the treatment of intermittents, he was satisfied that it was not inferior to Peruvian bark ; and that he had found it uniformly beneficial as a tonic in cases of debility. Among the number of cures by this medicine was that of his own case. Dr. Gregg estimated thirty-five grains of it equal to thirty grains of Peruvian bark; and observed that the only inconvenience accompanying its use was, that if taken within a year after being stripped from the tree, it some- times occasioned acute pains in the bowels ; but this evil was remedied by adding to it five grains of Virginia Snake Root, (Aristolochia serpentaria.) He recommends the bark as being in the best state after it has been dried a year. In an intermittent fever which prevailed many years ago in West Jersey, it is said to have proved, generally speak- ing, more beneficial than Peruvian bark. 1861.] s of the Southern Confederacy . 687 Drs. Jacob Bigelow, S. G. Morton, R. Coatcs and many other medical men have employed this bark with advantage in intennittents and in debilitated states of the system, ac- companied with loss of appetite and indigestion. I have myself used it with good success in the treatment of our climate fevers. In the southern part of Georgia I have known the planters to employ it extensively amongst their people in combination with Wild Cherry bark and Wild Horehound, (Eupatorium pilosum,) not only in the treatment of inter- mittent fever, but also in colds and dropsies, and in all cases of debility, accompanied with loss of appetite and indigestion. Dr. B. S. Barton states that a decoction of the Dogwood bark was found very useful in a malignant disorder of horses, called "yellow water." Dr. D. C. O'Keeffe, in the article previously referred to, gives an interesting account of the physiological as well as the therapeutic action of the extract of dogwood, and sup- ports his views by fifteen accurately detailed cases of inter- mittent fever. In order to ascertain with precision the effects of large doses of the extract on the system in a physiological state, Dr. O'Keefe instituted the following experiment upon him- self 10 A. M. First dose 30 grains ext.; pulse previous to taking it, * 2. II A. M. Second dose, 30 grains ; pulse intermittent, 72-76; temperature ef surface somewhat augmented; gen- eral perspiration ; a sense of fullness and slight dull pain over the frontal eminences, much increased on flexing the head forward and downward; uneasy feelings in the stom- ach and bow 12 M. Third dose 30 grains; pulse 76, not intermittent but somewhat depressed ; sensation in the head uniform On taking this dose a Bense of warmth was felt in the sto- mach, and radiated over the surface of the trunk. 688 Joseph Jones, on the Indigenous [September, 1 P. M. Fourth dose 30 grains ; pulse 7G and regular ; pain in the head augmented, and extended clown the fore- head to the eye-lids, with a disposition to sleep; slight op- pression in the precordia. Eating dinner, neither mitigated nor heightened the dull headache, which continued the same throughout the day; at night, tendency to sleep much more urgent retired early slept well during the night, and arose in the morning free from any uneasy sensations whatever. Southern Med. & Sur. Jour. Jan. 1849 pp. 10-11. The discrepancies between the effects observed by Dr. O'Keeffe and Dr. Walker may have been due to the fact that the former used the extract and the latter the bark ; be this as it may, it is nevertheless true that the profession needs an extended series of experiments upon the action of the various preparations and constituents of the Cornus Flor- ida. Until these data are supplied it would be worse than useless to attempt any critical analysis and description of its physiological effects. Dr. O'Keeffe not only substantiates the testimony of va- rious physicians to the great value of Dogwood in the treat- ment of malarial fever, but he also establishes the fact that the extract has no tendency whatever to disturb the stomach and bowels. This is important, for the alleged tendency of the Cornus to disturb the stomach and bowels mentioned by so many writers, has exerted no little influence in causing this valuable remedy to remain ueglected. According to Mr. Carpenter the Cornus Florida yields a beautiful extract resembling very closely that of Cinchona, differing, however, in its sensible character, from the extract of the superior species of Peruvian bark, by being less bit- ter and more astringent. The following is the most eligible mode for preparing! this extract: Evaporate in a sand or water-bath a tincture of the bark made by digesting it in proof-spirits in thef proportion of two ounces of the former to a pint of thc| latter, suffering it to stand for at least a week before strain- i 1 .] Remedies of the Southern Confederacy* 089 ing; occasionally during this time submitting it for a few hours to a moderated heat, an J thereby facilitating the so- lution. This extract, from its most prominent and sensible characters, is unquestionably much more active than the common extract, of Carthagena bark, and is a preparation admirably adapted, in all cases, where the Cornus may be employed with advantage; and in consequence of being a concentrated preparation, separated from the ligneous and Luble portions, and containing less gum and mucus matter, (which constitutes so large a portion,) is certainly much preferable to the crude substance, and no doubt will be resorted to by many country practitioners as a useful expedient, particularly in those places where this article is in profusion, and where bark of a good quality is frequent- scarce, and sometimes even unknown. Essays on Materia. Medica, &c. by W. P. Carpenter, pp. 203-204. The extract thus prepared has been exhibited with suc- cess by several practitioners in the same doses as the alco- holic extract of Cinchona. Dose of Extract of Cornus Florida from gr. x. to -Su- ited as often as the case demands. Dose in powder from 20 to 30 grains, to be repeated according to circumstances. It may also be given in decoction, made with an ounce of the bark to the pint of water, of which the dose is from an ounce to two ounces. In some parts of the country the ripe berries infused in brandy, have been used as bitters; and the infusion of the flowers are said to form a good substitute for chamomile tea. A decoction of the buds and twigs has been thought to agree better with weak stomachs than the other prepara- tions. CORNUS CIRCINATA. WILLD. (ROUND LEAVED DOGWOOD,) and CORNUS SERICEA. AVILLD. (SWAMP DOGWOOD.) The ten species of Cornus, indigenous to the United States and Southern Confederacy, are all supposed to | 44 690 Joseph Jones, on the Indigenous [September, sess similar medicinal properties. With the exception of the Cornus Florida the two under consideration have been most carefully investigated. Our knowledge, however, of both their chemical and medicinal properties is not only more imperfect than that of the Cornus Florida, but is vague and meagre. Professor Morson and Dr. Ives appear to have been the first to introduce the Cornus Circinata into medical practice. They recommend it very highly for its astringent and tonic properties, and affirm that they have successfully used it in intermittent fevers and dysentery. Mr. Carpenter announced that the alkaloid principle, Cor- nine, exists also in this species of Cornus. The alcoholic extract appears to be the most eligible mode of using this article. The extract is prepared in the same manner with that of the Cornus Florida, it possesses more astringency and is therefore better adapted to the treatment of dysentery. As this plant appears to be rare in most of the Southern States, it is not likely that it will ever be extensively employed, espescially as the Cornus Florida is not only more abundant but also fully as efficient. The bark of the Cornus Sericea (Swamp Dogwood,) was found by Dr. Walker to be equal to that of the Cornus Florida, and but little inferior to the common pale Peruvian bark, in the treatment of intermittents. It forms a beautiful tinc- ture with proof spirits. As the Swamp Dogwood inhabits the North American continent from Canada to Florida, growing in moist woods, in swamps, and on the borders of streams, especially in the mountains, it is well worth the attention of the physicians of the Southern Confederacy. The doses and modes of preparation and administration are the same with those of the Cornus Florida. POPLAR OR TULIP TREE. (LIRIODENDRON TU- LIPIFERA.) LINN. Botanical Characters. Calyx three-leaved. Petals 6. Capsules (Samara) imbricated, forming a strobilus, 1-1 seeded, not opening. Leaves truncated, pnemorse, four-lobed ; calx three-leaved. This is 1861.] Remedies of the Southern Confederacy. 691 one of the largest trees of the American forests. In the low country of Carolina and Georgia, it is somewhat rare and seldom exceeds three feet in diameter, but in the fertile soils of the western country in Ken- tucky, Tennessee and Alabama, it is sometimes found seven to nine feet, and one hundred and twenty to one hundred and forty feet in height. The wood of this tree though soft is durable. The leaves are alternate, three-lobed, with the middle lobe truncate, and varying with the angles of the lobe obtuse, acute and accuminate, glabrous, on petioles two to three inches long. Flowers solitary, terminal. Leaves of the calyx concave. Petals obovate, lanceolate, of a dull, yellow colour tinged with red. Stamens numerous, disposed in a simple series shorter than the petals. Germs numerous on a conical receptacle, Grows in most fertile soils. Flowers May and June. Elliott. Sketch of Botany So. Ca. and Georgia, vol. 2. pp. 40-41. Geographical Distribution. According to Michaux, the southern extremity of Lake Champlain in latitude 45, may be considered as the northern limit, and the Connecticut river, in the longitude of 72 as the eastern limit of the Tulip tree. It is only beyond the Hudson which flows two degrees further west, and below 43 of latitude, that it is frequently met with and fully developed. It is multiplied in the middle states and in the upper parts of the Carolinas and Georgia, and still more abundantly in the western country, particularly Iventucky. Its comparative rare in the maritime parts of the Carolinas and of Georgia, in Florida, Alabama and lower Louisiana, is owing less to the heat of the summer than to the nature of the soil, which in some parts is too dry, as in the pine-barrens, and in others too wet, a- in the swamps which border the rivers. The western states appear to be the natural soil of this magnificent tree, where they have been found 23 feet in circumference and from 120 to 140 feet in height. Forest trees of America, vol. 2, p. 35. Chemical Composition. The first chemical examination of the bark of the Liriodendron Tulipifera, appears to have been made in 1802, by Dr. Rogers. From the state of Organic chemistry at that time this examination was almost necessarily imperfect and resulted m the determination of nothing more than gum resin, an acid supposed to be mu- 692 Joseph Jones, on the Indigenous [September, riatic, iron, calcareous salt, mucus and fecula, as its chief constituents. In 1832 Dr. J. P. Emmet,* of the University of Virginia announced the discovery of a peculiar principle in the Pop- lar bark, which he called Liriodendrine ; and which he de- scribed in the pure state, to be solid, white, crystallizable, brittle, inodorous at 40p, fusible at 180 and volatile and decomposed at 270, and of a slightly aromatic odor, and a bitter, warm, pungent taste ; insoluble in water, soluble in alcohol and ether ; water precipitates it from its alcoholic solution ; incapable of uniting with alkalies and acids ; al- kalies precipitate it tfrom the infusion or decoction of the bark by combining with the matter which rendered it solu- ble in the water. It is obtained by mascerating the root in alcohol, boiling the tincture with magnesia till it assumes an olive green color, then filtering concentrating by distil- lation till the liquid becomes turbid and finally precipitating the Liriodendrine by the addition of cold water. When carefully heated in a glass tube closed at one end it gives off a white vapor which condenses again without any signs of crystallization. Prof. Emmet regarded it as analogous to Camphor. The fact that the bark of the Liriodendron is weakened by age and so far loses its bitter and aromatic taste, as to become almost insipid, gives force to the opinion that its peculiar properties reside in this volatile principle, Lirio- dendrine. Medical Properties and Uses. Formerly this bark was employed in the United States, both in domestic and regu- lar practice, and from the testimony which was then pub- lished in favor of its decided value as an aromatic, stimu- lating tonic, diaphoretic and anti-periodic, it appears to be well worthy of the careful examination of physicians at the present time. * Journal of the Philadelphia College of Pharmacy, iii. 5. 1361.] Remedies of Southern Confederacy. 693 Michauxf in his splendid work on the Forest Trees of America, states that in some parts of Virginia the inhab- itants were accustomed to steep the bark of the roots, with an equal portion of Dogwood bark in brandy during eight days; two glasses of this tincture, taken every day, some- times cures intermittent fevers. Dr. Benjamin Rush* states that he employed the Poplar bark in the treatment of intermittent fever "with as much satisfaction as any of the common bitters of the shops." The testimony of Dr. J. T. Young, of Philadelphia, to its value is decided and well worthy of consideration at the present time, when we are liable to be deprived of our most powerful and valuable remedies. In a letter* addressed to Gov. Clayton, of Delaware, in 1792, he thus states the results of his experience : " The Liriodendron Tulipifera, (Tulip or Poplar tree,) grows throughout the United States of America. The best time to procure the bark for medicinal purposes is in the month of February, as the sap at this time being more con- fined to the root increases its virtue. It possesses the qualities of an aromatic, a bitter and an astringent. The bitter quality is greater, the astringent less than in the Peruvian bark. It likewise posseses an aromatic acrimony, hence I infer it is highly antiseptic and powerfully tonic. I have prescribed the Poplar bark in a variety of cases of intermittent fever, and can declare from experience, it is equally efficacious with the Peruvian bark, if properly administered. In the phthisis pulmonalis attended with hectic fever, night sweats and diarrhoea, when combined with laudanum it has frequently abated these alarming and trouble?' iptoms. I effectually cured a Mr. Kiser, fifty years of t Vol. ii. p. 40. Transactions of the College of Physicians of Philad. 1798. \ Carey's American Museum, vol. 12. 694 JosEni Jones, on the Indigenous [September? age, who was afflicted with a catarrh and dyspeptic symp- toms for five years, which baffled the attempts of many physicians, and the most celebrated remedies, by persever- ing in the use of the Poplar bark for two weeks. I can assert from experience there is not in all the Mate- ria Medica, a more certain, speedy, and effectual remedy in hysteria than the Poplar bark, combined with a small quantity of laudanum. I have used no remedy in the cholera infantum but the Poplar, after cleansing the primse via;, for these two years. It appears to be an excellent ver- mifuge. I have never known it to fail in a single case of worms which has come under my observation. I prescribed it to a child when convulsions had taken place. After ta- king a few doses, several hundreds of dead ascarides were discharged with the stools. The dose of the powder for an adult is from a scruple to two drachms; it may likewise be used in tincture, infusion, or decoction, but its virtues are always greatest when given in substance." Gov. Clayton in his reply observes : " During the late war the Peruvian bark was very scarce and dear. I was at the time engaged in considerable practice, and was under the necessity of seeking a substitute for the Peruvian bark. I conceived that the Poplar had more aromatic and bitter than the Peruvian, and less astringency. To correct and amend these qualities I added to it nearly an equal quan- tity of the bark of the root of dogwood, (Cornus Florida or Boxwood,) and half the quantity of the inside bark of the White Oak tree. This remedy I prescribed for several years in every case in which I conceived the Peruvian bark necessary or proper, with at least equal if not superior suc- cess. I used it in every species of intermittent, gangre- nes, mortifications, and, in short, in every case of debility. It remains to determine whether the addition of those barks to the Poplar increases its virtues or not. This can only be done by accurate experiments in practice." Dr. Barton* recommended the bark of the Poplar in larton's Collections. 1861.] Remedies of the Southern Confederacy. G95 chronic rheumatism and in gout ; and from its tendency to produce diaphoresis, together with its tonic powers, there can be little doubt of its value in certain conditions of these dis- eases. Dr. Eberle* employed it repeatedly in conjunction with the Ulmus Aspera, in the form of decoction, in the treat- ment of advanced stages of dysentery with satisfactory re- sults. Dr. Bigelowf used it with success as a stomachic. The powdered bark in union with steel dust has been pre- scribed with great advantage in debilitated states of the stomach.;}: The most efficacious form of administering the bark of the Liriodendrum Tulipifera is in substance in the form of pow- der, 5ss to oij. The infusion i.5 of powdered bark to one pint of water, may be administered fji to fij., and the saturated tincture in the dose of f5i. The infusion and the tincture are not as efficient as the powder. No use that we are aware of has as yet been made of the Liriodendrine. The seeds are said by Rafinesque to be laxative ; this fact, however, has been noticed by no other writer, and needs con- firmation. The leaves have been used as an external application in headache ; and an ointment prepared with them lias been . with good effects in ulcers. In the administration of the bark in powder the bowels should be first opened by a cathartic ; and if the bark pro- duces pain in the bowels, it should be combined with small quantities of laudanum. * A Treatise on Materia Mediea and Therapeutics, by John E biladelphia, 1830. Vol. 1, p. t American Medical Botany, fro. Philadelphia, by I>. B !1. H2. | Thacher's ]' :y. G9(j Joseph Jones, on the Indigenous [September, SMALL MAGNOLIA OR SWEET BAY, (MAGNOLIA GLATTUA.) LINN. Botanical Characters. Leaves oval lanceolate, glaucous under* ncath ; petal? obovate, tapering at the base. A shrub frequently be- coming a small tree, remarkable for its white or somewhat glaucous bark. Leaves alternate, on petioles abont an inch long, acute, shining, and when young, pubescent, underneath glaucous, pubescence when young having a silken lustre. Flowers solitary, terminal. Leaves of the calvx oval, glabrous, membranaceous, sprinkled with pellucid dots as long as the corolla. Petals generally nine, obovate, white, as long as the receptacle. Filaments very numerous, compressed, with the point acuminate, and extending beyond the anthers. Anthers attached to the inner side of the filaments This is probably the most fragrant plant in our forests. It grows in great profusion along the margin of the rich swamps which border our rivers, and in the morning and evening, during the period of its flowering, the atmosphere of our streams is often literally perfumed with its fragrance. Flowers April and May. We have a variety with perennial leaves, which sometimes becomes a tree 50-GO feet high. I have been able to discover no other distinction between these two plants than this difference of habit. Elliott. Sketch of the Botany of South Carolina and Georgia, vol ii, p 37. Geographical Distribution. The Sweet Bay lias the most extensive range, especially near the seaboard, of any of the species of the Magnolias. According to Professor Bigelow* its most northern* boundary appears to be in a sheltered sAvamp in Manchester, Cape Ann, about thirty miles north of Boston. It here attains to but small size, and is frequently killed to the ground by severe winters. It is common in the Middle States, and abounds in the maratime parts of the Southern States. In North Carolina and South Carolina it is found in great- est abundance within the limits of the pine-barrens, growing abundantly in the brandies, marshes or swamps traversing the pine-barrens. It is not abundant in the large swamps bordering the rivers, and is very rarely found upon the islands which border the sea coa mical Composition. As far as our information extends, mplete chemical analysis lias been made of the bark of ibis tree ; it is highly probable that its constituents will be * American Medical Botany, vol ii, p. 68. 1861.] JR of (he Southern C ?/. 697 found to resemble closely those of the Magnolia grandiflora, which, bccot if Dr. Procter-, contains ven resin, a volatile oil, and a peculiar crystallizable prin- ciple analogous to Liriodendrine, which, as we have previously liscovered by Dr. J. P. Emmet in the bark of the Tulip Tree. Dr. Bigelow gives in his most valuable Ameri- can Medical Botany the fullest account of the chemical con- stitution of the bark of the Magnolia Glauea with which we are acquainted. The following are the results of his exami- nation. The bark of the Magnolia Glauea has a bitter taste, com- bined with a strong aromatic pungency, which approaches that ifras and of the Acorns Calamus. The aroma resides in a volatile portion, which is probably an essential oil or a variety of camphor. It is lost from the *b ark in the dry state, after it has been kept some time. Water distilled from the green bark has its peculiar flavor, with an empyreu- matic smell. Xo oil appears on the surface when the experi- ment is conducted in the usual way. The dried bark affords a little resin, and more of a bitter extractive substance. Cha- lybt 3 produce a very slight darkening of the green color of the decoction, but gelatine occasions no change. rht be anticipated from the little taste of astringency in the bark. American Medical Botany, vol. ii, p TO. The Indians used the bark he Magnolia Glauea as a remedy for autumnal fever and rheumatism, and in many parts of this country it has been used with si the treatment of malarial fever, both in regular prac Dr. J. -low thus testifies nedicinai properties and value : . lal article, the Magnolia is to be sidered an aromatic tonic, approaching in its character to ' :es of their class. Considered sim; is t'.;.:" powers, it is probably of a rjdary order, though from the additional properties which * American Journal ofPharmacv, vol. xiv, p. Oo. 698 Joseph Jones, on the Indigenous [September, it possesses of a warm stimulant and a diaphoretic, is found useful in certain disorders. Chronic rheumatism is one of the diseases in which it ex- hibits most efficacy. Not only the bark, but the seeds and cones which are strongly imbued with the sensible qualities of the tree, are employed in tincture with very good success in this disease. In intermittent and remittent fevers the Magnolia is one of the many tonics which have been resorted to for cure by the inhabitants of the marshy countries where they prevail. Suf- ficient testimony has been given in favor of the bark of this tree, to warrant a belief that it is fully adequate to the remo- val of fever and ague, when administered like the Cinchona, in liberal quantities between the paroxysms. In the more continuous forms of fever, of the typhoid type, it has also re- ceived the commendations of physicians. American Medical Botany, vol. ii, p 70-71. The dose of the powdered bark is from half a drachm to a drachm, repeated according to the character of the case. A decoction may be made in the proportion of one ounce of the powdered bark to the pint of water this may be administer- ed in doses of from fS to fSij, and repeated every one, two or three hours, according to circumstances. An extract has been made from it, but its powers have not been sufficiently tested. An infusion of the bark in brandy has been employed in rheumatism. The cones and seeds have likewise been employed to make a tincture, which has been a popular remody in the treatment of chronic rheumatism, and as a prophylactic against inter- mittent fever. CUCUMBER TREE, (MAGNOLIA ACUMINATA MICH.) and BIG LAUREL, (MAGNOLIA GRANDIFLORA MICH.) and UMBRELLA TREE, (MAGNOLIA TRIPE- TALA,) WILLD. Our information with reference to those three species of Magnolia, although less definite and far more meagre than that which we have presented concerning the Magnolia 1861.] i?' f the Southern Confederacy. 699 Glauoa. still as far as it extends, tends to establish their value in the treatment of malarial fever. The Cucumber tree, m)agn<>lia acuminata) which extends from the Falls of Niagara along the whole mountainous tract of the Alleghanies to their termination in Georgia, and also along the Cumberland mountains in Tennessee, has been em- ployed by the inhabitants of the country bordering on the Alleghanies as a preventative of intermittent fever. Michaux* states that they gather the cones about midsummer when half ripe, and steep them in whiskey ; a glass or two of this liquor, which is extremely bitter, they habitually take in the morning, as a preventative against autumnal fevers. AVe are not aware that there are any recorded observations of the results of these attempts to ward off malarial fever ; it would therefore be highly important that physicians living in the regions where this tree is found, should carefully deter- mine the value of the cones as a prophylactic. The discovery of a native prophylactic against malarial fever would be of incalculable value to our planters in the rich low-lands of the Southern Confederacy, and especially to bodies of white men exposed during marches, and in the defence of our coast, to the destructive exhalations of marshes and rice fields. We have before alluded to the discovery by Dr. Stephen Procter, of a principle in the bark of the Magnolia grandi- flora, analogous to the principle Liriodendrine of the Tulip tree. In addition to this he found a volatile oil, and resin. The medicinal properties of these different species appear, as far as our very limited information extends, to be almost iden- tical, and it is probable that they may be substituted one for the other without inconvenience in the same doses recom- mended for Magnolia Glauca. AYe need, however, accurate analyses and extended medical observations. PEBSIMMON (DIOSPYEOS V1RGIXIAXA.) MICH. Ereckel in his "History of North Carolina," says that the inner bark has been used with success in intermittent fever. *Forenic, stimulant and more powerfully anti- periodic than the Peruvian bark. I have been unable, after careful research with the best authorities to find any facts which bear either upon the chemical constitution, or the tonic, stimulant and antiperiodic properties of the bark of the Catalpa. Physicians should exercise caution in their experi- ments with it, because it is generally believed to be poisonous. When the bark is wounded a very unpleasant, and according to the testimony of some, a poisonous gas is emitted ; and it lias been stated, on good authority, that the honey collected from its flowers is poisonous, producing effects analogous, though less alarming, than those produced by the honey col- lected from the Yellow Jasmine of Carolina. The seeds have been employed by several practitioners of continental Europe in asthma. M. Automarchi recommends for this purpose a decoction made by boiling twelve ounces of water with three or four ounces of the seeds down to six ounces, the whole to be given morning and night. I u the use of the unripe fruit of the Diospyros Virginiana, as a thera- peutic a cut. By JohnP. Mettauer, At. I)., of Virginia. The American Journal of Med. Soi October, L842, p297. Amer. Jour. Pharm. xii, p 161. "Wood house, Inaug. Diss. + Dr. B. S. Barton^ Collections. 11. 1SG1.] Remedies of the Southern Confederacy . 701 VIRGINIA SXAXEROOT, (ARISTOLOCI1IA SERPENTAKIA.) LIXX. Botanical Description. Loaves cordate, oblong, acuminate ; stem flexuons; peduncles radical ; lip of the corolla lanceolate. Root pe- rennial, composed of many filiform fibres, pungent and aromatic. Stem i eight inches high, herbaceous, pubescent, erect, geniculate and knotty at base, as if formed of the remains of older stems. LcAves few, oblong, lanceolate, slightly acuminate, a little hairy, cordate at base. Flowers few at the base of the stem, laying on or sometimes under the surface of the earth. Peduncles one-flowered. Corolla ventricose at base, slightly three cleft at summit ; one lobe extended, lanceolate. Grows in drv soils. Flowers in summer. Elliott. Sketch of Botany of S. C. and Ga. vol. 2, pp 511-512. Geographical Distribution. Middle and Southern States. The most northern situation from which Dr. Bigeldw received specimens was from the vicinity of Xew Haven. There are many varieties, and according to some botanists, several species confounded in the market, under the common name of A. Serpentaria. In a medical point of view, this confusion of species is of no consequence, as they are almost entirely identical in properties and remedial action. Chemical Constitution. According to Bucholz, who ana- lyzed the root in 1807, 100 parts contain : Volatile Gil, 0.50 Greenish-yellow soft resin, - - - 2.85 Extractive matter, - - - - 1.70 Gummy Extractive, - - - 18.10 Lignin, 62.40 Water, 14.45 100.00 It was again examined by Chevaliier in 1820, and fonnd to consist of volatile oil, resin, extractive, starch, ligneous fibre, albumen, malate and phosphate of lime, oxide of iron and silica, Grassman obtained only half an ounce of volatile oil from 100 1!js. of the root, which he describes of a yellowish color, strong odor and moderately strong taste, and compares the odor and taste to those of valerian and camphor combined. 702 Joseph Jones, on the Indigenous [September, The bitter principle termed Extractive by Bucholz and Chevallier is very bitter, slightly acrid, soluble in both water and spirit ; its solution which is yellow, is rendered brown by alkalis, but is unchanged by ferruginous salts. The root com- municates its qualities both to spirit and water, but most to the former. Dr. Jacob Bigelow, subjected a quantity of the root to dis- tillation for one hour, and obtained in the receiver a wetish, pearly fluid, very strongly impregnated with aroma, but less bitter than the root. On standing twenty -four hours, this fluid deposited round the edges of the surface a considerable num- ber of small white cystals, which proved to be pure camphor. They were inflammable, fusible with a suddeu, and volatile with a gradual heat. American Medical Botany, p 85. Dr. C. Conwell,* more than thirty years ago announced the discovery in this root of a new alkaloid principle for which he proposed the name of Serpen taria. It forms in a defined cystallized mass of a bitter taste, and possesses all the alkaline properties. The sulphate cystallizes in quadrangular prisms, terminated in inclined facets. The hydrochlorate of Serpen- taria forms brilliant plumose fibrils. Both these salts are'in- soluble, except in an excess of acid. The preparation is the same as that by which quassa is obtained. This principle may be the same as the yellow bitter princi- ple of Chevallier, which he considered as analogous to the bitter principle of quassa. Medical Properties and Uses. The experiments of Jorg and his pupils, established that in small doses it promotes appetite ; in large doses, it causes nausea, uneasy sensations in the stomach, flatulence and more frequent but not liquid stools : after absorption, it increases the frequency and fulness of the pulse, augments the heat of the skin, and promotes se- cretion and excretion, and in very large doses causes disturb- Manual of Materia Mcdioa, by II. M. Edwards and P. Vavasseur, M. D. Translated by J. Tongo, M. D., and E. Durand, p 1S3. Philad. 1829. 1861. Remedies of the Southern Confederacy. 703 ance of the cerebral functions, producing headache, sense of oppression within the skull, and disturbed sleep. root is said to have been in common use among the Indians at the time of the arrival of the first settlers, and was much esteemed by them as a remedy in snake-bites. The early colonists soon adopted it as an excellent tonic and stimulant, and it is to this day extensively employed as a do- mestic remedy in levers and in debilitated states of the system. It has been employed and extolled by numerous physicians, and it will be profitable for us to review the testimony of several of the most intelligent and extensive American practi- tioners. Dr. Chapman considered the Serpentaria as possess- ing the mixed qualities of a stimulant and tonic, with active diaphoretic and diuretic properties. "Among the more early - of the medicine was its application in the cure of inter- mittent fever. Whether it is adequate alone to the purpose does not clearly appear. But it certainly proves an important adjuvant. It was used by Sydenham, in conjunction with wine, to prevent the recurrence of the paroxysm, and, from his account, not without advantage. As a general rule, he . that in all cases where it is expedient to combine wine with bark, the effect will be much increased by adding ser- pentaria. The correctness of this observation lias been fully confirmed by subsequent experience, and it is now very much the practice to unite these articles in the low states of disease. "To remittent fever, serpentaria seems to me to be best adapted. It has here, in many oases, an indisputable supe- riority over the bark, inasmuch as it is rarely offensive to the stomach, and maybe given, without injury, in those obscure states of the disease where the remission is not readily dis- cernible. As a popular remedy, more particularly, it is much employed in the secondary stages of pleurisy. After bleed- ing, it is the practice in many parts of our country, to resort to a strong infusion of this article, with a view to exciting piration, and the result is said to be generally favorable. Catarrhs, rheumatisms, and other winter affections incident to rustic life, are managed in the same way. It is also a noted 704 Joseph Jones, on the Indigenous [September, remedy in dropsy, to which, I should presume, it is adapted, and especially if the ease be of an intermittent type. "In that species of pleurisy which is properly enough desig- nated by the epithet bilious, I have repeatedly had occasion to recur to the serpentaria, and always with more or less utility. I know not, indeed, any modification of disease in which it displays its power more advantageously. The bilious pleurisy has all the characteristics of pneumonic inflammation, with the addition of some of the symptoms incident to autum- nal fever. There is considerable headache, much gastric dis- tress, and almost always violent vomitings of bile. It differs also from ordinary pleurisy in having less activity of inflam- mation, and consequently in not bearing the same extent of depletion. The system, indeed, will often be very evidently depressed by one or two bleedings. In this case, the practice which lias been commonly pursued, is after the removal of a comparatively small portion of blood, and the thorough evac- uation of the alimentary canal, to administer draughts of the infusion of serpentaria, in order to excite diaphoresis. As an epidemic, the bilious pleurisy prevailed in the neighborhood of this city many years ago, and I am informed, was managed most successfully by the practice which I have detailed. It is not, however, one of the ordinary complaints of the climate of the middle States. The cases which I have seen of it have for the most part occurred in persons coming from districts of country exposed to marsh exhalation, and who have previously had autumnal fever. I have only one more remark to make on the properties of this article, which is, that it is admirably suited to check vomitings, and to tranquilize the stomach, par- ticularly in bilious cases. It is given for the purpose in infu- sion, in the small dose of half an ounce or less at a time, and f req uen tly re pea ted. " * * Elements of Therapeutics and Materia Medica. By N. Chapman, M. D. &c. Philad. 1S22, vol. ii, pp. 432-433. 1861.] es of the Southern I racy. 705 Dr. John Eb eric thus testifies to the action and medicinal value of Virginia Snake* When taken into the stomach it increases the force and fre- quency of the pulse, exc! low of heat throughout the system, and produces pretty copious diaphoresis. It is not, however, simply stimulant and diaphoretic in its effects, for along with these qualities, it possesses very important tonic powers. Possessing, along with its tonic, pretty powerful stimulant properties, the snakeroot is peculiarly suited to fevers of a low grade of excitement ; on the other hand, however, it can never be employed without danger, when blood-letting is indicated. In every variety of fever, however, when the system is sinking into a typhoid state, the snakeroot is a remedy of un- questionable utility. It is especially serviceable in the latter stages of febrile diseases, when the skin and tongue remain dry and hot, and the pulse is feeble and frequent. When given in this state, it commonly excites a general diaphoresis ; the tongue becomes moist, and the pulse and the general powers of the system are invigorated. A good deal 1. . said in favor of the powers of the serpentaria in putrid fevers, and from the general properties of this remedy, there can be little doubt of its applicability to the treatment of fevers of this kind. The snakeroot was formerly much employed in intermit- tents. Of its efficacy, however, in the cure of thie when administered by itself, not a great deal can be said. I have employed it in some instances, but always without buc- . and I am inclined to believe that it is not often capable of arresting the disease. When united, however, with bark, me of the bitter tonics, it seems to increase their efficacy, and it is in this way thai it is now commonly employed in in mittent and remittee It is particularly useful, with Peruvian bark, in those intermittents wher n is depressed and sluggish during the intermission, with a small 45 706 Joseph Joxes, on the Indigenous [September, and feeble pulse, and a cold and dry state of the surface of the body. During the prevalence of the late epidemic, pneumonia typhoides, in this country, the serpentaria was much pre- scribed by some physicians. Being at once stimulant, dia- phoretic and roberant, it was particularly calculated to pro- duce beneficial effects in this disease by equalising the circu- lation and imparting vigor to the vital powers. Dr. Dyckman states that he has prescribed the snakeroot in combination with seneka, with marked advantage in this disease. It may also be employed with advantage in the latter stages of pneumonia and bronchial affections, being useful not only by its tonic operation, but chiefly, perhaps, by exciting the cutaneous emunctories, and thereby relieving the pulmonic system. The infusion of snakeroot may be used with advantage as a gargle, in ill-conditioned ulcers of the throat. Treatise on Materia Medica and Therapeutics by John Eberle, M. D. &c. Philadelphia, 1S3G, vol. i, pp. 258-259. The following is the testimony of Dr. Jacob Bigelow : Medically considered, serpentaria is a tonic, diaphoretic and in certain cases an antispasmodic and anodyne. It has been abundantly used in fevers of various descriptions, and has been commended by a host of medical writers. There is no doubt that it has been injudiciously employed in many cases, in fever attended with an active pulse and inflammatory diathesis. The early stages, also, of febrile diseases rarely admit the exhibition of so decided a stimulant without injury. But in the advanced stnges of fever, and those attended with typhoid al symptoms, this medicine is resorted to with groat advantage, both alone and in combination with other tonics and stimulants. It is peculiarly useful in supporting the strength and in allaying the irregular actions which attend ; febrile debility, such as subsultus tendinum, delirium, watchfulness, &c. Its bitter ingredients, and the camphor which it contains, no doubt contribute to their eflects. It is 1861.] Remedies of the Southern Confederacy. 707 most advantageously given in combination with bark, or witL wine and opium. American Medical Botany, vol. 3, p Dr. George B. Wood in his valuable work on Therapeutics and Pharmacology, considers Virginia Snakeroot as simply tonic and stimulant to the circulation, with a tendency to pro- duce perspiration, generally acceptable to the stomach in moderate doses, and probably without special influence on the brain or nervous system. "It may be employed injure dys- pepsia, attended with a degree of debility calling for some- thing more stimulating than the simple bitters, and especially when there is a disposition to dryness of the surface ; but its most appropriate application continues to be that for which it was early recommended, to the treatment, namely, of f< of a low or typhoid character. Whenever any febrile disease begins to exhibit this tendency, and stimulation is demanded, serpentaria is one of the first medicines to which we may have recourse, provided the stomach be wholly free from in- flammation or vascular irritation. It may be used, therefore, with the condition of stomach mentioned, in typhus or typhoid fever, when passing from the first stage of excitement into that of debility, in protracted remittent fever assuming a low character, in typhoid pneumonia, and in small-pox, scarlatina, malignant sore throat and erysipelas, under similar circum- stances. But it should be understood, that in none of these affections, does it possess any specific curative powers, that it can act merely as a tonic and gentle stimulant, and that it should be used only as an adjuvant in very serious cases, being alone wholly incompetent to the support of the system under powerful depressing influences. In many of these may be very properly associated with Peruvian bark or Quinia. "From my own observations, I should infer that serpen- taria pot do peculiar antiperiodic power, and that it cannot, therefore, be relied on for breaking the course of an intermittent or remittent fever; but in either it may be con- joined with sulphate of quinia when the system is feeble, and the stomach somewhat insusceptible. The association of Pe- ruvian bark has long been a habit among practitioners. It ex- 708 Joseph Jones, on the Indigenous [September, ists in the compound tincture of Peruvian lark of the British and American Pharmacopoeias, better known under the name of Huxhams Tincture of Bark"* I have employed Yirginia Snakeroot in conjunction with quinia and brandy, in the treatment of numerous cases of the various forms of malarial fever ; as the results of these obser- vations have been laid before the profession,f we shall merely state that while it has proved a valuable stimulant, diuretic and diaphoretic, we do not believe that it is by itself capable of arresting, as a general rule, the more violent forms of malarial fever. Administered in conjunction with sulphate of quinia, bran- dy and carbonate of ammonia, I have derived great benefit from it, as well as from the other remedies, in the severe forms of malarial fever, when the pulse is rapid and feeble, beating from 120 to 160 times in a minute, and feeling like the vibra- tions of a delicate silver thread ; when the heart thumps feebly, and spasmodically and rapidly against the walls of the thorax ; when the respiration is full, panting, labored, vary- ing from 30 to 50 in the minute ; when the skin is hot, and parched, and rough, or bathed in a cold, clammy sweat; when the temperature of the extremities is far below that of the trunk, which by no means corresponds with the increased efforts at the introduction of oxygen; when the circulation of the blood in the capillaries of the extremities is almost entirely checked ; when the chemical changes of the solids and fluids are in a great measure arrested and perverted, and the devel- opment of the nervous and physical forces arrested, and their correlation disturbed ; when the altered blood stagnates in the capillaries of the brain, and the intellect is either abnor- *A Treatise on Therapeutics and Pharmacology, or Materia Medica, by George B. Wood, M. D., &c. Philadelphia, 1856, vol. 1, p 302. tObservationa on some of the Physical, Chemical, Physiological and Pathological Phenomena of Malarial Fever; by Joseph Jones, M. D. Transactions of the American Medical Association, vol. 12, 1859. South- ern Medical and Surgical Journal, 1858. 1S61.] Remedies of the Southern Confederacy. TOO mall v excited or depressed ; when the altered "blood stagnates in the capillaries of the tongue and stomach, and the brilliant red, dry, rough tongue, is but a fit index of the consuming thirst of the restless patient tossing from side to side and plead- ing for a drop of water. In such cases, if brandy and snake- root be used alone, the beneficial effects will be only tempo- rary. To be permanent, some powerful antiperiodic, as sulphate of quinia, should be combined with the stimulants. The effects of carbonate of ammonia in such cases, although powerful, are in like manner evanescent, unless combined with large doses of the sulphate of quinia. If we should at any time be deprived of quinine, and be compelled to rely wholly upon the indigenous remedies, I should recommend in such cases the combination of large doses of brandy, carbon- ate of ammonia, Virginia Snakeroot, Georgia Bark, Poplar and Magnolia Bark. We would thus obtain the stimulant, diuretic, diaphoretic and antiperiodic virtues of several reme- dies, in a condition of the system where we need not merely active stimulation, but the excitation of the process of excre- tion, in all the structures and organs, by which the morbific agents and offending products may be eliminated. I have also derived much benefit from the tincture of snakeroot in the debilitated state of the system succeeding remittent fever. In such cases it is most beneficial when administered in con- junction with citrate of potassa, or carbonate of soda. These latter remedies act in conjunction with the diuretic properties of the snake-root. Dose of the powder 10 to 40 grains. The infusion made in the proportion of half an ounce to a pint of boiling wa- ter, may be administered in the dose of one to two fluid ounces, repeated in chronic cases ; and where we wish more especially a tonic effect, three or four times a day ; in fe . when we wish a more decided effect, it may be adminis- tered every half hour, or at longer intervals, according to The tincture, prepared by macerating for fourteen days three ounces of powdered snake-root in two pints of dilu- 710 JosEPn Jones, on the Indigenous [September, ted alcohol, and filtering, or more rapidly in two days by the use of the displacement apparatus, maybe administered in the dose of one to three fluid drachms. In the treatment of malarial fever the properties may be conveniently obtained and combined with a suitable stimu- lant, by pouring one pint of brandy on one ounce of the roots. One tablespoonful of this may be administered every hour, or more seldom, according to the urgency of the symptoms. In congestive fever it may be administered every half hour until reaction takes place ; of course the maximum dose of stimulants here stated would be used only to meet special indications and not as a general rule in pro- longed treatment. Dr. Eberle recommends the following mixture as very useful in the dyspeptic affections of infants ; ]$. Pulv. serpentaria3 ; Magnes. albi aa gr. xvi; Pulv. Rha^i, gr. xij. M. Divide into six equal parts. Iluxham's Tincture of Bark, (compound tincture of Pe- ruvian bark,) is prepared by macerating two ounces of Red bark in powder, one ounce and a half of bruised Orange peel, three drachms of bruised Virginia snake-root, cut Saf- fron one drachm, and rasped red Saunders one drachm, in twenty fluid ounces of diluted alcohol for fourteen days ; then expressing and filtering : or more rapidly with the same formula, in two days by the use of the displacement apparatus. (M-:XTIA^A QUINQITEFLORA. EsTDIA^ QUININE AGUE WEED. Dr. E. P. A\rood, of Wisconsin, has given this plant with success in a number of cases of intermittent fever, and he states that it is used extensively in domestic practice. Trans. Illinois State Med. Soc. 1857. acy. 711 THOKOTJGB WORT. (ETJPATOKIUM PERFO- LIATUM.) lied also Thorough "Wax, CrossT^ort, Boneset, Indian . The Herb, &c. Botanical Description. Loaves connatc-perfoliatc, rugose, to" mentose underneath ; stem villous, Stem three to six feet high, striate* villous, almost tomentose, and with the leaves and involucrum hoary and sprinkled with glandular dots. Lower leaves connate, the upper distinct, abruptly truncated at base, all tapering gradually to the summit, serrate, rugose, slightly pubescent on the upper surface, tomentose underneath. Involucrum many-leaved, (fourteen to sixteen,) eight to ten-flowered, leaves linear-lanceolate, acute, pubescent, imbricate. Corolla small, white, glabrous. Style nearly twice as long as the Corolla, two cleft, mple. Seed angular, pappus scabrous. A decoction of this plant is much used and recommended in fevers it acts as an emetic or sudorific, according to the constitution of the patient. Grows in wet soils. Flowers in September October, Elliott. Sketch of Botany of South Carolina and Georgia. Vol. ii. p. 302. G< ' ' Typhoid Fever. By Austin Flint, M. J)., Professor of inical Medicine, etc., in the New Orleans School of Medicine. GentloTnon I have chosen as the subject of my lecture to- day, a renewal of the eases of typhoid fever which have been under our observations during the winter, with reference es- pecially to abortive measure.- of treatment. > Abortive measures of treatment are those employed to arrest the pr f the disease either by cutting it short, jugulating it as the French writers say, or by abridging ma- terially its career. Up to a late period measures for these ends were employed habitually by physicians, and, as was Bupposed, with considerable success. Blood-letting, cathar- tics, emetics, mercurialization, and other means have been advocated as possessing the power of arresting the common continued or typhoid fever. But since the natural history of the disease has been more acurately studied, and its diagnos- tic characters better understood than they were but a few years ago, it has come to be considered very generally that it cannot be controlled by any measures at present known. The measures just mentioned have mostly gone out of use in the treatment of the disease; at all events, few, if any, now resort to them with the expectation of arresting the disease. The doctrine taught by the most approved writers at the present time is, that the typhoid and other forms of continued fever must have their course, and that the power of the physician is limited to palliating symptoms, sustaining the vital forces and guiding the disease to a favorable termination. This doc- trine, however, is not accepted by all. Son: "nee, Dr. Henry, of Illinois, communicated for the medical journals ral papers in which he asserted that opium in large di Combined with calomej, succeeds in arresting alike remitting and continued fevers. More recently, Dr. Dundas, of Liver- pool, has claimed in behalf of large doses of quinia a poti great in continued as in periodical fevers. My di hed friend and colleague, the Professor of Practice in this Prof. Fenner, advocates the use of quinia in large imbined with opium, as successful, if resorted to early and efficiently, in often cutting short continued fever, and in abridging its duration and modifying its intensity when the t at once 1. 1 have made some observa- abortive treatment of typhoid l\:\\r, and been led to think that opium in large,* doi the wet sheet employed often, after the manner of the hydropathists, 720 lyphoid Fever. [September, sometimes may succeed in arresting the disease. Now you will, perhaps, ask why this matter is not settled to the satisfaction of all candid minds? It may seem to you that the question as to the efficacy of any particular measure could ho very easily answered by an appeal to facts ; but it is more difficult to bring facts to bear on this question than at first appears. The difficulty arises mainly from two sources. In the first place there is a liability to error in diagnosis during the early part of the course of typhoid fever, and this creates a distrust in the minds of others, and in the mind of the observer, also, when the disease appears to be arrested. In the second place, the disease appears sometimes to abort of itself ; in other words, we meet with cases in which the phenomena attending the forming stage of typhoid fever are present, but the disease does not become fully developed, or if developed, it abruptly ceases and does not go on, irrespec- tive of any measures of treatment. To obviate the first of these difficulties it has been proposed to wait until the eruption appears, and not consider the diag- nosis as positive until this event occurs. This plan was pur- sued by Prof. Bennett, of Edinburgh, in testing the views of Dr. Dundas, and he found that the quinia failed in several cases in which he intended to give this remedy a fair trial. But the eruption in typhoid fever does not usually appear until the seventh day after the patient takes to the bed, and by this time the disease has advanced nearly half-way through its career. This plan involves too much delay to secure for any measure a fair trial. We must, theretore, base the diag- nosis on other circumstances, and make due allowance for a liability to error. In like manner, allowance is to be made for the natural abortion of the disease. You see, gentlemen, that the question as to the efficacy of any abortive measure is not very easily settled. Great cau- tion is requisite in the collection of facts. The observer must be competent for observation, and be careful as regards the diagnostic characters, exclusive of the eruption. His mind must not be warped by undue enthusiasm or credulity, and, unfortunately, we find that not a few persons, who are not wanting in conscientiousness, are apt to see precisely what they desire or expect to witness. If in a considerable number of cases correctly observed, the disease abruptly ends or fails to run its accustomed course in a larger proportion, when cer- tain abortive measures are employed, than when no such measures are employed, we must attribute to these measures more or less efficacy. Now, with regard to the efficacy of any i.] 7/// TlM particular remedies [ shall not express an opinion in general* terms, for I have not formed any opinion on the subj< I regard the subject as a legitimate one for clinical ol> ration, and that the accumulation of more facts than we at lary before we arc prepared to come to anv positive conclusions. Without further preliminary remarks, let us direct atten- tion to the cases of typhoid fever which have heen treated in my wards this winter. The cases are few, for this dis- has not pTevailed to much extent in this city during the present season. I have recorded all the cases in nay wards, and they are only lour in number. The first ease proved fatal in about two weeks after the admission of the patient. In this case abortive measures were not employed. The characteristic intestinal lesions were found after death, and exhibited to the class ; tuber- culous ulceration from another body being exhibited at the same time, in order to illustrate the points of contrast. In this case, unexpectedly, extensive cystoid degeneration of the kidney was found, these organs being full of cysts, va- rying in size from a pea to a hickory nut. 2 was admitted Nov. 14th^ The patient had been ill for six or eight days, but he was not confined to the bed before he came to the hospital. His age was twenty-eight. He had lived in this city for two years. On his admission he took to the bed. His expression was dull and the mind acted slowly. He had moderate diar- rhcea which had existed for several days. Before coming to the hospital he had had epistaxis, pains in the head and limbs, lassitude, loss of appetite and some nausea. Ten- derness was marked in the iliac region and gurgling. The abdomen was meteorized but not distended. There was Lerate febrile movement Xo eruption. On the day after his admission, when I first examined I ')) I prescribed fifteen grains of the sulphate of quinia. On the loth, at my morning visit, he was <: and sitting up. but he was evidently too ill to keep np, and he returned to the bed. He reported better than on tie' .-. but the symptoms were about the same. 1 quinia on this day. On the 17th he was in bed and reported not a- well. The diarrhoea had been troublesome during the night. The dullness of expression and slowness of mind continued. The 46 722 Typhoid Fever. [September, febrile movement was moderate. Tenderness in the iliac region continued. The chest was everywhere resonant, and some sibilant rales existed on both sides. I counted two or three sore spots on the chest. I prescribed on this day \'ov the diarrhoea, opium, gr. i, and tannic acid, grs. iii, throe times, discontinuing the quinia. On the 18th the daily record is as follows:' "He reports no better; says that he did not sleep last night, owing to had dreams. He had two dejections during the night and has had one this morning. The pulse is eighty ; the respi- rations sixteen. He dozes but is easily aroused. The skin is warm and moist. Slight capillar}- congestion exists on the face and upper limbs. Tenderness in the iliac region continues. Three or four sore spots are found on the chest and abdomen. He has no appetite, but complains of thirst. There have been no manifestations of delirium. Treat- ment opium, grs. ii, three times." On the 19th the symptoms were the same, and some in- coherent talking during the night was observed by the ward nurse. The treatment on this day had reference to an abortive effect, the case being now regarded as clearly one of typhoid fever. Five grains of the sulphate of quinia and three grs. of opium were directed to be given three times. Nov. 20th, the patient was dressed and sitting up, but was evidently quite feeble. Moderate diarrhoea continued. The pulse, while sitting up was eighty-four, but on return- ing to the bed it fell to sixty-four. No man testations of delirium. Tenderness in the iliac region, with gurgling, continued. The sore spots, previously observed, had dis- appeared. Treatment opium, grs. iii, and the sulphate of quinia, grs. vii, three times. Nov. 21. The patient sat up a portion of the previous day, and on this day he reported quite well. Xo dejection since the previous evening. ' Pulse sixty-four. Xo medicine was prescribed ; a diet of essence of beef, milk and bread was directed. Nov. '1-. Reported not so well. Did not sit up on the previous day. Several dejections occurred during the night. The pulse was seventy-two. The countenance was more dull. Treatment opium, grs. iii, and the sulphate of quinia, grs. v, three times. Nov. 23. The patient reported better, and the aspect was brighter. One dejection only. Pulse seventy-six. The 1861.] Typhoid F\ 723 patient sat up a portion of the previous day. Treatment continued. Nov. 24th. The patient remained the same. Opium, grains iii, and the sulphate of quinia, grains vii, were pre- scribed. Nov. 25th. The patient Bitting up a little daily ; the mind clear: slight diarrhoea ; no febrile movement. Treat- ment continued. Under this date I have noted in the record of the ease the following remark: "The remedies have appeared to exert some controlling influence over the disease in this case, as shown by the change for the worse on the 22d, when the remedies had been withdrawn tor a day, and the improve- ment when the remedies were resumed." Nov. i!ijth. Xo material change. The treatment was continued. Nov. 27th. Patient dressed and sitting up. Reported much better. The opium ami quinia were suspended on this date, and a drachm of the compound tincture of cin- chona, three times, was prescribed. . B. Xo medicine and full diet. Dec. 2. The patient reported well enough to leave the hospital, and was discharged. Dating from the time when this patient took to the bed, and com _ convalescence as distinctly existing when the medicine was discontinued and full diet allowed, the duration of the disc; fourteen days. The disease was not cut short, hut it i- to he remarked that the amount of quinia prescribed fell considerably short of that given by those who claim for this remedy an abortive efficacy in ty- phoid fever. The question m the case is whether the disease was short- 1 or modified by the treatment. I am not prepared to :vc answer to th tion, for, undoubtedly, . typhoid fever in which the disease U mild and shorter in duration than in this case. But, as d in the note which has been quoted, the change for the wore when the treatment i 'tided for a day, and the immediate improvement when it was resumed, render it probable that some controlling influence was ex< rted. i. we may be permitted to conclude that the opium and quinia given in the case did not exert an unfav t}|(. progress of the dise: No. -J 1 -ball read from my records, as it will not occupy much time. 724 Typhoid Fever. [September, James Ellis, aged seventeen, admitted January 17th, was first seen by me on the morning of the 18th, and the record is commenced on the 20th. lie stated that he had resided in this city since August last ; that he had been ill for eight or ten days, but took to the bed only two days before his admission. His ailments before admission were cephalagia, loss of appetite and nausea, moderate diarrhoea and pain imthe abdomen, lassi- tude and debility. Epistaxis occurred on the day after his admission. The symptoms on the 18th were, moderate fe- brile movement, capillary congestion of the face, moderate diarrhoea, tenderness over the abdomen and resonance without distension, want of appetite, thirst and debility. The treatment on the 18th was Dover's powders, grs. v. and the sulphate of quinia, grs. v. three times. On the 19th his condition was about the same. ~No eruption was discoverable. The pulse was one hundred and four. The treatment on this day was, opium, grs. ii, and the sulphate of quinia, grs. x, twice. On the day of the first record (20th) I learned that he had been delirious during the night, talking incoherently, and getting out of bed, saying that he wished to go home. At the time of my visit in the morning, he seemed rational. At the present time (2 p. m.) he lies dozing, and frequently talking incoherently. He is readily aroused and replies to questions promptly and rationally. The abdomen is reso- nant and moderately distended. Tenderness in the iliac region, and over the abdomen generally continues. He relapses into a dozing state immediately after being aroused, and begins to mutter. The skin is warm and dry. The pulse is one hundred and four, and the respirations twenty- four. There is no eruption. Physical exploration of the chest yields a negative result. This morning I prescribed opium, grs. ii, and the sul- phate of quinia, grs. x, three times, with half an ounce of wine every four hours, and sustaining diet. Jan. 21. He has passed a quiet night, without muttering or any manifestations of delirium, He states that he has had a little buzzing in the ears. The pulse is ninety-six; respirations twenty-four. Diarrhoea continues with abdomi- nal tenderness. He continues to dose most of the time, but asily aroused. Treatment opium, grs. iii, and the sul- phate of quinia, grs. x, three times, with wine and diet as before. II.] 7 rpkoid F Jan. 22. The /aspect m much brighter. Some muttering during the night, but no other manifestation a of delirium. The pulse is eighty-four; the respiration- are twenty. Abdomen not dsitended, and the tenderness is Blight diarrhoBa. To-day no medicine is prescribed, but wine and diet re. Jan. 23. Aspect bright Pulse seventy-six ; respirations twenty. Slight abdominal tenderness. He seems to be dis- tinctly convalescent. Xo medicine. Jan. 24. Continues bright. Pulse seventy-two ; respira- tions twenty. Xo diarrhoea and no abdominal tender nor distension. lie has appetite, but complains of o sional vomiting after taking food, for which a scruple of the sub-nitrate of bismuth, three times, was prescribed. Jan. 25. Reports perfectly well, excepting want of his usual strength. Tli3 bismuth has been discontinued. Jan. 30. The patient reported well enough to leave the hospital and was discharged. In this case, gentlemen, we have the career of the fever ending on the eighth day, dating from the time of taking to the bed. The diagnostic characters of typhoid fever, ex- clusive of the eruption, were well marked. Xow, it is un- deniable that this disease sometimes ends, of its own ac- cord, with as brief a career as eight days, and I am not prepared to affirm positively that the quinia and opium con- tributed to the short duration. That these remedies exerted a controlling influence, however, I cannot but con probable. Admitting the need of an accumulation of ca-es before a more positive opinion is admissible, the case shows, to say the least, that there is no hazard in repeating e Intal observations of this kind. Case Xo. 4 is also brief, and the reading of the notes will not occupy much time. It is proper to state that the greater portion of this case was made by Mr. Profilet, the hi student assigned to my wards. Robert Pricely, aged 19, was admitted February 1" and the record is commenced on the 10th. If that he was il! four days before his admission and confined to the bed three day-. lie has now diarrhsea, which has existed from the commencement of his illness, The abdomen is tympanitic, and tenderness in the iliac region is 726 Typhoid Fever. [September, marked. The mind is dull. The tongue is dry. The face is congested. The pulse is one hundred. On exploration of the chest, dullness on percussion, broncho-vesicular respiration and bronchophonic voice are found over a small space of the upper portion of the poste- rior lobe of the right lung. Treatment opium, grs. iv. three times. Feb. 17. He reports better. Pulse eighty. All the symptoms are improved. The physical signs of solidifica- tion continue within the circumscribed space in which they existed yesterday. Treatment continued. Feb. 18. The patient's mind is still sluggish ; he answers questions coherently, but after considerable hesitation. He is now sweating profuselv. Pulse sixty ; respirations twelve. The abdomen is still somewhat tympanitic, and tenderness in the iliac region continues, but is diminished. Six sore spots, with all the characters of the typhoid erup- tion, are counted upon the abdomen and chest. The solidification of lung has not extended, and the signs show that its degree is less. Treatment continued, with an ounce of brandy three times and sustaining diet. Feb. 19. Improvement is manifest. Pulse fifty-six ; respiration twelve. The eruption has disappeared. Xo diarrhoea. The mind is bright. No extension of the pneumonia, and the solidification is diappearing. Treatment the opium is discontinued;, the brandy continued and diet as before. Feb. 20. Convalescence continues and the patient de- sires to sit up. Feb. 25. The patient reported well enough to leave the hospital and was discharged. The career of the fever ended in this case on the seventh day from the time of taking to the bed, the treatment con- sisting of twelve grains of opium per day,- and this treat- ment continued for three days. The diagnostic characters of typhoid fever wore marked, and one day the character- istic eruption was observed. Did the disease end from an intrinsic limitation, or was it arrested by opium. In answer to this question, I have only to repeat the remarks which were made in connection with the preceding case. The last case is interesting from the existence of pneu- monia as a complication, which, like the fever, seemed to be arrested, not extending over the lobe, and rapidly disap- pearing. 1861.] Perineal Section. 7:27 We have thus, gentlemen^ reviewed our experienc the management of tpphoid fever during the past winter. Throe out of four cases have recovered. In the fatal i no abortive measures were employed. In one of the re- mainiog three cases opium and quinia were given in pretty full doses. The duration was fourteen days, and the dis- was extremely mild. In the second of these three cases the abortive treatment was commenced on the sixth day of the disease, dating from the time of taking to the bed ; in the second and third of the cases the treatment was commenced on the fifth day. In the first case the duration of the disease was eight days after the treatment with quinia and opium was commenced ; in the second case the disease continued for three .days after the treatment with quinia and opium was commenced, and in the third case the disease ended on the second day after opium was prescribed in large doses. These three cases, considered alone, are not of great value ; hut they are valuable in encouraging* experimental researches in the same direction, and as a small contribu- tion towards the stock of recorded facts, by means of which it is to be determined whether typhoid fever be amenable to abortive measures of treatment. N. 0. Med. Times. On Perineal Section. By J. Mason Warren, M. D. one of the Surgeons to the Massachusetts General Hospital. The distinguished surgeon, Mr. Syme, of Edinboro, lias of late years brought more particularly to the notice of the profession the incision of the urethra in the perineum for the purpose of relieving strictures of a had character. Some confusion seems to exist as to the cases for which this operation is more particularly applicable. So far as we can understand Mr. Syme, his operation appears to he directed to tbos< which are permeable to the instrument, yet ritable and intractable as to he a permanent Bburee of irritation to the patient. Mr. Syme considers that every stricture, with patience, is capable of being penetrated. Other gentlemen, and particularly Mr. Bryant, in an excel- lent paper in Guy's Hospital Reports, think there are certain 728 Perineal Section. [September? cases of stricture admitted to exist by most surgeons which no patience will overcome, and which the use of the knife alone will remedy. In these he advises that an instru- ment should be introduced into the urethra as far as allowed by the obstruction ; the finger of the left hand is then introduced into the rectum as a guide to the prostate or neck of the bladder. The integuments now being divi- ded, the knife is introduced with its back towards the rec- tum so as to strike the urethra in front of the prostate, and a cut is made forwards till it meets the instrument in the urethra. Mr. Bryant after mentioning the different forms of stric- ture requiring this operation, rejects that in which with retention of urine the urethra is impermeable to an instru- ment for which case he advises as the only proper operation the puncture of the bladder through the rectum. Without entering upon a discussion as to the merits of the operation we would simply state, that in our experience this is the very case whfch most frequently calls for the active inter- ference of of the surgeon ; and there seems to be no good reason, if the history indicate a callous and incurable stric- ture as the cause of the retention, why the operation should not be so extended as to divide the stricture at the same time, and give the patient a chance of permanent instead of temporary relief. In order to illustrate this subject and bring it more fully before the profession I propose by the exhibition of two or three cases, to show the advantage of the operation in these extreme cases which we are so often obliged to deal with ; as it is well known that in permeable strictures, to which Mr. Syme's operation would be applicable, the patient, so long as he could obtain relief otherwise, would be unlikely to submit to a cutting operation. One of these is a casein point with those mentioned by Mr. Bryant, viz: a case of organic stricture of long standing gradually diminishing the calibre of the urethra, and finally terminating in complete retention. In this case, it will be perceived, that instead of puncturing the bladder through the rectum, as would have been the practice of Mr."l>. the urethra was cut down upon in the perineum, opened near the neck of the bladder, and then the whole portion of the strictured urethra divided ; and a large instrument being introduced the urethra was moulded upon it until a complete cure was produced. The other two cases are those in which the operationof Mr. Syme 1861;] Perineal Section. 729 must have been rejected ; as, after much patient treatment in one of them, no instrument could be made to enter the bladder, and in the other, although for a time an instru- ment could pass through the stricture, ultimately this be- came impracticable, and the patient's life was gradually being exhausted by pain, confinement, and the irritation and discharge from the numerous fistulous openings in the scrotum and perineum. To Mr. Symc undoubtedly belongs the credit of having fully brought this subject before the profession, and shown the great relief that might be ex- tended to a class of cases allowed to linger on in torment through many years. In his very valuable paper Mr. Bryant has indicated yet other cases, a class to which the attention of hospital sur- geons is much more likely to be called, and of which the preceding are an illustration. We take the liberty of copy- ing Mr. Bryant's conclusions, to which we fully agree, with the exception of the first, upon which we have commented above. " Conclusions. 1. In uncomplicated retention of urine from organic stricture, the operation of opening the urethra in the perineum is not required, the more simple and safe one of puncturing the bladder through the rectum being preferable. 2. When complicated from extravasation of urine from an}* cause it should be performed at once, and the stricture when present divided if possible. 3. In laceration of the urethra from injury, when a ca- theter cannot be passed, the urethra should be opened. 4. And also when the above injury is associated with pel- vic mischief. 5. Strictures are occosionally met with which arc imper- meable, and urethras which are obliterated. 6. That in cases of organic stricture, when the passage of a catheter is possible and not difficult ; where it does not produce either any injurious, or painful constitutional or local disturbance, and where, after dilatation of the stricture an occasional passage only of the instrument is required to maintain an open channel, no other surgical means can be called for. 7. T! of stricture do occur occasionally, which o exquisitely sensitive, and in which the | of a heter, however skillfully performed, is followed by such ere constitutional and local disturbance as to produce 730 Perineal Section. [September, more harm than good ; and others, which are relieved by means of a catheter, and are even fully dilated, but which have a tendency to contract immediately upon the omis- sion of the treatment; in such cases the operation of "ex- terna] division" is most valuable. 8. That the majority of cases of what are called imper- meable strictures may be rendered permeable by constitu- tional treatment but that some are undoubtedly impermea- ble; in such cases the operation "perineal section " is of value. 9. When the urethra is obliterated the operation of "pe- rineal section" may occasionally be demanded, particularly when associated with perineal fistula. 10. That the worst and most intractable forms of stric- ture are the result of injury, and in those cases the opera- tion either of "external division," or "perineal section," is of great value. 11. That in boys the operation is not so successful as in adults, although no better can be suggested." Case 1. Organic Stricture of the Urethra of Ten Years' Standing; The Urine finally passed in Drops ; Retention; Pe- rineal Section ; Division of the Stricture ; Complete Recovery. A. L. Foydt, about 30 years of age, entered the Hospital on April 30, 1860, with a stricture of the urethra of ten years' duration. The water, when he entered, passed in a very small stream, and urine was constantly dribbling away from him during the night accompanied with a purulent dis- charge. He complained of pain in the renal region, though not of a severe character. After very careful attempts to pass a bougie of the smallest description, it was finally de- cided to attempt to cut the stricture from within, which was done from a canula with a concealed blade, on May 15, and which, although it cut but partially through the stricture, seemed to afford him temporary relief. On May 26, the urine became less free ; there was consi- derable dulness in the pubic region, and the patient com- plained of pain about the bladder, with general uneasiness. I had already made up my mind to perform the perineal section in this case, and ordered the preparations for the operation to be made for the following day. On visiting him the next day, 1 found he had a complete retention of urine, and therefore proceeded at once to the operation. The patient was placed on a table, on his back, :i I 1861.]- 'ncal Section. 7-U and after being thoroughly etherized, so that his joints v. \illy relaxed, he was tied as in the operation for lithotomy, ~ lave found it much better to confine the limbs in this way than to intrust them to the care ot assistants, who are apt to be worn out during an operation so likely to be long and tedious. A small staff was introduced, and it seemed to penetrate the first stricture, which as stated above, had been noised about a couple of weeks before, and brought up against a second stricture, apparently just behind the scro- tum. The forefinger of the left hand was now introduced the rectum, and the situation of the prostate ascer- d. The perineum was then divided, and a careful dis- >n made, to ascertain the site of the urethra. This rendered very tedious from the constant discharge of d at the bottom of the deep wound from the bulb of the urethra, which in tills ease was more than ordinarily troublesome. The urethra, however, was finally opened directly in front of the prostate, and a gum clastic catheter Dassed into the bladder; giving exit to a very large collec- [on of urine. The canal was u/nv opened forwards, and the callosities freely divided, until the staff was reached. A s mi-elastic catheter was now passed downwards ugh the penis until it appeared in the wound ; and the ivory end of the first having been cut off, the point of the second was insinuated into it and firmly fixed. In this manner it was dragged up through the whole extent of the urethra, It might be here mentioned, as a hint for finding the urethra, which I have before practiced upon, without the -tail* for a guide, and where other means have failed, to was done in the present case viz, allowing the pa- tient partially to recover from the ether, stimulate him to make an effort to urinate, and when the urethra behind the stricture became dilated, a minute stream of urine indicating the spot for the introduction of the probe, and the urethra was found. Xo unpleasant symptoms followed the operation. On the next day the patient expressed him- elfin great comfort, more so than he had experienced for many year.-. The sense of fulness, arising from probable disi -f the bladder, ureters and pelves of the kid] having entirely passed away. At the end af a week the firv ! at once replaced by an- other which had been piepared the day ame and curve. The catheter was found to have been par- tially acted upon by the urine, and its calibre hat obstructed. 732 Perineal Section. [September. At the end of a month the patient was able to introduce the instrument himself; and at the end of two months, tin wound in the perineum having nearly healed, he kept it up> at night, leaving it out during- the da}T. He shortly after left the hospital, well, with the exceptioi of a small aperture not larger than a pin hole, and soim weeks subsequently presented himself there on the eve ojf a voyage to the sea. I n Case II. Stricture of the Urethra of Twenty-five Year&fi} Duration ; numerous ZJrinaay Fistulas in the Scrotum am Perineum ; Perineal Section ; Cure. E. O. B., shipmaster entered the Massachusetts General Hospital on April 24 lei 1860, and gave the following history ot himself. He ha< suffered from gonorrhoea twenty-five years previously, an was treated by his captains at sea by strong injections The gonorrhoea terminated in gleet, which was treated b bougies for two years, when it was increased on account c s increased obstruction. He then remained pretty well unt pv eight years since, when tle stricture became so tight as t U give him a great deal of inconvenience, for which he entei od ed the hospital, under my care, and the stricture ws )\ divided by internal incision. This relieved the urinar trouble, and for a time he enjoyed gocd health. Two yeai since a fistulous opening appeared in the perineum ; fou months later, another in the scrotum ; five months since third ; through these openings parulent matter with urin was freely discharged. The whole of the scrotum wa tense, indurated and barred by sinuses. Two months pre vious to his admission, a ~No. 1 bougie was passed into th bladder, after much effort; his symptoms have been aggrf vated by it. 1 passed a 'No. 1 bougie down to the stricture, and ke] it applied for two or three hours daily) exerting a gent pressure against the stricture. After treatment for about week in this way, the stricture gave way, and the instn ment passed into the bladder. On May 1, I made an incision into one of the scrotal opei ings, and gave vent to a quantity of purulent matter, mixe with urine. Notwithstanding the passage of the bougu the symptoms of trouble about the scrotum increased, an towards the 1st of June, the stricture having again closec so that it was quite impossible to pass any instrument, th operation was done, at his request, on June 4. 161.] Perineal Section. 733 The patient being etherized, and confined in the position or lithotomy, Syme's sound w;> I through one stric- ture and encountered a second. An incision was now nade in the median line of the perineum, and dissection performed until the point of the staff was reached. The <3i issues were much hardened, and infiltrated by a deposit, no vhieh greatly opposed the progress of the knife. The flow 0 )f blood from these diseased parts interfered much with the >peration : the perineum also was uncommonly deep. In >rder the better to bring the continuation of the urethra i leyond the stricture into view, the end of the staff was 1 turned out through the incision, and served to hook up and [i ;hus bring the deeper parts more fully in sight. The wound i Iteing freely sponged with iced water, a puncture was made il jito the supposed urethra, in the neighborhood of the neck B)f the bladder, which allowed the passage of a probe into >ai ;hat organ; and the urine having escaped, showing it had b jone in the right direction, a large gum elastic catheter '( vas substituted for the probe, A sharp-pointed knife was it low passed up by the side of a small Syme's sound, and the I irst stricture, which lay behind the middle of the scrotum, I ind which would not allow anything larger than the sound ;i to pass, freely divided. i A second gum- elastic catheter was now introduced }] through the glans and urethra, insinuated into the mouth of the first, which remained in the bladder, and was thus drawn upwards as in the former case. Xo great constitutional irritation followed the operation, and the patient on the following day described the comfort of. freeing the bladder by a large stream, after having suf- fered for so many years in his efforts to do so, as beyond relief. The first bougie was left in place a week, then be- coming obstructed, it was replaced by another, and this was done weekly through the course of the treatment. The wound in the perineum, on account of the diseased state of was very slow in healing, and the patient re- mained in the hospital for two months afterwards. A communication was received from him in Nov. 1SG0, hich he states that he was well. , I E. Traumatic Stri im of the I V. thr . G. U.,3Gyear80 r, came into the ital under my care in the early part of the spring of .dd that live years before he had been jammed 734 Perineal Section. [September, K leu elii L 1 ( 1 against a wall by the buffer of a freight car with such force as to produce a rupture of the urethra He remained in a critical situation for a time, and had never since been able to pass his water, except in a very small stream. Two years previous to his admission, a fistula appeared near the tuber ischii of the left side, between that and the rectum. ] lis water has passed by drops through this fistula, and f another in the rectum, ever since. Various attempts have been made to perforate the stricture, but all of them without avail. On examination by the rectum I found that the bladder, intestine and surrounding parts were glued together and involved in an indurated mass, und the calibre of the in- testine was very much diminished. A probe being intro- duced into the fistula by the side of the rectum, passed up by the side of the gut through these indurated tissues, and apparently entered the interior of the bladder. Having made very careful attempts for a time to get through the stricture by gentle means, I finally advised him, unless willing to have the perineal section performed, to desist from any further efforts, for fear of producing irritation and complete retention, especially as he did not suffer much from his disease. In June, having heard of the success of two of the above operations, he came back to the hospital for the purpose of \m having one performed upon himself. Operation. A sound was passed down as far as the stric ture, an incision made upon it, and its point reached deep in the perineum. ~No traces of the urethra beyond could be discovered by the most careful manipulation. He was, therefore, allowed to recover partially from the effects of the ether, and to make an effort to void his urine. An in- cision was now made in the direction of the neck of the bladder, and a female catheter introduced as a guide, which was replaced by a ISTo. 8 elastic catheter. The parts were very vascular, and the steps of the operation, which lasted over an hour, much obscured by blood. jSTot the slightest unfavorable symptom followed ; but at the end of the week, when it was necessary to replace the catheter, it was found to be a matter of much difficulty to do so, the end of the instrument escaping into the rectum. This was, however, finally effected both at that time, and afterwards, bp hooking the beak of the instrument against the pubes, and then, instead of trying to force it forwards, ill! 1861.] Nvy 735 the handle was suddenly depressed, and it slipped into the gladder. Carried forwards in the ordinary way, it always went into the rectum. On the 27th, it was recorded that all the urine was dis- charged by the catheter, although there was purulent dis- charge through the fistulous opening near the rectum, and occasionally from the rectum itself. The patient remained in the hospital rather more than two mdhths, when he left, and has since been seen well. Am. Jour. Med. Sciences. A Paper 0/1 the Treatment of Constitutional Syphilis by repeated Inoculation* with the virus of Chancres, Bead before the German Medical Society of Paris, by Dr. Mansuroff, of Moscow. Syphilization, instituted by Auzias-Turenne, proposed by him in the first stage as a prophylactic means for syphilis, and applied to the tteatment of constitutional syphilis first by M. Sperino, and then by MM. Boeck, Sigmund, Stein- berg. Danielsen, Hebra and others, is a great fact, whose importance has attracted the attention of the learned world; but in the present state of science, ought this discovery to idopted ? or, ought it to be rejected even as a method of treatment for constitutional syphilis ':' This is an impor- tant question for science and humanity, which will be very soon settled in a definite manner by the learned of all coun- . The large number of cases which have been carefully studied for several years at Turin, Christiana, Stockholm, ma, Berguen, Pesth and elsewhere, the scientific au- thority and the well known honorable positioirof the phy- sicians who have studied this question, and the attention which I have given it for five months at Vienna and eleven months at Turin, authorize me to give in this paper a short ; int of my convictions and my observations, which will I some time hence in an extended work, and Which, I will say in advance, will be favorable to syphiliza- tion as a curative method for constitutional syphilis. 1. MM. Sperino and Boeck, who have observed and pub- it number of cases, have established the three following propositions: (".) The repeated inoculation of 736 Syphilis. [September, chancroufl virus produces immunity ; (b.) The symptoms of constitutional syphilis disappear under the influence of the inoculation ; (c.) Syphilization acts in a beneficial manner on the health of the patients. These three propositions form the basis of syphilization; and a certain number of observed cases have convinced me that they cannot be .con- tested whenever syphilization has been practiced regularly. Thus, I have seen that in general after twenty or thirty days the symptoms of constitutional syphilis began to dis- appear; and that after two, three, or four months, and rare- ly more, the cure of the patient takes place. The time varies according to the individuals, the gravity of the dis- ease, and the previous mercurial treatment which they have submitted to, etc. 2. As to syphilization as a prophylactic means in a healthy man, it has never been practiced by MM. Sperino and Boeck ; and since the year 1852, it has even been abandoned by M. Auzias-Turenne, who practiced it in some cases affected with chancres. The absolute immuni- ty procured by the inoculations is, besides, very transient. After some years, and even in some exceptional cases, after some months, the patient loses in part this immunity, al- though the cure of the constitutional syphilis continues ; and the relapses, or rather the cases of incomplete cure, have been cured easily by a small number of new inocula- tions, although these individuals are with difficulty inocu- lated. Consequently, if time proves that syphilization pre- vents the relapse of constitutional syphilis, as my observa- tions lead me to hope, it is easy to foresee the future of this new treatment. 3. If after some inoculations we interrupt the treatment for several days, wre see new syphilitic accidents supervene, or those which already exist to become aggravated ; but both disappear very soon, if we resume the inoculations and repeat tmSm until immunity is established. The pro- duction of chancre being the essential condition of syphili- zation, we may favor its evolution in mercurialized persons by a small dose of iodide of potas., which, however, may be replaced by other means. 4. Before and during the treatment, we must remove all causes susceptible of producing an inflammatory complica- tion. If these supervene, the artificial chancres may be- come inflamed and assume a certain gravity, especially with persona who have already been treated with mercurials. 1861.] SypkUis. HI Hence it is sometimes necessary to give a purgative, some baths ami mucilaginous drinks before or during the syphiliza- tion. jervation has demonstrated that the more recent and the oldest forms of constitutional syphilis may be cured by syphilization. Among these forms I can count several c; of affection of the bones of the cranium and extremities, affections of the nails and cellular tissue, etc. In these grave cases, when the organism presents but a feeble reaction to the inoculations, ye employ sometimes the iodide of potas., which we know is a go>tl remedy in mercurialism, and favors the development of the inoculated ulcers. In less grave cases the syphilid?-?, for example the effect of the iodide potas. was ineffective or injurious, because it favored the explosion of affections of the skin. 6. From all the facts known at the present time, it results that the relapses after syphilization do not exceed five in one hundred, whilst the relapses after the mercurial treatment have been observed in one-third or one-half of the patients (Boeck. The relapses after syphilization ordinarily present themselves in light forms, which are cured in a very short time by some inoculations. 7. The age and sex of the patients do not constitute any coutra-indication for the treatment of constitutional syphilis by means of inoculation. Prof. Boeck cured children of eight weeks as well as old persons of sixty-seven years of age. The experiments of Prof. Sperino were made almost exclu- sively on women, and demonstrate that the uterine functions were not disturbed by the treatment. On the contrary, with the improvement of the general condition the patients were cured of the syphilitic anaemia and of amenorrhcea. As to children affected with hereditary syphilis, they died often in spite of the syphilization and every other treatment (Boeck). 8. The health of the patients, improved during the treat- ment, continued after the cure, which encouraged MM. Spe- rino and Boeck to continue their studies. The patients are neither exposed to the dangers of mercurial or iodic intoxica- tion, nor to their consequences ; they do not carry mercury in their bodies or viscera (luring four months, or even longer, after the treatment (Gorup-Bezanez, Michaelis, Schroder van der Kolk, Kletzinsky, etc. 9. It is only the practical study which can convince a 'urative value. It is also the general opinion of the cele- brated Professors MM. Oppolzer, Hebra and Sigmund, that hilization ought to be studied practically before judging 47 i 738 Syphilis. [September, of its therapeutical value, and its applicability to the different itituticmal syphilis. Besides the opinions emitted id Italy on syphilization, we have read also the 5, more or less differing, of MM. Behrend, Huron, Yon prang, Michaelis, Simon, Sigrnund, Uerrman, Kalis* cher, and others ; we have also read the classical works of the >cck and Sperino. These works, and the r of cases observed clinically in the hospitals of Turin and Vienna, as also in the private practice of M. Speri- no. have afforded me advantages to study Syphilization, and to form a decided opinion of this new method of treatment. And when we think that there are physicians who never em- mercury, and apply syphilization at all times when they judge it necessary (MM. Boeck, at Christiana, Baumann, at Lillehammel and Wildagen, at Drammen), we can conceive then that this treatment has solid basis, although its practical importance has not yet undergone all the improvements of which it is susceptible. 10. It is useless to say that syphilization has inaugurated a reform in syphilology. and that this reform has been accom- plished by the study of pathological physiology. '-Syphiliza- tion proves to us by evidence/' says Michaelis (Compend. en, 1859, p. 345) "that syphilis is a disease which is cured alone by the powers of nature ; and if the physician succeeds in transforming the chronic syphilitic affection into an acute i; hematic affection, Byphilization becomes a benefit to the patient ; for it places him in the way of a natural cure (natur- heibung). and spares him any depressing treatment whatever." * words were written by a learned man who defends mercury, and who judges severely syphilization after having d it with success. His opinion differs, then, from the in- dulgent opinions of the recent anti-mercurialists. As the results and the facts of these observations cannot be I a -mere detailed manner in this paper, I will con- seli to name only the programme which I will follow later in ii iption. I will describe the methods of syphi- fche indications and the contra-indications, its process, the local effects of indurated chancrous inoculations, non-indu- s (or pustules), abortive, negative inoculations, the immunity, the effects of syphilization on the organism at- ihilis, but not suffering from concomitant dis- . m chancre bubo, and the Byphiiization ; upon nutrition, ] [ien will tbliow the effects of constitutional syphilis on the I ed with syphilis, and suffering from acci- ases as fevers, catarrh, rheumatism, anaemia* 1861.] nabis Indira. 739 mereurialism, etc. I believe that the study of syphilization, in all its aspects, being made at the bedside of the patient, is Ined much sooner to throw a light on its practical bear- ings as a method of treatment As it is supported now by numerous facts which prove its power of curing constitutional syphilis, even in its grave forms, 1 feel myself authorized to say, with M. Herrman, that the period of experiment is passed, and that it is no longer a question of judging from a large number of facts, but from a small number well observed. Hehdomadaire. Cincinnati Lancet cf' Observer. On the Action of Cannabis Indica. On the action of the Cannabis Indica, (Indian Hemp,) Dr. Charles A. Lee uses the folio wins.1: language in the Journal of Materia Medica. -The action of hemp on man is so various that when we oral descriptions given, (littering so widely, we viv considering the same agent; but it is, perhaps, no less remarkable than the every day exhibitions we witness of alcohol, with which, being more familiar, we give less attention. The great variety of phe- nomena presented in the use of the latter, according to the natural disposition or temperament of the person, and the lition of the mind, as well as to the quantity, alternately clew depressing in its effect, or producing the ex- treme of kind or brutal emotions, can, to a certain extent, be observed in the other. The mental phenomenon upon a subject possessing an aginative faculty in a high degree, when fully developed One writer de- ows: 'When it first begins to act, the ef- chisch may be considerably diminished, or becked by a firm exertion of the will. By de- the power of controlling at will and direet- the thoughts diminishes, till finally all power of fixing . and the mind b the sport of ev- ery idea which arises within itself or is forced upon it from 740 ( armabis Indica. [September without. "We become the sport of impressions of every kind. The course of our ideas may be broken by the slightest cause. We are turned, so to speak, 1)}' every wind. By a word or a gesture our thoughts may be successfully directed to a multitude of different subjects with a rapidity and lucidity which are truly marvelous. The mind becomes possessed with a feeling of pride corresponding to the ex- altation of its faculties, which it is conscious it had increas- ed in energy and power. The slightest impulse carries it along. " The errors of perception in regard to time and place, to which the person is liable during the period of fantasia, are remarkable. Minutes seem hours and hours are pro- longed into years, till at last all idea of time seems oblitera- ted, and the past and present are confounded together. "M. Aubert describes the influence upon him in the fol- lowing language : 'I was engaged in conversation when I felt a prickling sensation in my feet, and in my head a stricture which gave way suddenly and my skull seemed empty. Every object wore a new aspect ; my companion's face assumed a grotesque expression ; I burst out laughing and continued to laugh for almost an hour. The merest trifle renewed my mirth. Meanwhile the most varied and whimsical ideas coursed swiftly through my mind. I expe- rienced the most perfect sense of comfort. For me there was no longer past, present or future ; the fleeting moment limited my whole existence. Then followed a calm, and sleep stole over me. The whole night was but one long, delightful dream. On awaking, I remembered perfectly all that had taken place, and my head was not heavy nor my mouth dry, as it would have been after a debauch in opium or wine.' " Dr. Christian relates the following concerning hemp : 'On trying Mr. Robertson's extract once for toothache, I found that about four grains taken about 3 a. m. caused in an hour cessation of pain, a pleasant numbness of the limbs, giddiness, a rapid succession of unassociatefl ideas, and im- possibility to follow a train of thought, frequent interval of sleep, and slight increase in the force of the pulse. Xext morning there was an ordinary appetite, much torpidity, and shortness of memory, extreme apparent; protraction of time, but no peculiarity of articulation or other effect ; and these Bymptoms lasted until 2 P. M. when they ceased entirely in a lew minutes alter taking lemon- 1.] nabislnd 741 ade. On anotb ion I took one grain of the extract olved in spirit. I felt a peculiar numbness creeping through my body and limbs. On lying down the numb- continued but in fifteen minutes my sensations became eable. J laughed heartily several times, answered is incoherently, and immediately forgot what they about and what I bad answered. Delightful reveries came over me, and whatever I looked at became lost, as it wore, in amaze; the lamp appeared to be slowly turning round, and when I lost eight of this the red lines on the paper of the room appeared to intertwine in a most beauti- ful manner. The most remarkable effect was the constant succession of new ideas, each of which was almost instantly 2 >tten. When roused to tea I ate ravenously without feeling satisfied. I slept soundly at night, afterwards, and the night day was stupid and forgetful, but was much im- proved by drinking lemon juice. * * * * " Dr. O'Shaughnessy describes a singular form of insan- ity occasioned by an incautious use of the hemp, and which - singular as the delirium tremens by the prolonged use 3pirituous liquors. He says it is at once recognised by balancing gait of the patient, a constant rub- the bands, perpetual giggling, and a propensity to rid chafe the feet of all bystanders, of whatever :. The re an expression of cunning and mer- riment which can scarcely be mistaken. In a few cases the patients are violent; in many highly aphrodistie. in all that n voraciously hungry: there is no increased l circulation, or any appearance of inflamma- tion 'ii. and the skin ami general functions are in ; "Dr. Hooke in hi-; paper upon Indian hemp in 16*89, no- 3 the various odd tricks shown by persons while under influence of this plant, and says that when this condi- 3 the patient finds himself mightily refreshed and exceedingly hungry. - pain, and may be employed Mr. Donovan found that under its influ- >uch and feeling gradually became ob- . until al length he !<>-t all i tnlesa he pinched his ly. ataleptic condition, in whic are moderately contracted, but flexible the limbs retain any position or attitude 742 Cannabis Indica. [September, in which they may he placed. Dr. O'Shaugnessy gives an interesting case of this kind. " It does not appear to affect the secretions mnch. The testimony is strongly in favor of its increasing the appetite and very little that it causes nausea. It neither causes dry- ness of the tongue nor constipation of the bowels; and its effect upon the bronchial secretions is beneficial than other- wise. "Its habitual use is said, by Di. Stille, to produce conse- quences no less mischievous than are produced by alcohol, and opium ; the face becomes bloated, the eyes injected, the limbs weak and tremulous, the mind sinks into a state of imbecility, and death by marasmus is the ultimate pen- alty for the overstrained pleasure it imparts. We are not acquainted with any case of death directly resulting from the poisonous action of cannabis ; but several are recorded which illustrate its effects in excessive doses. u We shall now consider as briefly as possible the disea- ses for which it has been employed, under their several heads. " Tetanus. Dr. Christian states that Dr. O'Shaughnessy treated several cases of tetanus with apparent success. In one, ascribed to cauterization of the hand by a quack mix- ture of incandescent charcoal and tobacco, a state of in- toxication was excited by large doses of the extract of hemp, and the spasms were gradually put an end to ; but death ensued in the end from mortification of the hand. Another patient consumed one hundred and thirty-four graius of the extract, and was ultimately discharged from the hospital cured. A third case with similar results is detail eel. At the Native Hospital in Calcutta, Mr. O'Brien treated seven cases of tetanus, and in four of them he em- ployed ten grain doses. The result wa3 almost immediate relaxation of the muscles, and interruption of the convul- sive tendency. Four of these cases recovered. A case in the practice of Mr. Richard O'Shaughnessy is also detailed, where the disease was connected with suppurating wounds of the scrotum. The hemp had no effect for four days, and then the patient became tranquil, with fewer paroxysms and the appetite good. When the hemp was intermitted the symptoms became aggravated : latterly the hemp caused much excitement and was therefore discontinued. The last is one of infantile convulsions, where very large doses were given, and where the narcotic action greatly relieved 1861.] 743 ms. The child recovered. This gentlemai confident that the rosin rig the | of te - in a lar portion or" eases, it will cure the disease. It would certainly app hat In- dian hemp has : >f service in the treatment of t nn8, as it India. How far tl ined in Europe I shall now describe. That I may not extend my observations to too gre limit my remarks to the treatm in private practice, and in the loyal Infirmary. Pj Miller hi Med me with the following marl "My own experience speaks loudly in favor of the hemp. I can now record three fortunate cases under its use all traumatic tetanus and a case which proved fatal, but where great alleviation of &u was produced. " The first of these was a girl, even, admitted to the Royal Infirmary, Oct. IE SShe had received an extensive injury of the mid er of the right hand a . Infko yelling a be- a tendency to lex- ion of the fi] e to tak< becoming : in the j ieit she ell. A "brisk pi, L, and lest the re tetanus tincture of hemp v taken every four hours. Next d ptoms ^ ! marked without any influent hemp. The : died to the wound. The dose of hemp \va- creased to twenty drops, and after five <: hut the following day the symptoms were aggravated, lurpen- ordered and ice to the spine thin of cam ahis to b hourly. In tha the hemp to be givou . Aconite eke became mor er, the d lually re< 744 Cannabis Indica. [September, drowsiness or calm sleep ; it was soon discontinued, as it then seemed to excite the circulation. Throughout the whole period of its use, its effect was most obvious, the craving for food being at times absolutely voracious. After this no more medicine was given and recovery was complete. " The second case, occurring in private practice was that of a boy, about the same age, who had simple fracture of the thigh, with compound and comminuted fracture of the great toe. The treatment and result were the same. The third was a boy rather old, who had compound frac- ture of the bones of the arm. Treatment again resulted in cure. In these cases a few doses generally induced sleep, with marked mitigation of the spasms. The period of narcot- ism did not exceed two or three hours, the sleep was deep, and unbroken, and seemed to be refreshing. It was fol- lowed by no headache, or other apparent inconvenience. The most remarkable effect observed was the tolerance of the remedy, whereby a girl, aged seven, took every half hour, and sometimes many hours in succession, doses of hemp sufficient to narcotise an adult. " In these cases Mr. Miller is inclined to give the hemp credit for a chief share in the cure. In 1846 the virtues of hemp were tested in a case of tet- anus in the Royal Infirmary, in the wards of Mr. Duncan. In 1847 another case presented itself where hemp was ad- ministered. At that time sulphuric ether was much used as an anaesthetic, and it was thought probable that it would be of service in this case. The patient inhaled it at fre- quent intervals during a whole afternoon, with decided but only temporary relief. After this cannabis was given, without its physiological action being attained by nearly an ounce and a half of the tincture ; it was not persevered with. Ether was again tried, and also opiates with some benefit. The patient died on the thirteenth day. " The first of these cases was very accurately observed, and the following report of the case from the journal will be found to have considerable interest. " James Mackay, a railway laborer, was admitted under the care of Dr. Duncan, October 20, 1846. He had received a slight lacerated wound of the hand a week before, and tetanus had commenced on his admission. The wound ap- peared to be healing. He complained of great uneasiness particularly about the neck and spine, of some rigidity of 1861.] Cannabis Indlea. 745 the jaws, winch could only be separated three quarters of an inch, of inability to protrude the tongue, and of com- mencing spasm of the neck and upper part of the back. He complained also of a burning about the heart. His expression was anxious with but little 'risus.' His thirst was great but swallowing difficult. He perspired profusely. The spasms of short duration, recurred once or twice every minute ; pulse, one hundred and fifteen to one hundred and twenty, soft. Opening medicines were ordered, and at 11 o'clock tincture of hemp was given, repeated in doses of fifteen to twenty drops with appreciable effect. On the 21st the bowels were not opened, though a turpentine ene- ma was administered. The spasms were more violent and general, and a touch caused general spasm. He had not slept. One hundred and twenty to one hundred and forty drops had no effect. The doses were increased to sixty or eighty drops every three quarters of an hour, and croton oil was given producing free action of the bowels, and in the evening the spasms abated, but the hemp caused only slight dozing at intervals. The tincture was ordered to be continued and strong beef tea to be drunk. " On the 22d swallowing was easier, the spasms less vio- lent, but not less frequent ; one hundred drops were given at half past eleven, and continued about every half hour till four o'clock, when drowsiness was quite decided, he was not easily roused, even by the spasms, which though as fre- quent, were not so intense. At nine o'clock drowsiness was passing off; copious stools, colored as by the medicine, were brought away by injection ; one hundred and thirty drops were given, and repeated at midnight, at which time he was much relieved, but suffered from cough. On the 23d the spasms were again gaining strength, no hemp hav- ing been given for nine hours. A drachm of the tincture was given and repeated at eleven, when he became quiet. The doses were continued till evening, when he took mince collops and beef-tea without difficulty, and the bowels were copiously relieved. " On the 24th, at visit, the spasms were absent, but the chest symptoms were worse, with general mucous rale, and frothy sputa mixed with blood. Drowsiness had been kept up by doses of a drachm to a drachm and a half. In the evening he was much weaker, but quite sensible, with a ire for food. On the 25tD he was from spasm, but was evidently dying from accumulation of ma- 74 G Amputation through the Foot [September' ens in the chest. Very little hemp was given. lie died at 8 P. M. "In this case six ounces of O'Shaughnessy's tincture of Indian hemp wore given in all, being equal to one hundred and forty grains of the extract. The extract for the tinct- ure was reputed the best in Edinburgh. The doses at first were evidently too small. The examination of the body was not permitted. "It is a safe conclusion from these facts, that Indian hemp deserves further trial in the tetanus of Europe, as well as in that of hot climates. 1 would particularly urge however the necessity in all such trials of making certain by experiment on healthy persons, that the preparation to be used is good. For the present there is no other satisfac* tory test of quality." Med. Surg. Reporter. Conservative Amputations through the Jhootand Ankle The probability of the occurrence, to military surgeons, of frequent occasions for amputations through the foot and ankle, gives the following appreciation of the operations of Sym and Pirigoii, an importance at this time. The correspondent of the Medical Times and Gazette from Bonn, Switzerland, says, "that Professor Weber has recently given us a statistical comparison of the different amputations which are performed in the neighborhood -of the ankle joint, and which may be of some interest to your readers. The cases brought together have been collected from the German, English and French Hospital Reports. As regards Symc's operation, much preparatory work to this had been done in the valuable work of Professor Gunther, of Leipzig : t Lehre von den Bmtigen Operationen,' (A Treatise on Bloody Opera- tions,^ to which numerous plates are added ; and there is also a well written these on the results of Pirigoff's amputation by Dr. IT. Kestncr, of Strasburg, which appeared in 1857, and in which twenty-tv. i been collected. Altogether,' 216 ;en published. Of these, 3 i were made e above il : mall< bli, LOJ : /me, with ai rior flap, 40 accordii w the astragalus, at by Textor, later by ' me, 21 according to Ohopart. From these returns, it that the amputation, close e the malleoli and Chopart's method give the most favor- 1.] m- ; but, perhaj larger numl ses might give a different result. In the : cases operated upon according to Syme and Pirigoff, death was mostly due to gangrene of the heel having super- vened ; this is still more frequent if the nap is formed from the thin skin at the back of the foot, as is done in Bauden's Operation. In FirigoiFs amputation, the number of cases in whi induced, amounted to 12, in Syme's to in Bauden's to 25 per cent. Independently of this, how- ever, the first mentioned operations yield exceedingly favora- ble results; the stumps are always useful, and there is only case known of Syme's operation in winch t}m stump was rinful as to prevent walking ; and only one case of Piri- "s in which caries recurred, and a subsequent amputation became necessary. In this respect, the results are much more unfavorable in the amputation above the malleoli. The cir- cular incision, even if a large cuff should be formed, is not is the formation of a flap, especially if the made posteriorly and suiiiciently large. The com- :t that a e.'). by Rev. Mr. of Mr. Stone to its value; testimony of Fames White and Wilkin- of by Elaller : testimony of European phy- sicians to the value of Salicin, 48 754 i;i'Ji J'oXes, on the Indigenous [October, Yellow Jessamine, (Gclseminum sempervirins.) Accidental disco- very of its value in malarial fever ; use of in Western States ; testimony of Drs. Cleveland, Nash, J. A, Mayes and others, to its medicinal proper- ties and uses; dose and mode of administration. Milk Weed, or Root of Man, (Asclepias syriaca.) Testimony of Dr. Richard S. Oauthorn, of Richmond, Va., to its value in intermittent fever. Common Salt, (Chloride of Sodium.) Dr. Scclle Montdezert the first to call i he attention of the profession to the value of Chloride of Sodium in the treatment of intermittent fever ; testimony of Dr. W. P. Lattiinorc to the success of M. Piory with common salt in the treat- ment of intermittent fever ; testimony of Drs. Moroschkin and Dr. Hut- chinson ; dose and mode of administration. Sal Ammqniac, (Ilydrochlorate of Ammonia.) Testimony of Dr. Felix Jacquot to its value in intermittent fever. Nitric Acid. Testimony of Drs. George Mendenhall, Bailey, J. C. Thompson, and Dr. William A. Hammond. Arsenic. Testimony, experiments and investigations of Drs. Felix Jacquot upon its relative value in the treatment of malarial fever ; testi- mony of M. Boudin. Ligature oj r the Extremities in 1/an miiient Fever. Testimony of J. PeDrauw and others to the effects ci ligature of the extremities in intermittent fever. Cold Water in tJteTreatment of Malarial Fever. V^e of by Dr. Wright in 1786 : practical rules for its use, by Dr. J. Currie, of Eng- land; testimony of M. Fleury to the value of cold douches in the treat- ment of intermittent fever. WILD IIOEEHOUND1 (EUPATOIUUM EOTUXDI- FOLIUM. Eli.. Botanical Description. Leaves sessile, distinct, deltoid, nearly round, obtusely serrate, veined, somewhat glaucous; scales of the involu- crum acute, Stem two to three feet high, very pubescent. Leaves opposite, decussate, triplinerved, dotted, slightly scabrous, with a some- what glaucous, or perhaps more correctly, hoary hue. Flowers in a fas- tigiate corymb. Involucrum ten leaved, five flowered ; leaves lanceolate, acute, very pubescent. Corolla white. Stamens very short. Style much longer than the Corolla. Seeds angled, Pappus scabrous, longer than the corolla. Decoctions of this, as well as of the preceding species, used with much success as a tonic febrifuge. I have always sus- pected this plant te be the E, Marrbium of Walter. It is commonly known through our low country as the Wild Ilorehound, and its leaves bear more to the Garden Ilorehound, (inarrubiuin vulgare,) than those of an)- other of our species. Grows in dry pine barrens. Flower.- from .July to September. Elliott. Sketch cf Botany of South Carolina and Georgia, vol. 2, p 300. w England to Geor- gia : very abundant in the South examina that I am aware of, has Qver b< eterinihc the chemical constitution of this plant. M This plant has been exten- sively employed in domestic practice, in the treatment of in- termittent fever, colds, and in debilitated states of the system; The medicinal properties of this plant appear to have been first brought prominently to the notice of the profession, by the Honorable G [., President of the Georgia . who thus describes its medical virtues : "It - an excellent substitute for the Peruvian bark, and amoifg the planters in or near the sea-board, it lie bark in the cure of fevers. It is tonic, dial c and mildly cathartic, and does not oppress the the bark is apt to do hence it may often he e.\ hihited where the cinchona is inadmissable. It is usually given .: of infusion : one ounce of the dried lea* d into a quart of water, may he taken daily, in Four ounces every hour or two. It may he ad- van; ; mbined with Peruvian bark, and. thougl may sometimes fail of producing the desired effect, I think the articles of the mate- ria n Dr. Chapman in his Therapeutics, nt'^v quoting the : the President of the Georgia Medical : : "In this sentiment I entire! own prac- tice has not afforded me many opportuniti it, but 1 - tate, ir wj in the cases which have catarrhal a hitter tunic, in ich. [1 lee'H, in apd made ii nip or candy/' p 437. 756 Joseph Jones, on the Indigenous [October, I have employed the wild horehound both by itself and in conjunction with Cornus Florida, in the treatment of inter- mittent fever, colds, and debilitated states of the system, with very good success. In my native county, Liberty, it has for many years, (as far as I can ascertain from the oldest inhabi- tants, probably from the first settlement of this portion of Georgia,) been employed extensively as a domestic remedy in fevers and colds. It may be administered in somewhat larger doses than the preceding species. BLACK WILLOW. (SALIX NIGRA.) This willow, which is the most common of the American willows, and the most analogous to the White willow, (Salix alba) of Europe, is found in all the States from New England to Florida, and wesr, nearly to the foot of the Rocky Moun- tains. According to the younger Michaux, the roots of this small tree afford an intensely bitter decoction, which is considered in some parts of the country as a purifier of the blood, and as a preventative and remedy for intermittent fever. The ex- tensive genus of willow, which comprises not less than one hundred and thirty species, which, with a few exceptions, are natives of Europe and North Americo, is especially worthy of the attention of Southern physicians, since in several of the European species, a principle resembling quinia, has been extracted, and upon a fair trial has been found to possess the properties of quinia. With the exception of the testimony of the younger Michaux, which I have just brought forward, I am not aware that any experiments or medical investigations with reference to the American species have ever been laid before the profession. WHITE WILLOW OF EUROPE, (SALIX ALBA.) Although not indigenous to the Southern Confederacv, the White Willow of Europe has been so extensively introduced, that it is worthy of the consideration of physicians as tho source of salicin. 1861.] Remedies of the Southern Confederacy. 757 Chemical Composition. According to MM. Pelletier and Caventou, the bark of Salix alba contains bitter yellow color- ing matter, green fatty matter, similar to that found in cin- chona, tannin, resinous extract, gum, wax, woody fibre, and a magnesian salt containing an organic acid. These chemists failed to isolate the most important of all its ingredients, salicin, which was most probably mixed with the bitter yellow coloring matter. Subsequently, in 1828, Buchnei, of Germany, discovered a peculiar principle, which has since been discovered in fourteen species of salix, and eight species of populus. M. Fontana and Ttigatelli, of Italy, discovered this principle shortly after Buchner. M. Leroux, of France, appears to have been the first to accurately investigate its properties. When pure, salicin presents itself as white, shining, slender, inodorous, very bitter cystals, in- soluble in ether and oil of turpentine, soluble in alcohol, much more soluble in boiling than in cold water. According to Merck,- it may be prepared in the following manner : Dried or fresh willow bark is cut small, and exhausted by repeated boiling with water. The decoctions are concentra- ted, and, while boiling, treated with litharge till the liquor appears nearly colorless. The dissolved oxide of lead is removed, first by sulphuric acid, afterward- by Biilphuret of barium, and after the separation of sulphuret of lead, evapo- rated, when salicin crystallizes ; and is purified by repeated solution and cystallization. From willow bark which is fresh and rich in salicin, it may be obtained by cautious evapora- tion of the cold aqueous infusion. The oxide of lead rem from the solution gum, tannin and extractive matter which would impede the crystallization of the salicin. It also com- bines with the salicin, forming a kind of salt, which is decoin- d by the sulphuric acid and sulphuret of barium. I: latter be carefully added, neither sulphuric acid nor baryta 'Turn- I istryj 7th ed. p 7 58 Joseph J ones, on the Indigenous [October, remain in the solution ; and the sulphuret of lead which sepa- rates, acts as a decolorizing agent. I'wal Properties and Uses. The ancients arc said to have employed the Lark of the willow in the treatment of disease ; it fell into disuse, however, until 1703, when it was brought into hottce by Rev. Mr. Stone, who published in the Philosophical Transactions of the Royal Society of London, an article entitled "On the Success of the Bark of the Willow in the cure of Agues by the Rev. Edm. Stone, of Clipping- Norton, Oxfordshire:"' Dated April, 25th, 1763." As his observations are exceedingly interesting at the pre- sent time, we shall present a full account of them : About six years prior to 1TG3, Mr. Stone tasted the willow bark, and was surprised at its extraordinary bitterness, which immediately raised in him a suspicion of its having the pro- perties of Peruvian bark. As this tree delights in a moist, wet soil, where agues chiefly abound, the general maxim that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes, was so very apposite to this particular case, that he could not help apply- ing it ; and that this might be the intention of Providence, he owns had some weight with him. The plenty of this bark furnished him, in his speculative disquisitions on it, with an argument both for and against these imaginary qualities of it ; for on one hand, as intermittents are very common, it was reasonable to suppose, that what was designed for their cure, should be as common and as easy to be procured. But then, on the other hand, it seemed probable, that if there was any considerable virtue in this bark, it must have been discovered from its plenty. His curiosity prompted him to look into the dispensatories and books of botany, and examine what they said concerning it ; but there it existed only byname. He could not find that it ever had any place in pharmacy, or any suc'i qualities as ho Bnspected, ascribed to it by botanists. However, he determined to make some experiments with it; au! for the purpose he gathered that summer near 1 lb. weight of it, which lie dried in a bag, on the outside of a baker'.- oven, re than three mon reduced to a powder by pounding and sifting, at' manner that d. It was not long b( fore he had an opportunity of making a trial of il : bn1 being an nature, he gave it in is, he thinks it was abon :.sof the powder at very tour hoars be- tween the tits, but with great caution and the strictest atten- tion to its effects : the tits were considerably abated, but did not entirely ceae perceiving the least ill e< ices, he became bolder with it, and in a few days increased the I to two Bcruples, and the ague was soon removed. It was then n to several others with the same success, but he foun better answered the intention when one drachm of it n every four ;rvals of the paroxysi lie bad continued to use il with success, as a remedy agues and ii r five years successively. It bad been ailed in the cure, anal and quartan ague which the \ . u long and severely afflict then reduced, in 2 ree,but did not wholly tal oft*. The patient, at the usual time for the return of n't, felt some smattering of his distemper, v saut repetition of tl could not seemed as if th< ' v could reach thus far and tber, and he ed it would not have continued to r< nd that would have so< with its pristine violence, but be did no Tie added one-fifth part of the Peruvian bark t and with this small auxiliary it totally rout It was found necessary also in one 1 -her time- of the year, to mix tl bark with it. but th< abroad imprudently, an L caught cold, did. who being alm< an in vet' as:u he not 760 Joseph Jones, on the Indigenous [October, only neglected his powders, but meeting with bad weather renewed his distemper. One-fifth part was the largest and, indeed, the only pro- portion of the quinquinia made use of in this composition, and this only on extraordinary occasions ; the patient was never prepared cither by vomiting, bleeding, purging, or any medicines of a similar intention, for the reception of this bark, but he entered upon it abruptly and immediately and it was always given in powders, with any common ve- hicle, as water, tea, small beer, and such like. This was done purely to ascertain its effects, and that he might be assured the changes wrought in the patient could not be attributed to any other thing, though, had there been a due preparation, the most obstinate intermittents would, proba- bly, have yielded to this bark without any foreign assist- ance ; and by all he could judge from five years' experience of it on a number of persons, it appeared to be a powerful absorbent, astringent, and febrifuge in intermitting cases, of the same nature and kind with the Peruvian barks, and to have all its properties, though perhaps not always in the same degree. It seemed, likewise, to have this additional quality, viz : to be a safe medicine, for he never could per- ceive the least ill effects from it, though it had been always given without any preparation of the patient. The tree from which this bark was taken, is styled by Ray, in his sy- nopsis, Salix Alba Vulgaris, the common white willow. Philosophical Transactions of the Royal Society of London, abridged bv Ilutton, Shaw and Pearson, vol. xii. 1763-1769, p. 1-3. Messrs. James White, and Wilkinson published strong evidence in favor of the use of the broad-leaved willow in intermittents, foul ulcers and other affections. Dr. Cullen recommends the willow-bark in his Materia Medica, as a substitute for Cinchona. I taller was in the habit of using, with success, a decoction of the bark as a bath to dip infants in. Dr. Closs affirms that the bark of the willow, given in 1861.] Remedies of '1 7*51 the do>e of a scruple every three hours, has cured many eases o intermittent and bad scorbutic ulcers; numerous other English physicians have testitied to its value in inter- mittents; and its great value as a substitute for Peruvian bark is established beyond all doubt. The testimony of numerous European physicians shows that the active principle of Willow bark, Salicin, is capa- ble of arresting and curing intermittent fever, and stands next to Quinine as an anti-periodic remedy. According to Buchner, twelve grains, in divided doses, will irenerallv arrest aMMON SALT. CHLORIDE OF SODItJST. Dr. Scelle Montdezert appears to have been the first to call the attention of the profession to the value of Chloride Sodium in the treatment of intermittent fever; and however fanciful his notion that every paroxysmal fevev is cured by the presence of fibrin in the venous blood, which should in the normal state be e procee . and that th their power heir ability to dissolve fibrin pr< pable of arresting palu lal fever, Juinia il fardtohi lit for having discov< widely diifu uts that 'eruvian "veprin iiiia, which arc not onlyvcry 764 Joseph Jones, on the Indigenous [October, costly, but are liable to adulterations, monopolies, and to final destruction from the wasteful and reckless manner in which these are gathered and prepared for the market. In his memoir upon the treatment of Intermittent fever? presented to the French Academy of Medicine, July 1850, Dr. Scclle Montdezcrt declared that from the results ob- served during several years, with the beneficial effects of Chloride of Sodium in the treatment of interjnittcnt fever, this medicine should share with the salts of Quinia the pe- rogative of arresting the paroxysms of intermittent fever. He says that half an ounce of salt administered in half a glass of infusion of Coffee, in the morning before eating, during the apyrexia, will be sufficient to arrest the paroxysm. Its use in this manner should be continued three days. According to the testimony of Dr. W. P. Lattimore, M Piorry, who was one of the committee appointed by the Academy to report upon the Memoir of Scelle Montdezcrt, experimented extensively with the Chloride of Sodium in intermittent fever and confirmed the previous observations. This subject is of so much interest that we present the tes- timony of Dr. Lattimore to the success of M. Piorry with the Chloride of Sodium in intermittent fever, in full: " M. Piorry holds that in all paroxysmal fevers the spleen is enlarged ; that the anatomical lesion is the cause, the fe- ver only the symptom ; that whenever the spleen has a greater length (measuring in a line extending from the middle of the axilla to the anterior superior spenous pro- cess of the ileum,) than from 31 to 33 lines, intermittent fever exists. Believing thus, the symptoms for him are zero, while the state of the spleen stands at the other end of the scale, and is everything percussion (pleximetric) of course, being the ezperimentum cri< "We cannot resist the temptation of here paying a tri- bute to the skill with which M. Piorry employs percussion in making a diagnosis. With him auscultation is but an in- taut when compared with its full grown brother percussion. By its aid lie interrogates the abdominal viscera as frequently 1861.] Remedies of the Southern Confederacy. 7G5 he thoracic, and with no less success, for he has brought it to an almost incredible degree oi' perfection. With his plate of ivory and his flattened fingers1 ends lie diagnosti- everything tumors of the abdomen, abscess- rerywhere, aneurisms, &c. All acknowledge the deli- cacy and accuracy oi' his test, while the looker on is lost in admiration, and wonders whether all his senses are not really concentrated in the ends of his fingers, which by constant drumming have at length become the very reverse of tapering. " Wishing, then, to experiment with salt, a few cases of intermittent fevev, (old stagers,) contracted in Algiers were selected as subjects. Behold, then. Piorry at the bedside. The patient asserts that he contracted the fever and ague several years since in Africa ; that he has frequently been cured, but that the disease has constantly reappeared at the end ot fifteen days, or one month at farthest. The type of the fever is tertian. The spleen is pei cussed and found to be abnormally dull throughout its wbole extent; the entire splenic region is sensitive upon percussion, particularly over the dullest points ; and each blow is accompanied by marked contortions of the countenance. The sensibility extends but little beyond the region of dulness, which last occupies an extent of fifty-three lines, measuring in the di- rection indicated above. To this patient a drachm of sali- cin is administered without producing any change in the dimensions of the spleen. A few minutes subsequently, half an ounce of salt, mixed with a cup of soup is given, and upon carefully percussing the splenic region at the end of four minutes, this organ is found diminished one inch, from above downwards. The next day the spleen is found to be of the same size, but upon the administration of a second dose of salt, it suddenly contracts and measures nearly three quarters of an inch less than ay. The mance throughout the entire organ has increased while the sensibility has diminished. The succeeding day the attack of fever is very slight, and upon giving a third dose 7'! Should the spleen be undiminished in volume by the first . we may be sure that the remedy will not cure the and the same is true of all the anti-periodics. Ex* Lng in rare cases, the diminution of t lie spleen occurs immediately upon the administration of the remedy, (salt, sulphate quinine*) and may frequently be detected within one minute, after which the organ remains stationary until ond dose of the medicament he administered." On the Employment of Chloride of Sodium in the Treatment of Intermittent Fever. By W. P. Lattimore, M.D., Amer- ican Journal of the Medical Sciences, July, 1852, No. xlvii In . S. pp. 102-104. The observations of Dr. Moroschkiu upon the value of I in the cure of ague, agree with the testimony of the preceding obsen He states that during the prevalence of scorbutus and e in the Transcaucasian province of the Black Sea, Qui- nine sometimes entirely lost its power.-. When no very prpmim ' utic affections were present he administered one ounce of salt in water in tv. 3, daily, during the of the apyrexia. In patients in whom the parox- incomplete, very abundant sweating followed. the skin resumi >rnial appearance, and the various other signs of ainendn; d in a few <>\\. and he concludes that hydrochlorate of ammo- nia bears no therapeutical pretensions in the intermittents 1801.] // Ik Southern Confederacy. 771 of hot countries, and that there is much doubt of its capac- ity of rendering any service in those of Europe. " Exper- iments with several pretended substitutes for cinchona in the Military Hospitals at Rome. By Dr. Felix Jacquot, hives Generates, June 1854 p. 678.) Abstract of a Report on Materia Medica, by Edward Ballard, M. D. Brit. ft For. Med. Chir. Rev. vol. xvi. p. 191. NITRIC ACID. Dr. George Mendenhail, of Cincinnati, called the attention of the profession to the use of Kitric Acid in the treatment of intermittent fever in 1854 : the facts upon which his paper was based was chiefly derived from an Inaugural Dissertation by Dr. E. T. Bailey, of Indiana. Dr. Bailey states that in the section of country in which lie le8, there is a large portion of marshy land, and, therefore, the circumstances are favorable to the development of autum- nal fevers. His attention was first attracted to the use of nitric acid in the treatment of intermittent fevers, by noticing its effects in a case of chronic intermittent, which was attend- ed with pmfuse night sweats, and for which complication he administered the remedy. In this case there had been daily paroxysms for the preceding five days; night BWeats profuse, the tongue coated, and the bowels constipated. Nitric acid was given in doses of six drops, diluted with water in the evening; and he was agreeably surprised to find that the paroxysm.- did not return on the following day ; and this cir- cumstance induced him to try its effects in other cases as an anti-periodic. Since that time he has treated over ninety - of intermittent fever with this article, with remarkable success. Of this number, all recovered promptly except ten : and in every one of these unsuccessful r-a-es, the remedy was discontinued contrary to directions. Fifteen of the whole number were of the tertian type, and nty-five of the quotidian. In fifty cases there was no re- turn of the chill after commencing the use of the acid. The others were rarely attended by more than one paroxysm, and 77-? Joseph Jones, on the Indigenous [October; in no case by a third. When the patient had a paro. after taking the medicine, it was in every case diminished in intensity and duration. In Dr. Bailey's practice, this remedy Lag entirely superce- ded every other article for the purpose of interrupting the paroxysms oi intermit tents. His mode of proceeding is to give from five to eight drops of the commercial nitric acid, properly diluted, once in six hours, without regard to inter- missions or exacerbations. Cathartics and alterants may be necessary for the purpose of changing certain condition the system : but so far as the interruption of the paroxysms ig concerned, the acid may be given without any preparatn the system whatever, if we choose to do so. American Jour, of the Medical Sciences, October, 1854, pp 581-5xl'. Dr. J. C. Thompson, of Arkansas, has recorded in the Southern Journal of the Medical aud Physical Sciences, August, 1857, the successful trials of nitric acid in six cases of intermittent fever, in which the customary remedies had fail-, ed. In one case in which there was menorrhagia, a powderj consisting of one grain of opium and two grains of sugar lead was given every two hours until the discharge subside in two others, blue mass was prescribed in conjunction w the acid, and in the remaining three cases, pills of sulphate of iron, aloes and rhubarb were given in addition to the acid. lie recommends one ounce of the acid to be diluted with six ounces of water; of this the patient is to take one drachm in an ounce of water every two hours during the intermission. The chairman of the Ohio State Medical Society admin] tored nitric acid successfully in 35 cases out of 36, Dr. William A. Hammond has added his strong testimony to the yalue of nitric acid in intermittent fevers, published ii the Maryland and Virginia Medical Journal tor February 1861. Dr. Hammond, after presenting the results of the em ploymenJ of nitric acid, in tabulated form, remarl "The table forms the basis of a report made about four year since to the surgeon general of the army, and has never beei published. The cases were troated at Fort Riley, Kansa- lth 1861.] Remedies of thi Southern Corfederaey. 773 territory, in the post hospital, then under my charge, In a weeks in the summer. Upon referring to the able, it will be seen that in all, forty-one cases were treated, on of those being of the quotidian typo, and thirty-one of' tfie [ertian. Thirty-two cases were treated with the nitric acid, and nine with tlie sulphate of quinia. Of the cases cured by nitric acid, three had previously used quinine without effect} and of those in which quinine had proved successful, nitric acid had been employed without benefit in two, and in one other had to he omitted on account of causing nausea, heartburn, etc. The average period of treatment before the disease was permanently arrested, was the same witli cacli remedy three days. The nitric acid was uniformly given in doses <>f ten Jrops (properly diluted with water) three times per day, the Jninine in dose- of eight grains three times a day. Besides the fact that the nitric acid was equally successful with quinine in arresting the disease, the difference in the cost W the two articles rreatly in favor of the former Bub- kance as to render it an object of importance to make its curative properties more widely known. going cases were treated, I have very fre- quently employed nitric acid in the treatment of intermittent id have rarely been disappointed in my expections of action. In fact, in simple uncomplicated inter- nt, I seldom have occasion to use anything else, [n ncnt of the spleen, consequent upon fre- quent attacks of the ague, the remedy in question has, in my lands, proved very advantageous." Tli ly that nitric acid is a valuable substitute \'->v quinine; and we can readily by a v powerful alterative effec mercury, that it would be beneficial in remittent, typhoid and typhilfi f< hi and facility of administration, added to and decided eft' raid lead at Leas! to trial of it by the profession of the Confederate America. 7 74 Joseph Jones, on the Indigenous [October, AESENIC, (AKSENIOUS ACID.) The value of Arsenic in the treatment of malarial fever has been celebrated by numerous reliable observers; and the medicine ranks with many practitioners, second only to quiuia : we shall not, therefore, enter into any extended ex animation of its medicinal properties; but shall content our- selves with the presentation of the recent and most valuable investigation of Dr. Felix Jacquot in the Military Hospital at Home, premising that arsenic exists in the Southern Con- federacy, and only needs an effort for its extraction from the earth. The paper of Dr. Jacquot is a summary of a memoir addressed to the Conseil de Sante des Armecs, on the employ- ment of arsenic in the treatment of intermittent fevers in general, and of those of Home in particular, based upon 282 observations ; and we present it without alteration, as it ap- peared translated in the British and Foreign Medico-Chirnr- gical Review, vol. xvi, 1855, pp 189 to 191 "1. Mode of ' xperii7ienting. In order to establish the effi- cacy of arsenic as a febrifuge, its administration should be limited to those cases which have resisted treatment without the use of quinine. The author of the paper before us has not strictly followed this course, since, giving the arsenic at the outstep in the majority of the cases, he had no means of judging whether the fever was about to proceed steadily with its paroxysms, or whether, on the other hand, it had a tendency to spontaneous disappearance. But as the sulphate of quinia was administered in the same way, it was at least in a position to establish the comparative efficacy of the two medicines. His researches, too, permit him to consider sepa- rately the treatment with arsenic alone, and the complete treatment by this remedy, emetics, &c. Arsenic alone cut short the fever only in S.33 per cent, of the cases, but the complex treatment in 16.66. But while the efficacy of the arsenic is doubled by the con- joined uses of emetics, the febrifuge powers of the sulphate of quinine are so great, that those of emetics simultaneously em- A\ nu dies of the South I ifedi racy. ployed are lost, or absorbed in them ; thus, the per centagc of fevers cut short by sulphate of quinine without emetics is 2, and by sulphate of quinine with emetics, 50.47, as cal- culated in 210 teveis. 2. Formulw, Dose, Duration op Us< of Ars< ,,'(< -The lor muhe used was the following: Arsenious acid, 1 gramme; distilled water. 1 kilogramme. The arsenic is boiled with more than tin- quantity of water till dissolved, and the latter reduced to the prescribed quantity, some soda being added should the solution he imperfect. The dose of Bolution was administered in canella-wine. The author could derive nothing but confused ideas of the pro- per dose from writers on the subject, nor vet of the rapidity of its action. 3. ( I nts. Tolerance. Most subjects bear with- idents, three centigrammes at the outset; vet 'her hand, the tolerance has persisted sometimes in continued large doses. Out of 72 cases treated by arsenic, ho has only noted general accidents six times. never fatal, and only once a source of anxiety. The local and tolerances are quite independent of each other. The author considers the action of arsenic to le sedative, hyposthenic. In one of his subjects the pulse fell to fifty. General loss of strength, lassitude particularly affecting the - and loin-, have appeared to him the earliest phenomena of poisoning by moderate doses of arsenic ; and while lie thus differs from those who class it among the tonics, he asserts that it has no tonic operation, even upon subjects suffering under marsh cachexia. i. 1 -Out of the 7- cases treated by arsenic, i intestinal accidents. ! ammo may omiting and : hut, on the other hand, he ha- seen six ccntl- crai by the mouth tolerated ; and in others he ha- nth without the stomach it. Although the conditions favorable to arc not well known, yet he can mention the 776 Joseph Jones, on1 the Indigenous [October, smallness of the dose, its ingestion in divided portions, and the quantity, and perhaps nature, of the vehicle. The local acci- dents are nausea, vomiting, diarrhoea malaise, and sometimes pinchings at the epigastrium, and an insurmountable disgust at the medicine. Either general or local accidents followed, in 31 out of his 72 cases, or in 43 per cent. 5. Autopsies of Individuals treated with A n>enic. In three subjects examined, nothing was discovered which could be imputed to the employment of arsenic, either in the heart, or in any other part of the body. 6. Degree of the Efficacy of 'the Arsenic, Comparison with Sulphate of Quinine, die. The cases in which M. Jacquot iounds his comparison are those which had not received any previous treatment calculated to interfere with the accuracy of his experiments. Tie thns tabulates his results : SULPHATE OF QUININE. AKSENIC. Fevers cut short, i. e., which have not ) presented a single paroxysm from the > 50.00 13. SS the commencement of the medication, ) Fevers which had presented one paroxO ysm in spite of the medication, but in > 25.71 22.i!2 which the second had been averted. . j Fevers which have presented two par- ) oxysms, but in which the third has V 7.61 12.50 been averted ) Fevers which have presented three or [ r QO o < .-o more paroxysms j Fevers which cannot be introduced into ) these categories, but which must be > 11.42 16.66 regarded as not cut short ) The arsenic with or without the emetic has cut short the fever 13. SS times per cent.; the sulphate of quinine with or without emetic?, 50. times percent.; that is to say, the arsenic lias been efficacious as one, the sulphate of quinine three times and a fraction. The arsenic with emetics cut short the fever 16.66 times per cent.; the sulphate of quinine without an emetic, 50.47 times per cent.; that is to say, the arsenic has 1861.] Renu the Southern Confederacy. 777 been efficacious as 1, the sulphate of quinine as three and a fraction. The arsenic without emetic has cut short the lever v times per cent.; the sulphate of quinine without emetic, 49.52 times per cent.; the proportion being arsenic as l,to sulphate of quinine as 5 and a fraction. Lastly, in comparing the a the most favorable to the arsenic, viz.: those in which it was administered in large doses, three to ten centigrammes, accompanied by emetics, and a diet whose only limit was the appetite of the patient, with the cases least favorable to the quinine, we arrive at the following results : Fcvcr< cut short by arsenic, - - - 9.6S per cent. quinine, - - 49.52 " " As respects the cases not cut short, it will be perceived, on referring to the first four iigures of the two vertical columns of the table, that in the instance of the fevers treated with quinine, the numbers arc smaller and smaller, according as we examine the categories of cases more and more refractory, whilst the contrary is noticed in the instance of the arsenical treatment. The contrast is perfect. In about 35 cases it was possible to compare the effects of the quinine and arsenic, the two medicines having been ad- ministered in succession to the same patient, either for the same fever, or in two separate attacks. In a sixth of the senical and quinine treatment were of little effica- cy: in another sixth, the two medications were followed by : in the four other sixths, the sulphate of quinine showed itself the most active, or the only active remedy of the two ; and one observation furnished a very marked in- stance of fever resisting the sulphate of quinine, and cured by mic. In short, the author concludes that we see more rs which resist arsenic, yielding to quinine, than we do fevers, refractory to quinine, disappearing under arsenical treatment. lie believes, also, that h< ablished the fact of the greater activity of the sulphate of quinine in the cases which have received no previous arsenical treatment (T>4 per 778 Joseph Jones, on the Indigenous [October, cent, cut short,) than in those first submitted to the action of arsenic, (40 per cent, only cut short.) The general conclusion lie draws is, that the sulphate of quinine is not replaceable by arsenic ; and especially is this true in respect to the fevers of hot climates, where it is nee sary to apportion the dose to the intensity of the malady ; under the latter circumstances, we are immediately arrested in the arsenical treatment by the fear of poisoning. In those countries where, from one paroxysm to another, the pyrenia may become more severe, remittent and pernicious, arsenic should not be employed during the endemo-epidemic season. Confirmation of Results by other Observers. After mention- ing MM. Mayer, Cordier, Pasquier and Gouge, as arriving at similar conclusions to his own, he states that in the Pontine marshes, Dr. Minzi, physician to the Central hospital of that country, has experimented with arsenic in more than 400 cases, giving it to the extent of three centigrammes a day, and at last abandoning it from want of success. M. Salvagnoli Marchetti also, out of ID cases, found 15 resisting arsenic. Arsenic in Inveterate Cases and in Marsh Cachexia. The observations of M. Jacqnot do not encourage recourse to arse- nic in inveterate fevers ; and M. Cordier also concludes from his experience in Algeria, that it is the more recent and slighter cases which yield most readily to arsenic. In the palustrial cachexia he thinks that arsenic may perhaps be used as an alterative, but that it is incapable of replacing iron and other tonics, which it is necessary to conjoin with it. IZelajiscs. In preventing relapses, arsenic is inferior to sul- phate of quinine. Out of 72 cases treated with arsenic, the relapses wrere 22 or 20 percent. certainly a large proportion. They were less frequent in the cases treated with quinine. The relapses occurred even during the period of administra- tion of the arsenic, which was continued after the cessation of the fever. This was not observed in the instances of the qui- nine treatment. l.] /;//. )j Southern Confederacy, WO Ar& nic in th> Fngranesa nt and /?< mdttent Fevere. In five 3 it was observed that in spite of and during the employ ment of arsenic, the simple fever became aggravated remit- tent, sub-continued and pernicious a fortiori, then, this medicine would have no action npon a fever already of this character. >-. Arsenic is not for a moment to be regarded a^ a substitute for sulphate of quinine. It will probably find a limited place in the treatment of indigenous intermittent fevers, but it has absolutely no pretensions against the recent endemo-epidemic fevers of hot countries. We are scarcely authorized to employ it except in the fevers which resist all the preparations of bark. Uncertainty and contradiction reign over almost all points relative to arsenic. It is a medicine which we cannot yet handle with the double certainty of ob- taining the effect desired, and of avoiding the dangers con- nected with its administration." These results of the carefnl observations of M. Jaequot, arc worthy of most carefnl consideration by the physicians of the South, on account of the similarity of the held of experiment with a large portion -o/ the South; and they are especially worthy of most careful examination, from their antagonism to the most astonishing results which M. Bondin, of Paris, claims t<> have accomplished with arsenic in the treatment of inter- mittent fever. M. Boudin affirms that in 4,000 cases of inter- mittent fever treated with arsenic, in the hospitals of Mar- seil! ailles and Paris, from 1843 to 1851, he had not had occasion to resort in a >ingle instance to sulphate of qui- nine ; and out of 311 cases treated at Versailles in a period of 39 months, If. Boudin had but 10 relaps It may well be asked whether the intermittent feven Par [lies do not differ greatly in B< rity and obstinacy from those at Rome; if it be true that they are far then the observations of M. Jaequot would express far more truly the value of th [y to the inhabitants of the rich low 1. ramps and marshes of the mfedera 780 Joseph Jokes, on (he Indigenous [October, LKiATI Ki: OF THE EXTREMITIES IX INTEE- MiFEENT FEVERS. J have had no faith in and consequently no experience with this mode of treating intermittent fever. The following summary of a valuable article by Drs. J. DeBrauw and II. J. Braers, taken from the North American Medico-Chirurgical Review, of March, 1859, presents this method of treatment in a strong, and, in fact, the most favorable light which I have yet seen : 'According to Drs. DeBrauw and Braers, the ligature of the extremities is a measure which has been already employ- ed by ancient physicians to aid the treatment of intermittent lever, but has unjustly nearly fallen into oblivion. Already Pinius, (Hist. Nat. xxviii, G) knew this antiperiodic, as Pitts- clioft (Hufelands Journ. ii, 3, pp 47, 48) states, and in Tan Sweeten's Commentaries to Boerhaave* Aphorisms, the 'levis brevisque compresseo venarum in arbutus,' is strongly recom- mended as a means to relieve the burning heat of fever. Dr. V. Hildebrand, however, declares the remedy, in his Institu- tiones Practico-Medicce, to be unreliable, and in many re- spects unsafe, and recommends caution in the use of it. Jos Frank, (Prax. Med. TTniv. Precepta,) speaks of it in a very superficial manner, like many others, particularly more recent authors. One of the most enthusiastic commenders of this method is George Ecllie, (Duncan's Medical Commentaries, vol. xix,) who, during the seige of Willemstadt, by the French army, in 1793, cured many cases of intermittent fever (which had resisted the use of quinine) completely, by compression of the extremities. Upon this recommendation several physi- cians in England for instance, Veitch and "Wallich, (Mediz. .National Zeitung, July, 1798, and in the Netherlands, (Age~ mene Yaderl. Lettervefningen, 1808, 5) tried this method with signal success. Of the more recent communications on this subject, that of Prof. Chladni, (Ilufeland's Journal, xlii, p. 138) is worth particular attention. This celebrated savant being attacked il] L813 by an obstinate intermittent fever, used the remedy with much advantage. He discusses it. as quite innocuous, and explains its curative influence by f]\o l.| Remedies of the Souths leracy. 781 supposition, that by ligature of the extremities, the return of blood to the heart, and to tlie centres in general, is hindered or partially suspended, an gives a detailed account of the ligatures circu- mbre&j the ligature should be applied to the four extremities at the same time, but in such a manner that only the circulation in the superficial vessels is suspended. Marti- net. Robinau, Recamier and llusson,kept up the compression for not longer than twenty -live to fifty minutes, and com- menced with it in the cold stage. Jolly recommends taking off the ligature one by one, at intervals of several minutes, as by the simultaneous removal of the same, too much blood would be at once introduced into the circulation. The most complete information on the subject of his inves- tigation, the author found in a dissertation of E. V. Baerle : UJD valdi multipli m intermettentium mecticcUione latum membrorum majorum oiraumsirictione temtemvin- innosocomio acadetnico espplorata" Utrecht, 1809. In this treatise the ligature of the extremities is thoroughly illus- trated by the report of seven cases, and highly recommended. A'. Baerle commenced the treatment with the administration gentle purgative; the patients were kept in bed, and sub- jected to a rigid diet during the paroxysm : shortly before the commencement of the cold stage, the thighs and upper arms were encircled by ligatures exercising a moderate | Bure, which were removed in from six to fifteen minutes, or later, according to the effect they produced ; after Wallich's mple, he forbade warm drinks during the cold stage, but 782 Joseph Jones, on the Indigenous [Octob er recommended cold drinks in the hot stage. From observa- tions of this kind, the author draws the following conclusions : The ligature of the extremities is a safe and powerful means of assistance in the treatment of intermittent fever ; it is not only an adjuvant to other antiperiodics, but also a febrifuge by itself. It cures the febris intermittens simplex and duplex, as well as the quotidiana. In regard to the quartana no experi- ence has been made. The ligatures must be allowed to remain until the last stage begins ; a longer application does not lessen the effect. The method seems to owe its curative property to the dis- turbance of the usual course of the fever, (Chladni.) Sometimes the paroxysm is transferred under this treat- ment from the third day to the second, but generally so that the tertian type is not interrupted, or that a febris du- plex is developed. The compression of the extremities is always followed by some increase of the heat and perspi- ration, the signs of an energetic reaction. After repeated use of this method the fever gradually subsides. Contra indications to it never existed, but may be easily inferred from an examination of the modus operandi of the remedy. Dr. DeBrauer generally applied compression to the ex- tremities only, but considers the ligature of all four, far more efficacious in obstinate cases, and recommends the method as being capable in some cases to substitute the use of quinine. In cases of relapse of intermittent fever in which the pa tients complain of that characteristic pain in the lumbar region, (fifth lumbar vertebrae) against which cups are used without effect, Brocrs recommends the application of the galvanic current to the mentioned spot as a highly service- able, though occasionally inefficient means. After the se- cond or third application of this remedy the cachectic ap- pearance, as well as the depressed feelings of the patients, underwent a favorable change. Relapses of the fever, con- lequent upon a return of the patient into the malarious dis- trict, yielded quickly to this niodo oi* treatment, even when L861.] R dies )f the Southern Confederacy. , x^ quinine was administered without success*" (Nederland Tijdsche, 1858, and Medizinsche Neuigkeiten, 1858,No. 44. COLD WATER IX THE TREATMENT OF MALA- RIAL FEVER. It would be foreign to our purpose to enter into any dis- jion of the mode of action of water in Fevers, for, as the most universal of all solvents in which the elements of the blood are dissolved or suspended, and as the largest constituents ut the solid as well as of the fluid components, and as the great medium of the introduction of the nutri- tive elements, and of the chemical changes which develope the forces which work the machinery of the human body, as well as of the removal of the products of these chemical changes, water occupies such a prominent position in all the processes of health and disease, that it would be impos- sible to discuss either its value or its mode of action in fever in the limited space now at my command, and must content ourselves with a few practical observations and reliable tes- timony to the value of water as an external application, re- serving the extended discussion for a future occasion. Xow that the old notions with reference to the injurious effects of water and fresh air, have vanished with the progress of medical practice, based upon sound physiological principles, we can scarcely realise the powerful effects of water, in the treatment of fever, without a careful comparison of the symptoms, progress and mortality of diseases before and after its free use. I external application, the value of cold water though not unknown and not unemployed by the ancients, was not appreciated by the profession until after the publications of Dr. William Wright- 1586, and especially of Dr. J. Cur- of England. : Formerly of tin- [aland of Jamaica, published an account in tin < employed during the cold stage of the paroxysm of fever the respiration is nearly suspended, the pulse becomes feebli and fluttering and of incalculable frequency, the surfaci and extremities are doubly cold and shrivelled, and the pa tient seems to struggle with the pangs of instant deatl Under such circumstances the repeated affusion of a fei buckets of cold water would extinguish life. 2. Neither ought the cold affusion to be employed who the heat, measured by the thermometer, is less than, ( equal to the natural heat, notwithstanding the patient fee no sense of chilliness. This is sometimes the case towarc the last stages of fever when the powers of life are weJ 3. It is also necessary to abstain from the use of this 1 medy when the body is under profuse sensible perspiratic and this caution is more important in proportion to the co tinuance of this perspiration. En the commencement 18GL] Remedies qfth s p^ Confederacy, 785 specially, If \i haw been brought on by violent exercise, the affusion of / cold w^ter in the naked body, or even immersion in the cold bath, may be hazarded with little risk, and sometimes may he resorted to with great benefit. After the sweating has continued some time, and Mowed freely, -ally if the body lias remained at rest, either the aifusion or immersion is attended with danger, even though the heat of the body at the moment of using it be greater than natural. Sweating is always a cooling process in itself, but in bed it is often prolonged by artifi- cial means, and the body prevented from cooling under it to the natural degree by the load of heated clothes. A\ nen the heat has been thus artificially kept up, a practitioner, judging by the information of his thermometer only, may be led into error. In this situation the heat sinks rapidly on the exposure of the surface of the body even to the ex- ternal air, and the application of cokl water, either by affu- sion or immersion, is accompanied by a loss of heat and a deficiency of reaction which are altogether inconsistent with safety. Medical Reports, &c. By J. Curry, 1797. According to the experience of Dr. Carrie, if employed on the first or second day with the precautions recommend- ed, the progress of the fever is often checked, but it is scl- saful when applied so late as the third or fourth day, though when administered about the eighth or tenth day, or even later, it moderates the symptoms and shortens the duration of the fever.- More recent observations have shown, however, that whilst Typhus fever may be thus cut short, this remedy fails almost universally in arresting Ty- phoid fever, which runs a definite course and is character- by as definite pathological alterations, as Scarlet fever, and Small Pox. When the fever has rim on for eight or nine days and the patient is weak, the heat of tin- water should be only a few below that of the patient, and at this period it is preferable to sponge the body with cold or tepid vinegar and water. 786 Joseph Jones, on the Indigenous [October, Testimony of M. Fleury to the value of Cold, Douches in the treatment of Intermittent iever. M. Fleury in his memoir on this subject presented to the>French Academy states that lie was led to these researches by the assertion of Dr. Cur- ric, that the accessions of ague might be prevented by the affusion of cold water, and that by its repetition four or five times, the disease might be entirely cured. M. Fleury has employed this means one or two hours before the expected paroxysm in the form of a general douche, and in that of a local one to the region of the spleen. The ends attained by the above plan he believes to be 1 . A shock exerted on the nervous system, and on the gen- oral capillary circulation. 2. The opposing of a vigorous reaction and general stimulation of the surface to the cold stage of the fever. 3. A modification of the circulation of the spleen, combating congestion of that organ. lie has pursued this treatment in eleven cases of intermittent fever. 1 1\ seven of them the disease was recent, and there had been but from three to seventeen paroxysms ; quinine had not been administered in any one. In two cases the spleen preserved its normal size ; in five it was enlarged a cure was effected in all. In one a single douche sufficed to cut short the fever. In two others, two affusions were neces- sary to do so, and to restore to the spleen its natural di- mensions. In the remaining four, affusion was practiced three times. I n those patients where two of three douches were used, the effects produced were constantly the same. By the first a] (plication the accession was retarded two or three hours, the rigors loss violent, and shorter by one-half or five-sixths the time, the heat and headache were equally lessened, and the total duration of the lit was diminished at least one-half. Age and the type of the fever did not exercise any ap- preciable influence over the effects of the treatment. Where, however, the volume of the spleen was larger, the time required for the cure was augmented. Four patients had Buffered from the disease for from two to eleven months, L] ria. 787 baring had several relapses, and resisted the action of sul- phate of quinine, and presented the ana?mia, emaciation, anorexia, &c. seen in those who have long been affected by ague. Three douch< required in two of these eases, and five in one other to remove the fever, hut from eight to eleven were necessary to cause the splenic engorgement and the cachectic symptoms to disappear. In one case the liver was very greatly enlarged, but this condition disappeared by perseverance with the affusions. M. Fleury arrives at the following conclusions : 1. In the treatment of recent intermittent fever, simple and with little or no engorgement of the spleen, cold douches may be substituted for quinine. 2. In the treatment of old-standing ague, where several relapses have occurred, and there is considerable enlarge- ment of the spleen, or of the liver, with a cachectic condi- tion, cold affusions are to be preferred to quinine, for they cut short the fever, restore the viscera to their natural vol- ume, and remove the cachexy more safely than quinine, the latter in large doses, not unfrequently acting injuriously upon the nervous system, or on the digestive organs. (Bul- letin des Aeadem. and Lancet.) Kanking's Half Yearly Abstract of the Medical Sciences, Xo. vii. Jan. to June, 1848, p. OS. DiphtJu The following practical observations upon the treatment aken from a very interesting paper lead >re the New York Academy of Medicine, by Dr. James Wynne. After giving an elaborate history of the epidemics of this affection, he proceeds t}n\< : 1) -It la not a difficult matter generally t<> give a correct diagnosis in diphtheria, especially when the practi- tioner is cognizant of the fact that a false membrane has i or is forming. The diseases with which it is possible 788 Dvphtlima. [October, to confound it, are angina maligna and croup. In the first of these affections, the medical man has the general symp- toms of scarlatina to guide him, and especially the eruption whichis absent in diphtheria. In scarlatina, the tonsils are of a bright red, resembling the juice of the strawberry, and the membrane which covers them is simply inflammatory ; while in diphtheria the hue is deeper. The exudation in scarlatina is white, opaque, cheesy and easily furrowed ; while in diptheria it is yellowish, tenacious and not easily impressed by the action of a hard body. The inflammato- ry action in scarlatina is observed at the beginning in all the soft parts of the throat; while in diphtheria it almost in- variably shows itself at the commencement upon the ton- sils. As the disease progresses, diphtheria manifests a ten- dency to invade the air passages, which is not one of the characteristics of scarlatina. The main distinction between croup and diphtheria is to be found in the part affected. In croup the trachea is pri- marily the seat of diseased action ; in diphtheria it is only reached after the disease has made considerable progress. In croup the earliest symptom is stridulous breathing; while in diphtheria the primary symptoms are chiefly observed in the organs of deglutition. In croup the false membrane on the tonsils is not present; in diphtheria, it is an invariable symptom. Complications. Diphtheria may manifest a disposition to the formation of a false membrane in other parts than those primarily affected, as the skin, the mucous membrane of the nose, the ears, the lungs, and the anus ; or it may prevail coincident with other affections, as influenza, bronchitis, measles, scarlatina, erysipelas, or it may be affected by a particular epidemic condition, in which it becomes compli- cated with hemorrhage of the nose, skin, and mucous mem- branes of the intestines or lungs, or a typhoid type ol disease. Prognosis. When diphtheria is confined to the tonsils, \\ usually terminates in a restoration to health ; but when the false membranes extends to the nasal cavities or the laryni especially if accompanied with grave constitutional symp toms, the patient is placed in imminent peril. Even in fa vorable cases, the prognosis should be given with mucl consideration. Treatment. The practitioner has three important indica lion to fulfil in the treatment of diphtheria : 1861.] Diphtheria. 780 1. To arrest the spread ot' the pseudo membrane. '2. To alter the character of morbid action, upon which the formation of this membrane depends ; and '>. To sustain the patient until these shall have benn ac- complished. These necessarily involve both a local and general treatment. The local treatment consists chiefly in the application of caustic and astringent substances, in one form or another, to the affected part. Of these, the most usual are nitrate ot" silver, either solid or in solution, powdered alnm, chlo- ride of lime, chloride of soda, sesqui-chloride of iron, and hydrochloric acid. M. Bretonneau almost invariably employed the last of these remedies as a local application in his own practice, with the most marked success. The hydrochloric acid may be employed very nearly of the strength of the dilute acid of the shops, or considerably reduced in strength depen- dent upon the severity or mildness of the attack. The best method of applying it is to moisten a small sponge attached to a probang, or a camel's hair pencil with the fluid, and while depressing the tongue with the left hand, to carry the brush foiward with the right, until the fauces are reached, when those parts of the tonsils, uvula, or soft palate on which the membranous deposit appears, may be moistened with the fluid, and the instrument withdrawn. The hydro- chloric acid should be applied not only to the membranous surface, but to the parts immediately surrounding it, by which means the spread of the membrane is often arrested. The application should be renewed several times a day. Care, however, must be taken not to apply it of too great strength, or too often at the onset of the disease, especially if the symptoms are not of an aggravated character; other- wise the local disease may be enhanced, by the unnecessary injury inflicted upon the surrounding parts. The symptoms often appear momentarily aggravated by the local applica- tion, which is not unfrequently followed by an attempt to dislodge the membrane by vomiting. Should this latter result follow, the tonsils and palate will appear a shrunken in substance, and spotted here and there with a few drops of blood upon the surface formerly occupied by the membrane. When this does occur, the application may he renewed directly upon the surface of the gland, in order to arrest tie- 700 Diphtheria. [October,* almost invariable disposition of the membrane to renew it- self upon the abraded part. As the disease progresses, and the membrane extends towards or into the pharynx, the difficulty in making local applications becomes greatly en- hanced : but 1 he practitioner should not hesitate, for fear of inflicting temporary pain, from thoroughly exploring and covering the parts affected with the solution of hydro- chloric acid. For the purpose of effecting this, it is often necessary to place the head of the patient upon the knee of an assistant, and with a spatula to depress the tongue and the lower jaw firmly at the same time, by which means a view of the whole fauces may be obtained, and an oppor- tunity afforded of making a thorough application of the local remedy. Nitrate of silver has been warmly recommended by Trousseau, Gucrsant and Yalleix, in France, and was the application almost universally resorted to in England at the commencement of the epidemic in that country. The usual mode of using nitrate of silver in England was in so- lution. Dr. Kingsland advised a solution of 16 grains to an ounce of distilled water, and Dr. Hart, 30 grains to an ounce of distilled water. The mode of its use resembles that of the hydrochloric acid. When the local application ot nitrate of silver is made in a solid form, care should be taken that it does not slip from the holder, or break, as in such an event it might fall into the stomach. Such an accident actually happened to M. Guersant, fortunately, however, the stomach rejected it, but this might not always occur, and few medical men would be willing to take so hazardous a risk. Dr. Hauner, of Austria, considers nitrate of silver as the very best local application to the diseased surface, and advises its use in a solution of from a scruple to half a drachm, to an ounce of water.* Subsequent experience did not confirm the good opinion entertained for nitrate of silver among the English practi- tioners, and many who were at first loud in its praises came to disuse it altogether. A substitute for this was found in the scsquichloride of iron, which is recommended by Dr. Hanking as being very efficacious in its effects upon the false membrane. He advises its use in the form of a gar- gle, of the strength of two drachms to eight ounces of CEsterrtecliisclie JaftrbTw!) far Kinderheilknnde, 1^50, vol.ii. 1861.] Diphtheria. 701 water, to "be applied to the throat by means of a brush. In the United States, opinion appears to he divided as to the best local application. Dr. Blake, of Sacramento, has found the greatest benefit resulting from an application of strong hydrochloric acid : a view in which he is sustained by Dr. Bynum and Dr. Thomas, both of whom have had much experience in the treatment of the disease. f Frof. Comegys, of Cincinnati, is in the habit of applying nitrate of silver, either in substance or strong solution in water. Sometimes when the ulcerations are deep, he touches them with strong nitric acid, by means of a brush. In some cases he lias employed, with considerable benefit, inhala- tions of tannic acid dissolved in sulphuric ether, applied by means of a cloth wetted with it, to the mouth. J The for- mula is : IJ-. Tannic acid, - - f. 5ij- Sulph. ether, - - f. 5j. M. l>r. Jacobi, of New York, who, as physician to the Canal Street Dispensary, which treats a large number of German children, has had a very large experience, says: " The local treatment consists of cauterization of the membranes and surrounding parts with the solid nitrate of silver, or with strong or mild solutions of the same salt in water, (5ss-j.: j ;) of gargles consisting of solutions of (or applying in substance,) astringents, such as tannic acid, alum, sulphate of zinc, or claret wine ; in gargling with, or applying such medicinal agents as are known to have some effect on the constitution and tissue of the pseudo-mem- branes, as chloride of potassium, chlorates of potassa and soda, diluted or concentrated nitric or muriatic acids, liquor of sesquichloride of iron, etc. Astringents will prevent maceration, render the exudation dry and hard, and alter the consistency of the surrounding hyperaemic and (edema- tous tissue. It will thus prevent, sometimes, the extension of pseudo-membranes to the neighborhood of the parts al- ready affected, and in some cases may accelerate the expul- sion of the membrane as a whole. We have thus seen the best effects from tannic acid, either applied directly to the parts by means of a curved whalebone probaug, or dissolved Ranking on Diphtheria. t Transactions of the Third Session ol" the Medical Society of tin- St;it.- of California, p. 108. * Proceedings Cincinnati Academy of Medicine. 792 Diphtheria. [October, in water as a gargle (5ss-ii : 51.) Of the tinct. sesquichlor. iron we have seen no particular effect. Cauterization with nitrate of silver we have found to be generally of very little use when applied to the pharynx. Its effect is superficial only, it will form a scurf but will destroy nothing. Des- truction of 'the parts cannot be effected except by forcing the caustic into and below the membrane ; this can seldom be done in the pharynx of children, and for this reason cauterization is unavailing at this point, but will prove ben- eficial, we believe, by confining the process of exudation to its original locality. Tn cutaneous diphtheria cauterization may be exercised to its full extent, but as these cases are generally attended with extreme prostration, the general treatment will prove both more necessary and successful. If cauterization is to be resorted to, we generally use, and with good effect, more or less concentrated muriatic, or acetic, or nitro-muriatic acid. Where, however, cauteriza- tions are made, great caution is necessary not to mistake afterwards the result of the caustic for pseudo-membrane. This remark is particularly applicable where nitrate of sil- ver has been used." Alum, chloride of lime, and calomel are sometimes re- commended. When their use is deemed advisable, they may be applied by dipping a brush, or the finger, in the dry powder, and carrying it directly to the affected part, or blowing them through a quill. Prof. Metcalf advises the use of the bromide of iodine, in the form of two drops to an ounce of the mucilage, or gum arable, as a topical application. lie also gives drachm (loses of this mixture internally, with the happiest results. When there is a considerable accumulation in the nares and behind the velum, the debris and foul secretions may be removed, and much temporary relief obtained by an injec- tion of an infusion of chamomile with a few drops of creo- sote, which may be best effected by a laryngeal syringe. The syringe of \>v. Warren, of Boston, answers a very good purpose for injecting fluid either into the nares or below the epiglottis. It, however, is liable to the objection that it is likely to produce irritation, by coming in contact with the irritable portion, exactly at the opening of the glottis, which is found by the researches of Prof. Horace Green, to b the seat of sensibility, instead of the epiglottis, as has heretofore been supposed. The common glass syringe, with either a curved extremity or a straight one dependant up- lMil.] Diphtheria. 793 on the part to be reached answers all ordinary purposes, and s the advantage of being easily obtained at the apothecaries, and is of slight cost. For correcting the foetor of the secretions, the chloride aoda, in the proportion of one drachm to six ounces of water, may he used with much benefit Dr. Banking sug- gests on the supposition of the presence of some vegetable parasite, the use of sulphurous acid and hyposulphate of soda, in the form of a saturated solution.* uThe power of the latter," he adds, "in destroying the fungoid growth of favus, as well as the oidium which infests the vine, I have myself experienced, and I strongly recommend it provided the vegetable origin of diptheria be confirmed by further observations." Much relief is often afforded by inhalation, especially af- ter the second or third day of the attack. An excellent means of fumigation is to pour boiling water upon catnip, or the leaves of any similar plant, with the addition of a little vinegar, and to allow the patient to inhale the fumes, either by inclosing the head under a blanket, or by apply- ing the mouth to a tube connected with a close vessel con- taining the materials from which the vapor is generated. The immediate effect of fumigation is extremely grateful to the patient. Dr. Ghirdon Buck advises the addition of La- barraque's solution of the chloride of soda, in successive portions of a teaspoonful each, to the liquid used for fumiga- tion. Mr. ('. T. Ilodson recommends the inhalation of boiling water, to which has been added a tablespoonful of chlorinated lime. General Dreatrm ni. The general treatment must be regu- lated by the type of the disease. Shortly after the appear- ance oiM. Bretoneau's treatise, a great variety of treatment was recommended by different practitioners, all, however, with a view to arrest inflammatory action. Leeches to the neck, counter-irritation, especially by means of blisters, active mercuriaiization, and purgative medicines furnished the basis of most of the plans advised. Calomel, especially, obtained great celebrity, and was at one time considered as the most effective remedy in arresting the progress of the disease. It was first prescribed by Dr. Connolly, who was ling at Tours, at the appearance of the disease; and was so efficient in his hands, in minute doses, as speedily to Ranking on Dipl 704 Diphtheria: [October, find favor with tlie French practitioners. But, whatever may have been the success attendant upon its administra- tion at that time, it is now found to require great caution in its use. Blisters are contra-indicated, and so far from furnishing relief, tend to increase the danger by assuming an un- healthy, and frequently sloughy appearance. The bites of leeches often give rise to passive bleeding, extremely diffi- cult to arrest, which greatly reduces the already exhausted energies of the patient. Everything, in fact, which tends to lower the powers of life, or induce prostration, should be sedulously avoided, in the type of disease which at present prevails ; and certainly differs from that for which Breton- neau, Conolly and other medical men in France, at that period, were called upon to prescribe. The type of the disease as it now prevails exhibits a ten- dency to extreme prostration from the very beginning, and requires a tonic treatment to sustain the patient. The most effectual method of accomplishing this is by means of qui- nine, the various preparations of iron and steel, stimulants, in the form of brandy, milk punch and wine whey, and a generous diet, consisting of beef tea, Liebig's extract of meat, and a decoction of coffee. Sulph. quinine may be administered in grain doses, conjoined to two grains of the sulph. of iron, repeated as often as the symptoms appear to require usually every three hours. It is well to alternate this remedy with doses of chlorate of potassa, which appears to exercise a beneficial influence upon the disease of the mouth and throat. Chlorate of potassa may be given in doses of from five to ten grains, in distilled water, or a bit- ter infusion. Prof. Barker, of Xew York, advises the chlo- rate of potassa, in doses from 5ss. to 5j- The chlorate of soda has been recommended with the same intention, but does not appear to be equally efficacious with the chlorate of potassa. The tincture of the sesquichloridc of iron has met with favor among the English practitioners, as a tonic. Dr. Ranking gives it the preference to other tonics, although he frankly admits that it matters but little which of this class of medicines is used, provided the strength of the patient be sustained. "Personally," he remarks, "I give the prefer- ence to the tincture of the sesquichloridc of iron, not only from the inference drawn from the analogy of its unques- tionable usefulness in the more asthenic forms of erysipelas, 1861.] Diphtheria. 796 but al>o from the positive evidence of its benefit derived from the experience of several gentlemen in the country, amongst whom I may mention Mr. Dix, of Smallhurg ; Mr. Prentice, ofXorth Walsham ; and Mr. Cowles, of Stalham: each of whom lias had unusual opportunities of testing its advantages.'" The tincture of the sesquichloride of iron may he administered in doses of from eight to sixteen drops in a little water. Whatever may he the success or ultimate failure of this remedy, its first introduction into the treatment of this dis- ease is undoubtedly due to Professor Thomas P. Ilelsop, of Queens College, Birmingham, who after repeated trials in his own practice, brought it to the attention of his clinical - at Queens Hospital and the Medico-Chirurgical Socie- ty of Queens College. His own success appears truly astonishing. *T have given in this disease," he says, "to an adult twenty-five minims of the London tincture of the sesquichloride of iron every two, three, or four hours, and have conjoined a few drops of dilute hydrochloric acid. I have also applied daily, sometimes twice a day, by means of sponges, a solution of hydrochloric acid, but little weaker than the dilute acid of the London Pharmacopoeia, and have always enjoined the regular use of weak gargles of the same acid. This, with the constant administration of stimu- lants, beef-tea, milk and jellies, has constituted my treat- ment ; and I repeat here, what I have already stated in other quarters, that since I have become aware of the value of this medication, nearly ten months, I have not lost one An excellent formula for administering a combina- tion of chloride of potassa and the sesquichloride of iron, is : Chlorate of potassa, from , brandy, wine and coffee stand prominent. W"hen there is difficulty in swallowing, not only these articles of diet, but quinine may be introduced by means of injections ; a resort to which should not be deferred until it is impossible to administer medicines by the mouth, but whenever the difficulty of swallowing be- comes at all a prominent feature in the complaint. Injec- tions should not be administered in greater quantities than 1861.] Ul 797 two ounces at a time, and Bhould not be often repeated; otherwise they will give rise to a local irritation in the rec- tum, which will prevent their retention. One or more drops of tinct. opii, accordingl ; j of the patient, will greatly aid in the retention of the injection. A-'- the violence of the disease has been checked, a con- tinuance of the tonic treatment should he persevered in for some time, not only to prevent the sequelre liable to follow, but a recurrence of the attack, which often reappears after an interval of several w< pecially when the patient is exposed to those depressing influences which are too fre- quently attendant upon poverty and uncleanline On t: by Nitrate of Si and other Substitute .By E. J. Tilt, M. D., M. R. C. P. In using these agents, we only apply the general princi- ples of therapeutics to the treatment of inflammatory affec- tions of the womb and its associated organs. The utility o( ration of acetate of lead in inflammatory affections of the skin implies similar utility in inflammatory affections of the vaginal mucous membrane ; the utility of solutions of borax and of chlorate of potash in affections of the mouth pointed to their trial as vaginal injections ; the utility of sulphate of zinc and nitrate of silver in urethral stricture-, demonstrated by J. Hunter. Sir E. Home, Laliemand, &c., ed their employment in uterine catarrh; the sove- reign utility in the solid nitrate of silver for the cure of cu- ous ulcerations caused it to be tried in ulceration Ae womb. To whatever mucous membrane these agents arc applied, they act in the same way they substitute a therapeutical irritation, susceptible of being graduated to a morbid irritation, which might uncontrollably compromise the structure- attacked a temporary irritation that tends permanent In treating of injection-. I have already enumerated seve- ral agents which act in this way, such as borax, chlora; . alum, Bulphate of zinc, &c. They generally given largely diluted, but if used in a solid or highly concentn >n of these agents would 798 Uterine Inflammation. October, be analogous to that of two other important agents, nitrate of silver and tincture of iodine, which are called caustics by courtesy, but are no more caustics than tincture of cantha- rides. I wish it to be clearly understood that I hold these agents sufficient for the surgical treatment of uterine inflam- matory diseases in the large majority of cases, and so does Dr. II. Bennett, although it has been stated that we use strong caustics in ordinary cases of uterine disease. In a comparatively small number of instances, the structures of the womb have been too deeply modified by inflammation or by hypertrophy, are in so low a state of vitality that the above-named agents are insufficient to bring about a cure of the disease. Then I have recourse to another class of substitutive agents, which arc undoubted escharotics, for they cause a loss of substance proportionate to the amount of caustic used. Those caustics induce healthy acute in- flammation in the tissues tmderlying the eschar, and, by judicious management of this healthy inflammatory action, the cure of chronic cases is often induced. The caustics of which I shall treat are, the acid nitrate of mercury, potassa fusa cum calce, potassa caustica, and the actual cautery. At first sight it may seem strange to class together sulphate of zinc and potassa fusa cum calce, but one is justified in doing so, because the substitutive action which I ascribe to a solution of sulphate of zinc is pre-eminently shown in the results of potassa fusa cum calce, which often so raises the vital endowments of the uterine tissues as to promote rapidly healthy nutritive action in tissues which had been diseased for many years. Such is my mode of practice, and I am glad to find that it accords to a certain extent with the practice of all whose opinion carries weight, and who having in vain tried to cure uterine diseases by nitrate of silver or milder measures, have recourse to one or the other of the strongest caustics. Dr. Fleetwood Churchill depends on nitric and muriatic acids, and on the acid nitrate of mercury, which is also pre- ferred by Dr. E. Kennedy and by Dr. West, and although this distinguished pathologist considers ulceration of the cervix to be a condition of slight pathological importance, when he has to trace out a plan of treatment for his pupils, he has none other to propose than that already long ago carefully laid down by Dr. H. Bennett. The late Dr. Rig- 1>\\ though adverse to the surgical treatment of uterine affections, admitted that there were certain cases of uterine L861.] T99 ulceration requiring i fusa, or potassa fusa cum calcr. Jh\ U. Beunett prefers potae a fusa cum calce. This is not energetic enough for Professor Simpson, who a; while the French strongly advocate a remedy older than Ilippocrates, the actual cautery. These comments upon the treatment of uterine inflam- mation will show that i am an eclectic, and that I use all the valuable agents which I have enumerated in certain es which I shall specify. Again reminding the reader that I am not writing a treatise, I shall proceed to comment on the use of our principal substitutive agents. Tincture of I 'I'm'. It is the ordinary tincture of the Pharmacopoeia which I mean, not the caustic tincture. I shall he brief on this agent, having already mentioned it as a revulsive, and having compared it with others then under discussion. Tincture of iodine seems to act as an astrin- gent when slightly applied to the hypertrophied or in- flamed surface of the neck of the womb, but as a vesciant if several applications are made at one and the same time, and as a resolutive it re-applied every third or fourth day. It is much less useful than nitrate of silver as a topical ap- plication, but it suits better some idiosyncracies, and is well borne in diphtheritica! inflammation, when nitrate of silver should not be used. The fact that a solution of iodine can be injected into closed cavities and fistulous passages with- out severely inflaming them, marks it out as the best liquid to be injected into the bod}' of the womb, in the very rare es requiring such treatment ; for it has less frequently 11 rise to the alarming symptoms of peritonitis, which have very often followed the intra-urine injection of a solu- tion of nitrate of silver. I use one drachm of the tincture to an ounce of distilled water, and inject it by means of an instrument similar to that devised by Mr. Coxeter for in- jecting fluids into the larynx. NUtraii of SUvi r. --The application of nitrate of silver is a means, under certain circumstances, of subduing external inflammation. Might it not, on this principle, be of ser- vice in the treatment of the internal phlegmasia '.'" Such the question asked by Mr. Uigginbottom in the preface of his admirable little work on uThe Lunar Caustic," pub- lished in 1826. Jlis question i a answered in the affirmative by a great many practitioners, who have applied nitrate of silver for the cure of inflammatory affections of the mucous membrane of the irs, mouth, throat, 800 Uterine Inflammation. [October, urethra, the intestines and the rectum. As regards the mucous membrane of the genital organs, Dr. Sewel, in 1830, strongly advocated its use ; and I have no hesitation in saying that this great agent is quite as useful in curing the varied inflammatory conditions of the genital organs as in curing those of the skin. It is often necessary to preface the use of nitrate of silver by linseed tea, poppy-head, or other cooling injections, in the same way that Mr. Iliggin- bottom repeatedly inculcates the utility of cold poultices previous to applying nitrate of silver to the inflamed skin. If, after antiphlogistic treatment, the solid nitrate of silver increases too much habitual pains, or causes the ulcerated surface to bleed for two or three days afterwards, it is well to try a solution of from forty to sixty grains of nitrate of silver to an ounce of distilled water. In many cases the solution is sufficient to effect, a cure ; it gives less pain, but it may be necessary to repeat it every third or fourth day. Sometimes I nse a solution of nitrate of silver containing one ounce of the salt to two or three ounces of distilled water, as an application to ulcerated surfaces. Chronic uterine catarrh, or inflammation of the mucous membrane lining the neck of the womb, which has been truly called an open gland pouring out mucous from ten thousand folli- cles, seems to me the most frequent of all uterine diseases. Without having the slightest abrasion, the mucous mem- brane lining the neck of the womb and its vaginal surface may be of a dusky, livid hue, tender on being touched, and secreting pus. This condition may last for years, but it generally leads to more or less extensive denudation of the villi of the uterine mucous membrane, and gives an ex- coriated appearance to the neck of the womb. Such ca- with or without excoriation, can be cured by the nitrate of silver in solution, and every fourth or fifth day, with the occasional use of the solid nitrate. If the mucous mem- brane lining the cervix be principally affected, it is often so obstinate as to render the painting of it with the solution of little use. The solid nitrate must be freely employed, and when the cervical canal is usually dilated, I sometimes leave about one-eighth of an inch in the canal ; by which it will be clear that, so far as my experience goes, should the stick accidentally break in the cervical canal, it need give no alarm. What cannot be removed will cause more pain, some loss of blood, and perhaps even a return of menstrua- tion : hut the patient may be repaid for greater suffering by I. j i -/'. 893 a speedier cure. It has been stated by Nonat that this mod< of treatment has caused Btricture of the uterine canal in hie practice and that of Richet. I have never met with this accident, and I think its occurrence is to be prevented by the occasional } if the uterine sound lor a few weeks after this Beverc application. With regard to the treatment <>f the various forms of ulceration of the neck of the womb, I pan add nothing to what has been bo well laid down in J)r. II. Ben net's work. Mr. Higginbottom, whose statements with respect to the action of nitrate of silver deserve the highest eonsiderai affirms that its action does not extend beyond three day- after its application : and it is generally received that it is necessary to repeat the use of this agent so soon as the epi- thelian pellicle has fallen off, or every third or fourth day. In many instances this is the best way of ensuring the most rapid recovery: but I do not recommend the too strict ad- herence to this precept, as it is often well to leave five, six -ven days' interval between the applications, or we might work as did Penelope, and retard the cure of the . This, however, is a matter of surgical experience in each individual a Whether vaginitis occurs spontaneously or as the result of uterine catarrh, it is best cured by the injection of a solu- tion of nitrate of silver. This is an excellent idea of Dr. Jewel, but if the solution be sufficiently strong to do good it cannot be safely trusted to the patient. The patient being placed on her back, a small glass speculum should be introduced as far as possible, and an ordinary glass syringe full of a solution of nitrate of silver containing forty grains to the ounce should be injected. 1 ne speculum should then be withdrawn to the vicinity evidence of inflammation of the womb, with excoriations of its cervix, in virgin- in whom the integrity of the hymen prevents the introduction of a moderate-sized Bpeculum. This plae should be first tried before forcibly dilating or iucisiug the r>\ 802 Uterine Inflammation. [October, hymen an operation which is very rarely required. I have frequently made these injections in many cases, and I do not (nice remember having traced monorrhagia to their ad- ministration. I mention this as it seems to have often occurred in the practice of Dr. Fleetwood Churchill. So many serious accidents have followed the injection of the solution of nitrate of silver into the body of the womb, that I prefer using tincture of iodine in solution whenever intra-uterine injections may be required. In very rare cases of chronic internal metritis it may even be necessary to ap- ply the solid nitrate of silver to the internal surface of the body of the womb, as well as to adopt other modes of treatment, for an account of which I refer the reader to my papers on the Treatment of Internal Metritis.* In follicular inflammation of the labia in eczema and prurigo pudendum, or pruritus both external and vaginal, a piece of cotton wool should be soaked in the solution of nitrate of silver, and carefully rubbed for two or three min- utes over the diseased portions of the skin and mucous membrane. I can speak with confidence of this plan, for I have lately cured several patients who had been suffering in this way for four, eight, and thirty years. When cases have lasted so long the pudendal skin looks and feels like parchment. It was so in the case of a lady in whom the disease had lasted tor thirty years, and I first rubbed in the solution every day, then every other day, then every fourth and fifth day, until the skin became soft and pliable, and the sleep was no longer disturbed in darts of pain flashing along the nerves. This patient was cured in three months. and has had no relapse during the last year. I trust I have said enough m praise of nitrate of silver : but in many forms of uterine inflammation much more se- vere agents are required to restore the womb to a healthy state. This fact is admitted by so many authorities at home, in America, or in foreign countries, that I am surprised to find the contrary asserted by Dr. Meigs and Dr. Tyler Smith. After describing the evil effects of caustics in the treatment 'of uterine disease, the latter pathologist, in his work on "Leucorrhea," (p. 203) gives as his opinion that 'there is no good which can be effected by the more pow- erful caustics which cannot be accomplished by the nitrate The Lancet, 1853, vol. 1861.] Uierbu Inflammation* ver, or by other moans. It is true that by the prolong- ed application of the nitrate of silver, loss of substance may aused ; but this is far less likely to occur with lunar caustic than the more powerful escharotics, It is also true, that some practitioners apply the more violent caustics lightly that they do not exceed the milder medical action o[' the solid nitrate of silver : but in such cases it would be quite as well to use the safer remedy where a caustic is re- quired." And at p. 2(^6, "In applying the nitrate of silver, the aim should he not to produce any slough or loss of sub- Btan< Thus it is clearly stated that the slight applica- tion of the Btrong caustics is tantamount to the full action of the nitrate of silver in like cases of uterine disease. My experience, on the contrary, teaches me that nitrate of silver is no more a caustic than tincture of cantharides, a- Mr. Hiffffinbottom lias lonsr ago asserted. The distinc- PC ~ o tion that Dr. Meigs draws between the antiphlogistic touches and the escharotic action of nitrate of silver, does not hear examination. Use it as you may the nitrate of silver does not cauterize. Leave it in the neck of the womb, it will cause more pain, loss of blood and subsequent discharge, hut no destruction of tissue, unless coagulated mucus mixed up with epithelial scales and insoluble chlo- rides of silver can be called such. Even when applied to a fungous ulcer, the slight loss of substance is rather due to the friction of a hard body on a pulpy than to the chemical combination of the neutral salt and the diseased tissues, .V densely hypertrophied neck of the womb might be whiten- ed with the solid nitrate of silver every fourth day until doomsday, without much reducing its bulk. Indeed I have seen >\\o}i a plan of treatment injudiciously continued for a year or longer in a case of hysteralgia, the neck of the womb 1 - althy and of an average size, and the effects were rather astringent than caustic, condensing the tissues, narrow]' ervical canal, and rendering its dilatation necessary and difficult Thus, while nitrate of silver may repeatedly applied without inducing a loss of Bubstance, the slightest application of the potassa fusa to the neck of the womb produces an evident loss of substance ; ami th< fore, the two agents, however applied, produce totally dif- ferent effect- in similar cases. This i- a question of surgical therapeutics which can be decided by any experienced urgeon. Writing on the treatment of Btricture caused by gristly thickening of the urethral mucous membrane, Mi-. 804 me Inflammation. [October, Wade records his twenty-live years' experience of the com- parative advantages of nitrate of silver and of potassa fusa, and he states : "] cannot let this opportunity pass without again calling attention to the fact, that the effects of the argentum nitraturn and of the potassa fnsa admit of no com- parison, as they are totally dissimilar: that the former, when freely used, from its tendency to cause adhesive in- flammation, has often been found to increase the urethral obstruction, whilst the remarkably solvent powers of the latter have no such tendency. "* The too fret' use of the nitrate of silver to the modular tissues of the urethra causes Urethral stricture, as the too free use of the same agent to the cervical canal causes stric- ture of the neck of the womb, but without loss of substance. Indeed, if the whole range of diseases in which nitrate of silver is now nsed be passed in review, it will be found that it always acts by its dynamic, astringent and antiphlogistic properties : whereas escharotics can only raise the standard of vitality of any given tissues by the previous destruction of their superposed surface. I maintain, on the contrary, that there is one good to be done with the more powerfu caustics which cannot be accomplished by the nitrate 01 silver; that is, to shorten the treatment of many cases ii which it is ., of London. This paper was an appendix to a former, and its object was to solve two main questions : 1. The essential condi- tion or lesion of the limb in this affection. 2. The mode of production of this lesion. In regard to the first it was maintained that the presence of fibrinous serosity in, with more or less hypertrophy of, the fibro-cellular tissue, is the essential, the sufficient, path- ological lesion; that the inflammation, the abscess, the sloughing, etc. are not peculiar or necessary parts of the affection, but common to many diseases, and the result of an eliminative act to rid the system of some blood-poison ; that the latter may produce lymphatic and venous obstruc- tion, and hence phlegmasia dolens; but it passes beyond this, giving rise to a distinct disease, such as abscess, pyeemia, etc. Phlegmasia dolens in these cases is a local complication of the general disease, and the general symptoms are but parts of the phlegmasia. There are then two types of this disease : a. The complicated, in which an eliminative process (in- flammation, abscess, etc.) takes place, these being the an- swer acts of the tissue to the blood state ; the epidemic form, in which an effect is produced by a virus, superadded to what occurs in pJ7;. The other class the uncomplicated where the blood state does not require any eliminative actions to be per- formed on the part of the tissues, but where simple obstruc- tion exists, such as pressure by tumor, etc. and simple thrombus; this being the essential, simple, ample disease, all else being superadded and accidental. It having been shown that venous obstructions produced oedema only, and this plus lymphatic obstruction, (phleg- masia dolens,) the second question as to the mode of pro- duction of the lesion in the limb might be stated thus : I low can obliteration of the lymphatics produce the peculiar change of the limb in phlegmasia dolens ? The lymphat- ics being obstructed, the three offices of removing waste, of absorption, and of formative power, could not come into play. it was then argued at length that the amount of lymph- atic distribution and fibro-cellular tissue are in direct ratio 1861.] Termination . \ es. 807 that fibrin is the pabulum of the Utter tissue and that Yirehow's views on this point clash with sound doctrine. Lymphatic obstruction being followed by the retention of fibrinous serosity iu the cellular tissue, the inference allow- ed by the foregoing tacts was, that one office of the lymph- atics is to remove all superfluous material from the cellular tissue; to keep the balance of nutrition there correct ; hy- pertrophy and retention of fibrin in the cellular tissue ensu- ing upon lymphatic obstruction ; and this explanation is confirmed by the behavior of the lymphatics in cases i)[' cancerous ulceration, etc. (When a blood poison is present spec' actionSj as abscess and the like, are superadded.) It was attempted to be shown that absorption by the lymph- atics from ulcerated surfaces might give rise to thrombus at the entrance of the thoracic duct into the junction of the jugular and subclavian veins, and thus account for phleg- masia dolens occurring in the upper extremity in cases of disease of other parts of the body, e. , 1860. On th< Termination of Nerves in the Voluntary Muscles of Mm >>/<. vol. x. ]>. 619, SOS Termination of Nerves. [October, voluntary muscle be found which is not abundantly supplied with nerve-fibres. The elementary fibres of the tongue and diaphragm of the white mouse arc nearly covered with nerve-fibres and capillaries ; the sarcolemma indeed appears to be principally composed of these structures. The mus- cular fibres of mammalia and birds receive a much larger supply of nerve fibres than those of fishes and reptiles, but in insects the most wonderful structure exists on the sur- face of the muscle. In some muscles the entire surface is covered by some long, spindle-shaped, and very large nerve vesicles, which can be shown to be continuous with^he nerves. This beautiful structure is completely destroyed very soon after death, and not a trace can be discovered if a little water comes into contact with the muscle. In mammalia, the nerves arc seen to run for a long dis- tance with the arteries, and their ultimate divisions come into very close relation with the capillary vessels. As the nerve-trunks approach their distribution, each in- dividual fibre divides and subdivides, and the fibres result- ing from this subdivision often pursue a very long #nd com- plicated course, running for some distance parallel with other fibres derived from different trunks, but it is not pos- sible to follow any one individual fibre for any great distance. Fine trunks, composed of from three to seven or eight fibres, can often be seen traversing the muscle. The fibres pursue different directions ; some dip down between the elementary muscular fibres, some pass over the surface and form with others, from a different source, small compound trunks, while others may be traced onwards for some dis- tance : the individual fibres which gradually separate from each other being distributed to different parts in succession, of several different elementary muscular fibres. When the finest nerve fibres can be seen passing round the elementary -cular fibres, they cleailv consist of very delicate flat* tened bands. Of the Oral Bodies or Nuclei. Connected with all nerves in every part of the \)Oi]\\ sensitive, motor, vascular, and pro bably in all animals, are little oval bodies or nuclei, wnic" are the organs by which the nerves arc brought into th closest relations with other textures, and from them ne branches are developed. The nerves multiply at their di ti'ibution by the division of these little bodies, and upo them their action and, in all probability, the manifestatio il.] Termination of Nerx of the nervous phenomena depend. A great number of these little bodies are associated with perfection of nervous actions, aiul vice versa. They are found very freely con- nected with the vascular nerves, and are abundant on those nerves near the ganglia from which they proceed, and in the ganglia themselves. These bodies with the nuclei of capil- lary vessels and those of fat vesicles, and probably other structures with peculiar cells, which alone deserve the name have been included under the term " areolar-tissue corpus- cles," ( Bmdcgetoebe-JKprperchen.) As specimens are usually prepared, it is quite impossible to distinguish these struc- tures from each other. Beale believes that the gelatinous fibres, or fibres of Remak are, after all, real nerve fibres, and not a peculiar modification of fibrous tissue, as is now generally believed. The nerves and vessels, and with them, of course, the oval bodies, may be Stripped oil' from the elementary mus- cular fibre. the manner in which Nervei. terminate. The fibres con- necting the oval bodies or nuclei form with them a network the branches of which are of course, continuous with the subdivisions of nerve fibres. The arrangement of the net- work, and especially the number and proximity of the nu- clei to each other, differs materially in different localities. On sentient surfaces the meshes arc wvy small and the nu- clei close together: but from the complexity and great num- ber of the fibre- ; from the fact that many fibres which ap- pear to be Bingle can be resolved into three or four individ- ual fibres, and from the circumstances of the network being imbedded in mosl cases in the midst of fibrous tissue, it is very difficult to describe \\< exact relations and disposition. However, from the connections of this network with the nerve fibres, it would seem to follow that an' impression made upon a given portion of a sentient surface might be transmitted to the nervous centre by contiguous fibres, as well as by the one which would form, bo to say, the short- est route, and it is possible that impulse- to notion may be conveyed t< muscular fibres by a more or le Termination of Nerv October, ] towers (700 diameters) many fibres which appear to be single when seen by lower powers, can be resolved into three or more, all enclosed in the same transparent tissue. As the nerve-fibres approach their distribution, this trans- parent structure becomes much spread out. It is intimately connected with nerve-fibres and capillaries, and with them tonus a delicate expansion over the muscular fibres, and in other parts. Delicate libres also, in connexion with the nerves and capillaries, may be observed in it. In some cases this expansion seems to be incorporated with the sar- eolemma, and it is probable that in certain instances it is really the structure which has received that name. Axis Cylinder and White Substance. Beale has been led to conclude that in consequence of the free division of the axis cylinder and white substance near the point of distri- bution of the nerve, a single fibre in the trunk of a nerve may earrry impressions to or from a much larger extent of surface than is generally supposed. The white substance which surrounds the axis cylinder gradually diminishes, until in the finer ramifications it is impossible to say that a fibre consists of an axis cylinder and white substance, for its general appearance and refractive power are the same in every part, except where the nuclei are situated. Beale considers that the definite characters of the axis cylinder and white substance in the trunks of the nerve maybe due to the gradual growth and altered relations of the fibres which occur during the development of the entire organism. In the ultimate ramifications the whole fibre seems to con- sist of a very transparent and perhaps delicately granular substance, but no tubular membrane, medullary sheath, or axis cylinder can be demonstrated as distinct structures. Qf the Formation of New Fibres. In connexion with the terminal ramifications, new fibres are being continually de- veloped by the division of the nuclei, and old ones undergo removal. " The remains of the latter may, however, be seen in the form of very delicate fibres, in connexion with active nerve fibres. Beale regards much of the so-called connec- tive tissues between the elementary libres of muscle and in some other situations, as of this nature as the remains of structures whose period of functional activity was past, and which have been removed, with the exception of this small quantity of insoluble material. The method of preparing the specimens is then briefly described. Observations were conducted principally on L861.] Thrminatiqn ttf Ner Ml white mice, which wore injected with Prussian blue fluid immediately alter death. : l.eale concludes his paper. which will he published at length in the 'Philosophical Transactions,' with the following summary of the most important facts elucidated in the inquiry : '1. That nerve-fibres in muscle and in many other tissu if not in all, may he traced into, and are directly continuous with, a network formed of oval nuclei and intermediate tibr :2. That the organs by which nerves are brought into relations with other textures, and the agents concerned in the development of nerves and the formation of new fibres, are the little oval bodies or nuclei which are present in con- srable number in the terminal ramifications of all nerves. A -Teat number of these bodies is associated with exalted aerrous action; while, when they are sparingly found, Ave may infer that the nervous phenomena are only imperfectly manifested. ".. That every elementary fibre of striped muscle is abundantly supplied with nerves, and that the fibres of some muscles receive a much larger supply than others. 4. That the nerves lie with the capillaries, external to, but in close contact with the sarcolemma. They often cross the muscular fibre at right angles, so that one nerve-fibre may inline] . reat number of elementary muscular fibres. There is no evidence of their penetrating into the interior of the fibre." The paper is illustrated with drawings, most of thorn magnified 700 diameters. Brit. S- lr<>r.31e>?. Chirur. Rev 8 at their Periphery and in Differ- By Jacobowitch.f - author, from his observations, comes to the follow- ma : 1. That each nerve, of whatever nature, takes origin from The V ita application t< Practical Medicine, p. ',:;. r In a v mmunicafc A.cademi . 7th, 1800, ]. 7' 812 Development of Bloodvessels. [October a iutvous cell in the central nervous organs, and terminates at the periphery or in the interior of an organ : [a) Either in a nerve-cell, and, in the case of nerves o\ sense, in the nucleus itself; (l>) or in the mass of a cell {Hans la masse (rune cellule) in the interior organs in the ease of the ^anplio- nic nerv< or finally, by forming a nervous capillary network where the anatomical differences disappear, the axis cylinders passing the one into the other. 2. That the nervous system, central as well as peripheric, forms a whole which, like the sanguineous system, exists in every part of the organism, penetrating across different parte, and arriving at the ultimate elements without at all becoming lost in a vague or confused manner. 8. That the nervous elements, the cellules as well as the axis cylinders, are always in course of development in the central organs as well as at the periphery. 4. That the part played by the cellules varies, for they either preside over special functions, as in the organs of sense, or subserve the preservation of the organs them- selves, as in the case of glandular and nervous organs; the physiological function (properly speaking) of the organs arising from the connexion of these nervous cellules with the central nervous system. 5. That if the anatomical difference disappears in the capillary nervous network, owing to the axis cylinders being cOnfhsed, the physiological difference remains. Hid, On (he Development <>f Bloodvessels. By E. Rindiieiseh.* The transparent border of the tadpole is the best used for observation, and the most recent layer of connective sub- stances between the free margin and the outermost capillary loops is found to he that in which the new vascular forma- tion proceeds. In certain place's, blind projections take i-t. [naug. Berlin I860: quoted from Yin-how's Archiv., J5;m. They project with their free surface1, which is cover- ed* with the venous epithelium (the Bpleriic fibres of earlier authors) into the cavities of the cavernous network ; the meshes, consisting of areolar tissue, go between the epithelial cells with the Malpighian bodies, ami become narrower within them. On each Malpighian corpuscle, beneath the venous epithelium, runs a small arterial vessel which becomes lost on its surface (in a tuft-like manner) in ;i great number of capillary twigs, many of which allow but a r.ingle blood cor- puficle to pass. The capillary wsr-ols pass from the surface into the interior of the Malpighian corpuscles, and become larger within, owing to the concurrence of many twigs. After their union in a central vein, this passes out into the surround- ing cavernous network to embouchure into a larger vein. etiinee, hut rarely, Bmaller isolated veins also pass from these bodies in addition to the central vein. The larger cen- tral vessels are evidently veins, not only from their emptying into larger veins, hut also from their walls being thinner than those of arteries, and from their having the characteristic epithelial cells of splenic veins on their inner surface. The space between the- meshes of the cavernous network in the splenic corp: filled with white blood-corpuscles, which only appear to differ from those in the body generally by their being smaller, and having a BOmewhat clearer outline. This may be from the deficiency of fluid. On ligaturing the inic artery of a t\<>'j:, and killing it some days afterwards, it will he found that \\ic central vein of each splenic corpuscle may he seen with the naked eye as a red point on a white ground, and the corpuscles appear enlarged. Moreover, the central vein may he seen very clearly in the spleen in c, wherein >oine time previous to death the sympathetic nerve addressed to the spleen has been divided. Ibid. ],, J '), /, loprru at of tin Follicli 8 of //>> Ovarii a and of tin Ovum in tl- mammalia. By Otto Spiegelberg. The following ations were conducted <>n the human enduy... a- well a- on the embryonic and newly-born rabbits, The author was unable t' recognise the tKon: Ges : der Wiss. zu Gottiu i, Juli, No. 20; aa quoted in Virchow'fl Arohiv. Band rx. I!. 210. Mi; Ammomcemh. [October, tubes in which the ovarian follicles should be found, described by Valentin. At the time in which the sexual differentiation begins to proceed, and the male germ-glands possess seminal canals, the ovary is seen to be composed of large bright cells which, by reason of very delicate areolar-tissue-partitions and bloodvessels extending from. the hiius to the periphery, are arranged into irregularly-shaped heaps. These germ-cells Spiegelberg terms primary ovarian cells, and their large vesi- cular nucleated nucleus he designates "germs.'' During the growth of the germ-cell the nucleus divides, at first into two, later on to a greater extent, and the wall of the mother-cell so originating appears to he doubly contoured. These mother- cells are the primordial follicles, and are very like the sper- matic cells. As soon as they are quite tilled with germ, one of them, generally the central one, greatly enlarges; and besides the nucleus, a delicate investment and a granular con- tents may be seen within. The germs surrounding also increase meanwhile and form into cells, and become covered by an investment. The first of these cells is the ovum, the last forms the element of the "membrana granulosa." Thus, according to our author, is the formation of the ovum in the higher animals assimilated to that observed by Meissner in the ascarides, &c. Soon after birth the formation of germ- cells into primordial follicles is complete, the latter being, later in life, no more formed anew. In newly-born animals the younger follicles are always found at the periphery of the ovary, the older at the deeper parts. .By the growth of areolar tissue and vessels the mother-cells become isolated; very rarely only do two or more become fused into each other. Ibid. Aramonuvhuo. A paper by Professor Jaksch, in the Viertel- jahrschrift f. Praktische Heilkunde, 1S60, ii. Translated by C. A. Hartmann, M. I)., Cleveland, O. The word ammonhmma, first used by Prof. Treitz, should be applied to a kind of uraemia arising from putrescent urine containing carbonate of ammonia, being resorbed and intro- duced into the blood a condition which must not be con- founded with Blight's disease, for it is essentially different from it, although both affections may appear in conjunction with each other, drsemic manifestations are not developed, L861.J lid. 817 in Blight's disease, before the uriuiferous tubes beconie im- pervious ; but true ajnmoniaamia is the consequence of urine, in a - decomposition, being received into the blood ; an occurrence which may happen either from a torpid or para- lyzed state of the urinary bladder, from dilatation of Mal- pighi's pyramids and the renal pelvis while the ureters arc impervious, or from abscess, tuberculosis and other diseases of the kidneys. The urine has, in this disease, always a pun- gent, ammoniacal odor ; hydrops is never connected with am- monisemia, but there is a persistent dryness of the mucous membrane of the mouth and fauces; the patient feeling as if even* particle of humidity had been dried up by some absorbent. Sometimes this dryness will spread to the Schnei- derian membrane, the conjunctiva of the eye, and the liga- ments of the larynx, producing hoarseness or aphonia. There is always a strong and well-marked ammoniacal odor in the air expired by the patient ; and the same odor is perceived by lifting the bedclothes. A great aversion to meat is never wanting-, and violent intermittent chills arc of frequent occur- ence ; while neither convulsive fits, nor croups, nor diphtheric exudations have been observed during the disease we are treating of, nor have disturbances of the vision been noticed. A constant symptom is a singular grayish discoloration of the face, with progressive emaciation ; very acute cases are accom- panied by a rapid collapse of the features, and a muscular weakness bordering on paralysis. In such acute cases, vomit- ing, accompanied or followed by diarrhoea, is always present ; :ldom, or only for a short, time, occurs in the chronic form of the disease. Death is always preceded by a soporous state, lasting fmm a few hours l<> several days. Acute ammoniaunia runs its course in a few (from two to six) days, and terminates, if properly attended to, in recovery ; if not, in death. More or Less vomiting is usually the first symptom in such cases ; often soon followed by febrile mani testations, rapid collapse and sopor. The chronic form may last weeks, months and years, with temporary improvements and changes for the Averse ; it can terminate favorably, even after a long time, if recognised and correctly treated ; but may induce death in spite of all treat- ment when its causes cannot be removed. There are always ccompanying chronic ammonhemia, but they are often mistaken for catarrh of the gastric and intestinal mucous membra' may also occur which simu- late typhoid or intermittent fever. On account of these vary- ing symptoms, it is rather difficult t<> give a good description 818 Ammoniamia. [October, v^^%/\y of the* disease, and it appears, therefore, better to describe the different forms according to their cause and predominant symptoms, after having mentioned what is common to all the forms, and necessary to the diagnosis. Most frequently, ammoniajmia is produced by diseases of the urinary bladder more particularly torpor and paralysis ; a morbid condition of the ureters or kidneys but rarely causes it. Torpor of the bladder may develop itself gradually, turn- ing into complete paralysis only after a long time, or it may arise rapidly. Accordingly, the symptoms of ammonisemia will be either manifest, to a slight degree, but for a long time, so that they are scarcely heeded and easily overlooked ; or they appear more suddenly and with great intensity, so as to greatly embarrass both the patient and his physician. The torpor can be induced by some impediment in the urethra or prostate, or by a want of innervation or change in its texture (hypertrophy, catarrh, inflammation, ulceration, carcinoma.) In consequence of the paralysis, some ulcerative or diphtheric process, or gangrene may be produced by the stagnant and decomposing urine in the bladder. The progress of the dis- ease does not, however, depend entirely on pathological changes in that organ, but also on the action of the organs serving to the excretion of ammonia ; the lungs, skin, kidneys and intestinal tract ; further, in the age and constitution of the patient, as well as on external influences. A sojourn in the country, for instance, proves very beneficial in chronic ammoniremia. For a correct diagnosis, the following points must be con- sidered : 1. The degree of torpor or paralysis of the bladder, and the cause of the same. In the chronic form, sensible and motory paralysis are generally developed at the same time. Although there is a large quantity of urine accumulated, distending the bladder above the symphysis, and not unfrequently to the navel, the patient experiences no pain, or some dull, painful sensation, and no inclination to void his urine, unless the bladder be extended beyond the already habitual measure ; even then, only this surplus of the accumulation is evacuated ; the stagnant quantity remains unchanged, or increases even with the torpor. Acute paralysis commonly produces, in the beginning, violent tenesmus and pain, which decrease when the paralysis has reached a certain height, and disappears with the more developed distension of the bladder. . 2. With the torpor and paralysis, and usually before they have been carried to a very great extent, commences the de- '1861.] vmxmksmia. 819 composition of the stagnant urine, and its resorption, ft is evident that the decomposition must be hastened by the pre- sence, in the bladder, or catarrhons secretions, blood, or pro- ducts of exsudation. At this stage of the disease, the urine, he it evacuated spontaneously or artificially, presents a pun- gent, often distinctly anmioniacal odor, ana a mucous or puru- lent sediment, sometimes mixed with blood. Wherever an ammoniacal odor is perceivable in recently-voided urine, we may pretty certainly diagnosticate ammomsemia. 3. The carbonate of ammonia is eliminated through the? lungs and skin soon after its reception into the hlood ; this is proved by the distinct ammoniacal odor of the expired air. and other exhalations. Where this odor is not very distinct, the expired air may be tested with humid litmus-paper, or with a stick of glass, previously immersed in muriatic acid. The chemical analysis of the hlood would, undoubtedly, fur- nish the best basis for a correct diagnosis; but the patients afflicted with ammoimemia are always in a state which does not admit of the depletion of blood. i. Gastric symptoms, as already described, are always pre- sent. The evacuations in acute cases do not, at least not in the first time, present a distinct ammoniacal odor; but this \- always well marked, when emesis and catharsis appear with an aggravation of the disease. In chronic ammoniaunia there may be neither vomiting nor diarrhoea, but rather a tendency to constipation : the appetite is, however, with very rare ex- ceptions, disturbed, and a marked aversion to meat present, such as is not observed in any other disease, even not except- ing cancer of the stomach. Other gastric symptoms, for in- stance, a sensation of dull pressure or burning pain in the ach, accumulation of gases, bad taste, furred tongue, etc., are not characteristic of ammonisemia. But the dry condition of the month and fauces is important, and may often lead to the diagnosis when other prominent symptoms are wanting. The discoloration of the face, the emaciation and collapse the features, finally the continuous depression of spirits, which is frequently explained as hypochondriacal, will serve to confirm the diagnosis. The effect on the mind of the patient may grow >tr<>nir enough to induce the committing of suicide. In the treatment, stricture- of the urethra, which are fre- quently present, mnst be removed, and the urine regularly evacuated by means of the catheter. Milk diet, residence in the country, generous exercise in the fresh air. are often suf- ficient, in addition to these mean-, to restore the patient. Daring recovery, a vigorous diet is required, which may bo 820 Arnmoniccraia. [October, combined with the use of some acidulous or ferruginated mineral water. Strictures of the urethra have often been overlooked ; I think they alone have given rise to the haemorrhoids of the bladder, that we used to hear so much about in times not long gone. Of equal importance with the strictures are diseases of the prostate in connection with ammonisemia. Amongst them are, atrophy in consequence of preceding inflammation, general or partial hypertrophy and develop- ment of an accessory tumor, pressing on the urethra or the neck of the bladder. They impede, more or less, the evacuation of the urine, cause torpor of the bladder, hy- pertrophy of its walls, diseases of the ureters and kidneys, and consequently ammoniamiia, which sometimes appears soon, but often only after a long time. The difficulties of a successful surgical treatment, in such cases, render the prognosis rather unfavorable. Hypertrophy of the prostate will often yield to a strong ointment of iodide of potassium applied to the perineum, and combined with the internal use of acidulated waters. With the cautious use of the catheter, and a decoction of secale cornutum, exhibited in- ternally, the alread}r developed torpor of the bladder, and other symptoms, even of chronic ammonisemia, may be re- lieved. A long practiced intentional retention of urine is apt to end in the highest development of ammonieemia, without any difficulty in, or around the urethra. The greater the change in the textures, following this cause, the smaller is the prospect of recovery. That stones in the bladder result fatally through ammo- niaemia, has been long known to surgeons; the disease I designate by this name is well described, with all its symp- toms in their books. It certainly plays a very important part in its connection with urinary concretions. Without an operation death is certain to follow, while success with a surgical proceeding depends completely upon the presence and extent of ammoniaBmia. Under the influence of blood poisoned by ammonia, diphtheritic processes and exulcera- tions in the artificial wounds are unavoidable. Cancer of the bladder is always, in the end, accompanied by ammonisemia. Medullary carcinoma of the inner sur- face of the bladder induces 'hemorrhage, and thereby de- composition of the urine. Mechanical obstruction of the ureters, or destructive dis- Ammonimmia. 821 a of the kidneys, lead either to ammon"nemia or nra- mia. A painful anuria, sometimes relieved by copious dis- charges of bloody urine, pain and swelling in one or both sides of the abdomen indicate the primitive cause. If there is a concretion, the ureter becomes dilated above and around it, the walls are pushed outward, and the room thus made allows the urine to pass until the stone, pressed downwards is again wedged in. Even large concretions may, in this way, reach the bladder, and as long as the other kidney is not disturbed in its functions, there is not much danger. .V continued stagnation of the urine in the pelvis of the kidney may, however, result in decomposition and resorp- tion ; that is, ammoniaemia. Of course, death may ensue without that for instance, as a consequence of anuria and uremia in 6bl iteration of the ureter. Tuberculosis of the kidneys is also one of the exciting causes of ammoniremia. How far abscesses of the same ,ns may have the same effect, cannot be at present as- certained, besause they were complicated with diseases of the bladder, wherever observed with the disease in ques- tion. The kidneys may be destroyed by extensive ulcera- tion, ending in death, without one symptom of ammoniae- mia. Cancer of the kidneys is also not likely to produce it. Another form of ammonimmia, distinguished by a very rapid course, arises from the decomposed urine penetrating into normal tissues. This may happen, for instance, into the cellular tissue of the peritoneum, by ulcerative rupture oi* the urethra, or into the tissue of the abdominal walls after puncture of the bladder, when the urine was in a state lecomposition in consequence of previous dise; There are violent pains, frequent chills, vomiting and fre- quent diarrhea, ending in sopor and death. The senile vesical torpor developes itself, without any demonstrable morbid affection of the bladder or urethra, in persona about, or beyond the age of fifty. The circum- stances influencing its appearance and development, are not always easily determined. It is only certain that this tor- por . iher from insuiheient innervation or from retro- metamorphoHfl and fatty degeneration of the fibres lie detrusor muscle. Patients afHicted with this trouble cannot pas< their uri ept with strong abdominal pres- sure, and then only in a short and interrupted stream. A complete evacuation of the bladder, if it can be effected at 822 Ammonicemia, [October, all, requires a considerable time. With the torpor ad- vanced to a moderate degree, there remains always a certain quantity of urine in the bladder, although the patient thinks it completely empty. Upon strong and continued pressure he is astonished to see the flow commence again. This stagnant quantity of urine augments in proportion to the increasing torpor, and frequently forms the basis of acute chronic vesical catarrh. Cinder such circumstances, a slight cold, or an intentional repression of urine, are often suffi- cient to create complete paralysis of the bladder. This paralysis occasionally occurs as a symptom in other diseases, for instance, typhoid fever. Here it happens es- pecially, when the conscience is disturbed, the sensibility suppressed and the muscles weakened to nearly paralysis ; if overlooked, an extensive stagnation of urine follows, commonly inducing vomiting in spite of the unconscious- ness. This emesis is only removed by evacuation of the bladder, by means of the catheter. Amnioniremia may also arise during typhoid fever, in consequence of other morbid processes dependant upon the fever, for instance, catarrh of the mucous membrane of the bladder, or croupy exuda- tion on its internal surface. In some cases, however, these conditions are present, without exciting any symptom of ammoniaemia. Next to typhoid fever, acute diseases of the brain such as extensive meningitis and cerebri tis, induce not un- frequently paralysis of the bladder. A careful examination here always prevents the development of ammonioemia. But this cannot se easily be accomplished, where the paral- ysis follows diseases of the spinal marrow, and appears in association with paralysis of the lower extremities. In vessical paralysis of a peripheric origin, combined with cntaneous adynia, from suspended innervation of the detrusor muscle, I have never observed any symptom of ammoniaemia, but this disease occasionally appears under a very obstinate form in conjunction with dysentery. Then secale oornutum is the remedy. In all these remarks there is nothing particularly new : I have only collected and arranged under a system what was well known to Boerhaave, Morgagni, Van Swieten, Stoll, Lentin, P. Frank, Soemmering, and others. That they ex- plained the symptoms they observed as urinary metastases, don't matter. Although it was not my purpose to give a complete and 1861.] Ringworm. 823 exhausting delineation of the disease, I will add a few eon- elusions : 1. Uraemia and ammomemia are different conditions, pro- ducing, in many respects, different symptoms. '2. Both appellations point merely to those constituents of urine which mix with the blood, being* in the one case urea, in the other carbonate of ammonia. There may be in the hlood, besides them, some other elements of urine. 3. Ammonhemia has been mentioned and described, by former physicians, under the names : uroplania, urodilyasis ischuria, paralysis of the bladder, &c. 4. This disease may result either in direct resorption of decomposed urine from the urinary organs, or in absorption of urea changed to carbonate of ammonia, in the intestinal canal. The excretion of the morbid matter thus accumulating in the blood, is effected by exhalation through the lungs, the skin, and the mucous membrane of the stomach and intestines. Cincinnati Lancet $ Observer. On Ringworm. By Jonathan Hutchinson, of London. 1. True Ringworm, or Tinea tonsurans may be defined as a disease affecting either the scalp or the general surface, in which circular patches are formed, on which the hairs break short, and a slight, branny desquammation is seen, both hairs and epidermic scales exhibiting under the microscope the sporules and thalli of a fungus. 2. Ringworm in the scalp is rarely seen, excepting in chil- dren : but on the general surface is not very nnfrequeut in young adults. - contagious, and spreads by contagion only. 4. It is not attended by any peculiar form of dyscrasia, but on the contrary, often attacks children in perfect health. much more easily cm able on the general surface than on the scalp, owing to the circumstances, that in the latter situation the fungus has obtained access to the folic lea of the hair-. G. Being a purely local d ringworm does not require, ay constitutional treatment. 824 Galcano Cautery in Cataract. [October, 7. A purely local treatment, if efficiently pursued, is al- ways rapidly successful. 8. Epilation, and the use of one or other of the known parasiticides, arc the measures of treatment required. !>. There is no real difference between ringworm on the scalp and ringworm on the general surface. 10. Ringworm, although not unfrequently causing minute vesicles, has no true analogy with herpes. Medical and Sur. Ga zettc. Qahoano Cautery in Cataract (Academy of Sciences.) M. Tavignot read a short paper on the application of cau- terization by galvanism to the treatment of cataract. The apparatus used by this occulist is Grenet's pedal battery with two appropriate conductors. These consist in two exactly similar ivory rods, terminated at one extremity by a prolongation of the central wire to which is attached the conductor of the battery, and at the other end by a screw to which is adapted a cataract needle about 8 lines in length. 1. The operator holding a conductor in each hand perfo- rates the cornea in two different, but not opposite spots; one puncture corresponds to the transversal, the other to the vortical diameter of the eye. The external puncture is per- formed ffrst, the inferior perforation immediately after. 2. Pressure of the pedal of the battery with the foot, at once causes each ot the needles, when in contact with the other, to glow; by alternately parting and bringing together the points, the anterior capsule may be destroyed with the utmost ease, and the lens itself reduced to a pulp which ab- sorption will soon cause to disappear. 3. The foot being removed from the pedal, electric com- munication is instantaneously broken off, and the needles, } saving cooled, arc. rapidly extracted from the anterior chamber. The operation is very rapid, moderately painful, and pos- it account of t^p perfect immobility of the eye-ball, a remarkable degree of precision. The transparency of the cornea moreovci - the operator to follow distinctly b movement of he instrument', and to measure and regulate theii fland^ Virqnna Med. Jovr. l.] Editorial. EDITORIAL AND MISCELLANEOUS. ARMY MEDICAL BOARD. Surgeon General's Office, ) Richmond, Va.,gept. 27, 1861. ] "Army Medical Boards, lor the examination of Surgeons and Assistant Surgeous, have been ordered to convene at Norfolk, Richmond, York- town andMana Candidates for the appointments of Surgeons and Assistant Surgeons will be examined by these Boards, on presenting an invitation to appear before them from the Secretary of War, which may be obtained by for- warding their application, with testimonials of moral character, to the AYar Department. Examining Board- will be held at other points further South at a convenient time." The Board of Medical Examiners, appointed by the Governor of Ohio to examine candidates for the Medical Staff of the army, have adopted the rule that no person shall be appointed Surgeon who has not a respec- table diploma, and who has not practiced medicine ten years. A diplo- ma and five years' practice are required for Assistant Surgeons. The examination to be made by written questions and answers. The prevalent opinion that Army Surgeons have more to do with surgical than other affections is a grievous error, as the history of all campaigns abundantly t< I ndeed, the danger of being wounded is the least that a soldier should dread. A writer of distinction declares that in an army of one hundred thousand men, there will be ten thousand taken sick in the course of the three first months' service, exclusive of wounds! And the proportion will be still greater in the event of an epidemic! How important it is, therefore, that those who have to treat them should be men arum and some other nervine e. g. valerian. Its immediate effect is often to produce vomiting, and sometimes purging ; but the painful sensations at the epigastrium undergo relief, and the appetite becomes invigorated, Persons who have been long habituated to alco- holic drinks cannot, however, have these suddenly suppressed with im- punity; and in leg the author gives the asarum in brandy, apply- ing at the same time a blister or an issue to the pit of the stomach. By this means the normal activity of the stomach b< I and the longing for alcohol diminished. The author, however, cannot agree with those who would still allow a small quantity of spirits to habitual drink when the morbid desire for ir bac ppeased. The i nun, even when it does not succeed in extinguishing the de-ire for alcohol, ah: the patient ; and it is reinarkab! in which the individuals have been long accustomed to periodical intervals of drunkenness, ending in delirium tremens, how much longer those interval-- will become, and 828 Miscellaneous. [October, how much less likely delirium tremens is to recur. The patients them- selves are sometimes surprised at the comparative impunity with which they can continue their drinking. The author prescribes three or four glasses a day of an infusion made with three ounces of asarum root, one ounce of valerian root, and half an ounce of orange-peel, but he does not state the quantity of water employed. In cases of drunkenness, another formula is composed of decoction of asarum (made by boiling from half an ounce to one ounce of the root), six ounces; tincture of valerian, two to three drachms ; Sydenham's laudanum, gtt.xij ; syrup of orange-peel, half an ounce. A tablcspoonful of this is taken every two hours. He finds from two to ttve grains of bismuth, taken four times a day, a valua- ble adjunct. He has also found the following popular Russian remedy of service in cases of drunkenness : R. Amnion, carb. half an ounce ; aceti vini, lbj ; oxymel scill. half an ounce. Two tablespoonsfuls every two hours. Med, Zcit. Rztsslands and PJtarmaccutical Journal. "Mortality from Excision of the Knee Joint. In a memoir read before the New York Academy of Medicine, Dr. Krackowitzer dis- cusses more particularly the mortality attending excision of the knee- joint, and the objections which have been urged against the operation. He has collected, from various sources, two hundred and thirty-three cases, which give4a result of sixty-three deaths and twenty subsequent amputations ; the rate of mortality being twenty-seven in a hundred ; or, including the subsequent amputations, the ratio of failures being thirty- six in a hundred. Of the two hundred and thirty-three cases, thirteen occurred in the practice of American surgeons. Four of the thirteen patients died, and two were under treatment at the time of the report, with every prospect of recovering a good limb." American Medical Times. Excision of the Hip-Joint. In the statistics of resection of the hip joint collected by Mr. P. 0. Price, mention is made of the operation having been done 59 times. Of that number 33 recovered with good and useful limbs and greatly benefitted constitutions ; 11 were partially successful i. e., the patients lived for periods varying from three months to two years, and then died, more from other causes than from a recur- rence of the disease which demanded interference; 14 deaths resulted directly from the operation, and in 1 the result was unknown. A fair consideration of the question would show the mortality from the opera- tion to be only 14 out of the 59 cases, or about 23 per cent. Professor Pirrie states in his "Principles and Practice of Surgery," that he was extremely anxious to obtain accurate statistics of this operation, but failed to "procure them from some parts of the world where it had been several times performed. So far as he has been able to learn, the opcra- tion had been adopted in 70 cases, and death has resulted from it in 25. Sayre, of New York, gives an analysis of 30 cases, of which 20 recover- ed and 10 died, 4 of the latter within one week after the operation. Lancet. 1861. "s. 820 Labob Obstructed by Hydrocephalus. Professor Simpson ad- that when labor is obstructed by a hydrocephalic head, we should not perforate the cranium and to a certainty destroy the child, but should tap it with the trocar ; thus performing in utero the operation most calculated to be of service to it in mundo. Again, when it is a footliug casej and the hydrocephalic head cannot be born, he advises, in- stead of using great traction or endeavoring in this awkward situation to puncture with trocar, to cut across the spine, when the fluid will imme- diately find exit. Dropsy may occur in the other cavities of the foetus ; especially pleuritic and peritoneal effusions. Amer Med.. Times. Illumination. It appears that the difference in the illuminating power of the same gas may vary twenty per cent, when tested at the highest and at the lowest points of the barometrical range in this coun- try, from the effect of the rarefaction of the air alone, without taking into consideration the different densities of the gas at the opposite decree of pressure. British Medical Journal. On Saccharate or Colchicum. That Colchicum is so frequently found inefficient in cases of articular rheumatism and gout, Dr. Joycux regards as due mostly to the use of an improper preparation. He con- siders colchicum "as certain a specific in gout and acute articular rheu- matism, as iodine in goitre, and iron in chlorosis." The best and most uniform preparations arc the fresh juice rubbed up in the proportion of one to five with sugar, and dried in vacuo ; or 2, an extract obtained from the fresh juice by evaporation in vacuo. The former preparation he prefers for internal nsej giving, as an average dose, four grammes (one drachm) daily, in ten divided doses, while he employs the extract to rub on the painful parts. Giving such divided doses prevents all irritation of the bowels and diarrlnva, which so many consider as insepa- rable from the effects of the remedy. Attacks of gout so treated, yield, at the latest, in two or three days ; acute articular rheumatism "after fourteen to twenty days. In cases of subacute rheumatism, the remedy is not so efficient, though it usually gives considerable relief. Gaz. des Hospitauz. Maryland t\- Virginia Med. Jour. Arsenic in Apoplectic Congestion. 31. Lamare J'icquot, physi- cian to the Honfleur Hospital, as the result of ten years' observation and trial upon between forty and fifty cases, including his own among them, strongly recommends the prolonged use of arsenic as an effectual" means of subduing congestion likely to give rise to apoplexy. In very urgent cases in which hemorrhage seems imminent, he precedes its employment by a moderate venesection, but this is quite exceptional. In proportion to the severity and menacing danger of the case, the dose requires to be larger ; and although, even after a month, benefit may already result, to be of permanent benefit it will In ontinued for several month.-. 830 Miscellaneous. [October, The more urgent the case, the more tolerant docs the system become of the arsenic. The author, regarding apoplexy as consisting essentially in an extensive increase of globules of the blood, employs arsenic as a pow- erful agent for decreasing these, as well as the plasticity of the blood, It becomes, of course, necessary to assure oneself in a given case of the richness of the blood, for to employ arsenic when the blood is impover- ished, would be to do mischief. The author has generally found the dose of one-fifteenth to one-sixth of a grain per diem sufficient. Bull, dc Tlteroj)., tome lvii. pp. 193-252. Ibid. On the Efficacy of Digitalis and Quinia in the Treatment of Hemicrania. Dr. Debout, who has very severely suffered for many years from attacks of hemicrania, testifies to the efficacy of the combined use of sulphate of quinia and powder of digitalis in the treatment of this complaint. The proportions employed are three grammes (about three- fourths of a drachm) of sulphate of quinia, and one and a half gramme of powdered digitalis, made into thirty pills, of which one is to be taken every night at bedtime for at least three months. From the beneficial effects produced on himself, Dr. Debout prescribed the same treatment for several patients, and the results in many cases were equally satisfac- tory. Chemical Gazette. Ibid. Treatment of Old Fissures of the Anus. M. Gosselin observes that most of these fissures may be easily cured, whatever be the means adopted. Still he regards forced dilatation as the most expeditious and the most convenient for the patient, while incision best guards against relapse. In many cases he has combined with advantage these two modes. First dilating, and then incising the fissure, which is then easily visible throughout its whole extent. He has observed the fissure and its pains persisting after forced dilatation oftcner in women than in men. But besides these fissures thus easily cured, there are others which resist various modes of treatment successively employed, or, when cured, are succeeded by new ones, just as painful as the others. After, in such cases, trying the various means one after another, M. Gosselin resorts to daily dilatation, which he has found attended with good results. The index-finger is passed into the anus daily until the pains after de- fecation have disappeared or notably diminished Gaz. dcs. Ho])., No. 91. Ibid Honey and Glycerine in Surgery. Dr. C. F. Moore, Medical Superintendent of Middleton Hospital and Infirmary, says (Dub. Med. Press, Dec. 2G, 1860) that several mouths ago he commenced the use of glycerine to bedsores in bad fever cases, and finding it to excel his ex- pectations, he used it in all cases where a healing dressing was required. It occurred to him, some three or four months since, that honey might 1861.] Mi 381 answer as well ; and as a very great difference in price exists, that an important saving might thereby be effected by using an equally efficient agent, "as some of the properties of honey previously known to me led me to think it to be. I have now used it in several cases in hospital and private practice, as in ulcers left by scalds, in a wound after the removal of a large tumor presenting some malignant characters from the fascia of the leg in a woman of 70 years of age, in a case in which dead bone was being discharged after injuries to a man's leg, bedsore from fractured thigh, etc. To the readers of your valuable journal I will only now state that it seems especially useful in cases where a tendency is manifest in a wound or ulcer to throw up unhealthy granulations instead of heal- ing kindly. It seems also to protect the skin adjacent by its own con- itive agency, so to speak, as well as by correcting the styptic proper ties of the discharges. In evidence of this latter property, I may state that, in cases which I have treated with it, after having used the more ordinary dressings previously, the honey most unquestionably removed all unp easant smell from the discharges, itself no small gain. I must observe, however, that honey, when first applied especially, causes some considerable degree of pain, indicating its stimulating effects. In one case I used a wash of tiuct. opii and water on first applying the honey dressing, poured oyer the fine linen which had been applied, saturated with fine clear pure honey. In all the cases, however, the patients them- selves soon got reconciled to the pain, considering it indicative of benefit being received from the dressing. It is well, however, to bear this point in mind, especially in cases where a very large surface has to be dealt with, or a patient is very susceptible of or sensitive to pain. In such cases, glycerine, which | uore soothing qualities, might be pre- ferable. In conclusion, I would insist on the necessity of using pure clear honey, quite free from any of the numerous articles said to be used in its adulteration.1' Am. Jour, of Med, Sciences. Digital CoMniEssio.x in -l. r. M, Miranlt, of rela- ted to the Paris Surgical Society the following two cases of aneurism, in which digital compression had been successfully employed : 1. A man, aged 23, exhibited an ancurismal tumor at the bend of the arm, some time after being bled. When admitted into the hospital this tumor was about the size of half an egg. Digital compression was made on the brachial artery, at about the middle of its course, from 11 o'clock, A. M. to 9 P. ML, and next day it was resumed from 0 A. M to 9 P. 31. The tumor became more firm, and the compression was employed again at j A. M. of the third day ; at 8 the pulsations had become indistinct, and at 12 they had completely disappeared. Thirty-one hours had been occupied in makiDg compression. _ A child, aged 9, having had the trunk of the temporal artery opened, just anterior to the ear, an aneurism about the size of a nut ap- peared eight or ten days after the accident. Direct digital compression 832 Miscellaneous. was employed for five hours on the first day ; for ten and a half hours on the second ; for eleven hours on the third ; for nine and a half hours on the fourth ; for eleven hours on the fifth ; for ten hours on the sixth ; for ten and a half hours on the seventh ; and for nine and a half hours on the eighth making a total of eighty-five hours, at the end of which time the aneurism had become cured. Med. Times 4* Gaz. Jan. 19, 1861, from IS Union Med. No. 1, 18G1. A Substitute for the Catheter. Sir Some two years ago, 1 had under my care a man who had received a fracture of the spine. Inability to micturate was one of the symptoms, and I expected that I should in this case, as I had witnessed in some others, have to use the catheter very frequently. It occurred to me, however, that by pressing over the region of the bladder, the urine might be discharged, and so it proved ; for when any fluid collected in the bladder the patient was always relieved by gentle, equable pressure. He never required the use of the catheter, and, though he survived his accident about three months, no urine ever escaped except under pressure. Your obedient servant, J. Wearne, M. R. C. S, Helston, Cornwell, Nov, 18G0. Lancet, On Iodism. In a recent discussion on iodism at the Academic Impe- riale de Medecine, M. Velpeau made the following observations : He had treated about fifteen thousand persons with iodine either externally or internally, but he had never seen anything exactly resembling^ consti- tutional iodism. He had observed irritation of the digestive organs, pains in the stomach, dyspepsia, roughness of the throat, irritation of the mucous membrane of the mouth and nose, ptyalism, &c , but he had never seen cases of rapid emaciation, with atrophy of the breasts and testicles, and bulimia, or in short, with symptoms of poisoning. M. Velpeau suggests that the difference of the results observed in Paris and Geneva may be due to the difference in the doses employed, or the va- rying qualities of the iodized preparations ; but whatever may be the reasons of the discrepancy, he has never seen in Paris any cases of what 31. llilliet has called constitutional iodism. L1 Union Medicale, March 22d, 1860. SOUTHERN MEDICAL AND SURGICAL JOURNAL Vol XVI!. A! fiUSTA, BA, PVJIBB AND DECEIJES, 1$6l. ORIGINAL AND ECLECTIC, ARTICLE XIX. ABMY DISEASES. We are happy to be enabled to give publicity to the fol- lowing correspondence. It explains itself. The plain and practical suggestions of Prof. Diigas, the result of matured experience, are well deserving the attention of practitioners whether in or ont of the army : Augusta, Sept. 15, 1861. I am about to join the army, and as 1 apprehend re than rhe bails of the enemy, yon will do me a great favor by giving me sneb simple directions us I may cam onl in camp, if necessary especially for the treatment of Typhoid fever, Diarrhoea, Dysentery and Pneumonia, which I am informed aro the most common diseases of our soldiers. I an "ii will pardon this call upon your kindness from :r friend and Late pupil, I cheerfully comply with your reque.-t to furnish you directions for the management of the disease! you will be mpst like counter in your campaign. You are S34 Dug as. Army Diseases. [November, correct in believing that the risk of being shot is the least of the dangers to which new soldiers are exposed. The radical change to which they are subjected in all their habits of* life is well calculated to induce disease, independently of the exposure to contagious and epidemic affections. Typhoid f'Y.YKTj is the bane of military camps and hospitals, and nothing should be neglected that may tend to keep these places clean and well ventilated. As far as practicable, those suffering with this malady should be kept apart from those affected with other diseases, for typhoid fever is unquestiona- bly sometimes contagious as well as epidemic. But you wish some simple rules for its treatment. I will then say at once that, in the present state of our knowledge, typhoid fever is a self-limited disease ; that it cannot be arrested in its pro- gress, and that it usually requires from three to six weeks to run its course. You need not, therefore, trouble yourself, nor your patients, with attempts to shorten the period of its duration. Mild cases will naturally occupy less time than severe ones. What most behooves us is to enable the patient to live through it as comfortably as circumstances will permit. Tin's is to l)e done by avoiding all deteriorating medication, by subduing all debilitating symptoms, by allowing such food as may be readily digested, and by the administration of ner- vine* and stimulating tonics. 1st, Avoid deteriorating medication that is to say, do not bleed, give no purgatives, do not mercurialize, and eschew all nauseants. They all lessen the energies of the system, already unduly depressed by the disease. If the bowels are disagree- ably distended, an enema of tepid water will relieve them. The more quiet you keep the bowels, the better, for they arc apt to be too much relaxed. Do not yield to the vulgar error of supposing it necessary that the patient should have a daily discharge from the bowels. Asa general rule, the less often they are moved, the better, for tin's is an evidence that they are not seriously implicated. 2d. Subdue debilitating symptoms. The most common of t)n-s<> i- diarrhtiea. (Nmrrol it if possible at its inception- 1S61.] Pi / Diseat 835 and as often as it may evince a tendency to return. The mixture recommended below, nnder the head of diarrhoea) is one I have long been in the habit of using for that disei her idiopathic or dependent upon typhoid fever. The occurrence of hemorrhage from the bowels or from some other portion of the mucous surface is always an alarm- ing manifestation. If from the bowels, I use the dilated sul- phuric acid or the elixir of vitriol in doses ot 20 drops to the tumbler of water three or four times in '2-4: hours, (sweetened if desired by the patient.) This is usually found to bean agreeable beverage and is often very beneficial. If it fails, may give 20 grains of alum, dissolved in a quart of water, through the day, in such draughts as the patient will take without much reluctance. This may also be sweetened if de- sired. Large enemas of cold water, retained as long as pt ble, will, in bad cases, very materially aid in checking the hemorrhage. These may be repeated as often as the urgency may require. If the hemorrhage is from the nostrils or the s;iims, and will not yield ro cold ablutions, you should use styptic lotions, such alum, of sulphate of zinc, (5j. to a pint of water,) the muriated or nitrated tincture of iron, '5j- to a pint of warer) or the per-sulphate of iron. 1. Feed thepoti rd. 1 think it a matter of great import- ance to see that sufficient nourishment be taken. The desire of the patient for certain articles of food should be gratified, especially when very decided, for it is rare that what he ill injure him, if allowed in reasonable quant; Ver; 111 eat too much. The appetite should beencour- l by such delicacies as you may be able to procure. 4th. j <u will iind it advantageous to admini >risk bartic dose of Epsom or Glauber Palts, pr of Crjeam o1 Turtai at the onset of the attack. lrou fchus disgorge al capillaries and drive out the fecal inatters, and there- by relieve the tenesmus. Afier thi> you ^houJd keep up the - by smaller dos< (a ; dine two or three times a day, as long as there is an^ tendency to a return of tenesmus; twenty to thirty oVqps. of Laudanum will then close the treatment in most cases, .lint- when the! much fever, the use of Quinine for a few days will v< rj ma terially aid in the treatment Give eacli morning fifteen grains, in doses of 5 grains at intervals of A two hours. Tin.- must not interfere witli the use of the salines. 1 should have stated when speaking of the salines, thai after the first cath- artic, a teaspoonful or table salt will often do as well, if not er, than either of the other salts. In very bad or neglect- ed eases I have derived great advarifa fas of cold, or even iced water, repeated .!- return ! tenesmus or hemorrhage be relieved. I en >udiate the routine practice of Calom^Tan i Dover's Pqw<3 uicli lauded by old writer-. l!he Pneumonia, such as it has exhibit* ah- em i th-westorn ^r:iu< for the h oin the d of northei u The di found in (he type of tl te and able argument <<.' Lai ' with a form hich will pletion -f any kind. : ;!n:l. hie in the pneumonia of try. 1 cannot now discuss the quest oda\ S3S Dcgas. Army Diseases. [November, V^^v^. once to give you an outline of the treatment most successful, I may say usually successful, with us. We must recognise here, as well as in our epidemic dysen- teries, two elements of disease a remittent fever and a local (pulmonary) complication, either congestive or inflammatory. By subduing the former, the latter will usually yield readily. Give fifteen grains of Quinine then every morning beginning at day break, without regard to the fever, (5 grs. every two hours, three times) and do this until the febrile paroxysms are controlled. At night one-quarter of a grain of morphia, or ten gtii Dovers Powders, will, if necessary, procure good rest. Warm teas should be taken freely, if they can be had ; if not, cold water should be allowed as often as desired. The patient will crave but little nourishment and should not be denied it. If there be any pain in'"the side, showing a pleuritic com- plication, meet it at once by blistering the painful region. A blister from four to six inches square will be large enough. This may appear to be a very simple plan of treatment, but you may depend upon it as infinitely more successful than any other. If you bleed, purge, or antimonialise your patient, he will often die when you least expect it. Active antiphlogistics were formerly very successful here, as they may still be in the northern States, but the type of the disease has undergone such a radical change with us, that we can no longer resort to them with impunity, MEASLES. Although you do not name measles among the diseases up- on which you desire my views, I will add a few Avords on the i object because our army has suffered very much from tin's distemper. In the first"place you should bear in mind that this is a dis- of self-limited duration, and that we cannot arrest its course. Since we cannot cure it, therefore, onr business is to see that its progress be not aggravated by complications. In natural course of the disease the effect of the poison by !.. Duoas, Army Disease*. which it is induced manifests itself upon the skin and the ad- jacent mucous surfaces of the throat and air passages, an long as it goes DO farther, there is but little danger. Let us, then, by careful avoidance of exposure to cold, prevent a re- cession of the cutaneous affection and its invasion <>f the in- ternal organs. By so doing the disease will usually run Its course in ten days. The cough which is often quite trouble- sonic should be allayed by an occasional dose of Paregoric or Laudanum. The patient should commit no excess in diet, but may eat moderately of plain food if he desires it. Purging ild be avoided, for the susceptibility of the intestim very great and diarrhoea is one of the principal dangers we have to apprehend. Its manifestation should be immodi; checked by the astringent mixture already alluded to must especially remember that ti: - ibsidence of the cutaneous affection does not constitute the cessation of danger, for there seems to be in Measles an affection of the blood, or of the general stamina which ref six mouths. Andral, out of over 300 as occurring during the first mouth. 3 mentioned by M.. Trousseau, no case is re- d under 11 months. Cheyne, in his work upon " the PatholofiTV of the Larynx and Bronchia," mentions meeting croup in a child three months old. Marley, in his work on diseases of children, mentions seeing croup in one child at the state of their wives, and most often, parents the symptom.- experienced by their children. The physician then is always deceived concerning cpilep-;. : fa eived by the pa:. himself who knows nothing of his attack, excepting that he has lost consciousness, and that he remained several hours a state of half stupefaction. lie ived by the par who are loth to acknowledge, even ; tat they have an epileptic in their family. He is deceived by the recollections of his early medical education during which he has been repeatedly told that apoplectiform cerebral coi tion is a common disease. Let n ;>h*'d it' congestion is -to. si convulf a which assimila cerebral congestion. It happens, -. although \ rarely, that i unmehcenient of an epileptic attack, the c period, that i-: to sa; seles an absolute rigidity ; it happens some- $G Cerebral Congestion, &c. [November, times, I say, that this tonic period lasts two or three minutes, instead oi' lasting only fifteen or thirty seconds, and the individuals die asphyxiated, as persons die in a tetanic paroxysm, as animals die who have been poisoned by sub- stances containing strychnia, as our colleague, M. Segalas,has 60 well demonstrated nearly forty years ago. As, in this case, there have been no chronic convulsions, such as are best known to persons outside of the profession, and as during the whole continuance of the tonic convulsion, the face has been swollen, the vessels of the neck have been distended and knotty, as in fact there has been an enormous congestion, but an entirely passive one, similar to that which is produced by exertion, it is mistaken for an active congestion, while in fact it is only an attack of eclampsia or epilepsy. Let those of our colleagues who devote most of their atten- tion to the diseases of women in child-bed and children, recall their experiences, and probably they will partake of my opinion. Dr. Meniere has observed for a long time a large number of patients who are suddenly seized with vertigo, nausea and even vomiting, who fall upon the ground after having walked like drunkards, rise with difficulty, remain pale, covered with a cold sweat, almost in a comatose state ; and see these accidents very frequently recurring. The first attacks are considered cerebral congestions and are vigorously treated by bleeding, leeches and purgatives. The frequent relapses modify gradually the diagnosis, but the patients be- come exceedingly uneasy about them, and especially the doctors, and all enlightened persons who are aware of the seriousness of cerebral lesions. In the vast majority of cases, patients affected with these cerebral troubles, soon perceive noises in their ears, often even the hearing becomes embarrassed, and these unnatural sounds cause these persons who wish to free themselves from such an annoyance, to seek the aid of the physicians of the asylum for the deaf and dumb at Paris. It is easy, then, to prove that one ear and often even both are pingularly enfeebled, and M. Meniere has collected hundreds of observations establish- ing the fact that these supposed lesions of the brain are really lesions of the auditory apparatus. lie has pursued these re- searches with extreme care, and he lias been able to prove {hat the starting point of these phenomena is in the internal ear. We will let our colleague bring here the result of so highly interesting a study. It will' suffice for us to say that the greater part of the troubles so improperly designated Un- der tlie title of apoplectiform cerebral congestion have their 1S61.] hral Congestion, <&c. 847 in the semi-circular canals, that the lesions of these or- gans produce vertigos and sympathetic vomiting, take away the power of the limbs, and bring about sudden loss of con- sciousness ; in a word that many o\ the so-called legions of rim brain belong exclusively to the auditory apparat:; There is still another disorder which is constantly designa- ted by the title of cerebral congestion. I speak of vertigo connected with gastric disorders. This varied form of ner- vous disease is characterized by the following phenomena. If the patient makes a sudden motion in bed, the bed seems to turn round and carry him with it in its motion; if he rises. and especially if, having risen, he looks upwards, the vertigo becomes more excessive. As objects turn around him, he reels, and sometimes is unable to stand. At the same time, he experiences an insupportable sickness at his stomach, and very often vomits. These singular attacks are called by the patients rushes of blood to the head, and we must say, the greater part of physicians partake of this idea. They bleed. they apply cups and leeches, give mustard foot-baths, and in a word, do everything to dispel this imagined congestion, which they increase by their strange treatment. The vertiginous diseases of which I have spoken are rather akin to syncope, and consequently are just the opposite to congestion ; and, strange as it may appear, it is nevertheless true that too many physicians still do not recognise the ten deney to syncope, and confound it with cerebral congestion. Xevertheless, gentlemen, as I do not wish to exaggerate, I will suppose that the two states that I have been describing are unknown to physicians, and I will suppose that they are never taken for cerebral congestions. But there is an attack which often accompanies hemorrhages of the brain and which, by the generality of physicians, is considered a congestion. I explain myself. "When a patient is seized with apoplexy, whether this apoplexy be caused by a cerebral hemorrhage, whether it depend upon a softening, which is more frequently the case than it is acknowledged or thought to be, or whether it be the result of an embolus, or at least of a sudden obliter- ation of one of the principal arteries at the base of the brain ; when, I say, a patient is seized with apoplexy, there is some- times a sudden loss of consciousness, and the dullness of the intellect, and the loss of the power 01 motion last several hours or even days, then everything is restored to a natural condi- tion, with the exception of a slight hemiplegia, which dimin- ishes slowly and finishes by disappearing after some mom attacks have been almost fulminant, and a^ there ji 1 8 Cerebral Congestion, <&c. [November. 4,068 not seem to be a sufficient relation between the severity of these first phenomena and the ulterior troubles of intellect, sensibility and motion, they say that the cerebral hemorrhage has been accompanied by a congestion ; that the congestion, an essentially transitory phenomenon, has produced the apo- plectic attacks properly so-called, and that when it has passed away, it has left this slight hemorrhage together with another slight hemorrhage which has followed these severe apoplectic attacks, I do not wish absolutely to deny the existence of such a congestion, and I even acknowledge that I am tempted to admit it in a certain degree ; but tlicve is another phenome- non which has not been sufficiently taken into account, at least so far as I know. I wish to speak of, what I have called the cerebral astonishment. When the brain suddenly experi- ences a tearing and a compression, it bears this grave lesion with an impatience which varies according to the individual. but which can be borne to a very great extent by certain per- sons. I will offer as an example one of the traumatic lesions qf the brain. When a soldier receives a ball in his head, or when in a fight, an individual receives a stab from a knife which penetrates into the brain, they are thrown to the ground as if they had been struck by a bludgeon ; but little by little, notwithstanding the intra-cranial effusions of blood which are the consequence of the wound, and even notwithstanding the inflammatory congestion which is inseparable from the lacer- ation of the tissues, intellect, sensibility and power of motion return sometimes with wonderful rapidity, and thus afford, to the inexperienced surgeon, hopes which are never realized. This immediate stupor is what I have called the cerebral astonishment, and however incorrect this appellation which I will willingly renounce, may be, still the fact always exist- and can be contested by no one. Experiments upon animals give still more positive results. If one trephine the skull of a dog or a rabbit, and iitroduce a small ball of lead through an incision in the dura mater, be- tween the skull and the surface of the brain, one will observe at the very outset, phenomena of stupor, which rapidly pass off, to be replaced by hemiplegia which is proportionate to the amount of cornpres^ioi. In this experiment one cannot plead cerebral concussion a;- a caiBo one must allow that the brain is in a manner sur- prised by an accident which shows itself in transitory disturb- ances. Am I not, then, right in supposing thai when a sud- den extravasation of oloocl takes place in the striated body or 1861.] 'ruction of the Palmar Fascia. in the optic thalamus, the immediate stupor which is ordina- rily attributed to the simultaneous congestion may, in part at least, be attributed to cerebral astonishment. I ran it be said, gentlemen, that I deny absolutely the exist- ence Ural congestion * Certainly not. 1 admit the ingestion, hyperemia of the hrain one would be mad to contest the existence of it; but I do say that what has been called an apoplectiform cerebral congestion is, in the majority of cases, an epileptic or eclamptic attack, sometimes a m ncope. I Bay that, very often, simple epileptic vert:. or vertigos connected with a disordered state of the stomach, or from diseases of the ear, are wrongly considered coug tions of the brain. Moreover, if the propositions that I have endeavored to de- fend be true, it will be granted that therapeutics ought less frequently to have recourse to revulsive and antiphlogistic treatment which is continually resorted to to combat these supposed cerebral congestions, and that other indications should be sought out, more conformed to the idea which one ought to form of the different states that have too often been confounded under the same denomination. W. McX. W. "Maryland <.( Virginia Med. Journal. r Ike Palmar Fascia, and Us Mode of Treat- By Win. A. Elliott, F. R. C. S. L, Surgeon to the Whitworth Hospital, Drumcondra. .e following cases, illustrative of an affection which has received, from time to time, so much professional investiga- tion, may, I trust, prove, in some degree, of practical interest. 1. Mr. P. B. aBtat. 27, consulted me in June, for contraction of the left hand, which, upon examination, presented the following appearances: The little finger was flexed permanently to a right angle upon the palm ; the deformity seemed to engage the meta- carpophalangeal articulation chiefly, and was evidently the result of a contracted condition of the correspond] tion of the palmar fascia, which was distinctly to I and felt as a hard prominent cord leading from the anterior annular ligament of the carpus downwards to the root of 54 8S0 ( kmi ruction of the Palmar l.'" It appears to me that I ,.ey the laws ascribed to it by those ai in either to a peculiar constitutional dial orious occupation of the individual, : tamined carefully many persons Buffering from this affection, whose statements were opposed to such opinion-', and it is at \\ certain that the great majority of the which have s-~> I Contraction of the Palmar Fascia. \ November* fallen under my observation, occurred in persons whose oc- cupations were by no means of a laborious nature. ! v some surgeons attention has been directed to the par- ticular finger Which first becomes affected. In a practical sense, this is unimportant, but we find the disease usually commencing either in the middle, ring, or little finger, in each of which I have seen it originate. We sometimes ob- serve tins affection existing in both hands of the same indi- vidual. Lately I examined a singular case, in which not only both hands were engaged, but the contraction had extended to both thumbs, and to all the fingers. .- It is of the utmost importance that we should select the most eligible operation for the removal of the deformity under consideration. Dupuytren's mode consisted in mak- ing transverse and occasionally semilunar, incisions, about six lines in length, opposite the metacarpophalangeal articu- lation, and also in the palm of the hand, or, as occasion re- quired, in front of the phalanges, so as to enable the fascia to be fully divided. Sir Philip Crampton considered this disease to be of a peculiarly intractable character, and for its removal recom- mended that a free incision should first be made parallel with the tight cord and in its entire length. This he con- sidered most important, as by so doing the operator would be enabled to divide with greater ease and certainty the contracted portions of fascia. 'ho subcutaneous operation seemed to me preferable, and the advantages which it possesses are obvious viz., it is comparatively free from risk or pain. The punctures heal iu a few hours, thereby permitting the subsequent treatment to be conducted without embarrassment, and wounds are avoided which would necessarily be kept open by the process of extension, and when healed might eventu- ate in the formation of hard and contractile cicatrices, pos- sessing a tendency to reproduction of the original de- formity. The comparatively short duration of time in which (by tli is operation) we are enabled to cure the disease, should, I consider, entitle it to additional recommendation. In adopting the subcutaneous operation it will be necessary to select a proper situation at which to make the puncture. The most prominent portion of the fascial cord will be found invariably lying in front of the superficial palmar arch of arteries ; and as we cannot determine the depth to 186JU] Directions to Arm;/ Surgeon*. which pur incision may require bo be carried, this situation should be avoided. It will be found more satisfactory, and attended with less risk, to make the puncture about mid- way between the lowest transverse line in the palm and the root of the affected finger. AVhatcver may be the nature ol' the operation deemed advisable in these cases, the subsequent treatment will re- quire our utmost attention, ami much difficulty may be obviated by the use of the instrument which J constructed some years since, and have found most efficacious in the removal of many forms of digital contractions, in its con- struction it simulates somewhat the mote he pha- langes, and may be applied to one or all the fingers, as the case may demand. It should be worn for some hours at n time, but the period must be regulated by the feelings <^{' the patient. Dublin Medical Press, Directions to Army Surgeons on the Field of Battle. Uy G,J. Guthrie, Surgeon General to the British Forces during the Crimean War. (From his Pamphlet on the Hospital Brigade.) 1. "Water being of the utmost importance to wounded men, care should be taken when before the enemy, not only that the barrels attached to the conveyance-carts are proper- ly tilled with good water, but that skins for holding water, such other means as are commonly used in the country for carrying it, should be procured and duly iili 2. Bandages or rollers, applied on the field of battle are. in general, so many things wasted, as they become dirty and stiff, and are usually cut away and destroyed, without having been really useful ; they are not therefore forthcom- i required, and would be of no use. B. Simple gun-shot wounds requite nothing more, for the first two or three days, than the application of a piece of wet or oiled linen, fastened on with a strip oi stioking- plaster, or. if possible, kept constantly wet ami cold with water. When eold disagrees, warm water should be sub- stituted. 4. Wounds made by -words, $ Other .-harp-cutting instruments, arc to be treated principally by position. Thus, 856 Directions to Army Surgeons. [November, a cut down to the bone, across the thick part of the arm, immediately below the shoulder is to be treated by raising the arm to or above right angle with the body, in which position it is to be retained, however inconvenient it may bo. Ligatures may be inserted, but through the skin only. If the throat be cut across in front, any great vessels should be tied, and the oozing stopped by a sponge. After a few hours, when the oozing is arrested, the sponge should be removed, and the head brought down towards the chest, and retained In that position without ligatures ; if this is done too soon, the sufferer may positively be suffocated by the infiltration of blood into the areolar tissue of the parts adjacent, 5. If the cavity of the chest is opened into by a sword or lance, it is of the utmost importance that the wound in the skin should be effectively closed, and this can be done by sewing it up as a tailor or a lady would sew up a seam, skin only being included ; a compress of list should be applied over the stitches, fastened on by sticking plaster. The pa- tient is then to be placed on the wounded side, that the lung may fall down, if it can, upon, or appty itself to the wounded part, and adhere to it, by which happy and hoped- for accident life will in all probability be preserved. If the lung should be seen protruding in the wound, it should not be returned beyond the level of the ribs, but be covered over by the external parts. 6. It is advisable to encourage previously the discharge of blood from the cavity of the chest, if any have fallen into it ; but if the bleeding from within should continue, so as to place the life of the sufferer in danger, the external wound should be closed, and events awaited. 7. When it is doubtful whether the bleeding proceeds from the cavity of the chest, or from the intercostal artery, (a surgical bugbear,) an incision through the skin and the external intercostal muscle will expose the artery close to the edge of the rib having the internal intercostal muscle behind it. The vessel thus exposed may be tied, or the end pinched by the forceps, until it ceases to bleed. Tying a string round the ribs is a destructive piece of cruelty, and the pings, &c.*, formerly recommended, may be consid- ered us surgical incongruities. 8. A gun-shot wound in the chest cannot close by adhe- sion, and must remain open. The position of the sufferer should therefor e be that which is most comfortable to him. A small hole penetrating the cavity is more dangerous than a large one, and the wound is loss dangerous if the ball Lcoes through the body. The wounds should be examined, and enlarged if necessary, in order to remove all extrane- ous substances, even if they should be seen to stick on the surface of the lungs ; the opening should be covered with soft oiled or wet lint a bandage when agreeable. The ear of the surgeon and the stethoscope are invaluable aids, and ought always to be in use : indeed, no injury of the chest can be scientifically treated without them. 9. Incised and gun-shot wounds of the abdomen are to be treated in nearly a similar manner ; the position in both being that which is most agreeable in the patient, the parts being relaxed. 10. In wounds of the bladder, an elastic catheter is gen- erally necessary. If it cannot be passed an opening should be made in the perimeum for the evacuation of the urine, with as little delay as possible. 11. In gun-shot fractures of the skull, the lower broken pieces of bone, aud all extraneous substances are to be re- moved as soon as possible, and depressed fractures of bone are to be raised. A deep cut made by a heavy sword through the bone into the brain generally causes a consid- erable depression of the inner table of the bone, whilst the outer may appear to be merely divided. 12. An arm is rarely to be amputated, except from the effects of the cannon-shot. The head of the bone is to be aawn off, if necessary. The elbow-joint is to be cut out, if destroyed, and the sufferer, in either case, may have a very , useful arm. 1:5. ]n a case of gun-shot fractuie of the upper arm, in h the bone is much splintered, incisions are to be made for the removal of all the broken pieces which it is feasible to take away. The elbow is to be supported. The forearm is t> be Treated in a similar manner ; the splints used should lid. 14. The hand is never to be amputated, unless nil, or y all its part- are destroyed. Different bones of it and of the wrist are to be removed when irrecoverably injured, with or without the metacarpal bones and lingers or the thumb ; but a thumb and one linger should always be pre- served when possible. 16. The head of the thigh bone should lie sawn off when broken by a musket ball. Amputation at the hip joint r securing the ve>- 860 .Directions to Army Surgeons. [November, sel above and below the wound, being left unheeded. By this proceeding, when successful, the" knee-joint is saved, whilst an amputation above the middle of the thigh, is al- ways very doubtful in its result. 28. When mortification has taken place from any cause, and has been arrested below the knee, and the dead parts show some signs of separation, it is usual to amputate above the knee. By not doing it, but by gradually removing the dead parts, under the use of disinfecting medicaments and fresh air, a good stump may be ultimately made, the knee- joint and life being preserved, which latter i3 frequently lost after amputation under such circumstances. 29. Hospital gangrene, when it unfortunately occurs, should be considered to be contagious and infectious, and is to be treated locally by destructive remedies, such as nitric acid, and the bivouacking or encamping of the remainder of the wounded, if it can be effected, or their removal to the open air. 30. Poultices have been very often applied in gunshot wounds, from laziness, or to cover neglect, and should be used as seldom as possible. 31. Chloroform may be administered in all cases of am- putation of the upper extremity and below thekuoe, and in all minor operations ; which cases may also be deferred, without disadvantage, until the more serious operations are performed. 32. Amputation of the upper and middle parts of the thigh are to be done as soon as possible after the receipt of the injury. The administration of chloroform in them, when there is much prostration, is doubtful, and must be attended to, and observed with great care. The question whether it should or should not be administered in such cases being undecided. 33. If the young surgeon should not feel quite equal to the ready performance of the various operations recom- mended, many of them requiring great anatomical know- ledge and manual dexterity (and it is not to be expected l hat he should) he should avail himself of every opportunity which may offer of perfecting his knowledge. The surgery of the British army should be at the height of the surgery of the metropolis ; and the medical officers of that service should recollect, that the elevation at which it has arrived has been on many points principally due to the labors of their predecessors, during the war in the Pe- 1861.] Modem Ltihof)*>/. 861 ninsula. It is expected, then, that they will not only cor- rect any errors into which their predecessors may have fallen, but excel them l>y the additions their opportunities will permit them to make in the improvement of the great art and science of Burgerv. Lancet Modern Ltfholrity. Dr. dviale's Clinical Experience. To the Editor of the Lancet. Sir I have j as t received a letter from my friend and former instructor. Dr. Civiale, of Paris, in which he re- quests me to translate and send to you for publication the result of his practice in operating for stone in the bladder during the past year (1860.) Dr. Civiale's reputation as the inventor and perfector of modern lithotrity is so well known that I lose no time in sending you this interesting docu- ment. It may he in the memory of some of your readers that at the Medical Society of London, and in the Lancet, of Jan. 21st, 1760, I called attention to the following proposition, as one which appeared to me to he of the very highest im- portance : That stone in the bladder may, by the exercise of lair intelligence and skill, be deprived of nearly all its severity and danger to life ; since it may, in the great ma- jority of cases, be detected in its early stage when of small size, and because its destruction in that stage may be ac- complished with safety and certainty by lithotrity. I cannot forbear appealing to the following letter as a remarkable illustration of that great and pregnant truth. The facts of this letter suggest several objects for critical remark to the English surgeon, which I shall not touch upon here. Taken altogether, I think that English experi ence amongst those who practice lithotrity, will not much suffer by comparison with the excellent results of the great, master's work. The following is a literal translation of the article which Dr. Civiale has just published in the Gazette des Sciences, tc, and which he has sent me for the purpose named, i am. air, your obedient servant, Hum Thompson, k. R, C, B. 862 Modern Lithotrity. [November, RECORD OF CIVIALE'S CLINICAL EXPERIENCE IN THE TREATMENT OF STONE DURING THE YEAR 1860. I treated, In I860, 54 patients affected with stone in the bladder; 39 in my private practice, and 18 in the hospital. A. Private Patients. Twenty-six of these patients had stone for the first time; 10 had been already operated on by other surgeons or by myself ; the stone having reappear- ed, fresh operations were necessary. I operated on 26 of these patients by lithotrity ; 24 arc cured ; in 2 others I was obliged to relinquish the opera- tion, which appeared to aggravate the morbid condition of the bladder. One of these patients has died ; the other still lives, and the stone remains in the bladder. All those calculous patients who were most favorably circumstanced, whose organs were still sound and in good health, and who had no other disease than a small stone, obtained a rapid and easy cure. For this class of patients the application of lithotrity appears to me to have reached great perfection ; in fact, the stone is destroyed in a few minutes, and its debris are expelled with the urine ; all suf- fering ceases, and the health is re-established and main- tained. Surely this is all one can desire in the treatment of calculus. But lithotrity gives such good results only when its appli- cation is restricted to favorable cases, in which the stone has not had time to grow large, and to produce in the bladder^lesions capable of altering the form and natural conditions of that organ. I hasten to add, however, that the proportion of favorable cases augments every day, and that they will become more and more numerous in propor- tion as calculous patients, informed as to their condition by their medical attendants submit themselves to operation at the outset of the malady. Ten of those treated had not displayed this prudence; they only sought the aid of art when their existence had become insupportable on account of incessant pain. In two of them the diseased condition of the urinary or- gans offered an obstacle to the application of lithotrity, and as lithotomy w?is equally contra-indicated, death occurred from the progress of the complaint. Four having large stones were operated on by lithotomy ; one adult obtained a rapid and complete cure, the wound having cicatrized by the tenth day: in another adult the 1861.] Modern Lithotntj/. 863 convalescence was tedious, and the cure incomplete. Two old men died in the second week after the operation. Two patients are still under treatment; one will be ope- rated on by lithotrity, the other by lithotomy. In two others, who became ill at Paris when the winter set in and returned home, the treatment has been postponed until the spring. I). Hospital Patients. Amongst the 18 calculous patients admitted under my care, there were 3 women and 15 men, all adults, some old people. The first of these women, who had suffered during a long- period of time, was so bad that any operation was contra- indicated ; and the patient returned to her family. The second was in favorable condition as regards her general health, but the calculus was engaged in the urethra, where it was maintained by violent contraction of the blad- der. A division of the canal sufficed to accomplish the extraction. This proceeding appeared to me, in these cir- cumstances, to be preferable to that of crushing, which would have been very tedious and painful. The patient was rapidly cured. The third woman, an account of whom I have published, presented one of those extraordinary cases which one meets with at distant intervals. The stone, a phosphatic one, was formed upon a mass of teeth, of little bones, and of hair, arising from a hair-cyst, which had opened into the bladder. All these bodies and the stone itself were successfully ex- tracted by lithotrity. Four of the male patients were not in the condition which the application of lithotrity demands. Two were cut; one was cured, but the other has still a fistula. The third refused to submit to the knife, which indeed offered small chance of success: he died of renal disease. The fonrthjis under treatment. Another male patient was the subject, at the same time, of a stone of middle size and of strangulated hernia, requir- ing immediate operation, from which he died. The 10 remaining patients submitted to lithotrity were freed from the stone, but the cure in all wai hot complete. Amongst them, "2 retained some pain and disturbance in the functions of the bladder, arising from organic lesions of that vi ml against whicfe lithotrity avails no more than lith.otomv. 864 On Sub- Involution of the [November, The recent cases observed at the Hospital decker present a fact worthy of notice. Calculous patients form two great classes. In one, which embraces two-thirds of the cases, the organs retain their natural condition. Indeed it is only occasionally, and especially after bodily exercise, that the stone provokes some functional disorders, which cease by repose. Here the stone forming of itself the whole malady, it suffices to destroy or extract it by surgical operation for the patient to obtain a complete and speedy cure. In the other class, the phosphate of lime, or the am- moniaco-magnesian phosphatic calculi form and are devel- oped, under the influence of a morbid condition of the uri- nary apparatus. It is not uncommon for this state t'o persist after operation, to deprive the patient of the complete benefit of treatment, and even to favor the development of a, new stone. These cases predominate in the foregoing account. To resume. Of 54 calculous patients, of which I have just presented a table, 3T have been treated by lithotrity. In 2 cases I was obliged to relinquish the treatment ; 1 died; another retains his stone; 2 of them have not ob- tained a complete cure, because the stone has not formed the sole malady, but they are greatly relieved. The rest are cured. 7 were submitted to lithotomy, which saved 4 of of them ; but in 2 of these the cure is incomplete. 10 have not been submitted to any operation ; 3 have died from the progress of the malady, and 1 aftei; the ope- ration for hernia ; 1 continues to live with his stone. 3 are under treatment, and will be submitted, 1 to lithotrity and 2 to lithotomy. In 2 cases the operations are postponed. These facts prove anew the danger of long retaining the stone, and the utility of lithotrity when we apply it at an earlier period of the complaint. Lancet. Lecture on Sub- Involution of the Uterus after Delivery. By J. Y. Simpson, M.D. F.R.S.E., Professor of Medicine and Midwifery in the University of Edinburg. Gentlemen: I have seen this morning a case of a pecu- liar form of uterine hypertrophy, to which I beg you will 18G1.J Uterus ttftar Delivery. allow me to take this opportunity of directing your atten- tion. The pationt in this instance ia a lady from America, who has Suffered from disordered menstruation, and a fcel- irig of weight and great discomfort in the pelvis, aitfrce'tne birth of her last child. She has, in short, most of the na- tional symptoms oi' a fibroid tumour of the uterus, hut on making a physical examination, I found there was no brnil over the uterus, while that organ was equally enlarged t<> about the size oi' a uterus in the third month of pregnancy and readily admitted a sound t the extent of three and a half or four inches into its interior. Now, although T am not aware that any of the older authors have pointed out particular1;,- this peculiar form of uterino enlargement, yet i am sure it is not at all uncommon. There arc at present in our ward in the Hospital two patients who are the suh jeets of this disease, and in both of whom the hypertrophy of the uterus is complicated, as it not unfrce!w$r, 8l?9 delivery, and remains lor a lengthens! period < reet, while the womb is still more than usually targe, the circulation in its walls might yet get so impeded, and such an amount of congestion bo produced as would prevent the normal changes in its walls, and impede the free absorption of its disintegrated particles. 2. Repeated Miscarriages. However it may he, we. know, further, that in a number of eases an enlarged condition of the uterus of the same nature as that of which I am speak- ing, results from the frequent and rapid recurrence of a sc- ries oi% miscarriages, or abortions in the same patient. You are aware that a woman who has once aborted is extremely liable again to abort at the same period whenever she again becomes pregnant. In such cases it is, moreover, remarka- ble that the patient often conceives again in a very short time after the occurrence of the abortion ; and when this process has been several times repeated the uterus under- going the enlargement of a new pregnancy, before it has had lime, as it were, to recover perfectly from the hyper- trophy of a proccding one, the case sometimes ends in a complete disturbance of the normal physiological process of degeneration and diminution in the uterine walls, ami the womb is left in a permanently hypertrophied conditio! i. 3. Metritis* Again, if you inquire minutely into the his- tory of patients affected with this form of disease, and ask them particularly as to whether anything has gone wrong with them in their puerperal state*, you will very frequently iind, as in the case of the second of our Hospital patients, that within a short time after their confinement they have been the subject of an attack of inflammation in the uterus or ovaries, or neighborhood pelvic organs. They will, per- haps, tell you that a week or two after their child was horn had a shivering, followed by pain in the region of the womb and more or less fever, which compelled them to iain in bed for some time. It would appear as if the irrencc of metritis, or perimetritis, in the puerperal male, exerted such an influence on the substance oftlic uterus as to prevent the occurrence of those changes Hi.!' normally to its diminution in size. lis Sk:ieiolo.y. The patient whom I liave imagined you to b< tioti- ing as to the history other malady, will probably tell ynu. . II #J|Q On Sub-fa coin Hon of the [November further, that after --lie had recovered so far from her inllam- Tiiatorv attack, and from the consequences of the bleeding and glistering to which she laid been subjected for its cure, as to be able to walk about again, she began to be conscious of a reeling of discomfort in the lower part of the abdomen, to which she had never before been accustomed. There in frequently a sense of weight or bearing down of the ute- rus, of distress in the lower bowel, and of uneasiness in connexion with the action of the bladder, and a weakness, .sometimes amounting to actual pain, in the. lower part of the back, and, in some cases, a numbness of the lower limbs, winch are all new to the patient. She attributes, most likely, these feelings to weakness, and expects that as she gains more strength, the uneasy scusation will disap- pear. But some months may elapse, and she begins to be disappointed at her never getting entirely relieved of this local trouble ; and after lactation is accomplished, if, indeed, she have been able to nurse her child at all, she finds that her menses do not return regularly, or become too profuse and painful. Leucorrhea, too, is sometimes present to a greater or less extent; and altogether the patient is in a late of confirmed and anomalous bad health, that is diffi- cult of endurance.' By means, perchance, of tonics and sedatives she strives to regain her health and alleviate her uneasiness and continues for a time to hope that her former strength will still return, and that her ailments will disap- pear. Gradually, however, the conviction becomes forced upon her that something besides time will be needful for her cure, and that some kind of medical treatment is re- quired for her relief. Accordingly she comes to you, and when you have heard a history such as that I have endea- vored to narrate, you come to the conclusion that she is laboring under some disease of the uterus. But what the precise nature of the disease is you will not be able to fix and determine by studying the mere history of the symp- toxfis- To make out a correct differential diagnosis, you must institute an examination of the uterus. Its J'hysical Diagnosis. On placing the hand over the abdomen, you can usually : the enlarged uterus rising in the form of a tumour out of the pelvic cavity, and. lying above the pub era, more espe- cially in those casts w\;;ere the hypertrophy is very consid- il.] Uterus after Qdivery. 871 erable. In all casca you ci0 discover, on making an exam> nation per vaginam, that the vaginal portion of the cervix uteri is enlarged foi\thisis a form of hypertrophy in which every part of the organ is implicated; and you tiud the whole uterus to be unusually large and heavy. This kind of loeal examination is, in the majority of cases, most satis- factorily carried out when the patient is laid on her back ; sometimes it is more convenient to have her placed some- what laterally. But in every instance ol ihis kind you must hear in mind the importance ot* making an examina- tion with both hands simultaneously the forefinger of one hand being employed to explore the uterus through the vagina, while the lingers of the other are applied to the fundus through the medium of the anterior abdominal wall. There is, perhaps, no variety of uterine disease in the diag- nosis of which this sort ot examination can be employed to more purpose than in the case of simple enlargement of the organ. In a few patients the abdominal walls are too thick to admit of your feeling anything very distinctly on palpa- : and there are others, still fewer in number, in whom a certain degree of uneasiness renders the necessary pres- sure painful to the patient. When you have thus got the uterus between the two hands, you can easily recognise the existence of the hypertrophy, and even determine the de- cree to which it has taken place. You can i'eel thai, the -welling is not due to the presence ot fibroid masses in the walls of the uterus, for there is no irregularity and no pecu- liarity in its shape. It has unmistakably the shape and contour of the healthy organ ; it is only that organ in ;> 8 of equable hypertrophy. Such a condition oi matters might still, however, possibly be due to the presence of a Jibroid tumour growing from the submticuous layers of the uterine wall, and projecting into its interior; and to make sure that there is no such tumour present, you must have recourse to another simple means oi' exploration, viz.. the introduction of a uterine sound. The cavity of the healthy uterus measures usually, you know, about two and a half inches in length : and when 'the sound is introduced, you find its point i- afreste I at the fundus, when the knob placed on the convex >idc oi the instrument, at two and a half inches from the etftfrGmity, haa reached the level of the external orifice oi' the uru'u. . Where the organ is enlarged, however, the knob 1 speak of slips past the guiding finger, and tile instrument runs up 822 On Xiih-h)\:oli%iM oj 'the [November intn the interior to a depth of throe or more indies ; and when the enlargement of the uterus is of the kind I have j* .-ibly either an inflamed ovarian tumour, or an abscess, r as there was Considerable pain on pressure. On passing a j. ;,;nnd, however, it was found to run right ftp at once about | four inehes into the very ventre and" top of the tumour. ( 'Ihe supposed tumour '#aa thus shown to be neither more uor less than the uteres considerably enlarged and turned what to one side,., ga sometimes happens in such cases. 1.) / y ,, Delivery. ?73 That \v;is the first occasiou, so far as T know, in which this kind of uterine hypertrophy was clearly made out; bul since then, T have seen it very frequently, usually as a result of inflammation after delivery, but sometimes associ- ated with repeated miscarriages in the relation both of cause and effect Its Duration and I)e<;eee. In some cases you will detect the form of uterine hyper- trophy which I am describing, within two or three weeks, Of two of three months after delivery. These may be call- ed the acute, or sub-acute, types of the disease. But oftencr perhaps iu practice, you will not be applied to till the dis- ease is chronic till many months, or even years, have elapsed since the date of the last delivery, or of the last abortion, which left the uterus in the sub-involved or unre- duced condition which we arc considering. The degree or amount of remaining enlargement varies iniinitcly in differ- ent cases ; and is, perhaps, mainly regulated by the date of the confinement at which the arrest of the involution takes place, and the completeness or not of that arrestment. I have seen instances where the uterus was large enough to be felt some inches above the pubis, and where the uterine sound passed into the uterine cavity to the extent of four or rive inches. In other examples you will find the uterus in form and length remaining hypertrophied only to a slight extent, and the sound passing perhaps not more than two and three-fourths of an inch or three inches. Between these two extremes, you will meet in practice with all in- termediate degrees of this permanence of the puerperal hy- pertrophy of the uterus. Treatment of the Disease. In the more acute forms of the disease, I have almost in variably found that by the immediate employment of local antiphlogistic:-- the symptoms were speedily and successfully alleviated, and the process of absorption was set up. Where any traces of inflammation .till remain, the importance of this indication is at once apparent, and its fulfilment is in attended with rapid relief. J hit even in c where all inflammatory act; i have died out, and dts remain, we i ften find I cannot well tell you how that a local antiphlogistic course of treatment 874 On Sub-Involution rom"ule much more extensively, for it has this advantage over t\ie former salt, that its use may he kept up for almost any length of time by a patient without her becoming subject to the kind of marasmus which we sometimes rind attendant on the prolonged use of the iodide. The bromide. of potassium may not only he given with safety for a lengthened period, but it may be adminis- tered with confidence as a good tonic, as well as perhaps the best deobstruent in the Pharmacopoeia. It may be depended upon as an active stimulant to absorption, besides possessing the property, beyond all other remedies that I know of, of acting as a special sedative on the reproductive organs. In cases of this kind you must administer it in larger doses than usual, making the patient take six, eight or ten grains of it three times a day. Sometimes patients suffering from this form of uterine hypertrophy present themselves to you in a debilitated and ancernic condition. Under such circumstances, you need not hesitate to add iron, manganese or some form of metallic tonic, alone or in combination, to the more specific remedies, and endeavour, always in the more chronic cases of the disease, by means of good diet and other hygienic means, to raise the pa- tient's general standard of health. You will occasionally meet with cases of this disease inate, that the process of absorption does not begin, or docs not go on to any satisfactory degree, even after you have had recourse to repeated leechings, and have kept the uterus imbedded for a length of time in discutient oint- ments, and have duly administered all kinds of dcobstruents and tonics. In such cases you may follow up the course of treatment which I have sketched for a very lengthened period without producing any appreciable change in the size of the womb, or any marked alleviation of the patient's symptoms. If, however, by any means you can induce the uterus for a time so to take on an action of increased growth, you may confidently hope that this temporary hypertrophy will be followed by a process, of absorption which will go on perhaps uninterruptedly, until the organ 876 Oa Diseases within the Ear. [December is reduced to its normal dimensions. Such a transient in- crease in the size of the uterus you may at any time pro- duce by taking advantage of the physiological tendency of this organ to enlarge and become developed around any foreign body that happens to be lodged within it. You know that the uterus begins to enlarge when*stimulated by the presence of an ovum, or of a morbid tumour, or of a clot of blood in its interior; and in like manner it becomes developed in size when a foreign body, such as a sponge- tent or an intra-uterinc bougie, is introduced artificially. By introducing, then, a succession of very small sponge- tents into the interior of the womb, or by making the pa- tient wear for a time an intra-uterine pessary, you can cause the uterus to take on this hypertrophic action ; and by afterwards actively and fully taking advantage of the ten- dency of the organ to undergo a process of degeneration and diminution on the removal of the stimulus, you may succeed, by the due employment of the various discutients and deobstruents I have already mentioned as rest, coun- ter-irritation, and bromine in promoting the process oi' absorption to such a degree that the uterus at last be- comes reduced to the natural standard. In some obstinate instances I have been obliged to repeat from time to time this process of artificial irritation and dilatation before a perfect cure was perfected. Med. Times $ Geizctte. Oa the Means for Preventing Caries of the Petrous Boiie and the Formation of Abscess in the Brain in Cases of Disease within the Ear, By Joseph Toynbce, F. R, S. Annual Surgeon to St. Mary's Hospital, to the Asylum for the Deaf and Dumb, etc. 1 may, perhaps, be permitted to add a lew remarks to the highly interesting observations published in your Journal of February 23, on Abscess in the Brain, associated with discharge from the ear. In order that we may ascertain the causes which lead various affections of the car to produce disease in the brain, it is desirable that the ear be always carefully dis- sected, so that the nature of the affection, its exact locality, . 1SG1.] On Diseases within (he Ear. 877 and its relations to the petrous bone and surrounding structures, be clearly pointed out. Your reporter states that it "it is a very tedious process to take out the temporal bone for careful examination ;" inasmuch as a section with a saw in front of the petrous bone as far as the body of the sphenoid, and one behind, as far as the basilar process, fol- lowed by the division of the soft parts by a large scalpel, is all that is required to remove the parts necessary for an ex- amination of the ear, the process of removal can scarcely be considered "tedious." The subsequent dissection of the car doubtless requires some care ; it can be best effected by means of a small pair of cutting forceps, whereby piece by piece of the petrous bone is cut awa}r, and no saw-dust pro- duced, with which the state of the parts is apt to be marked when the saw is used. I have no hesitation in say- ing that the breaking up of a petrous bone by the aid of a chisel and hammer, can lead to no useful results^ indeed, the bone must be taken away in order that a careful and searching dissection may be made. Some recent obser- vations on the mode in which molluscuous tumours devel- oped in the external meatus, progress inwards through the petrous bone to the brain and its membranes, tend to con- firm the opinion I have advanced on several previous occa- sions, that in all cases of diseased petrous bone and brain, the nature of the disease, the particular part of the ear allected, and its relations to the brain and its membranes, must be ascertained. Of course it is desirable that the blood-vessels and other parts adjacent to the petrous bone be also examined. Before taking leave of this part of the subject, I may add, that if any Medical man, who is too much occupied to conduct a careful dissection of a diseased petrous bone that may fall under his notice, will send it to me, I shall be happy to make a dissection, and will return the specimen, with notes. The recent occurrence of a case in private, and one in Hospital practice, in which the brain suffered from disease of the ear, induces me to make some observations on the treatment of similar cases. There can be no doubt that the usual cause of the disease in the ear advancing to the brain is, that matter is pent up in one of the cavities of the ear. I have ventured to suggest that when pent up in the tympanum it affects the cerebrum; when pent up in the oid cells it affects the cerebullum ; and when in tjie vestibule it affects th rarolii, an<] base of the brain 876 On Diseases within the Ear. [December, Since I promulgated this opinion, some years since, in a paper in the Medico Chirurrjleal 'JVansactions^ I have had no reason to alter my opinion. If it be a correct view that matter, pent up in a cavity of the car, is the usual cause of disease of the petrous bone and brain, it follows that the duty of the Surgeon is to prevent the matter from collect- ing, or to remove it when collected, and if neither measure can be effected, to diminish by every possible means the effect of the matter, and to prevent the progress of the dis- towards the brain. The most simple and most man- ageable cases are those in which the tympanum is the seat of the disease, and where the whole, or a considerable por- tion of the membrana tympani has been destroyed ; the use of a syringe and warm water twice daily, is then usually sufficient to ensure the removal of the discharge ; but it must b<* laid down as a rule that so long as there is any discharge from an car, so long must the syringe be used, inasmuch as discharge is apt to become more or less solid, aria thus act as a barrier to its own escape, and to that secreted around it. While the discharge is being removed, of course the thickened state of the tympanic mucous mem- brane, which gives rise to the discharge, is to be treated locally and generally, so that, its condition being ameliora- ted", it may no longer pour out the unnatural discharge, and thus all fear of disease in the petrous bone maybe removed. I have met with several cases in which death occurred from diseased brain where there was no other impediment to the free escape of discharge than the inspissated secretion itself, and where the free use of the syringe would have averted the mischief to the bone ami the brain. In cases where the orifice in the membrana tympani is small, and where, in consequence, the discharge is apt to be detained by the re- maining portion of the membrane, acting as a barrier, addi- tional care is required by directing the stream of water ihrough the orifice of the membrane into the tympanum, in order to evacuate the latter cavity of its contents. The Inst and most serious consideration is how to avert mischief to the bone where there is evidence that matter i.- confined in the tympanum or mastoid cells without any outlet. The two classes of cases nnflr be placed together, inashlttch as when there is long-sianding irritation of the tympanic raucous membrane, an operation on the drum in eem to be aware of the danger liable to. follow long-continued discharge from the ear, but judging from instantly brought before my notice, as a rule, tla e I".. [\},i to he di regarded, until 1' a young officer, . -d himself in th au war aud Indian muti 880 On Diseases within the Ear. [December, may be cited in illustration of my observations on this sub- . L will give a brief outline in tlie case: Captain R. .!>., aged 25, was brought to me by Mr. Teevan on January 2, of the present year. He stated thai when a child he suffered from some infantile disease, which was followed by discharge from the left car. This discharge continued, with slight intermissions until I saw him, and it was accompanied by pain in and around the car. Irrita- tion within the ear, as is not uncommon, produced a polypus in the external meatus ; on account of this po- lypus Surgeons were consulted, and the growth was re- moved on one or two occasions. The irritation, however, increased, and while at Aldcrshott, at the end of the year 18G0, it became so severe as to induce him to come to Lon- don to seek further advice. At the first visit, although the patient walked into my room, and did not feel himself seriously ill, I felt convinced that the petrous bone was diseased, and that there was disease in the cerebrum. There was a polypus in the meatus; the bone was tender all around the ear ; there was great pain in the car, which extended deeply towards the brain. I expressed my fears to Mr. Teevan of the very dangerous character of the dis- ease, and stated my belief that there was an abscess in the cerebrum. In spite of all treatment, the head symptoms increased ; the portio dura became paralysed, and the pa- tient also lost the power of articulation, although he was perfectly sensible. Dr. AVatson, at a consultation a few days before the patient's death, confirmed my opinion of the probable existence of an abscess in the brain, but as the friends objected to a post-mortem examination, the verifica- tion of the opinion could not be made. At least there can he no doubt, and there was no doubt in the minds of his Medical attendants, that the patient died from injury to the brain produced by long-standing disease in the ear ; and to mc it is highly probable that if, in early life, the disease in the ear had been perseveringly combated, its fatal result mU'-ht have been averted. Medical Time? & Gazette. 1861.] fion. under the care of Mr. Bryant.) The live following cases illustrate some interesting points in the management of urethral obstructions from different causes. In the first two the cause of obstruction was lacer- ation from recent injury. Case 1. C of the Perineum. Hemorrhage from the Urethra Subsequent Extravasation of Urine Gathei Impossible Perm " / ft is v >. i Recovery. A man, aged 53, was admitted on September 5, 18G1, for extra a of urine. The history obtained was, that five days before he fell astride on a log of wood, some hemor- rhage from the urethra was the immediate result, and diffi- culty in micturition. The day following a catheter was passed and left in for twenty-four hours ; it was then with- drawn ; retention of urine followed, and as this persisted for two days he applied to Guy's. On admission the peri- neum was infiltrated with urine. Catheterism was impos- sible. Many fruitless attempts had been made to pass an instrument, before he was brought to the Hospital, and profuse hemorrhage had resulted. Mr. Bryant therefore determined to open the urethra through the perineum. lie introduced his linger into the rectum as far as the pros- tate, and then pushed a bistoury into the perineum in the middle line and cut upwards and succeeded in slitting the urethra. He then passed a grooved director into the blad- der, and was able, after passing the catheter down the penis into the wound, to guide the instrument into the bladder. ( >n the sixteenth day urine passed through the urethra, the wound healed kindly, and the man was discharged well on tember 30. Case 2. Fracture Irls and Laceration of ' hnpractii " Veri Death . In the preceding case, as we have seen, the operation wa-^ performed the day after the accident, and when tion of urine had already taken place. In the follow Mr. Bryant preferred to anticipate thee: fttion, au '1 be introduced, I once pi - 882 Perineai Section* [December^ A man, aged 50, was admitted for fracture of the pelvis and laceration of the urethra. A cask had fallen on his hip whilst he was laid on one side. lie had, luckily, made water about half an hour before. When admitted, there were evident symptoms of fracture of the pelvis, and rap- tured urethra, blood flowing from the passage. There was no extravasation. It was impossible to pass a catheter, and therefore Mr, Bryant opened the urethra from the perineum, cutting down on a grooved staff. The man never rallied, however, from the injuries sustained, and died shortly after. The perineum in this case was opened in order to prevent extravasation of urine taking place, which would necessa- rily have resulted on every attempt to pass water. After death the ramus of the os pubis was found fractured and the urethra lacerated. Case 3. Indurated Stricture of the Urethra anterior to the Scrotum Internal Urethrotomy Recovery. A man, aged 23, was admitted under Mr. Bryant's care for retention of urine. On examination it was found that he had a stricture in the urethra just at the root of the penis, and here an induration could be felt. Six months previously, he had had gonorrhoea. Mr. Bryant suc- ceeded by force in passing a catheter, and thus relieving the retention ; but as the stricture was a very tight one, and from its position was very favorable for internal section, lie determined to operate on it. lie, therefore, divided it internally by the urethrotome, and was then able to pass a No. 11 catheter into the bladder. It was kept in over a period of five days, after which the patient Was able to pass Water freely. He was kept in the Hospital a month and was then discharged cured ; tho local induration having dis- appeared. Case 4. Stricture and Extravasation of Urine Free Incisions Recovery Subsequent Coniraction of the Stricture Peri- neal Section Recovery. Robert A., aged 43, was admitted for extravasation of urine consequent on stricture, lie had had gonorrhoea twenty years before, but had, lie said, never used injec- tions. The urine was effused into the cellular tissues of the perineum, sqrotiim and penis, and extended into the abdominal wall. Mr. feryaul freely incised tltr- distended 1861.] parts; and also made an incision into the urethra from the perineum. Tie then succeeded in passing a catheter through the opening in the perineum into the bladder. The man rapidly recovered from the extravasation, and micturition was tolerably free, but the urethra subsequently contracted considerably, the passage of a catheter being almost impossible, the whole passage being like cartilage. On May 2, I860, chloroform being given, Mr. Bryant performed perineal section. The case did well, and a rail- sized catheter could be introduced with ease. A small fis- tulous opening remained, which proved obstinate. The es were, however, kept raw by strong liquor ammonia, and a perfect cure resulted, the man making water better than he had for years. Case -5. Retention of Urine in a Bon Difficult Catheleris/n in the Perineum Perineal Section Hecoveyy. A boy, aged i>, of good general health, was admitted un- der Mr. Bryant's care for retention of urine. Before he was brought to the Hospital, many attempts had been made to pass a catheter, but in vain. With great difficulty and with some degree of force, Mr. Bryant succeeded in -:ng Xo. 1, and drew off a large quantity of urine. The difficulty experienced was in the scrotal part of the urethra. An abscess formed in the perineum, and as it was on the next trial, found impossible to pass an instrument, Mr. Bry- ant opened the abscess. Urine flowed from the opening, and but a small quantity passed by the penis. The urine all along had been puriform. The opening in the urethra partially closed, but no improvement took place in the ling of the urine by the ordinary channel. Mr. Bryant, efore, on March 2, performed perineal section. The grooved staff was forcibly introduced. Xo Indurations could be felt at the site of obstruction. On March U urine ilowed freely through the urethra, and the wound healed, a perfect cure resulting. The cause of stricture m this case very obscure, indeed it was doubtful whether such lad, ami whether chc obstruction had not been some igenital malformation of the passage. Med, limes &Q . 884 Ff/cemia. [December. On Ptfgemia. By Professor Roser. (Archiv fur Ileilkundc Jahrg, i. BS. 37, 193 und 329.) The following observations form a brief extract of some interesting papers on Pyaemia, from the pen of Professor Roser, oi*Marburg: 1. The Specific Nature of Pyccmia. We are indebted to the obstetrician, rather than to the surgeon, for any progress which has been made in our knowledge of the nature of pyaemia, he having established the miasmatic character of the pyaemia of puerperal women, and its identity with the pyamiia of the wounded. The doctrine of " Surgical Fe- ver," so ably expounded by Simpson, has however made but little way in Germany, Virchow's views on thrombosis there predominating, as the doctrine of phlebitis formerly did in France. Professor Roser shows in some detail, that neither Hunter's theory of phlebitis, Rokitansky's disease of the bloodvessels, nor Virchow's thrombosis, afford any sufficient explanation of pyaemia, conditions being assigned as causes which are mere concomitants or effects. The at- tempt to explain its occurrence by the fact of the absorp- tion of ill-conditioned pus also fails ; for, although various analogous circumstances are producible by such absorption these differ much from those of pyaemia, and may be ex- pressed by the term septaemia. The two conditions, may indeed, be combined, and we may have a septic pyaemia, just as we have a septic variola or scarlatina. If pyaemia be followed out through its various modes of manifestation, it will be found to exhibit a marked similarity to typhus and other zymoses; and just as in the case of these zymoses, while sometimes it appears epidemically and as the result of contagion, at others it arises spontaneously, without the prior presence of piis. This fact has long been known in lying in hospitals, and careful observation will easily detect similar cases in surgical wards. Stromeyer has observed a whole series of such cases, and similar ones have come un- der the author's notice. The explanation of the occurrence of sporadic cases of pyaemia may be difficult, but it is no more bo than is the explanation of sporadic typhus or cholera or other zymoses. Forms of Pyaemia. Professor Roser confines his atten- tion io sonic-of these which have excited but little atten- tion. 1. Pycmtia Febricula. lust as duiingthe prevalence of typhus we find patients here and here exhibiting bu1 1.] /;., Blight symptoms, so in hospitals infested with pyemia, a mud form of the disease is observable which may be termed febricula. it has been but little noted, as was indeed to be ected, by those who were on the lookout for phlebitis, sepsis, or thrombosis, as the initial phenomena of pyaemia ; hut the author instances cases in his own and in St minever's practice. In lying-in hospitals the febricula is termed "milk fever " a term of doubtful propriety, seeing that the affec- tion is observed sometimes in almost all the inmates, and at others in none of them. 2. Pj/cumlc Hfrysipetds. When in a patient suffering from pyaemia, erysipelas appears, the natural conclusion is that the pyaemic blood-disease lias localised itself in the skin, just as it might have done in the pleura or in a joint. When, however, in a subject of cry- ymptoms of pyemia appear, the question may arise whether during the erysipelas the blood poison has become developed, whether the pyaemia has become added as a se- cond special process of disease, or whether the erysipelas itself was only the first manifestation of the pyremic condi- tion. Lastly, erysipelas and pyaemia may co-exist, and al- though they may not often be met with in the same patient they | uently found prevailing among different patients in the same ward. The author's conclusion is, that hospital erysipelas is a consequence of pyaemic infection and its lo- cation in the skin, although he admits that it is doubt- ful whether another variety of blood-poison may not also give rise to it. 0. Pyc&nic JJiarrhoca. This affection, well vn to clinical observers, has obtained but little notice in hand-books. There are cases in which no other symptom, the diarrhoea nt, but the author still regards the- emic, occurring as they do simultaneously with othe in which the diarrhoea has only been the first of the whole series of symptoms. When this diarrhoea is com- bined with the pyaemic erysipela , the disease exhibits king and rapid contagious properties, and in hospitals in which precautions against contagion are not taken, this has] hoea, though little spoken of, i lent occurrence. . Although the incurability in, practitioners in general are not aw;; number of recoveries which really do take place, and that even when excluding the .-lighter i >ove alluded ad admitting only examp ell-marked pyaemia. The number of re< \iv< increased in proportion as 886 J)/(cmia. [December, the essential conditions of fresh air and a good diet have been appreciated. Supporting the patient's strength by means of wine, has replaced the former mischievous anti- phlogistic treatment; and, indeed, judging from the use made of alcohol in England, there is danger of the opposite extreme being fallen into. Quinine, though usually of no great utility may, in some cases, be a valuable adjuvant ; and morphia is an invaluable remedy, serving not only to check diarrhoea, abate pain, and diminish danger in perito- nitis, &c., but also to tranquilise the excited and delirious patient. The most important agent in the treatment, how- ever, is a frequent renewal of fresh air, and the removal of all objects likely to pollute it. Prophylactics. Under this head the author lays great stress upon simplicity in dressing wTounds, observation of the strictest cleanliness, and checking the decomposition of pus by cold and chlorine applications. When the spread of pyamria is to be guarded against, instruments and nurs- ing appliances should not be used in common, no autopsy should be performed by those attending on the sick, and the surgeon,,, visiting his cases of pysemia last, should change and ventilate his clothes before seeing other patients. In all cases of ill-conditioned suppuration at Marburg, weak chlorined water is employed, and after waiting on such pa- tients, the nurses carefully wash their hands in the same fluid. Finally, Dr. Roser protests against the erecting hos- pitals with large surgical wards, unaccompanied by means for isolating the subject of pyemia. Small hospitals of even a very faulty construction, give rise to a less mortality than some magnificent structures in which the patients arc assembled together in large numbers. Juridical Relations. Under this head the author discusses the question that may come before the surgeon in court of law viz : whether a fatal pyaemia following an injury not in itself necessarily fatal, should be regarded as an essential condi- tion of such injury, or as an accidental and superadded cir- cumstance; the exact determination of this point modify- ing in the German courts the amount of punishment to be awarded. He cites cases in which the pyrcmic complication has been altogether overlooked, or has been wrongly inter- preted to the detriment of the accused. He lefers also to two other conditions to which the same considerations ap- ply, viz : diffuse inflammation and tetanus. Diffused in- flammation after wounds of tendons, &c., so often observed. 1861.] Cystwcrciis in the Eye. in hospital, and so seldom in private practice, should not be attributed \o the nature of the local injury, but to the pre- sence of miasmata. In fact it is of a pysemic nature. Wills respect to tetanus, we know nothing concerning^ its casual connexion with wounds, and when questioned juridically, should avow such ignorance. The author himself is posed to regard it as a zymotic affection, not only be- c no casual connexion with the wound can be made out but from its analogy to hydrophobia, which is a zymotic affection, and from 'its disposition to prevail as an endemic or epidemic Br. Fur. Med. Chit, Bcv. of Cystieercus CeUidosm in the Anterior Chamber of the By Dr. Memle. The wife of a shoemaker, 25 years of age, of healthy appear- ance, and far gone with her first child, applied to the author on account of an obscurity of vision. On inspection a cysti- cercus was perceived with the utmost distinctness in the anterior chamber of the right eye. The worm was of a deli- cate white, the bladder being so transparent that the brownish iris could be seen through it. It was of the size and shape of aall pea, and below was a process which was somewhat whiter and less transparent than the rest of the worm ; and from this projected a white transparent neck, about a quarter of a line in length, having at its extremity a small round head, which examined by a lens, exhibited lateral swellings, and re- bled the head of a tenia. The bladder of the worm cov- ered the lower part of the pupil, leaving this free for two- third circuiitferencc, while in appearance it dipnoi differ from that of the other eye. The worm was motion] movements were not induced when the patient in p when a strong light was directed upon the iy>\ pent examinations during the next three days tile TO was found to have assumed different positions and various shapes. It was very interesting to observe thrguhg a lens how it thrust its head here and there, just as a le >re it fixed on a spot to commence sucking from; When 888 Morbus Goxarius. [.December, it attached itself to the anterior of the iris, its neck was bent backwards, and the bladder almost completely obstructed the pupil a slight quivering movement, like that seen in the sucking leech, being imparted to the tube-like process of the animal while the bladder continued motionless. Sometimes the process was distended into a bladder much smaller than the other, below which it was placed, and from which it was separated as if by a ligature. The woman was confined on the third day after being seen, and continued under observa- tion for about three weeks before an operation was performed, the animal frequently changing its position, attaching itself to the various surrounding parts, without seeming to inflict any injury on them by its sucking process. The pupil at last became narrower than the opposite one, whilst its form was converted into an oval, and vision got more and more im- paired. Fearing the production of iritis, a linear-incision was made, and the worm, discharged with the aqueous humor, was carefully captured. It was placed in tepid water, but exhib- ited no movement. The wound in the cornea soon healed under the employment of ice, and the eye has regained its perfect powers. The worm three months after its extraction has contracted from eight to five millimetres in length. So far as the author is aware, there have been seven in- stances of cysticeri in the anterior chamber recorded. The first was discovered by Schott, of Frankfort, and Grafe, Ilirschler, and Appia have each described a case, and Mac- kenzie relates three cases. This last writer and Grafe have also collected cases in which the cysticercus has been found in various other parts of the eye. Grafts Archw. fur Ophthalmologic, vol. vii. p. 122. Morbus Coxarius. The Academy of Medicine, of New- York, has devoted the general portion of several of its later sittings to the consider- ) of the subject of morbus coxarius. The Section on Sur- gery had previously discussed the subject at great length, and had recommended it to the Academy. Dr. A. C. Post opened the discussion, by giving a concise history of the pathology and treatment of hip disease. He was followed by Drs. Bat- chehler, Puck, Sayre, Wood, Parker, Raphael, Krakowitzer, I . I M Branson, and others, and by invitation, l>rs. Banes and Pavis who were present, participated in the discussion. Little was said thai el as regards the pathology of the disease, bnt the mechanical treatment, brought to such a degre perfection by the Burgeons of this city, was minutely explained thoroughly criticised and universally commended* The prin- ciple upon which the mechanical treatment is based is the separation of the impinging surfaces of diseased bones by means oi carefully applied splints, producing extension and counter- :i, and admitting of motion of the joint. This treatment has been the gradual growth of years. As early as 1S35, Dr. Harris, of Philadelphia, is said to have ap- plied extension and counter-extension by means of Gibson's modification of Physic's long splint, with success in four cases. A report of these cases was made early in 1S39, but, as Dr. March states in his paper on morbus coxarius, "without giving rion of the theory or principles upon which the practice is founded.'' Later, the treatment was proposed by Dr. March, of Albany, as an entirely new treatment. He found he had been anticipated by Dr. Harris. Dr. March however, explained in his paper just referred to, which was I before the American Medical Association, and printed in Transactions of that body for 1S53, the theory of the :ment. " The most important part of the treatment," says Dr. March, "consists in the keeping of the joint in a use." This is accomplished by a splint, -ion and counter-extension are used with a view to rent undue pressure on the delicate and tender surfaces of bones." " In the advanced stage of the disease," continues Dr. March, "the cartilages of the acetabulum and of the head of the bone arc destroyed ; the carious and spongy .-red with coagulated lymph, and this adherii the surface of the bones becomes highly vascular. Now if a two surfaces, thus covered with organized or organiza- blc matter, could 1 e. kept in easy apposition and at rest without too mm re on the one hand, and on the other without exerting too much separating or sundering force in many instances a bony anchylosis would be the r This irst record we nave of the mechanical treal n pathological conditions. Put Dr. .have proposed it for other than the in the early stage, he says Mit be important to resort se of th -plint, to maintain the joint in a state immation may subside," while ext and counter-extension, it ap- 890 Morbus Coxarius. [December' pears, were used by him in the advanced -stages to prevent the deformity of the limb. Next in order to Dr. March is the treatment proposed by Dr. Bauer, of Brooklyn, by means of an apparatus similar to the double r/outtiere of Bonnet, of Lyons, having, however, attached to it a footpiece allowing of extension. This appa- ratus is made of wire, and has been dubbed with the sobriquet of the "wire breeches." This apparatus keeps the limbs im- movable, and permits the patient to be carried about. In April, 1860, Dr. IT. G. Davis described in this journal a method of treating hip disease he had employed for many years. The principle upon which his treatment was founded was the application, by means of a corrugated steel splint, of extension and counter-extension, permitting at the same time the patient to take active exercise in the open air. For the steps of the treatment and an explanation of the splint uesd, we refer to Dr. Davis' paper in the Monthly for 1S60. In this instrument is combined all the suggestions made by Drs. Harris and March, with the addition of elastic extension applied in all stages of the disease, not for the sole purpose of preventing or overcoming a deformity, but as a curative means, and with that freedom of action to the patient wearing the splint which permitted him to take exercise and air, so important to the general health. This was attempted to be accomplished in a measure by Bauer's wire breeches, but is positively accomplished by the Davis plan of treatment The report of the Section on Surgery, and the remarks made by most of the surgeons who participated in the discussion at the Academy, gave Dr. Davis the credit of having introduced the methodical plan of treatment to the profession. To the steel splint of Dr. Davis several modifications have been made by Dr. Sayre, Dr. Davis himself, and othe^. Dr. Sayre differs from most of the profession in his views of the etiology of the disease. He holds that, with few ex ceptions, the disordered action of the joint can be traced to direct traumatic influences, and not to a strumous origin, as is the almost universal opinion. He believes that the effects have been mistaken for the causes, the scrofulous cachexia being consecutively developed, and therefore being the results and not the causes of the disease. In these views he is sus- tained by Dr. Bauer, of Brooklyn. Amer.Med. Monthly & .V. Y. 'Review. - early as 1854, the anti-periodic properties of nitric acid had been pr< to the profession, by Dr. George Menden- hall in tl Lancet : and even prior to that time 'had n availed of by Dr. E. S. Bailey, of Indiana. A recent article in the Maryland and Virginia Medical Journal, by r Wm, A. Hammond, late U.S. Surgeon at Ft. Riley, Kansas, is again attracting the attention of the profession to its use tor this purpose ; and from it we condense the follow- ing : cases, ten of the quotidian and thirty-one of the terti; form a table, the basis of a report made to the Surgeon-General. Of these, thirty-two were treated with nitric acid and nine with quinine. Three cases cared by nitric acid, had previously used quinine unsuccessfully ; and two, cured by quinine, had been treated with nitric acid in- effectually, and in one other the acid was discontinued, on ac- count < i' creating nausea, heart-burn, etc. The average period of treatment was the same with each remedy three days. acid was given in doses of ten drops, three times per day, erly diluted with water; the quinine in eight grain doses, as often. Dr. Ilammo; les the fact -that the as equally successful with quinine in arresting the i 'he difference in the cost of the two articles is so rly in favor of the former substance as to render it an object of importance to make its curative properties more widely . known. Since the foregoing cases wore treated, I have frequently employed nitric acid in the treatment of in- termittent fijvui\ and have rarely been disappointed in my - of its curative action. In fact, in simple, uncom- plicated intermittent, I seldom have occasion to use anything In cases of enlargement in the spleen, consequent upon lent attack.- -T^e, the remedy in question has, in pr< ved 1 vantage- us. ( h icago j i communication on an important e by Dr. Grima: inx. This learned fellow-practi- tion ct is to make known the mode oi of ems m use at Venice, an< France 892 CUt'in [December, this advantageous manner of collecting and preserving potable water, for the private and public requirements of a, great number of places. At Venice, the greater part of the rain- water is collected in 2077 cisterns, 177 of which are public. Their united capacity averages 7,100,000 c. feet, and when all deductions are made, they supply 4rJ gallons of water per day for each individual of the 120,000 inhabitants of the city. Dr. Grimaud describes in the following terms, from information afforded to him by the engineer of the city of Venice, the mode of construction of these cisterns : The ground is excava- ted to about nine feet three-quarters ; a depth which the infil- trations of the lagoons do not allow to exceed. The well re- ceives the form of the inverted frustum of a pyramid. The surrounding earth is supported by a solid wood-work of oak or larch, bearing on the truncated summit and likewise on the four sides of the pyramid. On the wood-work is placed a layer of compact and consistent pure clay, the surface of which is most carefully smoothed down. The thickness of this layer is proportionate to the dimensions of the cistern, and in the largest is not more than twelve inches, a depth sufficient t:> resist the pressure of the water, and also to oppose an invincible obstacle to the roots of vegetables which may grow in the surrounding soil. It is considered most import- ant not to leave any cavities in which air may remain. At the bottom of the excavation, in the interior of the trun- cated summit of the pyramid, is placed a circular stone, hol- lowed in the middle like the bottom of a kettle, and on this stone is raised a hollow cylinder of the diameter of an ordi- nary well, constructed with dry bricks laid well together, those at the bottom only being perforated with conic holes. This cylinder is raised above the level of the ground, where it is finished off like the kirb of a well. Tims a considerable vacant space is left between the cylinder, rising from the middle of the pyramidal excavation and the walls of the pyramid, lined with clay and resting on the wood-work. This space is filled with well-washed sea-sand. Before the whole is covered in with paving stones, a sort of stone box closed by a stone lid and perforated with holes, is constructed at each of the four corners of the base of the pyramid. These boxes, called casscttoni, are connected with each other by a small pipe, made of dry bricks, resting on sand. The whole is cov- ered over with common paving-stone, inclined in the direction of the four orifices of the casscttoni at the corners. The water from the roofs runs into the casscttoni, penetrates into the :mw degeneracy which belongs to the third or fourth si Bright's disease ; the tubnli nriniferi were obstructed a1 their junction with the sinus renalis by crystals of iithal ... The parenchyma of the viscus was destroyed on the left side ana the gland was converted into a collection of small ts formed by the dilated infnndibula. The secreting- part of the texture was entirely diorganised. The cause of death was, therefore, hydronephrosis a dis- ease improperly described as albuminuria, and life had been troyed by nervous disturbances, which of late have been 'dered as resulting from the presence of urea in the blood; anemia in this instance had originated in retention of urine caused by the excessive narrowness of the prepuce. M. Aran was confirmed in this view by the fact that even energetic pressure of the bladder was inadequate to force Its contents through the urethra. The presence of urea in the blood which occasioned death in the present instance, is not uncommon, and induces very different morbid phenomena. When the disease assumes a rapid and acute form, convulsions more usually chronic may appear ; sometimes, en the contrary, the -ins are permanent, as in the child whose history we" have related ; in other cases, coma or delirium, with or without convulsive action is observed. In the chronic variety, the re much less marked. The patients complain of a sense of discomfort, of agitation, of more or less headache, I disturbances of the intellect, of memory, or of the senses, e\:c. are likewise observed. How are the convulsions, coma, delirium, and the various pathological conditions above enumerated to be connected with uraemia 2 The pathologist will be enabled to reply to question by the estimation of the precedents of the case, by the chemical examination of the urine, and more especially by the specific gravity of this secretion. It should be ob- ed that the nerve manifestations, referrible to the presence of urea in the blood, are not merely coincident with albumin- ous urine, but are also observable in cases of complete de- letion of the renal texture, when the excreted fluid contains neither albumen, urea, nor saline ingredients, but e almost pure water. The specific weight of the liquid is then very low, and this indication should on no account be neglected more especially when percuss ws the dulneE i in Uu\ re- the kidney to have much inc I 89G Editorial. MEDICAL COLLEGE OF GEORGIA. The absence of a large portion of the Faculty of this Institution, en- gaged in the service of the country, has rendered it impossible to open the College this season, and its closed doors indicate the determination which pervades all classes of the Southern community, to sacrifice every interest rather than submit to the iniquitous domination of our fiendish foes. No age nor condition has escaped the enthusiasm created by the war-cry. The robes of the divine, the magisterial ermine, and the professorial cap arc alike laid aside, to make way for the armor of deadly strife ; and beardless boys, panting for blood, hasten to the rescue, while their mothers and sisters prepare materials to dress their wounds. Such is the condition of our people from the mountain-tops to the very S2a-beach. No apology is therefore necessary for those who have left their chairs vacant in our halls of learning ; but we may indulge the hope that they will soon accomplish their patriotic mission, and return with laurels upon their brows, to resume their accustomed labors. Professors Ford and Campbell are at the Georgia Hospitals in Rich mond ; Prof. Miller with the army at Manassas ; Prof. Jones in the service on the coast of Georgia ; and Dr. D. Ford at the Culpepper Hospital, Va. The remaining Professors may bo called into the field at any moment. SUSPENSION OF THIS JOURNAL. It is with much regret that we find ourselves obliged to announce the suspension of this Journal for the present, and probably during the war. The high price of paper, the increasing difficulty of getting it at any price, and the probability that the supply will soon foil entirely, have combined to compel our worthy publisher to decline a renewal of his contract with us. We must, therefore, yield to the stern necessities of the times and take an affectionate leave of our numerous readers. "When we shall have achieved our independence, the Southern Medical Aconite in tetanus 432| Atropine 192 Ague 272J do in sciatica 4:;i Ague weed 710; do solution of \''>\ Alcohol, action of ' Ammoniacraia SKi Bailey, A. W. en vesico vaginal Ammonia, liydrochlorate of. . . . 77 J fistula U':; Amputation of leg 44o;Belladonna in sore throat 90 Amputations and resections-. . .. 558 Bellinger, M. on rectal touch. . .858 Amputations of foot and ankle. 746 Bignouia Catalpa 700 Anatomy, by Leidy 190|Bismuth, action of (L68 Angina, gangrenous 510 Bloodvessels, developement of.. 812 sthetics, action of 343 Bronchitis, chronic W Aneurism, digital compression in 340 Bronchocele 512 Aneurism digital compression in. 831 Burns by phosphorus 191 AneurismaT varix 499 Antigalactics 411 Calculus of bladder Anns, eruptions around 188 Camphor, antidote for strychnine.] 0 1 -eatment of fissure.*- 830 do an antigalactic Apoplexy of Ketina 54 f''aneer of lip Apoplexy, diagnosis of 232 Cannabis indica. lectio congestion, arsenic in. 820 Csrboni Apoplectic congestion, by Trous- Ca.-tor oil, to improve seau E - olachia serpentaria 701 Army, diseases of 074 health of do medical board 825 (Catheter, sul d<> diseases 83S{Oerebrs do surgeons, directions for iron 56 QIC 774 Chlorosis nic in apoplectic congest ion. 82i Chlorodync Asthma 2r>8 Chlorotbnn, dangers of I7ti - Syriacs : do and ether AsarnmEnropea, for drunkard-.. 827 db in hernia a#: INDEX ...768 Diuretic < ffects of PAGE. . ide ol Sodium .... Chlor. Pot. in gonorrhea 826 Dogwood Chorea 612" Cisterns for rain water 891 Cod liver oil, how to improve. ..852 Colchicum, sacoharate oi do as a diuratic , do (In do do do do PAGE, Colchicuin . . .405 677 Dogwood, swamp 689 Doughty, W. K. Diagnosis of Phthisis ' 113 48, 829|Doughty, W. K. Hospital oases. . . . .405|Douglas, T. on dysentery 50:'. 827 arm, .183 do locon rheumatism.282 I8d1 do lee. on tetanus. . . .433 ,203] do on army diseases. . 833 30] do on typhoid fever. ..834 do on Diarrhoea 836 on dysentery 837 on pneumonia 837 on measles 838 513 Complexion, pigmentary changes.450Drunkards, remedy for Contraction of palmar fascial. . . /B49|Dhjjas, L. A. paralysis of ( Jon v nlsive diseases Dymenorrh 92, 105, 203, 301, 864 do woorara in 3.46 75! do hvdrocvamUe of iron . . 352 112j do statistics of 5.08 &33LEpileptifonn convulsions 057 Cysticercus in the eve Delirium do do do do Oiabet -. 51 tremens do do do do new test Diarrhoea , 88 Diarrhoea treatment of 830 Digitalis in mania-a-potu 75 do do ' 410 Digitalis in hemierania 830 Diospiros Virginiana 099 Diphtheria, do 317 Ether and chloroform : 1 0 foipatorium rotunditblium . perfoliatum . . do do do do do .350 .754 do perionaium VI 1 E)ve J. A. lect on uterine polypi. 33 do do do 273 Excision of knee joint 828 do hip joint 828 (Exophthalmic goitre $55 Eye-halls, prominent 655 82[Eye, cvsticercus in the 887 91 False joints ['$ [Si Favus, treatment of I lo Fetus discharge^ through abdqna- U5 inal walls 198 Dislocation of hip, treatment. . Dislocation of lens, voluntary, do sh6ul5er,Jdia| llEever, rnarab ! ' J continued -:vi typhoid S:"> recurrent 169 'mine in typhoid'. .,.'.27! whiskey in typhoid. . nitric acja in intermittent. 891 .7S7 . 362 ,.<553 . 65o I do do do etc do ever. Ill id 719 i . Fevers, cold wat and qui n. in puerperal 826 pish-] 23d Ford, J. walls.. 198 frop. stearal I I Iron, uiuriated tr. Icterus with fattj In r Illumination by gas . criminal Indian quinine Iodine in spina bifida fodisra Iritis anacli, pn - . anion of - icrdm [bow '>14 do of craning) 515 rail in 528 gina 5J0 ;is. chronic mpervireus 7H1 Gentiana qninqnefolinm 71'' .'a Bark 675 rine in skin diseases 192 do an antigalactic 411 do ;; Ill ".; 432 Gonorrhoea! rheumal do almia 259 Ill 48|Ligature, metalic *s' militai ; . ;529, ,; m '',71 ichloride of 237 Iroii. rerro-cyanurel 272 Iroii. bydro-cyanate :;."<- rron, per-chloride of, in gangren . opening of '>-"- Tones, Joseph report to < planter's convention I Iph. pathic ( }. wild .... n - m. its grati :....: Bt Of .... . . . 272|Med*n a prof . . . 7 I, Mensl , in IV [NDEX. iwon. Mercury in syphilis 151 Mereurio-syphilis 185 Military surgery, bVGross. .520, Gil) ftjfflkweed.... 763 Morbus eoxarius 888 Morphia in neuralgia 512 Mullein in bronchitis 89 Muscular fibres in pulmonary ves Icles 818 Necrology 271 sson, H, diagnosis of Lip dis location 3G2 Nerves, termination of 807, 811 Neuralgia 112, 431, 512 Nitric Acid 771 do do intermittent lever... 891 Nitrate of Silver in uterine inlPn.70 Node on the patella 498 Opium 37, 1 Opium and quinine in puerperal fever 826 ( Ophthalmia, fomentations in 750 Ovaries, develop, of follicles. . . .815 Ox-gall in frost bites 528 Oxygen inhalations 91 Pains, chronic 4 To Palmar fascia, contraction of 840 Paralysis 108 d') of upper extremity. . . . L33 do wasting 156 do of spinal muscles 523 Perinearsection of urethra, .881,727 Persimmon 699 Pertussis, prescription for 82ti Phosphorus, detection of 53 Phoph. acid do 53 Phosphorus, hums i-y 191 Phlegmasia dolcns soo Phthisis Pulin 113, 447, 718 Pigmentary changes of eompln. .450 i'iu-kneya pubens 670 Placenta, detachment of 342 do previa 662 Pneumonia, treatment ol" 837 Poisoning by Lead 31 by stramonium 45 Poisons, fiflh Poplar or tulip tree 690 Pregnancy, rectal touch 858 Prolapsus, rectum 893,58 atorrhoen 814 PA Pupils, dilatation' of 79 Pulse, chronal law of 334 Pulmonary hemorrhage 433 Purpura hemorrhagica 432, 237 Pyemia 884 Quinine in Rheum. Dysincn 2(>2 do menstruation 432 do prophylactic 593 Rabies an epizotic 49 Rattlesnake bite, treatment of. ..377 Rectum, prolapsus 893, 58 Retina, apoplexy of 54 Resections of 558 Rheumatism and gout 48 do acute 236 do 282 do sacch. of colch 829 Rheumatic dysmennorrh 272 Rhus toxicod. in paralysis 108 Ringworm, true 823, 225 Ricord, banquet to 270 Root of man 768 Sacrum, fracture of 526 Salix nigra 756 do alba 756 Sal ammoniac 770 Salt, common 763 Santonin 72 Scarlatina, pathognomic sign... 072 do ' ." 81 Sciatica, atropine in 431 Shelby medical college 671 Short sight, treatment o( 2G5 Silver sutures 431 Small magnolia 696 Small-pox pitting 192 Snake-root, Va 701 Snake-bites, treatment of 877 Spina bifida 272 Spleen, malpighian corpuscles. . .814 Stereoscope 272 Sterility 280 Stramonium, antidote 45 Strionnine, antidote 191 do in typhoid fever. . . .271 do in bronehocele 512 Stomach, irritable (>72 Surgeons, directions for army. . .855 Surgical miscellanies 494 Sutures, wire and pins 412 Sweet Bay Syphilis, mercury in 151 da 289, :'. . .177 /5 VUp^L m.