jl f>' ] 6 1956 ..,, vxiTA SOUTHERN MEDICAL AXD SURGICAL JOURNAL Vol. I.] JUNE, 1836. [No. 1. INTRODUCTION. In commencing the discharge of our editorial duties, it is proper that we make some brief observations, explanatory of Hie nature and objects of the work we propose, and the motives that have induced ss to engage in the undertaking. Arguments need not be adduced to prove the great value and utility of medical periodicals their importance, as means of collecting and communicating useful information in a condensed form, is duly appreciated by the profession in all the enlightened nations oftks world,' and nowhere more highly than in the United States, to the circumstances and necessities of whose physicians they are peculiarly appropriate. Scattered over a thinly populated but almost illimitably extended country, in which the labours of physicians are most arduous and their remuneration inadequate, few individuals can command money to purchase or leisure to read a sufficient number of books to enable them to keep pace with the improvements that are con- stantly made in medicine ; besides, in many remote situations, the difficulties in the way of obtaining books are almost insu- perable, and new publications become old before they are received. Whilst European physicians, enjoying superior opportunities and facilities for the acquisition of knowledge and the cultivation of medicine, generally excel in medical erudition, and are justly entitled to the credit of having composed the most learned and I borate works, and having made manv of the most important 1 13S3 httrodact \jt\xaz and valuable discoveries and improvements in medicine, t are nevertheless so actuated by national jealousy and mutual animosity, that they not unfrequently refuse to acknowledge apply in one nation the most obvious improvements made in another, and they arc moreover too much d. to bow d< to authority, and yield implicit obedience to the dicta of distin- guished men. American physicians, on the contrary, at a happy distance from all such illiberal and improper influences, indepen- dent of the doctrines or dogmas of any school. una wed by authori- ty, lvgardkss of ages, names or nations, obedient only t-> the dic- tates of true philosophy, inductive and eclectic, reason for them- selves, and, selecting what is good and rejecting what is obj tionable in every system and from every source, render them- selves, as they may be truly styled, the most correct, energetic and successful practitioners in the world! How essential!} necessary, then, for the cause of humanity, that the details of American practice be faithfully recorded, as criteria wher< to test specious theories, not founded in practical observation ! There are now published in the United States several excel- lent periodicals, whose value and claims on public respect and patronage we most cheerfully acknowledge. So far from en- tertaining any sentiment of hostility or unkindness to those who have entered the field before us, we design and desire harmo- niously to co-operate with them in labouring toad ' \e the same great object, to advance tlie interests of that profession in which the good of society is most deeply and vitally involved. But although they have done and arc still accomplishing much for the improvement of medicine, and are justly entitled to the gratitude of physicians, and the appellation of benefactors of mankind the profession at the South have long regarded and anticipated, as a most desirable object, the establishment of a Journal that should collect and preserve the valuable discoveries and improvements of Southern practitioners relative to the na- ture and treatment of dis-ases incident to Southern climates, which, for the want of some such convenient and suitable n sit. -lv. are generally entombed with him with whom they or gate, and thus forever lost to the world. It has long been lanv nted that in consequence of the obsta- cles that have hitherto existed, with very rare exceptions, the rich treasures of individual knowledge arising out of extensive ;>().] Introduction. experience, close application, accurate observation, and the most correct and rigid reasoning, have not been allowed to emanate from or survive their possessor, unless through tlve uncertain medium of oral communication. Unwilling that such evils should longer exist, or that South- ern physicians should longer want an appropriate vehicle of communicating to each other and to the world the valuable results of their observation, practice and reflection, we offer to our cotemporaries the pages of a monthly periodical, cordially inviting them to co-operate with us in the enterprise* and confi- /dently trusting that they, with equal :zeal and interest, will come to our assistance, and sustain a work so desirable, so important to science and to humanity 1 As the principal design of this Journal is to collate and com- . municate practical information ; practical essays of all kinds, '1 histories of epidemics, reports of cases, the application of new remedies, and all interesting medical facts and experiments, will be thankfully received. Lung theoretical disquisitions, and 'prolix discussions on controverted points, will be excluded from uur numbers ; place, however, will always be given to commu- nications on the collateral sciences, and to all treatises that have a useful bearing, or that may be calculated to promote the grand object in view the improvement of medicine. The various branches of natural history at the South present fertile fields for cultivation. What wealthy treasures what rich rewards are here promised to the zeal, industry and enter- prize of the mineralogist, the geologist, the botanist, and the zoologist! May we not hope from these fruitful sources to derive mueh matter for our Journal, valuable and interesting, not only to physicians but to the whole scientific wrorld ? We feel deeply impressed with a sense of the weighty respon- sibilities and arduous labours in which we are about to engage, especially when we contemplate the vast extent of science which must be kept under constant review, the unremitting demands on our time, the enlightened tribunal before which we must appear, and above all, our obligations to the sacred cause of humanity I Nor should we have ventured to assume such high responsibili- ties and to embark in such laborious duties, were it not for the great advantages and facilities afforded us by our connexion with the Medica] College of Georgia, the pledge of support made Inlrodwch [June, as by the rest of the Faculty, the assistance promised us by many other eminent physicians, and a confident reliance on the cordial co-operation of libera] and enlightened mi mbers of the profession every where throughout our country, especially in the Southern and Western States. The College Library, to which we have constant access, will receive a regular supply of the most valuable medical books as fast as they issue from the press, to reviews of which a portion of our Journal shall be devoted. Our sole object, as reviewers, will be to present to our read a faithful and plain analysis of new books, whereby to attr: attention to their merits, and assist in promulgating useful know- ledge. We will only exercise the invidious office of exposing errors and defects, where they militate against sound doctrine and safe practice, and are thereby calculated to mislead the younger and less experienced members of the profession. Attached to no party in medicine, advocates of no particular doctrine, eclectics in science, zealous for improvement but Oppo- sed to useless innovation, we trust we shall be able, unbiassed Im- partiality or prejudice, to discern and commend what is excellent, and condemn what is erroneous, without reference to the source whence it comes. Besides the valuable Journals of our own country, the mi approved periodicals of Great Britain, France, Germany and Italy, will furnish an inexhaustible fund of materials, that cannot fail to add utility as well as interest to our numbers. The monthly form has been selected, because best calculated to an.v/, er tli" purposes designed, being preferable to either quar- terly or hebdomadal publications. The former do no1 emanate from the press sufficiently often to maintain a constant and regu- lar supply of the newest intelligence in medicine, and the latter are necessarily restricted to a compass too narrow to admit ol any but v< ry short pieces, without dividing them into several parts, to be continued through successive numbers, which at once destroys much of the interest they might otherwise excite. Contributors are requested t:> make their communications ovei their own proper nam< s, as anonymous and fictitiously sign' i ad with little interest, if read at all. 1836.] Remarks on Puerperal Peritonitis, Paet l original matter. ARTICLE I. *uerperal Peritonitis. By J. P. Garvin, M. D. of Waynesborough, Ga. Among the diseases to which the human system is liable, but re more dangerous in their character, or more- rapid in their course, than Puerperal Peritonitis. \From the first notice of ics appearance as an epidemic in 1664, to the present time, frequent investigations have been made of its nature, and of the treatment host adapted to its care ; but its true nature was long- involved in obscurity, and consequently the treatment Avas ge- nerally inefficient, and often pernicious. \ Modern research, how- ever, lias in a great measure dispelled tills obscurity, and at the present day, there exists but little difference of opinion as to its pathology. But in rclatidn^towito-.rcmcdial course proper to be pursued, practitioners do not evince the same unanimity. This fact renders it important, that observations tending to establish, or set aside the prevailing methods of treatment, should be laid before the profession ; and it is with a view to this, and not. with the expectation of offering any thing novel, either respecting its pathology or treatment, that the writer presents the results of his experience. m \ Puerperal fever has always been considered ^ disease of high* \y dangerous character, even in its sporadic form ; but it is when it becomes an epidemic, that it assumes its most formidable as- pect then dismay heralds its approach, and death too often follows its footsteps. \ Some writers have asserted that in fatal- ity it ranks next to the Plague. | This estimate of its danger may have been correct in former times, under the treatment suggested by an erroneous pathology, but at the present day, it will scarcely be ranked so high in the scale of malignity. Still, though modern investigation, by developing its true nature, lias disarmed it of many of its terrors, yet there are few diseases which excite greater alarm in the breast of the patient, or bring n^ore anxiety, to the mind of the medical attendant. vThe cases of Puerperal fever which have been observed by the writer, with a few exceptions, were of an epidemic charac- ler. XThe number of cases, the violence anil rapidity of their oursc, and the absence of all the usual causes, justify us, we think, in attributing to them an epidemic origin. No meteorolo- gical register was kept during its prevalence, neither was any marked peculiarity in the season observed. For some time pre- vious, anginosc affections had been common, and scarlatina pre- Remarks on Puerperal Peritonitis. [June. vailed to a considerable extent That the peculiar atmosphe- ric constitution by which some erruptive diseases are propaga- ted, has an agency in exciting puerperal fever, we are not pre- pared to assert, but the histories of this disorder generally, no- lice the ^contemporaneous prevalence of some of the exanthe- mata. Gordon states that 'leresypelas and puerperal fever be- gan at Aberdeen at the same time, and afterwards kept pace together they both arrived at: their acme together, and they both ceased at the same time." i Clarke says, that during the prevalence of an epidemic puerperal lever, which he describes, " eruptive diseases, particularly those which are attended with great depression of strength, had attacked great numbers of pa- tients. Ulcerous sore throat with or without scarlatina had been very general." Armstrong asserts that it frequently pre- vails with eresypelas. The constitution of atmosphere which generates disease, is a subject of deep interest, but the light of science is yet too feeble to penetrate the darkness by which it is shrouded. Wet, if we may be permitted to judge of the pro- gress of future improvement by the past, we may indulge the hope that at some day, not far distant, this mystery may be un- veiled. \ Puerperal fever has been supposed by some eminent writers to be of a contagious nature ^ and it must be conceded, that there are many facts recorded in the histories of the disease, which strongly tend to confirm this opinion, lllowever, in this country at least, it is believed that there areHout few who con- sider it to be contagious, except under peculiar circumstances^ In the cases which came under the writer's notice, there was nothing which in the slightest degree indicated a contagious origin. ) ^nis disorder generally makes its attack during the week suc- ling delivery ; but some cases have been related, which be- gan at a much later period, and a few which were supposed to have commenced before the confinement of the patient, llow- ever, the most common time of its access, is on the second or third day. I hi general, those attacks which are earliest made after delivery, are most violent and dangerous. The most ma- lignant case which we have ever witnessed, began a few hours alter the birth of the child./ Puerperal fever is generally ushered in with chills or rigors. In some cases the patient is not conscious of any cold stage; yet it is probable that in no instance i^ it entirely absent, al- though so slight and transient, as to escape notice. The cold stage lasts but a short lime, and is followed by considerable heat, and dryness of the surface. Pain is fell in the hypogastric re- gion, in some cases very acute, in others dull and obscure, and if pressure be made at, or near the seat of the pain, a sensation of soreness is produced. This soreness soon spreads over the lS3o.] Remarks on Puzrperql Perllonilii whole or the greater portion of the abdomen, which soon bo- comes slightly swollen. The pulse at this stage generally ranges between 120 and 130 in a minute, and is usually full and strong, and communicates a thrilling, or " vibratory'' sensation to the finder ; vet in some of the worst cases, it is small and weak from the beginning. The stomach is often affected with slight nau- sea, and occasional vomiting the bowels are constipated the tongue covered with a whitish coat, and the thirst considerable. The breathing is hurried and a cough attends, which in some instances, is very frequent and distressing. The patient is gene- rally restless, but in her moments of quiet, lies upon her back, with her feet drawn up. ( The secretion of milk, if it has com- menced, is soon entirely Suspended, and the lochial discharge is soon materially lessened in quantity, or is suppressed] After this state of things has continued for some hours, varying in different cases, there is generally a considerable remission of all the symptoms, with the exception of the frequency of pulse, which is rarely much abated. / This remission often raises in the minds of the patient's friends sanguine hopes, which are soon to be disappointed; for the disease soon renews its destructive career, with a violence which seems to have gathered strength during the previous calm. Some time after this return of the violence of the disease, the pulse increases in frequency, and loses some of its volume and strength the abdomen becomes more tumid, and the tenderness is sometimes so exquisite, as to render the slightest pressure insupportable. The countenance expresses considerable anxiety, and there is occasional delirium. \ The thirst is often insatiable the tongue assumes a dark or brownish color, and, in some instances, a vomiting of a dark fluid, and frequent and similar discharges from the bowels occur. As the disease continues to progress, the pulse becomes more feeble, and so frequent, as to render it difficult or impossible to count it the delirium is constant the abdomen very much swollen, and the discharges from the bowels involuntary. In this condition, the patient lies for a few hours, and death then eloves the melancholy scene. The foregoing is a description of the disease as it appeared in the most malignant cases witnessed by the writer. There was not, however, an entire uniformity in the symptoms, in every in- stance.' In some, but little nausea or vomiting occurred, and in one patient, neither of these symptoms was exhibited in any stage of the disease. The bowels were not uniformly constipated, and diarrhoea sometimes shewed itself at an early period, and was Usually a favourable symptom. With some patients the delirium was slight and occasional ; with others it was perfect and con- tinued. We witnessed one case in which the patient could lie upon either side during the whole continuance of the disease. In one or two instances there was -soms dysuria. The abdominal* n I ' Peritonitis, [June, pressure, and greal >ms uniformly pn - ( The duration of^uerperad fever varies in different I and in different seasons. In the sporadic cases, h c >urse in from five to nine days. I In the epidemic form and four or five days. Ir is stat stween one andfouror five days. Ir is stat h has taken place in less than twenty-four hours afti attack. AWehave seen no case fatal before the third, nOr at a later period than the fourth day. When the disease was subdued by the treatment adopted, the symptoms gave way early hut the patient rarely regained her usual health until after a consid rable lapse of time. No opportunity was afforded for post mortem examination, but so fully and frequently have these been made, by eminent .\\\A ipefent men, that there seems to be little left to be learned, in relation to the morbid appearances developed by dissection. \ Evidenced of peritoneal inflammation present themselves in every instance. Appearances of inflammation and its eon ces, are also manifested by various abdominal and pelvic viscera : but these seem to result from the spreading of the peritoneal inflam- mation to those organs; and, indeed, to this exi- risidn th< re seems generally to be an irresistible tendency. | This view of the nature of this disease will account for the want of uniformity in the symp- toms in different eases, and will explain the mode by which m of them arc produced. Thus,\the constipation probably r< si Its from the extension of the inflammation to the muscular c a* i f the intestines the diarrhoea in the latter stages, from its fart! extension to the mucous coat, and thedysuria, from thebladd< r having become involved. iThese examples will suffice to show in what manner many of tne symptoms are originated. Other appearances, which do not admit cf such a solution, arc proba- Lhe resr.lt of sympathy of other parts with the organs which ii ive thus become successively involved. There so.mii< to us to l)e no good reason for a b lief that this inflammation is of a pecu- liar character. It. resembles inflammation of any other serous membrane, and its peculiar fatality depends upon the extern membrane attacked, and the Dumber and importance of the or- which it involves in its course. With tins view of the nature of puerperal fever, it cannot be a matter for surprise that its unobstructed course is <<> rapid and its termination so fatal. Armstrong divides the disease into two the 6rs1 o inflammatory, and the second, or stage of effusion or collap Dewees con id ra that there is another, intermediate to th se stages, which he denominates the "gangrenous," and which he defines as that -state of the parts which resembles death, bui i- not death." For practical purposes, this last division is un. ary, as there are no known signs by which ii presence manifested l It is highly important thai we should be able. to & 1830.] tictnarks on Puerperal Peritonitis. 9 distinguish the inflammatory stage from that which succeeds it ; for it is only during the existence of the former that any mode of treatment offers the least prospect of success. J Yet it has been declared by high authority, that " the first stagps has no disco- vered character by which it can be distinguished from the se- cond." Armstrong has given a description of the first stage, and though it has been objected to it, that it depicts no appearan- ces which may not accompany the last, yet it is acknowledged to be the best which has yet been furnished. He says, "in the first stage, after tfie rigors have ceased, the pulse is hardly ever loss than 120, and sometimes (though as far as I have observed, very seldom.) as high as 140 in a minute; the blood does not seem to flow in a soft, easy, and natural current, but comes against the finger with a kind of vibratory motion, and more than ordinary pressure is commonly required to stop its course along the artery, which feels rather hard and tense. The skin is dry, and hotter than natural, the patient complains of great pain, and soreness of the abdomen, breathes forty times in a minute, vomits mucus and bile, is generally bound in the belly, has a white dry tongue, considerable thirst, and labors under the restlessness and irritation of fever." To this description we will venture to add, that during the continuance of the first stage, the pulse maintains about the same degree of frequency which characterized it when the disease was first fully developed. A very marked and permanent increase in its frequency, is usually the first appreciable sign that the boundaries of the first stage have been passed. There are but few diseases which require a more prompt and energetic application of remedies to ensure a successful issue, than puerperal peritonitis ; and yet it rarely happens, at least to country practitioners, that the patient is seen until some hours after the access of the fever. 1 The symptoms are too frequently attributed to some transient cause; and when at last the patient is undeceived, and the physician called, he too often finds that the golden moment for successful action has passed awray, and he is compelled to stand by with folded arms and witness the swift ravages of the destroyer, j These remarks are particularly applicable to sporadic attacks, and the earlier cases of an epi- demic visitation. I It is a truth, to which in the present state of our knowledge there is no exception, that it is only in the first stage that the disease can be successfully combatted. . It is irue that occasional recoveries have taken place after effusion had occur- red, but such instances arc rare, and cannot fairly be held to be exceptions to the rule, inasmuch as they never result from our remedial applications, but arc consequent upon some occult con- si ituiional operation. Since more correct pathological views of the disease have prevailed, venesection has generally been con- sidered as an indispensable operation in the treatment. Indeed T0 Remarks on Puerperal Peritonitis. [June; the testimony in its favor is ample and conclusive. The follow- ing statement of deaths under different modes of treatment, we have extracted from Mcintosh, and it plainly indicates the supe- riority of bloodletting over all other curative methods, from which it is excluded. "The celebrated Dr. William Hunter saved one patient only out of thirty-two ; his practice became fixed to give a good wine- glass full of brandy at the commencement of the disease. Dr. Hulme, who considered the disease partly of a putrid naiure, and who employed bleeding in small quantities, and only as a secondary remedy, lost almost every patient. Dr. Leake, who recommended bleeding in small quantities, and at long inte.vals, and who gave his patients bark, beef tea. and cordials, to prevent putridity, lost thirteen patients, out of nineteen, in one season. Dr. Gordon, when he adopted a wTeak, vacillating practice, lust twenty-three out of twenty-seven cases ; but afterwards he used early and large bleedings, and out of fifty patients he lost, only five. Mr. Hey, of Leeds, saved only three out of thirteen cases be- fore he began to bleed ; but by this sad experience he was after- wards led to bleed boldly and early, and he lost only two out of thirty-six." To this testimony in favor of bloodletting, we might add that of Denman, Armstrong, and many other distinguished practi- tioners. That of the first mentioned writer is particularly strong and convincing ; the more so, as he came to his conclusions in its favor in defiance of all his prejudices and preconceived opi- nions. These facts not only prove bleeding to be a powerful and appropriate remedy, but they also shew, that to be ser- viceable, it must be early and freely employed. \ Among the advocates for venesection, some difference of opinion exists as to the extent to which it should be carried, and the frequency with which it should be repeated. Some writers have specified the precise quantity of blood, more than which they deem it unsafe to take ; but it is doubtless injudicious to fix upon any given quantity as a limit. \The only safe rule is to abstract a quantity sufficient to make a decided impression upon the sys^ tern, and to repeat it whenever the pulse recovers its volume and, strength, and the abdominal pain and soreness arc still unabated. ^ Dewces and others recommend that the first bleeding be carried to an extent sufficient to produce faintness ; and this is a good rule for our government in all cases accompanied by high arterial action, and to which we have been called early ; but in those Cases where from the beginning the pulse has been very small. frequent, and feeble, there is some doubt as to the propriety wels, by the use of laxatives, was kept up for a few days, du- ring which time the patient continued to improve, and soon re- gained her usual health. But the use of purgatives should be co .lined to the first stage; after this has passed by, only the mildest laxatives should he administered, and when in the second stage, diarrhoea occurs, even these should be discontinued. There is some diversity of opinion as to what particular cathar- tics are best adapted to such cases. Armstrong advises large d B of calomel. In our hands, calomel has generally proved very sluggish and uncerta n in its operation ; and for these rea- sons, we have censed to rely upon it, except in combination with some more active article. As we believe that, purgatives are beneficial mainlv by the topical depletion which they effect, fr in the vicinity of the inflamed parts, we have generally pre- ferred those articles which produce the most prompt and copious discharges. Tl" ! are other auxiliary measures, whose application often proves beneficial. At the head of these, Armstrong, Blundell and others, place Opium. They advise that it should be given in I&36.] Remarks oft PUerperal Peritonitis. 13 lar \ d >s is. as its effects are of a less stimulating nature, than : used in smaller quantities. They suppose thai it possess- es s >me efficacy in lowering the irritability of the vascular system a j. I jhing inflammation. But there are many practitioners w ..> object t-. the use of Opium, not only in consequence of its stimulanl properties, but from a belief that it prevents, or retards, th ! > i mi of purgatives. This last objection we believe to be sr >undless; so far as our observation has extended, we have ir seen any such effect following the use of Opium ; and Armstrong asserts, that it does not interfere in the least writh the action of purgatives in this disease. In relation to its stimulant properties, the same writer declares, that they are manifested, only when small doses are administered. But Opium should never be given until after free depletion ; used then it will miti- gate the pain, and procure sleep, without increasing the inflam- matory symptoms in the slightest perceptible degree. Though Opium should not possess the power of extinguishing inflamma- tion, which has been ascribed to it, yet its action in mitigating the sufferings of the patient, renders it an article too valuable to be excluded from the treatment of puerperal fever. After bloodletting has been carried to as great an extent as may be deemed prudent, benefit will frequently be derived from the application of blisters. It has been advised to confine their use to the latter part of the first stage. They should be applied to the inside of the thighs, and not to the abdomen, for an irrita- tion of the abdominal surface would render those indications obscure which are to be derived from an examination of that part, by making it difficult to determine whether the sensation of soreness which pressure produces, is the effect of the blister, or of the continuance or increase of the internal inflammation. It has been recommended to mercurialize the system as speedily as possible ; and could this be effected at an early stage of the disease, it probably would prove serviceable. But puer- peral peritonitis is usually so rapid in its course, that we should very rarely be able to bring the system under the action of the mercury, except in a few of the milder cases, in which such a treatment would be unnecessary. Moreover, to produce ptya- lism by the internal use of mercurials, we should be compelled to administer it in such a manner as to prevent its rapid passage through the bowels, and thus, without any certainty of being able to procure its constitutional action, we should deprive ourselves of the opportunity of using purgatives, which certainly have much higher claims upon our confidence. However, in some instances, there is a degree of inflammation which remains even when the depletory process has been carried to its greatest possi- ble extent ; in these cases, calomel carried to the extent of slight: ptyalism, will be found highly beneficial. The best mode of ad- ministering it is in combination with opium, and aided by fric- tions of the abdominal surface with mercurial ointment. 1A Remarks en Puerperal Peiutonitis. [June, ? ^ _ Fomentations, with flannels wrung out of warm water, may he applied to the abdomen, as they often mitigate the pain; but as they are inconveiiient, and their beneficial effects but transient, it is probably besl to confine their use to cases attended by great severity of pain. Emetics, and oil of turpentine, have each their advocates ; but. our observation of their effects lias been too limited to warrant the expression of an opinion as to their merits. In relation to the oil of turpentine, the reports are very contradictory ; some lauding it highly, whilst others assert that they have never real- ized benefit from its use. The antiphlogistic regimen should be most rigidly enforced throughout the whole course of the first stage; and as the signs by which the commencement of the second is to be recognised are uncertain, it will be prudent to refrain from the administra- tion of anything of a stimulating nature, until the presence of this stage is distinctly ascertained. \ The treatment we have recommended is only applicable to the first stage for the second there is no known remedy. In the language of a late writer, "the wretched patient must in a great measure be abandoned to her fate, as regards medical treatment. Stimulants cordials opiates may be administered, without reserve or apprehension, for the disease has spent upon her the full force of its powrers, and in this instance, wre do not know what can injure or what can benefit the case." But how- ever hopeless the condition of the patient may seem, we should never desert her until life is extinct. Remarkable changes do sometimes occur, even under circumstances the most desperate, and we should always be ready, in events of this kind, to lend our aid. But even when no such alterations take place when hope has expired in our own bosoms, our presence will often prove a source of consolation to the despairing friends of the sufferer, and will enable us to mitigate her pangs, and smooth her passage to the grave. v 1S36.J Remarks oil the Treatment of RheumatisjtL ARTICLE IL. Remarks on the Pathology and treatment of Rheumatism, read' before the Medical Society of Augusta. By L. A. Dugas, M. D. Proiessdr of Anatomy and Physiology in the Medical College of Georgia, Member of the Geological Society of France, &c. 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 Ballonins, under the singular appeLation it still retains. Subsequently, the able pen of Sydenham delineated its charac- teristics in bold relief, and made it a prominent feature in No- sology. The term Rheumatism, according to Villeueuve, (Diet, des Sciences Med. torn. 48) is now applied to u a disease 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 continued or intermitting, fixed or wandering, and with or without heat, tumefaction, redness, and pyrexia. It usually terminates by resolution, sometimes suddenly, followed or not by metastasis, rarely by suppuration, and still more seldom by gangrene. Lastly its course is extreme- ly 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 tendons, apon- euroses, and ligaments , the synovial membranes of the bursa? and tendons ; and nerves; occasioned by tiie influence of varia- ble temperature, or by direct cold, or by moisture." It is called either acute or chronic, according to the intensity and combina- tion of the above symptoms. The causes of this disease are extremely obscure, although they have, by universal consent, been referred principally to atmospheric vicissitudes. Expo- sure to a cold and humid air is peculiarly favourable to its de- velopment Whether the low temperature and hygroscopick condition of the atmosphere, alone concur in such cases to give rise to Kheumatism, is extremely questionable. I believe it bv no means improbable that the electric state of this medium is highly influential in the production of Rheumatic pains, 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 causes assigned to this disease. The profession i< happily becoming satiated with speculations on aases which i i Remarks on the Treatment of Rjieumatism. [June. must over escape our present means of investigation; and a e are now disposed to cultivate a more fruitful field that oi fects. Lei us, therefore, hasten to the nature or Path* l< q < f Rheumatism. We have already said that it is now generally regarded . inflammation of the muscular and fibrous tissues. This is, in- deed, the doctrine which has prevailed, more or less, from the earliest notice of this disease. It is true that many have consi- dered this inflammation as of a peculiar kind. Sarcon ...id other believers in the agency of. animalcules, &c. in the c lusation of disease, exj lained this peculiarity by referring it to the ac q of those diminutive beings on the white humors of joints, Quarin viewed it as a constriction of the vessels, from cold. Boerhaave called it an inflammation not sufficient U jp- puration. Cullen admits the inflammation, but adds that the muscular fibres are in a state of rigidity, which impedes and renders painful any movement. "It is," according to this tinguished pathologist, "an affection of these fibres Ives an opportunity to the propagation of pains from one j< int to ano- ther, along the course of the muscles; and which pains are more severely felt in the extremities of the muscles t< rminating in joints, because, beyond these, the oscillations are not propa- gated." (Cullen's 1st lines.) Bichat and Scudamore insist that it is a peculiar inflammation, but do not attempt to define its nature. ViUeueuve 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. -it. P. 402). Villeueuve admits that the nerves of animal life may he the seat and even the primary scat of Rheumatism, but does not think those of organic life ever invaded by it. Scuda- more, 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 Rheumatic affection of the nervous trunk itself; whether of the nervous mat- ter or of the neurilemma, he docs not determine. It is evident that all the writers above cited looked upon Rheumatism as located alone at the scat of pain. Of late yens, however, attention has been called to a peculiar condition of the spinal marrow ;is invariably connected with lesions of sensibility, as well as with many of those affections classed among the Neurosc -. It appears that as far back as 1821, Mr. Player, in a letterto the Editor of the Quarterly Journal of Science, stated that " the occurrence of pain in distant parts (from tin* spine) forcibly at- tracted my attention, and induced frequent examination of the 1-S38.J Remarks on the Treatment of Rheumatism. .. 17 spinal column ; and after some years' attention, I considered my- self 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 affected parts, or to those spinal branches which unite them ; and that if the spine be examined, more or less pain will commonly 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 Glasgow Medical Journal a very interesting article *' on Irritation 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 pressure of the vertebra? at the diseased point. Some <>{' his cases were evidently Rheumatic, and indeed had been treated 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 Medical and Surgical Reporter, his " Observations on some forms of Spi- nal and Cerebral Irritation." He would establish the principle - that disorders attacking the origins of nerves, or their attach- ment to the central mass, whether this be the brain or spinal chord, always disturb the functions of the organs to which such nerves are destined." " A treatise on Neuralgic diseases, dependent upon irritation 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 l\as 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 impor- tant truths in the domain 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 sympathetic ganglia. I would, however, at present, refer only to that portion of his work which relates to our subject. It con- tains a number of cases illustrative of his doctrines, some of which, like those reported by Brown, had been considered as rheumatic by other physicians, and indeed presented symptoms *uch as are usually said to characterize some forms of this dis- ease. 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 countryman, Dr. J. K. Mitchell, of Philadelphia, who, in May 1831, published in the American Journal of Medical Sci- 3 lb Remarks on the Treatment of Rheumatism. [June, ences, his first article on the subject: In addition to the eight cases then reported, Dr. M. inserted five and thirty more in the game Journal. August 1833; all of which concur in confirming the spinal origin of Rheumatism, whether acute or chronic. I must confess that neither of the transatlantic publications to which I have referred, had led me to reflect on the nature of Rheumatism ; nor was my attention drawn to it until the ap- pearance of Dr. Mitchell's first paper. On reading this, how- ever, and comparing his doctrine with the prevailing theories of the Pathology of this malady. I became at once convinced that it was impossible to reconcile ihe various symptoms of this dis- ease, on any other principle than that of spinal irritation, and that with this view of the subject, the treatment would be per- fectly simple and efficacious. From the definitions usually given of Rheumatism, the pain is manifestly considered as dependent on the inflammation of the parts in which it is seated. That simple inflammation of the muscular or fibrous 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 degree of apparent inflammation,, and consequently that acute is more distressing than chronic Rheumatism. But, I would ask, why are not other inflamma- torv affections of the same tissues equally painful ? It is impos- sible not to perceive, on a close examination of the phenomena, of Rheumatic inflammation, that they present several peculiari- ties, 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. Inflammat on is usually said to be characterized by redness, heat, tumefaction, and pain, all of which we find united in the most violent fto book, s most interesting cases which came mirier my care-. Pressure over the vertebrae corresponding to the origin i nerves supplying the scat of suffering, though in many ins attended with more or less pain, is not uniformly So. In soine, not the slightest uneasiness is produced by it. I oannot howe- ver, coincide with Dr. Mitchell, in considering die tenderness, merely a proof of an irritated condition of the - spinal brac< s ;" for, whenever this tenderness dues 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 im- portance of localizing, and properly localizing diseases ; for so long as Rheumatism was thought to be an affection of the wrlole 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 sudorincs, antimonials, guaiacum, sarsaparilla, &c. the or- deals of steaming, vapourizing, 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 dis- ease as confined to the seat of pain, will torture their patients with frictions, fomentations, vesications, &e. with as little success as those who endeavoured to drive out or neutralize the consti- tutional impurity. We have now, I trust, traced Rheumatism to its true source, and every remedy based on this belief, gives additional evidence of its correctness. Regarding the disease as seated in the spinal marrow, and believing its nature to be irritation or sab-inflammation, the treatment to be instituted is perfectly obvious. The local abstraction of blood, by leeching or cupping the surface over the affected medulla, followed by the more permanent revulsive action of vesicatories, constitutes the most efficient treatment of Rheumatism. In many slight cases, the mere application of a sinapism will readily allay the pain ; in others a blister will be required and may be, or not, preceded by cupping, according to the tenderness of the spine. the constitution of the individual, dec. When the local affection is so intense as to induce high febrile excitement, it may be pru- dent to take blood from the arm, though this should not be car- ried to excesss. 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 as the disease manifests 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 >-) Analysis of the Hydrant Water of Augusta. [June, the sent of pain. Indeed, so confident do I feel of its efficacy, that I now look upon Rheumatism, not long since the apprpbri- um medicorum, as <5ne of the most manageable affections we are I on to treat. ARTICLE III. Analysis of the Hydrant Water of Augusta, passing through leaden pipes. By Lewis I). Ford, M. D., Professor of Che- mistry in the Medical College of Georgia. The extremely poisonous nature of the salts of lead has gen- erally and very properly created a doubt in intelligent commu- nities, as to the safety of using water that has been transmitted through leaden tubes. This feeling in this community, together with the occurrence of some cases of disease, which seemed to warrant the suspicion of injury resulting from the use of water conducted in leaden pipes, have led me to the particular exami- nation of this subject. I place the result at your disposal, be- cause I have not met with any detailed account of the method of proceeding in such an examination, and therefore, it may possess a general interest ; and because a knowledge of the fact us to the nature and degree of the impregnation of the water, with a saturnine preparation, may be of service to the commu- nity, cither in quieting their apprehensions as to its use, or in leading them to abandon it, according to their respective estima- tions as to the quantity of this preparation which may be used with safety. This water is brought in a wooden conduit from the spring, through the centre of the city. The service pipes inserted into the main conduit, are, iu the majority of instances, of wood, while others are of lead. There has never been discovered the slight- est trace of lend impregnation in the water that passes through the wooden pipes, although carefully examined in very many si- tuations: while it is uniformly discoverable in every situation when it passes through the leaden ones. This difference is not surprising when we consider for ;i moment the construction oi the aqueduct, and the constant flow of the water from the ser- vice pipe . 1. The qualitative analysis. None of the usual agents of lead produce any precipitate with this water, except the foe* 183*5.] Analysis of tlte Hydrant Water of Augusta. m:\ sulphuretted hydrogen gas, or its solution in water. Even the hydro-sulphates produce no discoloration. The sulphuretted hydrogen gas injures slightly the transpa- rency of the water, producing a brow color throughout it. The water thus discolored deposits no precipitate after many days rest. After passing the water through good filtering paper, it is not discolored in the slightest degree by the sulphuretted hydrogen. This fact assures us entirely, that the preparation of lead is insolu- ble but in a state of so minute division as to be suspended in the w iter without altering its transparency. It also explains the r i son why neither the sulphuric acid, the sulphate, the hydrio- date, nor chromate of potash will form a precipitate. To determine more satisfactorily the presence of lead, a gal- lon of the water was filtered the filter dried perfectly, burned and the rcsidium placed on a glass capsule and a few drops of nitric acid added, boiled upon a sand both, and the heat continued until the mass was dry. A few drams of water were added and boiled for a moment, and the solution filtered. I need scarcely remark, that the object of treating the incinerated filter with ni- tric acid, is to obtain the lead in the state of one of its soluble salts, the nitrate. This solution with the sulphate of potash gave a white precipitate, with sulphuric acid, and with the carbonate of Potash, a white precipitate, with the chromate of potash it gave a heavy dense yellow precipitate. With a solution of hydriodate of potash, this solution produ- ces a yellow^ precipitate, and if the solution of the hydriodate be added with as little agitation of the test tube as possible, the precipitate is recognized by a practiced e}reas the hyhriodate of lead, by the peculiar appearance of the contents, when they are thrown into motion, by turning the test tube in a circular direction ; the surface of the fluid in contact with the glass, ex- hibiting different shades of the yellow color, like the watered ribbon ; an appearance produced doubtless by the partial crys- tallization .of the precipitate. But this precipitate is recognized as the hydriodate of lead by a still more striking characteristic. By boiling the contents, a transparent solution is obtained, which, on cooling slowly and at rest, deposites on the sides and bottom of the tube beautiful, small, splendent yellow crystals. A polished plate of zinc immersed in a portion of the above solution, is speedily covered with a light spongy mass of pure lead. Thus each one of the foregoing: re-agents producing a change in this solution, characteristic of the presence of lead, their con- curring testimony establishes the fact beyond the possibility of doubt, that the water thus passing through these leaden pines is impregnated with one of the preparations of lead. What is this preparation? 24 Puerperal Convulsions. [Juno If a portion of the water he evaporated to dryness, and sul- phuric acid be added to the residuum, an evident efiervesc is produced. Whence we infer thai if is impregnated \\ Lb carbonate of lead. Again, if a piece oi' lead be immersed in a jar of this water, with its surface exposed to the atmosphere, the bad is covered over with minute crystals oi carbonate of lead, in the course of a few days. 2. The (j unit ('dative analysis. To determine the absolute quantity of carbonate of lead in a given quantity of the water, 233 ounces were filtered, the filters burned, and treated w ith nitric acid as above, and three ounces of solution of nitrate of lead obtained. A solution of chromate of potash being added in excess, the precipitated chromate of lead was suffered to side and washed three times, dried in the tube from wh< nee it was removed and weighed. Weight exactly one decigram equal to 1.544 grains Troy. Thus from 256 ounces, or two gallons, we obtain 1.696 grains of chromate of lead, which, ac* cording to Wollaston's scale, is equivalent to 1JJ8 grains of car- bonate of lead. Thus we arrive at the conclusion that th< re is 1.38 grains of carbonate of lead in every two gallons of this water, which contains so much of the oxide of lead as, if unite d with acetic acid, would form 1.044 grains of sugar of lead nearly one grain to the gallon. It is proper I should state that the water which has given this result was drawn from one of the longest leaden service pipes. I may at some future period en- deavour to estimate the reason wrhy this water acts upon the lead, when it is known that in innumerable instances water is transmitted through leaden tubes without being impregnated with it. ARTICLE IV. Puerperal Convulsions. hi the summer of 1633 1 delivered a lady of her second child. The d< livery was accomplished within an hour and a half from the first anouncemenl of labour. Beinghurried away to another rase. I left her very comfortable, 30 or 40 minutes after deliver) . About one hour and a half after, she was suddenly seized with a \ery violent convulsion, of that species described by Velpeau as Apoplectic Eclampsia. Before she could he administered to, mother convulsion returned on the profound stupor and heavy I J Puerperal ( 25 torous breathing which followed the first. A consultation of physicians was present The pulse being slow, hut full and il depletion was practise^ All the intermediate a;> ; ptoms pontinued notwithstanding. Soon after >nd paroxysm, I arrived. Whilst receiving the above account, a third paroxysui supervened, which I witnessed, and wfhich was very severe indeed commencing during the stupor and stertorous bri athing, full pulse, foe, by a drawing of the eyes then the head to .mil the body was universally con- ;ed, with frothing at the mouth, livid skin,/&cj This soon ;ided, and was followed by the same apoplectic symptoms. On examination, notwithstanding the copious depletion from the arm, it was discovered that the uterine hemorrhage was very copious indeed ; the whole nankin, which had been but 10 or 15 minutes in application, being completely saturated, beside a large quantity of coagulated blood surrounding her in bed. On the external touch, the uterus presented no firmness ; but the whole hypogastrium perfectly flaccid. The uterus was immediate ly sped and agitated repeatedly through the abdominal parietes, until its contractions could be distinctly perceived to return with increasing strength, every four or five minutes. From the first heat .on of the hand, no other paroxysm returned, and after Kit fifteen minutes from the. commencement of this operation, the apoplectic symptoms disappeared, and she opened her eyes with intelligent expression, looked about as if surprised at see- the family and physicians about her, and asked where was her child. It was brought, and she received it into her arms. She then asked for something to drink. A cup of weak tea was soon brought, which she drank sitting, spoke several times, was again placed in bed. I remained with her about an hour after, continuing the manual operation for exciting the uterus. Finding that she continued free from all alarming symptoms, I instructed her nurse to main- tain the perpetual contraction of the uterus by the same process i had used, and left her, complaining of nothing but some painful i ati ms in the uterus at every contraction, amounting to slight after pains. The haemorrhage had been reduced to the ordinary quantity for the period. A few months after, I was j ires* at with another lady, who, af- haying had several convulsions' of the same- character, the first occurring in the latter part of the second stage of labour, was then suffering the intermediate apoplectic symptoms. On direct- ive; attention to tha abdom n, the uterus was found in the same relaxed condition as in the form< r case. It was stimulated to action by the same means, and within from 20 to 25 minutes, the as well as the expression and color of the face, became na1 a) al ; she opened her i yes with a natural expression, yawned, I to uing her head to an * asy positio . It was found 1 2i> ml Convulsions. [Junc that she also had flooded very copiously. She had no more con- vulsions. In view of the present state of the profession on this very in- teresting and important disease, T cannot withhold the focts of these cases from the public. They are given in the hope thai in the present imperfect state of the pathology and treatment of* these convulsions, the curative indications, in some cases ai least, may be made so plain as- to lead to more favourable prac- tical results. What is the pathology of these eases? Was- there a passive haemorrhage From the uterus? And was there at the same time a strong general action of the heart, and a> great determination of blood to the brain ? And did the exci- ting means used with the uterus equalize the action of the wholi system, by arousing the energies of this passive organ ; and thus by a prompt and decided derivation of excitement, at once re- lieve the brain of its ruinous burthen? Or was the Eclampsia a mere nervous phenomenon, arising out of the debility and con- sequent increased irritability of the motor apparatus ; and the symptoms strictly apoplectic, only a secondary effect, arising from cerebral compression from blood forced into the brain 1>\ the violence of muscular contractions in this spasm ? And did the excitement of the uterus so far employ the excitability of the system as to relieve other parts of that excess which predispo- sed to spasm ? Would not Ergot have produced the same be- neficial effects as the manual operation employed, if it could have been administered ? (yet it could not have been in either case.) May or may not the previous bleeding have prepared the system' more perfectly for this counter-excitation ? And would further bleeding have ever produced this equalization of action? Would not the patients have died without proper exci- tation of the uterus having been directly effected? May not the powerful antispasmodics which arc, when they can be, almost always exhibited in these cases operate, when they do operate beneficially, simply on this principle, (i. e.) exciting the uterus particularly, rather than the system generally I Would not tar- tar emetic have failed as well as continued depletion in these cases ? It is earnestly hoped, for ihc good of humanity, and the credit of the profession, that these facts and interrogatories may ieadtd more accuracy in pathology, and consequently, successful the- rapeutics. 31. ANTONY. S:jt>.j Sketch of a case of Bfoficnoceh. ARTICLE V. ch of a case of Bronchocele, successfully treated hy Iodine. By Wm. W. Lee, M; D. of fcdiantown, S. C. Brohchocele is a disease of such rare occurrence in the Uni- ted States, that many physicians pass through life without even an opportunity of beholding it. Its origin is exceedingly obscure; the supposition that it arises from the use of snow-water, to which it is ascribed in the Alpine regions, is disproved by the fact, that it prevails to a great extent in Java and Sumatra, where snow is unknown. It is also singular that writers rarely mention the duration of cases when cured. The case about to be related is interesting, both as it displays the therapeutical efficacy of Iodine, and from the short time in winch the cure was effected. May 21st. 1833, I was requested to visit Mrs. R. D. set 32 years, labouring under goitre. The history of, the case wTas as follows: Her mother had a small tumour resembling the num adami in males, but which continued indolent through life ; the daughter, about thirteen years previous to my visiting her, perceived a small tumour forming in the situation of the I gland, supposed to be a wen: she soon after married, from which time the tumour, which had previously exhibited little change, now began to enlarge rapidly, particularly after Vie birth of each child; indeed this seems to be almost a diag- nostic of bronchocele : an eminent surgeon was consulted, who proposed extirpation, to which she would not consent. At the time of my visit, it had so increased as to project anteriorly as far as the point of the chin, extending laterally to the angles of the jaws, and occupying the whole space between the chin and clavicle; its surface was smooth, uniform, and hard; her head was tixed ; elevation, depression, and rotation, wTere alike impos- sible ; the dyspucea forced her to sleep resting on one side in a li-recumbent posture, and when labouring under catarrh, threatened suffocation. Recollecting the extreme danger, and, in one instance, fatal result attending two cases related by ( r;>ch, I expressed the opinion that the extirpation of a tumour of such magnitude, and so vascular, would cause death by ha> morrhage ; at the same time, I stated that although the proba- bility of a cure was greatly diminished by the long duration of the disease, I thought there* was a possibility of it by a newly discovered medicine (Iodine) ; and at the earnest solicitation of herself and husband, consented to make the effort. Considering Magendie's tincture needlessly strong, I preferred Cartwright's formula. (Med. Rcc. No. 44, p. 260.)' 8 Sk '''. B Iodine, xxvj. Alcohol, 5j. IP. 55 drops thrice a day ; also to apply by friction, morning and fcvening, the I imenl : 9 Tinct. Iodinte, (Gartwright) 3j. Liniment. VolaT. 5vij. u>. I considered the prospect of a cure sodoulJtftil, thai T neg ed (what I have since greatly regretted.) to take the dimensions i the tumour; still I recommended a svad\ perseverance in the use of the remedy. June 25th. 1 uas truly astonished at the wonderful change effected ; the tumour had been reduced to the size of a g< >< se i over the trachea, and had lost its redness; respiration was per- fectly free, for she could sleep in any' position : the power of ele- vation, depression and rotation was restored, and she seemed full of hope. July 9th. I was equally gratified at the rapid improvement ; without a manual examination, even the existence of disei would not have been suspected ; the power of motion was com- pletely restored ; she could sleep even in the horizontal position, and expressed herself both surprized and delighted at tne felici- tous results; indeed it was to me a source of equal thankful- ness and gratification that I had been instrumental in restoring to health and usefulness a wife and mother of a large family, dependent for subsistence on the personal industry of herself and husband. I made -a minute examination of this case at a sub- sequent period, (Nov. 1834) and found it precisely as last des- cribed; there was one circumstance which had caused me much solicitude, its possible increase after parturition; she had during this interval given birth to another infant ; but my gratification was extreme to perceive no disposition to a recurrence 'of disease; I was therefore led to consider her radically cured. 1836.] Diagn st. Vfa PaAt II. REVIEWS A#D On the Diagnosis of Diseatei of tl f anion of their phi/sic/' ark I general signs. B; Gerhard, M. J)., Physician to the mdckley Hospital; furer in the Philadelphia Medical Ass'ociatipn1 ; Fell Philadelphia College of Physicians; McmtaJ of the Society Modicale d'Observation, and of the Societe Anatomiqi Paris, &c. 8vo. pp. 1S;J, Philadelphia, Key & BiddleylS36. It is truly with pleasure, we call the attention of the Prbics sion to the work before us. The diseases of which it treats. certainly constitute one' of the most common and most lata I classes of affections we have to encounter. ' That a correct di- agnosis is the first and most important step in the treatment of ase, will not be denied; yet, without the possession of the physical means instituted by Avenbrugger and the immortal Laennec, it is absolutely impossible to attain this desiral knowledge. To those who are content with the stamp of me- diocrity on their front, we have no reflections to offer ; but to the honest, zealous, progressive physician, we would confident- ly appeal. The elements of diagnosis derived from physical means, have now been systematized at least ten years ; they have been extensively adopted in Europe, as indispensable to whoever desires to understand the affections of the pulmonary and cardiac organs ; these affections are quite as frequuent and destructive in our c >uritry as in any on the globe ; why is it then, that we find those principles so reluctantly adopted among us 1 Shall it be said, that whilst every medical tyro in Europe can, with ease and certainty, distinguish the locality, extent and nature of every variety of thoracic disease, that there are but few practitioners in our country, who can distinguish pleurisy from pneumonia? Tubercular phthisis from mere catarrh? The fact is too true ; and yet we know of no school in the union in which the principles of auscultation and percussion are prac- tically taught ! There can be but little doubt, that much of the apathy existing on this subject, is attributable to the prevalence of the same state of feeling among those who are ostensibly on the qui-vive for every information that can be of advantage to the profession. How can it be expected, that young physicians should strive to acquire that, which is of so little importance as not to merit the attention of their teachers ? We could not re- sist a sense of mortification, on hearing the acknowledgement made by one of the most distinguished teachers of the north, a few years since, when lecturing on pulmonary diseases, that Ik; could say nothing concerning the stethoscope, for he had thus $0 agnosia of Diseases of Vie Chest. [June, far d >ne v< ry well without it, and its use was foo troublesome cquire ! The influence of names unfortunately prevails to a I in the medical profession. In tne case just cited, how much error does it not cover! Auscultation will ne- ver become general, until it In* advocated by those at the head of the i i. T-he invaluable discdvery of lithotricy re- mained in Europe in the hands of its author exclusively for years. In cause Dupuytren preferred the knife. In this country its introduction was retarded until very recently, by an abortive attempt of one who, though deservedly pre-eminent, did not suf- ficiently study the new instruments placed in his hands. We sincerely hope, that the good sense of the profession will tri- umph over the vain authority of title, and that the stethoscope will, ere long, be deemed an essential part of every practition- er's outfit. That the little work of Dr. Gerhard, will do much to facilitate branch of the art of diagnosis? we can entertain no doubt. Its language is good, notwithstanding it is plain and intelligible English. Dr, Gf. appears carefully to have avoided any ofthajt irable pedantry, so commonly evinced by writers of.1 day, who, forgetful or ignorant of the richness and cogency of our own language, continually resort to words of foreign origin. Although the subject of which he treats is peculiarly French, we find very f< w instances in which he has drawn on that lan- guage f r words to convey his ideas. The review of a manual is always an ungrateful perform- ance, not only to the reviewer, but also to the author, for it Is difficult to condense what has already been reduced to so small a compass, ;md it is no less difficult to do justice to the work by mere extracts; we shall therefore attempt simply to convey some idea of the contents of the volume before us. The history of the physical signs of disease, is premised by general remarks on the conformation of the chest, on percussion and oil auscultation. The rules laid down forexaming the tho- rax aie highly important. Its anterior, posterior, and two la- teral aspects, are successively studied in the normal state, and with reference to the changes they undergo by disease of the contained viscera. The third chapter is devoted principally to the manual per- formance of percussion, which " is mediate or immediate. Im- " mediate percussion requires the ends of the fingers, or in some " cases, their palmar surface to be struck quickly upon the walls u of the thorax. Tins mode of percussion was once generally "employed^ but h is now very properly and universally aban- doned, on account of the production of less sound than may "be obtained from mediate percussion, the greater pain caused " to the patient, and the absolute impossibility of using this me- u thod, when the cellular tissue is infiltrated with liquid or loader! 183G.J biagnosis of Diseases of tk (I. :u - with fat. Mediate percussion was introduced by M. Piorry, now Physician to the Hotel Dieu, of i'aris. A dense resisting " body is placed in contact with the patient, and held with the >; fingers of the left hand, while percussion i made upon it with *; the right. The body interposed" between the fingers and the " skin, is called a pleximeter ; it may be a thin plate of tvory, - leather, or metal, or, what is generally most convenient, the; "fore-finger of the left hand. An excellent pleximcter is -i piece of caoutchouc, or common gum clastic about a quarter "of an inch thick, and tolerably firm. This pleximeter is Very - elastic* gives a good full sound, and prevents any pain 1.' by the patient." We give the decided preference to the ivory plate, such as is attached to many of the stethoscopes now in use. The resist- ance of the caoutchouc varies very much according to Chan of temperature, and when yielding, it cannot be used in those instances in which percussion is attended with pain. ,The chapter on auscultation is one of great interest, treating as it does, of the manner of using the stethoscope, and of the sounds detected in health and disease. " When the ear is ap- " plied to the chest of a person in good health, a faint rushing " sound is heard during the act of inspiration. When this sound " is carefully analyzed, it will be found to consist of two ele- " meats, more or less blended together. The first element, or " the blowing sound, is that produced by the air passing through '; the bronchial tubes. It resembles the sound made in the mouth ,J and fauces, when the air is quickly inhaled. It is heard most " distinctly at the root of thedungs, over the trachea, and near the ' clavicles, especially the right. The second sound is the soft " murmur caused by the expansion of the vesicles ; it is the best " characteristic of a healthy pulmonary tissue. This sound is " termed the vesicular murmur, or the vesicular respiration. " from its anatomical seat. It is best heard where the tissue of ' of the lungs contains the greatest number of vesicles and the " smallest bronchial tubes that is, at the base of the lungs, In " the axilla, and at their anterior margin. The sound of expira- tion is much more feeble than that of inspiration, and in a ft healthy subject is almost confined to the parts where the first " or blowing sound is heard. It is short, feeble, blowing, and s not resemble the inspiratory murmur.'' These sounds present varieties dependent oil anatomical structure, on difference of age, and on peculiarity of constitu- te >n. Those resulting from disease are much more complicated, and are arranged in classes and subdivisions, as follows : 1st. Increase and diminution of the normal sounds of respiration ; 2d. Increase of the blowing sound of respiration, withfeebli absence of respiratory murmur; 3d. Imperfect bronchial, or rude respiration. "In this variety, the blowin i 3<2 ''' - i Utz Cites! . [June. id is tn \\ than usual, and more pr-o icular murmur is stii) heard, and is usually more feeble than in a healthy lung ; in som it; is louder, but h is a i soun ." Bronchia] respiration, in which "the v murmur disappears when the pulmonary tissue is perfectly in- durated, the blowing sounds are sttll heard; but much m irigly than iu a natural state. * * * * The sensation < nmuiflkatcd to the ear is thai of the air pj ssing through solid ;, and not through the spongy tissue of the lungs." 5th. Strong bronchial or tubal respiration^ Here "the inspiration and expiration are not only strongly blowing, without the k i I trace of vesicular respiratiQn, but they are both very loud, and emble the sound which would be produced by some one ving strongly into the car." (>th. CaVernous espiration " differing from the tubal respiration in Being limited to a cumscribed portion of the lung, into which the air is heard to pass, and from which it is forcibly expelled." 7th. Amphoric riration. " As the air passes into cavities of very large si.. . it produces a sound not unlike that caused by blowing smartly a glass or metalic vessel." The second class of alterations of respiration comprises the accidental or adventitious sounds produced during the act of piration. These species of rattle are termed KhoncHi, and I >resent the following variety -s : 1 . The Cave? nous 1, Hon eh us, or gurgling, "is the loudest and most easily heard of all the humid nchi; the air passes through a liquid of moderate tenacity. contained in a cavity of a size varying from that of a sj almond to -i large orange, or in some oases ii nited only by die ])lcura and the; thoracic pariet.es." 2. The rMacou,s Rhonchus " is analogous in character to the cavernous; it is more diffused, but less intense. It is produced, like the gurgling, by the pas- ! of air through a liquid of little tenacity, but it must be con- tained in the larger bronchi, instead of a. circumscribed cavil)." 3. The Crepitant lilionclms "is produced in the same bronchial ramifications, or, ;is some suppose, in the pulmonary vesicles ; and is caused by the passage of the air through a x^vy tenacious liquid. The bubbles are, therefore, much smaller, and break with a sharper noise than the mucous rhonchus." 4. Sub-crcpi- tant Rhonchus. " This variety is distinguished from the prece- ding, by the larger size of the bubbles, mad'* by the air passing lUgh the smaller bronchial lubes, and the greater quanti:; liquid. >). Sonorous Rhonchus, "This resembles the cooing of ;i pigeon, or still more nearly the sound of the bass-string of a violin." 6, The Sibilant Rhonchus "resembles a tow whistle, and, like the sonorous rhonchus, is heard both in the inspiration and the expiration. '/. The Grating Sound "is caused by the friction of the two surfaci s "!' the pleura, lined with false mem- brane.-: up n ea< h other* and is heard in the. hitter stage i <>!' pleu- 1838.] Diagnosis of Diseases of the Chest. 33 risy, when the more liquid, part of the effusion 1ms been absorb- ed. 8. Metallic Tinkling, "This is produced by the fall of a drop of liquid from the upper p.u't of a cavity, upon the surface of a liquid contained in it, which gives rise to a peculiar tink- ling sound, a little similar to that produced by striking a pin against a glass vessel."' Having described the sounds produced by respiration, our author passes to the consideration of the auscultation of the voice. The modifications of the vocal resonance, consequent on pulmonary disease, are enumerated under six heads, viz : I. Increased resonance. 2. Bronchophony, or "a variety of resonance of the voice, which is much louder and much more distinct than is ever heard :n a healthy lung." *3. Pectoriloquy, or " the resonance yielded by a cavity in the lung of moderate size. * * * The voice seems to proceed from the cavity and to enter the ear." 4. Amphoric resonance, when 4i the voice seems more hollow, more distant, and more diffused than in Pectoriloquy." 5. Egophony. "When the voice is transmitted through a layer of liquid contained in the cavity of the pleura, it has a peculiar quivering intonation, resembling the bleating of a goat, or the voice heard through a speaking trum- pet." 6. Diminished resonance. The indications derived from the cough and expectoration arc sufficiently valuable to require some attention. The varie- ties of cough noticed are the short and dry, suppressed, sonorous, laryngeal, lo)sc mucous, hollow, and spasmodic. With regard to the expectoration, attention is directed to its quantity, colour, consistence, form, odour, and admixture with foreign matters. All these physical signs being well understood, it is easy to apply them to the diagnosis of the various forms of pulmonary disease. This is done by our author .with brevity and perspi- cuity. He successively passes in review Bronchitis, Emphy- sema, Pneumonia, Gangrene, Phthisis, Pulmonary Apoplexy, Pleur sy, Pneumo-thorax, and the tubercles of the bronchial glands. The limits assigned to this article preclude any details on these topics. The situation and action of the heart, render it peculiarly susceptible of study by auscultation and percussion. It is ob- served that, " as a portion of the pericardium, and consequently of the heart, is not covered by the lungs, percussion on the cor- responding part of the chest must yield a dull sound, because there is no lung and consequently no air benenth it ; that " in the normal state, the impulsion of the heart is felt opposite the cartilage of the the fifth rib, in a space about an inch square ;" that " by placing the ear near the heart of a healthy individual, we find that each pulsation is composed of two distinct sounds, ^^ which are followed by an interval of repose ;" that " the limit in a which these sounds are heard varies according to the dimensions ')4 Tartar Kmciic in Obs&tfic Practice. [June* of the chest and the thickness of its walls;" and lastly, thai "besides the increase or diminution in the loudness of the two sounds yielded by the heart, they may be changed in character and tone. " The most common cardiac affections are Pericarditis, lesions' of the valves, Hypertrophy, and Dilatation ; all of which are more or less readily detected with a knowledge of the physical signs ; whereas, without them, a correct diagnosis cannot be obtained. Dr. G's work concludes with a chapter on the method of ac- quiring a knowledge of the physical signs, to which I would espe- cially call the attention of the reader. The method recommend- ed will enable any practitioner of observation and industry to render himself familiar with them in a comparatively short time. We cannot conclude this paper without testifying to the merit of the work of which we have given so imperfect a sketch. We have made no criticisms, because we have had no occasion to do so. The work, although a compilation from printed books, con- tains many valuable additions, derived from the researches of men still labouring in the cause of science, and who daily add to our fund of knowledge. The opportunities enjoyed in Europe and in this country by Dr. Gerhard, together with his known talents, zeal and industry, entitle his productions to especial dis- tinction. We wish his present work every success, and hope that its favourable reception may prove an incentive to further exertions. D. Augusta, May 10///, 1836% ' Observations on the use of Tartar Emetic m Obstetric Practice By Eyoky Kennedy, M. D. Master of the Lying-in Hospi- tal, Dublin. The following very interesting memoir we have read with great pleasure. The same pleasure we cannot withhold from those of our friends who may not have seen it. We value it no less for the candid, faithful spirit which it breathes through- out, and the excellent field of observation of which it is the gleaning, than the great importance of the cases to which it is o well calculated to bring consoling and salutary assistance. VVe designed%o make extracts of the most, valuable portions j 83G.] Tartar Emetic in Obstetric Practice. &T> for the benefit of our readers ; but on making the attempt, we find it impossible, in justice to the author, and to the cause of truth, to omit any part of it. We are highly gratified to find that so valuable a practitioner as Dr. Kennedy lias been so fa- vourably disposed towards American medical literature, as to make this communication directly to the American Journal. We understand, from a note of the Editor of the Journal, that Dr. K. is the author of a valuable work on auscultation. We hope it will not be long before we shall be enabled to enjoy the pleasure we feel warranted to expect from its pages. As we have not room in the present number for the whole essay, and as it may be divided without other injury than withholding a part for our next number, we shall give the first half only in the present. "If it be the duty of the hospital superintendent to avail himself of the op- portunities afforded him of investigating new and interesting plans of treat- ment, establishing what is correct and rejecting what is erroneous in prac- tice, it is equally his duty to afford the results of his investigation and experience to the public. The following observations assume to be, not merely the result of one or two experiments or accidental cases, but the report of practice adopted and tested by the experience of years in what will be admitted .a sufficient field of observation. The plan here followed of selecting a medicine and treating of its efficacy in several different diseases, may appear to some to savour of empiricism. The only motive for this variation from ordinary habit is brevity, a plea that has novelty as well as simplicity to recommend it to my readers. Tedious labour from Rigidity of the Os Uteri and Vagina. Some patients continue for many hours in the first stage of labour, with partial dilatation of the os uteri and external parts, in whom there may be no want of what, are significantly termed grinding pains, a state more frequently met with in first pregnancies and those who marry late in life. This state is to be care- fully distinguished from false labour, which' it much resembles, by the partial dilatation of the os uteri, protrusion of the membranes, and presence of glairy discharge. It may continue for some hours, rendering the labour more tedious than it would otherwise have been, the parts eventually be- coming relaxed, and the labour terminating favourably ; it may continue for many hours, exciting our dread as to the result of the case : or, in its more obstinate forms, it may persist so long as to wear out the mother's strength in unavailing efforts to overcome the difficulty it opposes to delivery, the mother, child, or both, perhaps, falling a sacrifice. The difficulties to encounter here, are premature, too forcible or irregular uterine action, pro- pelling the child against the os uteri before it is sufficiently dilated or /lilatablc, and absolute rigidity of the parts. It should be constantly borne in mind that the first inconvenience is a very frequent cause of the second. With this view of the subject, then, the two objects to be held in view, are, mitigating too early, violent, or irregular uterine action when this is the cause of delay, and producing relaxation when rigidity is present. Of the efficacy of tartar emetic in producing the first effect, we shall presently treat, when on the subject of violent labour ; for the present let us inquire into its utility in the second. In tedious labour, from rigidity of the uterus, the os is found slightly gaping, with a thickened, tense state of the lips, nnd usually much heat of the parts. Bleeding from the arm, and, on the eonti- nent, the use of the warm bath, have been had recourse to in these cases i > 36 Tartar Emetic in Obstetric Practice, [June, Bleeding is attended with marked benefit when there is a full bounding pulse, in a strong plethoric habit; but, as a general practice, it is not unin- tended with inconveniences, often of a very serious nature. It. certainly procures relaxation of the os uteri, but along with this it causes depres - of too permanent a nature, and may thus seriously interfere with the future- progress of the labour. Tartar emetic solution has been successfully em- ployed in producing relaxation of the os uteri in these cases, and poj s< the advantage of being much less permanently debilitating. It is an agent by which the system can be with safety brought into a much greater degree of temporary depression; between which state and relaxation of the con- tractile tissues, a marked connection holds, if they do not absolutely stand in the relation of cause and effect. The principal'recommendation, however, to tartar emetic in these cases is, that in its use, the power of regelating the necessary degree of lowering the system, exists completely in the hands of the practitioner, as he has only to increase, or diminish, or suspend the doser in order to produce the effect he wishes; and, when the we ssary effect Is produced, the withdrawal of the medicine leaves the vital energies but little impaired. The medicine has been used in the ordinary nauseating doses, as in pneumonia, 5 or 0 grains of the tartrate of antimony, dissolved in e . ounces of water, and generally 20 drops of laudanum, and a small quantity of syrup added; one, two, or more table-spoonsful of this mixture are giv< n at intervals of from fifteen minutes to two, three, or four houTs, according to the effect it produces, and the necessity that exists for bringing the patienl speedily or otherwise under its influence. Sometimes it is necessary to cause irec vomiting in the first instance, or the ordinary doses produce no nauseating effect ; in such cases the laudanum is better wit hheld, but may be added afterwards if necessary. In other cases the medicine acts too vio- lently as an emetic, or produces purging; here increasing the quantity of the laudanum, and diminishing the dose, or allowing a longer interval to intervene between the dosesr will be necessary. The accoucheur must, therefore, watch carefully the effects of the medicine during its administra- tion in every case in which it is employed ; these observations applying with equal force to the forms of disease m which its utility has been proved. Under some of the circumstances described, or where the antimonial in every dose and form disagreed with the patient, small and frequently repeat- ed doses of hippo [ipecac] have been substituted (three to five grams every how or second hour,) and with good effect, not only in rigidity of the uterusT mil in the other diseases in which tartar emetic w;is found efficacious. It should be mentioned, that neither tartar emetic nor venesection have been relied upon singly in some cases where it lias been necessary to produce speedy dilatation of the os uteri, and where the plethoric state of the sys- i< m described was present. In such, after depletion, the patient, was kept for some hours under the influence of the nauseating mixture. One ci Be, in particular, of a most threatening nature, maybe mentioned, in which a strong, robusl woman was brought into the hospital with the arm forced into the vagina, through a tense, rigid, and slightly dilated os uteri. She was so treated, and with the besl results. T*here is a Bomewhat different of the os nti ri, in which it occai kmally dilates very tardily also; here the lip of the uterus is thin and stretched over the head of the child, not a'i'. -ding the sensation of heal or rigidity of fibre observed in the case abov< d< scribed. The extract of belladonna appeared of service in afewofthesi c - j, al hough its general efficacy appeared very questionable. In two ( - of rigid os uteri, in which it was freely \\^c(], its application was fol- 1 wed I v head symptoms and depression of pulse; in one of which even i isibility and stertor were present. It was, however, tried in many other 9, without being followed by these unuleasant effects. The last described stt '" of the os uteri is also occasionally benefitted by the nauseating medi- c Tt may depend, however,. upon other causes, not under our present consideration, nor is ft looked upon with the same anxiety by the occouch- 1836.] Tartar Emetic in Obstetric Practice. 37 rur as a cause of tedious labour.* In concluding this branch of our sub] not be inferred from what lias preceded, that tartar emetic will b eceedin procuring dilatation of the os uteri; as it is in some ci " unavailing, in others inadmissible. Its efficacy, however, in a : which it has been used, fully warrants its attracting the dtion of the obstetrician, and its success will depend much 0:1 a proper selection being made of the cases in which it is available. Irritable or Violent Labour. By no means an unfrequent eauee opposite idiosyncras arise from opposite diseases of the secerning vessels of the head, one pro- to excess, and tin1 other in an equal degree preventing, the effusion of the due quantity of ri i * the b salthy and vigorous if Mr nervous system. If it should be asked, How can the same cause operate in different waj s .' H \. ( ting process at one time cause sleep, and another not cause^t I How can it, though unremitting in activity, at one time paralyze the brain and nerves, and at another rather enliven and invigorate them.' questions are difficult, and the more difficult because, m the material world, we can find no object wherewith to compare and illustrate the phe- nomena of mind. The clement of fire must suffice on the present occa- sion, where no better ligament of analogy between tilings so different can be had : * Nutritnr ventis, ventis extinguitur ignis ; Levis alit flammas, grandior, aura nee at.' If a fire burns clearly, brightly, and fiercely, still it requires a constant sup- ply of fuel to keep up its intensity, and replace the solid particles expended m combustion, A small quantity frequently added, so far from paralyzing, increases the activity of the fire : but when that activity is exhausted, when the very energy of the rl lines, like the exertion of a powerful mind, has w isted away the substance on which it fed and these flames sink enfeebled and the fire is diminished and dull, if you heap over it a heavy mass of fuel, the flames are smothered, the activity ceases, the element sleeps. Hours are' required to extend the vivifying influence to the new matter ; at length the increasing warmth pervades the . whole mass, the assimilation is com- plete, and the smallest incitement stirs up again all the energies of the fur- nace. If too little aliment be supplied to the glowing mas?, it will burn out like an over worked brain in similar circumstances ; while too great a weight of fuel cast on the exhausted hearth overwhelms the expiring em- bers, and the result is the slumber of death, not of sleep."* The hypothesis (for we believe it may be considered only as hypothesis) of Mr. Carmichael is ingenious perhaps it may be true. The laws of al- ternate sleep and activity, like all the laws imposed on us by the Creator, are, no doubt, the wisest and the best that could be devised. We can trace the operations of many of them but very few of them can we ex- plain. It strikes us that there are some difficulties in the way of Mr. Car- michael's explanation of the causes of sleep. If this image of death be occasioned by the deposition of large masses of new matter on the delicate organization of the brain and nerves, inducing the "paralysis of sleep, it is curious how the bile of a Ilea or a bug will often disperse all these depositions, and start us into wakefulness ! It is also curious that all animals become more or less sleepy, during the very first process of digestion, in the stomach and long before assimilation, much less deposition of assimilated matters, can possibly commence. The dog, the hog, and the glutton fall fast asleep as soon as the stomach is crammed to satiety. They are most awake and active after digestion, and when assimUation, secretion, &c. arc in full play. * The Phrenological Journal, June 1, 1835, 16 On ! of the Vena Porta. (June. # L le cold and hunger induce an almost irresistible pro- is arise from depositions of matters on the brain :i- wal of their parte and powers .' [I . ry tiling is periodical or alternate in this world, and nothing cons! . . m for a short time. The muscles cannot - be in a state of contraction. The brain cannot always be flunking. But the organ of the mind cannot cease to think, except through the mys- p and, therefore, sleep was brd lined. How it is in- duced we know not. Opium will often lull to repose by diminishing sensi- ; but still we arc totally ignorant how the sleep is produced in conse- quence. We must, therefore "Wait the great teacher Death, and God adore." [Prom the American. Journal, Feb. 1830.} PkyswlogicQl and Chemical Researches on the Blood of the Vena Porta. The first No. of the forty-fourth volume of Rust's Magasin contains an account of some highly interesting researches by Professor Schultz, respect- ing the chemical and physiological differences between the blood of the ve- na" porta, and that of the arteries and other veins. The following is a suc- cinct summary of the results, as given in the Gazette Med. de Paris, (15th August, 1885.) 1st. The blood of the vena porta is in general blacker than other venous blood, although this difference is not always manifest to the sight : it is not reddened by the neutral salts, or exposure to the atmosphere, or by the ac- tion of oxygen. 2nd. The blood of the vena porta-dOes not generally coagulate, but when it does, the coagula are less firm than those of the other arteries. In those cases in which it has coagulated, it liquifies entirely or partly at the end of from twelve to twenty-four hours, and produces, as well as that which docs not coagulate, a black sediment, upon which is formed clear scrum. 3d. The blood of the vena porta contains on an average, when fresh, 5.23 per cent., and when dry, 0.74 per cent, less iibrine than the blood of the ar- teries and the other veins. 4th. The liquid blood of the vena porta contains generally a little less solid matter (O.ld to 0.3 per cent.) than the arterial blood and the other ve- blpod. 6th. Its serum contains generally 1.58 less solid matter than the arterial Brum, and 0.80 less than that of other venous blood, [n the dry slate, the first is of an ash-gray, the second yellow, the third greenish-yellow. 0th. The blood of the vena porta contains proportionably more oruor* ami less albumen ; the contrary is the case m the arterial blood : the dry cruor of the vena porta is browinsh gray, that of the Other veins deep red, that ,.i the arteries bright red. 7th. The blood of the vena porta contains in its solid parts almost twice as much fat as that of the arteries and the ether veins. The proportion is as follows : Blood of the vena porta, - - 1.06 per cent. Arterial blood, - 0.92 Venous blood of the other veins, - 0.83 rt 1830. J Hydrocele of the Ace/.-. 47 8th. The dry serum of the vena porta contains but 0/i7 per cent. tan the dry serum ofth fchfi other veins. 9th. rhe albuminous cruorof the vena porta - 1. 11 pei ,1 rre fat thanthatoftbe arterial Wood, and L.21 pi rem:, mora than I the blood of the other \ . . 10th. It is in the fibrin that this difference is th 1 yfibrin vend, porta contains 10.70 percent, of fat ; thai of the arteries 2.8-1 p< r . so that "he diffi at. llth. The fet efthe blood offche vena porta is blackisji brown and imctu- ,,:i.- ; thafcoi Lrl M-i-.l blood and other venous blood white, or yellowish-wiute if the white chyle to two^thirds liquid and one-third Hydrocele, of the Neclc. Ever since its existence was first declared, this di.sea.sr been generally unnoticed. by practitioners and by teachers. We are pleased with an opportunity of re-publishing the notice of it contained in the last No. of the American Journal, from James O'Beirne, M. D. alike on account of the great importance. of its diagnosis and treatment, and of the opportunity afforded of ex- p ising the injurious influences extended to the cause of humanity by the anathema of high authority. Those who arc full fledged with the brilliant plumage of fame, or whose vanity causes them to think themselves so, arc often wont to proscribe, in the most pointed and dogmatical manner, the opinions and facts of those who have not been so. puffed abroad as themselves. Thus it has been with the valuable manuscript memoir' of Professor Maunoir, of Geneva, on the disease to which he gave the name of Hydrocele of the neck, and which, though essentially different. in its nature, and requiring a very different mode of treatment. has such a resemblance to Bronchocele, or goitre, that it has been constantly confounded with the latter disease, and treated accordingly. This valuable memoir was read to the Royal In- stitute of France in 1815, and. as we are informed, subsequently transferred to the Academy of Natural Sciences, by which body the late celebrated Baron Percy was selected to report on its merits. It was not, however, until April, 1817, that the Baron presented his report, which proved highly unfavourable to Pro- fessor Maunoir's opinions and practice. With the burthen of this proscription, Professor M. did not rise to the publication of his memoir for seven whole years ; at the end of which time he did for the first time publish it, with the whole of the unfavour- able report made thereon, nnd a most able and satisfactory de- 18 of the N* [7une' juliar views on the subject. T3.it, (continues O'Bi Lrne) it would appear that, as too often happens, the autho- rity1 pf a greal same, aided by bold and specious objecti proved more powerful than either the strongest i". :is. as proven by the fact that nothing has been said about it ;'i Prance or England; and, even Delpech of the former, and Lawrence of the hitter, have reported cases of this ven which they have treated by incision, without making tin !^ast allusion to the less dangerous and disfiguring treatment so cessfully adopted by Professor M. Since he was ac fidentally possessed of the essay " sur FTIy- le du eou," O'Beirne lias been favoured with three stri examples of the d all of which displayed the utter fall of Baron Percy's objections, and which he proceeds to give. follows : Di removed from this gland. But he lias, in two instances, observed the con- trary; and the second of bis cases, in which the gland enlarged and indurated formed one-eighth of the whole tumour, is an example of this complication. Treatment. With respect to the treatment of this/ disease, the learned Professor's opinions and practice are these : "Although," he says, "there may be great affinity between encysted tumours in the neck, and hydroc le i tunica v iginalis, yet it appears to me that, in hydrocele of the neck, the cyst is more dense, and morcdifficultto.be excited to aabesive inflammal Accordingly its treatment should not be directed by analogy, and it is i ot proper to have recourse to the euro by injection, although it seems, at a first view, to be the best. I wished to try it, and have been obliged to renoi it as a bad plan, and not one free from danger. An injection, which is not . stimulating, will effect nothing, or almost nothing, on a very thick, and m general, an old cyst. If a very active inj< ctfon be employed, it wilKcause greal pain, andgive rise-to very alarming spasmodic symptoms. Moreover I have to observe, thai Bometimes enlargement of the thyroid gland compli- cates the treatment. In that case, the object is not merely to produ< e a l- hesion of the walls of the sac ; if will be necessary to employ a mode of cure by which we may succeed al the same time in resolving this glaj d, w ben it projects 'into the tumour, as 1 have soon in two patients." A- to I ying open the tumour bv incisions, as practised by Heister, or extirpation of the '- orofoidv a part ol the cyst, he condi inns these op< rations as being serioi I calculated to prolong producing a large oiii! d, and one of a kind very slow in cicatrizing. In short, the treatment 1830.] Hydrocele of the Neck. 49 which. he lias been led to adopt and recommend consists in puncturing the tumour, ani had seep, read, or heard of. Originally this tumour had been very small, but increased in quite an insensible manner. It did not force the head to incline to the left, but to the right side, and formed a sort of cush- ion for her head to rest upon. She had taken burnt sponge, and many other boasted remedies for .goitre, but without any benefit. Difficulty of breathing and swallowing came on, and increased in proportion to the growth of the tumour. One day, while washing at the river side, she threw up a very great quantity of blood, fainted, and was supposed for some moments to be dead. The haemoptysis and oppression continuing, and the swelling being felt to contain a fluid, a trochar was passed into the most prominent and fluctuating part of the tumour, and gave exit to a pint and a half of a deep brown liquid, which coagulated by the application of heat. Complete relief ensued. On the following day, the swelling had returned to its former size, but fluctuation was less manifest, for infiltration had taken place between the tumour and the skin. At the end of fifteen days this infiltration had disappeared, and Vie cyst was punctured by a trochar, and after being emptied, filled with warm red wine and a small portion of alcohol. This injection, although retamed but for a few moments, caused great pain and suffering. Swelling, redness, trismus, and increasing pain, on the following day : leeches, poultices, ape- rient medicines, and opium, ordered. -An abscess, external to the cyst, opened and treated in the ordinary way, untd it healed. A third puncture made in the upper part of the cyst by a sharp-pointed bistoury, and giving exit to as considerable a quantity of fluid as at the second. A button- pointed probe was then introduced into the -opening, and passed until it be- came prominent at the most inferior part of the tumour ; the point of the probe then cut upon, and the instrument withdrawn, leaving in its place a single thread. This thread frequently renevyed : no accumulation of fluid. A seton of ravelled linen passed, and caused abundant suppuration. This seton continued for six weeks, and then removed by the patient, on account of interfering with her ordinary occupations. Both openings iistulous for some months ; the upper first closed ; and in the year 1813, when she was G3 years of age, her neck was very slender, and her health robust. Case II. Monsieur C, of Vevay, aged 40, had for many yeais a tumour situated on the front and right side of the neck. This tumour extended from the chin and lower jaw to the sternum and clavicle : and in the greater part of its extent, there was a manifest sense of fluctuation, but points corresponding to the thyroid gland appeared to be hard and prominent. The swelling increased daily, became fatiguing from its weight, and ulti- mately caused difficulty of respiration and speech, and occasionally attacks m which he seemed to be on the point of expiring. A puncture made into the upper and left portion of the tunlour, and a pint of limpid, amber-co- loured, and perfectly inodorous fluid evacuated. This evacuation reduced the tumour to one-eighth of its size, the remaining portion being formed by the thyroid gland in an enlarged and indurated state. A blunt probe now Introduced into the opening in the sac, and carried down to the inferior and anterior portions of the tumour; the point of the probe cut upon, and a sin- gle thread passed, in the usual way, as a seton. Great freedom of rc-sni, 7 tfO Hydrocele of the Netk. [June- ration and in moving: the head, instantly followed the complete evacua of the tumour. Next day, a fresh accumulation of fluid, but much let quantity, and of a fetid, Banious kind; some fever; stomach deran. Hyppo," followed by infusion of bark, and Spa and Seltzer Waters emplo and restored the patient to Ins ordinary cairn state. Pieces of line;] gr ally increased in size, and smeared with simple digestive ointment, introdu- ced as setons ; injections of plain and hydrcsulpkurated water, and decoc- tion of bark, with honey thrown into the sac. Discharge less in quantity, and more purulent : the extent of the cavity greatly contracted ; and the thyroid gland diminished in size. In a f. v. months the patient's health was completely restored, ana his neck became- of its natural size. Case III. Mademoiselle T. D. aged 20, having for many years a large tumour on the front, and a little to the right side of the neck, had been subjected to all the known modes of treating goitre. This tumour was of enormous size, and consisted in a great degree of fluid. The least move- ment brought on cough, and attacks of suffocation. Her parents and friends refused to permit a seton to be passed, but a puncture with a trochar was made in the most depending part, and a cupful 6f fluid, resembling infusion of coffee, was drawn off. The canula was then withdrawn, with a view of retaining the rest of the fluid, and enabling a second puncture to be made and a scton to be passed. The tumour was very little diminished ; the wound was then covered with adhesive plaster, and a roller applied with moderate firmness. After passing some hours in a very quiet state, she indulged too freely at dinner, and in the evening felt oppressed in her breath- ing, and the tumour became quite black. It was evident, in fact, that the contents of the sac had passed into the subcutaneous cellular membrane. She passed the night badly, and could scarcely swallow a few drops of an anodyne draught. In the morning great difficulty of respiration, and total incapability of swallowing; the part? surrounding "the tumour so swelled that the neck was raised to the level of the chin and lower jaw, with which if seemed to form one continued pillar. The. whole of the upper part of the thorax was also infiltrated, and the alteration of the voice and dyspnoea were such as to lead to the belief that the effervesced- fluid had penetrated into the internal cellular tissue of the trachea.- In the course of the di \. however, all these symptoms gradually diminished in severity, and the swelling was considerably reduecd towards evening. She passed a good night, and on the following morning deglutition and respiration were free. On the fourth day from the operation, the original tumour was diminisl d by one half, the infiltration and black colour of the skin had disappeared, and the patient was in excellent health. On the 90th of January, 1812, that is, after about six weeks had elapsed, the tumour was as large and as distressing as ever. A hydrocele trochar. with a flat elastic canula, was passed into its most depending part, and two pints of a dark brown fluid, coagulable by heat, wit.1 oil charged. On emptying the tumour, the thyroid gland was found moderately enlarged. A blunt probe, armed With a single thread, introduced through the canula, made prominent at the upper part of the cyst, and there cut upon uu' could be withdrawn, and the thread left as a seton. For some days nervous symptoms appeared. The two little incisions contracted so much, that the thread could not be moved backwards and forwards but wilhgreat difficulty, and such as to create a suspicion of its being lodged in the tissues of the walls of the cvst, which it had cut in gliding, and of haying thus lefl the cavity of the tumour. The silk thread withdrawn, at the instance of her parents, and in order thai a fresh accumulation might perrail a puncti r a be made by a bistoury, (instead of the trochar which had been found bo i!J- siuted,) and enable a COtton wick to he passed as a seton. The tumour soon regained In former size, and the oppression returned. The necessity Qf this operation repeatedly urged, but as often delayed from some frivolous IS3G. ] Hydrocele, of tht Neck. g xt. The Professor sent for in great liaste, on the 16th of April, 1812. and found her with complete loss of sense and motion, slow and stertorious breathing, cold extremities, dilated pupils, and no pulse. iNo person being at hand to aesisl in the proposed operation, the tumour was punctured by a hydrocele trochar, and a pint of dark brown fluid discharged: Immediately pulse, respiration, and in short, animation were restored ; but permission to - a seton could net be obtained. On the 7th of May, the size of the' tu- mour required that it should be again punctured. On the 24th of June, she complained of violent pains in the head, great suffering and oppression. Another puncture made in the swelling, and a quantity of fluid mixed, with purulent matter, discharged. 25th, pains returned ; astringent applications; increased enlargement of the neck ; distress and oppression alarming. Six leeches applied, and the patient well purged. with castor oil, without any relief. 27th, tumour punctured, and a less quantity of fluid, but more mix- ed with pros, discharged. 21st of July, symptoms severe, and increasing so much in violence, as to require another puncture, which was rendered diffi- cult by the thickness which the infiltrated cellular membrane had acquired, ami, consequently the increased depth at which the cyst was placed. A -hread. and, subsequently, a large seton inserted; abundant fetid sup- puration ; gradual contraction of the sac ; an abscess formed and opened at the inferior and laternal part of the neck ; a fistulous opening for some months at this point, and at length healed by an injection of a weak solution of sulphate of copper. Seton removed ; tumour completely dispersed ; and recovery perfcci in all respects. Dublin Journal of Medical and Chemical' 5^ On Caiicrr. [June Past, hi. monthly periscope. Cancer. Professor Benedict states that during a certain pe- riod, the operation for cancer (not including cancer of the lip,) was performed at the Clinique thirty-seven times ; and that, with the exception of one or two cases treated by arsenic, a radical cure was not obtained in a single case. Extirpation of the breast was performed three times, and un- der circumstances apparently very favourable; in all of which the disease returned again. Of ninety-eight amputations of the breast, which he has performed since he undertook the charge of the Clinique, two ended fatally, from exhaustion during the healing of the wound; and in all the rest, with the exception of thirteen, the disease returned after the wound was healed, and terminated in death. With regard to the remaining thirteen, he observes he is morally convinced that, in several cases, an error in diagnosis was committed, and breasts were removed that were 'merely affected with scrofulous tumours, sarcoma, or some other innocent change of structure. On this statement, the editor of the Lancet observes : " The above results are worthy of serious attention, and serve, unfor- tunately, to confirm the opinion advanced by many surgeons. that in most cases cancer is a constitutional, not a local dis- ease." Amer. Jour. Feb. 183G, p. 513. We give the above extract, not by way of recommending the intelligence it contains, but of staying, if possible, its injurious tendencies. We had thought that it was plain to all surgeons by this time, that there were two grand errors in the practice of surgery in this disease ; 1st. A want of early diagnosis. 2d. 1 rocrastination of the operation to too late a period the latter arising sometimes from the former ; but most commonly from tve patient's objections to the operation, or the surgeon having been called in too advanced a stage or the disease. Our experience in the treatment of this disease has certainly not been great ; but still, small as it may have been, it leaves us in far better hope of benefit from the knife than the above state- ment would seem to justify, We have not kept a record of ca^rs, but will give the last four. Of these, two cases, as well characterized for the state of their advancement as those which ordinarily bid defiance to the knife, wen; amputated. The wounds healed kindly by adhesion, without any exhausting dis- charge or irritation. The Women remained well. In the third, the well marked scirrhus was so small and distinct that we could not. resist the temptation to extirpate ii : a practice so long and so justly condemned by the most judicious. This was done, with the removal of a considerable portion of the adjoining sub- IS.'**;.] On Cm stance, making in all three to four oz. in weight"; an3 a Btance whose whole diameter was not less than double that of the scirrhus. The wound healed within few days. A few months alter, however, the disease returned in the same place With rapidly exasperating symptoms. A distinct scirrhus tume- faction soon presented itself, larger than the whole substance before extirpated : manifi sting the extension of its influence to- wards that part of the breast nearest the axilla. Entire ampu- tation of the whole glandular portion of the breast, with all the adipose substance before the pectoral muscles, was now adopted the incision extending to the glands and lymphatics between the mammre and the axilla, whereby these were removed. This wound was found well on removing the dressing on the tilth day, and the patient has to this day, (now thirteen years,) had no return &f symptoms. The fourth case was one in an old lady, who had been watching its progress for ten or eleven years. Its developement, although it had been slow, had now arrived so near the state of ulceration that the nipple and a lit- tle of the adjoining part dropped off during the operation. It was, howrever, amputated very entirely, and the wound dressed for adhesion. A consecutive haemorrhage coming on, caused the wound to be re-opened for staunching the haemorrhage. This delaved the cure to about the thirteenth day, by which time it was so wrell that she was discharged to go home, about ninety miles. About six or eight months after this operation, I recei- ved a letter from the husband of the patient, stating that her health was every way greatly improved that there had been no threatenings of return of the disease, but that she had been extremely well, had thriven finely, and that, in short, her health was every' way better than it had been in twelve years. Be- fore two years had elapsed, however, this patient's health be- came impaired, manifesting, as her attendants said, a general cancerous diathesis, of which she died after some months. This experience, we say, leaves us in better hopes from sur- gery in these cases. And we are compelled to believe that there has been something, nay, much of the common errors to wdiich we have before alluded, in the practice, the ill success of which has been given us by Professor Benedict. We are not of those who are willing to allow an English or a Continental surgeon to doom a practice, because he may have been unfortunate in not making early diagnosis, or in not per- forming his operations with that science and thoroughness he should have done. And more especially are we so, when we know of very many practitioners throughout our Southern country, and freely venture the opinion that there arc many hundreds in these lTnitcd States, whose practice, if faithfully detailed, will prove these points : that the amputation of the cancerous breast, (not the extirpation of the scirrhus tumour,) N Morbid Adhesion of the Placenta. [June. will, if performed before a certain advanced and extended stage of the disease, generally, if not always, prove finally curative; and that when advanced to, or near the ulcerated state, espe- cially if its progress has been slow, and after the close of men- struation, the oi^ease will very generally return in the same, or some other part; or a general impairment of health supervene, l'or which the science affords no hope. We are aware that there have been, and still are many breast cullers, who occasionally find glorious opportunities of mounting surgical stilts by cutting off and curing as cancerous, a breast which has suffered a contusion by corsets, or a tedious obstruction of the milk tubes. Some such cases we have had the ill fortune to oppose in consultation, but too often unsuccessfully. These misfortunes are, however, the faults of ignorance or empiricism, and not of science. We have long been of opinion that in several of the important points of surgery, as well as practice, there is in the United States at least a practical superiority over the transat- lantic. We know this to be the fact in some places in the South as well as North. And we should be pleased to sec the results of Dr. Physic's practice on the point under consideration laid beside the practice at the Clinique. Morbid Adhesion of the Placenta.' In the American Jour* nal for Feb. 1830, we find a case of morbid adhesion of the pla- centa, as reported in the London Medical Quarter! v Review for July, by Dr. Litchfield. Mary Farrell, set. 32, was attended m her first confinement in March, 1835. by Mr. Barry, of Brunswick Square. Labour lingering pains light, and after long intervals. Sixteen hours after the commencement of labour, the accoucheur administered half a dracm of powdered Ergot, and repeated the dose every two hours. At the expiration of twenty-four hours, a dead child was expelled, and the uterus contracted forcibly around the placenta, so as to baffle the frequent attempts of the accoucheur to remove it. Eighteen hours after delivery, Dr. Litchfield saw her in consultation. The uterus was found high up beneath the abdominal parietes, and contracted at its fundus into a hard, irregular tumour. The external parts were swollen and pain- ful, arid the os uteri so rigid and unyielding as to resist the perse- vering efforts of the hand to dilate it. Pulse full, hard, and 95. Tongue furred and feverish : the face flushed, and severe pain in the head. Depletion, and small, repeated doses of tartarized antimony, with fomentations of flannel to the pudendum, were prescribed. Under this treatment the violence of the symptoms subsided, and I830.J Morbid Adhesion of the Placenta. ."."> fresh, long continued, but unsuccessful attempts we made to dilate the os uteri, and deliver the placenta: Bein opinion that it would be impossible in the present state of the parts to reach and overcome the adhesion, and having no fear of immediate haemorrhage, it was resolved to wait, and watch closely both the local and constitutional symptoms, abstain for the present from farther manual interference. Thus continued the case, the patient remaining in a wry satis- factory state, until the fourth day, when the discharge, which had set in as usual, became very copious, offensive, and of a greenish colour. Chloride of soda was used for the correction of the offensive odour, and the patient went on without unfavourable symptoms till the eighth day, when a portion of the placenta, equal to 1-3 of its usual weight, was thrown off in a putrid state. From this time, small portions continued to oe detached at in- tervals, until the twenty-first day, by which time all the placen- tal structure was thrown off. The progress of the case was unattended with pain or Iue- morrhag;* ; the patient improved rapidly, during the time, in its, strength, and appetite ; and at the end of one month from delivery, menstruated in a regular way. Strong ligamen- to is bands were found in the placental mass. We consider this case as one of no trivial -importance. And whilst we regard it as a faithful relation of lacts, we feel it a duty to guard young practitioners, (and we may say some old ones too,) against the danger of adopting a practice already too common, and to the increase of which this case is calculated to contribute we mean that of leaving placental delivery to na- ture, from an undue confidence, not only in the efficiency, of un- assisted nature, but in the safety to the mother with which the placenta may be allowed to remain and putrify within the uterus. It should be remembered, that a putrid foetus seldom fails to manifest by various symptoms its deleterious effects on the vi- tal energies of the mother ; and that the injurious influence of the putrid placenta is still more manifest and certain. It should be borne in mind also, that the decision of the con- sultation in this case, of leaving to nature the final deliverance, was not, by any means a matter of election ; but was really the absolute and unavoidable necessity of the case. It was done, and prudently too, because there could be no alternative but what would be fraught with still greater danger. The case truly resulted most happily. To adopt this plan however, in our practice, whilst it might suit the partial theorisings of the expectant practitioner, so well calculated to let patients die, would, we apprehend comport but ill with the duties and ob- ligations of the truly rational, which rank much higher than mere passive expectation. These surely demand not only a knowledge of the structure and functional arrangements ''the Morbid A i of the Placenta. [June, animal organization and the vital energies, both physiologica \ and pathologically considered; but also of the powers oj the various resources, whether medical, instrumental, or manual, which are at his command for assisting inefficient nature in Lh i removal of noxious causes, and the correction of their effects. To fold one's arms then, and rest in confidence, that unassis i d nature will accomplish every good, would be, in main of these es, but to leave the patient to die. Whilst, therefore practitioner is bound not to administer mortal powers, he is no less bound not to withliold anything which may contribute to the well being of the patient : for there is little difference to the in- terest and feelings of his employers, whether he kills, or allows death to supervene for want of those administrations, which were at his command. It is not enough for the practitioners to have done what he chanced to think best by his partial reason- ings, and speculative views- he is bound to do ad that die sci- ence of medicine can afford for the welfare of his patient. Whilst therefore, we acknowledge most candidly our great obligation to Dr. Litchfield, for having reported the case, and express our desire,, that all similar cases may be made public, still we would only look on them as messengers of hope from afar, which may serve to cheer us when we arc brought to bow under our impotence, and humiliation, and witness the final failure of our physical resources : and as calculated to shed a ray of hope and comfort on her wdio is otherwise overwhelmed with weakness, misery and despair. It is stated that during the latter months of pregnancy, the patient suffered fixed pains in the womb, arising, as she suppose d, from a blow on the abdomen. It seemed probable to Dr. Litch- field, that under these circumstances, the vessels of the uterus, being stimulated to undue action, had thrown out coagulated lymph, whereby fchc placental and uterine surfaces had become morbidly united. We believe Dr. Litchfield accounts correctly for the undue attachment of the placenta: and are able to give a case of very recent occurrence in corroboration, so far as relates to this pathological point; Lasl February we had the management of a case of very protracted premature labour. The presentation when made, was abdominal. Turning was of course effected as soon as the band could be passed, and an eight month child delivered. ( )n finding the placenta not detached, the patient being much fatigued and having no pains after delivery, was allowed to about two hoars. I't. rine contractions were then promoted by friction with the hand, but no separation was effected. Alter occasional efforts, for several hours, in the ordinary ways for deliverance, without any encouragement, the hand was passed to the placenta, which IQ'A Raid's Independent Spring Trt&s. f// ild not then be detached in less than two hours, v.iih all the effort pruden would affow. On inspection when delivered, a rable portion of the uterine face of the placenta present- ed an unusually d< rise, ev .1 and whitish appearance, which in- duced me to believe that adhesive mnammation had existed. This woman had, by a ride on the rail-rosR to Charleston, or so, ne accid nt attending the trip, brought oua flooding, which, though very considerable, and causing some days illness, was not followed by abortion, hhe recovered, and returned home ; after which she was occasionally troubled with irritations of the uterus, from depression, which continued to increase until the gravid uterus was placed high in the abdomen, and the patient confined to bed for several days. In one instance, free vene- section at the arm was necessary, on account of the inflamma- tion of the uterus from this cause. Indeed the present prema- ture delivery was brought 011 by a neglected return of the same circumstances. Do not these facts afford ground to suspect at least, that the circumstance of adherent placenta is generally attributable to inflammatory action some way produced ? And should it not serve to direct the attention of the practitioner more particularly to that state so often produced in the posterior region of the uterus by even slight degrees of prolapsus in pregnancy ? Reid's Independent Spring Truss. This is a truss invented by our townsman, Rev. Henry Reid, and is truly what its name imports an independent spring truss. It needs neither buckle, button nor strap for its accurate and effectual retention in place. It is retained solely by a spring power, and is alike applicable to Hernia) on either or each side, by having a block at one end and a cushion at the other ; or a block at both. A block simi- lar to Stagner's is adopted, but altered to suit the peculiarities of cases. The pressure is made by a well tempered spring, which passes from one groin, behind the pelvis and to the oppo- site side the metal being left untempered near the block, in order to make, by binding it at pleasure, any little change in its direction which the case may require. The whole metallic part is covered with a strip of flannel, and is so shaped as to lie in contact with the skin, making no sensible pressure but on the hernial openings. We have witnessed its application in a va- riety of cases, and are pleased with its neatness, simplicity, and efficacy in the power of retention; and we have no reason to doubt but that, whatever curative powers may attach to Stag- ner's or Chase's blocks, will also be found with this. It has an advantage over all other trusses in this, that as it needs no strap* ' I lull's has no strap, but has not the power of relcnUwH. 8 58 Dr. Praifs improved .Nipple Shield. [June. to pass before the abdomen, it will be applicable to women in parturition. This truss was subjected to the inspection of the .Medical Society of this place, at a late session, and was referred to a committee for testing its powers and reporting on it. That committee reported iheir application of the ins'rument to seven cases, in all of which its efficacy, neatness and conve- nience were well demonstrated. Dr. PratCs improved Nipple Shield. We have recently had the pleasure of witnessing the effectual use of Dr. Pratt's latest improvement of this valuable article; and have been delighted with the ease and efficacy attending its application. Although it would seem a trivial tiling, hcin^ nothing but a small metallic cup, with the nipple of the heifer attached, still, when we reflect on the great sufferings and injuries we have often witnessed in consequence of the want of just such an article, we cannot bul feci the greatest satisfaction in being able to recommend it most freely to the notice of all those whose Office it is to prevent nnd alleviate the sufferings of those for whose benefit it is intended. However simple the instrument may appear on superficial ob- servation, slill it is just what it should be. The metallic cup is so constructed as to adhere wellr and at the same time, prevent t' at drawing of the substance of the breast into it, as to obstruct the milk ducts ; and the nipplo is so finely tanned and prepared as not only to possess all the softness of velvet, or* of the best buckskin, but is so well dissected and prepared as to be ca- pable of being inverted for cleansing, and of collapsing so effectually on suction, as to retain its place on the breast with- out being held by the hand: We give below the report of the Committee of the Medical Society of Augusta, to whom it was referred. "The committee to whom Dr. Pratt's improved nipple shk Id wTas referred, take great pleasure in reporting, that they have h( en able to demonstrate, in the most satisfactory manner, tin- very complete adaptation of that instrument to its intended pur- Your committee have been so fortunate as to sec its applica- tion to a breasl in which, from great previous inflammation, the milk vessels about the nipple were contracted, and consequently always disposing to serious obstructions. All other means of drawing the breast had been repeatedly used in the ease, with n<> fetter effects than these <.f drawing so much of the breast into the Opening of the instrument as entirely to obstruct, the passage of milk ; and affording pain in various degrees. The peculiar shape of tic m< Gallic portion of Dr. rratfs instrument completely prevented both these difficulties; and at the same L83&.J Mr. flfiddlemore's Repbrt. ;o time, with all practical force in drawing, presented the lender nipple from touching the metallic cap withitt. The valuable quality of remaining adherent with) Lit being held on by the hand, or when the suction was discontinued, was also fully de- monstrated. In conclusion, your committee arc truly happy in feeling as- red that in the instrument invented by Dr. Pratt, the commu- nity is presented with the means of both obviating, and removing when present, all that incalculable sum of misery which women have been accustomed to bear for a length of time, in conse- quence of sore nipples ; and even of preserving the lives of many infants. Who, in consequence of diseased breasts, and the want of nipples, are turned over to hand-nursing a prolific source of disease and death; for this instrument supplies the place of the 'natural nipple most admirably and perfectly." Mr. Middlemore, in his annual report of the Birmingham In- 'firm, ry for diseases of the eye, which we find in the Medico- Cnirurgical Review for July, briefly describes his usual plan of operating on children from one to three years old, for complete i sjineta] cataract. He fully dilates the pupil by the use of a strong solution of hyosciamus. The child's body is securely enveloped in a napkin, with the arms fixed to the sides. The child is placed upon a table of convenient height, with the head slightly raiseo". The head is firmly fixed by an assistant press- in his hands on either side of it. If the right eye, he raises the upper eyelid, and fixes the ball by pressing the index finger upon the temporal, and the middle finger upon the nasal side of it. Thus prepared, he rapidly passes a very fine needle through the cornea, near its junction with the schlcrotica, and simply la- cerates the capsule by slightly moving its point a little back- Is, and to either side. He directs the needle to be very fine and slender, sharp at the point, a little flattened towards the point, having a cutting edge on either side for a short distance from the point ; and gra- dually becoming round towards the handle. Mr. M. gives the following very rational description of this mode of operating : " The advantages of this mode of operating, arc neither few nor unimportant. In the first place, it is quite efficacious, and quite competent to the removal of the disease, or, at least, only requires to be performed a second time ; secondly, when properly performed, :it involves no risk of injuring any important texture, except the cornea ; thirdly, it gives r'se to scarcely any pain ; and fourthly, it excites hardly an appreciable amount of inflammation." 09 Carcinoma of the Tongue. [Jkinc, Having always had a great aversion to wounding the cornea, wc have never operated through it, either for extracting, cr causing absorption. But we have some reason b I r. M s. experience, to believe in the superior claims of this particular operation. In two or three oi' our last cases we have been greatly perplexed with the severe and ungovernable inflamma- tion which has superceded en redinatien b\ Scarpa's needle in the common way, notwithstanding the inclination was easily and effectually done, and the power of very distinct vision pro- ved immediately after the operation. J hese operations were effected with but Very inconsiderable pain. The subjects were all old, but were as carefully prepared lor avoiding inflammation as possible. The pupils in these cases were all dilated by the use oi Belladonna, the long application of which was necessary to ef- feel the purpose. The inflammation, however, in all of them, ran high : and in one^asc, particularly, in which the ope ration appear- ed to have succeeded very finely, and the patient had been pre- pared under our own immediate attention, with great care, so extreme was the inflammation for more than a month, thai when it did subside, the power of vision was entirely destroyed ; aor has it improved in the least, now ten months since the operation. The pupil is perfectly clear, and the iris retains its natural susceptibilities. Perhaps, too, the Hyosciamus may be a more safe dilating power than the Belladonna* In the same report, ?>Ir. Middlemorc earnestly entreats his brethren to test the effects of Strychnia in Amourosis. With those effects he is amply satisfied, and is a warm advocate of (he value of this remedy. Yet he thinks it has been employed in an indiscriminate manner, andhe feels convinced that all who employ it with judgment and care, will form the same conclu- sions of its qualities as he has done. Medical Cliintrgical /?- \ for July, 1836, p. 254. Carcinoma of the Tortgue, successfully treated with the Liga- ture. In the American Intelligence contained in the American Journal for February, we have an account of a case reported by Dr. Donnellan, of Donaldsonville, Louisiana, of a large, ragged, ill-conditioned ulcer of the tongue, \\ hich, :; >m its presenl charac- ter and the history of the ease, he considered cancerous ; cured by the ligature, as recommended and practiced by Sir Edward Home, The ulcer occupied the righl anterior partofthe tongue to a << extent, and was progressing very rapidly. T*he subject w\ is very corpalenl woman, 25 years of age, and m the 8th month of pregnancy; "when lie first saw hef: at which 4;tiic there was but a sued! ulcer on the party apparently of no importance. On the 23d day alter, on being called to the case, 1 89&J GfoitreCure of by e i Hrpation. <: I he found that the ulcer had made such fearful | . thai he deemed it proper tOt operate, and risk its effects on her preg in preference to allowing the ravages of the ^disease, even for the short remnant of the gestation period. A crooked needle armed with a strong ligature was passed through the middle of the tongue* behind the ulcer. The liga- ture was then cut at the needle, and one tightly drawn and. tied en each side of the ulcer 5 thus cutting off the circulation from the diseased portion which constituted a considerable sigment of the right side and tip of the organ. The pain on tightening the ligatures was very intense, which was soon relieved bv 00 drops ofTr.Opii. A few hours after the operation, a copious salivation super- vened, which continued till the dropping off of the diseased part. Five days after the operation 29th April, deep sloughs were produced by the ligatures. On the 4th May, ten days after the operation, a single ligature was applied in the fissures caused by the old ones, so as to embrace the whole, which dropped off on the 6th twelve days after the operation. On the 11th May, the vacuity was found fast filling up with granulations, and .on the 23d, was perfectly cicatrized the patient havinggiven birth, some eight or ten days previous, to a fine healthy child. Her articulation was but slightly impaired, and at the last observation she continued in excellent health. Goitre cure of by extirpation. Two cases of this disease have been cured by Professor Graeefe, of Berlin, [n the first case given, the tumour was of the -size of a goose's e^g, in the middle and anterior part of the neck, which caused extreme dif- ficulty in deglutition and respiration. These symptoms assured the Professor that the tumour adhered closely to the larynx and trachea, which fact he bore in mind during the operation. An incision was made through the skin, commencing a finger's breadth above the superior margin of the thyroid cartilage, and extending down the median line, to the top of the eternum. The subcutaneous ind sterno-mastoid muscles being then drawn to the right and left, exposed the tumour, which presented a shining aspect, The surrounding parts were detached with the linger, and a bistoury, and some arteries were tied. The tumour was nowr found to adhere closely to the larynx and trachea, without the intervention of any cellular substance. The exci- sion of the tumour was then performed with the greatest caution, by small strokes of the knife; and the portion of it which adhe- red to the air-tube was.not removed. Only eight arteries were tied during the operation. The wound was tilled with lint, to avoid adhesion, that the still adherent part of the tumour might be (32 Reduction of Hernia, fy& Lithographic Plates. [June. discharged by suppuration, which accordingly took place. The lips of the' wound were afterwards closed, and placed in accurate apposition, and the cure was complete at the end of six weeks. In the second case, the tumour was much larger had ailiict^- cd the woman from infancy, and was divided into three distinct lobules. The immense size of this tumour prevented its entire removal at one operation; it was, therefore determined to begin with the middle lobe, which was the largest, and appeared to be the nucleus of the morbid growth. The operation was conduct- ed as in the preceding case, except that the tumour being attach- ed to the larynx and pharynx only by loose cellular tissue, there was no necessity for leaving any part of it adherent. The wound was dressed for adhesion, and w7as cicatrized in six weeks. The lateral lobes, instead of enlarging, as there was reason to fear, diminished considerably, confirming the opinion of EVi. Graeefe that the middle lobe formed the nuclus of the tu- mour. Perhaps, also, the inflammation consequent on the ope- ration, and the obliteration of the vessels that were tied, contri- buted to the absorption of the remaining lobules. American 'Journal, from Ryan's London Medical and Surgical Journal. Reduction of Hernia by the Air-Pump. Every efficient mea- sure in surgery which is calculated to prevent resort to the knife, we hail as an improvement of the first order. With Bell's improvement in the operation for hernia, we are greatly deligh- ted, because, severe, and dangerous as the bistoury sometimes is, we had in it a most comfortable and composing hope, on which we reclined in perfect case. But we rejoice to find in the European Journals several reports since the year 1818 of the successful application of the air-pump, for the reduction of stra- mulated hernia, which had resisted all the practicable means be- fore known except the operation, and when even this had been determined on in the consultation of surgeons. In such cases the exhausting pump has been applied over- the abdominal ring with the effect of speedily and completely restoring the parts to their natural portion. A scries of twenty, folio, Lithographic plates, illustrating the causes of displacement in the various fractures of the bones of the extremities, has been recently published in London, by G. W. Hind, M. II. C. S. Formerly House-surgeon to the Middle- sex Hospital, late curator to the Museum of Anatomy in the University of London. The subject of this very meritorious scries of Lithographic plates is, to exhibit, in a plain and striking manner, the causes 1836.] Pulsation of the heart of the Edtus. 63 pf displacement in .he various fractures of the bones of the ex- tremities. The w^rk is appropriately dedicated to Sir Charles Bell, vviiose pupil the author formerly was. Med. C/nryg. Iter. Oct. p. 487. The source, as well as the purpose, is a good one ; and as Litpgraphs are now well and cheaply executed in the United States, we hope it will not be long before Dr. Doane or some other ' ntcrprising American will place this work in the hands of American practitioners and pupils- Pulsations of the heart of the Foetus. The Medico-Chirurgi- cal Review for July, 1835, contains some observations on this p iu in Physiology, by G. O. Fleming, M. D. of the Pancras Jniirmary. Dr. F. feels authorized to consider Laenncc's and Kir^aradec's double pulsations as erroneous ; because, in the f. place, he listened to the foetal heart in Glasgow, and found the number of beats to be 140, and pronounced them not double, bat single beats ; and each two pulsations were one double beat or pulsation. And in the second place, because he had an op- portunity of counting the pulse in an infant just born, but which had not breathed, and it was 70. The moment, however, at which gasping and breathing took place, the pulse became much quicker. It was irregular at first, but soon became 140 in a minute. He concludes, therefore, from these facts, that the fcotal pulse is doubled immediately upon the perfect establish- ment of respiration. On this subject we are clearly of the opinion that Dr. F. has mistaken the whole matter. We have often observed the fact of the double beat as described by Kirgaradec, certainly less loud, but not less distinct than the beat of the adult heart. What we mean by double beat, is a pulsation of double the fre- quency of that, of the mother. We have also often observed the foetal pulse in that stage of semi- suspended animation which is presented to our view on the decline of placental circulation, and before the pulmonary route was well established. This wo have found of various frequency, and in many instances, none at all. for minutes. These, however, are only the temporary effects of the change the circulation undergoes, and are generally of short duration. For so soon as the new route is well esta- blished, that frequency of pulse which is determined by the ex- isting causes of frequency, is also re-established. We have seen a foetus born at the end of the sixth month, in which the pulsa- tion of the heart was not perceived at all until some time after birth, and never became more frequent than 25 to the minute, during the six hours of its life. Can this be considered as deter- mining the frequency of its pulse whilst in utero 7 Certainly n^t. 04 Delirium Tremens, eye. It docs appear to us that, setting aside all observation of facts, by auscultation before birth, and feeling, after, no one can con- template the foetal circulation, and find reason not to know that the causes of frequency exist alike before as after birth, with only this difference of circumstance, that the oxygenation is more direct after than before. The size of the heart is the same, the length of the circulating route shorter, and the delicacy of the fibre and redundancy of irritability very much 1 he same as bef< >re. These are, we apprehend, the chief causes which determine die frequency; Delirium Tremens. Dr. Cless, of Wurtemburg, professes to have found Digitalis purpurea to be a specific in Delirium Tre- mens. Ele\ en, out of thirteen cases in which he administered it, recovered ; tlie other two relapsed. A table spoonful of a strong infusion was given every two hours. American Journal. Extradrdinary case of Childbirth in old age. Tn the Boston Medical and Surgical Journal for April, 1836. we have the report (dated, Whitehall, N. Y. 23d. Feb. 1836.) of a case of pregnancy occuring in ihe person of Ann Cook, aged 64 or 65 years. She had not menstruated for the last fifteen years, and her la o o *r * REMARKS. 1 52 60 2 57 68 3 62 72 4 62 71 5 48 64 6 48 72 7 54 56 8 54 64 9 60 72 10 61 70 1) 51 72 12 50 58 13 64 68 14 59 74 15 62 81 16 61 70 17 62 60 18 53 64 10 74 72 20 64 61 21 63 73 22 50 68 23 58 78 21 54 82 25 61 82 26 68 82 27 63 85 28 64 84 29 68 84 3^ 61 80 62 72 72 68 60 68 52 70 69 07 62 56 73 76 77 68 55 67 67 61 69 71 70 78 75 76 79 78 79 78 56 75 64 66 5 66 3 53 58 53 75 61 59 65 These observations have been made in different parts of the county, where the observer happened to be. In all cases the thermometer was placed in the shade, and with a northern aspect. The mean heat was obtained from a variety of ob- servations during each day. Mean heat of April, - - - 62 61 Quantity of rain fallen during the month, inches, 1.83 Number of cloudy days, - - - 3 Rainy days, - - 1 Foggy mornings, 2 Thunder showers, 7 Prevailing winds, E., SE., S. and SW. In running the East and West section line, from Shell Bluff, on the Savannah river, to Jefferson county line, the same formation was found on each extremity of the line ; consisting of shell limestone and the genus Ostrea, of different species. On the extremities of this line, vegeta- tion is nearly a fortnight earlier than on the middle. The Buck-eye (JEsculus pallida) was in blossom at the two ex- tremities on the 29th of March, and in no instance in the middle until the 10th of April. The tern pern lure of springs issuing from the shell limestone formation, was found to be uniform at. 60 53 68 66 69 65 58 59 73 63 69 59 67 66 70 74 73 73 72 69 47 33 5 5 5 75 5 1 4 5 33 while tf lose ] ssuine from the marine sand or crag formation. the temperature was between 54 and 58 degrees. 1836.] Thermomelrical Ob$erva3ofi&. 77 Li all cases, it has been found, in the survey of Duike co that the forwardness of vegetation, and the high temperature of the water of springs, indicate the existence of a bod of limestone or calcareous marl. This fact is analogous to what has been observed in England and other countries in Europe. Bakewell, in his Geology, remarks that it is a well known fact, that the vegetation of perennial grapes, is, at least, a fortnight sooner on limestone and sandy soils, if not extremely barren, than on clayed, or even deep rich soils. It is equally true, though not so generally known, perhaps, that the difference is more than reversed in the autumn. This effect may be ascribed, with much probability, to the rich or clayed soils absorbing heal slowly, and parting with it again more reluctantly than the calcareous soils, owing to the greater quantity of moisture in the clay, which is a bad conductor of heat. [We take pleasure in presenting to our readers the above Meteorological Ephemeris and remarks, from the journal of our esteemed and scientific friend. Professor Cotting. This gen- tleman, who is devoted to the natural sciences, has for some time been engaged in making a Geological survey of Burke County, and designs, as we understand, to extend those investi- gations to some other parts of the State. The age, experience^ and extensive acquirements of Professor C. in the natural sciences, of which he has for many years been a successful teacher, fully warrant the belief that these researches cannot fail to afford results of deep interest to the State, the natural history of which has hitherto rested untold. We hope to draw, from time to time, from the same source, matter of increasing interest, as his investigations are extended; and indulge the hope that our State will extend to this able and worthy indivi- dual such patronage as shall secure to herself the incalculable benefits of his services in making a general survey. Ed.] 78 Removal of a large fibrous Polypus^. [July ARTICLE IV. Removal of a large fibrous Polypus from the base of the Cranium. By Paul F. Eve, M. D. Professor of Surgery in the Medical College of Georgia. Some of the particulars of the following case, having been verbally reported at the last meeting of the Medical Society of Augusta, a wish was expressed, to have them furnished the Southern Medical and Surgical Journal for publication and as they may not be devoid of interest to the profession, I have consented to comply with the request. Mr. Jonathan Stanford, now twenty-one years old, states that from early life he could not breathe through his right nostril. After having applied to several physicians of his neighbourhood, and tried every thing that promised relief, he was induced to visit the Faculty of our Medical College, in April, 1835. A few days after his arrival, an attempt was made to remove the por- tions of a Polypus projecting anteriorly into the naris of the right side, as well as posteriorly and downwards upon the soft palate, which latter portion could be readily felt by the finger introduced into the mouth and passed upwards alongside the uvula. By the use of forceps, &c. some inconsiderable portions were torn away, which permitted the patient to breathe through the nostril affected, after the slight inflammation produced by the operation had subsided. The part of the tumour directed backwards was found to be very large, and from the difficulty experienced in seizing it properly, it wTas deemed inexpedient to proceed further with the operation at that time, and the patient returned home. In October following, about six months after this very partial relief was afforded, Mr. Stanford again visited us; having now the antrum highmorianum of the right side very much distended, the eye of the same side being somewhat protruded, turned upwards and outwards, and the molar teeth depressed below their natural level, the Polypus also projecting both anteriorly and posteriorly in the nostril of the affected side. In the pre- sence of the class then attending lectures, an opening was made into the antrum, and a portion of the Polypus extracted from it. I9te.| Removal of a large fibrous Polypus. 7into the antrum, after which the alveolar process with six teeih, (the wisdom tooth not being developed;) was gradually detached from the malar bone and the pterygoid process of the sphenoid bone. Tiie palatine process of the superior maxillary bone, and the palatine plate of the palate bone, were now re- moved, and the soft palate completely divided through the centre. It being evident from repeated efforts with forceps; ligatures and hooks, that the Polypus could not even now be dragged away, after separating its slighter attachments from the surrounding parts, the curved scissors were employed, and it was found intimately adhering to the basilar processes of the occipital and. sphenoid bones, arrd also to the internal plate of the pterygoid process. The Polypus was of a very irregular shape, having several projections ; one into each nostril, the large one into the right antrum, which had been torn off, besides the large body resting upon the soft palate and attached as already mentioned ; and what was very remarkable, there was a small nipple-like pro- cess, extending into the left antrum. It was filled with large venous sinuses, and quite fibrous, particularly at its bony at- tachments. It was about the size of a man's fist after being macerated ten or twelve days, and deprived of all its blood, it. weighed three ounces, three and a half drachms. It can be seen in the Museum of our College. In dressing the wound, three common interrupted sutures were made in the soft palate, and five more with adhesive strips to the two incisions on the face. The patient, who bore the operation with great fortitude and resignation, had fainted several times, and did not folly revive until the third day, when he was considered out of danger. A little more than three weeks after the operation he returned home ; the external incisions had healed, but that in the palate was still open. There was little or no deformity ; the right cheek was neither depressed nor swollen. It is proposed to attempt hereafter, the operation of Roux, called Staphyloraphy, to remedy the defect in the soft palate. Ausnistt^, June 1th, 1836. 1386.] Purulent Ophthalmia of Infants. 81 ARTICLE V. Purulent Ophthalmia of Infants. By L. A.Dugas, M.D. Profes- sor of Anatomy, &c. in the Medical College of Georgia, &c. The obstinacy with which the purulent Ophthalmia of infants not unfrequently resists the ordinary modes of treatment, in- duces me to present a few cases in which the chloride of soda has been most signally successful. I am not aware of its having been hitherto used m this disease. The wrcll known anti- suppurative properties of the chlorides suggested the prescrip- tion, and its uniform success in the small number of cases I have had to treat, causes me to regret that I have had so few opportunities of testing it. Case I. 15th of December, 1834. Mr. J. H.'s child, when five days old, experienced in both eyes the ordinary symptoms of Purulent Ophthalmia, which progressed and con- tinued four weeks, notwithstanding the usual remedies. Mucila- ginous poultices and washes, were first used ; subsequently, lead water, alum curd, laudanum and water, breast milk, rose water, &c. &c. I now saw the infant, and found her eyes suppurating at least a table spoonful each in twenty-four hours. Palpebral so much swollen as to overlap each other considera- bly and render it impossible to separate them sufficiently to examine the globe of the eye. Child well in other respects, but cries very much ; ordered the eyes to be bathed every hour or two with tepid diluted chloride of soda, ( I ss to a quart bottle of water.) During sleep a bit of linen to be placed over each eye, and kept moist with the same solution. The bowels to be moved every other day with castor oil. 16th, the quantity of pus has notably diminished. 19th, child cried so much last night, as to cause the eye-lids to become swollen discharge still diminished mother so un- easy that she msists on applying blisters the size of 12 1-2 cts. coin to each temple chloride continued. 20th, eyes rather worse blisters dressed with cerat. simp. chloride solution. 23d, blisters quite well pus much diminished eye-balls maj be seen somewhat inflamed over the sclerotica. 11 S2 Pvm^rJ Ophthalmia of Infante. [July;* 26u . still improving rapidly. 30lh, palpebral swelling entirely gone no evidence of in- flammation in the eye no pus, nor agglutination case dis- charged. Note. It is worthy of remark that the disease was aggra- vated during the active stage of the blisters, and that its subsi- dence was in a direct ratio with the diminution of excitement in the blistered surfaces. The temporary swelling of the eye-lids, which led to the application of the blisters, was evidently caused, by the excessive crying of the child the previous night. Case II. 18th January, 1835. Mr. G. W. C.'s infant, six weeks old, affected with purulent Ophthalmia of both eyes, since the fifth daV after birth. Has had applications of mucil- ages, breast-milk, calomel, laudanum and water, &c. to the- eyes, with only temporary relief. The palpebral arc now very much swollen and overlap ; the inflammation extends from them over the eye-balls, as may be seen by separating them ; suppu- ration at least a table spoonful per day from both eyes treat- ment, chloride of soda and 01. Ricini, as in case No. 1. 27th. Have not seen the child since the above date, but am. informed by the father that the chloride " acted like a charm ;'T that the suppuration has entirely disappeared, that the inflam- mation and swelling of the eye-lids i. r moved, and in short, that the child is well. Case III. 20th May, 1835. Nancy's infant, (belonging to Mrs. B.) now thirteen days old, has had purulent Ophthalmia six days, and has been subjected to the mucilaginous treatment without benefit. Eye-lids now so much swollen as to overlap considerably, and to render any separation sufficient to see the. cornea impossible purulent discharge very abundant Ik al k otherwise good ordered chloride of soda, as above, without purgation. 23d, discharge much diminished. 28th, perfectly well. Case IV. 20th March, 183G. Mr. L. P. D.\s negro woman Pat, on the 5th inst. gave birth to a fine child, who, on the 13th, was taken with purulent Ophthalmia. The disease has conti- nued increasing to the present time. The eyes have been bathed with breast-milk nothing else done. They are now discharging immense quantities of pus eye-lids so much swollen 1836. J Mgftor Se?ato's Discovery. 8B as to prevent their separation prescribed the chloride wash, as above nothing else. 1st April, eves were well, but being neglected, have again, -commenced discharging a little chloride re-applied. 5th, perfectly well. Case V. 1st March, 1836. Mrs. P.'s infant, fourteen days old, has suffered five days from purulent Ophthalmia of one eye. T:ie palpebral and eye are both inflamed pus abundant. The ofher eye slightly irritated. Breast-milk alone has been used. The chloride of soda, applied a week to both eyes, gave complete relief to the diseased, and prevented the development of thfi affection in the other. ARTICLE VI. Signor Segato*s Discovery. We are indebted to our friend, Dr. A. Cunningham, of this ^ity, for the following very interesting communication, from our literary, scientific, and highly valued fellow-citizen, the Hon. R. H. Wilde, now in Rome. Although a considerable part of this paper is not strictly adapted to the pages of a medical periodical, still, on account of its great interest, and its necessary connection with that part which is of incalculable importance to the naturalist, and to the anatomist, we have determined on not interrupting its intigrity by publishing a part only ; and therefore present it entire for the gratification of our readers. To the Editors of the Southern Medical and Surgical Journal. I have just received from our friend the Hon. Richard H. Wilde, an abridged account of Signor Giromalo Segato's dis- covery, by his friend the Avocate Pellegrini. And inasmuch as it is one of great importance in the science of medicine, as well as to the naturalist, I cannot do better than offer it for publication in your Journal. Further proof I apprehend will ot be required than is appended to the abstract* A. C 84 Signer ftcgato's Discovery. [July, Giromalo Segato is a native of Yedano, a romantic village situated about seven miles from Belluno, in the Lombard- Vene- tian Kingdom. At the age of eighteen he attended the chemical and mineralogical lectures of Professor Tommaso Antonio Catullo, at Belluno, and accompanied that eminent person in various excursions to the mountains, for the purpose of collect- ing minerals and fossils. Even thus early, he gave indications of his passionate love of science, by exploring, alone, the moun- tains of Feltrino, and the environs of Agordo, returning laden with objects for the most part deserving the attention of the naturalist. In the short space of two years, 1812-1813, he col lected above a thousand specimens, among which those of fossil shells were the most valuable. He discovered a mode entirely his own, of detaching them from the hardest rock, without breaking, or leaving any part of the shell behind. His thirst for chemical and mechanical knowledge was insatiable, but Belluno was too confined a theatre for his genius, and he often lamented that his lot had not fallen in some pla( c where he could have executed some of the many experiments that occurred to him. Impatient of these obstacles he at length abruptly quitted his country and parents, and in 1820 his passionate love of travel led him into Egypt. An interesting outline of his journey is preserved in a letter to his brother, dated at Cairo on the 2Gth of December in that year, in which he says : " I will give you a sketch of my travels, of which you have already heard something by my letters written from Cairo at the moment of my departure, from the cataract of Assouan, from the island of Philoe, and from Abki, if they have reached you. 1 left Cairo on the 6th of May last, making part of an expedition destined for the conquest of Sennaar. To me, among others, was intended to be entrusted the superintendence of cer- tain works at the second cataract, which the Pacha wished to have constructed for the purpose of facilitating trade and the passage of troops. Handsome rewards were proposed to me, "but I declined them, desiring to avoid all restraints on my move- ments, and having no good opinion of the folks I should have to deal with; in which, as it turned out, I was not mistaken, for at the second cataract, disgusted with the dishonesly of one of our Italians, whose plan was plainly avowed by himself, I abandoned the expedition. But let us quit this subject and return to my 1836.] Signor Segaio's Discovert/, 85 journey* Leaving Cairo then, I passed on to upper Egypt, traversing the Tolcmaid, the Thebaid, and Sayd, and visiting the remains of thirty magnificent ciiies, as Ginqpoli, Antiohq, Ermbpoli Magna, Tani-Eptanomica, &c. &c. Arriving at Assouan, I pitched my tents near those of his Excellency Kihia- Key, with whom I partook of a repast. I visited the well of the San, the sacred island of Philoe, the ancient and magnificent place of initial ion- into sacred and sacerdotal mysteries, at pre- sent involved in the deepest obscurity. After a few days stay, I departed with his Excellency. I was the first who ventured to ascend the first cataract, being drawn against the stream by about two hundred men. The 20th and 21st we were at Qua- labseh, a place precisely beneath the tropic, and with a tem- perature under double tents of 49 to 49 1-2 of Reaumur. Ima- gine to what a distillation we were subjected 1 By Heavens ! I sweated as much in a day as a chemist's laboratory in ten. Quaiabseh, taken in a good point of view, is picturesque in its way. The two mountain chains, the Arabic and Libyan approaching each other, present walls forming a kind of theatre of the width of about eighty geometrical paces, or rather a gate- way or pass, which the Arabs call Bab-el-Nil, or gate of the Nile. The mountains are black, ferruginous obsidian, of dif- ferent varieties ; nature harsh and sterile ; the inhabitants darkly bronzed ; mostly wretched fishermen, belonging to the isles of the internal basin beyond the pass; the women full of spirit, less repulsive than the Egyptians, but of the strictest chastity. The girls go naked 'till the period of their marriage, that is to say with nothing more than a piece of skin tied round the waist, which is cut into thongs, like the fly-guard on the heads of our oxen, and ornamented with various coloured bark and shells. They are never more than a foot and a half long. Every age and sex are lovers of song and dance, and accus- tomed to them even in their daily labours. Only conceive that each little company of labourers of every description has its singer and musician, and does nothing without music. I visited sixteen other splendid temples, and, especially those of Ebsam- boul, excavated, like many others, in the mountain, but more beautiful than any of the same description, being ornamented with bas reliefs from the floor to the roof of every room. I reached Abedunacti and then Abedurgam, the first with its &6 Signor Segattts Discovery. ^July, eighteen cataracts forming the second. I saw Soda and Amis- chientino, on the west bank of the Nile, and ascended the peak of Bak-bak, where I found the names of nine European travel- lers, among which were two Italians. I made the third. This peak overlooks a great part of the cataract ; a grand but gloomy prospect. The Nile shoots its proud roaring waters amid a thousand isles of -dark granite, presenting a surface shining like glass. Some scattered palm and turpentine trees deck this dark solitude, inhabited by a few Berber families, who have a like disdain of clothing as -their neighbors, but a more agreeable language and greater probity. Here, as I said before, I left the expedition. Master of my own movements, I desired to form, from personal observation, an accurate idea of the desert. Accompanied by my faithful Berber servant, and pro- vided with some dried dates, water, and a little bread which 1 got from the soldiers, I passed on from Abki to Abdon, then traversed Colicombo, and ascended the intermediate Troglodyte chain dividing Nubia from the great desert of the Abadi, into which I penetrated in the direction of East, a quarter South- East. Behold me a solitary wanderer amid an ocean of burn- ing sand, precisely of the colour of melted metal, bounded only by the horizon on all sides, without a sign of vegetable and few of animal life, under a daily temperature of 64 to 65 of Reaumur, in a desert into which I was the first to penetrate. My dress was European, except the hat, which I exchanged for a red cap. In the evening when I stopped, my kingdom was all around me ; I ate my luxurious supper of dates, bread and water, and wrapped up in a woollen coverlet, slept sweetly 'till the morrow, without a sound to interrupt my slumbers. My own voice, my servant's, and our camels, alone broke the silence of the desert. Sometimes we saw Hocks of ostriches, but they fled like light- ning. It was the twentieth day before we exchanged a word with any human being. It was a wandering horde we met. We approaehed each other, we spoke, I gave them some pre- sents, they gave me some in return, and we parted. The thirty-seventh day we arrived at some miserable huts, the sight of which rejoiced me greatly. They wee formed of layers of dog's grass, and inhabited by an Aba- Ion chief, two young and pretty wives, and two beautiful children. I demanded hos- pitality, stammering in their tongue, and it was granted 1836.J Signor frcrafo's Disco very. 87 me to an unexpected extent. The master of the house!. invited me to sit down in the midst of them : the women eyed me from head to foot, with great wonder, but withe the least appearance of apprehension. The husband soon brought me some dates, and water which, though not good, was more delightful to my taste than the most exquisite liquor I ever drank. I had a few trinkets and skeins of silk. of winch I made presents to the females. This was sufficient to establish me in favor. I passed seven days with these kind people, who grew fond of me, and treated me with the greatest affection. I became much attached to them, regarding and behaving to those amiable women as sisters, kissing their chil- dren as if they were my own, and envying their felicity. The constant tranquillity, cheerfulness and harmony of this rustic family, founded on the rigid simplicity of their habits and man- ners, presented a contrast, I assure you, shameful to civilization. The 45th day, considering my slender stock of provisions, I resolved to return towards Abki, where I had left various ef- fects. I took leave of my kind hosts, who kissed me a thousand times, and commenced my journey. After tweny-two days' travel, during which we saw no living thing, and not the smallest plant, we fell in with a caravan of slaves going to the market of Cairo. I travelled two days, in company with them. for the purpose of becoming acquainted with the habits and cus- toms of their different tribes, for which the master of the cara- van, who spoke Arabic perfectly, gave me every facility. The sixtieth day, we encountered two wandering hordes, who did not molest us. These people were of tall stature, slen- der, very meagre, with fierce looks, eyes full of fire, and very little beard. They are tattooed in various parts of their bodies. The women especially, who are very lively, trace handsome drawings in blue-black upon the belly, under the breasts, and on other parts of the person. They stain the gums black, and have a spot of the same colour on the lower lip. All the men have black hair, curled, and hanging down behind, resembling a long wTig, cut straight across, about two finger's length below the shoulders, and always greased, which defends them against the heat of the sun. They have no riches or ornaments, but a camel or two, (not- all of ihem even this) a shield of crocodile or hippopotamus's kin. 88 Signor Segato's Discovery. [July, and a lance, which they manage With extraordinary dexterity. They have some peculiar superstitions, and practice circumci- sion and excision, which they perform in a barbarous manner with great solemnity. I had the good fortune to witness a mar- riage, a funeral, and an excision, of which I have preserved a minute description, as also of some other curious matters. Although I have often found myself jn situations where others would have been discouraged, my resolution never forsook me. Anxious to penetrate still further, but prevented by the want of means, indifferent to heat, hunger, and even thirst, the most dreadful of all sufferings. If you knew, my brother, what it is to travel on a dromedary, through" the desert, in the months of July and August, more than nine hundred miles within the torrid zone, for the most part without water, save such as is stagnant and stinking, and that hoarded as the most precious of your pos- sessions, since the want of it for one day only, were certain death ! Oftentimes I thought of the contrast between my situation in Italy in the midst of my family and friends, with all the comforts and amusements of life around me, in a temperate climate, and that of roaming a boundless desert, among naked black savages, where the whole of human desires are restricted to one want water, and the daily heat is from 64 to 05 of Reaumur. Yet all this is nothing compared with the pleasure of seeing unknown places, and collecting interesting facts and recollections, which you will one day hear. Finally, on the eighth day, I arrived at Oudi-Alfa, thence I went to Abki, at the second cataract, and descending Nubia, reached Philoe, and Elephantina, where I remained some days. From thence I departed for the Thebaid, to visit the magnificent tombs of Biban-el-Moluk, etc. The 29th ulto. I arrived at Cairo in thccvening,and experienced some moments of the greatest plea- sure. At first, when I entered the Coffee- Room, black, ragged, and with a long beard, six months old, no one knew me ; my good host, however, soon remarked and recognized me, crying out Se^ato ! Segato ! I cannot describe to you the salutations, the embraces, the demonstrations of joy that on all sides greeted my happy return. I can only tell you it was among the happiest scenes of my life. I swear to you my tears fell profusely at re- ceiving proofs of such sincere affection from persons on whom I fcad no peculiar claims." 1836.] Signor Segato' s Discovery. 89 It was in the course of these travels that the first' hint of his extraordinary discovery occurred to him. In going from Ouadi-. Elfa to Wograt, in the province of Sokkot, across the Eastern chain, he saw one of those tremendous phenomena, not uncom- mon in the deserts, particularly those bordering on the Nile, in upper Nubia, a whirl-wind of the desert, or terrene water-spout. These terrible meteors sometimes continue in one spot, expan- ded in an oblong form, where they touch the earth, thence assu- ming that of a perfect cylinder, they reach high into the air, and darken it with clouds of sand whirled about in every direction. At the point where they touch the desert, so extensive and pro- found is the excavation they leave, that it*might be taken for the bed of a huge lake. At other times becoming moveable, and in all other respects maintaining their ordinary character, they fly through the desert, tearing it up in their course to an extent in proportion to their width at the base, and leaving behind them what resembles the bed of a torrent. Segato fell in with the track of one of these progressive whirl- winds, and unintimidated by the proximity of so dangerous a neighbour, continued to follow the deep ravine it scooped out, and to examine the wrecks it made or disinterred. Some frag- ments of a carbonized substance, presented themselves to the scru- tinizing eye of the philosopher. Subjected to more minute ex- amination, he recognized animal remains, and especially those of the human species. He at last found an entire body, the flesh and bones completely carbonized, the one black as charcoal, the other of a sooty hue, and both friable. He plainly perceived in this corpse the human figure, though shrunk to a third of its na- tural dimensions. That which to another, would have been merely an object of barren wonder, became to Segato the first hint of his discovery. He brooded upon it for years ; he ex- hausted all his science upon various experiments ; often disap- pointed, but never disheartened, he continued to interrogate na- ture, until wearied as it would seem by his importunity, he has at length extorted from her one of her mysteries. In the course of his persevering researches, he effected with great labour, an entrance into the pyramid of Abu-Sir. Remaining there six day?, he contracted from the foul air of the catacombs, a tedious and painful malady, which was pronounced incurable, and the unfortunate Segato returned to his country, merely, as it was 12 90 Signer Segaio's Discover;/. [July- believed, to die. After arriving at Leghorn, however, 1 he- strength of his constitution triumphed over the disease. He- resumed his experiments with fresh ardor. The first public notice given of his success, was a very modest one, by the author himself, in the Antologia, Vol. 44, No. 132, December, 1831, p. 74. At that time, he had not acquired the means of petrifying animal substances so perfectly as at present ; and in employing" the terms petrify and petrifa* tion, he warns his readers that he uses them in a new literary sense, to signify an induration, resem* bling and approaching that of stone, not a petrifaction in the sci- entific sense of the world. The process of Segato acts upon entire animals as well as upon their separate parts. It endues them with a consistence- perfectly stony, which is more or less hard in proportion as the parts themselves are originally less soft and mucous. Skin* muscles, nerves, veins, tendons, fat, blood, all undergo this wonderful change, and what is most singular, is, that it is not requisite to extract the viscera or intestines for the purpose of effecting it : they themselves assume a like solidity with the rest of the body, and some of them even greater. Nor is there any material change of form, colour, or general appearance and character, all of which are retained. Not the least disagreeable smell is emitted from his preparations ; they are entirely inodor- ous. Such is the power of the agents he employs, that putre- faction already begun, is arrested at the very stage at which it had arrived when his process commenced. He has even found the means of rendering animal substances inalterable without destroying their flexibility. The joints and articulations may be bent, and when the force applied is removed they resume their former position. His skeletons remain united of themselves* by their natural ligaments, retaining their pliability, thus render- ing useless all the clumsy contrivances heretofore necessary for combining the bones together. So unalterable are the sub- stances thus preserved, that they are not only unaffected by atmospheric change, but even by a daily exposure to Water, aid the action of worms. Their volume is but slightly decreased, and their weight continues nearly the same. Even the spots upun the skin remain visible, whether natural or produced by disease. The hair adheres firmly ; not one drops from the human scalp, where they continue fixed as freshly and firmly f$3f>.j Signer Segau/s Discovery. 91 as in life. Birds do not lose a feather, nor fish a fin or scale- both preserve their hue. Insects retain every extremity, antenna?, and cartilage, however minute. Reptiles, besides their perfect preservation, wear so strong an appearance of life, that it is -difficult to believe them dead. With many of these animals even the eye still glistens, and from their immobility only is their death to be discerned. Many entire specimens, either petrified, or rendered inalterable, with a consistence less rigid, are to be found in Segato's cabinet. A few shall be enumerated which I have myself seen and handled. A mouse, with the entrails pro- truded, looking as fresh as if it were but that moment prepared. A canary bird, one of Segato's earliest specimens, yet retaining its life-like appearance. For ten years it has been annually exposed to the attacks of water and worms, without the least injury. During the first year thirty, in the next more than forty days, it was immersed in water to test its incorruptibility. For a longer time it was shut up in a box with worms, but came out unhurt. Various other specimens have been subjected to the same test with uniform success. A parrot, in excellent -preservation. The frog in every state, from the egg to the perfect animal, and thence through different stages of decompo- sition to the skeleton. The land tortoise (Tertudo Greca, Linn.) in every stage. Numerous spiders apparently retaining the agility of life. A water viper, (Coluber natrix, Linn.) a toad, (Bufo Viridis, Linn.) and a cameleon, (Lacerta Viridis, Linn.) all admirable. In ichthyology there were many fine specimens. 1 will enumerate only, Tench, Flounders, the scorpoena scropha, Jabrus julus, and Lophius piscatorius of Linnaeus, and the tor- pedo narke of Riss. The anatomical preparations of various parts of the human body are exceedingly curious, arms, legs, feet, hands, &c. The hand of a female, who died of consumption, in a state of extreme emaciation. That of a man, flexible in all the joints. A foot ac- tually marble, yet bearing every mark of the skin, even the fine circular lines of the heel. On both hands and feet the nails adhere perfectly. The intestines of a child of the natural colour and form, from which even the fasces had not been extracted. The liver of a confirmed drunkard, who died from intemperance, browrn and shining like ebony. The entire human brain pre- senting all its convolutions, but of extreme hardness. A female 92 Signer Segato's Discovery. [July bosom, white and full, of the natural appearance, even to the fine down of the skin, the roundness of the breasts, and the areola of the nipple. A scalp, or hinder part of the head with long fair hair, as bright and beautiful as in life. The head of an infant subjected to the process, after putrefaction had turned it black, and destroyed the eyes, yet by the power of the agent employed, saved from farther change. The flesh and skin have become hard, the cheeks continue full, the cars, nose, and even the fine hair of the head are perfectly preserved, and the brain also, be- ing equally indurated. Segato has constructed a tablet, composed of different pieces of the human body, indurated and inlaid in a tessellated form, after the manner of those productions of art which are known in Florence, by the name of works in Pictre Dure. It consists of 214 p eces of various shapes and colours, differently veined, and of such hardness that all admit of polish, none are scratched by the nail, few by the knife, and some scarcely by the file. The Jasper of Siberia is imitated by portions of the spleen, kidneys and heart. The Jasper of Sicily, Saxony, and Bohemia, by the pancreas, the uterus, the placenta, and the upper part of the toague. Almost every variety of siliceous and calcareous stone which has been applied to the purposes of use or ornament, except only the gems, finds in one portion or other of the human body, when thus indurated, either in its healthy or some disor- dered state, a singular and striking resemblance. So perfectly natural is the colour and appearance of the specimens of morbid anatomy thus preserved, that a most distinguished surgeon of our country,* who recently visited Segato's cabinet, on being shewn this tablet, named immediately various parts of the body, and the particular disease with which they had been affected, It was impossible, he said, to avoid recognizing them; they were exactly such as he had repeatedly seen in dissections. Warm and honorable testimony to the importance and utility of Segato's discovery, has been borne by several of his learned countrymen. His name has already acquired some celebrity in Europe, from his admirable maps of Africa, Mo^ rocco and Tuscany, prepared and engraved by himself, for among his other talents, he is an excellent chorographcr and engraver, and from a work on Egypt, part only of which has *Dr. Mott, of New York. ~ - 183C>.] Signor Segatrfs Discovert/. 9kA yet appeared. Several literary and scientific journals have mentioned his labours with the highest commendation. That you may not suppose me misled by ignorance or enthusiasm, I subjoin some extracts from communications on the subject of Segato's discovery, premising only that they are written by some of the most eminent anatomists and surgeons of Italy. In July, 1833, Dr. P. Betti, at that time Professor of human and comparative anatomy, and of practical surgery, in the Im- perial and Royal chief Hospital of Santa Maria nuova in Florence, says, " I have seen and examined, at different periods, various anatomical preparations dissected by the eminent Giromalo Segato, and preserved by him according to a parti- cular method of his own invention, in which the neatness of the preparation and the durability of the subject preserved, were carried to so high an extent, as to leave nothing farther to be desired in either of these particulars, for which reason I believe the method employed by Signor Segato is by far more perfect than any yet known and used." In April, 1835, Dr. Antonio Targioni Toretti, a member of the Medical College of Florence, Professor of practical chemistry in the Royal and Imperial Academy of Arts, and of botany and materia medica in the Imperial and Royal chief Hospital of Santa Maria nuova of Florence, declares, that " having atten- tively examined and observed the different anatomical and anatomico-pathological preparations, made by Signor Giromalo Segato, as well as others in comparative anatomy, and various fish, reptiles, insects, and other animals prepared for collections of natural history, I am enabled to assert : That besides the high degree of anatomical knowledge, and great skill in prepa- ration exhibited by him, he has discovered a method heretofore unknown, and altogether peculiar to himself, by means of which bodies and parts of animals are preserved, maintaining their natural colour, and exhibiting all the peculiar appearances inci- dent to certain pathological conditions. Besides this, they acquire a hardness which may be called stony, since they are not scratched without difficulty, and they resist the action of the air, of humidity and of worms, so that they may be con- sidered absolutely inalterable and incorruptible. Over and above this invaluable property of incorruptibility, is that pos- sessed by his preparations for exhibiting the natural form and $4 Signer Segato's Discovery. L.TuIy, colour, so that the most delicate specimens of anatomy seem freshly made, such is their truth and nature. I therefore be- lieve that the method practised by Signor Segato will be of infinite advantage to science, as well for collections of human, comparative, and pathological anatomy, as for those of natural history and zoology, and therefore worthy of all praise and encouragement." In April, 1835, Dr. P. Ferdinando Zanetti, Professor of Ana- tomy in the Iloyal chief Hospital of Santa Maria nuova of Florence, states, that having already, in June, 1833. given to the distinguished Giromalo Segato an attestation of his excellent mode of preserving organized animal substances, he feels it a duty, at present, in consequence of more recent and. repeated inspections of preparations since made by Signor Segato accor- ding to the same method, to certify the great utility of his dis- covery, as well for the perfect preservation of the form, and the identity of colour and lustre, as for the great solidity imparted, securing to his specimens, with the most entire certainty, an indefinite duration ; and this as well in reference to separate pieces and organs, as to entire animals, whether reptiles, fish, er others of more complicated formation." In May, 1835, Dr. Betti, before mentioned, then become Professor of Physiology, and Superintendent of the Public Hos- pitals of Florence, attests, " that he has examined various spe- cimens of parts of men and animals solidified by Signor Giro- iumIo Segato, to such a degree as to assume a stony hardness, similar to that of the finer marbles, and pietre dure : and more- over, that Segato in his presence tried the experiment of filing with an English file various specimens of marbles and other hard stones, and with the same file his own preparations, the latter not being touched by the file, which had more or less scratched, or taken off, portions of the former. The hardest pieces were muscle coats of the intestines and bladder liver placenta testicles arteries veins and the blood itself.'7 It is well known even to those little versed in such studies, that Nature has at all times exhibited specimens of animal and vegetable petrifactions. Petrified branches and roots of trees and shrubs, and pieces of the trunk half of wood and half of agate or other stone, are not uncommon. Walnuts, pine cones, and even peaches and melons, it is supposed, have been petrj^ 1S38.] Signer Segaio's Discovery. 6!) fied, though the latter are believed by eminent naturalists to be only stones accidentally formed into the resemblance of fruit, as the lapides Judaici of Mount Carmel are not olives, but a species of marine shell fish. It is scarcely requisite to mention the innumerable marine petrifactions, madrepores, corals, nau- tilii, &c. found in almost every part of the world. Germany and Switzerland abound in petrified fish. The Tyrol and cen- tral Italy are rich in fossil remains, some of them extinct species. In Asia, Africa, and Europe, as well as in America, huge bones of various animals have been discovered. In Tuscany, those of the Elephant, Rhinoceros, Mastodon, Tapir, Hippopotamus t and others, have been found. In various caverns of France, England, Germany and Hungary, those of bears, wolves, dogs, foxes, hyenas, tigers and lions. The petrified remains of birds are much more rare, but these too are said to exist. Fossil bones of the human species are the rarest of any, yet the petri- fied skeleton of a savage was found in digging the foundations of the city of Quebec, two human skeletons by Rosenmuller in the grotto of Geiss-knok, and one in the rocks of Guadeloupe verified by Cuvier. Nature, however, does not seem to have any where presented the petrifaction of the entire human body, more especially not of the softer and intestinal parts, nor of the blood. The tales of a petrified man said to have been found at Aix in Provence, in 1583, of those alleged to have been found in Switzerland of the pretended city of Bidollo in Africa, and village of Rassem in Barca, whose inhabitants with their cattle and utensils are said to have been turned into stone, are all certainly fabulous. A very few well attested instances of extraordinary natural preservations of the human body have occurred ; as that of Cristoforo Landino, one of the commentators on Dante, still shewn in Casentino, (Tuscany) turned into a mummy, and un- corrupted after the lapse of nearly five centuries. In the ceme- tery of Venzone in the department of Passeriana, there is found a narrow calcaro-siliceous stratum, in which dead bodies are preserved for ages, but only superficially, for ail the internal parts turn into dust. It is remarkable thnt the bodies interred partly in this peculiar stratum, and partly in that above, or below it, are partially preserved, and partially putrify- 96 Signor Segato's Discovery. [July* There are obvious reasons why the natural petrifaction or flesh should be much rarer than that of bones, in the different properties of the two substances. The latter being calcareous, have a greater analogy with the earths, winch replace them particle by particle as they decay, while the former is so soft, that it does not give time for the stony matter to insinuate itself and form, before putrefaction commences. Art has not heretofore succeeded better than nature. The Egyptian mummies the embalming heretofore practised the method of Ruyschius (unfortunately lost) the mummies made by Chaillot, Capron and Boniface, much talked of in France the preservations effected by Chaussier, 'and reproduced by Dr s. Tranchlna and Giovacchino Komco the sepulchres of Sicily, where bodies divested of the intestines and fluids are kept dry for many years, all attest the wonderful ingenuity of man. None of them however it must be confessed have arrived at that degree of perfection evidenced in the discovery of Segato. From an article obligingly communicated by the distinguished Dr. Passed it appears, that being made acquainted with the Creosoto*' discovered by Reichembach, and reflecting on its chemical properties, it occurred to him, that it might be employ- ed to render animal substances solid and inalterable. He men- tioned this idea to several, and his wish to try the experiment. Nor does his idea seem entirely unfounded, for about fifteen or sixteen mouths since, the eminent chemist Signore Gaetan Caramcsi having prepared an aqueous solution of Creosoto placed in it a human finger and a small bird. Three days afterwards they were exposed to the air to dry. They in fact became hard, but as to their incorruptibility, though it might in some degree be inferred from their solidity, it would not be proper to affirm it, as they have not been exposed to the test of humidity or worms, nor as yet, of sufficient time. Besides, they had contracted a dusky colour by reason of the action of the creosote, which becomes dark when exposed to the light. These specimens are now in the hands of Scgato. The ingenious Signore Carraresi imagined and tried another experiment, He deprived some small pieces of animals of *The Creosoto is a volatile oil contained in the Norwegian pitch, and is produced along with smoke whenever vegetables are burned, li was dis- covered not long- since by Reichenbach, and its most remarkable property is that of preserving animal substances. W. 1836.] Skgnor Segato's Discover]/. 97 their aqueous particles, by means of pure alcohol saturated with boracic acid, and that being effected, for the purpose of solidifying the albumine, so that it might be secure from putre- faction, he immersed it in the same alcohol, in a boiling state. Subsequently exposed to the air, and dried, they became solid, so as to be susceptible of some degree of polish. It must be admit- ted, however, that these preparations are very far from the per- fection of Segato's, as well with respect to colour as solidity. Besides which, his having for ten years resisted the attacks of moisture and worms, precludes all possibility of comparison between them and pieces recently prepared. I have not seen the specimens of indurated heart and blood, mentioned in an anonymous article inserted in several Italian Journals, said to have been prepared by Dr. Mori, of Piza, and of course have nothing to remark upon them. I suspect, however, that the observations of Dr. Passeri upon the experiments of Carraresi, will be found equally applicable to those of Tranchini and Mori also. Florence, 10th January, 1836. [It is now our painful duty to announce, on the authority of .letters of a later date, from Mr. Wilde to his brother, the Hon. John W. Wilde, the death of Signor Giromalo Segato. This is an event greatly to be deplored. There was a lively hope that Mr. Wilde would be enabled to induce him to come to the United States ; where his genius, scientific attainments, and un- tiring perseverance might have spread an influence around, the value of which to this.country no one could estimate. With re- gard to the process by which he effected those wonderful preser- vations above described, it is greatly to be feared the world will never be informed; for, at the date of the last communication Jrom Mr. Wilde, no account of it had been found. Ed.] 1Z i)S C nimilkier s Pathological .Anatomy, f the bones, of the brain, of the stomach, and of the heart. M. Cruveilhier having assigned no limits to his work, will, we trust, continue with his accustomed judgment and zeal, thus to treasure up the interesting cases which are continually pre- sented to him at the Salpetriere, and at the Societe Anatomique. The second edition of Alibert's large treatise on cutaneous diseases, is at last completed. The. fasciculus just leceivcd fully sustains the great superiority which has been claimed for this over the former edition. The plates are incomparably more perfect, many of the specimens better selected, and their number greater than in the old work. It is much to be regret- ted that such a work cannot be in the hands of all practitioners. There is perhaps no class of diseases less generally understood than that of which Alibert so ably treats. The reason is that they are difficult to describe, and require to be seen to be un- derstood. Alibert, in reprinting and improving his plates, has therefore rendered a signal service to the profession, by placing before the reader correct representations of every variety he describes. JS3(>.] C ruveff /tiers Pathological Anatomy ', <$-c. i) An >incr work received is Bourgery's Anatomy, with plates. It is the most extensive publication ever undertaken on any branch of medicine, and has, we believe, never been surpassed in magnificence and correctness. We hope that, notwithstand- ing the heavy cost of the entire work, the mode adopted for its publication will enable many to subscribe to it without serious inconvenience. The following is an extract from the prospectus handed us by Dr. L. A. Dugas, of this place, who is authorized to receive subscriptions. This great system of anatomy, then, will be comprised in eight volumes. folio, and be embellished with from four hundred and fifty to five hundred lithographic plates. It will consist of four parts : Descriptive anatomy ; Surgical anatomy.; General anatomy ; and Philosophic anatomy. The descriptive anatomy will be presented with all its details, and with its physiological and pathological applications. This division will consist of five volumes r the first containing osteology and syndesmology ; the -second, myology, the aponeuroses, and the synovial bursas ; the third, the nervous system, the organs of sense, and the larynx ; the fourth, the apparatuses of circulation and of respiration ; the fifth, the digestive and generative organs, and the anatomy of the foetus, or embryotomy. The surgical anatomy will be composed of three sections, comprised in the ixth and seventh volumes. The first section, or anatomy of inter-or- ganic isolation, will show the organs apart from the ensemble, and some of their diseases circumscribed mechanically and fixed in the interior of the aponeurotic cells and bony confines of" the viceral cavities. The second lection, or anatomy of inter-organic communication, on the other hand, will exhibit the means of connexion between the organs, the pathological effect of which is to facilitate the development and extension of disease. The third section will present the anatomy of every important region of the body in reference to the various operations of surgery, the whole of which, and the different instruments, employed, will for the first time be system- atically represented in the plates, and described in the text. Statistical corollaries, deduced from results obtamed in an immense number of opera- tions performed in different countries, under the most varied circumstances it various epochs, will show the relative value of each plan of operation pi; j-osed. The general anatomy will present the study of every tissue under two points of view, which form the connexion between histology, properly so !, and pathology: 1st, as a whole, as one of the separate systems of thy economy; second, as a part, in reference to the various places in which it 'is found, and as an integral item in the constitution of any particular organ jdi- srstL-m of organs. The philosophic anatomy will contain three sections : first, the laws of the formation of the organism or economy, depending on which are the theories of the vertebra and of monstrosity ; second, the influence of physical and moral causes on the economy; third, the comparison of the economy of man with that of Tic vertebrate animals; subjects extremely interesting not only to the MEDICAL MAN, but to the MORALIST, the PHILOSOPHER, the LEGISLATOR, and the political economist. The general and philosophic anatomy, together, will form the eighth and last volume of the work. The translation into English, now offered to the public, has been called for by a number of subscribers to the work both in Great Britain and Amer- ica. Undertaken by a gentleman familiar with the subject, and from a copy with the latest corrections of the author, it is presumed that it will be found in nowise inferior to the French edition. The plates for both the 'English and French editions are the same. 100 Tartar Emetic in Obstetric Practice. [July, The complete work, as has been sai, will consist of eight volumes, folio, and will appear in about fifty monthly parts, eacli containing from three t<* four sheets of test, and eight lithographic plates,, with their explanations. PRICE OF EACH NUMBER. IN FRENCH. The Plates uncoloured, on fine Vellum Paper,. - 8 francs, do. do on China Paper, - - - 12 The Plates on fine Vellum Paper, coloured with the greatest care, 16 " IN ENGLISH. The Plates uncoloured, on fine Vellum Paper, - - - 10 shilling^ do. do. on China Paper, - , - - - 14 " The Plates on fine Vellum Paper, coloured with the great- ) ,g est care, \ N. B. The publication has reached the middle of the third volume,. [From the Medical Journal of Medical Science.] Observations on the use of Tartar Emetic in Obstetric Practice. By Evory Kennedy, M. D. Master of the Lying-in Hospital, Dublin. [CONTINUED FROM JUNE NO.] Obstructed and Inflamed Mammae-. There .are two distinct states of the mammae, occurring after delivery, which demand our notice. lit both, pain and tenderness, tumefaction and hardness, are present ; but one is an inflammation, the other merely an obstructed state of the organ j though the latter generally precedes, and may produce the former, yet it does not necessarily go in all cases. There is no case within the range of obstetric practice so clearly under the control of the medical attendant, as the tumified, lobulated and obstructed state of the mamma?, and none so sure to terminate unfavourably, if improperly managed. To treat it with effect, it is necessary to look to its cause. The immediate state is a vascular determination to the glandules, together witli an accu- mulation of the lacteal secretion within the ducts and tubes, and often in- filtration into the connecting cellular tissue ; a state most frequently arising from a disproportionate action between the secretories and excretories. We can easily understand the frequency of the occurrence of this state of the br fasts, when we consider how suddenly in most cases determination occurs to them after delivery. Let us, then, bear in mind the function the glandular part of the organ is so suddenly called upon to assume, and this, perhaps, for the first time : thus rapidly converting the freely determined blood into a nutritive fluid. Let us also call to mind the obstacles afforded to the escape and extraction of the milk in impervious, ill-formed, or dis- eased nipples, as well as the difficulty that opposes itself tp the transmission of milk through ducts, perhaps for the first time ; or after a long suspension of their action, called upon to perform the office of conduits ior thSe new 183&] Tartar Emetic in Obstetric FrachcK 101 and rapidly formed secretion. These considerations tend to explain a fact observed in practice, that, with first children, or after long- intervals from child-bearing-, more trouble is experienced with the breasts, on delivery. When, in addition to what has preceded, we recollect the varying calibre of the conduits, their ramifications, and the accidental obstacles occurring in them, the effect either of present or previous disease, narrowing them, or perhaps rendering them altogether impervious, and amongst the most com- mon of these, determination to certain parts of the orga^i, from exposure to cold, we need not wonder at trouble being so frequently caused by the breasts, after delivery, but rather feel astonished that milk abscess is so rare an occurrence. The rationale of the plan of treatment necessary to adopt will appear from what has preceded, to be, simply, checking or pre- venting too rapid a determination to the breasts, and relieving the ducts and tubes by facilitating the transit and escape of the milk when secreted. In effecting the first object, free saline purgation is necessary in the com- mencement, after which nauseating doses of tartar emetic appear to act almost as a specific in preventing inordinate determination. They also, no doubt, act m producing absorption. Tartar emetic, however, appears to eft*'ct the second object as well as the first, by its well-known power of relaxing contractile tissues, thus rendering pervious the lactiferous ducts and tubes, and accomplishing the double object specified. It is not to be understood that tartar emetic has been had recourse to in all cases where the breasts were hard and full after delivery, nor even that this medicine would prove sufficient of itself to correct their obstructed state. The general plan wis to administer saline aperients, rub the breasts mosl assiduously, stupe them, extract the milk from them, if necessary, and im- prove the state of the nipples, if they were diseased or indented. In the freat proportion of cases, this is quite sufficient to produce softening of the reasts with free discharge of the milk. It is only when this plan don't succeed, or that symptoms are urgent, that it is deemed necessary to nauseate the patient. The result of this practice is, that in the Lying-in Hospital, where it is strictly enforced, a case of abscess in the breast is scarcely ever met with. It is but right to state, that in private I have not found the practice succeed so well; a circumstance ascribable simply to the impossibility of having the necessary directions strictly and effectually complied with. Ladies get fatigued with continued friction, and they do not like the nauseating medicine. Where it has been fairly tried, however, its results have been the same as in Hospital. Friction, to be attended with benefit, must scarcely for an hour be desisted from, until the hardness disappears and the ducts accommodate themselves to the secretions. The usual orders to our nurses are, " to rub until the breast softens under the hand." Warm oil is used to prevent irritation to the integument from the friction. In inflammation attacking the breasts after delivery, either the glandular or tubal structure, the investing sheath, or the connecting or sur- rounding cellular tissue may be engaged in the inflammatory action from the commencement, or the inflammation may occur consecutive upon the state of the breast already described. In either case, throbbing pain, general redness of the surface, with extreme tenderness to the touch, and hardness at one part, will be present ; and these symptoms may be ushered in with a rigor, or rigors may occur in their progress. When this attack is observed, the patient is to be put immediately and freely under the influ- ence of the tartar emetic. If purgation has not been previously attended to, a grain of tartar emetic, given in a full dose of black bottle, is a good commencement. This should be speedily followed by the nauseating mix- ture, and if vomiting should be twice or thrice freely produced at the outset, all the better, provided our patient can bear it. Warm stuping and fomen- tations must be used, and the breasts drawn by a strong healthy child, or by the exhausted bottle, and friction, if unattended with much pain, is to be persisted in.. Leeches, under this plan of treatment, are seldom necessary itru:2 ^Tartar Emetic in Ob&telric Practice. [July. arid their efficacy, when used, appears very questionable. By a steady persevererice in this plan, in cases even the most unpromising-, the inflam- mation has been again and again subdued. The child was generally applied to the breast early after delivery, at least as soon as milk could be obtained. Ulcerated and fissured nippies, which did not improve under slight stimulating lotions, as Sir A. Cooper's spirit and borax wash, were touched with a solution of nitrate of silver, ten or twenty grains to the ounce, a plan found particularly serviceable where there were sprouting granulations or excrescences projecting in the fissure, alto acted with excruciating pain. In obstinate cases of this kind, even touching with solid caustic was necessary, and often relieved the patient from immense protracted suffering. Puerperal Mania. This form, which constitutes so great a proportion of the maniacal cases met with not merely in the Hospitals for insane, but in the incurable cells, when treated properly from the commencement of the attack, is a very manageable disease. Were it only for its efficacy in this distressing malady, the accoucheur should esteem tartar emetic as a most invaluable article in his prescription formulary. In several years observance of this medicine's application, in Hospital and private practice, but two or three cases have been met with which held out against it, when commenced sufficiently early. The moment a patient was observed to exhibit any incoherence after delivery, attended, as it usually is, with rapid pulse and wild expression of the eye, she was placed under its nauseating influence, and retained so- for twenty- lour or thirty-six hours, or longer if necessary. In almost every case the disease yielded immediately ; the real ills produced by the medicine taking the place of the imaginary ones previously occupying her attention. The only treatment in general necessary, in addition to this, being the administration of aperients, and ensuring sleep by free opiates, when the patient had been sufficiently sub-, jeefced to the action of the tartar emetic. Diagnosis in puerperal mania requires attention. The case most likely to be mistaken for it, is hysteria ; an affection of no very Uncommon occurrence after delivery. An error in diagnosis, between these diseases, is not, however, attended with any very serious inconvenience in the treatment, as I have found from experience the plan here recommended for puerperal mania proves most effectual in curing hysteria ; although it is perhaps, somewhat more violent than the nature of the case demands. It may be right to mention that two fatal cases of peritonitis occurred in Hospital, which commenced witli all the symptoms of puerperal mania, and Which were treated at first with tartar emetic. In one case, in the course of a few hours from the exhibition of the maniacal, symptoms ; in the other, after a lapse of two days from their commencement, unequivocal -evidences of peritonitis set in, and in both the disease ran rapidly to its fatal termination. A peritonitic tendency was very r revalent at. the time. In puerperal mania peculiar care is necessary to prevent the depressing effects of tartar emetic being produced, and with this view a larger quantity of laudanum may be added to the nauseating mixture. Patients labouring under this disease, are not able to bear the same aetive treatment as some of the other cases alluded to where this in. ine has proved efficacious. The pulse in puerperal mania, whilst it is very rapid, is generally small and hard, often wiry, and here a medicine possessing such depresting propensities, must be used with the greatest ^caution. A case occurred to me in consultation with Dr. Harvey, of this city, some years since, strongly illustrating the necessity of caution in this respect. We had placed our patient under the influence of the medicine, with the usual directions to her friends of administering or withholding it- as might be necessary. These, however, were unattended to, and on our n< risit we found her in a most alarming state. The medicine having reduced her to such a degree of debility as to deprive her of the power c* .1836.] British Association. 103 motion, her pulse was barely perceptible, and the extremities and surface quite cold. Stimulants were freely administered, and friction and warm applications used to the surface and extremities, and she immediately recovered, not merely from the remedy, but from the original disease. In concluding' this paper, it may be mentioned, that it is not swelled out with cases, (an abundance of which could have been furnished;) as it is: neither wished to extend it unnecessarily, nor to put forward trie practice recommended as that tried experimentally in a few eases, but as the ordi- nary plan of practice adopted, as well in private as in an Institution con- taining one hundred and forty beds, and where about two thousand fiv'3 hundred patients are annually admitted. As much of it was adopted by my predecessor in office, Dr. Collins, an opportunity will shortly be afforded of testing its success, and observing the proportion of recoveries in these cases^recorded in that .gentleman's, report of his seven years' mastership., shortly to be published ; and it is confidently anticipated that in this report will be exhibited a degree of success, not merely m the cases treated of, but in midwifery practice generally, never before recorded. I ventured to publish an expression of my opinion of Dr. Collins' talented, accurate, and laborious undertaking two years since, how far correctly, the%*ecent vote of hanks presented by the Anatomical Section of the British Asso him, fbr this very report, has proved. Dublin, 8eplember9 1835. Extracts from that part of the proceedings' of the Medical Section of the British Association in the session of August, 1835, which is detailed in the Medico-Chiriirgical Review for October last. First Day, 10th August. Internal use of Chloride of Sodium in Fever. Dr. B. Graves read an interesting paper on the internal use of chloride of sodium in fever, from which we make the following extract, as embodying the pith of the practical portion of the communication. " With respect (said Dr. G.) to the time for its exhibition, and the cases to which it is adapted, the following remarks may be made. When the early stage of fever is past, when all general and local indications have been fulfilled, when there is no complication with local disease, when the patienf lies sunk and prostrated, when restlessness, low delirium, and more or les.- derangement of sensibility is present, when the body is covered with macula?, and when the secretions from the skin and mucous membranes give evidence of a depraved state of the fluids, it is then that the chloride of sodium may be prescribed with the most decided advantage. The mode in which I prescribe; it is in doses of from fifteen to twenty drops every fourth hour, in an ounce of water or camphor mixture. How it acts I will not attempt to explain ; it is sufficient to say, that there is no remedy from which, in such cases, such unequivocal benefit is derived. It operates energetically, though not veryrapidly, in controlling many of those symptoms vrhich create most alarm. It seems to counteract the tendency to tympan- 104 British Association. L^tyi itip, to correct the fetor of the excretion?, to prevent collapse, to promote a return to a healthy state of the functions of the skin, bowels, and kidneys ; in fact, it appears admirably calculated to meet most of the bad effects of low putrid fever. To these who have witnessed its efficacy, it is unneces- sary for me to say any thing. Of course it will fail, like all other remedies, when the disease has reached a certain point of intensity hi individual cases. There is scarcely any acute disease, to which the human body is liable, which may not in some particular persons assume an intensity capable of baffling ail the efibrts of medical skill. This, however, is no argument against the employment of a remedy of extensive utility and unquestionable value. Although it is not my intention to give an account of what has been don in France with respect to the exhibition of this remedy, yet I may mention that it has been extensively tried in fever by Chomel, and as I have learn- ed with great success. This excellent physician is still, I believe engaged in making further clinical experiments on the subject. In the Gazette Me- dicate de Pari?, published on the 28ii of last February, we have an accoi.it of Dr. Dor, of Marseilles, of several cases of typhus, in which the chloride of sodium was found beneficial in 18-33. He attributes a more rapid amend- ment to the use of tins remedy than I have even seen follow from its exhi- bition, and he also asserts, that if not given with great caution, it produces a very tedious convalescence. In the latter remark, especially, I cannot concur ; for all who witnessed this mode of treatment here, were struck with the security and quickness of recovery which ensued in those cases where it had been employed. Perhaps, the precaution we adopted of al- ways diminishing, as soon as possible, the strength and frequency of the doses, rendered the results in our hands more satisfactory than those ob- tained by Dr. Dor." Dr. Graves concluded his observations by reading a letter from his col- league Dr. William Stokes, in which the use of this remedy is stated to have been followed by the most satisfactory results. It gradually but stea- dily removed all the bad symptoms, and in -ill cases the patients had most favourable convalescences. Dr. Stokes remarks, that all these cases re- covered without any evident crisis. Second day, 11th August. Motion and Sounds of the Heart. The motions and sounds of the heart occupied the whole of this sitting. A committee had been appointed to experiment on this subject, and having made their experiments and drawn up their report, they presented them to the meeting. We cannot notice all, or many of the experiments per- formed by the committee, but only one or two to elucidate the inquiry. Experiments on the motions of the Heart. " Experiment 1. A calf, two days old, having been secured on its back, and prepared as above described, the sternum and a portion of the ribs on both sides were removed, when the following motions were observed. The heart was beating strongly, at the rate of one hundred and forty-four pulsations in the minute, but in a short time fell to eighty. While still enclosed in the pericardium, the heart was observed to have a slight vibra- tory motion on its longitudinal axis, which motion, it may here be remarked, may assist in explaining the phenomenon of frottement in disease. On cutting open the pericardium, and turning it aside, both the auricular ap- pendices were seen to project with a rapid motion upwards, or towards the place of the sternum, and immediately afterwards to recede. When coming forwards, they were swollen and soft to the touch ; when receding they became hard to the touch, were diminished in size, and flattened. Imme- diate! v after the recession of the auric idar appendices, the ventricles with 1836k J British Association. 105 a rapid motion assumed a somewhat globular form in their middle^ part, which projected towards the sternum, and the apex at the same time was pushed considerably in the same direction. During their continuance in this state, the ventricles were hard to the touch, and if grasped by the hand, at the commencement of the movement, they communicated a shock or impulse, and separated the fingers. When the ventricles had remained for a short time in the state just described, they suddenly sank downwards or towards tire- spine, and became elongated, broad and flat, and soft to the touch. This succession of motions having been observed for some time, a small glass tube was introduced through a puncture into the left auricular appen- dix, and the blood was seen to rise in the tube during the recession of the appendix, and to subside during its upward movement. A similar tube was introduced through a puncture in the right ventricle, and a jet of dark- coloured blood was thrown forth during the globular and hardened state of the ventricles, and subsided when these became flattened and soft. A puncture was made in the pulmonary artery, close to the ventricle from which it arises, and through it a stream of blood issued synchronously with the jet from the tube in the right ventricle. A tube having been introduced through a puncture in the left ventricle, -and one of the mesenteric arteries having been exposed and opened, the jet from the ventricles was observed to .recede the jet from the arteries, by an interval easily appreciable. The femoral artery was opened, and a similar observation was made as to the interval between the jet from the left ventricle and the jet from that artery. Previously to opening the chest, the committee had satisfied them- selves, that the beat of the hearty felt through the sternum and cartilages of the ribs, preceded the pulse, felt in arteries at different distances from the heart by intervals of time which were proportioned to those distances : and they were also satisfied, that the jets of blood from the mesenteric and femoral arteries were synchronous with the pulses felt in those arteries. Experiment 2. In a calf, prepared as the former had been, and placed on its right side, a portion of the ribs on the left side was removed, the sternum and part of the cartilages on that side being left in their natural position, and the pericardium was opened. It was now seen that when the ventricles assumed their hardened state, their apex, and a considerable portion of their anterior surface were closely applied to the sternum, and wiien the hand was interposed between the latter and the surface of the ventricles, a strong compression was exercised on the fingers, during each approach of the ventricles to the front of the chest. When the ventricles were in their softened state, their interior surface, by which is meant the one corresponding to that called anterior in the human heart, was some- times in contact with the sternum, and sometimes removed to a little dis- tance from it, and from the contemplation of this, and the preceding experi- ment, the committee were satisfied that the situation of the heart in the thorax is affected by the position of the body, as has been observed by others ; for instance, that in the recumbent state, on the back, the heart recedes somewhat from the sternum : if the individual lie upon the face, the anterior surface of the ventricles is in constant apposition with the front of the chest, the pericardium of course being interposed. The yielding- texture of the lungs, and the mode of attachment of the pericardium and the great vessels, are such, as to allow the gravitation of the heart to influence its position in different postures of the body. These experiments were repeated on different subjects, and the observations recorded above were confirmed." For the experiments on the sounds of the heart, we must refer to the Dublin Journal, contenting ourselves with the conclusions to wliich the com- mittee came from the said experiments. "From the experiments on the sounds of the heart, it appears to follow : 1 . That the sounds are not produced bv the contact of the ventricles with 14 0t> British Association. \S\3bf9 the sternum or ribs, but are caused by motions witliin the heart and its ves- sels. 2. That the sternum and front of the thorax, by their contact with the ventricles, increase the audibleness of the sounds. 3* That the first sound is connected with the ventricular systole, and coincides with it in du- ration. 4. That the cause of the first sound is one which begins and ends; with the ventricular systole, and is in constant operation during the contin- uance of that systole. 5. That it does not depend on the closing of the auriculo-ventricular valves at the commencement of the systole, because such movement of the valves takes place only at the commencement of the systole, and is of much shorter duration than the systole. 6. That it is not produced by the friction of the internal surfaces of the ventricles against each other, as such friction cannot exist until the blood has been expelled from the ventricles, whereas the first sound commences with the beginning of the ventricular systole. 7. That it is produced either by the rapid pas- sage of the blood over the irregular internal surfaces of the ventricles on its way towards the mouths of the arteries, or by the bruit musculairc of the ventricles, or probably by both these causes. 8. That the second sound coincides with the termination of the ventricular systole, and requires for its production the integrity of the semilunar valves of the aorta and pulmonary artery, and seems to be caused by the sudden check given by the action of these valves to the motion of the columns of blood driven towards the heart after each ventricular systole by the elasticity of the arterial trunks. The Committee wish, in concluding this report, to express their opinion, that although much light has been thrown on the subject of the Motions and Sounds of the Heart, by recent investigations, here and elsewhere, the na- ture of the enquiry is such as renders it difficult in many instances to arrive at satisfactory conclusions. They also think that the subject, from its im- portance, whether in a practical view, or as an object of philosophical in- quiry, is deserving of further investigation." As might be expected, a long discussion ensued, in which Dr. \ v illiamsr of London, and Dr. Corrigan, of Dublin, were the most prominent orators. Dr. Corrigan candidly confessed that he was wrong in some of his first con- clusions, and was convinced that his character would not suffer by this avowal. We are sure it will not ; but, on the contrary, be raised by such honorable and honest procedure. The thanks of the meeting were voted unanimously to Dr. Williams. Third Day. Action of the Heart and Pulse. Dr. M'Dormell, of Belfast, read a paper this day on the action of the heart and pulse. Our author has some claim to antiquity, as well as to "priority,''' mi such observations, having commenced as early as 1764," that is, rather more than half a century back. " He finds that in lying, sitting, or standing, there are three distinct num- bers in the pulse, any one of which being given, the rest may be discovered by inference. This variation amounts generally to twelve, fourteen, or six- teen beats per minute, as its normal state, and therefore, that all observa- tions of the number of the pulse, which have been made without reference to +his principle, must be considered as nugatory, unless it be implied that the person was in the horizontal 'position when the observation was made. This rule for reducing the number of the pulse to a regular standard, applies to health, but not precisely to disease ; the effects of posture must be inves- tigated separately in each disease. The differential pulse appears to be confined to man. It is not observed in brutes, probably because from their form, their posture may be considered as always horizontal ; but when placed erect, this peculiarity appears also in them. The variation, in the human species, is at its maximum in tall and feeble subjects, particularly in convalescents from typhus ; the minimum is gene- 1836.] British Association. 105? Tally found in children. These facts lead to the supposition, that this phe- nomenon is connected with some hydrostatic law, and not depending entirely on vitality. This, however, is merely thrown out as a conjecture, and re- quires further investigation. But in whatever manner it may be consid- erc d, it is plain that in all attempts to ascertain the effects of remedies, as wr H as of natural causes, due allowTance must be made for these fixed dif- ferences produced by posture. What avails it to say that a medicine, or venesection, or heat, or cold, or a thousand other natural causes, raise or depress the pulse by four, six, or eight beats per minute, when the mere -change of posture would raise or depress it twelve, fourteen, or sixteen per minute, and this merely in health, for in disease the differential pulse is often double this proportion. In tracing the connexion between the pulse and respiration in man and quadrupeds, he finds that it ranges in health from four to six pulses for one respiration. This he considers a new and material fact ; for if it be esta- blished by further observation, that this is a general law, we shall be able to infer the pulse from the respiration, and vice versa. This may be of advantage in enabling us to ascertain the number of the pulse in ferocious animals which we dare not touch, as well as in man during action or pro- gression. There is a coincidence between the number of pulses and steps in walk- ing, at the common rate of progression in man, that is very remarkable and iias not been hitherto noticed. His breathings are also singularly propor- tioned to his steps, so that it is easy to deduce these numbers from each other. But in hard labour or violent muscular exertion, as in running or ascending heights, the proportions are greatly altered. The same thing occurs in many forms of disease. There is reason to believe that the car- Jx iization of the respired air has a great influence in all those cases where the number of respirations is greatly disturbed. Dr. M'Donnell finds that the number of respirations, and by inference the number of pulses, are much the same in passing over the same space, whether we run or walk, i. e. they depend as much upon the space tra- veled as on the time. Thus he "finds, if he walks one thousand yards in ton minutes or in eight, or runs over it in five minutes, the number of breathings are nearly the same. It is to be observed, however, that this rule does not apply to small portions of space, such as fifty or one hundred yards. These facts, he thinks, are all complicated with carbonization and muscular motion, so as to require separate investigations. In quadrupeds, especially when trotting or cantering, he has found that the steps, divided by the respirations, never give any fraction in the quo- Ti"V, i.e. thai these are universally proportional without any deviation. In man this does not occur, a circumstance which may arise from some peculiar anatomical or physical law in the connexion between the respira- tory and muscular construction of these animals." " While engaged hi these enquiries, about thirty years since, he had found that the pulse in the arteries of the foetus, before it breathed, was sloteer than in those of the mother. He had found also, that if the child, when born, remained for some time without breathing, the pulse continued slow during that interval, and became accelerated only at the instant it took its first breath. This fact appearing to him new, he had investigated the circumstance in the cow, and finding the phenomena similar, he had commu- nicated his observations to Dr. Clarke, Dr. Labatt, Dr. Stokes, and Dr. Douglas in Dublin, none of whom had ever noticed it in any other. Dr. Jeffrey mentioned it in his lectures, and in his * Observation on the Heart and on the Peculiarities of the Foetus,' and thought it might hold true of quadrupeds, and of all warm-blooded animals. He thought it probable that the foetus before respiration was in the condition of a cold-blooded animal, and partook of that slowness of the pulse which characterizes the tribe." 108 British Association. ^J uly , Dr. Collins observed that, from the experiments he had made on the subject, he had come to a very different conclusion. "He had invariably found the circulation of the foetus much quicker than that of the mother." In this observation we concur. Why should the circulation be quicker in children than in adults, if it were slower in the icstus than in the child. Perhaps the respiration may account for this dhTerence. Fourth Day. Bruit de Soirfflet, (Blowing Noise.) " The sound to which bruit de soufflet has been given, is produced in va- rious parts of the circulating apparatus. Its existence has been ascertained within a comparatively short period, and is due to the inquiring spirit of modern investigation. Few things are more interesting, as objects of pa- thological curiosity, than the production of sounds in the vessels of the hu- man body under certain circumstances. The nature of these sounds has been examined with all the attention which the subject deserves, and not. only has their existence been determined, but it lias been iound that they constitute some of the most important signs of disease. It is interesting to inquire, on what peculiar mechanism bruit de souffle! depends, as unless we are properly acquainted with the manner in which it is produced, we never can apportion to it its due importance, or estimate its proper value as an indication of morbid change. The first part of this communication I shall not read ; it consists of an analysis of the various opinions of others, as to the mode in which this sound is formed. I shall merely s^ate, that Laennec supposed it to arise from spasm ; and to Dr. Williams, who has followed him in the same path of inquiry, we owe the suggestion that it might be found to arise from the operation of physical ca uses. Dismissing the examination of these and various other opinions, I shall proceed at once to the statement of my own views on the production of t iiis sound, remarking in limine, that it is heard under a great variety of circumstances. We hear it in narrowing and in dilatations of the aorta, in narrowing of the ventricular opening from disease of the valves, and in per- manent patency of the aorta, in varicose aneurisms, in aneurismal varix, in the vessels of the uterus during pregnancy, and even in vessels without any appreciable disease. For the production of bruit de soufflet the simul- taneous presence of the two following conditions are necessary: first, an irregular current-like motion of the blood, (instead of its natural equable movement,) tending to produce corresponding vibrations on the sides of the art Ties or cavities through which it passes; and secondly, the state of the art- ri^s or cavities themselves, by which, instead of being kept in a state of tense approximation on their contained inelastic blood (and which would necessarily prevent any vibration in their sides), they become free to vibrate from the play of the currents within on their parietes, and by these vibra- tions give to the sense of touch 'fremissement,' (trembling) and to the sence of hearing 'bruit do soufflet.' If you press on the femoral artery below Poupart's ligament, so as to di- minish the calibre of the vessel, you necessarily diminish the supply of blood to 'he artery below the point of pressure, while the outlet through its branches continues as before. You do not interfere with the action of the hi rt above or the artery below, you merely diminish the area of the vessel at ho part where pressure is applied. Now if a linger be placed en the artery, a short distance below the point of pressure, a fremissement is Pelt, and if the stethoscope be applied over the same spot, bruit de soufflet is heard. This BOi rid is present in a very roinarkabc degree in nar- ro.vmg of 1 he auriculo-ventricular openings of the heart, In this disease the free edge of the valves is most commonly the seat of morbid action, it be- comes thickened and drawn in, and thus narrows the opening. Now the ventricle after each contraction leav< s :{s Bides in a flaccid state, favourable for being acted on by the next gush of blood from the auricle into the ven- 1836.] British Association. 109 tricie. The consequence of this is, that the fluid, passing through the nar- rowed auricuio-venincular opening, is, in obedience to a well-known law in hydraulics, thrown into diverging currents, and if the hand be applied to the chest, a frennssement may be felt, and a loud bruit de soulhet heard. Having mentioned the occurrence of bruit de soufflet in the narrowed state of an artery, as also in narrowmg of the auriculo- ventricular ope sni 1 shall contrast with those a peculiar condition of the aorta, viz. permanent Dcy of its mouth, in which the sound is heard without any narrowing whatever. [Dr. Corngan here exhibited drawings of the disease in ques- tion.] In some of these cases, the semilunar valves nave perforations or holes in them; in others they are thickened and bound back to the sides of the aorta ; in others they are ruptured. In some instances, however, the valves remain healthy, the mouth of the artery becoming dilated, so that they cannot close across its mouth ; and in these instances, how is this sound produced ? It arises from the artery not admitting, hi these condi- tions^ of being kept in a sufficiently tense state, so that at the next rush of blood the blood sent in does not move equally, and this current-like motion of the blood playing on its sides produces in them corresponding vibrations, and the sound is heard. I have noticed all these cases to show under how many various and see- mingly contradictory circumstances it may occur. During pregnancy it may be distinctly heard in the vessels of the uterus after the fourth or fifth month. If we examine the state of these vessels, we shall find that the con- ditions necessary for the productions ot bruit de soufflet are present. Their free anastomosis with veins and sinuses permits them to become partially flaccid in the intervals of the heart's contraction, their sides are thin, and the rush of blood into these comparatively flaccid tubes at the next contraction of the ventricle, gives rise to the current-like motion en which the sound de- pends. The existence of similar conditions will explain its occurrence in varicose aneurisms and aneurismal varix. Having alluded to these cases in which it is heard in certain diseased conditions of the heart and arteries, I may notice those cases in which its occurrence is unconnected with vascular disease. If a patient be blooded too much, or if an animal be dying from the effects of haemorrhage, this sound is heard in the heart and great vessels. Here, in consequence of the quantity of blood which has been abstracted, the equilibrium of the circula- tion is destroyed, and the arteries not having a sufficient quantity to keep them in a tense state, bruit de soufflet is the consequence. We also meet with it occasionally in the healthy state of the heart, hi nervous and irritable individuals. In this case the equilibrium ot the circulation is destroyed by various causes of excitement, and the calibre of the vessels becomes dis- proportioned to the quantity of contained blood, so as to give rise to a cer- tain degree of flaccidity of their walls. It is a well known observation, that this sound is never heard in plethora or inflammatory fever, for in these con- ditions of the system, there is not room for the vibrations of the arterial tunics. Dr. Corrigan concluded, by detailing an expriment in proof of the fore- going theory. A small bladder in one instance, and a length of gum-elastic tube or gut in another, were interposed between two cocks, the upper connected with a water cistern ; the cock at the other or lower end being the discharging orifice of the bladder or gut. On allowing the water to flow through, the sound of bruit de soufflet and the sensation of fremissement were percepti- ble in the intervening bladder or tube until (from the upper pipe pouring in fluid faster than the lower discharged it) the bladder or gut became tense, and then both sensations ceased, the discharge of fluid from the lower pipe continuing all the time. This experiment was applied to explain the occa- sional presence or absence of bruit de soufflet in aneurisms , the sound be- ing present in an aneurism, if the parietes can from any circumstance be- 110 British Association. [July, come at all flaccid in the interval of the heart's contraction, and being ab- sent where the parietes are distended and tense." The than!:? of the meeting were voted to Dr. Ccrrigan by Mr. Cramptcn. Dr. Harty had observed bruit de soufflet in all the arteries where a polypus of the left ventricle of the heart existed. Dr. Williams observed that his views had not been stated quite correctly by Dr. Corrigan. He had attribu- ted the bruit de souiliet to narrowing or obstruction of the vessels; but he did not deny that circumstances might modify the course of the blood, and have a share in producing it. Hr- thought Dr. Corrigan's explanation would not apply to ossified aorta, in which the bruit is sometimes heard. But Dr. C. was able to defend his doctrine against all objections. " In reply to Dr. Williams' observations he would say, that he was aware of the esistence of the bruit in ossification of the aorta. In such cases, when the first current has been thrown back, the next impinges on a portion of the tube most likely to be thrown into sonorous vibrations. This circumstance had been already noticed by Dr. Wm. Stokes, and he had remarked that where this intense musical sound occurs, you may guess fairly that the dis- ease is ossification of the aorta." A paper was then read by Dr. Perry, of Glascow, on typhus ; but no par- ticulars are published. An ingenious curved drill catheter was shewn by Mr. L'Estrange when the meeting was adjourned. 1836.] Pathological Anatomy of Phthisis. Ill Part III. MONTHLY PERISCOPE- Pathological Anatomy of Phthisis. The plan of medical improvement which now occupies the profession, of investigating with the knife in the most careful and patient manner the seat of disease, preserving the morbid specimens, and illustrating the views obtained, by paintings and coloured engravings, is worthy of all attention. It cannot fail to afford important aid to diagnosis, and consequently to therapeutics and prognosis. Whilst, therefore, we should be careful lest, by our observations on the mortal effects of disease, we be drawn into improper theorizings ; and whilst we are particularly cautious that we be not led to look to those effects of disease as the only cause ; we cannot, on the other hand, fail to derive great benefits in practice by as full a knowledge as may be obtained of their pathological truths. Few things, therefore, can be more valuable to us than minute, candid and faithful accounts of these phenomena, as detailed by those of ample talents, and who have no favorite doctrine to sustain ; but only search for the truth as exhibited by nature herself. The excellent opportunities afforded M. Louis, in the Hospi- tal of la Charite, during some years in the prime of life, with the vast store of the most valuable acquirements of which he was previously possessed, to which we may add his present service in the Hospital of la Piete, and an independence of mind and a spirit of honest research after truth, alike creditable to the moral and intellectual man, have enabled him to determine the fallacy of some of the fashionable and exclusive doctrines of his late preceptor, M. Brous-.ais; and to establish many facts of pri- marv importance in the pathology and diagnosis of Phthisis. We shall direct our attention for the present to a few of those results, which we have extracted from the Medico- Chirurgical Review, the truth of which, says the English Reviewer, M. Louis has the merit either of having first an- nounced and proved ; or if they had been discovered before, of having finally and irrevocably established. 1. The existence of tubercles in any organ or tissue of the body, after the age of fifteen, indicates their simultaneous pre- sence in the lungs* 2. Tubercles, when co-existent in the lungs and in other parts of the body, are invariably more advanced in the former ; whereas, in the latter, the developement is usually equal. Whilst the experience of M. Louis in these is confirmed by Dr. S' acker, C. Smith, Bonitus. Morfrasmi and others, it is contrary to M. Lienttoe's 112 Pathological Anatomy of Phthisis. [July, 3. Tubercular deposition almost invariably commences in the upper lobes of the lungs; it is found mure frequently in the left than in the right side, in the proportion, as far as his obser- vation has gone, of five cases of the former to two of the latter. 4. Simple Bronchitis commences at the base of the lungs, pursuing a course inverse to that of phthisis. 5. Chronic Peritonitis generally indicates pulmonary tuber- cles. 0. Large vomicae are generally nearer the posterior than the anterior surface of the lobes of the lungs. 7. Large excavations are almost exclusively formed in the upper lobes ; and it is a very rare occurrence that when a very small vomica is discovered in the lower lobes, when the upper ones are altogether exempt. 8. Although tuberculous deposition more frequently takes place on the left than on the right side, still, in a large majority of cases, both lungs are simultaneously diseased. 9. Of eight cases of vomicae which had opened into the cavity of the pleura, seven were observed on the left side. 10. The great tuberculous excavations of the upper lobe were nearer the posterior than the anterior edge of the longs : nnd in many instances their sides in the former direction wTere found almost wholly formed by a false semi-cartillaginous mem- brane from a line to a line and a half in thickness, enveloping the summit of the organ, lnferiorly they were sometimes only separated from the pleura of the interlobular fissure by a thin layer of pulmonary tissue, more or less modified; or there was a perforation of their parietes communicating with another ex- cavation situated in the posterior part of the inferior lobe. In no instance did M. Louis find extensive excavations in the cen- tre of the lower lobes. " These, and other results of M. Louis' researches," says the reviewer, " speedily attracted the attention of his cotemporaries ; and although they were contradicted and cavilled at on their first announcement, their truth and value have since been very generally admitted, and have tended to establish the reputation of the author as one of the ablest pathologists of modern times." Such are the merits of this acute and independent inves- tigator, and such the power of truth, that, we are informed, "by far the greater number of the advanced students in Paris, (prin- cipals English, American, and German.) have of late deserted the Clinique of M. Broussais, and now follow the visits and lec- tures of his pupil." The extremely accurate and minute observations of M. Louis, on the whole one hundred and twenty-three cases of his inspec- tion, do not confirm the observation of Laennec and others, of the existence of cavities communicating with the bronchia, and lined, as in tuberculous excavations of long standing, with a 1836.] Pathological Anatomy of Phthisis. 113 light grey false membrane, semi-cartilaginous and semi-opaque, surrounded by healthy pulmonary parenchyma ; for he found this in no one case. He also failed to meet with those masses of condensed cellular tissue in which the bronchial ramifications, more or less dilated, terminate ; and which Laennec considers as the. cicatrices of tuberculous cavities. We think it strange, but nevertheless not impossible, that the observations of all may have been correct, and that in Louis' one hundred and twenty-three cases, there may have been none of those cicatrices which were observed by others. But we would suggest a view of this phenomenon, which may perhaps tend to reconcile these apparently opposite observations. We are of the opinion that abscesses do form in the lungs, as simple, and every way of the same character as those which form in the superficial cellular tissue ; that they terminate by suppura- tion, and discharge through the bronchii ; and entirely heal, and the patient recovers from all appearance or evidence of disease. This opinion is founded on actual observation of facts. The fact relative to this matter, then, is probably this, that those masses of condensed cellular tissue, and fibrocartilaginous membrane which were by Laennec and others considered cica- trices, were really those of obliterated or healed, but not of genuine tubercular cavities that they were only the cicatrices of abscesses which had been previously formed in the pulmonay parenchyma, discharged and healed ; after which, and when the strumous character of the case became more completely developed, genuine tubercular cavities were formed. 11. In one hundred and twelve cases, M. Louis found but one case in -which both lungs were free in their whole extent from adhesions between the surfaces of the pleura. In eight cases the right, and in seven the left lung did not adhere at any point of their surfaces. It appears that the pleural adhesions indicated, by their extent, firmness, &c. the number and size of the tuberculous excavations of the lungs. 12. M. Louis observed in one-tenth of his cases, that pleuritic attacks had been made in the last stage of pulmonary Phthisis, as evinced by a layer of soft yellowish coagulable lymph on points of the pleura, indicating its formation within four to eighteen days preceding death. 13. The false membranes, formed by pleural inflammation, were found in a few instances to have acquired quite a car- tilaginous firmness, in consequence of the deposition of genuine tuberculous matter in them. 14. An effusion into the cavity of the pleura of a clear fluid, in quantity a pint and upwards, was found in one-tenth of the cases. This, M. Louis believed, had taken place very rapidly ; because he had found in two instances, that the thorax gave <'Vcrv where a Very clear sound on percussion thirty-six hours 15 114 Pathological Anatomy of Phthisis, [July. before death, in which, after death, he found two pints of fluid in one side of the chest. 15. In thirty-one out of one hundred and two cases examined, there was ulceration of the mucous membrane of the bronchia, with or without inflammatory redness of its surface. These ulcers were round or oval ; and when small, were scattered throughout the circumference of the air-tube, and varied from a line to a little more or less in diameter. These, we are told, have, from their edges being flat, and their base formed by the cellular tissue, slightly or not at all thickened, escaped the at- tention of many pathologists. 16. The ulcerations are usually more numerous and large in the lower than in the upper half of the trachea. 17. The large ulcerations of the trachea are more scattered and apart than the smaller ones ; and are generally found on- the posterior, fleshy part of the tube. 18. In two cases M. Louis found a certain number of the cartilaginous rings completely denuded, diminished in thickness, and either partially or entirely destroyed ; and in five cases the complete destruction of the mucous membrane of the tra- chea throughout almost the whole extent of its fleshy portion. 19. These anatomical investigations have proved that the symptoms of ulcerated trachea are very obscure. Pain, with a sense of burning, and of obstruction just above and behind the sternum, was experienced in a few cases. These distresses were sometimes referred by the patient to the larynx, whilst this part was exempt from disease, and only the trachea ulcer- ated. There were no pathognomonic characters in the breathing, cough, or expectoration. As an example, in one case wherein the whole length of the wind-pipe, with the epiglottis, including the appendages, to the termination of the trachea, exhibited patches of deep and extreme ulceration, so that some of the cartilaginous rings were denuded, and others more or less com- pletely destroyed, no prominent symptoms were present during the life of the patient. 20. Simple in^ammation of the trachea is more frequently accompanied with pain, and a sense of heat in the part, than ulceration. 21. Ulcerations of the larynx are more frequent than, but are very rarely unaccompanied by, those of the trachea. They were found in twenty-two out of one hundred and two cases. They were generally more or less irregular, of a certain depth, and from one to two lines broad, their edges of variable thick- ness, sometimes lardaceous, and greyish or whitish ; the mucous membrane was pale, and perfectly sound in the rest of its extent. 22. The most frequent seat of laryngeal ulcerations was first the junction of the vocal cords themselves ; especially their 183&.] Pathological Anatomy of Phthisis. 115 posterior part. Only once was a very small ulceration obser- ved at the back of the arytenoid cartilage, the superior part of the larynx, and the inferior of the ventricles. Sometimes one or more of the vocal cords were completely destroyed, and the base of the arytenoid cartilage laid bare ; the cartilages them- selves remaining unaffected. 23. The signs which during life, characterize ulcerations of the larynx, are much more obvious than those which accompany ulcerations of the trachea. They vary according to the part of the tube affected, and the depth and extent of the ulcers. When the vocal cords, the ventricles, or the arytaenoid cartilages were the seat of disease, hoarseness, more or less alteration of the voice, pain, sense of heat, and pricking, and subsequent aphonia were generally present. The pain was sometimes very acute, pungent and lancinating, and in most cases exasperated by coughing, speaking, &c. 24. Ulcerations of the epiglottis were almost as frequently found in phthisical patients, as those of the larynx. Of one hundred and two cases, eighteen were found to have ulcerations of the epiglottis. i hese were sometimes found alone, but most commonly associated with those of the larynx and trachea ; so that twelve cases out of eighteen were thus associated. Only in one case was the ulceration on the upper surface of the valve. In four cases was the edge festooned by ulceration, and in one was there complete destruction of the epiglottis. 25. In no instance were tubercular granulations found in the. substance, or on the surface of the epiglottis, larynx, or trachea. This led M. Louis to conclude that inflammation was the most frequent cause of their ulcerations. 20. These ulcerations were twice as frequent in men as in women. This M. Louis considers not the effect of hazard; because the proportion was about the same in the three species, viz. six examples of this state of the epiglottis in women, out of eighteen, seven of the larynx out of twenty-three, and nine of the trachea out of thirty-one cases. 27. The symptoms of ulceration of the epiglottis are often obscure ; but may be stated to be a fixed pain in the upper portion of, or immediately above the thyroid cartilage, soreness of throat, hoarseness with greater or less dysphagia, increasing with the progress of the disease, so as to cause fluids to be rejected by the nose ; the pharynx and tonsils remaining healthy at the same time. As symptoms during life are more or less equivocal with regard to those ulcerations which attend genuine Phthisis, we feel it important to familiarize the reader, as much as possible, with those which are more or less connected with such cases. We therefore give the following case, in which the epiglottis, fhc lateral ligaments, and tho superior vocal cords were found 1 10 Medicinal Leeches. [3uh'> after death completely destroyed, and in which the succession of symptoms was well marked. At first the voice was hoarse, unequal and discordant ; a lancinating pain was felt between the thyroid cartilage and the os hyoides ; this was increased by any exercise of the vocal organs, by flexion of the neck forward, and by deglutition ; the latter being frequently so difficult as to provoke the rejection of fluids by the nose. Towards the close of the case, the pain in the neck became more severe, and the deglutition so destroyed, that no solid food could be swallowed ; complete aphonia had supervened. The progress of these symptoms had been slow and constant the rejection of the liquids by the nostrils having existed for four months preceding the death of the patient : and the acute local pain had been felt during the whole of this pe- riod. " It is however," says M. Louis, " to be remembered that these symptoms are by no means invariable occurrences, even when the destruction of the epiglottis is complete." Magendie relates two such cases, in which deglutition was not at all impeded. Medicinal Leeches. We find, by an advertisement in the Boston Medical and Surgical Journal, that the Massachusetts Medical Society have, with a spirit and liberality becoming Americans, offered a premium of jive hundred dollars, for the best sample of not less than one thousand leeches from a foreign stock, bred in that commonwealth the premium to be awarded at the expiration of seven years, if occasion should be. We are much pleased with the spirit which actuates that respectable body to such a movement. It appears to us, however, unnecessary to require that they should be propagated from a " foreign stock." This requisition is calculated to embarrass the experiment with unnecessary expense and trouble. Some of the varieties (of which there are a number,) of the native leeches which abound in our creeks, branches and swamps at the South, are, when well selected, found with us to answer all the purposes to the fullest extent, of the best foreign speci- mens. They arc brought in by the country people, and sold to the apothecaries and physicians at six to twelve cents. Many are of small size others are very large. Doubtless they would be much improved by a system of management which a minute knowledge of their natural history could afford. Last autumn we had occasion to deplete from the dorsal region for the relief of spinal irritation, which had produced colic and other neu- ralgic distresses to a considerable extent. Knowing that there wex*e no foreign leeches in tlie city, we prescribed forty domes- 18.36.] Cancer of the Lap. 117 tic. Our apothecaries sent us the remnant of their stock, amounting to twenty-six, qll of which were applied on the dor- sal vertebra). Not one of the whole number failed to operate. They were allowed to remain until they dropped. The deple- tion was afterwards encouraged by warm napkins for twenty or thirty minutes, by which time the patient became very sick arid faint. The circumstances render it reasonable to suppose that between twro and three pounds of blood were lost by the operation. The depletion was indeed excessive ; so much so that our patient was troubled for a week thereafter with a cold- ness of the extremities, and debility with oedema, such as ordi- narily follow excessive haemorrhage. The same leeches have been preserved during the past winter, with no more care than daily changing the water in which they were kept ; notwith- standing the bottles in which they were have been sometimes broken by the freezing of the water, which was entirely con- gealed. These leeches were left charged with the blood which they had imbibed at their first application in October. They have all been since used with the best effect, except two which died in the beginning of spring, and two which are still on hand. There was no selection of these they were the remainder of a considerable supply which had been but a few weeks be- fore received, and were probably the smallest of that parcel. None of them wrere, however, less than six, and many of them upwards of seven inches long, when swimming or suspending themselves by one end in the bottle. They were larger than most of those which are brought to this market ; but our apothecaries inform us that there are certain streams in the neighbourhood winch afford such samples abundantly. An observation of the peculiar character of the streams and places where they are found, would doubtless afford some use- ful hints relative to procuring as well as propagating them. The following very interesting case, serves well to illustrate the wonderful resources of the system and powers of surgery, for surmounting inveterate and otherwise mortal disease. We scarcely know what we may not expect from the knife, with good constitutional powers. Cancer of the lip resection of the lower jaw. M. August. Marseille, in a recent letter to Dr. Clot-Bey, gives an account of a very extensive opera- tion on the lower jaw and the neighbouring parts. The patient had been attacked three several times' with cutaneous cancer of the lower lip. Twice the tumour was excised, but the third time, the disease had made horri- ble progress before surgical aid was requested. When the case was pre- sented to M. Marseille, the condition of the patient was as follows : He was decidedly attenuated, his complexion pale yellow, with a slight ILS Removal of Sequestra without an Operation. [Juh. h aden hue, and there was no fever. The cancerous afi'ection invaded ex- ternally al] the lower lip and parts about the chin, extending, in the shape of hardened lump.--, to the region above the hyoides. All these parts were in a disgusting state of ulceration, pouring out foetid pus. The lower jaw lied and softened to within half an inch of the angles, the teeth dis- ci and sticking here and there over the tumour, and the sublingual cellular tissue in a decidedly cancerous condition. The operation being demanded by the patient, and refused by the surge on, the former declared his determination to commit suicide unless indulged in his wish, on which the latter reluctantly consented. The mouth was dilated by cutting the commissures to the right and left above the level of the diseased shin, and from the extremities ot these incisions two others were carried down ob- liquely, until they met each other at the little groove or centre of ihe cs hyoides, thus enclosing all the diseased parts in one large V incision. The lower i aw was then sawed through by a chain saw, within half an inch of each of its angles, and the bone, with the mass of the diseased parte, v ere then removed by the straight bistoury. The frenum lingute was next Fo- rmed by waxed thread, and the tongue thus held aside by an assistant, while the diseased sublingual tissures were dissected off by curved scis- sors and forceps. Many vessels were secured seriatim, and the patient, was imminently threatened with suffocation, but no actual cautery was ne- cessary. The wound was nearly closed by six points of suture, one of which held and drew forward the frenum linguae, and by a methodical ban- da{*e. The shocking deformity was concealed by an artificial jaw7 or mask, and the constant percolation of saliva was prevented by a sponge. The patient departed for his native village two months after the operation, eat- ing easily and speaking intelligibly. A/ii. Jour. Gaz. des Hopitaux, May 9//(*1835. O;? the Removal of Sequestra without cm Operation. Dr. Bouget has pub- lished a new plan for the removal of sequestra without an operation, in the Journal de la SactiM de Medecine de Bordeaux^ in an article entitled, "Souvenirs de la Clinique de Delpcch." M. Delpcch, discouraged at the unfortunate results in several cases of necrosis of the tibia, turned his attention to measures which might remove the sequestrum without having recourse to the painful operation which is ary. In this search he was successful, for he found that, by means of diluted sulphuric acid, lie could destroy the phosphate of lime m the bone to be removed, which is then reduced to its gelatinous paren- chyma, and can be easily taken away with the common dressing forceps. D pech first employed this application in the year L814. At ihis period, Dunded at the battles of Orthes and Toulouse, flocked in such i am- bers to Montpelier, that the Hopital St. Eloi was soon crowded, and a supplementary one was formed, at the head of which was placed M. U.Fa- nce so well known by his valuable lectures on external pathology. Hospital gangrene soon appeared in both hospitals, and caused such exten- sive ravages that the majority of the amputations terminated fatally: even in those cases which were the most successful, a greater or smaller portion of bono was Left exposed by the destruction of the soft parts, A young man who had undergone amputation of the arm, and had twice Buffered from hos- pital gangrene, winch had been with difficulty arrested, had the humerus projecting about an inch and a half beyond the flesh. According to the or- dinary treatment the sequestrum would not separate perhaps for months, bltt it happened far otherwise under M. Delpoelfs directions. He caused i he external surface of the hone to be covered with a pledget of lint, soaked in dilute sulphuric acid, and a wad of the same, equally wetted, to be passed into the medullary canal, whence the reticular apparatus had been prove- 1830. J Treatment, tf Co lica Pictonton. 119 ously removed ; at the end of twenty-four hours the portion of denuded bone was so softened that it could be easily detached : ton days after the extremit) bfthe bone was covered with fleshy granulations, and a complete cure was sjxv.'.'.ly accomplished. In the year iyl(>, a man entered the clinical ward, having a necrosis which extended through the whole length of the tibia. Although he evi- dently possessed a good constitution, and was apparently capable of under- going a serious operation, M. Delpech determined to have recourse to the proceeding which had proved successful in the previous instance. He des- troyed the soft parts at the upper part of the leg by means of the pot issa fusa, and when the eschar, winch was about the size of a crown piece, had sloughed, he applied a pledget of lint, soaked in the dilute sulphuric acid, to iii i bone ; after two or three dressings, renewed every live or six hours, if became .soft enough to be taken away by dressing forceps. This being ef- fected, the application of the potassa, followed by the acid, was made lower down ; the sequestrum was exposed to the extent of five or six inches in length, and an inch and a half in width ; it was then extracted with the greatest ease. It was more than six inches long, and constituted nearly two-thirds of a cylinder. The patient left the hospital quite well one month afl r his admission. From that time untd 1822, when I left Montpelier, adds M. Bouget, I have seen M. Delpech constantly have recourse to this plan of treatment, both at the hospital and in private practice, and always with success. I have also used it myself with advantage in a case of necrosis of the tibia in a child. Amer. Jour, of Med. Sci. Treatment of Collca. Pietonum. Lead Colic cured bu Hy- drochloric Acid. M. Gendrin communicated to the Academy of Sciences, at their sitting in December, 1834, some additional observations on the treatment of Colica Pietonum. He has ascertained that the administration of sulphuric acid does not produce the same relief where the colic has been induced l>\ the deutoxide of lead, as when it has been caused by the car- bonate. In white lead manufactories, the use of this acid has always been attended with the happiest prophylactic effects ; whilst, in those of red lead, it has proved powerless. He then announces that he has found that diluted hydrochloric acid would remove the poisonous effects of the deutoxyde, as rapidly and certainly as the sulphuric cures those caused by the carbonate. Am. Jour. Pharm. Jour. Hebdom. It may be well to remark in this place, that the form in which lead is found in the hydrant water conducted through leaden service pipes in this place, and probably in all places, is that of carbonate. According to the cxperienor then in the treatment of this disease in white lead manufactories, the sulphuric acid would be found prophylactic of lead colics and other forms of disease liable to be produced by drinking hydrant water, and curative, when they are produced. The following is the formula of M. Foucat in the treatment- of lead colic. " To a pint of water, add half an ounce of sulphuric 120 Correctives of Opium, <$-c. [July, Alcohol, (Elixir of Vitriol) two ounces of Magnesia, and four oupces of Syrup of Gum. This is to be used as a commi n drink ; besides which, a draught composed of half an ounce of Caster Oil, as much Lemon Syrup, and a quarter of a grain of Opium, is to be given night and morning." Am. Jour. Pharm. Jour. Hebdom. Correctives of Opium. According to M. Puchelt, a German physician, sulphate of soda is an excellent corrective of the unpleasant effects of Opium, given in the proportion of a scru- ple to half a grain of Opium. This dose may be repeated two or three times a day. In combination with Glauber salts, he says that Opium may be' administered when it would otherwise be contra-indicated. In obstinate haemorrhages especially, this mixture will produce the happiest effects. The author also asserts that if this neutral salt prevents the congestion some- times produced by opium, so castor prevents its narcotic effects, without diminishing its sedative powers. Am. Jour, of Pharm. Load. Med. and >Sur. Jour, and Am. Jour. Med. Sci. Dignified Consistency. The governors of the London Fever Hospital, an institution of high reputation, at a special meeting a few weeks ago, at which four hundred persons were present, removed Mr. Hentsch, the House Surgeon, from his office, in consequence of his having given a written testimonial in favour of a quack medicine. A resolution was brought forward, also, to remove Mr. Tweedie from the post of Chief Surgeon, for a similar offence; but before it was acted upon, the meeting adjourned for one week. Mr. Bransbury Cooper was present, and defended his professional brethren with considerable energy, but to no purpose. The further doings will be narrated when- ever the intelligence arrives. Boston Med. and Sur, Jour. Antidote, for the poison of the Hygeidn (Morisoivs) pills. A correspondent of the London Lancet makes known, for the benefit qi those who are guilty of the folly of taking Morison's pills, a remedy for the distressing vomiting and purging which frequently follow their use, viz. copious draughts of luke-warm water, which will assist the stomach in its attempts to dislodge ihe poison. Muciliaginous and gelatinous drinks, such as bar- ley water, linseed tea, mutton and chicken broth, will also miti- gate the severity of the purging, and afford some protection to the internal coat of the intestines from the acrid and irritating effects of the gamboge, aloes, and eoloevnth. which are found in the pills.- Ibid, 1836.] Butlers Aperient effervescing Magnesia, fyc. 121 Butler's Aperient effervescing Magnesia. Of all the frauds practiced upon the public, in these times of nostrums and quack- ery, this is one of the most shameful. It is called, forsooth, a magnesian preparation, and recommended as serviceable in heart-burn, acidity and the numerous ills dependent on acidity of the stomach ; and yet in the state in which it is swallowed, there is not a particle of alkaline property in the mixture; on the contrary, there is a considerable quantity of free acid remaining in the solution, after the effervescence has subsided. We shall here give the true composition and qualities of this fashionable absorbent, that those who are using it under the idea of its providing them with an alkaline medicine, to correct the dreadful inconveniences of Dyspepsia, may no longer continue to use this saline and acid preparation. For although, by its purgative properties, it may afford temporary relief to some of these dist esses, yet its continued use cannot fail to injure the stomach and lead to a stnte of hauitual constipation of the bowels. It is simply a mixture of Sulphate of Magnesia, (Epsom Salts,) Tartaric Acid, and super carbonate of Potash. So that it purges by virtue of the Epsom Salts it contains. It is analogous in its effects and composition to the Seidlitz Powders, and far less pleasant to the taste ; for the neutral salt used in the composition of these last, is the Tartrate of Potash and Soda, (the tasteless purging salts.) In order to prevent the Tartaric Acid and super-Carbonate to be mixed with the Sul- phate of Magnesia, without exciting their mutual action upon each other, all the water of crystallization must be driven from it by he^t, which can be done without decomposing any portion of the salt. We object not to the preparation itself; it is useful in some cases, and frequently very convenient ; but our objections are against the imposing name which it bears, and the outrageous fraud attempted upon the public. F. Preservation of Anatomical Preparations. M. Le Reboulet, conservator of the Museum of Natural History, at Strasburg, has given the following formula, for a liquid for the preserva- tion of anatomical preparations, &c. This fluid is peculiarly applicable to the preservation of the brain. When any tissues kept in this solution become hardened, as sometimes happens, they can be restored to their usual flexibility by keeping them in fresh water for a short time. R Water, 16 parts. Chloride of Lime, 4 parts. Alum, 2 " Nitre, 1 " Am, Jour. Pharrn. Jmcr tf.c Pharni. .16 122 Influence of different Professions on Consumption. [July Influence of different Professions on Pulmonary Consumption. By II. C. Lombard, M. D., Geneva. The following facts were derived from five sources, viz. 1. The list of cases collected by the pupils of the hospitals of Paris. 2. That of M. Julius, in his researches on the sanitary state of the town and hospitals of Hamburgh. 3. The Medical Annuary, published at Vienna in 1803, containing the sketch of the diseases treated in the General Hospital during the years 1798, 1799, and 1800. 4. The results of the recent researches of M. Benoiston de Chateauneuf, on the number of patients furnished by each profession to the hospitals of Paris, with the number of deaths caused in each profession by pulmonary consumption ; and 5. The results of M. Lombard's own researches in the mortality re- cords, from 1776 to 1830, of the city of Geneva, including the township of Plain-Palais and Eaux-Vives. All these sources afford him records of the death of 57,463 persons of various professions, 5,752 of whom died of pul- monary consumption. By ascertaining, in the several lists, how many of the professions of the subjects of this disease were above, and how many were below, the average,' in the number of cases of consumption which they furnished, and by subse- quently comparing the results together, he was enabled to arrive at the following facts : Professions situate above the mean. " A. In men. "1. In all the lists. Sculptors, printers, hatters, polishers, gendarme*, brush-makers, soldiers, jewellers, tailors, millers, quiltmakers, lacemakers, lemonade dealers, domestic servants, and wigmakers. "2. In the majority of the lists. Copying-clerks, cooks, turners, joiners, barbers, cordwainers, and coopers. "3. In a single list. [M. Lombard gives a great many professions, but we select only those of our own country.] Ironmongers, commission agents. brokers, tin smiths, pavers, engravers, design-painters, street-sweepers, pastry-cooks, teachers, draymen, upholsterers, file-makers, chimney sweeps, feather-dressers, lapidaries, &c. &c. " B. In women. "1. In all the lists. Laundresses, cordwainers, and embroiderers. "2. In the majority of the lists. Polishers. "3. In one list. Dress-makers, teachers, smoothing-ironers, knitters flower-makers, lace-women, &c. &c. "A. In men. r "Students, plasterers, stone-cutters, saddlers, terrace-makers, clock- makers, carmen, cellar-butlers, goldsmiths, stocking-makers, charcoal deal- ers, gilders, musicians, sawyers, and glass-makers. " B. In women. "House-keepers, day-labouring-women, wire-workers, weavers, gauze- makers, gilders, patchers, and mantua-makers. " 3. Professions situate below the medium average. " A. In men. " I . In all the lists. Coachmen, quarrymen, carpenters, inn-keepers, butchers, hall-porters, wharf-porters, street-porters, tanners, bleach* re, watermen, confectioners, slaters, founders, infirmary-attendants, and nurses. "2. In the, majority of the lists. Bakers, blacksmiths, farriers, locksmiths, masons, and weavers. " 3. In a single list. Surgeons, braziers, cutlers, different merchants, wood-cutters, advocates, agriculturists, literary men, grocers, public officers, ninders, druggists, annuitants, groojns, dyers, physicians, lawyers, candle* 1 836.] Influence of different Professions on Consumption. 120 makers, snufF-dcalers, book-sellers, harness-makers, professors, miners, mercers, comb-makers, &c. &c. "B. In women. " 1. In all the lists. Wadding carders, infirmary nurses, bleachers, and garden women. "2. In the majority of lists. Dress-makers. ' -i. In a single list. Cooks, domestic servants, annuitants, laundresses, grocers, midwives, bakers, appliers of leeches, door-keepers, &c. &c. M. Lombard's next inquiry is into the causes which may influence the frequency of Consumption in (liferent professions, and under the following heads he has arranged the results of his researches : I. State of comfort or indigence. His calculations show "that the more indigent classes of society are twice more accessible to consumption than the persons more elevated in the social scale." II. Muscular Exercise. Of the eighty professions situate above the average, fifty-eight, or nearly three-fourths, are almost completely seden- tary. A fact showing that the sedentary life furnishes a much great r number of consumptive cases than an active life. The proportion M. Lombard found to be that of 141 to 89. He also ascertained that "con- ditions completely sedentary produce a greater number of consumptive patients than those which require a certain degree of muscular exer- cise ; and from it may be inferred, that if the sedentary life augments the frequency of consumption, muscular exercise is in some degree a means of counteracting tins influence. Concussions given to the chest by the continual motions of the arms, which have been enumerated among the causes of consumption, he found to have a tendency varying according to circumstances in slightly dimin- ishing the frequency of consumption in sedentary occupations, and augment- ing that frequency in active professions. The constant exercise of the voice he statistically proves, is not an un- favorable circumstance in reference to consumption. The mean number of victims to this disease being one hundred and fourteen in one thousand that of the professions in which the voice is much exercised is only seventy five ; a result in accordance with the observations of M. Benoiston de Chateauneuf, and with the experience of the celebrated Cuvier, who asser- ted that the frequent exercise of his voice, consequent upon his appointment to a professor's chair, was the means of curing him of a pulmonary affec- tion. The incurvated attitude is unfavorable in reference to consumption, but is more so in those professions which are completely sedentary than in those in which much muscular exercise is required, where this influence is fully corrected by the exercise of the muscles. This conclusion is strengthened "by the rarity of consumption among tanners, gardeners, bleaching and washing women, who are constantly bent at their work." III. Influence of the purity or impurity of the surrounding atmosphere. An epitome of the results of liis comparisons and calculations under this head^is as follows : 1. Those workmen who pursue their occupation in the open air are twice less liable to consumption than those who work in shops, and the degree of liability is in proportion to the smallness of the shop, or the im- perfection of ventilation. '2. Workmen surrounded by an atmosphere charged with watery vapour for example, dyers, tanners, washer- women, &c. are much less liable to consumption than the general average. In Geneva, the average number in this class of workmen who are attacked with consumption is inferior, cnore than one half, to tho general average. 124 Influence of different Professions on Consumption. [July, 3. On the contrary, workmen surrounded by a hot, dry atmosphere, yield more readily than other workmen in the proportion of one hundred and twenty-seven to one hundred and fourteen. 4. Workmen surrounded by animal emanations, butchers, tanners, can- dle-makers, sick-tenders, &c, are about twice less liable than others to contract pulmonary consumption. The exact proportion is sixty to one hundred and fourteen. 5. Air loaded with emanations of living plants, (in day-time of course,) is a preservative against consumption. The emanations, from fermenting or decomposing vegetable substances, on the contrary, are injurious ; and the volatile vegetable oils, as turpentine, the drying oils, &c, exert a very unfavorable influence. G. Among the mineral emanations, are the gazes arising from the combustion of charcoal, wrhieh are unfavorable : the vapours of the mineral acids, which are not as unfavorable as is generally believed : chlorine,, which has been used as a remedy in consumption. M. Lombard asserts, that consumption is rare among the workmen employed in the manufacture of chlorine. He tested the statement as to the harmlessness of this gag in a great manufactory of chloride of lime. "The only inconvenience felt by a workman who had been employed in it for more than twelve- years, is a transitory uneasiness, when one of the retorts, from which the chlorine is disengaged, happens to break and to diffuse the vapours abundantly in the manufactory." Metallic emanations, he found, are not directly injurious to the lungsr and notwithstanding their action on the nervous system, and the debility which they produce, the production of consumption does not seem to be one of their secondary effects. 7. Bodies suspended in the atmosphere are highly injurious to the lungs. Mineral particles are more so than animal, and these more so than vegetable particles. Coarse particles are less hurtful than minute ones, and hard particles are more injurious than soft ones. Hence, "the powders most hurtful to the lungs are those which proceed from very hard bodies, and are reduced to an impalpable powder." The inhalation of the dust of emery, steel, or flint, is well known as a frequent cause of con- sumption. " The workmen who employ emery, the hardest of all the substances used in the arts, are also the first in the order of frequency of consumption. Thus the watch-hand makers present fifty-five per cent., and the steel- polishers furnish thirty-five per cent., of consumptive cases. " Almost all the workmen employed at Sheffield in polishing steel, be- come the prey of pulmonary consumption. It has been observed, that in two thousand five hundred persons employed in this department, scarcely thirty five reach the age of fifty years, and scarcely seventy that of forty five years : while the majority die before the thirty sixth year. Dr. John- son remarked, in 1799, the great frequency of consumption among the workmen occupied in pointing needless on ground stones ;* and recently. Dr. Knight, of Sheffield, published anew memoir on the same subject, aud has added new facts to those already known. f He remarks, that no polish- er of steel-forks reaches his thirty sixth year. Among two hundred and fifty steel-polishers admitted into the dispensary of Sheffield, one hundred and fifty four had diseases of the chest, and thirteen died within the year; while of two hundred and fifty pursuing other professions than that of pol- ishing, fifty six only had diseases of the lungs, and only one died within the? year. The age of eight hundred and twenty seven of these patients deserves to be remarked. Memoirs of the Med. Society, London, vol. v. (North of England Med. and Surg. Jour., Aug. 1830. 1836. J Influence of different Professions on Consumption. St rcl- Grinders. Oilier trades. "Above 30 years 125 140 :35 83 11H 40 40 92 45 24 70 50 10 56 55 4 84 60 1 19 287 :m " This table shows how much steel grinding abridges the lives of tho workmen engaged in this occupation. Numerous attempts have been made to render this operat:on less injurious, but all have been inadequate, and the grinding of steel is at the present moment as hurtful to the health of the workmen as it was thirty years ago." The inhalation of silicious or calcareous particles is also injurious ; the former much more than the latter ; the inhalation of light filamentous sub- stances, as cotton, flax, hemp, is also very injurious, owing probably to their flexibility, and the ease with which they may thus be introduced far into the bronchi. The practical importance of these facts is evidently great. We will give the author's conclusions in his own words : " Reviewing, meanwhile, the preceding facts, we arrive at the following conclusions. "I. The circumstances which multiply cases of consumption are, indi- gence, a sedentary life, and the absence of muscular exercise, the concussions of the workshops, the bent posture, the impure air of shops and manu- factories, the inhalation of certain mineral or vegetable vapours, and lastly, air loaded with powders, coarse or impalpable, or with bodies light, elastic, and filamentous. "2. The circumstances which exercise a preservative influence are, opulence, an active life spent in the open air, the regular exercise of all parts of the body, the inhalation of aqueous vapours, or of animal or vege- table emanations. " But it is not enough to specify these different circumstances. It is requisite to estimate the degree of influence of each in the production of consumption. The following table, which gives the mean number of con- sumptive persons among the workmen exposed to these several influences, will serve to determine this question : Mean number of Consumptive cases 114 per 1000. 1. Noxious Influences. 1. Mineral and vegetable emanations, 0,177 2. Various sorts of powders or dust, 0,145 3. Sedentary life, 0,140 4. Life spent in shops or manufactories, 0,138 5. Hot, dry air, 0,127 6. Bent posture, 0,122 ^. Motions of the arms causing shocks of the chest. 0,110 2. Preservative Influences. 1. Active life, (muscular exercise,) 0,080 2. Exercise of the voice, 0,07.") 3. Life spent in the open air, 0,073 4. Animal emanations, 0,000 5. Aqueous vapours, 0,053" Thus the most hurtful circumstance to the lungs is the inhalation of sun- dry mineral and vegetable emanations; and the most important prophylactic influence is the inhalation of aqueous vapour. The author makes the following hygienic and therapeutic applications of fhe foregoing facts : 126 New and successful remedy for the Croup. i_JuIy> 1. That from the influence of these circumstances in the production and prevention of this disease, it may be inferred that consumption is the result of general disease, and is not a primary local affection of the lungs; and quently, in attempting a cure our means must be general. 2. The rarity of consumption among sick-nurses and infirmary servants, shows that there is but little foundation for the belief that the disease is contagious* 3. Attention to ventilation is of the highest importance in this disease. 4. The moisture in the atmosphnre exerting such a remarkable prophy- fact ic influence in this disease, we should, in selecting a climate favourable to consumptive persons, take the moisture of that climate into consideration ; and workmen liable to be exposed to hot, dry air, should use means to secure the presence of aqueous vapour in their shops. 5. Exercise of all parts of the body should be taken by all persons engaged in sedentary pursuits, who wish to prevent consumption ; and 6. A judicious change of trade or occupation should be recommended by the physician in suitable cases. Comment on this memoir were useless. Every reflecting physician will at once see its valuable practical application; and although M. Lombard differs in a few circumstances from others who have investigated the same subject, and possibly may be in error in some unessential particulars, yet, the extent of his examination, and the ability with which it has evidently been conducted, should ensure to the author of this valuable memoir, the belief of his readers in his main and important conclusions. R. P. Trans. Jour. Ed. Med. and Sur. Jour. f misplaced action of Ergot. 145 tker series of events ; each event composing this train, succeed- ing each other in a different order* We have now compared infl immatioti and fever with regard to the series of events and the order in Which they occur in each, and find that they differ ; and as different terms are used to express different things, we conceive that the term idiopathic is a very proper word to designate such fevers, as we sec do not owe their existence to a pre-established inflammation in some [.articular organ. Although the state of the system in the primary attack of fever is not. identical with inflammation, it is acknowledged that the morbid condition into which the system is brought, in the progress of lever, is for the most part that of inflammation : still, even in a practical regard, though the remedies are the same in febrile as in ordinary inflammation, they must be modified in the same proportion that the febrile inflammation is modified by the pecu- liar pre-disposing and exciting causes. Venesection is equally necessary in each ; but the abstraction of sixteen ounces of blood in febrile, will effect as much as double the quantity in ordinary inflammation. Thus, though not for a moment deny- ing the abundant existence of symptomatic fevers, wre insist, that, whether we observe the causes, the phenomena, or even the treatment of fevers, we are compelled to recognize also a '-lass which arc properly termed idiopathic fevers. ARTICLE V. .1 case of misplaced action of Ergot. By Isaac Bowex, M. D. of Augusta, Geo. - On the 17th of May, 1823, I was called to see a negro woman, who had been in labour for more than twelve hours. On examination per vaginam, the os tinea) was widely dilated, and the vertex of the child's head nearly even with the Labia. The presentation was strictly the first of Baudelocque. I arrived precisely at 4 o'clock, P. M. at which time I was 19 1 ii A ease of nttsplacc^ action, of Ergot. L-^uc- informed by a midwife then id attendance, that labour was going on very favourably until 12 o'clock, M. when the woman1 was taken with a cramp in the right hip, and labour pains ceased altogether. It will be perceived that she lay in this situation during four hours, only complaining with a pain in the hip. The case appeared to me one of the fairest for the administra- tion of Ergot. Accordingly, I made an infusion of twenty-live grains of this article, and gave it every fifteen minutes in broken doses. It was all given in about one hour and a quarter, pro- ducing no other effect than apparently to increase the pain in the hip, which became so excruciating as to require some device for a speedy relief. I ordered a brick to be heated, which was quickly done, wrrapped in a woollen cloth, and placed to the painful part. Almost immediately after this application was* made, the pain of the hip was relieved, and labour then recom- menced with unusual rapidity, and was terminated in a few minutes by the expulsion of a living child. I have seen Ergot. produce Asphyxia, in several instances, in which the pains were- not so violent. From all. the circumstances of the case, it wasp manifest to me that the action of Ergot was invited by the pain in the hip to assist in its increase. The same Ergot has been given since, in a great many cases, and has never failed to pro- duce labour pains in less than twenty-live minutes. In all other cases, in which I have seen it given where labour was partially suspended by erratic pafhsr, it seemed to rectify thee process by a direct actjon upon the uterus. Note. The facts of the above case oflaj&our, our favourable acquaintance with the author will not allow us for a moment to doubt. But under the guidance of our rule for philosophising, we feel bound to a different view of the sequence of phenomena, and conclude that the rationale is. 1st. That as regular labour existed; and 2d, a cramp or other severe painful affection. seized the hip ; that 3d, this cramp overruled the actions of re- gular labour ; and 4th, that when this overruling cause or influence was removed, the regular actions of labour were resumed, &c. The two first points are admitted. They are declared in the text. The third is supported by the fact of the proportion or adequatcness of the cause to the cfloct. as is proved by constant 1836.] A case of misplaced action of Ergot. I4S demonstration of this proportional power. Who has not often witnessed the overruling of labour by spasms in the Lumbrici 1 is, or the Gastrocnemian, or other muscles of the lower or upper extremities, or ether parts? Indeed much less powers, or those which appear less, are very common retarding influ- ences ; as bashfulness on the approach of the accoucheur, desire to evacuate, &c. One of the most provoking causes of retard- ation with which the accoucheur meets, (provoking because generally avoidable,) is the disposition of the patient to talk, or to change her position by voluntary effort at the approach of regular pain ; either of these being quite competent in most cases to the serious interruption of the progress. But there is another view of the proportion of cause to effect to be taken in this case, calculated to render doubtful the philo- sophy advanced. 1st. The quantity of Ergot given Was very small, such as often fails to exercise a controlling influence on the case, espe- cially wh.:n of such impaired power as that ordinarily procured of the druggists in the South for the last twelve or fifteen years. 2d. It is the common tendency of Ergot to operate contrari- wise to this alleged operation give point to the pains by pro- moting uterine action, and thus overrule what has been called misplaced labour. 3d. Supposing the Ergot to have been better than usual, and the quantity well adapted to the susceptibilities of the system ; still the time, so far as we can form an opinion of it from the text, was not more than what was about necessary to develope the ef- fect of Ergot given thus moderately by the time the expulsory efforts became efficient, which was immediately after the warm application to the hip, the pain in which, from its intensity, hav- ing demanded " a speedy device for relief." The unusual rapidity of the labor, which " in a few minutes'* terminated m the expulsion of the child, was very like Ergot operation ; and if the article produced any effect itself what- ever in the case, it appears to us imst probable that it was in this part of the labour only. Ed. 148 On Amygdalus Persica Extract of Belladonna. [Aug. ARTICLE VI. On Amygdalus Persica Extract of Belladonna. By M. Antony, M. D. Professor of Obstetrics, &c. in the Medical College of Georgia. Amygdalus Persica. (Lin.) Fol. Common Peach Tree. I am not conscious of any difference in the medicinal powers of the numerous varieties of this species of Amygdalus, but have for many years used for their sedative powers the leaves of any of those varieties which wre cultivate for their fruit. During the summer of 1831, after the prevalence of East winds for some weeks, a fever of unusual severity appeared here. These fevers were of remittent type, and rendered peculiarly fa- tal by their being generally attended with gastric irritation ; and indeed in very many cases, a high degree of gastritis and gastro- enteritis, with all their usual distresses and dangers prevailed. No symptom was so uniform, especially during the first half or two-thirds of the fever season, as a total inability to retain in the stomach the lightest article of diet, or most simple drink, with more or less tenderness of the epigastrium, on pressure. These distresses attended early with a sallow pallor, shrinking of fea- tures, and sometimes a pale leaden hue of skin, and general prostration. This state of the stomach at once, and as long as it continued, precluded all possibility of internal administrations, adapted to the treatment of bilious cases. Effervescing draughts even a spoonful of cold water was often rejected. Sinapisms and Epispastics were used in vain. The state of stomach reminded me of some of those cases of plague in which this condition of stomach is a regular and troublesome symptom, and in which Laurel water has been found the chief corrective. Our Apothecaries could not furnish that article. Believing its vir- tues consisted mainly in the Prussic Acid which it contained, I determined to substitute it by some other article from which I could obtain the same power in a safe form, for ordinary use. For this purpose the Prunus Padus (wild Cherry) and Amyg- dalus Persica (common Peach) were presented to my mind. The latter being always at hand in every garden, I determined 1 836.] On Amygdahs Persica "Extract of Btftado n nd. 1 1 9 on making my first experiment with it. The time for the petals had past. I filled a small vessel with the fresh leaves from the tree, loosely thrown in, then filled the vessel with boiling wa- ter and covered it closely. Of this infusion I gave * ss. every 15, 30, or 60 minutes, according to the greater or less violence of the symptoms. I rarely, if ever, used the 4th dose before the distressing symptom was sufficiently removed to need no more. That acute most distressing, distracting thirst, which called incessantly for drink, and was in many of those cases perfectly insatiable, was generally allayed with equal ease ; and although the taste of the infusion was most bitter and disgust- ing to the natural sense, in these cases it was' scarcely ever re- jected ; but on the contrary, called for most anxiously after the first taste of it ; even by children, to whom bitter drugs are gen- erally so offensive. I frequently applied to the epigastrium also with good effect, the leaves taken warm out of the infusion ; but the infusion was generally found far more successful. The gastric symptoms in this fever were not so commonly met with towards the close of the season ; but the distressing thirst was common to the end. The efficiency of the remedy was almost hourly tested until the close of the season, and my confidence in its uniformity of ef- fect thereby continually confirmed. One or two cases of ordinary Cholera Morbus came under my notice in the latter part of the season, in which it was equal- ly prompt in relieving the vomiting. Several sporadic cases of Cholera Infantum occurred after the close of the fever season, in which it was used with no less conspicuous benefit. Since the above experience, 1 have often used this infusion with the most marked benefit in that irritable stomach which often attends Cholera Infantum, as well as gastric and gastro-entcritic fevers. In addition to the above, I am happy in being able to state, on the authority and observation of my colleague, Dr. Dugas, Professor of Anatomy, that it has proved a convenient, prompt, safe and uniform remedy in Pertussis. His prescription is t<> give the patient one pint of a pretty strong infusion each day, in divided doses, until the disease disappears ; and that, in fami- lies having 12 or 20 cases, he very rarely has occasion to make another prescription the disease generally disappearing within four or five days. 150 On Amygdalus Persica Ediract of Belladonna, [Aug. The power of Prassic Acid in actually curing this disease, immediately on arriving at the full dose for the patient, was abundantly demonstrated in my practice in 1822. But the dif- ficulties attending the use of Off. Prussic Acid are such, owing to the various strength, age, l&c, that it cannot ever become a remedy in general practice, except near a competent and cor- rect Chemist. But we here have great cause of gratitude to an ever bounti- ful Providence, for strewing around us a simple, safe and cheap remedy, accessible to all. I need say nothing of the efficacy of this medicine in the cure of those cases of Hsematuria which depend on irritations in the urinary passages, as it has been long known to the profession. Extract of Belladonna. This article has been recently brought before the medical public by several northern practi- tioners, as a new discovery for securing an early and easy dila- tation of the os uteri in certain cases ; and practitioners have been requested to test its efficacy by experience. We also find since the publication of Velpeau's Midwifery, that it has been used for this purpose for a length of time in France. I notice this article on the present occasion, not for the pur- pose of claiming priority of discovery, or use of the article, but simply for the purpose of bearing testimony to its virtues. Some cases of rigid, iron-like hardness of the os uteri had, in my early practice, greatly perplexed and called loudly on me for some means for its relaxation. At length, about 18 years ago, when labouring under such a perplexity, I reflected on the power of Belladonna in dilating the pupil of the eye for cataract operations, and determined on the propriety of resorting to it for my present necessity. Considering it an article of much power, my next difficulty was to determine on the manner of its application. On searching for some preparation which might answer the demand, 1 finally adopted that of Chaussiers oint- ment, which I prepared and applied to the os uteri by menus of a vaginal syringe, truncated near the round end. I filled the end to the extent of about 1 inch with ointment, and after introducing it to contact with the os uteri, whilst, my patient was laying on her back, forced the ointment out of the syringe into the most depending part of the vagina, where the os uteri rested. The syringe was then withdrawn, and the ointment 1830.] On Amygdalus Perslca Extract of Belladonna, 1 r> i more particularly applied with the fingers to the whole of the os uteri. After two hours the opposing rigidity was found 1" In- yielding, and the case progressed without farther difficulty. Several cases have since occurred in which I have used it with similar success. In only one, was the second application needed. I have no fears in its free application in that way. after the libe- ral use made of it in those cases in which I have witnessed its safety and eificacy. It will not be forgotten that its use to the eye for dilating the pupil in cases of cataract is almost universal, and although this organ is one of proverbial delicacy, still we have, heard no complaint of its injurious effects : and I have myself often used it in these cases to my very great convenience, notwithstanding the great susceptibility of the part and the concentrated form in which the solution of it was applied. I would, however, from the fact of the unusual inflammation which attended my two last cataract operations, in which its application was needed for a long time before the pupil seemed to feel its influence, enquire whether other practitioners have observed, after its application, a degree of inflammation, out of all proportion to the good pre- paration and other circumstances of the case, supervene ? The extract used in these two cases, was procured of such as rould be obtained at the time for those operations, and may not have been of the best. Or, as both of these patients were old, and were black, it is possible that it was the rigidity of old age, which being hard to yield, required too long application of the article. For many years, I have been in the habit of recommending freely its use to my private pupils, and for several years past in my public instructions, under the name of Dilating Pomade ; not only for* the relaxation of the os uteri in cases of a fixed hard- ness thereof, but also for promoting its more pro?npt relaxation in those cases of labour in which general convulsions arc re- peated at every period for pain; also in those cases of that rigidity of the os uteri which retards the progress of the first stage of labour, and which is the most common, troublesome resistance in the first stage. But it has not fallen to my lot to have an opportunity, when it was at command, for using it in these convulsions ; nor have I yet been informed of its success or use in such cases. I think it worthy at least of trial. 152 Cases with observations. |A-Ug- Chaussier's ointment contains 3 i.j- extr. Belladon. to ' i. sim- ple ointment. Prepared Lard will be found better than the simple ointment, especially in winter. It should be remarked that none of the extracts are subject to greater variation of power than that of Belladonna, as we find it in the shops. ARTICLE VII. Cases with observations. By F. M. Robertson, M. D. of Augusta, Geo. Those who have devoted their attention, in any degree, to the subject of Phrenology, are aware of the function assigned to the cerebellum, in the arrangement of this system. The science not only recognises separate and distinct elementary faculties, but these faculties are manifested by means of separate and dis- tinct cerebral organs. Appeals are made, by those who advo- cate the science, not only to the physiological laws which gov- ern the progressive developement and decline of the encephalic mass, but also, to its anatomical structure, the pathological state of the organs, and the derangement in the manifestations of the functions dependent thereon. From these sources, a mass of evidence may be accumulated, which will almost set opposition at defiance ; for one fact is worth a volume of abstract reason- ing; and, while the flimsy tissue, of which the latter is compos- ed, is made to vanish before the superior light of truth and ob- servation, the former stands Unaltered in its intrinsic nature. Many cases, having the same bearing upon this point, as the two we are about to relate, may be found in the surgical obser- vations of Baron Larrey some of them arc so remarkable, and apparently, unnatural, that they would at once appear question- able, was it not that the veracity of the author stands "above suspicion." Case 1st. On the Oth of October, 1834. I was called to a ne- gro man between thirty-five and forty years of age, who had fallen through a dray while the horse was in motion. In de- scending, the back of his head and neck struck one of the cross- 1836.] Cases with observation^. 153 bars of the vehicle with such force as to produce a severe con- lion and fracture of the fourth and fifth vertebra; of the ':. The details of the case, so far as relates to the symptoms sequent upon the fracture of the vertebra) and compression of the spinal marrow, and the appearances on dissection, are recorded in another .Medical Journal.* The patient lived thirty- three hours alter the accident, occurred. On the day after the injury was received, from his having voided no urine, a disten- of the bladder was feared, to obviate which the introduction of the catheter was proposed. On examining the parts, previous to the introduction of the instrument, the penis was found to be in a state of rigid erection. The catheter was introduced, but no urine followed. The penis continued in a state of priapism until the death of the patient, and though the instrument was in- troduced repeatedly, not more than an onnce of urine came away. Upon pressure above the pubes, no marks of a distend- ed bladder could be observed. No twitching of the muscles, or the slightest convulsion occurred during the progress of the case; so that the priapism could not be accounted for upon the grounds of a spasmodic action. Doctors Cunningham, Patterson and J. E. Bacon visited the case with me, and the two last named gen- tlemen witnessed the introduction of the catheter. Independent of the fracture of the spine, a severe blow was received imme- diately over the region of the cerebellum. It is to be regretted that the examination, post mortem, could not have been carried beyond the fractured portion of the spine ; but as this was per- formed clandestinely, it was impossible, under the circumstances, t > proceed further. Case 2d. This case occurred during the late Seminole cam- paign, and was related to me by Dr. Ogleby, the Surgeon to the Battalion of Volunteers under Major Cooper. In the engagement with the Indians, in what is termed the cove of the Ouithlacoochee, on the morning of lie 31st March, Mr. Robin- lemberiofthe Louisiana A'oluntecrs, received a rifle ball in the back of (lie head. It entered behind the car. immediately over the region of the ce h, and penetrated through the skull, and was supposed, by his medical attendants, to have \\\ the substance of this portion of the encephalon. His is were those usually developed by such injuries, I. 1st, "" ' *>(^ . 154 Cases with observations. L^llS- and contrary to the expectations of his friends, he lived seve- ral days after the wound was received, notwithstanding the unfavorable circumstances under which the army laboured relative to hospital comforts and suitable transportation for the sick. As the main body of the army took up the line of march for Tampa Bay, on the 1st of April, he was left, under the care of Dr. Ogleby, at Fort Cooper. In the progress of the case, the Doctor found it necessary, in consequence of the accumula- tion of urine in the bladder, to introduce the catheter ; and, to his surprise, when the penis was exposed, for the purpose of per- forming the operation, it was found to be in a state of rigid erection. The instrument was introduced and the urine evacua- ted, but the penis remained in a state of permanent erection un- til the death of the patient. The reaction, of course, was consi- derable after the reception of the injury, and it is reasonable to suppose that the portion of the encephalon nearest the foreign bo- dy must have suffered most, from the consequent inflammation. In this case one might suppose that the priapism was occasion- ed, partly, by the stimulus of the excessive quantity of urine ac- cumulated in the bladder ; but, this supposition is completely set aside by the first case, in which no urine at all was secreted for nearly thirty-three hours, and yet the priapism was as complete as in the second case ; and again, in the latter case, the evacua- tion of the urine produced no change whatever in this singular symptom. Those who have any curiosity to look further into this sub- ject, are referred to the work of Gall on the functions of the brain, Spurzheim's system of phrenology, and Baron Larrey's surgical observations. The object of this article is not to discuss the principles of phrenology, or to enter into an elaborate defence of the science, against the many unfounded and unjust imputa- tions which have been brought against it, but merely to give two cases, which certainly claim some merit as facts in proof of the science. Many of our readers will be inclined, no doubt, to underrate the bearing which these cases have upon the point in question, but we feel assured that strict observation cannot fail to render almost positive, even with the most skeptical, many of the positions maintained by the advocates of the doctrine ; for the truth of the fundamental principles of phrenology may iioav be considered as established upon too firm a foundation to be 1 836.] Injury of the Head. 1 55 overthrown by the ridicule of its opponents. The science has recovered from the momentary shock which was given to it by this once powerful engine. Facts are now looked upon as more important than opinions, though the latter may claim high sour- ces as their origin, and appeal to the consecration of antiquity. These are no longer a barrier to the investigator into the laws of nature, and fashion now possesses no terrors to him, who seek- ing for truth, resorts to the universal volume, in which the hand of Infinite Wisdom has inscribed His immutable laws. The science of phrenology is based upon observation, and our oppo- nents must resort to the same course before they can hope to ar- rive at their ultimate end. Ridicule we do not fear, and aa appeal to observation is all we ask. If the science be contrary to facts, let it perish ; but, ifsup.poi ted by the truths of nature, its own omnipotence will vanquish every foe. Augusta, July 1st, 1830. ARTICLE VIII. Remarkable case of fracture and depression of the parietal bone, from which the patient recovered, without the operation of tre- panning. By B. B. Strobel, M. D., Lecturer on Anatomy and Surgery, Charleston, S. C. I was sent for in haste on the 14th day of March, 1830, at 4 o'clock, A. M., to Mr. L * * * * *, on board of the French ship Isaie. He was lying on the deck in a state of extreme pros- tration, uttering a feeble cry. His extremities were cold, coun- tenance pale, lips livid, and pulse scarcely perceptible. The first indication under these circumstances, was of course to produce reaction. I ordered off the crowd which had col- lected, so as to admit the access of fresh air, and had the pa- tient's head sustained by an assistant, whilst I dashed cold water in his face. Reaction ensued, and the patient was conveyed 1 56 Injury of the Head. [ A ug*. upon a litter to an adjacent house, and v i *1 in an airy room upon a comfortable bed. The patient being now in a situation where I could operate advantageously, I proceeded to an examination of the injuries which he had received. I observed an extensive lacerated wound of the scalp, corresponding to the right parietal protuberance, and by the introduction of my finger into the wound, ascertain- ed the existence of a fracture and depression of the parietal bone. The fracture was about fourteen lines in length, extend- ing in an oblique direction from the anterior superior to the pos- terior inferior angle of the bone. The depression, which was very evident to the touch, was from six to eight lines in depth. My attention was next directed to an injury of the right leg, where I found both bones (the Tibia and Fibula) fractured. The extremity of the tibia projected through the lacerated integu- ments on the internal side of the leg, about four inches above the ankle joint. The patient was about thirty-five years of age, of good habits and sound constitution. The following statement was. made to me of the accident by which these injuries had been inflicted : Mr. L # * ** * was first mate of the ship, which had been "hove down" for the purpose of examining her keel. The ne- cessary repairs being completed, she was righted, and two sail- ors were ordered to unrcave the fall and send down the block from aloft. They neglected to make it fast to a rope, and threw it off from the main top, from whence it descended on the 1 of the mate who was walking on deck. He was immediately struck to the ground, falling on his left side, and receiving the mass on the outside of his right leg, both bones being fractured by the concussion. That symptoms of compression would ensue, was to my mind almost certain, when 1 took into consideration the severity of the blow, and the extent of fracture and depression. I therefore prepared my instruments, and held myself in readiness to per- form the operation of the trephine. Indeed, J was disposed to proceed at once to the operation, as night was rapidly ap- proaching, and it seemed better to operate by daylight in anti- cipation, than to wait for symptoms of compression, with the chances of an operation by night. A moment's reflection, how- ever, and a reference to the opinions of the best authorities, de- 183G.] Injury of Ih U a '. 157 terminal me to defer it, until ito'genthj demanded by the necessity of the case* In the mean time, I adopted such precautionary measures as were calculated to keep down excitement, and to prevent determination f;> the head. The wound of the sc:dp was freejy laid open, and fomented with clodts wrung out in warm water to encourage hemorrhage, and a stimulating in- jection administered. The injury of the leg was m xt attended to the hones were properjy adjusted, and easily kept in place by the ordinary splint and bandage, the fracture being trans- verse. I visited the patient several times in the course of the evening, and saw no material alteration, the hemorrhage from the wound had been considerable, the injection had operated well. The * We are principally indebted to Desaiilt for this improvement in modern Surgery. By the ancients the operation was performed in all doubtful ca- ses. Their practice was adopted and received without its merit being ques- tioned, until that justly distinguished Surgeon was induced to doubt.its pro- priety, from having remarked that it seldom succeeded at the Hotel Dieu at Paris. lie therefore declined trepanning in cases of fracture, without depression, or effusions of blood, and this practice, which in his hands was attended with great success, is generally adopted now-a-days. Sir Astley Cooper in his lectures commends this course. Larrey, in his Surgical Memoirs, page 117, makes the following remark : " The trephine should not be applied in wounds of the head, accompanied bv fracture of the bones of the cranium, whatsoever may be the extent of the fracture and the number of the radii, if the fragments of bone be not driven inward?, no foreign bodies present, or symptoms of compression not i evident." Boycr in his Traite J"s Maladies Obnrurgicale^ entertains similar opin- ions : " ?.Liis lorsqu'il n'y a ni enfoncement, ni epanchemenl de san~, on no tr. pane point ; on s'en tient aux moyens generaux, tels que les saignces du bras et du pied, les purgatifs, surtout remetique en I Lvage, qui procure des evacuations alvines abondantcs sans irriter bcaucoup le tube intestinal." vol. v. page ?.">. "The instances of death, after the setting in of inflammation from very trilling causes, are of almost daily occurrence, and would induce us to anti- cipate its certainty after all violent injuries : but it is a great mistake, now acknowledged by the best Surgeons, to suppose thai every depression re- quires an elevation, and every fracture the interference of art ; although it is a common one fallen into by the juniors : and even among the older ciass I have seen operations attempted on very unnecessary occasions." II- li- nen's Principles of Military Surgery. 158 Injury of the Head. L^ug. fomentations were continued to encourage the oozing of blood. About 8 o'clock at night, however, a very evident change for the worse occurred. The pulse had risen, was full, hard and slow. The patient complained at first of a violent head-ach, which was soon followed by drowsiness, stupor, and difficult and ster- torous respiration. Notwithstanding the unfavorable state of the case, I resolved to make one more effort for the relief of the patient, before resorting to the operation. My impression was, that the symptoms of compression were produced rather by a fullness of the vessels, than by the depression of the bone. Had the symptoms depended upon the latter cause, they would have shown themselves, soon after the occurrence of the accident. Four hours had, however, elapsed, before they began to be mani- fested it seemed, therefore, reasonable to conclude, that the subsequent determination of blood upon the brain, which took place, when full and perfect reaction ensued, was sufficient to account for their occurrence. The remedies which I proposed, if they proved beneficial must be prompt and efficient in their action but little time would be lost in giving them a trial, and there was a possibility of avoiding a serious and dangerous operation. I tied up the arm and bled the patient until he fainted tap- plied cloths wrung out in cold water to his head, placed his feet in a tub of hot water, rendered more stimulating by the addi- tion of mustard, and gave an injection composed of spirits of Turpentine and Molasses. The conjoined effect of these remedies was soon evinced. The difficult and stertorous breathing, stupor, drowsiness and head ach disappeared, and the pulse became soft and natural. I was not, however, satisfied with having attained this much, but de- termined if possible to prevent a recurrence of the unpleasant symptoms. Cathartics were not only likely to keep up a con- stant drain from the bowels, but were also calculated, by their irritating impression on the intestinal tube, to counteract deter- mination to the head on the principle of revulsion. The furred condition of the tongue, also seemed to indicate the propriety of their administration. I therefore ordered 15 grains of Calomel to be given immediately, and in two hours after taking it, a wineglass full of a saturated solution of Epsom Salt every hour "pro renata." 1836.] Injury of the Head. 150 I visited the patient at 12 o'clock. His Medicine had operated several times. No return of head ach pulse natural skin warm and moist directed the solution of Salts to be continued, the same dose, but at intervals of two hours. March 15th, 5 o'clock, A. M. The patient doing well, pulse natural, skin moist and warm, tongue clearing off, no uneasiness about the head.- The medicine had operated ten or twelve times, producing large watery stools, mingled with bile. Or- dered the Cathartic to be discontinued, and the patient to be kept on a diet of arrow root, rice or barley water, and cold water. From this hour the patient complained no more of his head, although he suffered much from his leg. I visited him several times during the day, and observing no returning symptoms of compression shaved the scalp and approximated the edges of the wound with adhesive straps. It healed as kindly as could have been expected, in part by granulation, and in part by the adhesive process. The patient wras kept on a rigid system of low diet for twelve or fourteen days, to prevent a recurrence of the unfavorable symptoms. In the course of five weeks the wound of the scalp, had entirely healed the depression of the bone remaining very evident. The fracture of the leg had so far united at the expiration of six weeks, that this individual was enabled to return home in the vessel. After the recovery of the patient, I had the curiosity to make an examination of the block. It was what sailors term, "a three sheave block," used at ship-yards for heaving down vessels. It was bound with iron hoops or straps, and weighed two hun- dred and fifty pounds. It really seems surprising, (almost incredible.) that such a mass should have fallen from a distance, upwards of thirty-five feet, on the head of a man, without instantly killing him. Cut the result is easily explained by a reference to mechanical princi- ples. Had an iron ball or any hard irregular shaped substance fallen from the same height upon the head of an indivi- dual, it is more than probable, that the fracture and depression which would have resulted, together with the consequent inju- ry of the brain, would have been attended with fatal consequen- ces, and the reason is obvious the whole momentum would have been communicated at a given point. Here, on the con- trary, we have a large mass of great weight, with smooth round- *60 hiju LAl,,r- ed surfaces slrHiing obliquely the momentum bei reat as instantly to throw the body from the line in which i was falling'. " Had th< sam< mass fallen frcm the same dists ? in a straight lin ead of striking 6bliquely, the ce vvhich the body would hafce offered, would probably have shattered the cranium to>atams>hut would in all j tlity have crushed the bones of the inferior extremities, ; well as many of the bddy generally, f It is thus by the application of the principles of Physical Science, that we are enabled to ex- plain the nature of injuries, and not unfrequently to* deduce our prognosis. * Mr. Quesnay, in an essay od the use of the trephine in doubtful cases, (published in the 1st volume of the ?! >,,';.- s de I'Academie Royale dc Chi- rurgie,) slates "that a stone of twenty pounds weight tell perpendicularly from a heighl on the head, and occasioned no fracture, whilst a blow from t lie list on the temple produced a fatal eif Vision." There can be no doubt that the force of the blow from the stone was greater than that inflicted by the fist. How then can we explain the diilerent results, except by the angle of incidence ? the blow from the fist being direct, or in a straight line, whilst the stone must have struck obliquely. I once made a post-mortem examination of a woman who died from a rupture of a blood vessel on the brain, producing effusion within the cavity of the cranium. This injury fol- lowed a blow on the top of the head from the fist of a man. The woman was an habitual drunkard, and had brought on a condition of the vessels, which predisposed them to rupture. It therefore became a very nice point of me- dical jurisprudence to determine, whether such a blow under other and favorable circumstances would have proved fatal. { By calculation the momentum may be ascertained with some degree of accuracy. The following process may not prove uninteresting. Let the quantity of matter (M) = 250 pounds. Space through which it foil (S) = 30 feet. Space through which a body falls in one ,\ cond, (M) = 16 icet. Then {Oh mics, An. 53.) T (time of falling) = y/l = yj \[~- \ seconds nearly V (velocity acquir- ed hi that time) 2 m x T = 2 X 1G x -A =40. This di \ for re- sistance of atmosphere, etc. leav< s3*2 for the velocity. T1;" momentum would th refore be equal to M x S = 250 x ''- 8000, a force sufficient to crush a man's skull to pieces, had it fallen upon it directly. This however did not, occur m the preseni instance. Let us th poi e that . from the perpi i 0 degrees, i.e. at an angle of * I s. This by the resolu- tion of forces would give for its momentum, the si ht angled triai'/ i - L330.] Injury of the Head. 161 [Cambri tge Trig. Art. ' '. BC - 8000 A = 30 n 60 As Radius 10,00000 ito BC. 8090 3,90309 jsin. C 30 9, 897 to AD -1009 3,60206 Vri: 18 of the same.) Here the n a is reduced to just; one half of what it was at first. Four ll . however have crushed the scull to all intents and purposes, as effectually, as 8000, had the head been confined in its posir by a force equal to tjie momentum. But as the resistance offered, was only that of the muscles together with the inertia of matter, which in this case may be estimated at 100 lbs., we have the. force of infraction greatly Med. For action and reaction being equal itis evident that the force of the stroke must have been equal to the momentum lost by the body (block) in the concussion. This we ascertain as follows : (Sec Cavallo part 1, art. 2.3, 24.) A (Block) == 250 B (Head) = 100 V (velocity required to make the momentum of 250) = 4000 A B V 250 x 100 x 16 = 400000 = = _. 1143 lbs. A -f B 250 + 100 == 350 Momentum lost, or force of percussion, supposing the block to have struck with its center, but as it probably did not strike with its centre the force of the blow would again be modified by this circumstance, and probably not exceed a force of 5 or GOO pounds. This proposition may be rendered more intelligible by supposing an iron or other metallic weight of 1000 lbs. to fall di- rectly from a moderate height, upon a leaden ball resting on an iron floor the effect would be to flatten the ball. If however both were freely suspended and the weight made to impinge against the ball from a distance equal to the height from which it had fallen directly upon it, the effect would be no1 to flatten, but to send it off with oreat velocity. 1G2 Grey Sulphur tyring*. [Ar-u- Part II. REVIEWS AND EXTRACTS. Account of the Mcdiccit I Properties of the Grey Sulphur Springs, Virginia. Charles ton, printed by A-. ii. Miller, lbS&v. p. p. 18. It is not every bearing of our professional duties which is cal- eulated to add directly, and some of them not eyen remotely to* the dollars and. cents of our annual income. Indeed, some ot> the most dignified and honorable duties those to which the profession is largely indebted, for the respectable rank it enjoys-; amongst the liberal and exalted callings* instead of ever tending, to pecuniary gain, have only for their reward the happy con- sciousness of having discharged duties to humanity at our own expense of having done good to our friend* our neighbour > not only by being accessary to his welfare, but also in effecting this good at the least possible expense to him. Such arc the duties of searching out and effecting the correction of local cau- ses-of disease instructing the community on- the subject of in- jurious customs, habits or fashions ; as imprudence in dress, in- dulgence in the enervating, health-destroying luxuries of lifer &LC. &LC. These duties when faithfully performed', tend most certainly to lessen, to a greater or less extent, the sum' of physical evil* to which humanity is subject ; and thereby diminish the calls oru the practitioner.. Their faithful and abundant performance i properly considered as an indication of the in-dwelling of that humanity and benevolence which are the diamonds and rubies- among the jewels in the professional casket. If aught in man- can be disinterested, such must be these noble deeds. And here we would not withhold a tribute of respect due to the medical men of the world, and particularly of the United States ; not individually, but as a community, for the noble stand they have taken in the temperance reformation. Regardless of the effects of the wrath of those whose income from the grossly immoral manslaughtcring custom of traffick- ing in intoxicating liquors would be lessened by their successful influence on the community, they have exercised a noble deci- sion, and independence of character, most honorable to any fra- ternity or class of men. They have, in many instances, know- ing that their daily bread must come from the popular favour around them : and, regardless of self-interest in the virtuous hope of arresting the fatal progress of a mighty and devastating torrent, filled with the worst of physical and moral enemies to humanity, dared to bring forward the armamentary of their conclusive testimonials and pathological science, and occupy with unwavering firmness the posts i f greatest danger. V836.] Grey Sulphurr Sjorings. MB Nor have fbey been merely passive watchmen on the ram- frizes of health and morality, but have led. the croisnde against .a ruinous and mighty enemy to both, which was cherished, like the frozen viper by I he husbandman, in the houses of their best friends sanctioned, like all vice familiarized by universal ap- probation ; and made strong and resisting, like the chains of superstition, by the habit of centuries. We have been led to these reflections by reading tlrc little pamphlet described at the head of this article, and searching for the reason for the infroquency of the prescription of mineral waters by physicians. As medicinal means afforded by a kind Providence for the relief of human afflictions, mineral waters -should be regarded as amongst the most important. Nor are there any good reasons why they should not be used in medical (prescriptions with as much promptness as any other articles of tthe materia medica. We may say, and with truth too, that these are articles with which, from their distance, and want of observation of their opera- tion, we have not become so familiarly acquainted, as with the articles of commerce which are found with the apothecary. But this should not be so. These natural productions are not less worthy of our attention than other mineral, vegetable and animal productions, which make up the sum of our .ressmedieoa. For when the whole assemblage of all things an&erreum stances (brought into operation by a travel to some watering place, is better calculated to imeet the necessities of our patients, than our protracted and too often unsuccessful attempts to imitate by art what nature has better prepared, it becomes our imperious duty to prescribe them. Nor w'ffl that ignorance of them which may prevent our knowing their superior powers, fully excuse us ; for it is not only the duty of the practitioner to do for his patient the best he knows, (a common, but not a very .flattering recommendation by the way,) but it is to do the best that can be done. The infrequency of these prescriptions cannot be -attributable to the desire of retaining the business of the patient in hand. Such a charge cannot hold at the present day amongst those who merit a place in a profession in which the purpose of ma- king a fortune, or even a competence, must be secondary to that of doing good to suffering humanity. And such is the profes- sion of medicine ; and he who cannot subscribe to, and act upon this principle, should be as promptly proscribed as one who would traffic or indulge in the use of intoxicating drinks. In the pamphlet we are presented at once with two most im- portant medicinal powers ; the productions of no Swaim nor Mo rison imposition or secrecy ; but of the pure and perfect labora- tory of nature, accompanied with a qualitative analysis of their 'elements, and satisfactory attestations of their operations as anedicinal powers. 164 Grey Sulphur Springs. [-^ll3 For the benefit of the profession, and through them, of the community at large, we give a few selections from the pat of the pamphlet itself: for we think these, as well as m >sl other medicinal means, suffer great loss of good effect, and con- sequently, loss of character to say nothing of the injuries they effect, in consequence of a promiscuous and unscientific adop- tion of their use. And we would here say in passing, to such (if such there be) as would dislike too much the loss of their daily attendance, to recommend their patients to a course which would compel their absence ; that it were better to make the prescription, and satisfy their thirsty avarice by a bold de- mand at once on the pockets of their employers for the prescrip- tion, than not to make it at all. On the first page, the location of the Springs is thus de- scribed : "The Grey Sulphur Springs are situated near the line, dividing the coun- ties of Giles and Monroe, Virginia , on the njain road leading from the Court-House of the one to that of the other. They are three quarters of a mile from Peterstown, nine miles from the Red Sulphur, and by the County road, twenty and a quarter miles from the Salt Sulphur Spring. In travel- ling- to the Virginia Springs, by either the main Tennessee or Goodspur Gap Roads, and crossing the country from Newborn, by the stage road to the Sulphur Springs, the Grey Sulphur are the first arrived at. They are thirty miles distant from Newborn. The location is such as will admit of many and varied improvements, which when completed, will render this spot an elegant and desirable resort during the summer months, indepen- dent of the high medicinal properties of the mineral waters." On the same and following pages, we have a description of the Springs : "There are two Springs at this establishment, situated within five feet of each other, and inclosed in one building. Although rising so near to i otiier, yet they differ most materially in their action on the system. Both appear to be peculiarly serviceable in dyspeptic cases, and in such as origi- nate in a disordered state of the stomach the one, in those in which inflam- mation exists, the other in such as proceed from torpidity. They have hitherto been known as the large and small Springs ; but having succeeded towards the close of the last season in procuring a much larger supply of r at the small Spring than is afforded at the large, a change of names ime necessary. The large will hereafter he known as the Anti-dyspep- tic, and the small as the Aperient, winch names wdl serve to point out their peculiar characteristics. "Thei e Springs have been classed by Professor Shephard, as AVcalino i\- so i- ' ly met with, that another is not known to elsewhere in th( United States. The waters are beautifully clear; ai i liighly charg< 1 v ith gas, which render them light and extremely plea- sant, thei iti-dyspeptic Spring, which produces none oi tho- unpleasant sensations so frequently felt on the first drinking of mine- ral v \V; . me f the water was submitted to a. chemist for analysis ..the qua;" ' DO small for him to ascertain all its I has been made by Professor C. IJ. Shcnhard, who has famished us with the following abstract of an articlq 1836.] Grey Sulphur Springs. 103 which appears in the April Number (1836) of Professor Silliman's Journal of Science and Arts." "The following is the most satisfactory view which my experiments ena- ble me to present of the condition of these water.- : Specific gravity, 1,003. SOLUBLE IXGREDir.VTS. Nitrogen, Hydro Sulphuric acid, Bi-Carbonate of Soda,* A Super Carbonate of Lime, Chloride of Calcium, Chloride of Sodium, Sulpliate of Soda, An Alkaline or earthly Crcnafe, or both. Silicic acid. INSOLUBLE INGREDIENTS. ' , Sulphuret of Iron, Crenate of Per Oxide of Iron, Silicic acid, Alumina, Silicate of Iron. My experiments do not permit me to point out the differences between the two Springs with precision. The new Spring appears to give rise to a greater amount of hydro-sulphuric acid, as well as of iron and silicic acid. Probably it may differ in still other respects. I have not examined it for Iodine or Bromine. As no regular analysis was attempted, the quantities in which these seve- ral ingredients exist, still remain undetermined. That they are in different proportions in the two Springs, is evident rot only from their depositee, but also from their action on the system. The action of th anti-dyspeptic Spring is diuretic and gently aperient, tending to restore the healthy per- formance of the functions, and reduce or diffuse the local irritations or" dis- ease. The Aperient Spring wThile it possesses all the alkaline properties of the other, has an aperient and alterative action. Possessing more iron, (of which the other has but a trace,) it acts more powerfully as a tonic, whilst its other ingredients cause it to act in some cases as a very powerful aperient. As these Springs have been visited by invalids, only during the two last seasons, it is reasonable to suppose that all their properties have not yet been discovered, nor all the cases ascertained in which they can be bone finally used. In fact, owing to the small quantity of water furnished hither- to by the Aperient Spring, its qualities have been but little tested, and there can be no doubt, (judging from its constituents) that it will be found equ salubrious as the anti-dyspeptic Spring, only better adapted to another class of cases. To give a general idea of the properties of these waters, we might say that they are peculiarly serviceable in those diseases which originate in a disordered state of the stomach and bowels, and also in he- patic affections. It is proper, however, to enter more into details, and we therefore submit the following synopsis of the medical properties of the etntUdyspeptic Spring. Medical Properties. 1. It relieves nausea and headachs, arising from disordered stomachs. 2. Neutralizes acidity, and if taken at meals, or immediately after. * It cannot be determined whether free carbonic acid exists in tin tors without going into a quantitative analysis. C. U. S. 1GG Roslan on Diagnosis* I Aug. a tendency to prevent those unpleasant sensations so often experienced by invalid?, from indiscretion in dieting*. Jl> Is an excellent tonics exciting- appetite and imparting strength to di- gestion. 4. Quiets irritation of the alimentary canal. 5. Controls and lessens the force of the circulation when unnaturally excited by disease, and often in this way, is remedial in internal inflamma- tion of the organs. 6. It tranquilizes nervous irritability. 7. Is a mild and certain expectorant, often allaying dyspnoea, and pro- moting recovery from chronic ailments of the chest or wind pipe. 8. It alters the action of the liver where this has been previously de- ranged, in a manner peculiar to itself, and under circumstances in which the ordinary alteratives are forbidden by reason of their exciting, or other- wise irrelevant properties. 9. It is also sudorific or diaphoretic ; and 10. When taken at bed-time, often proves itself soporific : apparently stilling that indescribable, but too well understood inquietude, which so fre- quently and unhappily interrupts or prevents the repose of the invalid, and especially of the dyspeptic." Next follow seventeen minutely and well detailed cases which have been subjected to the powers of these waters, which tend most satisfactorily to sustain the above account of their medici- nal virtues : to which we may add, by looking over these cases, a peculiar and valuable power of so allaying vascular irritation, as to reduce with great promptness the morbid frequency of the pulse, &c. In addition to the testimonials of the medicinal powers the pamphlet contains, the originals of which, with their proper signatures, are in the possession of John D. Legare, of Charles- ton, we have found in several instances corresponding evidence in the accounts given by invalids who visited these Springs in 1835, and- with whom we have conversed. The pamphlet concludes with the decided and favorable judg- ment of Professors Moultrie and Dickson, of Charleston, from the testimonials submitted to them : and the time has gone by when such men as Moultrie and Dickson may be expected to give their names to an expression of approbation which is not fairly deduced from sound premises. Rostan on Diagnosis. We know of no better appropriation of a few of the pages of this journal, than to the insertion of the following extract from a work rarely found in the hands of the American practitioner ; 1836.] Rostan on Diagnos s. 1(>7 to whom it is of too much practical importance in every day's business, to await the circulation and reading of an entire trans- lation of the whole work, should it be ever offered to the Ame- rican public. We feel assured that a diligent attention to it cannot fail to add greatly to the facility and clearness of Diagnosis, and con- sequently to the correctness and value of therapeutic efforts. On the mode of interrogating and examining a patient, and of recording cases. Translated from Rostan's Work on Diagnosis. Nothing is more embarrassing to the physician commencing the practice of his profession, than the act of interrogating and examining a patient. Indeed, this part of the art, of undoubted importance, since without it we can arrive neither at a sure diagnosis nor a rational treatment, is so ne- glected, that few practitioners, even among those of great experience, acquit themselves in a creditable manner. We frequently remark the in- coherence and disorder of their questions, their uncertainty and hesitation ; losing sight of certain fixed principles, we see them passing without motive, from one object to another, between which there is no connection. They repeat unnecessarily the same questions, and those immaterial ; they forget the most important points ; they confound subjects the most dissimilar, and separate those having the greatest similarity ; and to crown the evil, they are involved in obscurity, and by the merest accident, arrive at a just diag- nosis and at a rational plan of treatment. All these disadvantages are the result of a defective order of a want of method. On first approaching a patient, we almost involuntarily examine Ins exte- rior : his physiognomy first attracts our attention ; at first sight, we form an idea of his age, his strength, his mcro-1 state, &c, circumstances of great importance, connected as they are with the prognosis and the thera- peutic indications. This first examination should not be confined to the head, but extended to the whole surface of the body ; but unfortunately, this can be done only in a very few cases, particularly in private practice. At least, we must not dispense with the examination of the part affected ; if neglect- ed, it is at the hazard of committing the gravest errors of diagnosis and treat- ment. Some examples will illustrate the utility of this investigation. An aged female, of limited intelligence, was brought to the infirmary, &c. She complained of a violent pain in the abdomen, about the left iliac region. The face was animated, the skin hot and moist ; the pulse strong and fre- quent, tongue dry, thirst urgent ; otherwise the digestive functions in a na- tural state : little or no change in the other organic or animal functions. The abdominal pain was increased by pressure and by motion. Behold our diagnosis ! The phenomena of reaction [the strong pulse, flushed face, thirst, &c] indicate an acute state of disease, doubtless inflammatory; the local symptoms point out the abdomen as its seat, but the digestive functions being in a normal state, it cannot be in the organs of this function ; as the slightest pressure is painful, the disease must be superficial ; and as the slightest motion is painful, then the organs of motion must be affected. Tlie muscles of the abdominal parietes must be diseased ; although rheumatism, especially in old subjects, is not usually attended with such marked symp- toms of general reaction. Satisfied with this reasoning we left the patient, after prescribing a weak infusion of cumfrey, an enema, diet and rest ; when a student, having exposed the part to view, discovered the existence of zona ! This lesson impressed us more forcibly than ever with the necessity of using mr senses, as tlie only means of positive knowledge. A patient after a fall, experienced pain in the left side of the chest ; there was also cough, and bloody expectoration, with symptoms of general reac- IoS Rostan on Diagnosis, [A.ug. tioa. One of the most experienced and attentive pupils was charged with tha examination of the case, lie arrived at the conclusion that the diss ase was - umonia, inasmuch as the cough and bloody expectoration in- dicated the lungs as the seat of the affection; and although the pain, very \ dent on pressure and on the motions of the chest, might possibly be seated ia the pariet^s of the chest, yet the general symptoms indicated a more profound affection of the lung itself; moreover, by the stethoscope the orepitous rale was discoverable. Behold.' titers was afractur of it ribs. uredly, an attentive examination of the diseased region would hav< se- cured him from falling into so grievous an error. The examination then of the exterior of the 'body, and especially of the regions diseased, is of the utmost importance. We should propose it to ourselves as the definite object of this examina- tion of a patient, to obtain a knowledge of the'" disease and of the curative judications, as promptly and certainly as 'possible. There are those physi- cians who -continue this examination for a length of time. In some rare cases this method maybe preferable. People generally love to receive our attention to their cases they love to entertain their physician with the least circumstances of their constitution, their antecedent dii , then* manner of living, &c. The physician in listening to- these superfluous de- tails, and even in encouraging them, secures the confidence of his patient, and inspires him with the hope of relief at liis hands, and thus produces a cerebral disposition favorable to the resolution of the disease; for the brain, holding all the organs of 'the economy in dependence upon it, we perceive that its state, whether good or bad, will exercise upon them an in- fluence salutary or hurtful. But, how many circumstances there art. un- der which this protracted method would produce unhappy results r In all the diseases of the respiratory organs for example, haemoptysis, peri-pn* u- monia, pleurisy, catarrh, phthisis, is it not very dangerous to encourage the patient to speak for a length of time ? If a suffering organ is thus exercised, shall not the disease be increased? Will not the spitting of blood be more abundant, or if checked, will it not thus be renewed? Will not the inflam- mation of the various tissues be thus increased in intensity? In such ca- ses, the man whose office js to soothe and quiet pain, and heal the sick, may thus by this method, become himself the cause of increased suffering, id even of death. These same remarks are strictly applicable to the diseases of the brain ; indeed, in these last cases, by multiplying your questions, you act directly upon the diseased organ. It is then, in the great majority of cases, of the utmost importance, to trouble the patient with as few ques- tions as possible, and to accomplish, our object promptly. The first question that we should address to a patient is this : Where is your pain ! This question, which at first sight seems so simple, long ex] ,- rience and reflection commend as the best. Patients are remarkably prone to give their opinions about their diseases ; one will tell you he has a nervous affection, another that the bile torments him; this one that, his blood is diseased, and the other that the humours are disordered; and fe- males are ready to refer to milk diffused and misplaced as the cause of their diseases. We will not fail to receive souk- such answer, if instead *of the question above, we ask How arc you ? Now, if the patient answers, I have a nervous affection, &C., we have gained nothing, but in reply to the other question, he will very generally indicate both the function and the or- gan diseased, which is an important step towards the knowledge of the dis- fsotwiihs-tanding the precision of this question, if is. frequently im- possible to check this disposition to speculate upon their diseases. Some- times they will mistake one organ for another, complaining of pain in hte stomach; when the chesl is ' cted, &c. il istlien f< re-important, in order ti tvoid all possibility of mistake, to insist on the hand being applied over the painful region. lvS.'U).] Rosffin on Diagnosis. 109 There is one other question not less important than this first one, which will much abridge the labour of investigating the case. This question is eminently analytical How long hare you been sick? If the disease be re- cent, we then at ouce exclude from our attention all the chronic diseases to which the organ now affected is liable if it has existed for a long time, we then concentrate our attention upon its chronic affections. This ques- tion then is scarcely less useful than the first. After discovering what function is injured, we should pursue the examina- tion, until we shall have passed in review, all the morbid phenomena which it is capable of presenting. This object accomplished, we should then fix our attention upon the organs most closely connected with the one diseased, and examine their state with equal care : indeed, we, should then proceed to examine all the organs and all their functions, without any exception. This precept should never be neglected, for by this examination, thus care- fully made in the commencement, we acquire an exact knowledge of the sympathetic phenomena. When an organ is profoundly altered, it reacts upon others, disturbing their action and altering their organization ; how shall we be able in the progress of the disease, to recognise such alterations as consecutive, if we have failed to acquaint ourselves with the state of these organs at its commencement ? Again, by this general examination, we inform ourselves of the existence of concomitant diseases ; for it frequently happens that many diseases exist simultaneously in the same individual. The patient then points out the most prominent of these diseases, and if the physician be satisfied with the diagnosis of this one disease, he will overlook the others, and may subject his patient to a fatal treatment. This, unfortunately, is not an unfrequent occurrence. Satisfied with dis- covering the existence of one disease, we are disposed to forget that others may exist. We cannot, then, insist too much upon this precept, that we examine with the most scrupulous care all the organs of the animal economy and the state of all their functions, at the commencement of every disease. After examining the patient in this manner, we should acquaint ourselves with the state of the organs in the various cavities ; for this purpose we resort to percussion and auscultation for the chest, percussion and feeling, for the abdomen, &c. Percussion of the thorax is executed in the following manner : the patient should be seated, and present most prominently the parts of the thorax to be examined if we examine the back, the head sltould be bowed, the spine curved, the arms folded on the breast ; in this attitude, the back is most fully developed, and its muscular covering as thin as possible. If we would examine the side, the arms should be alternately raised upon the head, and the body inclined successively to the side opposite the one we are exploring. For the anterior part, the recumbent position is preferable, with the arms separated from the trunk. It is almost needless to add, that there should be as little clothing as possible. The physician, having united his fingers in the form of a cone, strikes successively the different regions of the thorax, taking care to compare the corresponding parts of the two sides only, and to strike these always at tli same angle not comparing the sound which percussion renders, when made upon the intercostal spaces, with that which it renders when made upon the ribsand proportioning the force to the thickness of the thoracic parietes, and especially to the degree of sensibility of the patient ; for there are cases, in which the degree of pain forbids this mode of exploration. On examining the chest of a sound man, by percussion, we obtain a sound which we may compare to that of a tambour covered with a thick cloth. This resonance is most remarkable at the anterior, superior and lateral part of the thorax ; it is less in the back, upon the shoulder-blades, in the re- gions of the heart and liver. In some thoracic affections, this reverbera- tion, which depends upon the presence of air in the pulmonary cells, ceases, 22 HO Iioslan on Diagnosis. [Aug _ and in others it augments. In the first case, we obtain a dull sound, on- percussion, which has been compared to that produced by percussion of the thigh ; we may then conclude, either 1st, that the air no longer penetrates into the pulmonary tissue ; or 2d, that either a tumour or a fluid is inter- posed between the lung and the side of the chest. If, on change of position, the dull sound also changes its location, and occupies t! e- most depending position, while the clear sound is heard in the most elevated part, we may infer that the cause of dulness is a liquid body. Percussion is one of our most certain and profitable means of examina- tion. It seldom deceives those who practice it with skill. But it is neces- sary to pronounce cautiously upon slight differences ; that this sign may be valuable, it is neeessary that the ear be able to distinguish the difference of! sounds from the two sides of the chest, that exists in numerous cases. As to the increase of this resonance, it depends upon the fact that the? thoracic cavity contains more air than natural. As we shah have occasion to recur to this subject, we will confine ourselves to the remark, that this phe- nomenon may lead us into a singular mistake it may induce us to believe that the side which resounds most perfectly is the sound side, and the other- side is diseased, which is the reverse of the truth. But if percussion be thus useful, it is not without its inconveniences. lit the first place, it compels us to throw the patient into fatiguing positions, and" the efforts he thus makes, may exasperate the disease.. In the second placer. the acute diseases of the chest in which we chiefly resort to this mode, hap- pening generally in the winter season, it is to be feared, that the impression- of the air upon the chest nearly naked, may coincide with the original cause and augment the disease. Finally, we should dread dangers from the act itself, since it is impossible to strike thus in the region of pain, without ex- tending a hurtful shock to the suffering part itself. These inconveniences are such as almost to balance the advantages of this plan; at least, we- should resort to it only when the diagnosis is obscure, and when iL, may fur- nish some important indication ; when the diagnosis is sufficiently clear, we should abstain from it. Recently, M. Piorry has contrived to effect percussion, by applying upon the region to be examined, a thin plate of wood,, of metal, or of ivory ; by this means he avoids the inconveniences of immediate percussion, and obtains^ more exact and precise results. This mediate percussion is less painful than the direct ; the shock and commotion of the organs are scarcely perceptible ; we may practice it over the clothing and upon soft parts ; serous infiltration of the sides of the abdo- men or thorax, excessive fat, even a blistered surface will not hinder this mediate percussion. It is more easily practised, and the mode of applica- tion being constantly the same over all the regions, there will result no dif- ference of sound occasioned by the process itself which we cmplo)', so that we can determine exactly the regions corresponding with certain organs, measure their dimensions, estimate their consistence, &c. It is in abdomi- nal percussion that these advantages are most conspicuous. By means of this instrument, M. Piorry recognizes numerous varieties of sounds, which he has endeavored to express by the terms femoral, jecoral,. cardial, pulmonary, intestinal, stomachical, osteal, humoral, hydafic, o- *0n >n ^n to *-< ^0 2 *% p << *% >% !^*r r>r FK- *** REMARKS. 1 2 a 4 5 a ? 8 9 10 11 12 13 14 15 48 66 65 52 46 50 51 58 60 62 67 67 59 52 52 65 73 72 53 50 59 62 63 70 62 77 78 64 62 50 Cloudy. Cloudy. Rainy. 16 49 63 17 50 62 18 62 70 19 64 64 Rainy. 20 68 76 21 61 GQ Cloudy. 22 63 74 23 60 68 24 63 78 25 71 78 26 70 78 27 64 70 Cloudy. 28 60 60 29 62 74 30 65 70 Rainy. By this it will be seen, that the average temperature in Burke, at sunrise, is about e- qual to the average temperature here, at 10 o'clock, A. M. and that the average at 12 o'clock in Burke, con- siderably exceeds the average here at 3 P. M. which is about the hottest hour of the day. 21 G Medical Education. [Sept. ARTICLE VI. Medical Education. By Joseph A. Eve, M. D. Professor of Therapeutics and Materia Medica, in the Medical College of Georgia. The present defectiveness of medical instruction in the United States is acknowledged and deplored, by the most enlightened and distinguished physicians of our country. But so long have these defects and abuses existed, so sacred have they become by age and custom, that it is believed innovation would be attended with difficulty, if not danger, and that the necessary and much desired reform must be the result of a gradual change of public sentiment, the conquest of light and principle, the work of time. No one can be more zealous for a radical reformation in our Colleges than an eminent professor in the University of Phila- delphia ; he recommends the creation of additional professor- ships and the introduction of other newly originated branches of science into a course of medical education, and observes farther that " a prolongation of the term is essential ;" but he says it is not for the present generation to undertake this reform. Whilst we admire the, zeal which Professor Jackson displays on the subject of reformation, we are compelled to differ from him al- together in the sentiment, that it is not to be attempted at pre- sent. We hold that the proper time for correcting abuses is as soon as they have been perceived and acknowledged, by those best qualified to judge respecting them. How long would this distinguished professor delay this reformation? How long would he defer a consummation so devoutly to be wished ? Would he wait until these evils become more enor- mous and flagrant than they are? To what more auspicious period would he postpone the enterprise ? What generation more meet than this what school more able than that to which he is attached, to commence this reform ? The spirit of the times calls aloud for reformation the rapid march of intellect the numerous important discoveries and improvements in the arts and sciences require it now, and ere long the voice of a more enlightened people will demand it. 1838.] Medical Education. 217 But shall our colleges wait until an indignant people, pro- voked by the ignorance and incompetence of their graduates, demand it ? Is not the wide spread of empiricism in our country indubita- ble proof of the degradation of the profession, and of the necessi- ty for improvement ? Where should be the origin and whence the emanation of this reform ? in the colleges themselves? or among the people ? With whom commenced the Reforma- tion ? the priesthood ? or the people ? And the temperance re- formation the glory of our age and nation with whom did it originate ? Did the temperate-, the moral and the pious, with folded arms and unavailing lamentations, bewail the awful ra- vages of Intemperance, and wait for his victims to commence the reform, or defer the glorious enterprise for generations yet to come? No! It is not thus with the spirit of a Luther or a Melancthon. When the light breaks in and the evil stands re- vealed, the true reformer, with a noble daring and a heaven- kindled flame of holy zeal, that danger cannot damp, and nought but death extinguish, asks no further omen, but uncon- querably firm, resolves on reformation, or a martyr's grave! For the correction of evils we should certainly look to those whose exalted position affords them the best opportunity to perceive, and the greatest power to reform them ; and therefore, this distinghished professor has not discharged his duty to sci- ence and society, in merely " shewing the necessity of a radi- cal reform," and waiting for " a rising generation" to under- take it. 1/ Onward ! onward ! to improvement and perfection, is the motto and watchword of the present age ! All around is press- ing forward. Why then should medical colleges alone be con- tent to tread the same antiquated path, and perpetuate the errors and defects of darker days? Can the profession of medicine ever assume or maintain the elevated position it ought to oc- cupy, whilst the courses of collegiate instruction are so imper- fect, and degrees conferred on such meagre attainments ? \J How limited, how imperfect is the course of instruction in the medical schools of our country compared with that of Paris, in which the faculty consists of 24 professors and 24 agreges or adjuncts, and the period of attendance on lectures requisite to render a candidate eligible to a degree, comprises four years. 28 218 Medical Education. [Sept. How defective, how small in comparison arc the provisions and requisitions of the colleges in the United States? That medical schools are on a better footing in France, than in our country, or any other on the globe, is chiefly attributable to the greater liberality of the French government, in creating and cherishing literary and scientific institutions. In the annals of history, no government in any age has ever been so munificent in the pro- motion of science and literature. The professorships in the Parisian schools, are endowed by government, and every pos- sible facility, opportunity and advantage afforded for the pro- secution of every department of medicine ; but we must not attempt in this place to recount all that France has done to facilitate the acquisition of knowledge, and advance the me- dical sciences to the highest state of perfection. The abuses and defects so deeply deprecated and deplored, are not how- ever to be charged against our government. Had we the industry, zeal and enthusiasm of our Gallic brethren in the cul- tivation of science, we would not look to future generations to undertake this reform ; nor would government be slow to lend a fostering hand ; the acknowledgement of its necessity would scarcely precede its accomplishment. The principal defect that requires correction is the shortness of the term, which in most of our colleges continues only from three and a half to four months ; this at best merely allows time sufficient for a very elementary and imperfect course, and re- quires so many lectures to be delivered each day, that the stu- dent, unless previously well prepared, cannot comprehend them, and very little time is allowed for reading and reflection, or for the prosecution of practical anatomy. This which we regard by far the most important and radical defect, has been partially but imperfectly corrected by the Me- dical College of Georgia, \whose course continues six months; fewer lectures, (three, at most four,) are delivered each day, all in the forenoon ; the whole afternoon may be devoted to dissec- tion and the evenings to reading. The trustees were so im- pressed with the imperfection and inefficiency of the plan hitherto adopted, that they determined to make this important innovation, and the result has proven highly gratifying to them; for all who have had an opportunity of testing the comparative advantages of both, have uniformly expressed the most decided 183G.] .. Medical Education. 219 preference for the prolonged over the shorter course ; indeed, it is their general declaration, that a student can derive at least, double the benefit from the former that he can from the latter. This is certainly correct as respects beginners in the study of me- dicine. But the length of the term has deterred and doubtless will always deter many from attending the lectures of this college, whilst others pursue the old system ; for important and obvious as are the advantages of the prolonged term, unfortunately, alas ! for the honor of the profession and the good of humanity, too many students desire no more-aspire no higher than to obtain a de- gree in as short a time, and with as little exertion as possible content to practise the honourable and exalted profession of me- dicine, as a mere trade, or at most to attain to an ignoble medi- ocrity, scarcely less disgraceful than professed empiricism. Such will always go where they can procure a diploma, the object of their highest aspiration, most easily. Such alumni can only reflect discredit and disgrace on their alma mater, and therefore should not be desired by any college. The extension of the term to six months, although a very great- improvement upon the shorter course, is still but an ap- proximation to the proper duration ; lectures in medical as in other colleges, ought to be continued through the whole year, with the exception of one or two months' vacation ; the course should comprise many more branches than are taught in the schools of our country ; and at least four years' attendance should be required to render a candidate eligible to the Docto- rate. And certain requisitions should be adopted with respect to preparatory education. No student should be allowed to matriculate, or to be enrolled as an eligible candidate for a de- gree who could not stand a creditable examination on the stu- dies prescribed. So desirous for reformation have the faculty of the Medical College of Georgia been, (since the first establishment of this institution) that they suggested the idea of calling a convention of delegates from all the colleges of the union, to devise some general plan, and adopt a system of education, which should be uniform throughout the United States ; to accomplish which great and desirable object, they addressed the following circular to all the respectable medical institutions in this country. 220 Medical Education. [Sept. MEDICAL COLLEGE OF GEORGIA, ) May, 1835. \ To the Faculty of the Medical College of, diminished, pain. z o o fa n "vision, f audition, | augmented, senses. ^ smell, J j taste, ] diminished, &c. Uouch, (._ C augmented, intelligence 1 diminished, stupor, idiotism, I perverted, delirium, &c. / somnolence, coma, / carus, lethargy, dreams, night-mare, &.c. convulsions, contraction, rigidity, cramps? numbness, paralysis, tremors, &c. SLEEP. MOTIONS. ORGANS OF LOCOMOTION. VOICE, SPEECH. GENITAL FUNCTIONS. increased, diminishd abolished, mute, aphony, &c. ( pectoriloquy, perverted, 1 egophony, ^ ( metallic tinkling, C menstruation, ( augmented, } lochica, ( diminished, &c. ( lactation, 1836.] The Doctor. 233 The Doctor. Republished by Harper & Brothers, New-York. The above, is the title of one of the most incongruous, absurd, and nonsensical publications, that was ever issued from the press. We are glad it comes from across the waters ; and our only regret is, that it was not quashed upon reaching our shores. The Harpers ought not to have republished it ; and we, insigni- ficant as we are, would not now notice it, were it not that some sage critics have pretended to see wit and humour in it, and that we have now before us a review of the Doctor in the Sou- thern Literary Messenger. While on our passage from Charleston to New- York, in a steam-packet, a few weeks ago, our attention was called to the Doctor, by a lady passenger who had been reading it with great apparent gout. Upon replying negatively to the question, if we had read it, the work was kindly put into our hands. A few moments perusal and examination of it, satisfied our com- mon sense, and it was laid aside with distrust. Subsequently, circumstances forced us to become the owner of this work, but we assure the reader, it was for only a very short period, du- ring our passage from Norfolk to A ugusta. But to the object of this publication the Doctor. No one has pretended positively to know what is its meaning, what is its purpose. Neither are we better informed as to its author, or, as some imagine, authcrs. We are rather inclined to the opinion, that it is a hoax ; and we perfectly coincide with the reviewer in the Literary Messenger, that its meaning is precise- ly nothing. We must also believe one man alone wrote it, at least we hope so and another thing, that that man wras no Doctor! To say the author is, would be a scandal to the pro- fession of medicine. The Doctor professes to contain two volumes in one cover. We have only looked over some pages of the first, and from them, together with extracts, &c. which we have seen, have derived our impression of the nature and character of the pub- lication. As the Messenger has it, volume one commences with a Prelude of Mottoes occupying two pages. Then follows a Postscript then a Tahle of Contents of the first volume, occu- pying eighteen pages. Volume two has a similar Prelude of Mottoes, and Table of Contents. The whole is subdivided into chapters ante-initial, initial and post-initial, with inter-chapters. The pages have now and then a typographical queerity a monogram, a scrap of grotesque music, old English, &c. To complete this description, we must add these figures, resem- bling triangles, pyramids, or even the Egyptian hieroglyphics ; and the book contains the life of Dr. Daniel Dove and his horse Nobs. At least this is its profession. 30 234 French Medical Institutions. [Sept. Now to some, all this may be wit or humor, but to our hum- ble conception it is neither. The book may contain something good or useful, but we never expect to derive either from it. Certainly we shall never attempt to read it again. We feel persuaded that much of the attention and the sensation said to be created by it is owing to its foreign growth. We would not even be surprised if it has beeir gotten up for the purpose, seeing to what extent and to what success Jonathan can be gulled by John Bull. Be all this as it may, we venture to say the book is a libel the Doctor, no Doctor. We repeat, such a work ought never to have been published, it can answer no good end. Although this is not a professional book, we have been in- duced to make this brief notice of it, to save our readers the expense of purchase, and the task of perusal. P. F. E. [From the British and Foreign Medical Review.] Extract from a review of Mr. Lee, on the Medical Institu- tions of the continent. French Medical Institutions. " A clear and good account of the Parisian hospitals is given (in pages 2 and 3) : we think, however, that it is not correctly stated that all the hos- pitals are attended by the sarnrs de la cliarlie as nurses : this, however, is of small importance : the question of their efficiency is more material. Few students see the wards of foreign hospitals except during the visit of the physicians or surgeons. In the absence of these, the general service of some of the French hospitals is, we know, performed in a very slovenly manner. We have been surprised to see the house-pupils performing all the minor operations, including venesection, unattended by any nurse, even in the women's wards ; and in case a patient fainted, it was sometimes ne- cessary to summon the aid of the man who was polishing the floor by rub- bing a cloth over it with his foot. Not a sccur de chante was then to be seen. Neither did it appear to us that these sisters were remarkable for the gentleness of their manners. We made these observations with regret, and in opposition to all our previous impressions ; and the conclusion to which we came was, that ordinary nurses, with all their defects, were more efficient hospital attendants, such offices "pour l'amour de Dieu" being little better than certain tonsorial services recorded among authentic face- tiae as performed for a like consideration. The following is the prescribed course of study for those who take the diploma of Doctor in medicine or surgery in Paris : 2d ditto. 3d ditto. 4th ditto. 5th ditto, 6th ditto. 7th ditto. 8th ditto. 183G.] French Medical Institutions. 235 " Candidates for the diploma of Doctor in Medicine or Surgery, are re- quired to have studied four years, during which period they have to take out an inscription every three months for attendance on the lectures and hospitals. Members of foreign colleges and universities may, however, present themselves for examination after two years' study in Paris. The scholar year begins on the 1st of November, and terminates on the 31st of August. The expense of the course of study required for taking a degree does not exceed a thousand francs (40.) " The following is the prescribed order of study : 1st half year. Anatomy, Physiology, Chemistry. Medical" Physics, Hygiene, Medical Natural History. Anatomy, Physiology, Operative Surgery. Hygiene, Medical Pathology, Pharmacy. Operative Surgery, Medical and Surgical Pathology. Clinical Medicine, Clinical Surgery, Materia Medica. Clinical Medicine, Clinical Surgery, Medical Pathology. Medical Jurisprudence, Therapeutics, Obstetricity. " The examinations for the diploma are five in number. The first takes place after the fourth inscription has been taken out ; the second after the twelfth inscription ; the three remaining examinations take place at the termination of the course of study, " The subjects of the first examination are, natural history, physics, me- dical chemistry, pharmacology ; 2d, anatomy and physiology ; 3d, general pathology, medical and surgical pathology ; 4th, medical jurisprudence, hy- giene, materia medica, and therapeutics ; 5th, clinical medicine and surgery, operative surgery, obstetricity. " Each examination lasts two hours, during which four candidates are questioned by three examiners. * For the anatomical examination the candidate is required to make a preparation from a part of the body, which is indicated to him on the same morning, and to answer questions proposed to him relative to the prepara- tion. Candidates have also to write and defend a thesis on some point re- lative to medicine or surgery. The clinical examinations take place in the clinical hospital at the bedside of patients. The examination fees amount to one hundred and fifty francs." The examinations, we may add, are public, and searching and efficient, but conducted with politeness. In France the profession is divided into physicians, surgeons, and a low- er rank of practitioners called officers of health (officiers de sante,) the practice of the latter being nominally restricted to cases of minor importance: we say nominally, for the restriction is plainly impracticable. Midwifery is chiefly in the hands of women, and although they are regularly educated, we think that a suspicion expressed by Mr. Lee, that this circumstance has some connexion with the great frequency of uterine diseases in France, is not quite unfounded. There are lying-in charities in our own country, in which from a spurious delicacy, women only are employed as midwives, and we have seen much of the bad effects of this regulation : it is however to be considered, that our English midwives are uneducated persons. " Apothecaries," says Mr. Lee, " are not allowed to prescribe, their busi- ness being confined to the selling of drugs, and the preparation of prescrip- tions, as with cliemists and druggists in England :" who, it may be added, do not so confine themselves at all, but practise very extensively. " Mr. Lee's account of the state of msdical practice in France is succinct and interesting : it is evident that French physicians are becoming less go- verned by theory, and more guided by symptoms : or, in other words, that the practice among them is becoming more rational. Since the publication of the opinions of M. Broussais, bleeding has been more boldly resorted to ; but the French seem negligent of following up bleeding by medicines calcu- lated to amend the secretions, or even to remove vitiated accumulations ; 286 French Medical Institutions. [Sept. the consequence of which is that symptoms arise which appear to call for a repetition of the bleeding, and patients are sometimes bled and starved to death. We believe this even not to be very unfrequent in fever cases, and Mr. Lee gives a striking case of typhus in illustration of it. M. Louis and M. Andral should be mentioned, however, and are so, by Mr. Lee, as excep- tions to this practice ; both of them employ saline purgatives and other me- dicines in such cases. The more frequent and varied employment of baths in chronic diseases appears to be advantageous in French practice, and is, we think, beginning to be attended to in this country. Mr. Lee very pro- perly thinks that " the practice of abstracting blood and applying irritants at a considerable distance from the seat of the disease, on the principle of revulsion, might be more frequently adopted with advantage in England, especially in affections connected with cerebral irritation or congestion." A small bleeding from the ancle, a few leeches applied to the thighs or arms, especially to the latter, blisters to the legs, sinapisms to the feet, &c. arc often singularly useful ; and it is certainly to be regretted that English practitioners are often so inclined to condemn measures of this kind as tri- lling ; we mean, of course, only in chronic cases. " In the treatment of burns and scalds, stimulating applications are less used on the continent than in England : bleeding, opium, cataplasms, or emollient dressings, being the usual means employed. Whatever is the seat of the injury, the application of ice to the head for an hour or two is strongly recommended ; its effect being to cause a cessation of pain, and to prevent cerebral symptoms. " Under the head of each Parisian hospital, a concise account is given of the practice of the medical officers, and this is illustrated by occasional ca- ses. We can only find space for a few brief extracts from this interesting part of the work. "The hospital La Pitie has the advantage of the services of some of the greatest men in Paris, MM. Louis and Andral being the physicians ; and MM. Lisfranc and Blandin the surgeons. M. Lisfranc is well known to English students for the boldness and dexterity of his practice, especially in cases of diseased uterus." " M. Lisfranc has charge of two men's and a women's ward, most of the cases of the latter being marked as disease of the uterus ; many of these patients are, however, young women affected with superficial erosion of the cervix uteri, and are cured by a few days' rest and appropriate treatment ; the means resorted to in these cases, as well as in ulceration of this part, being chiefly confinement to the recumbent position, occasional venesection to three or four ounces, on the principle of revulsion, small doses of cicuta, and cauterization with a solution of mercury in nitric acid every six or eight days : when the ulceration is of a cancerous nature and too deep to be re- moved by cauterization, M. Lisfranc has recourse to excision of the cervix Uteri ; this part being exposed by the speculum, and firmly seized by pimces d, musmux, is brought down beyond the orifice of the vagina and excised with a knife, as in cases of polypus. M. Lisfranc has met with more than four or live cases of dangerous hemorrhage after this operation, the symp- toms which supervene being mostly of a nervous character and sometimes alarming, but mostly yield (yielding) to sedatives. Of ninety-nine cases in Which he operated, eighty-four recovered ; many of these patients became subsequently pregnant, and experienced no particular inconvenience in parturition." f Mr. Lee adds, whal few will doubt, that the operation has been perform- ed in many cases in which it might have been avoided. M. Lisfranc treats phlebitis (supervening on venesection) by emollient fomentations and cata- plasms on the inflamed pari, with the repealed application of leeches be- tween the point where the inflammation terminates and the heart ; and he states, that since he adopted this practice, he lias not lost a single patient from this disease; whereas when he employed other incans, and applied 1836.] Dr. Coated Scheme of Elementary Instruction, 237 leeches near the wound or over the inflamed vein, the majority of cases ter- minated unfavorablv. H MM. Alibert and Biet, the physicians to the hospital of St. Louis, are also well known to English practitioners ; the first by a splendid publication on diseases of the skin, the second by his enlightened practice in cutaneous scrofulous, and malignant affections. The opinions of M. Biet on the use of Baths in cutaneous diseases may be useful to the English reader." " Simple tepid baths are most beneficial in the dry scaly forms, though only as an accessory means ; their efficacy is less marked in the pustular varieties : they are serviceable in vesicular affections when the inflamma- tion begins to" decrease, and may be used with advantage in impetiginous affections where incrustations have succeeded to the pustules. "Alkaline baths are efficacious in the" papular and dry scaly forms, and in the impetiginous and tubercular varieties. An alkaline bath may be formed by dissolving in a simple bath from half a pound to a pound of car- bonate of soda. " Sulphur baths are most useful in the decline of vesicular affections ; they are less useful than alkaline baths in the chronic stage of psora, and if used in the inflammatory stage the symptoms are aggravated. Sulphu- rous baths are composed of two ounces of diluted sulphuric acid and eight ounces of hydro-sulphuret of potass added to each bath. " Acid baths may be made by adding to each from four to eight ounces of hydro-chloric acid ; they are mostly applicable in dry scaly eruptions." " In the account of the Hopital des Enfans Malades, we perceive that the mortality among the unfortunate children is stated to be one in four, which we believe to be rather under than over the truth. According to our own painful observation, this horrible mortality is to be ascribed, in a great measure, to the expectant system of medicine ; to starvation, and gum water, conjoined with the too free use of leeches. " M. Civiale, whose name is familiar to us in connexion with lithotrity, has a small ward in the Necker hospital, and the following is mentioned in the account of his practice." " Paralysis of the bladder, and vesical catarrh, in elderly people, are trea- ted in the following manner : a stream of cold water flows from a reser- voir fixed near the ceiling, through an elastic gum tube, having stop-cocks, and terminating in a silver catheter formed into a double tube by a central partition. The patient being in the recumbent position and the catheter introduced, the water passes into the bladder by one side and out by the other. A continued stream of water through the bladder is thus kept up for about ten minutes, and repeated every second or third day : the quanti- ty of water passing into the bladder may be regulated by the stop-cock, so as to prevent undue distention. The beneficial effects of the method are attributed to the clearing away of the accumulated mucus, and to the tonic action of the cold water upon the bladder." Sclieme of a full Course of Elementary Medical Instruction. By D. Ret. nell Coates, M. D. of Philadelphia. The following outline of the natural classification of the principal branch- es of Medicine which should be taught in Collegiate and Subsidiary Schools, 238 Dr. Coated Scheme of Elementary Instruction. [Sept. arranged according to their mutual dependence, and proper order of suc- cession, is here given at the request of a few scientific friends. The scheme is not founded upon the existing systems of this, or any other country, but upon an analysis of the great divisions of the Science, and its collateral ra- mifications. COLLEGIATE STUDIES. I. Natural History of Man in Health. PhGStry' \ Two sll0rt Courses' " " " -One Professor. These branches relate to the agents which act upon the living body ac- cording to mechanical laws, and should be taught with special reference to medicine. As a very large majority of students of medicine commence their studies in this country while extremely ignorant of these subjects, they cannot be regarded as part of their previous education, but must be taught in the collegiate schools. SpTckf An" tomy!' \ ne shor^ and 0ne lon2 Course' ne Professor. Under the first of these heads should be included such a view of Compa- rative Anatomy as is necessary for the student of the elements of medicine. II. Science of Healthy Vital Operations. Physiology. One great Course, - -- - One Professor. III. Natural History of Disease, and Science of Diseased Action. g^of fcttK^e.. \ e ^ <*u*e, - One Professor. Pathological Anatomv, and J nna , n r* -n t r> ,i i rr , i tv > Une long Course, . One Professor. Pathology of External Diseases. $ fe ' . It may be remarked that it is difficult to separate Pathological Anatomy from Special Pathology, as is done in some European schools. We think the effect of such a division injurious, if not unnatural. IV. Natural History of Remedial Agents. Materia Medica, One long Course, - One Professor. V. Art of Healing. Therapeutics of Internal Diseases. One long Course, One Professor. Clinics of Internal Diseases. One long Course, - - One Professor. Therapeutics of External Diseases. } Surgical Anatomy and Operative >Two Courses, - One Professor. Surgery. ) The two or rather the three last brandies arc properly thus arranged ; because Surgical Anatomy cannot be properly detached from Operative Surgery, unless mad.' a distinct, professorship, for which it is too limited. Operative Surgery is obviously a Therapeutic branch, and the .Materia Chirurgica cannoi be separated from Surgical Therapeutics and the Surgi- cal Clinic ; it is therefore left for tacit division between them. Clinics of Exlerna! I) One Professor. Obstetrics, } Diseases of Women and >T\vo Courses, - - One Professor. Children within the year. ) I83G. | Dr. Coalcs' Schema of Elementary Instruction. 239 VI. Art of Preserving Health. Hygiene. One short Course. This branch scarcely deserves a separate professorship in tins country, and may be associated with Medical Jurisprudence and Police, with which public Hygiene is closely associated. VII. Medico-Legal Relations. Medical Jurisprudence, > Q Q _ . Q Professor, Medical Police and Health Laws. C ' Number of Branches 17. - - Number of Professors 12. Such an arrangement, we think, covers the ground of a good Collegiate School, ami no more. If compelled to contract the list of branches, we could part with none but Hygiene. If compelled to lessen the number of Professors, we could only effect our purpose by associating the duties of the Clinical chairs with those of the Therapeutical chairs ; by which means the number would be reduced to ten, at the expense of imposing four heavy and scarcely compatible tasks on two individuals, with the additional disadvan- tage of being compelled to choose our teachers of the two most important theoretical branches, from the slender list of Hospital Practitioners, whose habits and engagements often render them incapable of executing such du- ties. Moreover this contraction of the scheme would tend powerfully to destroy the independence of opinion which should always characterize the medical student. The proper object of a Collegiate course is the inculcation of correct ele- mentary medical knowledge, such as is necessary for every young practi- tioner; but there are many other subjects of public medical instruction, which are necessary or highly desirable for medical men in peculiar situa- tions, and for persons prosecuting particular researches. These subjects should be taught in Subsidiary and collateral schools. Some of the most important of these are as follows : Practical Anatomy. Subsidiary to the Anatomical, Physiological, and Surgical Chairs. Pharmacy, Pharmaceutic Chemistry, Chemical Manipulations, and Botany. Subsidiary to the Materia Medica, and referable to the College of Phar- macy. Comparative Anatomy. Referable to the Academy of Natural Sciences. Diseases of Children. Diseases of the Chest. Extensions of the Medi- cal branches, and referable to the Clinical schools. Diseases of the Eye and Ear. Diseases of the Skin. Orthomorphic Treat- ment. Minor Duties of Surgery. Extensions of the Surgical branches, and referable to the Clinical schools. Transcendental Anatomy and Physiology. Medical Etiquette, and Medi- cal Ethics. History of Medicine, and ^Medical Biography. Referable to Private Lectures, under the patronage of the College of Physicians. 2 10 The Western Medical Reformer. [Sept. The Western Medical Reformer. Our printers placed in our hands the other day a printed pa- per of eight leaves, purporting to be The Western Medical Reformer called also by the editors A Monthly Journal of Medical and Chirurgical Science. (!!!) This paper printed at Worthington, Ohio, last July, and being the 7th number, ap- pears to have commenced its career under the auspices of this bissextile an ominous season truly. It is a year in which the odd hours of the four last are manufactured into a new day, and adopted on the last end of February ; and which makes the year 1836. Now it has been generally understood, that a year contained 365 mean solar days : and certainly it is true ; but this peculiar time gives it of course 366 days. Years of this curious kind have been observed before ; and have been supposed to posses peculiar virtues, in the way of reversing the common order of things. Some have believed that waters have on those occasions reversed the laws of gra- vitation and run up-stream, particularly about Whitsuntide. Others say that Caesar made it by appointing that the 24th of February should be twice numbered ; and thus was formed an intercalary day, corresponding with the sixth of the calends of March, long celebrated by the Romans on account of the ex- pulsion of Tarquin. Others believe that it leaps over one day in the week, so as to not alter the day of the week from that of the month, as in other years. Others again have thought that Venus sallied forth, wresting from its rightful owner the bow and quiver, and claiming them for her own, dispenses the mis- siles of love to Cupid's own heart, now made vulnerable to her attacks by the wonderful agency of that which reversed the natu- ral order of things. An easy transition from this, of only half a step, has enabled young maids, by virtue of a superior elective affinity which this year dispenses to them, of power to overrule all prior affinities in exercise between bachelors and their books, business, or fair ones, to become successful suitors for matri- mony ; and old matrons, the menstrua for dissolving together the heterogeneous elements of the two sexes into one homoge- neous compound. When we contemplate the wonders of leap year, in presiding over the expulsion of the Tarquin family from Rome, to whom she was so much indebted for her splendor, magnificence and power ; and when we behold its wonder-working transposition of the natural order of things rendering the weak strong, and the strong weak, &c. we think we arc brought by the very easy gradation of another half step to sec why some men beyond the alleghany have been inspired to embark in the wonderful enter- 1S36.] The Western Medical Reformer. 241 prise of overturning all science. Why medical science has sprung up on the impregnable basis of nature's truth risen through seas of primeval simplicity, stupidity, presumption and knavery, and stands like the Andes, in the midst of mighty wa- ters, and crowned like these, with undissolving honors. And do we see on the sea beaten granite of its wide base the vermin of equivocal generation erecting their mucous domicils in the recess of the surges which try the strength of foundations, and calling them truths? Or do we behold the vampires of knavery, seek- ing the treasure and the blood of the weak and unwary? Now these men surely believe in their simplicity ; or pretend in their knavery ; that stupidity will become philosophy and philosophy will become stupidity that falsehood will become truth, and truth become falsehood that sin will become righte- ousness, and righteousness become sin, by the wonderful trans- muting virtues of leap year ! They have herded themselves under the wing of the literary institution of Worthington, (whose trustees should have had more sense.) and tell us that medical degrees will be conferred on the judgment of men wrho deny the Jirst and all principles of science ; and not only so, but men who either in their simplicity or knavery, prop up falsehood ruin- ous falsehood, at the expense of all truth and humanity. The first part of this redoubtable " Western Medical Reform- er" is expended in telling us what Dr. Morrow told a committee of students, he liked, and what he disliked ; and of course, the same of his college* owning that the same medicines mainly are used, but denying deriving their notions from the steamers. Then we are furnished with a bird's eye view, condensed from matter enough of the same kind, to make an octavo of 800 pa- ges, of his reasons for differing from the old school. We cannot spare room for quotations of such stuff, as only tends to prove that the man knows nothing of the " old school," as he pleases to call scientific physicians ; but one short speci- men taken from the beginning of a paragraph which strikes the eye without selection, as we look from the pen, wTe beg indul- gence of the reader for giving. After condemning all minerals, he says : " It is well known that the various preparations of mercury, arsenic, antimony, iron, bismuth, &c. are regarded as the Samp- sons of the materia medica of modern fashionable practice ; not- withstanding the operations of these agents are evidently injuri- ous to health and life." &c. * A "committe of students, it appears, entertained a suspicion, and not without much reason, that this "reformed college", were a mess of the disciples of Thomson and Howard, and questioned the principal (whom we suppose Dr. Morrow to be, as he appears to return the answer) on the point. 31 242 The Western Medical Reformer. [Sept. When thought gets to the boundary of knowledge, it requires some energizing influence to arouse it to step beyond this terra firma, into the next territory which is the terra incognita. In all our perambulations in aetiology, we have found but two ac- tive powers sufficiently potent for this purpose. One of these is an ignorance, too profound to know that it is necessary to look, before leaping. Another is a knavery which would em- bezzle the very liv'ng, by entombing the mental energies of the weak though honest. There is a truism contained in the expression, What can we reason from, but what we know V* . which is a key admirably suited to the purpose of unlocking the casement of a man of letters, and shewing the interior ; whether the casement be an A. JVJ., or D. D.; or an L. L. D. or M. D. With this key in hand we need, so long as truth is truth, and sci- ence is science, no more help to know a little more of some men, than they know of themselves; and determine pretty pre- cisely their differential attitude, than only to see them publish their views on some of the common place topics. We see at once the overwhelming of Nubian sands, or the ingulfing of the dark deep waters. And as effects prove cause, our conclusion is unavoidable, that these arise from one of the two only com- petent active powers ; for in reasoning from effect to cause we can only reason from "what we know." We should not have noticed so far, this miserable production, but for observing a full page spent in lauding lobelia inflata as a medicine of such virtues, as are calculated to call it into hourly use. We know but few things of practical importance about lobelia ; but we do know amongst these few things that long since, physicians who have both knowledge, and feelings of hu- manity, have laid it aside on account of its uncertainty, and its dangerous power, to which they have resorted only under very peculiar circumstances. Our chief practical knowledge of its powers which have compelled regular practitioners to deprecate its use, has been derived from observations on numerous cases to which we have in these latter years been palled, for the pur- pose of endeavouring to remedy its peculiarly ruinous effects on the digestive and nutritive powers, and on the general constitu- tion. These lead us to mourn over the manslaughtering use of it which has become so common, whenever we reflect, as we often do, on the scene of misery and ruin which we have seen entailed on the bereaved husband, the disconsolate widow, the orphan child, and the last hope of the parent. This is no new article in the materia medica ; but a stupidi- ty and hard heartcdncss which can kill yes, kill, often in twen- ty minutes, any and all orders of mankind, and continue the practice for years, and not be able to see, mourn over, and/07*- 1836.] The United States Medical and Surgical Journal. 243 sake the ruinous course, is a novelty in the profession which has been reserved for the Thomsonians and the " reformers." Lobeliv stands before the profession chiefly a beacon to tell where danger lies. Its name is looked on by those who really hnow its powers, almost as the poisonous atmosphere of the Upas to be avoided ; or, if approached at all, with the greatest circumspection. The United States Medical and Surgical Journal. The number of this work- for June 1836, is before us. Hi- therto we have not been so fortunate as to have seen the United States Medical and Surgical Journal. We have experienced no small degree of surprise on seeing this periodical not from what we would call positive faults, but negatives. Before we saw it, we measured it in all res- pects by the mighty state and city from which *it emanates. We had often contemplated with pleasure the beautiful medi- cal organization of the whole state of New- York, by county and state societies ; and when we beheld the professional zeal, and excellent police, concentrate their rich and abundant me- dical commodities into one point the great state society, which would provide means for dispensing the same to the medical world. We would not be uncharitable towards the constituents of that great medical community, and we will cherish the hope, that still some plan is in way of maturation, whereby the trea- sures of medical observation, experience, and mental research, which that extensive, enlightened, and well organized medical community must possess, shall cease to be lost to the world. But men are apt to form opinions, by the facts before ihem: and should we judge by the specimen of the United States Me- dical and Surgical Journal, which is before us, a small month- ly (we suppose, for we are not told) of about forty pages, filled with valuable matter surely but all foreign; and without hav- ing attached to it the professional responsibility of any particu- lar man or set of men, but said to be conducted by " a number of respectable physicians," and left to a publishing agent, we 244 On the Chemical condition of the Saliva, eye. [Sept. should be led to fear that the eye of the medical police of New- York has been directed mainly to the cash income, instead of medical science. We will hope that a new effort will be made, that the societies will carry into effect the great purposes of their organization, and set" a system in operation which shall pour at once into the lap of responsible professional ed:tors, their valuable matter; and that the United States Medical and Surgical Journal, may soon appear before the world swelled and enriched by an abundant store of medical valuables. On the Chemical condition of the Saliva, as an indication of the different murbid affections of the Stomach. No one thing in the practice of medicine, or in the philosophy of pathology can be of more vital importance than diagnosis. The introduction of the physical signs of auscultation and per- cussion is justly hailed in Europe, England and America, as a brilliant era in medicine. We hail with joy of the same kind the recent introduction of chemical evidences in aid of this im- portant branch of pathology. Indeed if we contemplate the practical utility of the diagnosis which we are about to notice, should it be well confirmed by future experience, (which we honestly believe will be the case.) we may look on M. Donne as having bestowed on the science, a greater benificence than Avenbrugger or Laennec. We say a " greater beneficence," not only because the diagnosis is m febrile the most extensive class of diseases, which spares no country, and by which the great sum of mortality is mainly marked annually; but also be- cause this diagnosis is available for good. We would not depreciate the value of auscultation, or percussion. The clear- ness and accuracy to which they lead are in wortli beyond cal- culation. But how often does it happen that the diagnosis to which these lead, cannot furnish us with any new remedial means, or only enables us to make more accurate prognostica- tions, or withhold many useless doses ! It is available for good in more ways than one. It places at once the practitioner in the true road to success in a disease generally curable ; and wherein the ill success has been chiefly attributable to errone- ous views of the nature and seat of the disease, or the patho- logical condition. 1835.] On the Chemical condition of the Saliva, $c. 245 Such is in our estimation the deep interest attached to every effort for the improvement of diagnosis, and such the novelty of the subject of the following, that we cannot withhold from our readers any part of the notice of M. Donne's experience in the testing of saliva for diagnosis. [From the Mcdicc-Chirurgical Review.] M. Donne is well known in Paris as one of the most zealous and intel- ligent vouno- physicians there. For several years he was clinical clerk to M. Louis, as our readers may have learned from the foreign Periscope of our Number for July last ; and subsequently he attached himself very en- thusiastically to the service of M. Bouillaud" in the wards of the great H6- pital La Charite. " The pages of the Journal Hebdomadaire for the last three years attest his great activity as a diligent and enlightened observer of disease. For some time past he has been engaged in collecting materials for a work on the Chemical Properties of the Animal Fluids in Health, and also during the progress of various morbid affections. One branch of the subject appertains to the investigation of the changes which the saliva undergoes in disease, and more especially in that form of it, which has been of late years far too indiscriminately designated gastro- enteritis. Although a devoted disciple and admirer of M. Bouillaud, (who is generally considered as one of the most ardent and able followers of the physiological or Broussaian doctrine,) he candidly admits that a multitude of stomach affections, differing greatly in their characters, and requiring verv different m -des of treatment, have been most erroneously grouped to- gether under this very much abused epithet. Numerous are the cases, where patients have been tortured with the long continued but ineffectual use of antiphlogistics and refrigerants, and where a few doses of emetics and purgatives' subsequently have dissipated all distress in the course of a dav or two. The diagnostic symptoms between the genuine " gastro-en- terite," and mere embarrass gastrique," hitherto pointed out by medical writers, are indeed, it must be confessed, often unsatisfactory and even de- lusive and it has been owing in a great measure to this very uncertainty, that the exclusive doctrines first promulgated by Broussais have been car- ried to so extravagant a pitch by one party, and condemned so indiscrimi- nately bv another. " It is with the hope of dispelling part at least of this uncertainty, that M. Donne has ingeniously proposed the chemical state of the saliva as the means to determine the real character of various stomachic diseases. "He premises his remarks by alluding to those excellent observations of M. Andral, wherein he states "that no relation can be established between the existence of nausea and vomiting, occurring during the progress of fe- vers, and any lesion of the stomach appreciable on dissection ; for, on the one hand, these symptoms have been often absent, when the stomach has been found le plus rouge et le. plus gravement affecte ;' and on the other hand, when they have been present, often no morbid change of the viscus is discoverable after death. The mere existence therefore of these symp- toms in fevers is no proof of even irritation, far less of decided inflammation of the stomach. " Unless the vomiting be accompanied with epigastric pain, redness of the tongue and thirst, we have no good reason to predicate the existence of gastritis. What M. Andral says of the state of the stomach in continued fevers is equally applicable to many other cases of less serious importance, where the physician is not a little perplexed to determine whether there exists a mere" "embarrass gastrique" (in the language of Stoll "saburrcs 2i6 On the Chemical condition of the Salica, <c. 217 "The chemical examination of the secretions during life belongs to the second of these great branches of medical science. Hitherto it has been too much neglected ; for, with the exception of urinary complaints, there id scarcely a class of diseases, in which its assistance has ever been invoked. " Without further details, we shall now narrate briefly a few cases which will illustrate the good effects of attending to the chemical properties of the saliva in disease. " It may be necessary to state, that the only testing means, which M. Donne recommends, is the use of slips of litmus paper, such as are gene- rally employed in examining the urine. Some of them are to be reddened by immersion in a weak acid, to serve as tests of alkalinity. " The saliva of a man, labouring under intense bronchitis, was uniformly found to be acid. On dissection, the mucous membrane of the stomach was found " pointillee et ramollie" in some points, and red and highly in- jected in others. " A young woman, when admitted into La Charite Hopital, was labour- ing under a severe attack of bronchitis, attended with great tenderness of the abdomen, excessive irritability of the stomach, diarrhoea, ardent thirst, &c. The saliva was strongly acid. " The disease assumed in its progress a marked typhoid character, the tongue was parched and coated with a brown crust ; the abdomen was al- ways very tender ; delirium and coma supervened, and the patient died on the 10th day after admission. The saliva was acid during the whole course of the illness. " Dissection. The mucous coat of tfys duodenum and jejunum was highly injected ; the intestinal follicles were enlarged, and many of them ulcerated. The stomach exhibited "une injection pointillee" in its large extremity, and its mucous coat was soft and easily lacerable in several places : in other piaces it was very vascular, and of a dark colour. " A young man was received into the La Charite Hopital as a fever pa- tient. All the symptoms of ataxic fever soon developed themselves. The saliva during the first days was only slightly acid ; but later it became more strongly so. He died comatose. The saliva remained acid to the end. " Dissection. The mucous coat of the stomach was healthy in four-fifths of its extent ; its large extremity, however, exhibited " une rougeur poin- tillee avec ramollissement pulpeuse de cette membrane." " In a patient who died of severe pneumonia, complicated with great irri- tability of the stomach and with diarrhoea, the saliva had been found to be unusually acid, so that it reddened the litmus paper " comme le ferait du vinaigre." Besides serious lesions of the thoracic viscera, the inner sur- face of the stomach presented in different places a state of high injection, of partial softening, and of complete disorganization of the mucous tissue. " The preceding cases are intended to illustrate the coincidence between a permanently acid state of the saliva and the existence of inflammatory irritation of the stomach, as ascertained by dissection. We shall now de- tail somecases, where the saliva was acid at first, but gradually lost its acidity and recovered its alkaline properties, as the patients were restored to health. " A young man was received into the hospital as a fever patient. The symptoms were not serious : there was a yellow hue of the skin ; the epi- gastrium was rather tender on pressure ; there were however, neither vo- miting nor diarrhoea present ; the tongue was white, and the saliva was alkaline. During the progress of the case the saliva became acid, conti- nued to be so for three days, then became neutral, and as the patient reco- vered, gradually assumed its alkalinity. " A student of medicine, who had been but scantily fed for several months was seized with shivering, pains in the loins, loss of appetite, &c. The epi- gastrium was tender on pressure ; the tongue was covered with a thick white coating ; the saliva was strongly acid. As the feverish symptoms 248 On the Chemical condition of the Saliva, 1 the bod} being soon found sufficient, it was dispensed 282 Fracture of the Os Fcmoris. [Oct. with. This case required no farther assistance, except occa- sionally tightening the many-tailed bandage as the tumefaction of the thigh decreased. After two weeks, the weight was laid on the foot of the bed, except when the patient was asleep. At three weeks, the short splints were removed and the limb re- freshed by gently rubbing with a wet cloth ; after which they were re-applied, for a week or two, and the patient discharged. Six months after, I met this patient in the road walking and dri- ving his wagon. He stopped to manifest his gratitude, when I requested him to perform several exercises for my inspection, such as walking, running, leaping and dancing; all of which were performed without the least imperfection of the limb being man- ifested. Case 2. This was a lad, about 11 years of age, one of the most rude, uncontroled and uncontrolable, in the city ; who had by a fall from a cypress tree, suffered a fracture of the femur, a little above its middle. The patient was laid on his back on a firm mattrass placed on a table. A fulcrum for the upper part of the leg was prepared by rolling a soft pillow transversely on it- self, so as to render it very firm. A half brick was suspended to the foot, by a string passing over the lower end of the mattrass, some six or eight inches from the foot the fragments adjusted, and short splints applied as in the other case. A counter-exten- sion bandage was, on account of the ungovernableness of the pa- tient and lightness of his body, thought necessary and applied in this case ; but this restriction from movements, he used every opportunity afforded by the absence of his attendants, to rid him- self of; until after a few days it was dispensed with. Such was his impatience of restraint from motion, that so soon as the great soreness in the wound began to abate, he was often found sitting on his bed, having raised his body by pulling the pavilion which was suspended over him to protect him from flics in the day and musquitoes in the night. The patient was however dis- charged well in the fourth week : no untoward circumstance ha- ving occurred. Case 3. This was a very rude and ungovernable girl, in her seventh year, who in attempting to slide down the hand-rail of the stair -way, as she was wont to do, fell from near the top of the first flight, to the floor ; fracturing the femur a little above its middle. She was placed on a mattrass, which was laid on the 1836.] Fracture of the Os Femoris. 283 dining table, and a fulcrum made of a pillow, placed beneath the upper part of the leg as in the other cases just described, and a weight of one pound and a half suspended to the foot and pas- sing over the end of the table; with a counter-extension bandage passed over her breast, short splints, &c. as before described. This patient was of strongly marked sanguineo-nervous tem- perament, and was much disposed to spasmodic twitchings du- ring sleep, from irritation in the wounded thigh, for the first 48 hours. As this irritation subsided, she became free and slept quietly. During her waking hours she became very restive, so that her arms and sound leg were perpetually engaged in some exercise or other for expending her super-excitabrlity. The counter-extension bandage was necessarily retained in use to prevent her from rising, and from sliding too near the foot of her bed. 'In the course of a week or ten days, however, she had become so subdued by its eontroling influence, and so desirous to be released from its use, as a means of restraint to which she seemed to abhor subjection, that she was easily retained in her place without its use. The wounded limb having ever remained still since the subsidence of the first irritation, it was found safe after eight or ten days to rest her, when awake, from the little pressure of the one and a half pound weight which hung to her foot, by placing it on a chair, or on the bed during her waking hours. All went on favorably in the case until four weeks had elapsed when she was liberated from all the apparatus and allowed free motion on her bed. On comparing the length of the wounded with that of the sound limb, before she began to walk, the for- mer was found four or five lines longer than the latter, from the extension of the articulations during the suspension of muscular action in the limb. On walking, the limb at once resumed its proper length, and like the other cases left no deformity in gait or shape. Case 4. This was a negro boy, about 10 or 11 years of age, who fell from a wagon heavily laden with nine bales of cotton, which ran over his thigh on very hard ground, leaving a com- minuted fracture of the femur, extending from about the middle of the bone upwards, the full extent of between four and five inches, with considerable swelling, and a small external opening which constantly discharged blood. This patient was treated in the same manner as those above, except that the swelling was 284 Fracture of the Os Femoris. [Oct. gently compressed so as to cause a discharge of the blood effused within, as effectually as possible ; and the bandage and splints so applied as to afford convenience for daily dressing the external wound. This case, occurring during the medical lec- tures in this place, was exposed to the frequent observation of the pupils of the class and daily dressed by some of them, and was discharged well at four weeks ; three short splints being however retained on the limb until he should arrive at home, a distance of more than 70 miles, whither he had to be conveyed in a common wagon. No difference was perceptible between the wounded and sound limbs, except the hardness at the scat of. this comminuted fracture, of about double the diameter of the bone of the other thigh, and a little increase in the length of the limb. He was sent home and did well in all respects. Case 5. This is the last case which I shall give. It was in a little girl nearly 3 years old, who caused a garden gate to fall on her, which fractured the left femur, a little above its middle. For this, a small pillow was rolled so as to make a fulcrum about three and a half inches ill diameter, and a pound weight suspend- ed to the foot by a string passing over the end of the table as be- fore. The counter-extension bandage was applied; but this was a sprightly, active cjiild, who would not submit to its continued use ; it was dispensed with after the first day, and its place sup- plied by the hand of an attendant being kept almost constantly on the lower part of the abdomen and pelvis ; and when by her various little muscular movements, she was brought too near the end of the table, she was gently drawn back by the hands ap- plied to the axillae. This case was managed in all respects as the rest. No extension and counter-extension were needed in adjusting the bones, the limb being found on measurement after applying the weight, to be restored to its proper length, and the bones well adjusted. At the end of three weeks, the weight was finally dispensed with, and the splints taken off for the refresh- ment of the limb, and reapplied to guard against accidents from the sprightly, actfve disposition of the child. She was then re- moved to a bed and left to the attendants, to be kept on bed a week or ten days longer continuing the splint-'. In giving the above live cases, I have made a selection from all the cases which have occurred in my practice for the last eleven or twelve years, all of which have been treated on the 1830.] Fracture of t lie Os Feinoris. 285 plan herein detailed, and with like success. My purpose in se- lecting these, has been to present the greatest variety which my practice has afforded, in different respects interesting, in proof of the merits of this plan of treatment. The first case presents an athletic laboring man, of rigid fibre, and aged 46. years, whose voluntary and locomotive muscles, (the displacing powers) were overruled by the trifling weight of about two and a half pounds, in steady action. The second and third present Sanguine and sanguinco-nervous temperaments at the most irritable and un- governable age, and both of them having never been subjected to government when well. The fourth case is selected on account of its being one of extremely comminuted, and of compound na- ture ; and the fifth, a child less than 3 years old. In the man- agement of fractures on this plan, the excretions are easily dis- posed of by the use of cloths and oil-cloths, and of urinals or sponges, according to the age, &c. of the patient ; and no distress whatever is suffered by painful compression of any of the dres- sing confinement from exercise constituting the chief source of affliction attending the recovery. Duty to the science of Surgery, as well a^ to the cause of hu- manity, seems to demand of me this exposition of my practice in cases of fracture of the femur, whjch establishes in the most sat- isfactory manner, the propriety of a plan of management at once calculated to ensure the best success, with the simplest appara- tus and the least distress. Of this invaluable improvement in surgery I can speak the more freely, because it is not an invention of my own. The course of management herein detailed, is so rational, and at the same time so simple, that I am not only surprised that the pro- fession did not lay hold on it when first suggested ; but that my- self, or any one else, should ever have contemplated the condi- tion of a fractured femur, the displacing powers, and the cura- tive resources of the system, without having it at once suggested to his mind. One would suppose that even necessity, the parent of so many discoveries, would, on some occasion, nave sugges*- ted it very early in the practice of surgery. During the first fifteen years of my professional life, I was in the habit of applv- ing the various apparatus under recommendation by different eminent surgeons, as Dessault, Physic, &c. &c., having for their chief merit, adaptation to the purpose of preserving juxtaposition 280 Fracture of the Os Femoris. [Oct. by great extension and counter-extension. Such was, however, the severity of pressure on the points where extension and coun- ter-extension were made, that I often found my patients most ungovernable, or more or less severely afflicted with excoria- tions, and sometimes with alarming ulcerations. Indeed, so dif- ficult, troublesome and painful, was "the setting of the bones" as it is called so distressing was the treatment, and so doubtful the result under the most approved plans from time to time in use, that I became exceedingly averse to encounter a fracture of the Os Femoris, on account of my feeling for the unavoidable sufferings of the patient, or his chance for a crooked or a short limb. In the early days of the Boston Medical and Surgical Journal, I first observed on its pages, (if my memory be correct,) an ac- count of the experience of my friend, Dr. Wm. C. Daniel of Sa- vannah, with this mode of practice, which was to me perfectly new, and so evident an improvement, that I determined on adopt- ing its use in the first case which should occur. Soon after- wards, however, I observed some suggestion of the same plan, of a much older date ; but which had of course escaped Dr. Dan- iel's observation, as it had my own. I adopted its use, however, with the exception of the pully, over which he advised the cord suspending the weight to pass. This I found unnecessary ; as the motion was sufficiently free over the end of the mattrass, or of the table. The principle on which this plan of treatment operates, must be evident to all. In the first place, the inconsiderable weight attached is often sufficient to adjust the bones ; and always suf- ficient by its steady action, to exhaust the active energies of the muscles of the limb, long before union commences, and before the soreness of the part is so removed as to render the patient wil- ling to effect any motion of it. The constant, though gentle trac- tion secures the proper length and straightness of the limb, and the short splints, bound on with moderate and easy force, is a con- stant safeguard against accidental movements of the fractured ends, which would tend to irritate the soft parts, and render union doubtful. From my experience with the retaining power of this dressing, I feel assured that no plan is so well calculated to se- cure success in cases of fracture of the neck of the Os Femoris, (a case always produced by violent motion of the pelvis down- 1836.] Meteorological Observations, c. 287 ward, relative to the femur,) as it would, with the help of the muscles of the part, very securely retain the fragments in appo- sition with great steadiness, especially if the pelvis were well fixed to the mattrass; whilst the weight of the body would af- ford counter-extension, without the pressure of a counter-extend- ing bandage, which might tend in any degree to displace the up- per fragment. In conclusion, I will observe, that from the excellent adjust- ment preserved, I have ho doubt the splints and weight might have been removed still earlier than they were; but I was un- willing to risk any thing in experimenting, to determine how ear- ly they might be safely dispensed with. Augusta, August, 183G. Meteorological Observations, fyc.for Burke and Richmond Coun- ties* Extract from the Geological Survey of the two Counties. By Professor J. R. Cotting. Greatest heat at sunrise, - - - 74 Least heat at sunrise, - - 62 Greatest heat at 12 o'clock, - - - - 92 Least heat at 12 o'clock, - - - 78 Mean heat of the first half of the month, - 80.68 Mean heat of the last half of the month, - - 75.5 Mean heat of the whole month, - - - 77.2 Coldest day, August 31. Warmest day, Aug. 5. Rain Guage, 6 inches 8 lines. Foggy mornings, 7. Cloudy days, 6. Rainy days, 3. Thunder showers, 11. Prevailing winds, NE., S. and SW. From the 19th to the 31st, there were no thunder showers, the longest interval that has elapsed since May ; still the air has been very serene, and the Counties remarkably healthy for the season. The mean temperature of these Counties for August, differs about 4 from that of Cambridge, Massachusetts. The form- er being 77 2; the latter 72 16. 288 Analysis oft species of Clay, tyc. [Oct. Analysis of a species of Clay found in Richmond County, which is eagerly souglU after, and eaten, by many people, 'particular- ly children. By Professor J. 11. Cottixg. 100 1-3 grains Troy Silox, 31 Oxide of Iron, - 12 Alluniina, - 34 Magnesia, - io "Water, - 12 1-3 Loss in Analysis, - - 1 100 1-3 grains. This substance, in its external characters, resembles Litho- marge, or Hock Marrow. Colours, dark red, yellow, yellowish red, yellowish white, purple and reddish white. Occurs massive and stratified, strata undulating, opake, fracture conchoidal and earthy; texture, fine grained; soft; may be polished with the linger nail ; adheres slightly to the tongue ; gives a faint argilla- ceous odour when moistened, or breathed on ; has the feel of hard soap ; falls to powder in water, but docs not form a ductile paste. Spec. grav. 2.53. But its chemical characters and geological position, rank it with the talcose family. It appears to have resulted from the decomposition of talco-micaeous slate, which is found in the vi- cinity. It underlies the ferruginous sand [formation , and silici- ous rocks called pitchstone, resting on light sandy clay. I have not been able to detect any organic remains of animals in the formation. It sometimes contains vegetable remains in the state of petrifaction and lignite. That it must have been the result of the decomposition of older rocks, is evident from the above an- alysis, its geological position, and from the fact of its containing fragments of older rocks notinpla.ee. I found it associated with other minerals in many parts of the survey, in both the Coun- ties of Burke and Richmond, but the purest and most abundant was on land of David F. Dickinson, Esq., near M'Bean Creek, Richmond County, on the east side of the great road leading from Augusta to Savannah, about fourteen miles from the for- 1 836.] Analysis of a species of Clay, <$-c. 289 mer place. Here large excavations have been made by ignorant dirt-eaters to obtain it. It has a slight sweetish taste, not unlike calcined magnesia ; which property, combined with a certain morbid state of the sto- mach, has probably induced to the unnatural, filthy and danger- ous use of it. Its action is mechanical on the stomach, as it con- tains nothing capable of being decomposed, and nothing on which the gastric juice can act. This juice, although it is capable of corroding iron and steel, as is found by experiment, has no action on silex. It is a well known property of silex, that it will wear away, or polish the most obdurate metal. It is an extremely hard, brittle substance, in minute divisions, this adheres strongly to the coats of the stomach, causing irritation of that organ, de- rn nging the appetite for wholesome food, inflammation ensues, and if persisted in, death. I am informed by respectable people liv- ing in the vicinity of localities of this mineral, that many deaths have occurred from no other perceptible cause, than from per- sisting in the use of this dirt as a luxury. We find it universally the case with these habitual dirt eaters, that their countenances present a sickly, palid, cadaverous hue, not unlike those mechanics whose constant occupation is polish- ing metals, who are generally afflicted with disorders of the chest and sooner or later fall victims to consumption. A boy about fifteen years of age, whom I met at the above locality, taking his favorite repast, informed me that he was in the habit of eating daily of that substance, "as much as he could hold in his hand." Admitting his statement to be true, and judg- ing from the specific gravity of the substance, he must have swal- lowed daily, nearly an ounce of pure flint ! He might, with greater impunity, have swallowed as much white sand of the pine woods, because in that the particles are rounded by attri- tion, and in this they are angular, and the angles very sharp, like the edges of broken glass. I asked the boy if his parents did not inform him better ! He said, " he had only a mother and she ate it too, when she was well, but she was almost always sick." This peculiar species of clay is said not to be found north of the Potomac ; a species in some respects similar, is found at Bare-hills, Maryland. That, however, is deficient in the pro- portion of iron and magnesia. 37 290 Note to Professor Cotting's Piece. [Oct. This substance may be employed as an excellent substitute for Fuller's earth, in the dressing of woollen cloth. Note. A very general error has, in our opinion, always pre- vailed to a great extent, on the subject of the location of this practice of dirt eating, in the series of phenomena which consti- tute the chain of cause and effect. Nor is this an error of trivial importance, so long as effects depend on causes for their produc- tion. In medicine it is peculiarly dangerous, inasmuch as it tends to conceal, or divert attention from primary causes, by which, whilst they continue, subsequent effects must be perpet- uated. All-important as it is considered, diagnosis itself is less indis- pensable than causality, in connexion with morbid phenomena. The reason of this is, very obviously, that in the institution of new causes, (which is the purpose of therapeutics,) the effects of which are to be the correction or removal of some cause or causes present in the concatenation of disease, the new causes or powers thus instituted, must be endowed with some character- istics peculiarly adapted and proportioned to the effects in view, viz. the removal or correction of the present noxious cause. It is as plain as that an alkali must be possessed of the peculiar powers and qualities of its nature, to be calculated for the cor- rection of an excess of acid introduced into the stomach. But if an excess of acid abound in the stomach in consequence of func- tional lesion of the stomach itself, whilst an alkali will tend to the palliation of the symptoms and distresses, it will not be calcula- ted for the correction of that organic lesion, which caused the acidity. The best consequence then which may be rationally expected from the use of an alkali, would be a temporary palli- ation of the distresses of sour stomach : whilst in the other case, or that which supposed acid introduced, it would effect curative ends which nothing else could. But let us illustrate with the case directly in point. If dirt-eating be looked to as the cause of the attending phe- nomena, as curative indications must have a peculiar adaptation to the end to be effected, all attention and effort must be directed to the purpose of confining the patient from the supposed nox- ious power. Now it is certainly true, that the unnatural articles taken into the stomach in cases of Bulimia, or depraved appe- 1836.] Note to Professor Cotting's Piece. 291 tile, often, perhaps generally exert noxious influences on the system in some way or another. The withholding the patient then, from the use of such unnatural and injurious articles, is right, and calculated to palliate some of the troubles in the case which arise secondarily ; but still the health of the patient, with- out the operation of other causes or influences, not only fails to recover, but continues to decline, just as surely as that a man would continue to be wet who should stand in a shower of rain, and constantly wipe away the water to make himself dry, in- stead of spreading his umbrella over him. In this case, he must do both. He must remove the water already on him and ward off from him, by the use of his umbrella, that which would con- tinue the wetting. 1 have never succeeded in curing these cases by directing my indications solely to the taking in of unnatural articles: for with this alone, the disposition continues. I have removed from the primae viae the indigestible accumulations which have been found there, and withheld the article for the future ; but the patient would resort to others, as paper, rotten wood, bark, old rags, &c. ; and in one instance, I recollect that a youth of about 14 years of age, consumed for his last precious morsel, a whole pair of Os- naburg pantaloons, with the exception of the waistband and some small part of the seams. Thus it is, that although purga- tives often remove those offensive things, they cannot, simply as such, essentially and radically benefit the case. The truth of this case is, that the habit, as it is considered, of dirt-eating, or any of the displays of depraved appetite, is to be looked on mainly as a phenomenon consequent to and perpetuated by its own peculiar cause ; and whilst it is the duty of the practitioner to remove from the system unnatural ingesta, with as much cer- tainty as if they had been accidentally introduced, it remains his paramount, and consequently indispensable duty to correct the cause whereof this is the effect. A new set of causes have then to be searched for. They are those which wrought out the im- pairment of the normal condition of the stomach, &c, and plan- ted in its stead a desire for things indigestible, unprofitable and deleterious. Such a case is very analogous in its philosophy to a case of dropsy. If an hydropic accumulation take place acci- dentally, the cause of which is not continuous, as simply a check of perspiration, or the compression of pregnancy, its removal is 292 Note to Professor Cotting^s Piece, [Oct. a matter of trivial concern nothing being more easy than to cure such a case, by removing the obvious effect, the cause of which is not now operative for its renewal or perpetuation. It is just so when we contemplate the effects of Bulimia, produced accidentally, or without that depraved condition of stomach, which is so calculated to perpetuate them. But if dropsical phenomena be perpetuated as fast as they'are corrected, the mind must, if it have not before determined this point, go in search of other anterior lesions, structural or functional, which, although themselves the effects of other and more remote causes, become the cause of the phenomena of dropsy. Precisely similar is the case of the dirt-eater. He feels as absolutely compelled to eat improper substances, as the healthy man does wholesome food. This act is as legitimate a consequence of the state of his system* as the act of eating wholesome food is of that of the healthy in- dividual. Each eats that to which his stomach most strongly im- pels him. But the two individuals eat things diametrically op- posite one partaking of nutritious, digestible and salutary arti- cles, whilst the other, of such as are perfectly indigestible, innutri- tious and injurious. Like causes produce similar effects. It is a healthy condition which alone impels to the eating of wholesome diet. Every appreciable deviation from health is disorder : there- fore, as in the other case, unwholesome and unnatural articles are commanded by the appetite, it follows that the organ of ap- petite deviates from healthy condition, and is therefore disor- dered. We remember the days when that mighty corrector of visce- ral derangement, calomel, was weighed out with all the care and nicety that gold would have been, and was in but little use ei- ther by practitioners or the common people. In those days there were twenty dropsies for one now ; and although our ac- quaintance was then limited to a very small circle, comparative- ly speaking, still it is obvious that there were twenty, if not dou- ble that number of dirt-eaters then, for one at the present day when calomel is in universal use. Eds. 1836.] Stricture of the Urethra treated by Excision. 203 Stricture of the Uretlira, successfully treated by excision of the indurated portion of the canal. Reported by William Henry Robert, Student of Medicine. Ellick, a negro man about 40 years of age, belonging to Mr. J. P. Setze, had been afflicted with Stricture of the Urethra fif- teen years, during which period he was treated by several phy- sicians of this city and its vicinity, and repeatedly relieved by the application of caustic and bougies. The disease, however, always returned soon after the abandonment of the bougies. The man says he has never had gonorrhoea, but was troubled with gleet a long time. He was placed under the care of my preceptor, Professor Dugas of this city, who, on examination, found the stricture situated about three inches from the orifice of the Urethra; the induration was easily felt externally, and^ex- tended nearly an inch along the course of the canal. Attempts to introduce a bougie, even of the very smallest dimensions, were made in vain during several days ; the urine continually oozed o,ut by drops, the patient being unable to empty his bladder. He had been in this aggravated state one month. The impossibility of introducing any dilating instrument, and the fear of inducing total occlusion by the use of the caustic, together with the re- flection that the latter remedy had already several times failed to give permanent relief, determined Dr. Dugas to remove the indurated portion of the Urethra with the knife. The operation was performed on the 7th of June last. A longitudinal incision, made through the integuments on the median line, exposed the canal and permitted the excision of its diseased and thickened portion, through which it was found difficult to pass a wire the size of a common bristle. A gum elastic catheter of the largest caliber was introduced into the bladder, and the lips of the wound drawn together with adhesive strips. June 12th. Wound healed by adhesion ; the patient has suf- fered no pain from the catheter, which still remains introduced ; urine slightly tinged with blood ; cream of tartar and nitre for common drink ; catheter to be drawn half out, in order to relieve the bladder. 1 5th. Catheter being bad was removed, and another intro- 294 A Case of Monstrosity. [Oct. duccd four hours after, without difficulty or pain ; urine limpid; some appearance of two very small fistulae, through which a little pus escapes from the wound ; adhesive strips renewed dai- ly, and catheter continued. 20th. Small fistulas entirely closed ; urinates without cathe- ter, and without pain ; purulent discharge from the orifice of the urethra pretty free ; metallic (pewter) bougie substituted for the elastic, and kept introduced only through the night. July 1st. Is apparently quite well, wears the bougie two or three hours daily, as a precautionary measure. Sept. 1st. Discontinued entirely the use of the bougie about a month ago, and has felt no inconvenience since. Urinates now in a bold stream, and savs he " is as well as he ever was in his life:' Augusta, Sept. 1836. A Case of Monstrosity. By D. Waties M'Junkin, M. D., of Tyrone, Georgia. The object of the present short communication, is simply to relate a singular case of Monstrosity, which occurred in my prac- tice a few years since. Those who believe in the influence of the mother's mind over the child in utero, would certainly regard it as a strong proof of the truth of their doctrine. To say the least, it is a remarkable coincidence and can not be satisfactori- ly accounted for on any other principle. Mrs. was threatened with miscarriage about the sixth month of gestation, which accident was determined by the vio- lent and ridiculous interference of an ignorant midwife, such as attempting to thrust her hand through the parietes of the uterus, mistaken for the membranes ; making her ride on a hard trotting horse, Brothers, N. York; 1836. We have carefully examined this new publication, in order to give it a full and candid notice in the Southern Medical and Sur- gical Journal. There is one characteristic feature about its au- thor which all must admire that deserves our highest encomi- ums it is the industry he displays in his profession. Few in- deed exhibit more ambition to be useful in getting up new pub- lications in medicine than Dr. Doane. On an extra sheet attach- ed to the Surgery Illustrated, we find his name connected with no less than ten works, eight of which have already been publish- ed within a few years, and two are now in the press. Notwith- standing they consist of translations, compilations or new edi- tions, still they are the result of great industry and patient labor. The work now under consideration, professes to illustrate the operations of Surgery by plates. Of these there are fifty-two in number, containing no less than two hundred and eighty figures. They are intended to exhibit the dressings, bandages and splints now employed in surgery; then follow the appearances of the different fractures of the extremities, the positions of the bistou- ry, sutures, ligatures to arteries, amputations, operations on the eye, for the removal of stone in the bladder, &c. with the various instruments for performing each. This work is of royal octavo size, and contains a text of 200 pages the price of which, at Richards & Stoy's in Augusta, is 85 50. We cannot speak very highly of the execution of this work. The plates and figures designed to give it value are very poorly gotten up. Those on dressings, bandages and splints, add noth- ing to what we have had already, particularly from Gerdy. We seriously object to those on fractures of the extremities, be they even exact copies of the originals. They fail in the object intend- ed they do not illustrate the subject of fractures. We ac- knowledge this to be a very difficult task to execute; but these plates might have been better shaded. Here too is a very im- portant omission in surgery ; we have nothing on dislocations, no illustrations of a class of the most frequent and interesting of all surgical afflictions. We do not understand the figure, nor the directions given for the continued or glovers suture, nor do we acknowledge the importance ascribed to it in this work. The description and the preparations for applying ligatures to arte- ries, though taken from Velpcau, are very obscure in the trans- 38 298 Surgery Illustrated, c. [Oct. lation. The frontispiece, which also serves for the sixth regular plate, is a very meagre affair, and of little or no use in illustra- ting the subject to which it refers. In plate 37, in both opera- tions the saw is held in the left hand, and is represented as work- ing from left to right, across the chest of the operator, instead of forward and backwards. In plate 38, the position of the bistou- ry in making an incision in the scalp for the application of the trephine, is certainly a novel one; so also of the position of the elevator, which by the by is a very queer one. Plate 48 we de- fy any one to recognize what is meant by the figures ; not even with the text can we comprehend the operation for fistula in and as there described. Finally, we have never known lithotomy performed, as a friend at our elbow remarked, without the pa- tient being properly secured ; we think in all instances he ought to be tied, except when the arms and hands are wanting, as is represented in plate 50. There are also many errors in num- bering not only the figures, but the plates. This necessarily produces great confusion and ought to have been carefully cor- rected. It is very evident that the author of this compilation, is not a practical man ; nor indeed can it be expected of one so much en- gaged in writing. On the very first page he commits himself He says nothing of patent lint, now so generally used, but speaks of charpie made by scraping fine linen rag with the back of a knife. Those who scrape lint will find it sufficiently slow in accumulating even by using the edge of the knife. Pessaries are made not only of ivory, wood and elastic gum, as stated in the text, but also of metal, glass, wool, &c. The instruments generally are badly selected; we must par- ticularize the amputating knife and saw. We cannot conceive how any one prefers the shape of the French to the English or American Instrument. Whoever has used one of Weiss' knives of English steel, will never go to Paris to look for a better, or if he does, will assuredly be disappointed ; and certainly every one must select the firm bladed saw with the teeth widely set apart, and not the bone-like saw of the French case. At page 159, we read, " The operation of trephining is requir- ed in simple fractures, with depression, on symptoms of com- pression continuing after depletion ; in compound fractures, with depression, unattended with symptoms of compression." We know not whether Dr. Doanc derived this last idea from Cutler, Hind or Blasius, (we know he did not from Vclpeau) ; but it is most assuredly at variance with modern experience in Surgery. No one has done more to simplify the instruments and opera- tions of Surgery than Lisfranc, yet his name is not mentioned in the whole work. Altogether, we apprehend this book has been gotten up more for effect than for practical utility. The plates are of little val- 1830.] Extracts from the Note-book of a Physician, fyc. 299 j > ue, the figures arc unnecessarily multiplied. They arc both too numerous for the accompanying explanations, which are very unsatisfactory. Whatever may be the opinion expressed of the Surgery Illus- trated, and we assure its author it is given from honest motives, we cannot conclude this notice of it, without again commending the zeal and industry of Dr. Doane. His example, his great efforts to be useful, particularly to students of medicine and those unacquainted with foreign languages, ought to be imitated and deserves our thanks. P, F. E. Extracts from the Note-book of a Physician of this City, during his attendance on the Parisian Hospitals, LISFRANC'S CLINIQUE. Anatomy. The vulva is sometimes found so very small that it is almost impossible to introduce a speculum. This does not, however, invariably indicate the same narrowness in the vagina, for it may be produced merely by the integuments of the perin- eum, extending higher up than they should. It would be advi- sable when women thus constituted become pregnant, to resort early, say the fourth or fifth month, (for earlier might cause a- bortion) to the slight operation of dividing this part of the perine- um, in order that it should not be torn too much during labour. If it be necessary to introduce the speculum, the incision should be performed without any fear, for the parts contain no blood vessels capable of affording a spoonful of blood. Ruysh mentions having sometimes seen the hymen double. M. Lisfranc says he saw one instance of the kind. The membrane is not, as is generally thought, very thin ; it is on the contrary nearly two lines thick, and as tough as leather. When imper- forate, it should be entirely removed, and a dilating pledget, or meche applied. In individuals arrived at the age of 40 or 50, and who have not cohabited for several years, the vagina becomes, as it were, atrophied, and as narrow as that of a virgin. The parts are then dry and hard; it is therefore necessary to be very cautious in such cases, not to introduce the speculum too large, nor with too much force and haste. Very corpulent females have their labia pudendi considerably thickened, and as this does not diminish during hbor, they can- not be completely effaced, and impede the exit of the child. STOO Extracts from the Note-book of a Physician, <-c. [Oct. It is ridiculous to say that the nymphae are destined to direct the flow of urine. It is evident that their office is to afford ma- terials for dilatation during labor. As they are in some measure connected with the clitoris, it may be that they enhance the ve- nereal orgasm during coitus, and thereby tend lo insure impreg- nation. It has been lately proposed, in cases of rupture of the perineum during labor, to make, previous to the sutures usually practised, an incision on each side and at a small distance from the rupture, so that the contact of the torn surfaces may be facilitated. In women habituated to coitus, the uterus is not beyond the vagina, but actually projects in it. There is an erectile tissue in the perineum, which assumes the appearance of a tumour when efforts at stool are made. The direction of the pudic ar- tery should be carefully studied, for its course is very different in females from what is seen in males. The vagina is generally longer in tall women than in those of small stature. The pubes are more prominent in southern than in northern females ; and it will probably be found that the pelvis is also deeper and the va- gina higher in southern women. The attachment of the vagina to the cervix uteri, is six and a half lines thick anteriorly, and seven and a half lines posteriorly, so that the amputation of the cervix may be carried much high- er up without injury to the peritoneum than is generally thought. Introduction of the Speculum Uteri. For the introduc- tion of the Speculum, the patient should be placed in the same position as if she were to undergo the operation of Lithotomy, save that her hands are not to be fastened to her feet, nor any ligatures applied. The legs, or rather knees, arc to be held by two aids if admissible ; if not, the feet must rest on chairs of an equal height with the bed. The back must be horizontal, and but a small pillow placed under the head. The size of the spe- culum used should be proportioned to the dimensions of the va- gina ; this may be judged of from the length of the vulva, for the vagina is generally proportioned accordingly. M. Lisfranc mentions a case in which the vulva was only an inch in length, but very dilatable. The extent of the perineum varies exceedingly in different individuals, and Mr. L. has seen it occasionally two and a half inches. The labia? are to be separated with the lin- gers of the left hand, and the speculum, previously smeared with sweet oil, gently introduced with the right hand according to the axis of the vagina. As soon as the instrument has passed the external orifice, the labia arc to be left to themselves, otherwise, the dilatation of the vagina would be impeded. The speculum should be urged forward with the utmost caution, lest, by sud- denly overcoming some slight opposition, the instrument be for- pibly thrust against the os tinea:. The eye should be kept as 183C] Extracts from the Note-book of a Physician, the' amelioration of the nervous system ; at the menstrual period, the patient, however, should always take more or less exercise on fool. The state of the digestion and of the ali- mentary canal should be very strictly attended to, for when dis- 183G.] Extracts from the Note-book of a Physician, c. 306 cases of the uterus become complicated with an affection of the digestive tube, the chance of success is very much diminished. Leeches may, sometimes, be applied to the os tinea;, when the case is positively ascertained to be merely hypertrophy, without schirrus ; and then, with the intention to stimulate the vessels, and thereby bring about the removal of superfluous matter. If the case be schirrus, there is great danger of producing as many carcinomatous ulcerations as there arc leech bites, as has been repeatedly seen in cases of schirrous mamma. Frictions with Iodine may be useful ; the " Douches de Vagin" are highly ben- eficial, as are also those of the uterus. They may be made sul- phurous when there are also discharges. They should be con- tinued at first about five minutes, and the length of time gradu- ally increased. They are administered by means of a tube communicating at one end with the vagina or uterus, and at the other with a reservoir of water, placed in an elevated position ; the atmospheric pressure throws in the water with considerable force. IlYrERTRoniY of the Uterus, with transformation of tissue. The increased size of the uterus does not always ne- cessarily indicate a schirrous state, for there may be simple hy- pertrophy without alteration of tissue, or else hypertrophy with transformation of tissue. This kind of hypertrophy may be compared to the state of the mamma when said to be "engorge." It is characterized by the almost total absence of pain ; the ra- pidity of its progress; it very soon becomes chronic; does not yield as readily to remedies as cases of simple hypertrophy. The antiphlogistics should not be carried too far, for the disease continues acute but a very short time. An excellent remedy is compression, applied by the use of the pessary, of the shape of a "bilboquct;" this instrument being well placed, the uterus, by its tendency to descend, especially whenever the patient moves, takes exercise, or goes to stool, is pressed against it, and thus produces the effect desired. The pessary is to be removed when- ever it occasions the least pain, and reapplied when the irrita- tion has ceased. It may be left applied or not during menstrua- tion, according to circumstances, for it often happens that the uterus at this period is sensitive and necessitates its removal. Injections should be continued, and cleanliness strictly attended to. Tumours of the Uterus. These should be treated pretty much as the preceding diseases, viz: by ant iplogistics, regimen, rest, abstinence from coition, &c By such means, the progress of many very voluminous tumours, although of a schirrous na- ture, may be arrested, and the patient permitted to live a great number of years, especially if she attend strictly to the reduction of every symptom of irritation that may return 39 306 Extracts from the Note-book of a Physician, fyc. [Oct. Milliary Folypi of the Os TiNCiE. Milliary Polypi about the os tinea?, cither on the internal or external surface of its lips, frequently exist and pass unnoticed for want of careful examina- tion. They are extremely small, semi-transparent, not very hard, roll under the finger, and do not increase in size. The pain is excessive and similar to that of cancer ; no hemorrhage ; no enlargement ; irregular menstruation ; such are the ordinary symptoms. These increase and are attended with emaciation, diarrhoea, and even death. If situated externally, they may be readily seen ; but if within the orifice, the finger must be intro- duced in order to feel them, or the double branched speculum used so as to permit the orifice to be opened and inspected by the eye. Unless the physician be very particular, he may not notice them, so small and unimportant do they seem. The treat- ment consists in taking hold of them with a pair of forceps and twisting them off. Should they return, cauterize with nit. ar- gent, after their removal. It is worthy of notice that the pain ceases at the instant they are extirpated, and returns no more. This operation should be followed by antiphlogistics and such diet as will prevent imflammation of the parts, also cleanliness. Tubercles of the Uterus. Tubercles may exist in the pa- rietes of the uterus and also in the cervix. Lasnnec has an excel- lent article on the subject in the great Diet, des Sciences Med- icales. M. Lisfranc says he first detected them in the mamma?. The inflammation of uterine tubercles, may be prevented by proper means. It may remain latent, and then become cither acute or chronic. The tumour produced, may be easily mista- ken for hypertrophy with white tissue, or for schirrus ; but its progress will evince its nature, for, according to the intensity of the inflammation, it will assume either the form of a cold or a warm abscess, suppurate, and discharge the kind of matter pecu- liar to such tumours. The nature of the discharge will prevent its being mistaken for an ulcerated carcinoma, as it is very dif- ferent from the ichor of the latter ; is whitish, cheesy, ("caseeusc") floculent, (floconneux,) as is the case with suppurating tubercles of any other part of the body. By pressing the cervix uteri, this peculiar matter is sometimes abundantly discharged. In carcinoma we sec ulcerations simply ; but here an abscess. Ex- tirpation is necessary in cases of carcinoma, whereas tubercles may be cured without, as is often seen in cases of tubercular testicles. The proper remedies are antiphlogistics, baths, injec- tions with infusion or decoction of bark, the chlorides, &c. The granulations should be touched with the " proio-nitraie- acidc liquids de mercure" Rest and abstinence from venery, are absolutely necessary. It is perhaps impossible to establish pos- itively the diagnosis before suppuration takes place, hence tu- mours of the womb should always be suspected to be of this na- 1830.] Extracts from the Note-hook of a Physic urn, $c. 307 turc, and treated accordingly. The abscess may open into the vagina, rectum, perineum, &c, and produce more or less mis- chief. When long continued, these ulcerations may degenerate and become carcinomatous. Ulcerations of the Os Tinc^e. The simple ulceration of the mouth of the uterus is generally difficult to cure, even when unattended with loss of substance. This may be owing to the peculiar nature of the uterine tissue, and also to the irritation kept up by the continual friction of these parts, at every motion of the body, especially walking and riding. The irritating qual- ity of the matter secreted by these ulcerations, may, by coition, communicate to the man a species of gonorrhoea. These ulcera- tions may eventually become carcinomatous. Simple ulceration of the cervix is most frequently met with in females from 20 to 35 years of age, and not, as some have thought, at the critical age. This may be accounted for by the increased action of the parts at this age, for excesses of venery, and preg- nancy, are more common at this than at the age of 45 or 50. Whenever a female complains of discharges from the vagina, suspect ulcerations or redness of the os tinea? ; the slight degree of redness very frequently observed, is not of much importance, and should not be confounded with ulcerations. It is true, how- ever, that when neglected, this redness often passes to the state of ulceration. The posterior lip of the os tincse is much more commonly af- fected than the anterior ; perhaps because it is more exposed to the action of the acrid humours which pass from the uterus and collect in the most dependant parts of the vagina. This affec- tion consists, in the first stage, of a merely denuded surface, which, when exposed to the air, appears free of any discharge ; at the second stage, a bloody fluid is discharged when the part is ex- posed to the air by the speculum, or wiped with a soft lint brush. By a side view, a slight loss of substance may be perceived, but it is as yet extremely superficial, and seems scarcely to penetrate beyond the external membrane. In the third stage, the ulcera- tions arc much more evident, and true ulcerative granulations, ("bourgeons charnus?) as well as slight vegetations, may be seen. The parts increase in size, become softened, are easily torn by the least violence, feel soft to the touch, and soon degenerate into complete carcinoma. It may, however, advance very far without partaking of the cancerous nature, and this will always be detected by the kind of discharge, which, if there be no can- cer, is rather of a mucilaginous (glaireux) nature, than of that of ichor. Simple ulceration produces nearly all the symptoms of can- cer; it causes as much constitutional disorder, and often death. The paia is excessive, the discharge sometimes profuserand often 308 Extracts from the Note-book of a Physician, fyc. [Oct. has the peculiar odour of that produced by cancer ; the consti- tution undergoes that change called a cancerous diathesis. The increase of pain during the progress of treatment, should not always cause alarm, for this is often the case when the disease is fast yielding, and has, in fact, nearly disappeared. Instance a patient completely cured a year ago by amputation, but who still suffers very much. Are these dependant on habit ? In this affection, the cervix is almost always found inclined strongly towards the rectum, and, in many cases, the patients complain more of the rectum than of the uterus. These ulcerations may complicate all kinds of hypertrophy ; they may be stationary change places, or extend to the entire uterus, its attachments, &c. Strict attention to regimen and rest, is absolutely necessary. Cauterization may prove fatal when carelessly employed; but, otherwise, it can be considered perfectly innocent and free of danger. First abate the irritation or inflammation, in order to prevent metritis from supervening. Never cauterize when there is pain, but then order baths, emollients, low diet, and even ven- esection if necessary. The caustic should never be used when the ulceration is combined with tumefaction, (engorgement]) but act as if this existed without ulceration ; order emollient injec- tions and antiphlogistics. Hypertrophy of the os tineas, compli- cating ulceration, should counter-indicate the use of caustic. In order to apply the caustic, the speculum should be used, and the cervix alone included in it. If this cannot be sufficiently well done by the instrument alone, small pledgets of lint should be wedged in between the os tinea; and end of the speculum, so as to isolate this part from the vagina, and thereby prevent the ac- tion of the caustic from spreading too far. This being done, wipe the os tinea? clean, with a small lint brush, in order to re- move the mucus which might prevent the action of the applica- tion; touch wilh the caustic very lightly and repeatedly ; but only in a small surface. This remedy acts by changing the na- ture of the diseased action. After cauterization, the parts should be well washed by injections, to prevent too much action. The cauterization should be repeated every six or eight days, unless circumstances prevent. The disease is sometimes aggravated; then cease its use. It may be applied advantageously even in cases of mere redness. Injections of diluted chloride of soda, decoction of cinchona, cau de Barrrgc, and douches, may be used for months, either with or without the assistance of cauterization. The engorgement of the ovaries, when chronic, is not an objection to cauterization. The proto-nitrate-a.c'uh liquide de mercure, may not unfrequent- ly be substituted with advantage for the lunar caustic. Diseases of the uterus are extremely liable to return after ha- ving been cured ; hence the necessity of attending particularly to the state of the menses ; resort to venesection whenever they 183G.] Extracts from the Note-book of a Physician, tyc. 309 are disturbed. The continuance or return of pain after cessa- tion for some time, is not always a symptom of a return of dis- ease, but is often nervous, and will yield to narcotics. When the ulceration, however simple, continues to spread, notwith- standing the use of these means, and produces or threatens great constitutional disorder, amputation should be resorted to, for otherwise death may be occasioned. Why not amputate the os tineas as well as a limb, when its diseased state affects the general system and threatens life ? Leucorriicea. M. Lisfranc considers leucorrhcea sometimes an endemic affection, or dependant on atmospheric influence, (constitution medicate). It is very often occasioned by the use of foot-stoves, (chauffrettes) so common in this country; by a humid season; occasionally by excessive venery; sedentary ha- bits, especially if warm chairs are used; but perhaps the influ- ence of hot climates tends more to produce it than any other 'known cause. The discharge may proceed either from the va- gina or from the uterus, or at the same time from both. Chronic inflammation of the vagina may gradually extend to the uterus, and, if neglected, may give rise to a schirrous condition, polypi. &c. It should be borne in mind, that w7hen these discharges have long continued, they are true emunctories, and must therefore not be suddenly suppressed. The organs of the chest should al- ways be carefully explored previous to arresting this discharge, for Mr. Lisfranc has known this neglect prove fatal to a great number of females, whose lungs, being tubercular, ulcerated very rapidly after the successful treatment of Leucorrhcea. It will, when the lungs are the least suspected, be prudent to establish -setons or issues previous to such suppression. The general state of the system should be attended to, and tonics or antiphlo- grstics used accordingly. The use of the speculum will decide whether the discharge be from the vagina or uterus If from the vagina, Mr. L. has used the " Potion de Chopart," (a mixture of Bals. Copaiba, Spirits ^Ether, Nit. &c.,) or Bals. Copaiba and opium internally or by enemata. The doses should be gra- dually increased until either costiveness or diarrhoea be produced. The opium may be carried to six grains daily, with advantage. Injections of claret and wratcr, gradually made stronger, and even carried to pure wine ; rose water; sulphate of zinc, &c &c. Injections of chloride of soda, (diluted.) very rarely fail to arrest it; their strength should be gradually increased. The posi- tion of the patient's pelvis should be such as to retain the injection in the vagina, at least ten or fifteen minutes, and thereby render the injection rather a hath than a lotion. This injection cannot be used for men, because of its liability to cause false membranes to be formed in the urethra, and consequently strictures. This objection might, in some cases, be obviated by the introduction of a bougie immediately after the injection. 310 Extracts from the Note-book of a PJiysician, fyc. [Oct. When the discharge proceeds from the uterus, its suppression is more difficult to obtain. After the flow of the usual menstru- al fluid, there sometimes succeeds one of a serous nature, almost limpid, and so abundant that it soaks through thick folds of linen, and even leads some to believe themselves affected with inconti- nence of urine, or dropsy of the uterus. This flow, in some ca- ses, appears but a few days after the cessation of the menses, and continues a week more or less. The discharge may be thick, opaque, acrid, &c. Here also the general state of the system is to be carefully attended to, and prepared for the injections. If these, made in the vagina alone, will not suffice, they should be carried directly into the uterus, by means of a catheter intro- duced into the orifice of this organ. This may be done without the least pain, as was proved by Mad. Lachapelle, Mr. Dume- ril, &c. Emollient injections should be tried before resorting to those of an astringent nature. The decoctions of Elder flowers, and Marsh mallow roots, are very good. It is necessary, during the treatment of these discharges, to abstain from coitus. When using the astringent injection, beware of metritis ; watch the whole system. On Amputation of the Os Tinc^. M. Lisfranc has just re- lieved a female of the most troublesome palpitations, by the am- putation of an ulcerated os tincoe. It is wrong, he says, to think that the neck of the uterus should be amputated, only when it is the seat of a cancer. Certainly no one would hesitate to take off* a leg or arm, if either were occupied by an ulcer of such a nature as to seriously in- jure the whole system ; he does not see why the same rule should not be applied to this organ. It must therefore be borne in mind, that whenever the ulceration covers the whole os tincoe, and threatens to spread to the vagina, no time is to be lost, else the disease will rapidly degenerate into- cancer, and probably render an operation impossible, by extending to the body of the uterus. When the neck of the uterus is very short, as is seen occasionally, the danger of the body of the uterus becoming dis- eased, is very great. We should never be frightened by the phantom of " cancerous diathesis," for it is impossible to say positively that it exists, until the patient is nearly exhausted. Moreover, the books are full of cases in which Extirpation has proved successful, when there was every reason to believe in the existence of the diathesis. M. Lisfranc has now [1830,] amputated the os tinea? about sixty-five times, and lost but very few patients ; the cicatrix is generally complete in from four to six weeks. Treatment after Amputation of the Os Tincoe. I wit- nessed this operation performed the day before yesterday, by M. Lisfranc. The patient (".'meed no pain, and indeed remarked 1836.] Extracts from the Note-book of a Physician, tyc. 311 that she had experienced none whatever at the moment of the excision. Mr. L. observed, that the uterus resembled, in this respect, the liver, testicle, c. [Oct. was contracted, pale or livid, eyelids injected, great thirst, very hot skin, pulse T-iO, belly tympanitic and painful, particularly the epigastrium, gener- al depression, and constant vomiting and purging, since the poison had been taken. The symptoms of the younger were rather milder. M. Majeste returned to his dispensary, and in less than an hour prepared twelve ounces of the hydrated tritoxide of iron, and he gave to each two ounces at four doses, in twenty minutes. The vomiting ceased, but returned in an hour, when he gave two ounces more at longer intervals, and a lavement with half an ounce. At eight o'clock the vomiting returned with colic, and an ounce was given to each, with half an ounce in a lavement: the vomiting ceased, and did not return. They passed a good night. W ith the excep- tion of some little intestinal irritation, and an~eruption in the eldest, which yielded to simple treatment, there were no other symptoms. The other child, aged 9, was less violently affected. The vomiting ceased on taking the antidote, and in eight hours after the attack all danger was over. The action of the tritoxide as an antidote was evident. The dose in each case was very large, above thirty grains of arsenic ; and, although vomiting took place, yet a much smaller quantity has been often known to kill, al- though there was vomiting. The symptoms were always immediately re- lieved by the iron. The antidote itself appears harmless, as from four to six ounces were given to each child without any ill effects; and, as this is the case, it is advisable, even long after the poison has been taken, to estimate the quantity rather by its effect on the symptoms, than by any proportion to the poison, It is advantageous that this antidote is tasteless. British and Foreign Review. Journal des Connaissanccs Medico- Chirurgicalcs, Novem- bre, 1835. Fumigations in Hooping- Cough. Dr. Dohm, of Heide, in the duchy of Holstcin, has accidentally discovered a remedy for hooping-cough, that pro- mises to be of considerable use in that too-oftcn obstinate and dangerous disease. Two of his own children, a boy and a girl, (the former one, and the latter three years old,) had been suffering from hooping-cough for be- tween two and three months ; during which time several remedies, inclu- ding belladonna, had been tried m vain. The paroxysms were very frequent ami extremely violent, so that the faeces and urine used sometimes to be ex- pelled involuntarily. An accident of this kind occurred one evening during the absence of the father ; and, to remove the ill smell thereby occasioned, the bedroom was fumigated, and that to such an extent that the child was enveloped in the smoke. Contrary to the expectation of the doctor, the child had not another attack that night; the cough became much milder, and the repetition of the same treatment soon cured it. This encouraged him to try it in other cases, and he invariably found the paroxysm greatly relieved by it, if not completely stopped. The fumigation was made with the common species of fumales of the Pharmacop. Slesvico-llolst. (Olibani hbr. dins, BenzoeB, Styr, Calamitffi, sing. libr. dimid., Flor. Lavendul., Ro- sar. rub., singul. unc. qoatuor.) lie [we think, very justly,] considers the benzoin to be the most efficient ingredient. British and Fori ign Review. Pfqff's MUiheilungen. ERRATA. Page 208, line 11, for fistula in and, read fistula in a\o. Same page, second paragraph, last line, fur bonc-likc, read BOW-LIKE SOUTHERN MEDICAL AND SURGICAL JOURNAL Vol. L] NOVEMBER, 183G. [No. 6. Part I. ORIGINAL COMMUNICATIONS. ARTICLE I. Medical reflections, with two cases of Spinal Irritation, Simula- ting Colic and Gastro-Enteritis. By J. W. Heustis, M. D. of Mobile. The enterprising and indefatigable researches of the physiol- ogists and pathologists of the present day, and we may say of the medical profession generally, have greatly extended the scope of observation and inquiry, and produced more enlightened views m relation to the functions, diseases, and influences of the ner- vous system in all its phenomena, bearings and relations, as well in health as disease, than were ever anticipated in the days of Cullen and Brown. This is as it should be. No physician, who properly estimates the exalted dignity and responsibility of his profession, can consider any labor and assiduity too devoted, that have for their object the alleviation of the amount of human suffering, of mitigating the pangs of disease, and of contributing to the restoration and health of the afflicted. An office so be- nevolent and god-like, when undertaken with the true spirit. confers a dignity upon human nature, and gives a character of respect and veneration to the enlightened and successful prac- titioner, alike calling forth the admiration and esteem of the civ- ilized and barbarian. And what feelings can be more congenial to the heart than those produced by the overflowings of grati- 11 Medical Reflections, tyc. [Nov. tude, greeting the physician wherever he goes, as the messen- ger of comfort and the disposer of blessings to possess such a hold upon the confidence of the sufferer, relatives and friends, that the very appearance of the familiar and cherished counte- nance of the physician, lights up the beams of hope upon the vi- sage of anxiety, suffering and despair? True, we sometimes meet with unmerited and ungenerous treatment and mortifica- tions, from the fickleness and caprice of those who should have considered themselves under permanent obligations. Cases of this kind, however, are so common, that they should cease to leave any permanent impression on the mind of the more experienced, satisfied in himself in relation to the correctness and propriety of his conduct. The payment of an account is generally consid- ered the liquidation of all obligations : with respect to the medi- cal profession, however, such an idea is illiberal and unjust. It is rare with us that the fees are larger than are necessary to cover the expenses ; so that without other resources, the physi- cian must be content to drudge on through years of penury, well satisfied, if in the decline of life he is placed beyond the reach of want and apprehension. And is such a perquisite a full equiv- alent for all assiduity, solicitude and care? Is it thus that our services are considered in the light of mere mechanical or mer- cantile employments ? To a sentiment so unworthy, it has been my good fortune to know many and honorable exceptions ex- ceptions, affording a satisfaction more pure and genuine, than any that could be yielded by mere pecuniary reward and com- pensation. With these remarks, I enter upon the more imme- diate subject of consideration. The connexion of rheumatism and various painful affections, with existing irritation in the spinal origin of the nerves of sensa- tion and volition, has shed a new light upon the former disease, promising to be of essential practical utility, as well in this as in other affections which it may resemble in character and symp- toms. As serving to elucidate this subject, I submit the two fol- lowing cases, much abridged and condensed. Case 1. I was called, Sunday, July 10, to see Mrs. W. During my absence, Dr. B. had been called in, and had bled her. As I, however, was the attending physician in the family, the case came more exclusively under my care. The attack had very much the appearance of a violent colic, viz. excruciating 1830.] Medical Reflections, fyc. 323 pain in the bowels or abdomen, and a strong spasmodic undula- ting heaving of the thorax and abdomen at every inspiration, by which the latter was thrown convulsively and violently forwards. These symptoms were relieved by bleeding and the subsequent free use of laudanum and other antispasmodics. There were still, however, great soreness and tenderness of the abdomen on pressure, for which the lancet was used twice, besides the free bleeding at the commencement of the disease ; the warm bath was also used, and also warm fomentations. On the third day of the disease, to open the bowels, a moderate dose of caster-oil was exhibited ; as this operated too freely, an opium pill was gi- ven. From this time she was seized with convulsions, which would frequently recur at irregular intervals, perhaps as often as eight or ten times in the course of the day. At night she wras generally composed, and rested well with the aid of an anodyne, given either by the mouth or injection. She also took infusion of valerian, as there was little or no excitement. Pills composed of the blue mass , calomel and camphor, were also exhibited. As she complained much of her head, this was repeatedly cupped and blistered, as was also the region of the stomach. As there was tenderness about the lower portion of the dorsal vertebrae, a cup was applied to this portion of the spine, and subsequently, a blister. July 16. The blister drew well, but notwithstanding this, and the various other means, she has had several severe convulsions, and now lies in a state of stupor. July 17. Had the cuticle removed from the blistered part, and the surface dressed with cerate, containing about one grain of the acetate of morphia : took an anodyne injection last even- ing, and has been taking to-day, every two hours, about the sixth of a grain of the acetate of morphia, and two grains of the blue pill : took also, this evening, an anodyne enema, as there were symptoms indicating the return of spasms. The opiates have produced nausea and some vomiting; let them be discontinued: has had no return of spasms since the evening of the 16th. The pains, spasms and convulsions now, became much miti- gated, and their return protracted to longer intervals. Great relief appeared to be afforded by dressing the blistered surface, with simple cerate, containing about half a grain or more o( the acetate of morphia to each dressing. As there were pretty dis- 324 Medical Reflections, <$. [_N ov. tinct intimations given of the threatened attack of convulsions, by the appearance and sensations of the patient, these were pre- vented by enemata of starch, containing two or three drachms of laudanum. Under this treatment she soon recovered. The first decided impression was made by the blisters and the application of morphine to the denuded surface. The anodyne injections were also of essential benefit. It is worthy of remark, that the cupping of the temples, and all the applications that were made to the head were entirely unavailing, clearly showing that this was only sympathetically affected. From all the circumstances connected with this case, I was convinced that its seat was in the spinal origin of the nerves of the lumbar vertebrae, or in the cord itself; and with this view the treatment was finally directed. And it is proper to mention, that previously to each attack of convulsions, she would be seized with intense pain in the spine, sympathetically affecting the head at the same time. Case 2. Mrs. D. had been confined to her bed a number of days, with what was called a bilious colic, and for which she had been treated accordingly, by her attending physician. As hey case continued without improvement, and the symptoms became alarming, it was deemed expedient to hold a consultation. She complained of severe abdominal pains, subject to frequent exa- cerbations, for which her only relief was in the free use of mor- phia. As there were some symptoms resembling those of the case above related, I suspected an affection of the lumbar or dorsal nerves, or of the cord from which they originate. Upon pressing upon the spinous processes along the four or five lowey dorsal vertebra), and the upper portion of the lumbar, she shrunk from the touch, making great complaint of the tenderness and pain therefrom : and, indeed, she referred the origin of her ab- dominal pains to the spine, radiating from thence as a common centre. 1 suggested to her physician, the propriety of exciting counter-irritation of the spine, by blisters or tartar emetic. He, however, appeared rather to lake a different view of the case, considering it as chronic enteritis, originating from an attack of bilious colic; and so we compromised, directing the warm bath occasionally, morphia to allay the pain, enemata to keep the bowels free, and food of the mildest and least irritating kind, as ar- row root, crackers and tea.drv toastand things of that description. 183G.] Hfedical Reflections. $c. 325 She was already in a state of salivation, and the cheeks and fauces were considerably ulcerated. In nearly the same situa- tion she remained several days, under similar treatment, occa- sionally a little better and then worse, without any permanent improvement. The pulse was rather full and strong for a person in her debilitated state, although she had been bled the day pre- vious. As the case belonged more exclusively to the former physician who had previously attended her, I saw her but seldom. On the 18th of August, I was particularly requested to visit her again; there was but little alteration; she was still confined to her bed. She complained of great tenderness and soreness of the abdomen, along the tract of the colon, for which I cupped her, but without any permanent relief, as she was attacked the next day with pain and spasm as violent as ever. Agreeably to my original idea, I now applied a pitch-plaster, strongly im- pregnated with tartar emetic, to the affected portion of the spine. She still found it necessary to use the morphine. Her former physician saw her, in company with me, and from his represen- tation of the previous good effects of mercury and salivation in her case, she was put upon the use of the blue-pill night and morn- ing. On the 23rd of August, four days from the application of the plaster, I found her sitting up for the first time, attending to some light domestic employments, quite cheerful, saying that she was getting well that she could now put her feet to the floor without that dreadful pricking and stinging sensation that she before experienced in her feet when attempting that movement. Upon enquiring whether the plaster had produced any uneasi- ness of the back, she said it had, and that it was very sore and raw, but that she did not regard that if it would only assist her recovery. Her former physician had, a day or two previously, suggested the propriety of putting her upon the use of the blue- pill, with ipecac and opium, every two hours. She wished to know of me whether the object was to produce salivation, I re- plied that was, in part, the design ; she thereupon strongly pro- tested against the prescription, and against the use of mercury in any quantity or form, having already, as she said, suffered so much from salivation. The prescription was not insisted on, and her rapid convalescence rendered it unnecessary. I consider the tartar emetic plaster, as the sole efficient agent in the relief of this case. 326 An Account of Cholera, fyc. [Nov. The probability is, that were cases of supposed colic and en- teritis more closely analyzed, they would frequently be found to proceed from spinal irritation ; and, indeed, so important is the relation which the medulla spinalis bears to the general system, that in all painful, spasmodic and convulsive affections, its exami- nation should never be neglected. Mobile, August 31, 1836. ARTICLE II. An account of Cholera, as it prevailed in the City of Savannah and its vicinity, in the Fall of 1834. By P. M. Kollock, M. D., of Savannah, Georgia. Since the subject of Cholera began, more particularly, to at- tract the attention of European and American physicians, its history, pathology, treatment, and in fine, every circumstance relating to the disease, as presented to the observation of those who have witnessed it, have been so minutely and voluminously discussed, that it might appear rather supererogatory and per- haps presumptuous, to attempt at this time to present any thing which could be considered original, or at all interesting in regard to it. But, however minute have been the descriptions, and how- ever voluminous the essays on the subject, every man of judg- ment and candour, every one interested in the establishment of truth, and in the advancement of science, is compelled to ask himself the question How much good have they done ? how much have they contributed towards the establishment of the pathology of the disease, and more particularly of its treatment? In considering the first part of this query, the philanthropic physician has much cause of triumph and rejoicing. The scal- pel of the pathological anatomist, particularly of our own coun- try, has revealed to us most satisfactorily, the condition of the 1836.] An Account of Cholera, fyc. 327 organs, which is the result of the operation of this most mysteri- ous agent and taught us that cholera is not to be considered a disease of extreme debility, in any of its stages, and demanding for its cure the administration of the most powerful stimulants known to us ; but rather that it is to be classed with those disea- ses which exhibit the phenomena of the most intense phlogosis. Far less reason, however, has the profession to exult in their success, in having established a sure and uniform course of treat- ment, deduced from a pathology, which seems so clearly and sat- isfactorily ascertained. Notwithstanding the apparent certain- ty which exists in regard to this point, the treatment of the dis- ease in general is as fluctuating and unscientific as can well be conceived; and consequently its success is proportional. On this account, when it makes its appearance, practitioners, as well as patients, are panic-stricken their unsettled notions lead to failure in practice the community lose confidence, and are rea- dy and anxious to plunge into the vast ocean of empiricism. Having had cause to feel most forcibly the truth of the above remarks, I have been induced to offer the following paper to the notice of the profession in this section of country, not with the hope of presenting, in any strikingly original point of view, a subject, about which so much has already been written, or of adding any thing very important to the mass of information on the subject. But believing that the disease on its irruption at this place, exhibited features differing in some respects from what were observed in other parts of the country, particularly at the North ; and consequently that it required a modification of treat- ment accordingly, my object has been to invite the attention of Southern physicians to these points, in order that they may test the correctness of my observations, and with the hope that my hints may not be found altogether without utility. This fell destroyer of human life had visited almost every part of the American continent, before it reached Savannah.* Early in the Summer of 1834, it broke out in Canada and New York, and we could not hear of its being nearer Savannah than Washington City, when about the 1st of September, it was re- ported by the health-officer of the port of Savannah, that some *It had approached in October, 1832, within 100 miles of Savannah ha- ving been carried to Folly Island near Charleston, in the brig Amelia, from New York, which was wrecked on Folly Island. 328 An Account of Cholera, fyc. [Nov. cases very much resembling in their appearances, Cholera As- phyxia, had occurred on the plantation of Maj. Wightman, about 12 miles above the city, immediately on the Savannah River. These cases were soon followed by others. The disease con- fined itself to this plantation for, some little time, and the number of cases was large, before it extended itself to other adjacent plantations. It at length progressed, and after attacking one or two places above Maj. Wightman's, pursued a downward course, until it visited every plantation on the river, even the last below the city. This occupied about three weeks, and during this in- terval there occurred but six or eight deaths in the city, and most of these cases originated in the country. A very few days after the disease broke out at Maj. Wight- man's, we heard that it had made its appearance on the River Ogeechee, 15 miles from Savannah, and without any of the in- termediate places being affected. Cases of the disease continued to occur in the city and along the course of the Savannah river, until late in the Fall. Since 1834, cases have occasionally been met with, resembling the disease under consideration, more or less nearly ; but usually they have proved very manageable. In the year 1832, when Cholera first made its appearance in America, and prevailed to such an extent in our northern and western cities, there was observed a very strong predisposition to bowel affections among the inhabitants of this vicinity, in com- mon with those of all other parts of the United States. So much was this the case, that we were obliged to administer cathartics with the greatest possible caution, in the treatment of our ordin- ary fevers. But in 1834, previous to the appearance of the dis- ease at Maj. Wightman's, it is remarkable that there was no strong epidemic tendency to bowel affections observed. As the disease advanced, the predisposition accompanied it, and three- fourths of our population were affected with cholerine or chole- raid. It was remarked, however, by other physicians, as well as by myself, that other diseases did not so far assume the "liv- ery" of the reigning epidemic, as to render any material modifi- cation of their treatment necessary. In the treatment of our or- dinary fevers, we were enabled to prescribe cathartics with the same freedom as in ordinary seasons. According to the accounts of writers on the subject, it will be 1830.] An Account of Cholera, fyc. 329 observed that Cholera, among us, differed in this respect from the disease which prevailed elsewhere. The symptoms of the disease which raged in this vicinity, were at variance in many respects with what it assumed in other places. According to my observation, the cramps in the extremities were not as much complained of as is generally stated nor do I think that the discharges from the stomach, bowels, and skin, were usually as profuse. It was not always possible to ascertain with precision, the quantity which had been discharged from the stomach and bowels; but I judged of the lesser profuseness of these discharges, by what I could gather from enquiry, and from the extremely phlogosed condition of the mucous membranes, which remained after death, as discovered by dissection. When the dischar- ges have been very profuse, the inflammation is relieved, and there are no traces of it observed in these membranes, excepting such as are indicated by their diminished consistence, &c. In every case it could be ascertained on enquiry, that the patient had been affected with diarrhoea, accompanied with more or less pain in the bowels, for some days or hours previous to the su- pervention of collapse; and this diarrhoea was always at first bilious. With greater or less rapidity, the stools lost their bil- ious appearance, became almost perfectly transparent, or semi- opaque, like water in which rice has been washed or boiled and often the same matter was thrown up from the stomach. The patient soon became as cold as marble ; lost his pulse ; the skin for the most part was dry, and not always shrivelled ; but inelastic. The tongue wTas sometimes blue and cold at other times warm, always moist sometimes clear, then again foul: The patient in the cold stage complained of no pain, merely of weakness and fatigue. Sometimes when not disturbed, he lay in a stupor, with his eyelids half closed, and the balls turned up ; at other times there were great restlessness and tossing from side to side. The voice in some cases was very weak, and reduced to a whisper ; in others, where the collapse was confirmed, the voice continued nearly as strong as natural. Although great weakness was com- plained of, the muscular strength was retained to a surprising degree. I have been informed by other physicians, that they observed the sensibility impaired to so great a degree, that boil- ing water poured on the skin was scarcely felt. I did not notice this in any case. I poured boiling water on the legs of a negro 42 330 An Account of Cholera, $c. [Nov. man in confirmed collapse, which he felt so acutely, that he leaped up instantly and appeared to be in great agony. In those cases which were fortunate enough to pass through the stage of collapse and react, a pretty severe bilious fever suc- ceeded, attended in some instances with violent gastritis, as manifested by the blood-red and furred tongue, and with great determination to the brain, producing coma more or less intense. Sometimes this reaction rose so high, as to require very profuse and frequently repeated bloodletting, to protect important organs. My personal acquaintance with Cholera, commenced at the plantations of the estate of Thomas Young. On the 6th of Sep- tember, 1834, 1 visited the place on the upper part of Hutch inson's Island, called " Ham." Two negro men had been attacked with the disease, while cutting rice in the field, and were found dead on my arrival. It is most probable that these individuals had laboured under diarrhoea some days or hours previously, which had been neglected by them the fact, however, could not be ascertained. On the 7th of September, I visited the back river plantation* called u Fife." I found two men collapsed one with very little pulse, the other with none. Not having seen any case previous- ly, I prescribed the treatment which I understood had been suc- cessful at Wightman's, and which was as follows: R. Calo- mel, gr. x. ; Gum. Camphor, gr v.; Gum. Opii. gr. i. : every hour. Sinapisms to the extremities and abdomen. I endeav- ored to excite vesication by pouring boiling water on the ex- tremities ; but found it productive of such extreme distress, even in the deepest collapse, and attended with no perceptible good result, that I very willingly abandoned it. Uncertain as to the treatment best adapted to the disease, as presented to my notice, 1 determined to avail myself of the first opportunity of post mortem examination, in order to ascertain, if possible, the true pathological condition of the organs. Ac- cordingly two cases presented themselves both had passed into the stage of collapse before I saw them. The treatment above detailed was prescribed death supervened in from 12 to 24 hours after they took to their beds, although I have no doubt a diarrhoea must have existed previously. At the time of their death, they had taken about xl. grs. Calomel, xx. gr. Camphor, iv. gr. Opium, 1830.] An Account of Cholera, fyc. 331 In the first case examined, the mucous coat of the stomach was found intensely inflamed throughout the Calomel had not pass- ed from the stomach. There was a slight inflammatory blush throughout the mucous coat of the small intestines, which con- tained a tenacious creamy matter. The large intestines exhib- ited no traces of inflammation, they were entirely empty, with the exception of the Coecum, which contained small particles of hardened feces resembling gall stones. The vessels of the ex- ternal coat of the intestines were much injected, and the whole exhibited a bluish tint. The liver was pale and exsanguine ; gall bladder distended with bile; kidneys pale and bloodless; spleen rotten ; bladder contracted and empty ; mesenteric glands enlarged. The abdominal muscles, when cut through, exhibi- ted an unusual stagnation -of blood in the small vessels. The second case examined displayed the same intensity of gastric inflammation as the first; but in this case, the inflamma- tion of the intestines was quite equal to that of the stomach, and in the colon blood was effused in several spots. The intestines and stomach were filled with the rice water effusions In this case, the bladder contained some urine. The appearance of the liver, kidneys, mesenteric glands, and external coat of the bow- els, was similar to what was observed in the other case. In both cases, the fat of the omentum, as also that surrounding the kid- neys, was entirely absorbed. In the last case, the spleen was natural as to size and consistence. As the result of this examination, I became averse to the em- ployment of active stimulants and narcotics, in the treatment of a disease which presented so many and such decided appearan- ces of intense phlogosis. The idea of applying camphor, opi- um, capsicum and alcohol, to such surfaces as the scalpel had brought to lijjht, was revolting in the extreme. I therefore en- deavored to adopt a practice as strictly sedative as possible. Bloodletting was accordingly resorted to at the commence- ment of the attack, when the subject was robust and the pulse active a blister was applied to the abdomen and gum-water the only nourishment allowed. In some slight cases, unattended with vomiting, a few grains of pulv. dover. were prescribed with benefit; soda-water was given to check vomiting; sinapisms and stimulating frictions, with an infusion of capsicum iu alcohol, or spiritus terebinth. 332 An Account of Cholera, $c. [Nov. were employed to favor determination to the surface, where a centripetal tendency was observed. These means, in a vast number of instances, were sufficient to check the disease, even in some cases where collapse had com- menced. As the disease advanced in its career. I was induced to modi- fy the treatment and adopt a course still more antiphlogistic and depletory. Hitherto, I had refrained from the use of cathartics at every stage of the disease, and every thing calculated to increase the peristaltic action of the bowels being governed by the injunc- tion of northern physicians, who asserted that instances were frequent, where the disease was aggravated, and the patient pre- cipitated into the stage of collapse, by the injudicious adminis- tration of a cathartic. And accordingly my efforts were always directed to arresting the frequency of the discharges, and for this purpose, as has been stated, the narcotics were occasionally employed. I found, however, that the first stage of the disease could be treated with more certainty, and much better effect, by the speedy removal of bilious accumulations, which usually ex- isted J?t that time, and by a total abstinence from narcotics. The following course was therefore pursued : The patient being attacked with cramps in the bowels and diarrhoea, with frequent and profuse bilious dejections, he was bled from the arm until the commencement of syncope, or until the pulse be- gan to yield a large blister was applied to the abdomen and as soon as the effects of the bleeding had subsided in some mea- sure, xx gr. of calomel were administered and succeeded by a table-spoonful of castor oil, in two hours ; gum-water the only drink allowed. When vomiting has supervened, and the discharges have as- sumed the rice-water consistence and hue, the cathartic is a doubtful remedy, and I think, should be avoided. The vomi ting will usually soon cease, if the patient is not allowed to take any thing into his stomach, even the smallest quantity of drink, and a sinapism applied to the epigastrium. When the collapse has commenced, venesection should be practised with great cau- tion, as I have seen it obliterate the pulse entirely, and confirm the collapse. The cold stage of the disease, -or as it is usually called, the 183G.] An Account of Cholera, tyc. 333 stage of collapse, was regarded here as elsewhere, the moribund condition. The patient has parted with an important portion of his vitality ; the hand of death is upon him. The vital spark is nearly extinguished, and we know not'with certainty, " where is that promethean heat, which can again its light relume." If the profession here cannot boast of more success in the treatment of this stage, than occurred elsewhere, I do not believe that they have to reproach themselves with less. Recoveries from collapse arc pretty nearly as rare, as from the black vomit stage of yellow fever; the community, therefore, should be deeply impressed with the importance of commencing the treat- ment of the disease with energy in its forming stage. Many lives have been lost by neglecting a midnight attack, until morn- ing light exhibited the hopelessness of their condition. The stage of collapse has generally been described, as induced by exhaustion from the immense effusions of the serous portions of the blood. Doubtless this explanation will suffice in many instances, and in such, the mucous coat of the stomach and in- testines is found free from all traces of inflammation, it having been reduced by the excessive effusion. But in a great number of cases which came under my notice, it did not strike me that this cxplanat:on was altogether satisfactory. It did not appear that the discharges had been as profuse, as were usually repre- sented ; and in most instances, the skin was dry, instead of being bathed in perspiration, and not shrivelled. This was the fact in regard to the two cases, the post-mortem examination of which has been detailed and it was to the comparatively small amount of effusion, that was to be attributed the intensity of the mucous inflammation exhibited by them. It seemed as if the general ex- citement of the system, was wholly absorbed by that of the in- ternal organs, which induced the collapse. It would be difficult to say what course of treatment was not essayed by our physicians, during the stage of collapse. One plan was very nearly as successful as another. Some pushed the diffusible stimulant practice to the utmost extent ; others ex- hibited an incredible amount of mercury in an equally incredible short space of time. According to my observation, the patients under both plans, sank with more rapidity, than when they were left almost entirely to nature. Nor could it have been reasona- bly expected to be otherwise, considering the pathology of the 331 An Account of Cholera, $c. [Nov. disease. For is it not more probable, that when the balance of excitement is so much in favor of the central organs, the appli- cation of active stimulants and irritants to them, will serve to fix this hyper-excitement more firmly ; and that it. will be much more difficult, if not impossible, to diffuse the excitement, however much we may stimulate the surface and extremities? Very soon after the appearance of Cholera among us, I tried during the cold stage the emetic practice, as recommended by Drs. Chapman and Hopkinson of Philadelphia. I visited a plantation below the city, where I found two ne- groes collapsed ; one a young girl, the other a middle-aged man. The girl was pulseless the man not entirely so. The salt wa- ter emetic was administered to each, which vomited them ac- tively. The puking having ceased, xx. grs. of calomel were given, and it was directed that it should be repeated in x. gr. doses, every hour, until they had taken 3i. At my next visit, on the following morning, I found that the girl's system had react- ed completely the man was in articulo-mortis, and died in a few minutes. The girl labored under the usual fever of reaction for some days, and slowly recovered. This was the only instance in which I observed this practice successful, although I em- ployed it repeatedly. I have siace, however, had reason to believe that the emetic would be followed by good results in many instances, if it is not succeeded by the calomel and would therefore recommend, that when it be employed, every thing calculated to irritate the sto- mach and bowels in the smallest degree, should be withheld, and that the patient be allowed to take nothing but mucilagin- ous drinks in small quantities, of which gum-water is best. At the same time, the excitement should be invited to the surface, by the application of sinapisms and stimulating frictions. The emetic appears to act beneficially in some instances, by means of the shock which its operation communicates to the sys- tem, and the centrifugal impulse which it occasions. It is pro- bable that the emetic is better adapted to those cases, where the inflammation of the mucous membranes has been in a great mea- sure reduced, by the excessive profuseness of the; discharges. Where there is much inflammation remaining, its utility is ques- tionable. I do not think that calomel should ever be given except in the I83t>.] On Intermittent and Remittent Fevers, c)-t\ 3J35 forming: stae;e of the disease, and then as a cathartic. I consider it a doubtful remedy after the discharges have assumed the rice- water character. I am aware that the remarks, contained in this paper, may net escape the cavils of a portion of the profession. I give them, however, as the result of my convictions, and they must stand or fall by the test of subsequent experience. ARTICLE III. Remarks on the Pathology and Treatment of Intermittent and Remittent Fevers, with cases. By Lewis D. Ford, M. D., Professor of Chemistry in the Medical College of Georgia. I have united these two forms of fever in the following remarks, because of the striking resemblance of their features generally, and under the conviction of the great similarity, if not identity of their pathology. They resemble each other strikingly in the symptoms precursory of the formal attack, and in the first dis- tinct paroxysm so closely, that the most expert ob>erver will not pretend to foretell which of the forms the disease will subse- quently assume; also in the progression of the symptoms of a paroxysm and in its duration. We infer their general similar nature further, from the fact of their simultaneous appearance in different individuals under similar circumstances of exposure, and from the fact that they mutually run into each other. Taking it for granted, that they both arise from an external cause, which cannot be doubted, whatever difference of opinion may exist as to what that cause is, what it should be called, &c, the question naturally occurs Can we render an account of the fact, that under the agency of this identical cause, one 336 On Intermittent and Remittent Fevers, c. [Nov. form is determined in one individual and the other in another? for if we can, we may be confirmed in the opinion of their gen- eral similarity and deduce from this explanation some useful practical directions. On exposure to this external cause, an in- dividual suffers a regular paroxysm of fever. After a certain intermission, comes another and another ; we may infer, that the cause, at the moment of becoming efficient in producing each paroxysm, finds the organs of the system generally in the same state, as at the commencement of the first or if previous par- oxysms had produced alterations in some of them, they are not such as to counteract the regular succession of the phenomena of the paroxysm. But, while under the same external circumstan- ces, this case becomes remittent, when we will generally be able to discover some physical or functional signs of disorder of some of the organs of the head, chest, or abdomen this morbid change, at first slight, not of a degree to produce danger, under a state of quietness approaching to that of health, but liable to be increased to a dangerous degree by the agitations of succeeding paroxysms; and it is matter of observation, that if these super- added disorders of the organs be not relieved, they are increased by every succeeding paroxysm, and disturb more and more the regular periodicity of the fever ; which in its progress to a fatal termination, exhibits more and more distinctly, the marks of this local affection. Hence we conclude, that if of two individuals under similar exposure, an intermittent be determined in one, and a remittent in the other, that there is some visceral irritation in the last, either pre-existing the attack and increased by it, or al- together determined by the first paroxysm itself, and that as long as the fever preserves its periodical character, even in this mod- ified degree, it does so under the influence of the same organic condition on which the perfect and regular periodicity of an in- termittent depends. What then is the pathology of this intermittent fever ? which from the time of the earliest records of medicine, to the physi- cians of all ages, has presented in its different forms, one unva- rying character a character so uniform, that the description of the simple disease by Hippocrates, would graphically represent those cases seen by ourselves. For it is worthy of remark, that the practical history of intermittent fever was perfected by Hip- pocrates himself; that is, its external dcvclopcmcnts accurately 1830.] On Intermittent and Remittent Fevers, fyc. 337 marked and even the names of its various forms, imposed by this great father of the science, are retained to this day. The question then, as to the pathology of this disease, becomes one of peculiar interest to the philosophical physician, since from this uniformity, it has presented a subject so favorable for investiga- tion allowing the science of each succeeding age, to hold fast and establish those principles as to its nature, which were true, and gradually to discard those that were erroneous. In this point of view, its history is calculated to illustrate the powers and resources of the science. It may be interesting to trace its history in a very general manner, and to connect the opinions entertained as to its nature, with the prevailing philosophy of the most prominent systems ; for the fact, that we do not now under- stand its pathology, is well calculated to produce doubt as to the certainty of the science of medicine, after all the confident and boasted pretensions of these various systems to have explicated its nature ; which doubt will be removed by the conclusion to which we must necessarily arrive, that the science has not at- tained to this knowledge of its nature, because of the defective modes of its investigation. Hippocrates, with his admirable principles of forming medi- cine into a science of observation and of facts, with wonderful exactness, recorded the phenomena of this disease ; and if he had applied the same scrutiny to the interior of the human body, his theory might have been valuable but what could be expected as to its pathology, from him, who understood not the difference between a ligament and a nerve, nor that these were the chan- nels of sensation ; who attributed motion to the agency of the tendons; who was ignorant of the circulation of the blood, and understood not the functions of the brain ? The philosophy of his age, had established the dogma of the existence of the four elements of nature, and in accordance with the spirit of the times, which was seeking for comparisons and strained analogies be- tween the universe and the human body, he established the dog- ma in medicine, that the body wras composed of four humours, &c. and that diseases depended upon a super-abundance or deprava- tion of one or other of these. Author of the excellent principle of ever having some definite and specific object in view in the treatment of disease, his indi- cations in this instance, wTere founded upon his pypothetical views 43 83S On Intermittent and Remittent Fevers, c. [Nor, of its proximate and occult causes viz. : to aid nature in the concoction and expulsion of the peccant humour. Such is the conclusion of him, who set out with the declaration, that obser- vation and just deduction are the only true means of advancing medicine. What a conspicuous example of the uncontrollable tendency of the human mind to vain and unprofitable speculation, do these views of this great man exhibit apt prototype of the medical philosophers of all succeeding ages ! Galen, 500 years after him, his admirer and commentator, with greater exactness, attributed the quotidian form to the pre- dominance of the phlegm, tertian to that of the ordinary bile, quartan to the black bile. The opinions of Hippocrates, thus extended and stamped with the seal of this great master, contin- ued to control the minds of their successors to the time of the introduction of the system of chemical medicine. To give but one single example of their pathology : A celebrated partisan of this school, had determined very exactly, the composition of the globules of the blood to consist of phlegm, salt, sulphur and earth that fever in general consisted in an unnatural fermenta- tion of these and that intermittent fever especially, was gen- erated when the salino-acid and acrid principles, happened to get into the small vessels ! Whatever credit is due to the celebrated German reformers of the commencement of the 18th century, for overturning the chemical and humoral doctrines, their pneumatic system was calculated to establish nothing certain with respect to the inti- mate nature of this and other fevers. Stahl distinctly discoura- ages the application of physical and chemical science to medi- cine, and especially denounces the study of minute anatomy, lest it might lead men to the belief that disease sprung from changes in these delicate parts, and thus draw them away from the study of the great laws of the organization, and from an ex- amination into the alterations of the vital principle. We are not surprised at the deductions of this system as to the nature of fever fancifully representing it to be a commotion of the sys- tem, excited by this active principle this soul, thus roused to this extraordinary effort to free itself from an offending cause. In the " First Lines," the text book of the elder of the present generation of medical men, we find this same mysterious agent, under the name of the vis medicatrix naturae, raised up to explain 1830.] On Intermittent and Remittent Fevers, tyc. 339 some of the changes in a paroxysm of intermittent. It is there characterized as "an agent," as "making efforts," and we would suppose from the peculiar phraseology, that all the instances in which this supposititious power exerts itself, and even the modes of its operation, were well known to, and exactly apppreciated by the Edinburg professor for there is this remarkable sentence, occurring too by way of argument in favor of his peculiar theory: " Because, in almost all the cases in which an effort is made by the vis medicatrix, a cold fit and a spasm of the extreme vessels are almost alu:aj/s the beginnings of such an effort"! And after making this agent bear so conspicuous a part in his pathology, he arrives at the flattering conclusion, that "this doctrine will serve to explain the nature of fever in general," &c, and mod- estly congratulates himself upon having thus been led into "the proper train of investigation." An American critic* upon Dr. Cullen's theory of fever, ex- pressly avows his belief in the "existence" of this hypothetical agent, formally assigning to it functions; and he too, is well ac- quainted with its various offices, for after mentioning some, such as the knitting of fractured bones and the healing of wounds, he adds, " and many other processes which we cannot now enu- merate"! He speaks of it as "a curative cause" In his opin- ion, it controls every thing, medicines and all " were it not for its action, recovery from disease would be absolutely impossi- ble." After declaring that the reasoning of Dr. C. is " forced and artificial, unsatisfactory and confused," he asserts his belief with the fanciful Darwin, that fever is a disease of association that it is formed alone through the medium of " sympathy." We are irresistibly tempted to apply to this criticism, the re- mark of Dr. Johnson, upon some of Mr. Travers' speculations: "this is like casting out devils by Beelzebub the prince of devils." And even in the latest of those " Practices of Physic," with which our medical literature so much abounds ; in which one man attempts to develope the nature of all diseases in a general and superficial manner, instead of confining himself to the critical and philosophical investigation of one those books that tell " Baith the disease and what will mend it," and the popularity of which books we believe to be one of the causes of our lean and meagre * Professor Caldwell. 840 On Intermittent and Remittent Fevers, <$-c. [Nov, attainments in medical science, by discouraging the printing and reading of Monographs the " Practice of Physic" of M'lntosh, contains an illustration of the difficulty of putting down and keeping down this volatile serial spirit, which from Hippocrates even till now, under the names of "Nature," "Archeus," " The soul," "The vital principle," the "Vis medica,"and the "Vis med- icatrix naturae," has been called up, to cover with its imposing veil, the ignorances of the science. He says, "It is best to at- tribute the reaction of fever to the Vis medicatrix natures, which is ever in action to prevent injury and to remedy the evil after it has occurred." This remarkable sentence follows the formal declaration in the same paragraph, of "Acting upon the princi- ple of not enquiring into occult causes "! To those in and out of the profession, who are disposed to undervalue it from an examination into the history of opin- ions upon the nature of this disease, w7e would say : Shall it bear the reproaches, which are justly due only to those, who have so far departed from all true philosophy, and indulged themselves in this idle hypothesis-making? Who, instead of frankly and unreservedly acknowledging that they could not render a just and true account of it, have resorted to the agency of fanciful fictitious principles, thus contributing to the perpetuation of this false philosophy of occult causes, and to the stifling of judi- cious enquiry, by leading the minds of the young to rest in these false explanations. But the times of this scientific magic have passed away. The severe medical philosophy of the present day, basing itself upon the principle which lays at the foundation of both the science of physiology and pathology that there is no action of the human system, healthy or morbid, that does not. result from the appli- cation of material agents acting upon the tissues of the system ; rejecting with utter abhorrence, the agency of any of these fan- ciful abstractions ; refusing to spend its high powers in investi- gating diseases of elementary properties and qualities ; question- ing the validity of every dogma, ancient or modern ; studying medicine as a physical science ; is seeking for the nature of dis- eases in the alterations of the tissues ; is patiently collecting facts, declaring that we arc not yet ready for the deduction of general principles to form a system. The celebrated disciples of this true philosophy in France and other countries, warned anew by 1836.] On Intermittent and Remittent Fevers, cj-c. 341 the ephemeral history of the commanding physiological system, of the danger of being too hastily betrayed into generalization, seem disposed to adhere with increasing faithfulness, to this only rational method of investigation And accordingly one of the most eminent of the present French physicians, M. Rostan, au- thor of organic medicine, classes this intermittent fever among those affections, whose pathology is unknown; and calls it "the despair of organic medicine" ! considering it hopeless ever to arrive at any certain and definite knowledge of the cause of in- termittence. This last conclusion, however, we cannot but re- gard as unphilosophical it is a denial of the omnipotency of the philosophy of observation ; for who shall limit its discoveries, that regards the present state of the physical sciences, attained under its happy guidance ? We should not doubt that the accumulated observations of the present age, will discover some fixed and uniform physical, organic changes, upon which this singular disease depends, and thus arrive at a knowledge sufficient to guide us with a steady and satisfactory light, into correct principles of its treatment. For we anticipate that this disease will claim in an eminent de- gree, the attention of the present generation; the pride of the science is concerned in explicating the nature of an affection treated so empirically, yet so successfully. Convinced of the importance of recorded facts, I have been induced to make from my note-book, a brief abstract of the fol- lowing cases, observed from the 23th July to the 1st of October. 1. First visit, Ju.iy 2S. A negro woman, a3t. 40, of good habits, a washer with a regular quotidian : suffering during fever, with distressing nausea and oppression of the precordia, sighing, and hurried, irregular respiration. Having suffered in December last an attack of colic, with excessive pain over the whole peri- toneal surface, but without effusion, and treated by cupping and blistering the spine, 1 was induced to examine it now, and found a remarkable degree of tenderness on pressure, at the 2nd, 6th and 1th dorsal vertebrae pressure there increasing the nau- sea and labor of respiration. She was cured by calomel pur- ging, and subsequent use of quinine; sinapisms to the spine re- lieving nausea, when applied during the fever. 2. August 4th. A negro waggoner, aet. 30, suffered with bil- ious fever, according to his account, at Macon ; has been lip for 342 On Intermittent and Remittent Fevers, $c. [Nov. a fortnight. Now has fever at night ; pain in the bowels and stomach ; pain on pressure over the whole abdomen ; regular stools; tongue slightly furred white ; diminished appetite; pulse not increased in frequency; general languor and anxious coun- tenance ; spinal tenderness at superior of the back. By gruel diet and a blister to the spine, the following day he was entirely relieved from pain, bearing the freest pressure of the abdomen ; appetite returned, and tongue clean ; countenance cheerful. August 10. After severe exercise, had a chill last night, fol- lowed by fever, which has declined. Now, same soreness of ab- domen ; yellowish-white furred tongue ; pulse 90, and soft ; some tenderness of dorsal vertebrae. After being purged freely with calomel, the soreness of abdomen unrelieved, on the evening of 11th, had another chill with fever but a lighter paroxysm than the first; the spine still tender on the 12th. A blister then re- lieved all soreness of abdomen and checked the chill without fur- ther medicine. On the 27th, while at work, was again taken with fever, and took calomel, &c. On the 28th, at 4 p. m., a se- vere ague, followed by fever. On the 29th, saw him the ver- tebrae still sensitive on pressure ; a blister again checked the chill and he has had no further return. 3. August 6. A negro boy of 9 years ; irregular fever, after eating much fruit; no spinal tenderness. Relieved by emetic and purging. 4. Negro woman, set. 25, of good constitution, uniformly healthy. Case of quotidian intermittent, accompanied during the paroxysm with great depression of spirits, weeping and sigh- ing, and distressing nausea and vomiting, with general soreness of the abdomen ; exquisite pain of the upper and middle dorsal vertebrae, on pressure. After purging with calomel, &c. ; cups with scarification of spine during a paroxysm, entirely relieved the nausea, vomiting and soreness, restoring her cheerfulness; and a blister to the spine arrested the disease. 5. August 8. A white boy, set. 16; delicate; six weeks since had chill and fever, which was checked by quinine. Six- teen days ago, was suddenly seized with violent pain in the right knee, which was relieved by stimulating applications ; the fol- lowing day, a chill, and since a regular double tertian. The 7 or 8 superior dorsal vertebrae distinctly tender on pressure. On the decline of paroxysm to day, was purged with magnesia 1836.] On Intermittent and Remittent Fevers, <$*c. 343 and salts, and freely scarified and cupped on the spine, which was repeated on the 9th; and the chill, without the use of other means, was arrested. On the 17th and 18th August, he suiTered a paroxysm each day ; the spine still sensitive ; a blister checked the disease promptly, and he has since continued wTell. 6. August 15. A mulatto boy, act. 16, a painter. This was a case of double tertian, characterized by excruciating pains du- ring the paroxysms, in the limbs and epigastric region. Ex- tremely offensive breath and heavily furred tongue ; and very great tenderness of the spine, from the third vertebra down. Treated with calomel and oil, and cupping and blistering the spine, which brought it to the simple tertian form and much mit- igated the violence of the symptoms during the paroxysm ; the quinine was finally used, and on the 19th, he was discharged. 7. August 14. A female, set. 60 ; full habit ; has within the year past, suffered frequent attacks of colic, which have been uniformly relieved by blisters to the spine, which wras always found sensitive. On the 12th, under strong moral excitement, was seized with a chill at 12 M., which was followed by intense fever. Took magnesia and salts, on the 13th, which operated well, and had no chill. 14th. Ague at 8, a. m. ; at 10 a. m. found her with flushed face, very loquacious, great fullness of head and confusion, tongue clean, bowels open, great oppression at the epigastrium, frequent sighing, pain in the shoulders, sides and bowels generally ; epigastrium very tender on pressure ; exqui- site pain on pressing 4th and 1th dorsal and 1st lumbar vertebrae. Three cups, with scarification to the spine, relieved the oppres- sion of the stomach and head signally, before the end of the oper- ation: which was followed by copious perspiration and relief to all pain ; she passed the night sleeping and waking alternately, in unusually quiet sleep, and great calmness when awake. Sin- apisms being repeatedly applied to the spine, and quinine taken for the two following days, there was no return of fever, and her general health since is very much improved. 8. August 17. This was a case of protracted remittent, a girl of 14; subject to monthly epistaxis, never having menstru- ated ; of a feeble constitution, &c. ; frequently renewed by im- proper diet, lasting to the 1st of September. Early in the dis- ease there was acknowledged sensitiveness of the 4th dorsal ver- tebra, but in frequent subsequent examinations it was not mani- #14 On Intermittent and Remittent Fevers, fyc. [Nov. fest. It disappeared after copious diarrhoea, produced by eat- ing a tart. 9. August 24. Negro boy, aged 15 ; a race rider; has had repeated attacks of quotidian intermittent ; a paroxysm to-day, but he is now up and in good spirits; no tenderness of spine. Toast-water and gruel ; blister to spine drew before the usual hour of attack, and he has since escaped the chill. 10. August 24. Negro man, aged 30 ; carriage driver ; stout hearty looking fellow, enjoying ordinarily, perfect health. Chill and fever 22d ; 23d, fever at night ; 24th, at noon, slight fever ; head-ache and back-ache ; furred tongue white ; no tenderness of epigastrium ; very great tenderness of 4th, 5th and 1th dorsal vertebrae; was purged freely to-day; 25th, no tenderness of spine ; chill at 12 m. ; 20, still fever continued, increasing in the afternoon ; 6th and 1th dorsal vertebrae very sensitive ; oil as fe- ver declined, and blister to spine at n'ght. 27th, blister drew ; no fever. 28th, had light chill, (it was a cold rainy day.) follow- ed by very little fever. 29th, took quinine ; and subsequently had but one light paroxysm of fever. 11. August 24. Stout, healthy field negro, aged 25, has had from the 19th a double tertian, and on 22d took large doses of calomel and oil, which operated copiously ; this the day of the lighter paroxysm ; now 1 p. m., slight head-ache, tongue covered with thick, white furr, moist, no appetite; great tenderness of epigastrium, producing panting on pressure ; bowels open : great tenderness of the wltole dorsal spine, particularly of the lower re- gion and of the last cervical ; free pressure produces great dis- tress, and particularly, irregular respiration. No medicine, nor *ood; blister six inches long to spine. 20th, blister drew well ; pain of abdomen on pressure, none, except at the epigastrium ; expresses a sensation of great relief from the time of drawing of the blister. Toast water, and a small blister to epigastrium. The following day his appetite was imperious ; tongue clean ; no pain, and walking about. 12. August 28. A gentleman, aged 50, of good general health and habits; unwell generally on the 24 and 25; fever on night of 25 ; 26, chill at 5 p. m. and yesterdny at the same hour ; suf- fered a violent paroxysm of fever last night, has dieted closely ; oil yesterday, producing great prostration after each stool ; this morning, at 10, is setting up; no pain, no cough, no tenderness 1S3G.] On Intermittent and Remittent Fecers, st perfect case we can, by varying slightly the position of the finger, accomplish our object Another advantage of this exami- nation by percussion, I have already hinted at, that it may be ac- complished even upon a recently blistered surface. Another question naturally presents itself what is the force and value of this symptom ?-~ whence this uneasiuess ?-r-what 356 On Intermittent and Remittent Fever*, fyc. [Nov. does its existence indicate? Certainly not that the skin at these particular points is sore and tender ; I have endeavored careful- ly to verify this fact, by taking it up between the thumb and fin- ger and compressing it with more force than was applied by the direct pressure; uniformly receiving the assurance of the patient, that the uneasiness was of a different character from that pro- duced by pressure upon the bone. But if this might be the cause of pain, in the method by pressure, it cannot be in that by percus- sion ; for it is well known to those who make use of mediate percussion, that it may be employed freely, even upon a blistered surface, without producing pain. It as certainly does not indi- cate that the bone itself is tender and diseased; for we cannot conceive why pressure upon a diseased bone, should be followed by sighing, coughing, increased oppression of the precordia, nau- sea and faintness. It is as unsatisfactory for the same reasons, to attribute this symptom directly, to a diseased state of the liga- ments of the vertebrae. Having thus excluded these three parts from any participa- tion in the production of this phenomenon, we next enquire Can it proceed from a diseased state of the dura mater lining the bo- ny channel? We answer unhesitatingly, that the symptoms a- bove referred to, developed in distant organs by the examination, cannot arise directly, from an inflammation or anv degree of irri- tation of the dura mater, for reasons assigned already; but we can conceive very readily, how the dura mater, being in a swol- len state, might produce such symptoms, by compressing t\n> or- igin of nerves supplying these distant organs, when an unusual degree of motion is communicated to the vertebrae by percussion. But we perceive that this unusual motion oi'lhe v( rt; l.ra would produce the same degree of pressure, if the dura mater were in its normal state, and the substance of the chord il self enlarged. We therefore must, necessarily, adopt the conclusion, that this phenomenon indicates a diseased state, either of the medullary substance of the spinal chord, or of its investing membranes. I am not prepared to infer from th< se few cases, that this local affection of the spine always exists, nor that it is the primary irri- tation upon which these fevers depend; but if subseqm n! obser- vations shall establish the uniform existence of this spinal irrita- tion, at the commencement of intermitting and remitting fevers, it will confirm the* opinion now almost universally held by the 1836.] On Intermittent and Remittent Fevers, $e. 3 37 profession, of the local origin of all fevers, and the equally uni- versal persuasion, that this location is in some part of the nervous system. I shall barely, in conclusion, suggest some considerations cal- culated to raise the presumption at least, that this local disease may account for many of the phenomena of these fevers. First. I consider it established beyond all controversy, both by direct facts and reasoning, that rheumatism is of spinal origin. Without entering into any particulars, I take great pleasure in referring to an article on this subject, by Dr. Dugas, in the first number of the Southern Medical and Surgical Journal. Second. Ordinary colic is uniformly attended with the evi- dence of spinal irritation, and I am ready to assert from my own experience, that more conspicuous relief is obtained in this dis- tressing affection, from topical applications to the spine, than from any other mode of treatment. Third. Colica Pictonum, it is certain, is not a disease of in- flammation at the seat of pain, for it is treated with success by the most violent and drastic cathartics a course well calculated to aggravate the disease, if it depended on local inflammation. On the records of La Charite, there are more than five hundred cases treated in this manner, and five fatal cases in neither of which, were there but slight traces of local disease in the bowels; and two in which there was a collection of fluid in the arachnoid of the spine, and in one of these, softening of the dorsal portion of the marrow. In the record of these cases, no mention is made of examination of the spine during their course, this mode not then being in use. M. Andral establishes the conclusion, that this dis- ease depends upon lesion of the spinal marrow and abdominal plexus of the great sympathetic, and that the- constipation de- pends either on paralysis of the muscular coat of the intestines or suspended secretion of intestinal mucus. Fourth. Asthma This affection for 3 years past, I have found almost constantly, accompanied with spinal tenderness, and promptly relieved by cupping and blisters. Fifth. I can apply the preceding remark to Hysteria, with its almost infinite variety of symptoms. Sixth. The records of medicine, recently, contain many cases of intermittent neuralgia in distant parts, co-existing with spinal irritation, and promptly relieved by topical applications to the 358 On Intermittent and Remittent Fevers, tyc. [Nov. spinal column. I refer to two conspicuous cases in Teale's work on neuralgic diseases. Seventh. The same work contains cases in which pulsations in the epigastrium, tightness across the epigastrium, great mus- cular debility, disorder of the secretions, palpitations, tremors, flatulence, pyrosis, &c. &c. &c, existed simultaneously with the evidence of spinal irritation, and were relieved by its treatment, even when there was reason to believe, they were accompanied with a diseased state of the sympathetic gauglia. These considerations, shewing the intimate connection in par- ticular cases, between spinal irritation and diseased function of almost every tissue in the body, together with the fact of the in- termittency of those diseases called nervous, are calculated I say, to raise the presumption, that the phenomena of these intermitting and remitting fevers depend upon a local or general diseased con- dition of the spinal marrow. If this local affection of the nervous system does exist in these fevers, can the fact be established by autopsic examination, and why has it not been thus ascertained before this ? I answer that possibly, in this way the fact of this disease and its nature may be revealed, by the dissection of subjects that die of casualties, while in the early stage of these fevers; but it is very obvious, that the absence of organic lesion of this portion of the nervous system, in cases fatal after a protracted course, is no evidence whatever against its existence at their commencement ; because, on the presumption that the most distinctive, characteristic feature of these affections, their intermittency, depends upon this local irri- tation, it would be unreasonable to expect to find it, after the fe- ver had lost this character universally the case, as it advances towards a fatal termination. Again. These fevers are treated by some practitioners, with drastic cathartics, by others with re- peated doses of calomel, on the belief of their hepatic origin ; both we suspect, relieving this local affection, on the principle of revul- sion ; in the same manner, it may be, and no doubt is resolved by the predominance of serious affections of other organs arising in the course of the fever. My limits will not allow to add but a tingle illustration of this principle. How often do we see gastri- tis existing in fever, so unequivocally, that the judicious practi- tioner withholds all active and irritating medicines from the sto- mach, and uses his utmost endeavors to arrest it, believing that 1836.] On Inteiinittent and Remittent Fevers, fyc. 359 upon its reduction depends the safety of his patient we see this gastritis often, relieved in the course of twelve or twenty-four hours, by the development of bronchitis so entirely cured, as to permit the free use of antimonials,to overcome the bronchitis ; but if this patient should die of suffocation, from bronchitis, who ex- pects to find organic lesion in the stomach? Will the practi- tioner doubt the fact of the previous existence of gastritis, from its absence? I must add on this subject, the declaration of M. Andral, that in fevers called essential, there is no nervous symptom but may be manifested without appreciable alteration of the brain and its ap- pendages. I have so far transgressed the limits assigned me, that I add but one or two remarks on the treatment of these fevers. In the first place, we infer the propriety of the early use of re- vulsive applications to the spine; leeches, cups, sinapisms or blis- ters one or other of these, according to the wrell established principles regulating their use. If this affection of the spine be the original irritation upon which all the other phenomena of intermitting and remitting fe- vers depend which determines their individuality then we may with the more confidence, at their commencement, make free use of cathartic medicines in general, and particularly of calomel, a medicine of so much power in correcting the disor- dered secretions of the abdominal and thoracic organs: for in- stead of being deterred from their use, by the apprehension of ex- citing infl lmm ition in the stomach and bowels, alreadv exhibiting functional dcra lgement. this pathological view will sanction their use, to accomplish a two-fold intention to relieve the original affection, by their revulsive operation, and to remove the conges- tion and those depraved secretions of the abdominal organs, which are generated by every paroxysm of fever which conse- quences, if long neglected, may determine a pathological condi- tion of these organs, and destroy the periodicity of the fever. So far (rem being led to a treatment directed only to the spi- nal column, to the exclusion of ordinary modes, we consider this legitimate deduction from the pathology we have suggested, of the highest practical importance. The unvarying experience of nearly two hundred years attests the eilicacy of Peruvian bark and its more valuable, refined, mod- 300 Remarks on use of Quinine in Bilious Fevers, fyc. [Nov. era preparations, in the treatment of intermittent fevers; this view of the general similarity of the pathology of intermittents and remittents, suggests the early and liberal use of quinine in the latter form, even in the faee of the objection, that the diseased condition of some of the organs, (constituting the very differ- ence between these two forms) forbids it; regarding this state dependent on the original local nervous irritation, it suggests, that it is far more prudent to run the risque of increasing the succeed- ing paroxysm, than to leave this original focus of irritation unat- tempted by this heroic remedy, so likely to reduce it ; for this once subdued the paroxysmal return of fever dependent on it, prevented the disordered -state of the organs may be more safe- ly corrected, afterwards, by appropriate remedies. It thus con- firms a practice formerly more in vogue here, than at present, the value of which was attested by the experience of our prede- cessors. ARTICLE V. Remarks on the use of Quinine in Bilious Fevers. By D. Hooke, M. D. 1st. The instantaneous and certain cure of intermittent and remittent bilious fevers, depends upon promptitude. The proper remedies should be applied as soon as the attack commences. There is no danger except in delay or improper treatment. 2nd. They are ushered in with lassitude, stretching, aching of the bones, chill or ague. For these symptoms, nothing is necessa- ry but warm drinks and warm applications ; but when to these, there are added, anxiety, restlessness, great distress about the stomach, or retelling and vomiting, and inequality of the circula- 1836.] Remarks on use of Quinine in Bilious Fevers, qc oul tion, indicated by great heat on the forehead and stomach and little or none at the extremities, then besides warm teas, warm applications and frictions, mustard plasters, and these very large, should be applied over the stomach, and if the symptoms are v ry argent, on the extremities also, and kept on until they pro- duce a deep scarlet redness in the skin, which they will usually do. in from fifteen to thirty minutes. If this redness disappears after they have been removed, they should be reapplied. As soon as the redness remains permanent, the danger for that pa- roxysm is over, because the circulation has been equalized, and the dangerous congestion thereby overcome or removed. In ad- dition to the foregoing. I would suggest, in very alarming cases of collapse, the extensive use of frictions with red-pepper and salt. 3d. After this cold, comes the hot stage, or what is properly called fever. If it be the first paroxysm, and the patient former- ly of good health, a dose of castor oil, or if this is not at hand, one of calcined magnesia and epsom salts combined, should be given to cleanse the stomach and bowels, and aided if necessary by injections one of the best is a table spoonful of salt in a pint of warm water. To this course, add diluent and cooling drinks, and if the excitement is very great, occasionally bathe the hands, face and feet, with cold water, A towel wet with cold water may too, be laid over the stomach. If it be a second paroxysm, or if the disease be still further advanced, or if the patient la- bored previously under some bilious affection, a dose of calomel, followed in three or four hours by one of oil, is to be preferred to the oil alone. 4th. When the fever has gone off by perspiration or other- wise, quinine, the true remedy for these affections, should be gi- ven in one, two or three grain doses, every hour, until at least fifteen or twenty grains have been taken, if the patient be an adult. It may be given in solution or in pills in any way, so it is giv- en, and that largely. I have in very alarming cases, given it in five grain doses every fifteen minutes; and have seen it thus gi- ven, even restore to health, those who were supposed to be dying. [L/~ No remissions of lever should be suffered to pass without the quinine, even if purgatives have been neglected during the exacerbation of the fever. C/JQ Injections, however, should be used in a case of this kind, as 46 362 Remarks on use of Quinine in Bilious Fevers, $c. [Nov . an important adjuvant, and also in cases of great irritability of the stomach. Sometimes the quinine does not set well on the stomach, even after the bowels have been evacuated, in such a case a mustard plaster should be applied over that organ. 5th. The above course may always be pursued, and will always cure, if commenced before the disease has continued long enough to produce local inflammations ; but when these take place, they must be subdued before the quinine would be ad- missible. But as there is no necessity for this state of things, if the above treatment is pursued, I will not now take room to say how it should be remedied, 6th. Should a remission be so short, that quinine could not be given in sufficient quantity to arrest the disease, the cold and hot stage should be treated again as above advised prefering calomel as the purgative, and as soon as the remission is again apparent, commence with the quinine. Let it only be remem- bered, in order to induce every one to give the minutest direction all due attention, thct these fevers, which can be thus so easily arrested, destroy more human life than any other whatever. 7th. The quinine does no lasting injury it sometimes pro- duces a ringing in the head, some giddiness, and occasionally a little deafness, all which disappear in a short time, generally in a day. To compensate for these temporary evils, it cures without any waste of flesh or strength, or constitutional energy. This ought to he constantly remembered. 8th. The drinks throughout the attack should be of the mild- est kind, such as water, toast water, gruel, chicken water, rice water, or the like. Every thing heating and irritating should be carefully avoided ; and so also, should all drastic purgatives, narcotics and blisters. Drastic purgatives never fail to do mis- chief, and narcotics and blisters so seldom, that they should never be used in these fevers, except under the advice of an experi- enced physician. 9th. Occasionally, after the fever is cured, the patient con- tinues to feel dull and disinclined to action here the diet should be light, and the bowels kept moderately open until these sympr fjoms disappear. 1830J On Hcemorrhoids. 833 Part II. REVIEWS AND EXTRACTS. Hcemorrhoids. We are much pleased with the remarks of Dr. Salmon of London, on this important subject. Of all the diseases that afflict human nature, there are few more common, attended with more suffering, or followed by more disastrous consequen- ces, yet there is none oftener neglected, or treated on erroneous principles or no principles at all 'empiric nostrums and patent remedies, being the means generally resorted to for relief, until too frequently irreparable injury has been sustained. " A just consideration of the causes of any disease, (says Dr. Salmon,) will be our best guide not only to prevent its occurrence, but likewise as to the method of treatment we should adopt for its removal or alleviation ; let us therefore briefly inquire into the causes of piles. Various as these will be found, they all tend towards the same results ; viz. deposition in the cellular tissue, which unites the mucous and muscular tunics of the rectum ; distention of the minute vessels of its mucous coat, and mere or less enlargement of the hemorrhoidal veins. Piles may therefore be pro- duced by any circumstance, constitutional or mechanical, which preternatu- rally excites, or mechanically obstructs, the circulation in these particular parts. Thus they not uncommonly arise from an injudicious perseverance in the use of peculiar or violent purgative medicines, or excessi\ e bodily exer- tion, particularly horse exercise ; hence, also, results the prevalence of the disease in persons accustomed to a sedentary mode of life, the warmth exci- ted from the constant sitting position of the body promoting an inordinate ac- tion in the vessels of the lower part of the rectum ; while the want of proper exercise induces a torpid and confined state of the bowels, in a great degree assisted by a deficiency in the biliary secretion. I believe the disease is often caused, or much increased, from the fashiona- ble, yet pernicious custom of sitting upon chairs having hair or stuffed seats. Persons, especially those whosp occupations are of a sedentary description, should accustom themselves to use chairs, the seats of which are composed of cane, formed into a net work. The soft blue hsemorrhoidal tumor, which may be said to be the true pile, will always be found in conjunction with an enlarged, or otherwise diseased condition of the liver, which circumstance is physiologically explained, when wo consider the immediate connection that exists between the vena porta and the hemorrhoidal veins. From this cause, these veins will sometimes become distended to so great a degree, as to form tumors of a very consider- able size ; and I have seen an instance, in which from extreme enlargement of the hemorrhoidal veins, the fore-finger could not be introduced into the rectum beyond the first joint ; the patient was likewise the subject of fistula in ano. Another effect of irritation in the rectum is, that coagulable lymph is from time to time thrown out upon the inner coat of the intestine, but more partic- ularly in the cellular tissue which connects the mucous and muscular portions of the bowel. This deposition organizes and gradually increases, till at last a huge mass of superstructure is formed, which is productive of extreme annoy- ance and exquisite suffering. But another and extremely prevalent cause of the disease will be found in i 364 On Haemorrhoids. [Nov. contracted condition of some part of the rectum, which causes an accumula- tion of faeculent matter in the bowel ; this necessarily irritates it, and sooner or later produces ulceration of some portion of its mucous surface ; while the perpetual straining which accompanies the desire to relieve the bowels, the result of the accumulation, injects the minute vessels of the intestine, distends, and finally causes them to rupture ; from which sources arises the haemorrhage, more or less expeiienced by those who are subject to piles. Now it is not al- ways judicious, suddenly to correct this effect, for although it is a diseased action, it, not unfrequently, is the mode by which nature relieves herself, and it thus, perhaps, .prevents the formation of a more serious disease. Dr. Salmon's observations on the treatment of piles, are not less philosophical and judicious as they are too concise for far- ther condensation and too valuable for any omissions. We will present them to our readers in his own words. " This, (the treatment, says Dr. S.) in a great measure, must necessarily depend upon the cause from which the disease arises. Should it be connect- ed with any hepatic affection, we of course principally direct our efforts to re- store the healthy state of the liver. Surprising relief will often be imparted from the loss of four or six ounces of blood at intervals repeated according to the discretion of the medical attendant. This may be taken either from the arm or by the application of cupping glasses to the region of the liver ; the latter is, perhaps, the most preferable mode. The application of leeches to the orifice of the bowe'i is a valuable remedy, in those instances when the tumors are situate within the sphincter; but when they are external to it, I have often found that more irritation is nrodticed from the bites of the leech- es than benefit from the quantity of blood which they abstract. Not unfre- quently they mance great tumefaction of the parts, which seriously aggra- vates the patient's sufferings. But in the cases of internal piles, especially those which are attended with any hepatic disease, the use of leeches will be found of great sen ice, for they not only diminish the general volume of the- blood, but, by unloading1 the vessels at the inferior portion of the alimentary canal, operate move immediately upon the affected parts. I have lately been in the habit of puncturing that description of pile which is almost wholly produced from distension of the hcemorrhoidal veins, with the acupuncturation needle ; by this method some ounces of blood may be abstracted, which will afford instantaneous relief to the patient. This plan may be adopted almost ad libitum by the medical attendant, and is entirely free from that apprehension of real, or imaginary danger, which by some is considered to belong to dividing these veins with the lancet ; which latter practice I have often adopted with great service ; neither have I ever found any untoward result from it. Furthermore, I am acquainted with an indivi- dual who was in the habit of performing this operation on his own person, a practice which, notwithstanding its successful issue, cannot be too strongly reprobated. Evaporating washes* are of service, not only by alleviating the inflamma- tion in the piles, but also that irritability of the sphincter which almost inva- riably accompanies the disease, to a greater or less extent. I prefer using these in a tepid state, for when they arc applied cold, patients are oftentimes not sufficiently cautious respecting their use ; either from inattention, or dis- like to the momentary feeling produced from the application of cold, they permit the linen rag to get dry; hence an increase instead of a diminution of the local action ensues. r- * I have been in the habit of using the following formula : Recipe, Spirit. Rorismar. 1 ii.; Aquce Am. Acet. 5 iv.; Mist. Camph. I x.; Misce. Fiat lotio. 1830. J On Haemorrhoids. 865 A gentle stimulus by anointment applied to the sphincter twice or thrift' in the course of the day, will, in the milder attacks of the disease, not uncom- monly be of essentfal. benefit ;j tins plan will not, however, agree with all constitutions, and shoul 1 1 1 1 ( *:- r be adopted with caution. Th administration of medicine forms a most, essentia] part of the treat- ment of the disease. It i- well known that particular drugs, as for exam- ple alo^s, exorcise a peculiar action upon the intestinal canal ; such descrip- tion of m die i nee are therefore to be avoided; large doses of any kind of purgatives adopted as a habit arc improper; nevertheless, as the disease is often connected with extreme costivenesBj it is best at the commencement of an acute attack, to give a brisk dose of medicine, so as fully to unload the intestinal canal, and by such means facilitate the pro.'' ss of the circulation through the rectum. In the milder forms of the complain*, the bowels may be kept regular by the use of small doses of castor oil, the confection before described, milk of sulphur, or any mild aperient. Th? use of enemas, when the situation of the tumors admits of the ready introduction of the pipe, ought never to be omitted ; they not only lessen the local irritability of the parts, but sometimes, by removing the feculent collec- tions in the intestines, supersede the necessity for any kind of aperient me- dicine. All violent exercise, particularly riding, must be abstained from. Tnese, together with a reasonable attention to diet, constitute the principal features to be observed in the ordinary treatment of piles. With the most cau'ious attention, however, the disease will not unfreqaently progressively increase, tiil at last we are compelled to relieve our patient's affix' ion by the mans of operative surgery ; and this brings me to the next division of my subject, viz : the removal of the Hemorrhoidal Excrescence." Dr. S. has not mentioned two remedies, which we hnve found most beneficial in those cases of piles accompanied with hepatic disease, and which we believe is a very frequent association in southern climates. We have long been convinced that one of the most usual cau- ses of haemorrhoids, was the obstruction opposed to the free re- turn of blood from the hasmorrhoidnl veins, through the portal circulation, and that our curative efforts should be directed main- ly and primarily to the liver and portal system. In our hands no remedial means have proven more efficacious in removing portal engorgement, and restoring the liver to its healthy condi- tion, than calomel or blue pill and the external use of nitro- m una tic acid. We do not object to any of the remedies pro- posed by Dr. S., we would only recommend the occasional em- ployment of mercurials and nitro-muriatic acid, in chronic and obstinate cases. After discussing at some length the question of the removal of hoemorrhoidal tumors by excision or ligature, arraying the principal authorities in favor of each plan, and summing up their respective advantages and disadvantages, he gives most decided preference to the former. The succeeding paragraphs are too important to be passed by. f Recipe, Pulv. Gum. Camphorse, 3ss. ; Gallse, 3i. ; Opii, 3i. ; Ung. Flor. Samb. 5 i- ; Misce. Fiat Unguentum. S63 Extracts from the Note-book of a Physician, tyc. [Nov. " I can only say, that I have for many years been in the habit of perform- ing tha operation by excision, and that with the most perfect success ; occa- sionally, I have had to encounter haemorrhage ; but never, save in one in- fetance, to such an extent as to endanger the life of the patient. I am in- clined, therefore, to believe, that when bleeding ensues to any material ex- tent, the tumors are accompanied with an enlarged or otherwise diseased condition of the liver, with stricture of the bowel, or such an unhealthy con- dition of the constitution, as may give rise to an hsemorrhagic disposition in the vessels at the lower part of the alimentary canal; and, in the neglect of the due observance of any of which circumstances, not only the danger, but the unsuccessful issue of either description of operation is very likely to originate. And here I think I should be guilty of no inconsiderable dereliction of duty, was I to omit adverting to the careless manner in which these tumors are frequently removed. Not only are the causes of the disease altogether lost sight of, but its extirpation decided upon without the slightest degree of con- stitutional preparation ; indeed, were we to judge from the observations de- livered in some of the medical schools of this metropolis, it might reasona- bly be supposed that the excision of piles was an operation, altogether so simple, that it might be performed at the convenience either of the surgeon or his patient. More thin once have I known fatal results to arise from this mistaken confidence, this injudicious, not to say rash proceeding ; which, though it may be practised perhaps many times without any untoward re- sult, is certain eventually not only to end in the compromise of the surgeon's reputation, but in what is of much greater moment, the loss of human life. Prior to the removal of the hemorrhoidal excrescence it is the duty of every surgeon carefully to survey the various points to which I have allu- ded; and, above all, cautiously to examine into the condition of the rectum ; for, in the early stages of piles, where the disease is accompanied with any contraction of the bowel, we shall often be able to mitigate the former by the removal of the latter ; I have seen many instances which confirm this observation." Extracts from the Note-hook of a Physician of this City, during his attendance on the Parisian Hospitals. Sub-cutaneous Fibrous Tumours. Mr. Dupuytrcn enter- tained the class this morning on a case truly interesting, and il- lustrated his observations by the performance of an operation, trifling in its nature, but important in its results. The patient is a woman, fifty-five years of age and of a good constitution, who experienced for the first time, about two years ago, slight pains in the right thigh, which in five or six months became very se- vere. The pains were irregularly paroxismal. She observed that the pain always commenced in a certain part of the outside of the thigh, and from thence radiated, as it were, to the knee, the hip, the glutcei muscles, the pubis, &c. Her sufferings wTere 1836.] Extracts from the Note-boook of a Physician, y becom i p jrpendicular to the axis so soon as dislocation on t!if palmi r or dorsal surface takes place; hence it is evident that their length must be diminished by this kind of twisted position. Besides this di ficulty, must be overcome that produced by the head of-one bone slipping behind that of the other. This last consideration caused Mr. D. to deviate from the ordinary meth- od's adopted for the reduction of such cases. He therefore takes hold of the thumb, and, acting on it as a lever, throws it back so as to hring the phalanx perpendicular to the axis of the metacar- pal bone, and at the same time causes traction to be made by the means of a ligature placed at the proximal end of the phalanx. So soon as the traction has brought the head of the bone of the phalanx sufficiently forward, the reduction is completed by a sudden flection of the thumb, until now kept drawn back. In the case of the young man alluded to, he tried this method for some time, bui just as he was about to succeed, he perceived that considerable excoriation had been produced, and thought it would be imprudent to continue any further efforts until this was cured. Hut, the next morning (to-day) it was perceived that reduction was nearly complete, and that nothing more was re- quired but a splint and bandage. Mr. D. did not attempt to ex- plain how such a change could have been produced spontane- ously, but merely observed that it was an evidence of the supe- riority of his mode of proceeding over all others. On measuring, this morning, the. length of the thumb that has been dislocated, and comparing this with the length of the unaf- fected thumb, they were found to correspond exactly, so as to leave no doubt of the reduction. Motions of flexion and exten- sion can now be executed with but little pain comparatively. Schirrous .Mamma. Mr. Dupuytrcn disapproves very much of the use of leeches and compression, to affections of this nature, as only tending to deteriorate the patient's system and to allow the disease to become more inveterate. He says, that it is not the size of the schirroUs that is diminished by these means, but merely that of "its atmosphere," to use his expression; that is to say, of the surrounding tissues that have become swelled by the irritation its presence causes, and that whenever the pressure and use of leeches are suspended, not only these tissues swell again, but the schirrous enlarges with increased rapidity. There is now in his ward, a case that has been submitted to that treat- ment, and for which he will have to use the knife. 47 370 Notice of Lisfranc's Clinics. [Nov Notice of Lisf rands Clinics. In the October number of this Journal, we were 'favored with a continuation of the valuable "Extracts from the Note-book of a Physician of this City, during his attendance on the Parisian Hospitals." It will be found by reference to that number, that it contains under this head, much of the unpublished practice of M. Lisfranc, one of the most eminent surgeons of the French metropolis. Much of this matter is new, and all of it, on subjects too much neglected ; both in instruction and in practice. In a note to that article, we promised some remarks on one of the to- pics ; of which promise we now purpose the fulfilment ; toge- ther with some notice of the rest. The paramount object of this Journal is usefulness to the me- dical profession, and through it, to the cause of humanity. Whilst therefore, we feel thankful to the friend who has been so obliging as to furnish us with liberal extracts from the notes which his most commendable Zealand industry have accumula- ted, and trust they will continue to enrich the pages of the Jour- nal, we may remark, that they are given as a faithful account of the views, instructions, and practice of some of the first prac- titioners and teachers of the day. And whilst they serve the purpose of informing the- profession, of the views and practice of such persons, as a matter of medical intelligence, they Can- not, emanating from such a source, fail to be of great utility to those of the profession who have not been favored with the op- portunity of witnessing the same themselves. But we are not of those who are disposed to think that every thing which is brought from alar, is to be valued according to its distance, and the cost of procuring it. Nor are we willing to a- dopt the opinions, or practice of any man ; however loudly the trumpet of fame may have sounded his name, unless such opin- ions or practice be found not wanting before the lawful tribunals of truth, reason and propriety. Gold is not precious according to that by which it may have been mineralised, or the country from which it came ; but according to its intrinsic purity : nor do the richest stones produce the most. It is often \'o\\)u\ alone, or mineralised by clay and sand. A Georgia or a Carolina speci- men then, if it stand the furnace of purification as well, will make as fair an ornament, and as rich a treasure as that of South America or of Ophir. But the unwary are too apt to be deceiv- ed by the glare of a reflected hue; or to receive as gold, that which is made to shine by the hands through which it lias passed. In America, where we have learned to put crowns and sceptres under our feet as little toys, where indeed, we contemn them, and where mere merit may accede to the highest honor, we arc 1836.] Notice of. Lis francs Clinic?. 371 pable of r * into our hands the productions of men, as I j not with .the wildness theintoxi cation of menials wh scended to by their superiors, but I tamely, as freemen : independent alike, of all the s of authority, and the honori-Qi knighthood : And them, we can sit down to their contemplation an 1 examination, re thought which had been presented to p ir rain I : and this to >. with a consciousness that we stand be- m humanity and error the protectors of the former and of it!(> latti r. The teach r,1 to 3 of whose instruction are now before us, has long since des Tvedly been before the world as an eminent surgeon; His practice in many cases has been detailed in the journals of the day, and much of it has been valuable. But the m )i i hi> rank, and the more influential his name, the more cl >s !\ sh >uld his movements be scrutinized. We have however, occasionally found, as we have thought, m >s1 insuperable objections to some of his capital surgery. For instan '. his proposed improvement on amputations, offered to the world some 12 or 15 years ago, which consisted in allowing th ! woun I made by an amputation, to remain open and exposed to the atmosphere for a few hours, in order, the better to secure adhesion. We felt bound to object, without ceremony, to the propriety of this practice, on the ground of its cruelty to the pa- ti it ; esp "ially when the same end, (i. e.) the suppression of the oozing ofb] i i I from the small vessels, might be most perfectly implish I within ten minutes, by the application of a solution of the sulphate of alumen, or of zinc. In evidence of the truth of this, we are able to state, that so long ago as 1812, we amputa- ted the thigh of an adult immediately below the trochanter minor, secured but two arteries by ligatures, and suppressed all other dissh irg the wound by the application of a sponge with a solution of alum, so completely, that although the wound was sed and dressed for adhesion within fifteen minutes after the bone was sawn, the wound never discharged enough of blood, s aam an 1 pas. to wet through the ordinary dressing. On the fifth dav. ta" dressing was removed down to the adhesive strips, which v. i i left. On the eighth, these were removed, and the wound found most completely united; and by the twelfth, the ligatures having passed away and their places healed, the patient w is dis iharg I. But we hasten to notice M. Lisfranc's prac- {' ' l;\ I IS Of til ! UlerUS. T i !ir- topic in that part of his clinique now before us, is a n lie anatomy, which he seems to think necessary as a nail ! to the student an I practitioner, in the examination by the speculum. Those remarks are well enough for those who are already possess?;! of a good knowledge of the special anatomy of the parts. 872 Notice of Lisfranc? s Clinics. [Nor. The next topic treated is the "introduction of the speculum uteri:'' " For the introduction of the-speculum.the patient should be placed in the same position as if she were to undergo the op- eration of lithotomy, save that her hands are not to be fastened to her feet, nor ligatures applied. The legs, or rather knees, are to be held by two aids, if admissible; if not, the feet must rest on chairs of an equal height with the bed the back horizontal, &c." We are compelled to dissent entirely from M. Lisfranc's plan of introducing the speculum uteri; and we are forced to the con- clusion, that nothing could have suggested such a plan, or retained such a man as Lisfranc in its continued use, but a kind of gen- eralizing in practice, and entire disregard of delicacy in female practice, but too common in hospitals, and which cannot be too strongly reprobated. Certainly M. Lisfranc never gave a thought to the additional afflictions of the female, which never fail to be added by the unnecessary wounding of her modesty. The exposures which their necessities unavoidably demand are severe, and nothing can justify an unnecessary extension of them in any instances. Even the fact of the inmates of public hospi- tals being often persons of loose morals, docs not justify the prac- titioner in allowing the least unnecessary exposure. But in view of the convenience and the utility of the speculum examination, we have, ever since our first attempt, adopted the reverse posi- tion to that of Lisfranc ; and we venture to say. that if the prac- titioner will place his patient on her knees, with her breast and head on a pillow, and the abdominal muscles preserved in perfect relaxation, he will find neither difficulty nor danger in the intro- duction of the instrument, or of mistaking any other part for the os uteri. In this position, if the natural; or any Considerable mo- bility of the uterus remain, so soon as the os externum is dilated, and the air passes into the vagina, instead of that fullness which prevents the easy introduction of the instrument, and contin- ually presses the folds of the vagina before if, a large space is often formed, of severaj inches in every direction: extending from the vestibule tot lie os linear, and from one side of the vagi- na to 1 lie other, large enough to contain a man's fistj and with some, as large as a child's head at term. The uterus -will gener- ally bo found to have passed from the vagina, and strait ol* the pelvis to its greatest elevation, in the direction pf the axis of the superior strait : and if it have not done so, it is easily caused to do so by the pressure of the fing< rs in that direction, The reader will at once perceive the gnat, safety ol' the os uteri from I eing easily wounded by the speculum, and the greal facility to thefree motion of the inner part of the instrument, in the large space thus afforded by the vagina proper. Even its walls may lie freely in- spected by ebanging the direction, or by partially withdrawing the instrument. In cases of great immobility of the uterus, the advantages of 1830.] Notice of Lisfranc s Clinics. .H3 this position arc not so conspicuous still the convenience in eve- ry way, isa decided improvement on that which Lisfrancs' posi- tion affords, Lastly, in this p jsitibn it is perfectly convenient fo perform this examination without the exp >sure of any portion of the ext irnal surfaceof the patient ; or any part whatever, except the precise point of insp Kstioti a thing impossible in the plan of Lisfranc. For this, tin* manner of usin5 the. speculum is, in th;* first place, to clothe il With a piece of calico or other lighj clothof ordinary width, and two yards long, by passing the speculum two thirds or three fourths of its length through a small hole made in the cloth ahout half a yard from one end. The cloth is fixed to the speculum at this place by a string, if necessary, then reflected over the large end and handle, and the bodv of the instrument properly greased. The instrument is then passed under the cover, to the vulva, and is easily intro- duced after gentle dilatation with the fingers of the other hand. So soon as it is introduced, (which should be in the direction of that part of the axis where the small end is at all times.) the short end of the cloth is spread over the sacrium and back of the pelvis, and the Long end over the thighs, legs and feet, so as completely to cover the woman. The sheet or blanket with which she will have been hitherto covered, may now be removed, and the internal parts lobe inspected, fully exposed to view. The speculum should be the simple tube speculum ; the inner surface of which should be kept in good polish. M A candle, of course, must be used," said Lisfranc. This is not a thing "of course." No candle or taper of any kind is necessary in the day-time ; the reflection from the instrument being sufficient to display the part as fairly as the palm of the hand at noon-day. M. Lisfranc has advised that touching be practised before the introduction of the instrument, in order to determine the precise position of the os tineas; as this part the common subject of the examination, is often turned downward and backward. Xow in M. Lisfranc's position, it is barely possible that the os tineas can be inspected in these cases. It will be found no very easy matter to rectify this uterine displacement in this position, which the reader of the filth number will remember, is on the back; on account of the general fullness and pressure of parts which are afforded; and against which, the elevation of the uterius has to be made. If corrected by the touch in this position, the ute- rius most commonly follows the fingers as they are withdrawn, carrying the vagina m transverse folds before it. which constant- ly impede the introduction of the speculum, and obstruct the view. In the position herein recommended, all pressure and fullness are taken off, and the uterus most commonly restored to, and retained in its proper place, at least during the continu- ance of the position. Moreover, the uterus is carried so high in the pelvis that there is no danger barely a possibility, of touching it by the means of the inner end of the speculum. o* 1 Notice of Lisfr one's Clinics. [Nov. tm the next paragraph, M. Lisfranc gives the "general symp- toms of uterine disease." Under this head he has giyeji us most of the symptoms i \ which we may he led to apprehend uterine se. We conceive there is not a class of diseases, the elear diagnosis of which is more important than that which includes the various uterine :>!ii c'tions. The importance of these diagnoses docs not stop at the accuracy neccssnry merely for the purpose of correct prescription. This is an interest common to all diagnoses. But i is the relationship of the uterus and its functions to the fe- male economy, that many of the most serious secondary troubles and dangers are often, nay, almost certainly produced by the ill condition of one, or irregular or imperfect performance of the other. Amongst these we may name habitual abortions, exhaus- ting leucorrhcea. barrenness, bronchitis, phthisis, chronic hepati- t's, dyspepsia, hysterica, hypochondriasis, chlorosis, bulimia, va- rious afflictions from spinal irritation, mania, chorea, general and obstinate disorders of the nervous system, colics, hormorrhois, fis- tula?, &c. &c, any of which in the female, should direct inquiry in- to the condition and functions of the uterus. The importance of diagnosis extends in these cases to the delicate nature of these dis- eases, Which', on this account, more than in any other diseases, should be made plain, and well defined by external evidence, be- fore either examination, or operation per taxis can be justiiicd. In this class of troubles, it is always possible to locate the disease, if not to distinguish in every instance its specific character, previous to manual examination. Some of the symptoms named by M. Lisfranc, are certainly very foreign to the pur- pose of diagnosis; such for instance as " gastro-cnteritis resisting ordinary means"' "pains in the spleen, without increase of size" "pains at the umbilicus without any other symptom of dis- ease." Whilst strangury, involuntary urination, pains in the di- rection of one or both of the lateral ligaments, dysmenprrhoea, leucorrhcea, hysteria, abortions without pth< r obvious cause, &c. &c, should by no means have teen omitted. His remark, that " uterine haemorrhage as surely indicates a diseased state or mor- bid tendency in the uterus, as haemoptysis docs that of the lungs," is most correct and important; not only for its truth as to the fact of disease, but its very sure testimony of actual ulceration of some kind, or that condition which consists in a serious tendency thereto. Of like value is that of (unnatural ?) "discharges per vaginam." And here should not have been omitted, nil irregu- larities in the menstrual discharge: any and every deviation ot which from the natural quantity , therate of flowing, iho case, and the period of occurrence, may be considered to constitute. 1830.] Treatment of Urinarp Calculi,!)!/ LUhutrity eye. 375 Part III MONTHLY PERISO Extracts translated for this Jour:!;-', from the Journal i: ire of 3rd September, 1S3C>. Parallel between the Tret f Urinary Calculi, hy Lithot- Cystotomy, following statistics are d iew of the in- ly published by M. Civiale, on the relative success of the various methods employed for the removal of cal- culi deposited in the bladder. The value ofsu h numerical state- its must he obvious to all: they c invey irrefragable refuta- tion 6f'the vain theories and opposition of the bigoted adherents to the use of the knife. ' Of 1915 patients subjected to Lithotomy at Luneville. at the Hotel-Dieu, and.at La Charite, from 172:) to 17-27,371 died, say 1 in 5,12. 1335 individuals underwent the lateral operation in various countries, of whom 275 died, or 1 in 4,S5. The Recto- vesical op 'ration, performed 157 times, proved i'atal in 29 instan- ces, 1 in 5.41. Even- the Bi-lateral operation, the advantages of which have been so much eraggeratedj does not present better r. f Pus, he has uniformly found them in thai of Chancres; also, that having inoculated with this pUS the thigh of ail individual affected with chancres, he exam- ined the pus derived from the pustule produced by the inocula- tion, and found it idled with animalcule, He observes, that in this instance, the pus had not yet been exposed to the action of the air, being covered by the epidermis. M. Donne adds, that he 183G.] Chances of Life, $C. 377 has not yet detected animalculffl in the pus of buboes, lie has not yet sufficiently studied the form of these diminutive beings to determine it, but they appear analogous to the infusories. M. D. is inclined to consider these animalculae, rather a medium of transmission of the syphilitic virus, than active agents in the contagion of this disease. In a number of cases, the admixture of a little diluted vinegar with the pus of chancres, has sufficed to prevent the success of its inoculation. Chances of Life. The following summary of statistics relating to the chances of life, is chiefly from the lecture of Dr. Robert Graves, of Dublin, on Medical Statistics. It is stated and admitted as a general fact, that of a given num- ber of children born in Ireland, one-third die before one year, one-half before the cigth year, two-thirds before the thirtieth year, and three-fourths before the fiftieth year. But such gen- eral facts are necessarily drawn from data in the mass, and av- erages like this include opposite extremes. For example, on Patrick's-day, 1782, nine students walked from Trinity College, Dublin, to Bulloch, where they dined. In 1833, eight of them were still alive, and it is believed, are to the present time, a pe- riod of more than 54 years. Again : Of a certain company of grenadiers of 59 men, who served in the Irish volunteers in 1782, only one is now living. It is evident from these, that the above general conclusion as to the rate of life, can only be useful in point of political economy of life, and not a ground for estimate in life assurance. But if we carry the inquiry down to the physical causes influencing in each of these parties, we shall find instruc- tive and useful facts in a medical point of view, and for estimate for life assurance. It should be remarked, that the party, of whom 8-9 have lived 54 years, were students in Trinity College, and doubtless were dedicated to a literary life. The party, of whom only 1-59 lived the same time, (and indeed in the very same years, and country, so that there was no peculiarity of season or climate influencing in one case more than the other,) were Irish volunteers, subject to a very different course of physical influences. Here it is evident, that the physical causes peculiar to the different 48 378 On the Chances of Life. [Nov. occupations of each, are to be looked to, in the estimate of chan- ces of life, and the cause of the difference in each. Another fact of the same kind may be advanced. It is re- markable how long a certain set of men, holding the same office, often live in succession. It is believed that the steady policy of the imperial court of Vienna has been partly, at least, owing to the extraordinary length of time the modern prime ministers of Austria, including Metternich, have lived. A similar succession of longevity on the part of the rulers of Prussia, is believed to have aided other circumstances in aggrandising their territories. Dr. Graves mentions the following as a calculation of the chances of life, approaching the truth. The chances are equal that every healthy adult will live half the difference between his own life, and eighty-one. This, which is the mode of computation generally employed, is very near the truth. Thus, if a man is forty years of age, the chances are e- qual, that he will live half the difference between it and eighty- one years, that is, twTenty and a half years ; and therefore, that the duration of his life will be sixty years and six months. The total number of male and female children brought into the world are very nearly equal, a small excess only existing on the side of the males. In Germany and England, the proportion of males to females is as 21 to 20 ; while in Ireland, it is generally as 21 to 19. The slight excess is, however, ultimately corrected by the greater mortality of the males before the age of puberty; after which the excess is slightly on the female side. M. Giron divides individuals into different classes. The first consists of individuals whose employments tend to develope their bodily powers. He found that in this class, the number of male births exceeded the average proportion of male and female births throughout France. The second class consists of those whose business tends to en- ervate. In this, the number of female births exceeded the aver- age proportion of female to male births throughout France. The third class consists of those whose employments are of a mixed description. In this, the proportion of male and female births was nearly the same as the average proportion throughout France. Hence the conclusion arises, that the pursuits of agri- culture tend to the increase of the male population, and that the habits of commerce and manufactures favor an augmentation of the female population. On the subject of the proportion of births to marriages, Dr. G. observes, that the fecundity of marriages, is not, as has been sup- posed, in proportion to the comfort and independence of the com- munity, and that fewer children are not horn from a given num- ber of marriages, in countries which an; deficient of agriculture, industry, and the blessings of civil liberty. In England, the pro- portion of births to marriages from 1800 to 1810, was as 4 to 1, 18 3G.J On the Chances of Life. 379 and from 1810 to 1821, as 4.22 to 1. In Scotland and Holland, it is as 4.2 and 4.20, while in Russia and several Italian States, it is as 5.25 and 5.45 to 1. It is here observed, that in the degree in which a nation advan- ces in prosperity and civilization, premature and imprudent mar- riages will become less frequent, and the number of births be pro- portionately diminished. The lateness of marriages should gen- erally stand as a good test of an improved state of society, and as an evidence of the prevalence of reason and good sense over the otherwise controlling passions of mankind. Contrary to the generally entertained opinion on this subject, it may be given as a fact, having an important bearing in the estimate of the chances of life, and consequently of importance in the business of life as- surance, that the cultivation of science and literature appears to be favorable to longevity. He who is chiefly engaged in mental labour, has a fairer prospect of length of years, than he whose occupations consist exclusively in bodily toil. Of 104 Italian mathematicians enumerated by Franchini, the ages at which 70 died have been ascertained. Of these 70, eigh- teen had attained the age of 80 and two of 90 ; and this in a cli- mate not generally considered favorable to longevity. In France, 152 men of science and letters, have been taken at random about half of them cultivated science, and the other half devoted themselves to general literature. The average life of these 152 was upwards of 69 years. Longevity of female authors of the last century from the Quarterly Review, No. 99 : Lady Russel, 87 Mrs. Rowe, 63 Lady M. W. Montague, 73 Mrs. Centlivre, 44 Lady Hervey, 70 Lady Suffolk, 79 Mrs. Sheridan, 47 " Cowley, 66 " Macauley, 53 * Montagu, 81 663 The average life of these literary ladies is found to be 71 9-20 years. The extremes are 44 and 93 Out of 120,000 who insured their lives in the Equitable Insu- rance Office, the number of suicides in twenty years was only Mrs Chapone, 75 a Lennox, 84 U Trimmer, 69 U Hamilton, 65 a RadclifFe, 60 a Barbauld, 83 u Delany, 93 it Inchbald, 68 Piozzi, 80 it H. More, 89 766 663 - 20)1429(71 9-20 380 Curious Case of a Wound Healing, fyc. [Nov. fifteen. Countries and cities vary from peculiarities of circum- stance Dr. Graves thinks France affords five times the suicides that England does that the Irish are the least suicidal nation in Europe, and that Dublin and Naples afford fewer suicides than any other cities. At the same time it may be remarked, that murders are in an inverse ratio. There were forty murders in Ireland for one in Prussia, and forty suicides in the latter, for one in the former. It is believed, that there is no one fact entitled to more consi- deration, in estimating the chances of life, than the temperance of a community, or an individual no one circumstance more cal- culated to limit or extend the longevity in a country, and conse- quently in an individual. This is a truth, firmly fixed in the facts of the physical effects of excessive stimulation on the hu- man organization, the moral evils which it entails, or with which it is associated, and of which it is at least a fair index, and the various accidents to which it is accessary, and which increase the chances of death. When we consider the many diseases which are produced by any of the various intoxicating liquors, the various dangers to which the intoxicated state subjects the individual who is thus deprived of Reason and Judgment his great protectors, and the increased fatal tendency which the habit of their use gives to most diseases, the fact of habitual use of intoxicating liquors alone, even supposing the external evidences of health to be good, should (cet. par.) enhance the price of the risk somewhere between five and ten fold. Curious Case of a Wound Healing over an Extraneous Sub- stance. A letter to the Editors from Dr. Benjamin Aycr, of Columbia County, Ga., gives a well authenticated account of the extraction of the blade of a knife, from the nostril of a Mr. Murphy, on the 14th July, 1831, where it had been left in an affray which oc- curred on the 4th January, 1830. a period of more than 18 months. Dr. Ayer found on examination, the lower end of the blade within the nostril, about 3-4ths of an inch from the aper- ture. On announcing it, Mr. M. denied the possibility of such a fact; whereon, the doctor called in a number of most respecta- ble witnesses, and proceeded to the extraction of the blade, which proved to be that of a dirk knife, 2 3-4 inches long and 3-4 of an inch wide at one end, and weighing half an ounce. It was found on extracting it, to have passed through the base of the septum posteriorly and extended laterally into the nasal cavities. The 1S3G.] Tincture of Copaiba, Properties of Aconite, fyc. 381 external extremity was in the right nostril, and was seized by strong forceps, and after several efforts, was removed from its lodgment. The patient had made no particular complaint of it, and was unconscious of its presence in the nose, until, as he thought, he discovered an unusual bone on his nostril. Tincture of Copaiba. The London Medical Gazette, gives us the following formula for the preparation of a tincture of copaiba. Rub twelve ounces of copaiba with six ounces of calcined magnesia. Digest this in a pint of alcohol, filter, and add half an ounce of sweet spirits of nitre. This is said to be the best form of administering copaiba. The dose is one drachm twice or thrice a day ; increasing if ne- cessary, to two, three, or four. Emmenagogue Properties of the Aconite. Dr. West of Soultz, extols, in an article in the Archives Gen. the remedial properties of the Aconite in amenorrhea, arising from chronic engorgement, or spasmodic condition of the uterus. He administers the aqueous extract, commencing eight days before the expected period of menstruation, in doses of one grain, and gradually augmenting the quantity, until eight grains are taken daily at the ordinary day of menstruation. Am. Jour. Phar. Am. Jour. Med. Sciences. Chorea. The following mixture is said to have proved successful in the treatment of this disease, but the quantity of the cyanide is too great for most cases ; it would be safer to commence with half the quantity, and in- crease it gradually. I. Tincture of Castor 3ss. ; Musk ; Nit. Potass, aa. gr. iv. ; Cyanide Potassium, gr. ij. To be mixed with eight ounces of orange flour water, and taken in spoon- ful doses, in twenty-four hours. Am. Jour. Pharm. Bull, de Thcrap. Tlydrochlorate of Quinine. Dr. Spielman asserts, that the mu- riate of quinine is a more speedy and effectual remedy for inter- mittent fevers, than the sulphate. It is more soluble also than the latter. The dose is from half a grain to a grain. Am. Jour Ph. Jour, de Conn. Med. The great solubility of this article, with even the same medi- cinal virtues as the sulphate, should give it a decided preference, for the practitioner would not be under the necessity of adding, tor its solution, a superabundant acid, as is commonly done for the solution of the sulphate, whereby, as our observation informs us, its virtues arc impaired in a very appreciable degree. 382 Freezing Mixture Prussic Acid, tyc. [Noy> Freezing Mixture Prussic Acid. Freezing mixture. " Four pounds of pulverised sulphate of soda, (not efflorescent,) and three pounds of cold dilute sulphu- ric acid, (seven parts of strong acid to five of water, mixed the day before using.") Am. Jour. Sciences and Arts. This will prove a convenience in the distillation of Prussic Acid, when ice cannot be obtained for condensation. It is cheap, and always at the hand of the practitioner or chemist. Prussic Acid should, from its unequalled power as a sedative, be ever ready to fill the prescription of every practitioner. But this can only be effectually done when it is fresh from the recei- ver. Consequently, the practitioner must, if he would avail himself of its benefits, unless he have a competent and willing chemist at hand, be always prepared for the distillation of small parcels of it. It is an article which deteriorates in consequence of many circumstances, and of none, with more certainty than that which is of all others most remote from our control, which is time. Were this article furnished fresh, and of a standard for- mula, to the practitioner, it would be to him at once, one of the most indispensable of his remedial agents. This we are fully justified in saying, by our extensive experience with it for many years. Stimulus of Light. Another most powerful natural stimulus, which has been generally overlooked, or underrated as a sanatory power, is light, or the direct rays of the sun. One of the most common causes of the loss of health, and the establishment of morbid irritability in the systems of children, females, students and mechanics, is living in the shade. Like plants, growing in similar situations, a large portion of those who do not labor in the sunshine, are feeble, pale and sickly. The solar bath, properly used, I am persuaded would more benefit a large portion of our patients than the best selected articles of materia medica. Boston Journal. Composition of Hygeian Pills. No. 1. R. Gum. Aloes. ; Crem. Tart, partes equalis. Pills of common size. No. a. R. Aloes ; Crem. Tart. aa 3 i. ; Gambog. and Colocynth ua ^ i. Pills of common size. Boston Journal. Poisoning by Datura Stramonium, or Jamestown Weed. An Irish fami- ly was taken suddenly ill, after eating a dinner of corned beef and boiled greens. The family consisted of five persons, Mr. T. his wife, and three children, the eldest about eight, the youngest about five years of age. I saw them about an hour after dinner, when the symptoms were immediate- ly recognized as the effects of the Datura. The countenances had a wild idiotic expression the pupils widely dilated the sensorial functions per- verted fed the muscular system subject to an irregular agitation some- what resembling that of chorea. The appearance of the family was ex- tremely ludicrous. The children were laughing, crying, singing, dancing, 183G.] On the Treatment of Croup by Sulph, Cupri, tyc. 883 and playing all imaginable antic pranks. They had no correct estimation of distances, or the size of objects were reaclung their hands to catch hold of objects across the room, and again running against persons and things which they appeared to view as distant. The nail heads in the floor were pieces of money, which they eagerly tried to pick up. A boy, ap- parently fancying himself undressed, caught a hat belonging to a student, thrust his foot into it, pulled with both hands on the brim, and began to fret that he could not " get on his trowsers." The parents frequently called on the children to behave themselves ; but, their own actions being equally eccentric, they alforded a ridiculous exhibition of family government. Sulphate of zinc with ipecac brought from the stomachs a large quantity of the Datura plant with other green vegetables ; and under the use of Camphor, Carb. Ammonia?, and a warm aromatic infusion, the narcotic symptoms soon subsided." On the Treatment of Croup by Sulphate of Copper. By K. G. Zimmer- man, m. d. The sulphate of copper was first recommended in croup by Hoffmann, (1821 ;) who prescribed it in the dose of a quarter to half a grain every two hours, and during sixteen years did not lose, according to his own statement, a single patient. Serlo treated from forty to fifty patients with sulphate of copper, and four only died : after venesection, he gavo three or four grains as an emetic ; following this with a quarter of a grain every two hours. Such was also the treatment adopted by Dr. Zimmer- man, except that he generally applied leeches, and only bled from the arm when inflammatory symptoms ran high. He gave the sulphate of copper to fifteen children labouring under well-marked symptoms of croup ; and, although the disease in some was very intense, in others far advanced, only two in the fifteen were lost. Cases. 1. A boy, aged three years, was seized with symptoms of croup, March 9th, 1830. He had had a cough and hoarseness for several days ; after exposure to a north-east wind, the symptoms became more severe, and on the evening of the 9th respiration became " crowing." Twelve leeches were applied to the neck, and a quarter of a grain of the sulphate of copper, with sugar, was ordered every two hours. On the 10th, twelve more leeches were applied in the morning. The danger increased, so that in the evening the dose of copper was augmented to half a grain, and twelve more leeches were applied. 11th. One grain of sulphate of copper was given every two hours. 12th. The child died at nine o'clock in the even- ing, on the fourth day of the disease. 2. A boy, six years old, seized on the 19th of March, took a quarter of a grain of sulphate of copper every two hours, till, after repeated vomitings, all the symptoms of croup disappeared on the 20th. On the 23d, the fifth day of the disease, the boy was perfectly recovered. 3. A stout boy, one year old, was attacked by croup on the 4th of April : 1m '('lies were applied to the neck ; a quarter of a grain of Cupri Sulph. was given every two hours, and although this was followed by vomiting every time, eight doses were administered, when t lie respiration was relieved. The hoarseness gave way on the 13th, the tenth day of the disease. 4. A blond, scrofulous boy, aged three years, had an attack of croup on April 13th: there was a sudden invasion of laryngitis, and the cough was crowing rather than barking. Six leeches over the trachea, and a quarter of a grain of Cupri Sulph. every two hours, were ordered : each dose ex- cited vomiting, but the disease did not yield till the 15th, the fourth day. The hoarseness continued till the eighth day of the disease, when the re- covery was perfect. 5. A strong boy, four years old, seen at the commencement of the dis- ease, recovered by taking the sulphate of copper, without previous bleeding. The medicine was, as usual, followed by vomiting. 384 Salutary Effects of Small Pox, $c. |_Nov. 6. A lively boy, aged six years, seized in the night of the 27th of April, 1831?, was not seen till the evening of the 26th, when the symptoms were very intense, these of laryngitis and tracheitis combined. Venesection to three lasses, (cups), twelve leeches, and Sulph. Cupr. live grains, were perscribed immediately. At eleven o'clock, sixteen more leeches and a blister were applied ; Cupr. Sulph., a quarter of a grain, was administered every two hours : the first powder was followed with relief. On the 30th, the third day of the disease, all the symptoms, except the hoarseness, were gone, which only remained till the ninth day. 7. The same boy had another attack of laryngitis on the 12th of Janu- ry, 1634; he recovered, under the same treatment, on the 16th. 8. April 27th he had a slighter attack, cured by Cuph. Sulph. alone. 20th. He \vas quite well, and has not had another attack. \). A weakly boy, aged six years, had been unwell a week, probably with measles ; had a decided attack of croup on the 11th of October, 1833. On the 13th, twelve leeches were applied to the neck ; four grains of the sul- phate of copper were prescribed, and given afterwards in half-grain doses; in the evening, twelve more leeches and an emetic were prescribed. The Cupr. Sulph. was omitted on the 14th, and five of sulphur were prescribed, &c; the copper was resumed in the evening. He died on the evening of the 15th, the sixth day of the disease. The trachea and larynx were exa- mined : the mucous membrane was pale, soft, and a few of the vessels were injected ; the bronchi appeared filled with, a purulent mucous. A younger brother had measles five days afterwards. 10. On the 20th of April, 1834, (a year afterwards,) this brother, now four years old, had an attack of laryngitis. Leeches and the sulphate of copper were employed, and in a few days he was restored. 11. A red haired strong boy, four years old, seized with croup at 10 p. m. on the 28th September, too~k the sulphate of copper, and had leeches applied twice : he re-covered on the third day of the disease. 12. A delicate blond girl, four years old, had a sudden seizure of laryngi- tis, from which/she recovered in twenty-four hours, after taking four grains of sulphate of copper. 13. A child, one and a half year old, recovered on the second day, after six leeches, Cupr. Sulph. four grains as an emetic, and a quarter of a grain every two hours, had been employed. Dr. Zimmerman concludes that the sulphate of copper is a very valuable remedy in croup, particularly when conjoined with leeches and blisters. Where there are bronchitis and tracheitis, calomel is preferable ; but, in simple laryngitis, the sulphate of copper is advantageous in the majority of cases. British and Foreign Review. Hvfeland < Osann's Journal. Salulaiy Effects of Smallpox. This case is related by Professor Lionello Polletti, of Ferrara. A girl had for a considerable time complete loss of sense and motion of the right leg, with permanent contraction of the right arm, which had been succeeded by what has been called paralysis agitans ; all the usual remedies had been tried, but without success, so that she re- fused losubmit 1<> more, when she was seized (although previously Vaccina- ted,) with confluent smallpox. She recovered, however, from the attack, which was very severe and alarming in all its stages, and at the same time lost the paralysis of the arm, and regained the motion and sensation of her leg. BuUettmo (telle Scienze Mcdichc. Bologna. Fcbbrcjo, 1835. SOUTHERN MEDICAL AND SURGICAL JOURNAL Vol. L] DECEMBER, 1836. |_No. 7> Part I. ORIGINAL COMMUNICATIONS. ARTICLE I. Surgical Cases : By Paul F. Eve, M. D., Professor of Surge* ry in the Medical College of Georgia. SERIES NO. II. Injuries of the Fore-finger. To a proper and easy com- prehension of the following cases, it may be well to preceed them by a definition of the manner in which the bones and joints of the fingers are here distinguished. The first bone of each finger, which articulates with the metacarpal row, is called the proximal phalanx, because the nearest ; the second, the middle, for a very obvious reason ; and the third, the distal, because the most dis- tant from the body. So also of the articulations of the finger. The first is the metacarpophalangeal; the second, the proximal phalangeal; and the third, the distal phalangeal articulation. With this necessary explanation, I proceed to relate five cases of injuries of the fore-finger, which are chiefly interesting by de- monstrating the fact, that a mutilated part may be often saved without benefiting the individual. For I now believe that am- putation, in a majority of these cases, would not only have shor- tened the sufferings of the patients, but in the end have left a more useful hand to them. Knowing, however, the great importance of the fore-finger, and acting upon the principle that it is better surgery to prevent one operation than to perform a hundred skil- fully, I, in each instance, attempted union of the divided parts. 49 Surgical Cases. [Dec. Case 1st. About the 1st of September, 1832, a negro man, aged 35 or 40 years, and belonging to Mr. J. L. Coleman, was placed under my care. He was a brick-layer by trade, and \ry Using the trowel to cut bricks, had materially injured the fore- finger of the right hand. He had been under the charge of ano- ther physician, and when I first saw him, suppuration had com- menced. The finger was freely and repeatedly lanced on its palmer surface, near the distal phalangeal articulation. Under the use of flax-seed poultices, a considerable quantity of matter was dischai'ged, and with it some shreds of the flexor tendon. After the openings healed up, the finger was diminished in size and remained stiff'; the proximal as well as the distal phalangeal articulations being partially anchylosed. Several months after this, the patient, finding his fore-finger useless, and believing the middle one would supply its place, requested its removal, and it was amputated at the proximal phalangeal articulation. He, as well as his employer, now state that the right hand is not half as useful as it was before the injury was received. Case 2nd. Dick, aged about 40, and belonging to Mr. Wm. J. Eve, had his left fore-finger very much mutilated while attending his master's cotton-gin, September 19th, 1835. The saws had cut it in three places ; half an inch of its most distal extremity, including half the nail, was entirely lost; the proximal phalan- geal articulation was completely laid open on its palmar surface, dividing of course the flexor tendon, and the third incision was over, but not into the metacarpophalangeal joint. The edges of the two latter wounds were brought together; the parts healed, and on the eighth day after the accident, the patient left for the plantation. I saw Dick the other day at the gin, and upon ex- amination of the hand, I found the left fore-finger much diminished in size and permanently extended. He said he wished I had taken off the finger at the time of the injury, for it was now use- less to him. Case 3rd. On the day of the above accident, 19th Septem- ber, 1835, a boy about 10 years old, belonging to Maj. G. L. Twiggs, was brought to my house, having received the follow- ing injury of the right hand, also from a gin in motion. The lit- tle finger was much mutilated up to near the proximal phalan- geal articulation; the ring-finger from above its metacarpal joint, had the skin torn off from its whole dorsal surface, inclu- 1836.] Surgical Cases. 38? ding the nail ; the middle, like the little finger, was greatly lace- rated and its bones fractured ; and the fore-finger, from its prox- imal phalangeal articulation, was divided longitudinally nearly in the centre, through skin, tendon, bones and even nail. It pre- sented the appearance of a bifurcated finger, up to the above named joint, which was freely opened. The little finger was amputated at the proximal phalangeal articulation, the middle one at its metacarpo-phalangeal, the ring-finger was simply covered with lint, and to the fore-finger a bandage was applied after the divided tissues were brought together. It unexpectedly reunited. The finger is now permanently extended and much diminished in size, its only motion being at the metacarpo-phalangeal articula- tion. Case 4th. On Sunday, 17th September, 1836, a boy about 10 years old, belonging to Mr. Wm. J. Eve, while using a hatch- et, nearly cut off his left fore-finger. The incision extended di- agonally through the proximal phalangeal articulation, laying open the joint, cutting off a portion of the cartilages and bones,, and, though received upon the dorsum of the finger, the convex edge of the hatchet had penetrated the palmer surface. The lat- eral ligaments, at least the external one, and a portion of the skin on each side were all that remained undivided. The parts were brought together, without even removing the partially detached cartilages or bones, and although there was considerable inflam- mation and discharge of matter, the wround healed in about two weeks, and the boy returned to the plantation. Two days after- wards, there was a very severe change in the weather, when from exposure, the little patient took cold, the finger and whole hand became very much inflamed, the wound re-opened, and when he presented it to me, I at once removed the portion of finger now lying pendant in the palm of the hand. By subduing the inflam- mation, the stump, though the incision was made diagonally to correspond with that of the wound, regularly healed, and the patient again returned home, the 24th October. Case 5th. On the 13th of O * 1836, Nathan, a negro man belonging to Mr. John Moore, while opening goods, had an anvil to fall upon his right fore-finger, which fractured its distal phalanx just behind the nail and also laid open the distal phalan- geal articulation. Notwithstanding the nature of the accident, a severe contused wound, a fracture, and a compound disloca< 388 Essay on Recuhwii, $c. [Dec. tion, with simple dressings and the use of chloride of soda the parts entirely reunited in a week. At this time, the nail is com- ing off, the finger is still somewhat swollen, but the patient can bend a little, even the distal phalanx. Remarks. It will thus be seen that of the five cases, ampu- tation was performed in two, numbers 1 and 4 ; but, in each case, after the injury had healed; in one it was from choice and in the other from necessity. In numbers 2 and 3, the fingers are permanently stiff and reduced in size. In number 3, there is no middle finger to supply the place of the fore-finger, and even the ring-finger cannot be flexed from the injury it also sustained by the accident ; but I think it questionable, whether it would not have been more useful to have amputated it at the proximal pha- langeal articulation, and whether it ought not even now to be performed. In the other, number 2, I do not hesitate to say, that amputation at once would have been preferable, the injury being on the left hand, and the middle finger of the same side be- ing entire. Finally, the 5th case, produced by an accident cal- culated to be as serious in its results as any other, seems to be the only one of the five where saving the finger was of decided advantage. Augusta, October 27///, 1836. ARTICLE II. Essay on Revulsion : By Joseph A. Eve, M. D. Professor of Therapeutics and Materia Medica in the Medical College of Georgia. Although the history of Revulsion may be considered coeval with the earliest records of medical science, the principle of its operation having been evidently referred to by the Coan Sage, in his invaluable aphorisms, still its almost universal application and its paramount importance in medicine appear to be, by no 183C] Essay on Revulsion, means, fully recognised and appreciated by the profession in gen- eral, even at the present day. In the whole range of medical philosophy, there is no subject more interesting none that involves so many important consid- erations, both in pathology and therapeutics. In all the language of medicine, there is no term more beauti- fully expressive of the idea intended to be conveyed than Revul- sion, owing its derivation to the Latin verb revellere, to draw away, thus signifying a drawing away or abstraction of excite- ment from one part to another. Without delaying time to examine the opinions of the ancients, or to consider the difference between revulsion and derivation, which Bouchard has satisfactorily proven to be imaginary and futile, we would simply signify by revulsion, an augmentation of excitement in one organ, part, or system, which causes a suspen- sion or depression of excitement elsewhere whether this aug- mentation be spontaneous or the result of artificial means. The object of revulsion is to create a centre of fluxion which shall interrupt the tendency of the fluids towards a diseased part, "where there is a focus of irritation with exaltation of the vital properties," that is, to cause a diversion or abstraction of ex- citement, or irritation from one point to another, w7hereby to ar- rest haemorrhage, remove congestion, or relieve pain. By restricting the signification of Revulsion, merely to the op- eration of external revellents, physicians have generally conceiv- ed a very limited and imperfect idea of the importance of this principle of revulsion and its almost unlimited applicability, in solving the mysteries of disease, and explaining the modus op- erandi of therapeutic agents. There is indeed, scarcely one mean in medicine, whose effects do not depend more or less on this principle. Emetics, cathartics, dinretics, diaphoretics, and all local excitants, operate not only by the secretion and conse- quent depletion they cause, but by effecting a revulsive determi- nation of excitement and afflux of blood to the organs whose func- tions they excite. Cupping glasses and leeches are as unequiv- ocally revellent in their operation, as blisters and sinapisms the only difference being, that the irritation caused by the latter is more violent and persistent, whilst that made by the former is resolved as fast as formed by the afflux of blood, from the bites and scarifications, thus approximating more nearly, in their 390 Essay on Revulsion. [Dec. mode of operation, to those medicines that promote the secre- tions; in the action of which, the same phenomena are 'observa- ble, in the same succession stimulation, irritation, afflux, con- gestion and effusion which last event, producing immediate res- olution, prevents the irritation from affecting sympathetically the rest of the economy. In the employment of general blood- Jetting, more than is generally supposed, is attributable to the re- vulsive determination of blood toward the part from which it flows; this is particularly conspicuous in the effect that venesec- tion, practised on the foot, exercises over the brain, especially if the foot be immersed in hot water, and the patient be sitting or standing erect syncope results, under such circumstances, from the loss of a very small quantity of blood; a quantity, which, taken from the arm, would not sensibly affect the head. Inas- much as the object of revulsion is the production of sedation or depression of excitement in the part affected, some authors have styled revulsives indirect sedatives, but as their mode of opera- tion is essentially stimulant, and the sedation caused, only an ul- terior consequence, the appellation is inappropriate and should not be retained. Our knowledge of revulsion is based upon an observation of the most ordinary and obvious phenomena in physiology such as the reciprocal concentration and abstraction of excite- ment the suspension of some processes, whilst others are exal- ted, and the numerous reverse sympathies or antagonistic rela- tions that exist between different organs and systems, by virtue pf which, an exaltation of excitement in one is attended by a cor- responding depression in another which principle is also beau- tifully displayed in pathological facts of every day occurrence the metastasis of disease from one point to another, and the miti- gation or entire subsidence of one affection by the supervention of another, in a different part. By a wise and happy provision in the animal enconomy, irri- tation has a constant disposition to extend itself from the part first attacked to other parts of the system one part or organ invoking, as it were, the sympathetic aid of others, in sustaining or resisting an injury, which, otherwise becoming more and more intense and insupportable, would produce disorganization and death. Pathologists designate this law or principle in the econ- omy, very appropriately by the term sympathy: upon it depends 1830.] Essay on Revulsion. :*D1 reaction, .-without which every irritation of much intensity, or in- volving an important organ, would prove inevitably fatal ; for the suffering part becomes a focus <>f attraction and concentration of the excitement and of the fluids \'vo\n all parts of the organiza- tion, until it is overwhelmed; or other parts beginning to sympa- thize and share the irritation, the excitement becomes diffused and reaction established ; as we sec admirably exemplified in the cold and hot stages of intermittent fever. In the cold stage, the excitement and the blood forsake the exterior of the body and concentrate upon the interior, which is oppressed and deluged with the most intense irritation and con- gestion ; which are overcome, after a shorter or longer duration, by reaction, which causes an equalization of excitement, if the sympathies be sufficiently active alone, or by the aid of artificial revellents, to cause its diffusion, thus constituting the hot stage. But if the sympathies fail, the irritation and congestion still in- creasing, the balance of excitement is irrecoverably lost, and the patient succumbs in the cold stage. Thus, we perceive without the play of the sympathies, constituting reaction and causing a revulsion of excitement from the interior to more superficial and less vital parts, no patient could survive the cold stage of fever ; but the equilibrium of health is not restored, until the hot is suc- ceeded by the sweating or critical stage. Irritation and inflammation frequently extend, by sympathy, to remote parts, without materially relieving the primary loca- tion such sympathetic affections are very common attendants on all inflammatory diseases, both acute and chronic thev are generally regarded as symptoms and often serve as diagnostic of the original malady. But when the sympathetic replaces, that is, proves revulsive of the primary affection, it constitutes a me- tastasis if to a more vital part, it is attended with more danger and its cure is to be effected as promptly as possible, by re-exci- ting the first. If a depuratory organ, such as the skin, kidneys, &c, be the seat ofirritation thus sympathetically transmitted, and the irritation be such as to remove the primary disease, but not so intense as to suspend the functions of these organs, the sympa- thetic irritation will, in turn, be resolved by increased secretion from them, and entire resolution of the disease be the result, which in medical language is styled a crisis ; thus physicians ppeak of critical sweats, diuresis, &c ; and it is thus on the prin- 392 Essay on Revulsion. [Dec* ciple of revulsion, that we can comprehend the philosophy of the mode of operation of medicines addressed to the secretions, in the treatment of febrile diseases. But every determination of ex- citement to a secretory organ, causing copious secretion there- from, does not invariably prove critical, because the sympathetic is not always sufficiently intense or persistent to replace the o- riginal irritation, and the crisis is therefore not effected the dis- ease is only temporarily or partially relieved. There is then, only this, though by no means an unimportant, difference between a metastasis and a crisis in each there is a transmission of irri- tation from one part to another, which proves revulsive of the original affection; but in the former, we have only the substitu- tion of one disease for another whereas, in the latter, the secon- dary irritation is resolved, immediately, by secretion from the organ that receives it : thus for example, if a gastritis be transla- ted to the brain or its meninges, a disease is developed more grave and dangerous than the first ; but on the contrary, if the skin be the part to which the translation is made, the direct re- sult will be a free perspiration which will most probably prove critical of the gastric inflammation, unless the reflected irritation be of such intensity as to suspend secretion, and then the conse- quence will be an erysipelatous or phlegmonous inflammation, which may still be revulsive of the gastritis, and the patient will have exchanged a dangerous internal, for a comparatively mild and safe external disease. Innumerable examples might be ad- duced of similar sympathetic transmission of morbid excitement from one organ or part to another, constituting metastases or cri- ses; and it is by attentively contemplating these, that we are enabled to derive correct views of revulsion, and deduce proper principles and precepts for its employment. Keeping always in view the grand principle of revulsion and the sympathetic con- nections of organs, but never losing sight of the importance of the humours in the pathology and treatment of disease, the sci- entific practitioner endeavors, in the management of fever, to excite the secretions with the double purpose of eliminating effete and injurious matter from the circulation, and of causing a re- vulsive determination of excitement and afflux of blood to the secretory organs, with the hope of effecting thereby a crisis: and he only resorts to the more violent and unnatural method of inflaming the surface to produce revulsion from the interior, 183G.J Essay on Revulsion. 99$ when milder resources are inadequate and the danger to be a- verted, threatening. When the secretory organs arc in a state of excitement too high for secretion, any means calculated to excite them must, of course, not only be nugatory but hazardous, instead of produ- cing critical evacuations they would cause inflammation. It is therefore always proper, in diseases of high excitement, to em- ploy direct debilitants to reduce the forces of the system, before having recourse to exciting medications, either to promote se- cretion or cause revulsion; otherwise they will not only fail to accomplish the object intended, but exasperate the disease by in- creasing the general excitement. Some modern authors proscribe altogether the use of revul- sives during the continuance of fever, except when an important organ, as the brain or heart, is violently and dangerously affected, in which cases nil agree that the most powerful revulsion and copious depletion should be, immediately and simultaneously, practised. The employment of the more active or inflammatory revellents should certainly be deferred, during an exacerbation and until violent excitement has been moderated ; but they may often be very advantageously employed long before the entire subsidence of fever; and the gentler revulsive means may be beneficially resorted to, in the very commencement. The principle of revulsion is, indeed, as applicable to the rem- edial management of the incipient as of the final stage of fever: but during high excitement, while the sympathies are active and the vessels replete with blood, direct depletion is necessary be- fore any appliances that would increase excitement are admissi- ble. Energetic revulsives arc not therefore to be postponed, in the first stage of fever and in acute inflammations, from a fear that the artificial will be translated and added to the original in- flammation; but because they will aggravate the disease by aug- menting the general excitement. We should then commence the treatment of such affections with the mildest revellents, such as fomentations, cataplasms, baths, frictions, leeches, cups, &c. ; and should these fail in effect- ing revulsion, resort to the more violent epispastics, as the vio- lence of excitement subsides or is reduced by depletory mea- sures. We are aware that what we have said impugns a prop- osition very generally received as an axiom in medicine, and par- 50 394 Essay on Revulsion. [Dec. ticularly insisted on by the author of "the new medical doctrine;" that is, " that revulsive irritations must be stronger than those they are intended to replace, otherwise they turn certainly to the benefit of the latter" that there is no medium between extin- guishing and exasperating the original affection: but we consid- er this to be a dangerous error in theory, which has led to very prejudicial results in practice causing on the one hand an un- necessary and injurious postponement of the employment of re- vulsives, or on the other determining the selection of those unne- cessarily severe. If this proposition were true, the most acute inflammation would require the most intense revulsion ; whereas we know that acute inflammations are often greatly mitigated, by very gently revellent means, as for example, gastritis by fo- mentations over the epigastrium pleurisy by warm applications to the side croup by warm wet cloths applied to the throat even the physiological excitement of some organs will, frequent- ly,moderate or suspend the sufferings of others thus we contend that irritations and inflammations may be relieved without being entirely extinguished, and that grave affections may be mitigated and sometimes entirely replaced, by very mild revulsive excite- ments, even by such as may be attended with no pain and not even transcend the normal point. Were the position assumed by our opponents correct were there in the employment of re- vulsives, no medium between exasperating and extinguishing the original affection did the more intense always overcome and appropriate to itself the lighter excitement, we should never suc- ceed in producing revulsion; for the primary would always at- tract to itself the artificial irritation in its incipiency, and as fast as formed, and thus never fail to be aggravated by it. But of this observation constantly declares the fallacy ; for we fre- quently sec blisters fully drawn without either removing or in- creasing the inflammation, for which they were prescribed, which remains unaffected, and sometimes requires a succession of blisters or a perpetual blister for its final extinction. We would by no means contend for the exclusive use of the gentler revulsives, we know very well that they will not always suffice; we would only argue that they may often be, advantage- ously and safely, employed in the first stage of acute diseases, when the more potent would be altogether inadmissible. We can generally, with oxcellent effect, commence the treatment of 1836.] Essay on Revulsion. 506 acute inflammations of the thoracic and abdominal viscera, by employing gentle rcvellents that will not sensibly increase the general excitement, and as it becomes moderated, substitute those that are more active, until the strength and activity of the system having been sufficiently reduced, the most energetic may be employed, not only safely, but with the effect of causing com- plete revulsion and preventing the inflammation from becoming chronic, and terminating in disorganization. A very important consideration, in the administration of re- vulsive medications, is the adaptation of the means employed to the indication to be fulfilled in different cases. As a general rule, subject however to some exceptions, the revulsive irritation ought to correspond to that which it is intended to replace ; for exam- ple, in haimorrhagic irritations, as hoemoptysis, &c, cups and leeches will be most appropriate and beneficial ; and if the dis- ease to be treated have resulted from the suppression of a period- ical or habitual sanguine discharge, the proper revellents are those whose operation involves evacuation of blood : in nervous irritations, rubefacients and such other revulsive medications as excite the surface, without producing inflammation, are generally preferable in colic, while the affection is confined to the nervous tissue, the sanguine not involved: that is, before inflammation commences, warm fomentations, cataplasms, stimulating fric- tions, sinapisms,. &c, are much better adapted to the case, than the more permanent epispastics ; but when inflammation has been developed, the latter are much more efficient, it is however often necessary to premise or accompany their employment with free sanguine depletion. When it is desired to recall a superficial af- fection, such as erysipelas, &c, whose disappearance has been attended with injurious results, sinapisms are the most proper remedies; but if the malady we design to relieve, depend on the sudden healing of a deep ulceration, or if the indication be to cure an internal abscess, such rcvellents will be required as shall cause and maintain an artificial suppurating ulcer, setons, issues, moxa, &c. The choice of the means to be employed should, in a great measure, be determined by the duration and obstinacy of the disease: recent and light affections generally yield easily, and seldom require more than the most simple and transient revul- sives ; but the more chronic a malady is, the more intense ahd 396 Essay on Revulsion. [Jjec. permanent will be the revulsion demanded for its extinction. In the incipient stage of croup, warm fomentations to the throat are, often, sufficient at once to dispel all the symptoms: in the same stage, affections of the lungs and liver are frequently re- moved, promptly, by the revulsive operation of an emetic or ca- thartic, which later in the same cases would prove ineffectual if not injurious. In sudden metastases to important organs, as the brain, heart, &c, the selection of a revulsive should be governed by the power and promptness of its action; such cases demand the immediate application of the most prompt and energetic sina- pisms, actual cautery, scalding water, concentrated mineral acids, &c. the same speedy and powerful revulsion is requisite, in congestive fevers, to equalize the excitement and determine the circulation to the surface. One of the most important points to be regarded, in the em- ployment of revulsion, is the selection of the place upon which it should be practised. As a general rule, external revulsives should be applied to the surface directly over the suffering part ; as to the side in pleurisy to the breast in pneumonia, &c. ; but there are many exceptions to this rule. Active revellents ap- plied very near sensitive organs, instead of proving revulsive, often aggravate irritation in them, by causing toward them a determination of excitement and consequent afflux of blood. In affections of the brain, for example, revulsives applied to the scalp woulJ prove highly prejudicial, if not fatal, except in ex- tremely low states, when the vascular system is so exhausted of blood, the sympathies so paralyzed and the excitability so nearly extinct, that inflammation of the cutaneous covering can. extend its influence no farther than to cause a feeble afflux thereto from the cerebral mass within. In acute gastritis, the same danger attends the action of blisters on the epigastrium, before the general excitement has been sufficiently reduced by blood-letting, and that of the stomach by appropriate means, not on account of any direct or intimate sympathy, as Goupil asserts, between the skin and digestive mucous membrane, by which one constantly par- ticipates in the affections of the other. According to this author there exists, between the skin and pulmonary mucous membrane, an inverse sympathy to which he attributes the success of revul- sion in inflammations of the lungs and between the skin and digestive mucous membrane, a direct sympathy, and consequently 1836.] Essay on Revulsion. 397 that " revulsives can only have an injurious effect in ^astro-intesti- nal inflammations. Yet with the strangest inconsistency, he recom- mends the application of leeches to the epigastrium," and says, "we should not hesitate to range these animals amongst the re- vulsive means," and that " to be convinced that they can not act, except in this manner, it is sufficient to recollect the effects which they procure in gastro-entcritis, when applied to the epignstrium." The skin then, according to M. Goupil,- sympathizes directly, under the influence of one revulsive mean, and inversely when acted on by another. Who can listen to such reasoning such extravagant assertions? And farther, is it not equally absurd to suppose, that the skin over the thorax entertains an inverse sym- pathy with the gastro-pulmonary mucous membrane and over the epigastric region, a direct sympathy with the same mem- brane? or, that the gastro-pulmonary mucous membrane, de- scending into the lungs and into the stomach, should hold differ- ent relations with the cutaneous surface ? But with the same inconsistency, this author tells us again, "in cases where gastro- enteritis is the result of the disappearance of inflammation of the skin or subjacent organs, it is necessary to(employ revulsives to recall it," and concurs with his preceptor, Brousshis, in direct- ing blisters to the abdomen in cases of intestinal haemorrhage, but condemns the application of a vesicatory to the thorax in the commencement of pneumonia or pleurisy, as an incendiary prac- tice. We object more to his fanciful theories, than to his prac- tical precepts. The same principles are applicable, the same effects attend the employment of rcvellcnts, in thoracic and ab- dominal inflammations. The gastro-pulmonary mucous mem- brane bears the same relation to the skin, over the thorax and over the abdomen: in the acute inflammations of either cavity, violent revellents are improper, because they increase the gen- eral excitement and augment the force of the circulation, which affects in an especial manner the inflamed organs. Blisters may generally be applied somewhat earlier, in inflam- mations of the lungs than of the stomach, inasmuch as the form- er are less excitable than the latter and not situated so near the surface. When inflammatory revulsives are applied very near inflamed organs, that is where there is but little substance inter- posed, there is danger of the revulsive inflammation, by sympa- thy of continuity, as it is termed, extending to and aggravating '08 Essay on Revulsion. [Dec. the original affection. This danger, however, is seldom to be apprehended from blisters to the epigastrium :* and we appeal without the least hesitation, to the experience of American physi- cians, for their beneficial effects in gastric fevers, after the first violence of excitement has been subdued by bloodletting and other proper measures ; and in debilitated subjects at the very commencement of an attack ; for in such patients the general system is very little if at all disturbed, by the excitement of a blister and perfect revulsion is effected, from the gastric mucous membrane to the external surface. But generally, in cases of gastric fever, it is more safe and efficacious to apply them, first, to the arms and legs to abstract the excitement as far as possible from the point of concentration, and in the latter stage, after the system has been much reduced, to the epigastrium should it then be necessary ; it will, however, seldom be required, at least such is the result of my own experience : but milder revellents, such as fomentations, cataplasms, cups and leeches, may be advan- tageously employed at the very first and simultaneously with blisters to the extremities. Besides the greater efficacy of epis- pastics thus applied at a distance from the suffering organ, a blis- ter to each leg and arm will not cause one-fourth as much dis- tress to the patient, or one-fourth as much disturbance of the system, as one to the epigastric region; and they will heal in half the time. So far from exciting much pain, in some cases of intense gastritis, the extremities suffer such a distressing numb- ness from the excitement being concentrated on the stomach, that the drawing of blisters is sometimes even pleasant to the pa- tient, seldom the source of much complaint. In cases of acute gastritis suddenly occurring in persons previously much enfee- bled, it will often be proper to employ blisters or sinapisms sim- ultaneously to the. extremities and the epigastrium, or in very quick succession. With respect to the choice of place for the application of re- vi llents if the disease to be combattcd supervene on the retro- cession of an external inflammation, or the disappearance of some * Applied too near the diseased place, if the parts are thin, we run the ri&que of causing the external inflammation to unite with the internal, and consequently augment the evil. In the eu i where the affection we wish to displace, is without inflammation, this inconvenience docs not exist any- more than if the mean employed does not produce inflammation, as blood- letting, cups, &c." Diction, des Sciences Medicates. 183G.] Essay on Revulsion. 399 other affection, revulsion must he exercised on the part or organ originally affected ; a much slighter irritation, excited there, will prove more certainly and effectually revulsive, than a much more intense degree elsewhere, hi proof of this position, many interesting cases might he adduced, did our prescribed limits ad- mit: the following very curious one must suffice. A patient admitted into the Hotel Dieu of Paris, complained of a most vi- olent pain in the tendo achillis of the left leg, without either red- ness, heat, or swelling. After many curative means were em- ployed in vain, it was discovered that some days previous to the attack, the patient had suddenly suppressed a gonorrhoea, and the affection could not be removed but by establishing the dis- charge from the urethra by the aid of ammoniacal injections.* If the prominent affection be sympathetic of some other more obscure disease, it will be necessary to direct our attention pri- marily to the latter, on whose removal that which was sympa- thetically produced will subside. Pain in the right clavicle and shoulder is a symptom of hepatitis, and only to be relieved by means addressed to the liver. Headache generally depends on gastric disorder, and is removed by remedies that correct the state of the stomach. Distressing irritability of stomach and obstinate vomiting are, frequently, caused by sympathy with the uterus and requires remedies directed to that organ in such cases, we have found a blister over the sacrum more effectual than any other remedy. Abortion may often be prevented and doubtless many of the distresses incident to pregnancy greatly mitigated, by revulsion practised on the same part. A host of oral affections, some anomolous, others simulating colic, he- patitis, gastritis, pleurisy, &c. &c, are produced sympathetically, by irritation of the spinal marrow, and demand for their cure, leeches, cups, sinapisms, blisters, &c, along the course of the spine. f Two very important considerations, in the administration of revellents, are duration and extent of surface. We often fail in our attempts to produce revulsion, by not continuing the appli- cation of revulsives long enough, and by not persevering to repeat * Diet, des Sciences Medicales. f See Teale on Neuralgic diseases, and Essays in the 6th No. of this Journal by Dr. Heustis of Mobile and Dr. Ford of this city. 400 Essay on Revulsion. [Dec. them when the first does not succeed. Blisters, though much less violent than sinapisms, generally effect much more, because they are more permanent in their operation. On the same prin- ciple, more benefit may frequently be derived even from cata- plasms and fomentations long continued than from si lopisms. Much benefit may be effected by the proper manage ment of warm pediluvia, but to evince their best effects, they should im- merse the legs nearly up to the knees, be continued from one to two hours, frequently repeated, and in the intervals substituted by bottles of warm water, warm bricks, warm cataplasms, &c. to the feet. A comparatively mild revellent, long continued and applied to an extensive surface, will produce much more revulsion, than one much more intense, of less duration and extent: hence the efficacy of the general warm bath, of stimulating frictions of the skin and of diaphoretic medicines, whose beneficial effects depend, chiefly, on their causing a revulsive determination, to a part of such immense extent as the external tegumentary system. Cer- tainly one of the greatest improvements, in modern medicine, is the more frequent substitution of external for internal medication. The steam bath is doubtless a potent mean, for causing revulsion to the surface and relieving the super-excitement and congestion of internal organs, and may be often very advantageously em- ployed by scientific practitioners, in the treatment of congestive diseases ; but its ignorant and ill-timed exhibition, in the hands of empirics, especially when immediately followed by cold appli- cations, is unfortunately, too frequently the instrument of death. In persons of nervous temperament, much caution is requisite in the administration of active revellents, as distressing and even dangerous results not unfrequently attend their application in such subjects; their use should, therefore, be avoided, except in very urgent cases, and the most gentle employed in their stead ; but the state of the system, or the nature of the disease may afford a paramount indication for their employment, when the influence of temperament will not be felt as exemplified in the following instance: A sinapism applied to a lady of nervous temperament, for the relief of a local affection, was followed the third day by a most tormenting secondary irritation which continued several days, notwithstanding all the remedies that could be suggested to allay it; subsequently, when in most imminent danger, caused 1836.] Essay on Revulsion. 40b by repercussion of measles, the same individual derived, from the application of eight large sinapisms, the most signal benefit, with- out the slightest ulterior discomfort. These different results, under different circumstances, are easily explained. When the first sinapism was applied, the skin enjoyed its accustomed de- gree of excitability ; at the time of the second application, the excitement was abstracted from the surface and concentrated on the interior, and the most powerful stimulation was demanded to restore the equilibrium. Notwithstanding so much has been written on revulsion, so commanding is its importance and universal its application in medicine, and so confused and vague the views generally enter- tained by physicians, that if these remarks afford any useful sug- gestions to the young and inexperienced members of the profes- sion, or even serve to direct their attention more forcibly to it, my labor will be amply rewarded. We have endeavored to set forth, plainly, a few of the most prominent principles concerned in the operation and employment of revulsion ; it would be an agreeable task, did our limits and engagements admit, to pursue the subject farther and consider the application of these principles to the remedial management of all or nearly all diseases, and to the modus operandi of at least a majority of our therapeutic a- gents ; but this would be little less than to write a system of practice ; for it will be found, on an attentive and philosophic ex- amination, that this grand principle of revulsion is almost uni- versally involved in the pathology and treatment of disease. *1 402 Cases of Colica Pictonum. [Dec* ARTICLE III. Cases of Colica Pictonum: By L. A. Dugas, M. D., Professor of Anatomy, &c. in the Medical College of Georgia. Case 1st. M. J., about 12 years of age, apparently of a good constitution, and an apprentice printer, was taken in July last with pain in the bowels, which gradually increased in in- tensity until it became excrutiating. It had continued thus more than a week when I saw him, and learned that the most powerful cathartics had, during this time, been administered lib- erally without the slightest alvine effect. I found him writhing with agony ; the pain had extended to the lower extremities, but especially to the feet ; his system evinced no febrile action ; his tongue was normal; in short, he presented every symptom of colica pictonum, to which his avocation exposed him. Having long since considered this a nervous affection, although the effect of a specific agency, I examined carefully the condition of the spine, but detected in it not the slightest tenderness when sub- jected to pressure, percussion, and lateral motion of the vertebra?. This circumstance deterred me from immediately directing my treatment to this region, and a few cathartic pills and a sinapism to the abdomen were ordered. On seeing him the next day, I found lh :t the pills had not operated and that his sufferings were unmiti^j-teJ, notwithstanding large doses of laudanum had been added to my prescription, during the night, by the lad's mother. I now ordered a blister to be applied to the spine, extending from the middle dorsal to the last lumbar vertebra?, and three inches wide ; also another dose of the cathartic pills to be given when- ever the vesication should commence. On my next visit, the following day, I had the gratification to find my patient perfect- ly free from pain ; the blister had drawn finely, and the cathartic had acted kindly. Convalescence was rapid, and the boy return- ed in a few days to his former occupations, without any other remedy. Case 2d. M. B., an apprentice printer, about 15 years of age, has had several attacks of colica pictonum, at intervals of about six months. Called to him on the 0th August last, I found 1 036.] Cases of Colica Pictonum. 400 him laboring under a violent return of this disease. The feet were also affected in this case. No tenderness of the spine. A dose of oil and a sinapism to the abdomen were ordered, and re- mained without effect. On the 10th, finding the pulse full and resisting, at the same time that a tendency to stupor and deliri- um were manifested, 20 ounces of blood were taken from the arm, and the oil repeated. No diminution of pain having taken place, in the evening the dorsal and lumbar spine were freely cupped 1 1th; passed a much better night than usu?l and feels much better, though not entirely relieved. A blue pill to be ta ken morning, noon and night. 12th ; pains have returned with redoubled violence, delirium and slight convulsions from excessive suffering; bowels have been slightly moved; cups reapplied to the spine, and a blister over the cupped surface at night; blue pills continued, 13th ; blister has drawn well ; relief is complete. The bowels were now opened with oil, and the ca'e discharged the next day. Case 3d. This is a leturn of the disease m die subject of the first case. It occurred on the 20th October, with precisely the same symptoms it had before presented. The costiveness had been endeavored to be removed by oil, &c. on the /irst day of the attack, but in vain. I immediately ordered a blister to the spine, which gave relief as soon as it acted a cathartic then c.dminis- tered, acted without difficulty; and the case vns dischaiged well the second day. Here the spine presented no tenderness. Remarks. It will be noted that the spine in neither oi' hese cases, evinced the slightest sensitiveness ; yet revulsives applied to it were invariably and promptly followed by the most decided relief. We may infer from this circumstance that the poisonous effects of lead are principally manifested in the sympathetic nerves, and that it is because of their free communication with the spinal marrow, that revulsives applied near this column act so advantageously. Indeed it would seem that the disease may in some instances extend, by continuity of substance, or other- wise, from the sympathetic nerves to the spinal marrow itself, thus accounting for the pains of the extremities, and even loss of motion, which so often complicate colica pictonum. Augusta, November, 1836. 404 Amussafs Lessons on Retention of Urine, <$-c. [Dec. Part II. REVIEWS AND EXTRACTS. Amussafs Lessons on Retention of Urine, caused by Strictures of the Urethra, and on the Diseases of the Prostate. Trans- lated from the French, by James P. Jervey, M. D., Charles- ton. Page 246. The work before us is the substance of a course of Lectures annually delivered by M. Amussat, in the amphitheatres of the Faculty of Paris. Professional rectitude and zealous industry have long since characterized this gentleman's labours and im- pressed on them a practical importance far above the visionary productions of the closetted book-makers of the day. M. A. is essentially a practical man ; one whose observations are all made at the bed-side and in the dissecting room, with an eye solely directed to the detection of truth and one whose purpose is the good of humanity. The writer of this notice, from his personal acquaintance with Mr. A., takes much pleasure in thus testifying to his claims at least to public confidence. It is not our design to enter upon an elaborate Review of this work the limits assigned will not permit it. We desire merely to call the reader's attention to the subjects on which it treats, and to point out some of the views peculiar to the author. The first chapter is devoted to the consideration of the several varieties of stricture of the male urethra, their pathological anatomy, and the means of diagnosis ; the second treats of catheterism with curved and straight instruments; the third relates to the means proper to relieve retention caused by strictures; the fourth in- cludes the treatment of strictures ; the fifth enumerates the acci- dents complicating strictures ; and the last refers to diseases of the prostate. M. Amussat divides strictures into three kinds, viz. : the organ- ic, the spasmodic, and the inflammatory. Of the organic he es- tablishes four species: first, frocni; second, valvular strictures ; third, those produced by a chronic swelling of the mucous mem- brane ; fourth, callous strictures. The froeni he considers formed in some cases by an acute inflammation of the mucous membrane of the urethra, passing into the chronic state at different points of this surface, and depriving it at these points of its natural ex- tensibility. In other instances they appear to result from the cicatrization of ulcers, and arc then met principally about the fossa riavicularis. M. A. denies that they are ever formed by falsi; membranes, as has been supposed. With regard to the valvular strictures, which he thinks more common than all others, he views them as nothing more than frceni which occupy the whole circumference of the Urethra. 1830.J Amussat $ Lessons on Retention of Urine, $c. 405 Mr. A. denies that strictures ever exist beyond the bulb, and states that they are most frequently located about the junction of the bulbous and muscular portions, and at the origin of the fossa naviculars. His " exploring sound" is intended for the purpose of*" examining the urethra from behind forwards, a direction in which the strictures arc always more appreciable." Its mechan- ism is simple, and well adapted to the end proposed. In the chapter on cathetcrism, the author advances his claims to the discovery, or rather to the practical application of straight ca- theterism. Although many passages may be found, in authors who preceeded him, which allude to the possibility of this oper- ation, it must be conceded that the attention of the profession was not forcibly drawn to its advantages prior to M. Amussat's pub- lication in 1822. There are strong grounds for the belief, that M. A's. researches had no inconsiderable influence in the perfec- tion of the instruments subsequently invented tor crushing urin- ary calculi, for nothing useful had been done on the subject until it was demontrated that the bladder could be penetrated as read- ily by straight as by curved sounds. It will be perceived, (p. 77.) that it* is to M. A. we are indebt- ed for the valuable suggestion of 'forced injections," in the treat- ment of retention. " Convinced of the difficulties often presented by catheterism and the introduction of bougies in cases of reten- tion of urine from stricture, as well as of the dangers to which the patients are exposed, M. Amussat invented forced injections, a process still too little known, and which was unjustly at the time endeavored to be attributed to a German surgeon." This operation consists in forcing water into a catheter introduced as far as the strictured point; the urethra being pressed against the catheter prevents the reflux of the fluid, and this gradually pen- etrates the narrowed passage and finally makes its way to the bladder, after having sufficiently dilated the canal to permit the flow of urine. After exposing the difficulties of obtaining a faithful impres- sion of the stricture in the manner recommended by Ducamp, M. Amussat insists that, in certain parts of the canal, impres- sions may be left on the wax bougie whether the urethra be strictured or not. " The bulbous portion of the urethra is so arranged, that an impression can always be taken with the ex- ploring sound, when the canal is healthy or diseased, when the experiment is made upon the living or the dead subject. When the extremity of the instrument has arrived at the bulb it is ar- rested by the cul-de-sac formed by the fibrous membrane which envelopes this body. However slightly the exploring sound be then pushed forwards, the spongy tissue which is thicker at the bulb than any where else, allows itself also to be more easily depressed, and then forms a kind of hollow in which is moulded the inferior part of the end of the wax with which the bougie is 406 Amussat's Lessons on Retention of Urine, fyc. [Dec. armed, whilst above the wax enters into the area of the canal. Thus whenever an impression is taken at the bulb, if the operator be guided by this impression, he will believe that the stricture is more projecting below than above, and consequently will be in- duced to cauterize especially in the former direction. " To how many false passages has not this error given place ! It is so true that the cul-de-sac of the bulb can impose upon the operator, that the majority of these accidents occur at this point." M. A. gives the decided preference to the cutting instrument over the use of caustic, in cases of valvular strictures. Indeed, cauterization is attended with so much risk, that we are not sur- prised to find it avoided as much as possible by so prudent a prac- titioner as M. A. His instruments for scarification, though good, are not described with sufficient lucidity to be understood by one unacquainted with them. Whether this defect should be attrib- uted to the translation or to the original, we cannot determine, not having the latter by us. The chapters on the accidents attendant on strictures, and on the diseases of the prostate, are replete with interest. M. A's, work is one in which the reader will find neither rhetorical nor pedantic display ; containing no theories, nor metaphysical spec- ulations ; it may appear dry and uninteresting to those who pre- fer fiction to truth ; its merits will be duly appreciated only by the man of practical experience. The translation we doubt not is faithful, for in his zeal to ren- der it so, the translator has but too frequently been led to give us rather the words than the ideas of the author. These Gallicisms, however, being rather more disagreeable than injurious to the sense of the phrase, will not be uncharitably censured by those who are aware of the difficulty of translating a language, with- out being so much imbued with its genius as to confound this with that of their vernacular tongue. The translator will, we trust, not lay down his pen after this effort ; if he will favour us again with some of the many trea- sures locked up in the French language, we promise no more to notice the peccadillos of inverted and foreign phraseology. The judicious notes interspersed through the body of the work, by Dr. Jervey, will be duly appreciated by the profession. Augusta, November, 1836. 1836.] Extracts from the Note-book of a Physician, c. 407 Extracts from the Note-book of a Physician of this City, during his attendance on the Parisian Hospitals. M. Piorry's Remarks on the Blood. M. Piorry thinks it pretty certain, that most, of" the cases of softening of the substance of the heart, now so often met with, are occasioned by protracted abstinence. He says, that independently of his having observed this very often, the analogous effect being produced on the other muscles, even during life, will strengthen his assertion. He con- siders coagulable lymph and the serum of blood as the very same fluid, and founds this opinion on experiments made by M. Serres and himself. The buffy or inflammatory coat that ap- pears, on permitting blood to coagulate, is, according to him, nothing else than the deposit of a certain quantity of fibrine, held in solution in the serum. Thisonceadmitted.it is very easy to ac- count for the formation of a greater or less quantity of buffy coat, according to the manner in which the blood is drawn, and the shape of the vessel in which it is received. If the orifice in the vein be made large, the quantity desired will be drawn in so short a time that the coagulation will commence in the entire mass at about the same moment, so that all the serum will separate from and cover the crassamentum, and deposit on the surface of this a thick buffy coat; but if on the contrary, the orifice be small, the discharge will take place so slowly that coagulation will have commenced long before the necessary quantity be drawn, and consequently, the deposit of fibrine from the serum will be made throughout the mass of cruor, instead of on its surface. With respect to the form of the recipient, it is obvious that if it be shal- low and present a large surface, the coat will be thinner than if the same quantity of blood be allowed to deposit its fibrine on a smaller surface. Mr. P. adds in support of this opinion, the fact that by adding a small quantity of distilled water to the se- rum, a deposit will be produced precisely similar to that just al- luded to. Mr. P. confirms the experiments of M. Baruel, who says that the aroma evolved by pouring sulphuric acid on blood, is so strong and so different in that taken from different individuals, that he can thus very readily determine whether it has been ob- tained from a man or a woman. Lastly, Mr. P. speaks of the effects produced on the quantity as well as quality of blood, by long fasting. Death from fasting, is caused by the diminution of its quantity and its almost total disappearance from the body. What is formed in such cases contains but very little fibrin. Reference is made to the experi- ments of Collard de Martigny on the subject. 408 Extracts from the Note-book of a Physician, c. [Dec. M. Boijillaud's Remarks on the Liver. He considers hypertrophy of the liver to be caused, in most cases, by irritation and not inflammation. M. Piorry attributes it for the most part, simply to congestion ; whereas Mr. Bouillaud seems to think the substance of the liver actually increases. The softening of the liver is characteristic of inflammation. He thinks many of the cases of suppuration of the liver reported, especially after surgi- cal operations, are nothing more than the deposit of pus brought here by the veins, and previously absorbed from the suppurating surfaces. He makes the same observation with regard to the brain, &c. ; but remarks that this deposit may, by its presence, induce the inflammation observed, and erroneously considered as the cause of the presence of the pus. If even an abscess be found without a softening of the parenchyma surrounding it, the pre- sumption should be very strong that the pus was deposited by the veins. Pain may either exist or not, in hepatitis. Care should be taken not to confound the want of sound and of respi- ration in the lower part of the region usually occupied by the lungs, and usually owing to pleurisy, with that occasioned by hypertrophy of the liver, causing it to elevate the diaphragm and occupy the place of the lower portion of the lungs. The liver in its healthy state is perfectly insensible to the knife. The in- flammation of the liver may extend by continuity of substance and cause peritonitis, pleuritis, &c. In hepatitis, the secretion of bile is generally increased; the stools are bilious; icterus often supervenes. Mr. B. thinks hepatitis often caused by irritating ingesta and all remedies which irritate the gastrointestinal canal. These arc absorbed and carried immediately to the liver, and consequently affect it also. He alludes especially to irritating cathartics; mercurials; alcoholic drinks. He thinks many of the cases attributed to the warmth of tropical climates, are due to the immoderate use of stimuli of all kinds, so freely used in those countries. M. Dupuytren on Chorea. M. Dupuytren exhibits to the class, a young girl, about 1 1 years of age, who was affected with chorea to such a degree, that she could not without much diffi- culty, carry food to her mouth. The only treatment has been cold affusions used daily ; and in the course of about a fortnight she has so much improved as to be able to use the needle with facility. Mr. D. insists upon the great efficacy of this remedy. Encysted Tu^or of the Wrist. M. Lisfranc mentions the history of an encysted tumor, situated beneath the radio- carpal ligament, whicn was laid open, and discharged a quanti- ty of mat tor somewhat analogous to milk curd. In order to prevent the violent Inflammation that usually supervenes in cases of this kind, and not unfrcquently injures the movements of the 1836.] Extracts from the Note-book of a Physician, tyc. 409 joint, he ordered the application in the vicinity of the wound, of one hundred leeches after the operation, and a daily application of fifty until all danger of inflammation had subsided. Through mistake only fifty were applied the first day, which permitted the development of a slight degree of inflammation ; but the succes- sive employment of the depleting animals soon allayed this, and the patient is now well. Mr. L. thinks this p I*appy application of the physiological principles, to the treatment of a disease here- tofore no less difficult to manage than rare in its occurrence. M. Louis on Expectoration. M. Louis contends that the appearance of the expectoration can seldom lead to a certain diagnosis in cases of pulmonary consumption. In fact, that there are very few diseases of the lungs that can be characterized by the expectoration. These are pneumonia and gangrene. The former by the rusty, semi-opaque, or reddish expectoration ; and the latter by the peculiar gangrenous odour which occurs in no other case. Mr. L. is aware that it has been said that in cases of pleuritic effusion, attended with perforation, the expectoration is of a peculiar nature, perfectly similar to the liquid pus found effused in the pleura in such cases, and easily distinguishable. He however has never met but one case of pleuritic perforation, and in this he could not discover the kind of expectoration de- scribed. He thinks it probable, from the scarcity of the disease, that many of the cases reported have been done so through error of diagnosis. Blushing. M. Louis remarks, that Bichat was in error when he thought the skin of the face different from that of the rest of the body, inasmuch as it evinced by blushing, the emotions of the mind. Had he ever uncovered a person at the moment of blushing, he would have perceived that the whole surface of the body partakes of this phenomenon and becomes flushed. It is so marked in the patient before us, that he seemed at first to have scarlatina. Vaccine. M. Gucrsent mentions the singular fact, that it is with the utmost difficulty that vaccine can be made to take effect in this hospital, (Hopital des Enfans). Mr. G. recommends the matter to be taken from the arm as early as the seventh day, for when taken later, or when the fluid becomes opaque, it produces in this hospital no eruption. Is there no danger of destroying the antivariolous effects of the vaccine in the individual whose arm is robbed at so early a period? Rheumatism, &c. M. Trousseau recommends as very effec- tual, the introduction of morphia, or of belladonna, into the skin ; this being previouslv deprived of its cutis by hot water, or aqua, 52 410 Extracts from the Note-book of a Physician, <$-c. [Dec- ammonia. Its known efficacy in tic-douloureux, led him to try it in rheumatic pains, gout, and obstinate head-aches, with the most signal success. The remedy should, of course, always be applied as near as possible to the affected part. Buffy Coat. M. Rostan refuses to yield to the reasons as- signed by Piorry and others, in proof of the want of coincidence of the buffy coat with inflammation. He thinks it not only indi- cates this pathological condition, but also its intensity. Sudden Death. M. Rostan remarks, on speaking of sudden death produced by rupture of the heart or aorta, that it is a great error to believe that apoplexy ever produced instantaneous extinction of life. It is impossible for any haemorrhage of the brain, unless it be situated at the protuberautia annulare, which very r?rely occurs, to cause sudden death. There is always more ov less lingering. We should therefore always suspect a rupture of the heart or aorta in such cases. Cancer. M. Trousseau considers cancer a living tissue, be- cause it contains blood vessels, is subject to ulceration, granula- tion, &c. ; but especially because it is neither expelled nor encys- ted, as are all foreign bodies. Diluents. M. Piorry says, the term Diluents, (Delayans,} applied to a certain class of remedial agents is highly correct, for by their use the blood is actually diluted and rendered less stim- ulating to the parts to which it is sent. False Membranes. M. Ducrotay de Blainville states, that false membranes never become organized, and that, consequent- ly, inflamed membranes never form adhesions with each other when separated by effusions or other substances, nor unless they be in^immediate contact. This assertion is in direct opposition to what I this morning saw in the dissecting room ; for on opening the body of a woman whose chest was the seat of an immense collection of pus, (say a gallon,) the lung of that side was found compressed against the mediastinum. Between the lung and the mediastinum there was a considerable quantity of albuminous looking matter, (coag- ulable lymph?) through which an immense number of capillary vessels could be very distinctly seen running from one pleura to the other. It was impossible "to determine whether they origin- ated in the plura pulmonalis, that of the mediastinum, or in the centre of the interposed substance, 1830.] Review of Eclectic Journal. 41) The Select Medical Library and Eclectic Journal of Medicine: Edited by John Bell, M. D., Lecturer on the Institutes of Medicine and Medical Jurisprudence, Member of the College of Physicians of Philadelphia and of the American Philosophi- cal Society, &c. &c. Philadelphia. The above is the title of a new periodical, the first number of which, published last month, we have just received. This work, as its title implies, is intended to furnish its subscribers with re- prints of the most valuable foreign works, with the accompani- ment of a portion of Journal matter. At the end of each year the subscriber will be in possession of about 2450 large octavo pages of choice medical works, printed on the best of medical book paper and with new type, so arranged as to be bound in complete and separate works, with title page and index to each. In addition to this, he will also have a volume of 432 pages of Journal matter, consisting of " histories of cases which have a definite bearing and application, summaries of opinions and prac- tice, criticisms brief and pertinent, circumstances which exert an influence over the health of individuals and of communities," &c. &c. ; making in all 2870 pages per annum for the very moderate priee of $10 something less than half the cost of the same bought otherwise. We fully agree with Dr. Bell, that "a periodical publication so deservedly and obviously beneficial," and we will add, econo- mical, " to the profession, for whose use it is intended, as the Select Medical Library and Eclectic Journal of Medicine, needs little to bo said in the way of explanation and eulogy." We are pleased to see such an undertaking in the hands of Dr. John Bell of Philadelphia, whose well known professional worth is a satisfactory warranty of the most judicious selection of works and the best editorial management of the Journal. The first number commences with the republication of Arm- strong's Practice of Medicine, and comprises the first twenty lectures. It is not our purpose in this place, to notice the med- ical writings of Dr. Armstrong. They have been ably review- ed, and their merit established. Our space is too limited for an analysis which would do justice to a work, which should cer- tainly be possessed, without abridgement, by every lover of med- ical science and usefulness. We feel it due to our readers, however, as well as to the Edi- tor, to notice, briefly, the Journal portion of the first number. And in approaching this duty, we are disposed to say, that in addition to the promise of usefulness which the able editorship affords in this department, the very name, Eclectic, (and names, in modern nomenclature, mean the very nature of the things 412 Review of Eclectic Journal. [Dec. named,) points to the solid basis of those truths, whereon alone can the edifice of true science be erected. It seems happily por- tentous of a faithful record of those truths from which alone the general laws or principles may be deduced, which like the sun's rays in discovering to us the beauties of nature, shall dis- pense the light of true science around us, on all morbid phenom- ena. We rejoice at every signal of the approaching day, when physicians shall be teachable enough to receive the truths of na- ture, as facts which must govern their reasonings and their prac- tice when they will acknowledge that effects have causes, and that these bear a due proportion to those ; and farther, that there are generally, in medicine, several causes, without either of which the effect could not exist. We see, in these signals, reason to hope that time past may suffice for us to have mourned over the desolations of systems which never had a solid foundation in truth ; systems which sprang only from the phrenzied imaginations, tho vanity, or the false reasonings of their authors. But we hasten to the contents of the Journal. The number before us opens with Retrospection in Medi- cine. This is a subject which every candid physician will be ready to acknowledge has been too much neglected in almost all, and strangely and peculiarly in the latter ages. Such has been the intoxicating charm of novelty, and such the captivating sway of indolence, and we may add, such the servility of man, that he has only needed the phantastic trappings of novelty, with the prospect of exemption from mental toil, to induce him to follow superfici?Jly in the wake, to the neglect of every thing like pro- fundity in science. And these things have been peculiarly grate- ful to the medical student who was delighted in being able to combine pleasure with the pursuit of fortune, " and gain the re- wards of industry without suffering its fatigues," & therefore fixed his eye on the printed parchment, rather than on that of which it should be the faithful testimonial. The idea of digging, deeply and toilsomely in ancient professional lore, has been spurned from him at the very onset. The name of Hippocrates, or Boerhaave, or even of Mauriceau or Cullen, has been scoffed at as out of date as unfashionable. They have not reflected that truth is not, like an almanac, useless when out of date that fashions have nothing to do with true science, and that, of all sciences, truth is of most importance in that of medicine. The whole article is so full of merit, proving the importance of retrospection, that we will not attempt to epitomize it, but refer the reader to it in its place, with the urgent request that every one will read it. The second article is headed Clinical Medicine. With the spirit of building up science on the foundation of truth, the author very evidently purposes drawing the attention of the profession to the subject of clinical observation, and shews, by an able re- view of the subject, the value of a close and minute attention to 183G.] Review of Eclectic Journal. 413 the characters of disease, at the bedside, and the indispensable ne- cessity of a knowledge of anatomy and physiology, in order to be able to determine wherein, and to what degree the former may have deviated from healthy structure, or the latter from healthy function, under the influence of disease; as well as to be enabled to make those nicer specific distinctions, without which a correct -diagnosis cannot be had. " We must not only use, (says our author, p. 11,) but train our senses and intellect into the habit of patient attention, and learn to guard against the illusions of the former, and too hasty deduc- tions by the latter. A preliminary acquaintance with the natu- ral mechanism and healthy function of the human body, whose deviations from these states we propose to notice, is of course, Indispensable." " If (continues he, most correctly,) we know not the standard of health, how can we measure the deviations from it which should designate disease? This is almost a self-evident proposi- tion, and for repeating which an apology would be due to the reader, were it not a matter of every-day observation, that hun- dreds, professing to pursue a regular course of study, hurry on at once to an investigation of morbid phenomena, and engage with ardour in disquisitions respecting their causes and seat, and the changes of structure by which they are accompanied, with- out the smallest preliminary knowledge of healthy organization and function. It is impossible for the most skilful and conscien- tious teacher of clinical medicine to put students, thus ignorant, in the proper path for accurate and independent observation on the phenomena of disease. They may learn to group symptoms, and to apply their information thus obtained after a nosological fashion ; but for a due appreciation of the true changes, probable result, and indications for cure, they must be incompetent." The whole of this article is one of great interest in the present attitude of the profession -just awaking to a sense of the neces- sity for the knowledge of the truths of nature, in order to the es- tablishment of rational and sound therapeutics. For, as by the great law of inductive reasoning, pathological phenomena, con- templated as effects, determine by their analogy to other known phenomena the causation concerned, and, by a comparison with healthy structure and function, its kind and degree ; so, reason- ing from cause to effect, does the general law established deter- mine the new powers or causes to be introduced into the concat- enation of phenomena for the correction of morbid effects, which new causes or powers are the remedial means or therapeutic agents. And here is at once demanded for therapeutics, in general practice, as anatomy and physiology were for diagnosis, a knowledge of these powers, which is only found in materia unedica and chemistry: and for surgery, all are required both for diagnosis and therapeutics. 414 Review of Eclectic Journal. [Dec, The next article, is under the general head of Pathology and Therapeutics, and is on the subject of Acute Rheumatism. The subject of this article is one of great importance, because it is one of the most common, painful, tedious and uncontrolable af- flictions one which has but too often foiled the most faithful and talented of the profession. In this we have M. Bouillaud's announcement, as a dis- covery worthy of note, of "the almost constant coincidence with acute articular rheumatism, of inflammation of the lining membrane of the heart (endocarditis,) or pericarditis, or both conjoined -endo-pericarditis." The editor is not struck with the novelty of M. Bouillaud's announcement, though he is fully satisfied of its truth. We are confident that we have, many months since, seen the announcement of the accompaniment of endo-carditis in these cases ; and a demonstration of the fact has, we are sorry to know, occurred in our own practice during the present year. We did regard it, as the editor says, as a metas- tasis, instead of apart of the primary disease, and we confess we are yet inclined to the same opinion, both from the general char- acter of rheumatism, and the want of conspicuous endo and peri- carditic symptoms, until the wane of the primary affection of the arm. According to M. Bouillaud, " the true seat of articular rheumatism is in the synovial membranes ; the ligaments and parts external to the joints being only secondarily affected." In proof of this position he gives the fact, that in some fatal cases the synovial membrane has been found covered with coagulable lymph. The treatment recommended is precisely such as the patholo- gy of the case would suggest, viz.: "antiphlogistic, and above all, bloodletting." As the formula of M. B. goes to mark out to an extent proportionate with the nature of the lesion, a rigid an- tiphlogistic course, a point too often neglected in practice, we shall give our readers a concise view of it. The first day of admission, the patient, if strong and of good constitution, is bled to 1 6 ounces. If very plethoric, 20 to 24 are taken 16 being, however, the usual quantity. Second day. Two bleedings from the arm of 12 to 16 oun- ces each, and in the interval, leeching or cupping, (the latter pre- ferable,) to the extent of 16 to 20 5. The cupping glasses are applied around the affected joints, or to the pre-cordial region, if, as usual, the heart be implicated. Third day. One bleeding from the arm and the abstraction of 12 to 16 1 , by cupping the joints, or the region of the heart. Fourth day. Fever, pains, swelling, &c. have sometimes com- pletely subsided ; in which case, no more blood is drawn. But if otherwise, the patient is to be once more bled to the extent of 12 or 165. Fifth day. Generally, the disease is in full progress towards 1636.] Review of Eclectic Journal. 41 5 resolution. But should the fever, as is sometimes the case, con- tinue well marked, depletion to 121, or cupping to the former extent becomes advisable. Prom the sixth, seventh, or eighth day, the patient convalesces rapidly, and may now begin to take food. In case of relapse, which however M. Bouillaud thinks less common than after the usual method of treatment, bleeding may be again and again necessary. Slight relapses may be treated by emollients, abstinences, baths, anodynes, &c. the dis- ease wearing itself out in a few days. To avoid relapses, the patient should guard most carefully against the slightest breath of cold. As auxiliary to the above plan, M. B. resorted to abstinence, dimulcent drinks, blisters, compresses with mercurial cerate for resolution, emollient cataplasms, baths, opium in moderate doses, internally, or by the endermic method. To the last of these, the editor very properly enters his protest until the disease has been somewhat subdued by depletion. The next subject under this head is the Difference between Acute and Chronic Rheumatism. Dr. Johnson of London, and M. Parise of France, have endeavoured " to separate acute from chronic rheumatism" considering the former as arthritis, and the latter as a peculiar affection, probably neuralgic, of the in- vesting sheaths of the muscular fibres, or perhaps the neurilema of the nerves themselves. The former of these opinions, we consider at least as old as the " Eau Medecinale d'Husson ;" and as to the latter, we freely' join with Dr. Bell in considering that there is no great novelty in them, and we design, on some favor- able occasion, to give some views which we believe peculiarly our own, and of the truth of which we have been satisfied ever since we first saw Ten-Rhyne's account of acupuncture. Connexion of Hypertrophy of the Heart and Apoplexy. Lal- lemand, Broussais, Andral, &c, but more fully, Bricheteau and Hope, have all conceived (the very evident fact) that the heart, particularly the left ventricle, exerts a very great influence over the brain, and have given cases illustrative of the position. M. Bricheteau gives twenty-two cases of apoplexy, in all of which hypertrophy of the left ventricle of the heart existed to greater or less extent. M. Bouillaud found that out of fifty-four cases of hypertrophy of the heart, there were eleven in which cerebral disease, six in which apoplexy, and five in which ramollissement was found on dissection. Dr. Hope gives twenty-nine cases of apoplexy, in twenty- eight of which, disease of the heart was found co-existent. He thence "concludes that the periods of life at which fatal apoplexy is most prevalent, are those in which hypertrophy of the muscu- lar substance, or ossification of the valves and vessels of the 416 Review of Eclectic Journal. [Dec. heart is of most frequent occurrence namely, between forty and fifty, and between seventy and eighty," In some cases the lesion of the heart eluded suspicion. "The practical deductions from this pathology are clear viz. : avoidance of all severe bodily exercise and all exciting emotions of mind. And as pointed out by M. Bricheteau, we should direct the occasional application of leeches over the region of the heart, instead of the temples, or any other part of the head, the internal use of digitalis, hydrio- date of potassa, and other diuretics. The next article contains Dr. Rennes' account of thirty-two cases of Frontal Neuralgia. Neuralgic affections have for several years occupied so large a portion of the journaJs, and be- come so familiar to most reading practitioners that we shall pass this article without farther attention. The next article gives us an account of Dr. Barrea's ease of Hemiplegia, which was cured by a formula, which it would be rather beyond the province of our apothecaries to supply, and which moreover is beyond the command of the whole Philadel- phia College of Pharmacy : viz. " heavy thunder and lightning." Still, however, the case may have its uses. It may make a loud and forcible impression of a truth on man, which he has too long and too much neglected, that electricity in its various habitudes, is of infinitely more importance in the philosophy, as well as the practice of medicine than men have been willing to suppose. For it seems that our old friend Magendie has taken the hint, and made the application of galvanic electricity to the chorda tym- pani of a young Polish officer, who lost his hearing at the battle of Ostralenka, which, after seven or eight applications, enabled him to hear the sound of a drum, then of clocks, bells, and finally speech. "It is, M. Magendie thinks, essential for the success of the plan, that there be direct contact between the nerve and the conducting wires" which opinion is confirmed by two corrobo- rative cases given by M. Roux. We next have the use of Magnetism in Gout. We have here a narrative from the Bulletino delle Scienze Mediche of Bologna, which informs us that the cx-Dey of Algiers communicated, in 1831, to a Catholic clergyman, (Father Campagnati,) who was suffering under the gout, that the application of the loadstone was an Oriental remedy for the disease, and one of certain effi- cacy. The patient immediately procured a piece of loadstone and applied it in the next paroxysm, which was entirely removed by it ; since which, he has always had recourse to it with the effect not only of invariably relieving the paroxysms, but of les- sening both their frequency and severity. Similar results have followed its use by his friends, to whom he has advised it. Fa- ther Campagnati had been subject to the disease since 1805. On the first symptom, he goes to bed, and places the loadstone in close contact with the painful part; he soon falls asleep, and awakes free from pain and able to walk. 1S3C] Review of Eclectic Journal 41 fr The next article is on the subject of the Fever, typhoid and continued, described by Chomel. This is an article of great in- terest too long and too valuable to be condensed in this place, and we must refer our readers who have not the Lecon de Clin- ique Medicale, &c. of Professor Chomel, to the first number of the Eclectic Journal of Medicine, or the third number of the British and Foreign Medical Review, article, second. It may be profitable to our readers to observe, however, in pas- sing this article, that the p ist summer has afforded us a number of opportunities for using the chloride of soda, as noticed by Cho- m 1, but the use of which was more definitely and accurately established by Dr. Graves of Dublin, and have found it, thus used, a most invaluable acquisition to our remedial resources C >ming happily into a place where all other resources had failed. As an anti-tympanitic in such cases, we hold it, at once entirely u.iri vailed. For its successful use, we refer the reader to the state of the system in which Dr. Graves found it most signal- ly beneficial, which will be found in the Southern Medical and Surgical Journal, vol 1, no. 2. The next article given us in this number, is on Obstetrics. Having already taken more space than we designed, we should piss this article by without comment, especially as it contains lit- tle of practical value; did we not feel bound to dissent from the position assumed by the Editor on some points in obstetrical in- struction. Dr. Bell seems to object seriously to the time and spice taken in lectures and in books, on the subjects of violent remedies, the use of instruments, dangerous incidents, unfavora- ble positio s, menstruation and the generative function, formation of the deciiua, &c. It ;s most true that the knowledge of these matters is of com- paratively rare use in practice ; but if the consideration of violent remedies, or the use of instruments, or the occurrence of haemorr- hage, convulsions, faintings, and such incidents ; or if a bad po- s'tion. were to occur but once in an age, the practitioner would be who 1 v inexcusable, who had not the means of decision in the cisc. And as some of these have their dangers as well as uses, great pains are necessary in instructing in their use and manage- ment. Xor are the functions above named, unimportant, either as facts of the natural history of man, or as to the light which a knowledge of healthy texture and function is calculated to shed on diagnosis, as well as treatment of female cases. We must piss over the extracts from Drs. Davis and Hamil- ton on the subject of prolapsus uteri, with the observation only that the frequency and importance of this disease are such, that it demands much more close observation and reasoning on its na- ture and treatment, than we are inclined to believe they have gi- ven it. We have not the opportunity in this place of enlarging on the subject. 53 41 $ Use of the Cochlea in the Organ of Hearing, $c. [Dec i i i . i i We pass over the subject of Hygiene in this number, as con- taining nothing of practical importance to us. A notice of Dr. Graves' lecture on the Chances of Life, we have given more at length in a former number. Under the head of Medical Jurisprudence, we have a case of Suicide of a boy 12 years old, by Hanging. The case affords nothing of peculiar interest. The efficacy of Hydrated Per-oxide or Tritoxide of Iron, in cases of Poison by Arsenic, we have before noticed more fully. Under the head of Surgery, we find nothing to attract our at- tention but the use of the Belladonna Ointment in cases of re- tention of urine, spasmodic constrictions of the uterus, and in strangulated hernia. The ointment for these purposes is as usu- al made of 3ij. of the extract, to I i. of Lard. Thus we close our notice of a beginning undertakmg, the first number of which has afforded us much pleasure, and which has our most cordial wishes for its success. [From the Medico- Chirurgical Review.] On the use of the Cochlea in the Organ of Hearing. We need scarcely observe that the functions of the various parts that compose the internal ear in man, are imperfectly understood. That so complicated an apparatus should be essential to the perfect sense, is consistent with analogy and rea- son. But physical science has not hitherto informed us, what part is played by each component section of the mechanism, nor what is the individual office of the cochlea, the semi-circular canals, and so forth. Weber, a physiologist of no mean rank, has laboured to prove that the office of the cochlen, is to appreciate those sounds which are transmitted through the cranium as a solid. The opinions and the reasoning of Weber on this subject are presented to the English public by Dr. Graves, the able Editor of our Dublin contemporary. We shall introduce such portions of his paper in that Journal, as will put our readers in possession of the main points which are urged in favour of the hypothesis in question. "It is evident," says Weber, "that the propagation of sound to the inter- nal ear, takes place not merely through the meatus auditorious cxterniis, but also through the bones of the cranium; by the former we receive notice of sounds from without, by the latter, we more readily hear our own voice. The vibrations produced by our own voice are indeed also heard by the route of the external ear, but they are conveyed with greater distinctness through the medium of the bones of the skull. Thus, if you stop both ears firmly with your fingers, so far is your voice from being rendered inaudible, that you hear it more dislinctly and louder than before. If now we remove the finger from one ear, immediately we find that the sound of our voice appears stronger in the other. / shall now nuieavor to prove that sounds propagated by and conveyed through the bones of the head, arc heard chiefly by means ofths 1836.] Use of the Cochlea in the Organ of Hearing* 410 cochlea, whereas sounds coming from without by way of the meatus auditorius externus, are not so readily received by the cochlea, as by the route of the ves- tibule and the semi-circular canals " Weber observes that in almost all animals, the vibrations on which sound depends are communicated to the extremities of the acoustic nerve, by the two-fold means of a vibrating1 solid and a vibrating fluid. Why it should be so, is not at present clearly understood, but M. Weber asserts that it is the fact with regard to the greater number of animals. Sounds lose comparatively little of their force by propagation through an uniform medium; but the contrary is the case when they pass from one me- dium to another, as from a solid to a fluid, or from a fluid to a solid. Thufl sounds transmitted through water may be heard at great distances, while the head is under water; but they become inaudible the instant that the head emerges above its surface. "Now it is found," continues Weber, "that solid bodies communicate their vibration to fluids, with a facility proportioned to their extent of sur- face, and that solids receive vibrations from aeriform media more easily when the solid is shaped in the form of a membrane. A tense cord does not easily communicate its vibrations to the air unless it be fixed to some flat body, which being of a like nature solid, receives the vibration of the string without difficulty or loss, and propagates them to the air through the medium of its own extensive surface. It is an observation of these phe- nomena which has led to the adoption of sounding boards in those musical instruments, when the vibrations causing sound proceed from strings as in the case of the violin, the piano, and the harp, whereas sounding boards are not required in the various species of wind instruments. The reason of this difference is sufficiently obvious, in the one case a solid with an extensive surface must be brought into connexion with the vibrating string in order to diffuse its vibrations more energetically through the air* whereas in wind instruments the vibrations being derived from the air itself, no such provi- sion is necessary." The two preceding facts may be considered as the premises of Weber's argument. The conclusions follow thus. The sonorous vibrations of the air in the mouth pass to the internal ear through the medium of the cranial bones. They impinge by preference on that portion of the acoustic nerve which is distributed upon the cochlea, ta- cause on it the nervous expansion is in intimate relation with its walls, which are themselves connected with the cranial bones. But the acoustic nerve where distributed through the vestibule and semi-circular canals is not so favourably circumstanced for receiving the vibration of the cranial bones, for here the nervous expansion is separated from the bony panetes either by means of a liquid secretion or of a loose cellular membrane. In accordance then with the law that sound is transmitted with most facility when the medium is not changed, M. Weber supposes that the acoustic nerve in close connexion with the bony cochlea, is more readily affected by vibrations of the cranial bones, than in the vestibule or semicircular canals,, where another medium separates it from the bone. With the following remarks, which we cannot materially abridge, we conclude. "The preceding observations," concludes Weber, "render it sufficiently apparent, that the membranaceous vestibule and membranaceous semicir- cular canals, differ in structure from the osseous vestibule and the osseous semicircular canals, in such a manner, that vibrations travel through the bones of the cranium with more facility to the cochlea and round sac, than they do to the membranaceous portions of the internal ear. The next question is, whether the sonorous vibrations that are derived from the external air and proceed through the meatus externus to the ear, are propagated with greater facility and strength to the nerve of the vesti., 429 t7se of the Cochlea in the Organ of Hearing. ^Dee. bule than to the nerve of the cochlea. In the first place, it is evident that the vestibule and the semicircular canals directly connc ctcd with it, must receive a stronger impulse from the aerial vibrations than the coch'ea, for the former have a solid communication by means of the chain of ossicula with the membrana tympani, whose vibrations are consequently imparted at once to the membrane of the fenestra ovahs, whereas no such direct com- munication exists between the membrana tympani, and the fenestra rotun- da. The membranes of the semicircular canals and the vestibule toe, seem to be more easily set in motion by the fluid which invests and surrounds them, than is the case with the lamina spiralis of the cochlea. The latter is, nevertheless, furnished with provisions calculated to enable it to receive impulses from the external air also : for the fenestra rotunda, being closed by a membrane, must impart the vibrations that occur in the cavity of the tympanum, while another opening', by forming a communication with the vestibule itself, must place the cochlea in connexion with the latter, in such a manner that the vibrations which the chain of ossicula have imparted to the fluid of the vestibule, must through that fluid be at once propagated to the cochlea. T have next to prove the assertion which I made at the commencement, viz. that nature has so constructed the ear in man, and various other animals, as to make a provision for the reception of the sonorous vibrations in a two- fold manner, by means of the acoustic nerve, which is so disposed in the in- ternal ear as to presenf, for receiving these vibrations, a double surface of contact; the one consisting of a soft, pultaceous, nervous expansion, sur- rounded by a fluid, the other formed of a reticulated net-work ot extremely minute, but firm, nervous, ramifications. The former receive the sonorous vibrations through the medium of a fluid, the latter of a solid. In mail the cochlea is the portion of the organ where the firmer extremities of the acous- tic nerve are disposed for this purpose. Fishes and amphibious animals have no cochlea, but they have an arrangement which answers the same purpose; for in osseous fishes we find that the membranaceous lal yrinth contains three white little stony bodies, of great specific gravity, very hard, and much resembling vitrified argillaceous clay; two of those are enclosed with a sac full of fluid, adjoining the vestibule, "aid lodged in ihe 1 r.silrr por- tion of the occipital bone; these lapilli are furnished with fine nervous fila- ments, fastened to rough depressions and elevations on their surface; thus vibrations are imparted from the lapilli to the acoustic nerve s ; tie third la- pillus is situated in tho anterior portion of the membranaceous vestibule, and receives no nervous filaments. It has, however, another mode of communi- cating with the acoustic nerve, for it lies against a very large branch of 1 hat nerve where it expands on the membrane of the vestibule, and thus eempres- ses this nerve between itself and the cranium. In cartilaginous fishes and in amphibious animals, in the place of these lapilli, we find certain little lodiYp consisting eiiher of concrete gelatine or of a chalky pultaccous matter, rrdio which both Scarpa and myself have traced ramifications of the acoustic nerve; neither is the lamina spiralis of cochlea in man formed without rea- son of two structures, anosseoUs, and a cartilagino-coriaccous tissue; for P.fl the same nervous branches pass from the osseous to the oartilrgincus portion of the lamina spiralis, it is natural to conclude that receiving ser.orous im- pulses from both, those impulses are communicated by means of a difTerent mechanism in the two cases. This idea is confirmed 1 y an exrminalicn of the calcareous fragments found in tho labyrinth of Flays, and which are com- posed of two portions; one pellucid and rescmblirg a tremulous jelly, the other white and chalky, seem to discharge tho same function in thrse ani- mal1-', that the cochlea does in m-\n. These fragments arc so divided, that their gelatinous and chalky portions lie in contact by means of extensive smooth surfaces. Nature has so disposed the extremities of the auditory nerves in the semicircular canals of all aniraaKthat these extremities receive 1836.] Comparative Mortality of Male and Female, <$-c. 421 the sonorous impulses directly from a fluid. This is very phin, even in map, where the dilatations termed ampullar and which correspond wi h a simi] >r enlargement of the nerv , are both filled with and surrounded by a fluid. In fishes it. is still more eviden*, for in R ay , a nervous filament can be traced to each ampulla, which i' enters and forms within a crescent like septum." We fear that in renious as the m* c aling reasoning must be owned to bo, it La still extremely speculative. When we reflect on the facility with which soporous vibrations are commun'ented through the whole bodv, composed as it is of m dia differing much more in nature and exten*, than the nervous ex- pansions ou the cochlea and the semicircular canals can do, we are almost involuntarily led to pause berore we yiey implicit confidence to M. Weber's conclusions. Unfortunately, in the case of the internal ear?, decisive experi- nmn* cannot be perform id, and the observation of pathological changes in connexion w'th alterations of the functions, is attended with nearly equal difficulty. T le amount ofconfidence pxtended to M. Weber's opinions will varv wi h the turn of mind of tjje individual who peruses them. One man y:e\l-- assent -o the evidence o^ probabilities, wi^h much less difficulty, than another. Whatever m"v be the actual truth of M. Weber's suppo'i'ioo, it i= certain that it is ingenious, and Dossessed of plausibility. We think Dr. G-av3s entitled fo many thank", for bringing1 this a* well as o'h?r Continen- tal papers before the proe^ion in this country. TIrs is not the first time, no-, we are sure, will it be the las% that we have had or shall have occasion to express our sen=e of the Z3al and the talents of that gentleman. Cnrninra'ivi Mwr'ality <>f Ma1", and Femrfe Life. Mr. R-'ckman has been publi"Vu7 come ela'^ora'e remark-: on thi", as indeed on othnr subjects con- nected wi*h medical statistic8, in the Medical G'.zette. We shall notice soth of th? general r^ul^s wh'ch M*. Rickman draws, or which may be oVawn from fh? data that hefurmshes. Mr. Rr.kman deserves great credit for+h? inlusfry he has evned in collecting materials, and the zeal he has d'snhy .r] h\ communra*ing bis observations and conclusions to the public. T' i=? no" ne^e^sarv for us to repeat that the longov;'y of females exceeds that dc males. This was fir"* systematically she vn by lOraboon in a trea- tise o ibbsh d in tin year 1742, and founded on the mortality of o-overnment ana ptanf in H ifaani. It is not th/m to nrove this fact, already ful'v proven, that Mr. R'ckinu writes" or that we condense -his observations. His object is *"o sbo v the varlo is d?gr3es of female longevity in the various classes. He exhjVts several tables. In thi first are shewn the results of a tonfin-\ established unler"lhe MMliou Aof," in the year lr>9">; the last ef the 1003 annuitants un pier which died in the yew 178-5. Ii the second table aro the reS,t'<5 of var"o is too'mes an 1 olior government annui-ies, cnrrenf from 1785 to 18"! \ the ra^e of mor'ality i 1 uncertain as to the means by which it enters in'o the cellular structure) is washed out, the rami nutritii will become evident. The rami nutri'i of tie ppongy substance (which, since they are upon the walls of the sun ens veins in the interior of the perns, may be also .called the ^asa vast rum) are found to be as minute as the arteries of any other part: they distribute themselves upon the pilars of the spongy subs' ance, until they become too tine to be perceived by the naked eye. As in the arteries of other parts, they anastomose; and lastly they form, as in o'her pi r's, 'he capillary net-work which is so difficult to be injected in the penis owing to the facility with which the injection escapes into the cavities of the corpora cavernosa. 2. Arteri.c HeUciruB Corporis cavernosi 'in man). In order to see these arterial branches satisfactorily, an injection conn ne< d of si/e i n 1 verm 1 on must be thrown into a separated perns, through the arteria profunda, fin the horse the pudendal and obturatoriaJ ar'ery ue to he injerted together.) As before mentioned, a part will escape into the caviti< s of he cor] ora ca- vernosa. When the injection has become, cold, the corpora cavernosa must be cut open longitudinally, and that, portion ofthe injection winch has es- caped into the cells is then to be washed out wit h great car*. If asiz-ofa greater degree of consistence has heen employee1, it will be found to have become solid on cooling. In this case the penis must be soaked in water, and the mass squeezed out softly and carefully, until the cellular tissue is 1836.] Professor Mueller on Erection of the Penis, <$-c. 425 emptied. When a thin size lias been used this will, of course, not occur; then washing- alone will be sufficient If the tissue of the corpora cavernosa be now examined with a magnifying lens on its posterior third, it will he seen that, in addition to the distribution of the arteries already described, there is another class of vessels, having an entirely dilferent form, size, and distribution; these branches are short, being about a line in length, and a fifth of a millimetre in diameter; they are given off from the larger branches, as well as from the finest twigs of the artery. Although fine, they are still easily to be recognised with the naked eye ; they come off from the artery mostly at a right angle, and projecting into the cavities of the spongy substance, they either terminate abruptly, or olse swell out into a club-like process, without again subdividing." Omitting the reference to these vessels in the stallion and the dog, we may proceed with M. Mueller's description of them in man. "These twigs branch off from place to place, sometimes alone, sometimes in greater number : little bundles will be seen, in which from three to ten twigs stand together ; these, as well as the former, project constantly into the cells or venous cavities of the corp. cavern, penis. When the arteries thus form a tuft, they arise by a common stem, which immediately divides itself into the separate branches. Sometimes such a vessel, wmether it pro- ceeds from the artery as a single branch, or forms part of a cluster, divides itself into two or three parallel branches, which also end either abruptly, or else swell out near their extremity. Almost all these arteries have this character, that they are bent like & horn, so that the end describes a half circle, or somewhat more. When such a branch so divides itself, there are formed doubly bent twigs, inclined one to the other. I have before observed, that many of these arteries enlarge to- wards their end ; this enlargement is gradual, and is greatest at some little distance from the extremity, so that the end is somewhat conical. This cone, however, is rounded at the point, and giving off no branches, termi- nates immediately. The diameter of these twigs, in their middle, is from the fifth to the sixth of a millimetre : they preserve a great similarity : thus those which branch off from the large trunk of the artery, are not thicker than those which take their origin from the finest subdivisions." Although these vessels project into the venous cavities, yet they are not entirely naked, but possess a delicate membranous covering. "The arteries have no openings which can be detected, either on their surface, or at their extremities ; and if the blood, as it is probable, proceeds from them during erection in greater quantity into the cells of the corp. ca- vernosa, so it must either pass through invisible openings, or at least through openings which only become enlarged by the great extension of the vessels. If the great number of these tcndrd-like branches which are given off from the art. profunda penis be considered in comparison with the many fine nu- tritive twigs of the same vessel, it must be evident that when the former are filled, they must take up by far the greater portion of the blood conveyed by it. The "diameter of the art. profunda, therefore, not only includes the nutri- tive twigs which arise from it, but also the tendril-like branches, which like- wise deriving their blood from it, yet it is probable, allow none to pass except during erection ; therefore the blood in the unexcited state of the penis only pervades the nutritive branches, and thus only reaches the commencement of the venous cells in smaller quantities ; whereas during erection, it is proba- ble that the blood passes in quantitv through these tendril-formed vessels in- to the cells." M. Mueller states that these vessels are most numerous in the posterior part of the corpora cavernosa penis, and in the bulb. In the middle and an- terior portions of the former, they occur but seldom, and in the anterior part of the corpus spongiosum uretlira) they are less frequent; in the glans, M. Mueller has not distinguished them. 54 426 Treatment of Inflammation of the Testicle, fyc. fyc, [Dec. Such is the account of M. Mueller. These minute anatomical investiga- tions can be prosecuted by so few, that the statements of a discovery must be taken for granted, until some industrious injector or dissector arises to con- firm or to confute them. As the phenomenon of erection is by no means confined to the posterior part of the corpus cavernosum, it appears rather anomalous that there only these vessels, so essential to that phenomenon in the opinion of our author, should be numerous. This difficulty may perhaps, be more apparent than real, and we shall congratulate M. Mueller on his dis- covery, if it is supported by the examinations of others. On the Treatment of Inflammation ofilie Testicle by means of Compression : By J. C. F. Fricke, Surgeon to the General Hospital in Hamburg. [In presenting to our readers the following important document relative to a new mode of treating Hernia humoralis, or swelled testicle, we shall for the most part make use of the author's own words, merely omitting phrases and brief paragraphs, here and there, which do not seem essential. It may be well to inform the reader, that Dr. Fricke is a surgeon of great reputation and of most extensive experience, and the author of some surgical works of much practical value.] I had long meditated (says Dr. Fricke,) on the discovery of some means to obviate the tediousness and other numerous inconveniences attending the common mode of treating inflammatory affections of the testicle, by leeches, poultices, &c. ; and at length it occurred to me that compression, which I had found so very serviceable in some analogous cases, offered the fairest prospect of a favorable result. The event completely answered my expecta- tions ; and I had soon the pleasure to perceive how, by means of this, the disease could be removed, in a simple, easy, and surprisingly rapid way. Generally speaking, compression may be employed in every kind of inflam- matory enlargement of the testicle, and from whatever cause produced. We have found it equally useful in cases arising from gonorrhcro, whether springing from sympathy in the inflammatory stage, or originating in what is called suppressed claps, and in such as have arisen from external injuries. The degree or period of the inflammation makes no difference. The only contra-indication to the employment of this treatment, worthy f consideration, has been found in an affection of the genera] system. For instance, if the local inflammation had arisen from errors in diet, such as a- buse of spirituous liquors, or if, contemporaneously with it, considerable dis- order of the gastric system had shown itself, it was found necessary to re- move this state before recourse was had to compression ; as, otherwise, the usual result was not obtained, and the employment of compression was o- bliged to be postponed for a period. In many cases the compression at first increased, in some degree, the pain of the inflamed testicle ; in some cases (particularly when applied too forci- bly,) it produced great pain ; but this never continued long : the patient, af- ter a short time, often in a quarter of an hour, and even in cases where the pain had been extremely severe, finding himself so completely relieved as to be able to leave his bed and to walk about in his room. In inflammatory swellings of quite recent origin, a single application of the compression was found sufficient, in many cases, to remove the disease. "When it was of longer duration, (say, from three to eighl days,) it was found necessary to repeat the compression two or three times. Swelling of the spermatic cord, if it was not very considerable, did not at all contra-indicate compression; nor yet did other contemporaneous local affections, such as buboes, ulcere, &c. When a general febrile state was produced by the or- chitis, compression was found the best means, speedily to remove it, at least where the vascular reaction was not too great ; although, in extremely rare casce, this was produced by the compression itself. 183G.] Treatment of Inflammation of the Testicle, jjc, 437 The unpleasant part of the treatment by compression was, as I have said, its occasioning pain in some cases. This result was observed chiefly in the early period of my practice, and I considered it as owing1 to our making the compression too st rong. J n my latter practice, on avoiding this, we heard no more of pain being produced by it. In some cases, in which the affection had been previously treated by cataplasms, &c, and where we had only made one application of the compression, there still remained for some time a slight painful swellirtg of the testicle; but it gradually disappeared. In several cases I had occasion to observe, as the consequence of compres- sion, nausea, inclination to vomit, and bitter taste in the mouth, coming on without any other evident mark of gastric disorder. When this was the case, compression evidently was of no avail; the pain remitted little or not at all, and the swelling did not decrease. On removing the compression, giving an emetic, or applying a poultice to the stomach, the symptoms of dis- turbance soon disappeared. In the few instances in which this affection of the stomach was observed, the compression had been for the most part too strong ; in two of them, however, it seemed to depend on previous disease in the abdomen. It is however to be observed, that the cases in which this sympathy exists in such a degree as to give occasion to gastric disorder are, generally speaking, so rare as no to be regarded as any drawback on the superiority of this mode of treatment. It is necessary, however, in all cases where such a disposition shows itself, immediately to put an end to the com- pression. The ood effects of the compression show themselves very soon after its application, and the speedy abatement of the pain is always the surest sign of its efficacy. If the pain continues some hours in any considerable degree, a general disorder of the system may be looked to as explaining the failure of the treatment- I will now give a comparative statement of the results of the treatment of orchitis by leeches, cataplasms, &c, and of that by compression, taken from the journals of the. Genera] Hospital, since the commencement of the prac- tice in 1832. In all, we have compared seventy-four cases : of this number, fifty-one may be regarded as acute cases, or cases in which the symptoms of inflammation were strongly marked, and twenty, three as chronic cases, or cases in which the inflammatory symptoms had more or less remitted. Of the first division (of fifty-one), eighteen were treated with leeches, cata- plasms, &c, and thirty-three by compression ; of the second division (of twenty-three), nine were treated with poultices, leeches, &c, and fourteen "by compression. The following are the results of the two different kinds of treatment, as regards the time occupied during the case : Of the thirty- three cases of acute orchitis treated by compression, the average period of treatment was nine days ; of the eighteen acute cases treated without com- pression, the average was thirteen days : of the fourteen chronic cases where compression was employed, the average period of treatment was twelve days ; of the nine cases submitted to other treatment, the average was fourteen days. Such were the average results; some of the compara- tive results of the two kinds of treatment, in reference to individual cases, were ;is follow.' : Of the thirty-three acute cases treated by compression, five were cured in three days ; five, in five or six days ; six, in seven days ; of the eighteen acute cases treated by other means, one case was cured in three days; one, in five days; two, in from seven to eight days, seven, in from eight to eleven days. In regard to the chronic cases, out of the four- teen treated by compression, one was cured in two days, and the greater number in ten or twelve days ; while, of the nine cases in which cataplasms, leeches, &c. were used, the cure took place in no case in less than eight days. Latterly, when experience had enabled me to treat the disease with more circumspection, the results of compression were much more favorable. In the 428 Treatment of Inflammation of the Testicle, <$c [Dec. present summer (1835,) I treated in this way seventeen cases, which are not included in the above statement. Of these were cured in one day, one ; in two days, four; in three days, four; in four days, two ; in five days, three ; in nine days, one ; and two in ten days. The three last were severe and unfavorable cases. In nearly two-thirds of the whole of the above-men- tioned cases, no hardness or swelling of the testicle remained behind. I will now describe the manner in which I apply compression. At first I attempted to compress the testicle against the thigh and pelvis, by passing over it long and wide strips of sticking plaster, from the nates up to the ab- domen. I was soon forced to give up this plan, as well because the com- pression produced by it was neither secure nor equal, and the patient was forced to keep himself in bed, and, even while there, to avoid all considerable movements. After many other unsuccessful attempts by means of tempora- ry bandages, &c, I at length adopted the following, which is proved by ex- perience to be the best. For the purpose of compression, I employ strips of sticking plaster ; the plaster being made very adhesive, but not of too irritating materials,* and spread on linen the breadth of the thumb. No preparatory measures are re- quired ; no leeches, cataplasms, &.c. In slighter cases the patient may stand before the surgeon, leaning against the wall, or he may rest on the edge of the bed or sofa, in such wise that the scrotum may hang freely down. If the scrotum and neighboring parts are much covered with hair, this must be removed ; but, generally speaking, this is unnecessary. The surgeon takes the scrotum in one hand, and separates the diseased from the sound testicle, while with the other hand he gently stretches the skin of the scrotum over the former ; the spermatic cord is isolated in the same manner. If the testicle is much swollen, it must be held by an assis- tant; otherwise, it suffices for the patient himself to keep the sound testicle somewhat separate from the diseased. The surgeon now applies the first strip of plarter over the isolated spermatic cord, about a finger's breadth a- bove the testicle, holding the end of the strip with his thumb, and passing it round the cord. He proceeds in the same way with the second strip, which must either in part or altogether cover the former. The first part of the process must be carefully done; the strips must compress the cord closely, (and for this purpose it must be kept approximated to the skin, which is to be tightly stretched over it ;) otherwise, when the other extremity of the testicle is compressed, the upper end will be apt to slip upwards through the loose rings of sticking plaster; a circumstance not only occasioning pain, but rendering the whole operation abortive. In this manner we proceed, laying strip after strip, the last always lying over the former by a third of its width, until we have reached the thickest part of the testicle, and where it begins rapidly to decrease in diameter. The surgeon now changes his mode of proceeding, and, laying hold of the testicle already covered, passes his strips from above downwards over the lower portion of the testicle, and up over the back part. In this way the whole remaining portion of the tes- * The following composition, contained in our Codex, is the plaster which I have employed for some years, and has been found preferable to all oth- ers: .ty. Emplastri Lithargyri, partes sex: Colophonii pulverati (Picis nigra',) partem imam. Seorsim liquata commisceantur. The Emplastrum Lithargyri employed is made as follows : I. Lithargyri subtuissime teevigati, lib. v. Olei Oliv. lib. ix. M. Coqoe igne moderate, spatula lignea semper agitandoet pauxillum aqiue subinde instillando, donee Lit ha r- gyrum perfecte solutum sit, &c. 183C.J Employment of Belladonna in Injection, $C 439 tide is closely enveloped and compressed. I have already said that the compression must not be too great ; and in most cases the surgeon will be able to judge as to the proper decree by the speedy disappearance of all the pain which had previously existed. If both testicles are affected, we proceed to envelope one in the manner now described : when this is done, it will be found that there is not room left for applying the circular strips in the same manner to the other; we are therefore under the necessity of including both testicles in the circular strap- ping, the testicle already covered serving as a point of support for the other. Over the lower portion of this second testicle the strips are passed, as in the former case, from behind backwards. In some cases where the skin is irritable, ulcerations take place ; in this case small slits m ist be cut in the plaster, and a goulard lotion applied, which soon heals them. Generally speaking, the patients can leave the bed immediately after the strapping, and walk about the room ; and, in cases where the inflammation is not very great, or has been taken early, they may even go out and work a little. The renewal of the straps must depend on the decrease of the swelling and other symptoms. In many cases one application suffices ; otherwise, we remove the plasters when they have become so loose as to admit the introduction of the scissors between them and the skin. Any other treatment the patient may require must depend on the compli- cations of the disease : the orchitis, as such, needs nothing besides the com- pression. In those inflammations of the testicle which originate from blows or pres- sure, &c. compression has proved the best treatment. Here, if the inflam- mation ran very high, I have usua31y applied leeches in the first instance, and kept on poultices for one or two days ; but in slighter cases I had re- course immediately to compresion. The following are the principal advantages which the treatment of orchi- tis by compression possesses over other methods : 1. The speedy removal of pain. 2. The quick removal of the disease itself. 3. The simplicity of the method, and the slight trouble thereby given to the patient. 4. The small expense of the treatment. 5. The comparatively slight care and attendance required on the part of the surgeon. The two last points are of considerable importance in the hos- pital practice. British and Foreign Medical Review. Zeitschrift fur die gesammte Medic in. B. i. h. 1. 1830. Hamburg. On the e?nployment of Belladonna in Injection, and Mercury in the metallic state in Ilius. M. Hanius has had recourse, with three patients affected with Ilius, to the following lavement: K. Fresh Root of Belladonna 3j. Pour upon it a sufficient quantity of boiling water and digest in a close vessel for one hour. Add to I ij of the strained liquor, Infusion of Chamomde 2. s. for an injection. The administration of this injection was almost always imme- diately followed by a cessation of vomiting and the evacuation of stercoraceous matter by the natural way. Once only was ob- served pretty profound narcotism, which was nevertheless promptly dispelled. The same medication has been crowned with success in a case of colica piclonum. 430 Continuation of Notice of M. Lisfranc's Clinics. [Dec. With respect to the treatment of Uius by mercury, M. Hanius alleges, 1st. It is not correct to say, as M. Ebers recently has, that the metal passed promptly and by its own weight, from the stomach into the intestine. 2. Supposing that had taken place, and that the metal had accumulated against the obstruction, we cannot conceive how the antiperistaltic movement, provoked by obstruction of the digestive canal, will be overcome by an obstruc- tion more considerable. 3. Still more inconceivable is it, that the intestine is not torn by the weight of metal accumulated in one point alone ; weight which, according to HaufF, has been borne, in certain circumstances, even to three pounds. 4. That when the continuity of the intestinal canal is re-established, the mercury, instead of being passed together, as it ought to be, is, on the contrary, expelled by small parcels. 5. That the hori- zontal disposition of many parts of the digestive canal, will not allow us to suppose that the mercury will run through them, by the power of gravity alone. M. Hanius has proven the correct- ness of this reasoning by experiments directly in point, on dogs, and he has seen that the mercury is arrested in the stomach, that it remains there a shorter or longer time, that it passes into the intestines only by little particles, and by virtue of the peristal- tic motion; finally, that it attaches itself strongly, in separate globules, to the surface of the intestines. If then the injection of this metal soon causes a cessation of the vomiting, it is because accumulated in the lowest part of the great curvature of the sto- mach, it opposes, in that point, by its weight, to the antiperistaltic motion an obstacle equal, if not superior to that which is op- posed to the peristaltic motion in the intestines, by the invagina- tion or accumulation of fecal matter, &c. Journal der Praktis- clien Heilkunde von Hufeland and Osann. Journal des Con- noissanees Medico- Chirurgicales. Continuation of the Notice of M. Lisfranc's Clinics. We now come to the subject of "Chronic Metritis, or Simple Hypertrophy of the Uterus. It appears evident from this par- agraph, and the next, which he denominates "Hypertrophy of the Uterus, with Transformation of Tissue" that M. Lisfranc uses the term Hypertrophy generically, as including two species, viz. simple hypertrophy and hypertrophy with transformation of tissue, &c. We are compelled to dissent from such a view of the cases herein detailed by M. Lisfranc. We consider the name hyper- trophy, eminently calculated to lead to error in pathology, and consequently in therapeutics. We are also disposed to find fault with that looseness of nomenclature which confounds metritis, or any species of inflammation with hypertrophy. We should 1836.] Continuation of Notice ofM. Lisfranc's Clinics. 431 have been pleased to see the first term, metritis, continued alone in application to the cases on which M. L. pave this clinical lec- ture, as, with the assistance of a prefix, it is calculated to point with great precision to the pathology in the different varieties of these cases. But the instant things so different in themselves are made synonimes, each confounds the other, and the definite bear- ing of either or of both, is destroyed. But this subject enlarges so much on our attention, that, for want of room in this place, we must refer the reader to the first part of the next (January) No. of tins Journal, where we intend to notice it at greater length. The next subject noticed by M. L. is what he calls " hyper- trophy of the uterus, with transformation of tissue." This sub- ject we must also refer as above. This paragraph does not af- ford us any pathology of this case. It contains a good descrip- tion of a certain case of diseased uterus and without any satis- factory reference to causes. Certainly there are causes of effects which are only momentarily in application on the production Of continued effects. Such are not necessarily required for correct indication, if that their manner of operating be well understood ; and the principle use we have for a knowledge of such, is that, knowing their mode of operation, we may the better understand their effects, which are presented to our view in the character of morbid phenomena, or ciisease. But often some of the causes are abiding, and are continually renewing and extending their effects. Such must be both detected and well understood, before we may hope for rational indication in the case. The treatment, as far as it goes, is well adapted to the state of things in the case de- scribed. But the modus operandi of the principle remedy the pessary in the shape of a bilboquet,*' which he considers is by compression, we think entirely defective. We should surely not expect prompt, or certain effects from compression alone on any one point in diseases elsewhere, and especially when that pres- sure is only made occasionally and for a short time. Yet such we perceive to be his views by the following sentence. " An excellent remedy is compression, applied by the use of a pessary of the shape of a bilboquet ; this instrument being well placed, the uterus, by its tendency to descend, especially when- ever the patient moves, takes exercise, or goes to stool, is press- ed against it, and thus produces the effect desired.,, We shall pass over " Tumours of the Uterus," " Miliary Po- lypi of the Os Tincae," " Tubercles of the Uterus," and " Ulcer- ations of the Os Tinca3," which contain so much that is valuable, * Bilboquet, is a term which the reader may not be able to understand even with the assistance of his French Diction ary, unless he be familiar with the French toy of that name. The hour-glass shape, with which all readeis are familiar, will be about as descriptive. 432 Continuation of Notice of M. Lis franc's Clinics. [Dec* that every one should read these notes ; though they are not ex- empt from errors in pathology, nor from some in practice to which these lead. On the subject of Leucorrhaea, we find renewed evidence that M. Lisfranc is a practical, rather than a reasoning man. Whilst we are bound to consider him as having taken most shal- low etiological views of this case, his practice for its correction is well calculated for good eflect stopping short, however, as it must necessarily do, of that extent to which a rational pathology would have led. We intend to allude to this subject, however, in the next No. The following remark of M. L. is worthy of all attention. ** It should be borne in mind, that when these dis- charges have long continued, they are true emunctories, and must therefore not be suddenly suppressed. The organs of the chest should always be carefully explored previous to arresting this discharge, for he has known this neglect prove fatal to a great number of females, whose lungs being tubercular, ulcera- ted very rapidly after the successful treatment of Leucorrhcea." He recommends, that in those cases in which the lungs may be suspected, setons, or issues, be established previously to their sup- pression. The next and last subject we shall notice in this place, is the Amputation of the Os Tincce. This is an operation which has become very common in the practice of M. Lisfranc; his num- ber of cases amounting now to more than one hundred, within the last few years. The operation is an important one, and has surely been performed with great success by M. L., but we are forced to the conclusion, that like most other new or rare things, when brought into use, the frequency of this operation has been extended far beyond the bounds of necessity or prudence : and that the cause of these boundaries being thus transcended, is the error in the etiology of the cases. If we judge from all the au- thentic accounts of his operations of this description, we cannot fail to be convinced, that he has amputated in very many cases, wherein the disease for which the operation was performed might have been easily and speedily cured by duly liberating the ves- sels of the part, and suitable washes and application thereto. Nevertheless, the operation is doubtless one which will some- times be not only prudent, but indispensably demanded by the necessity of the case ; and for a knowledge of the best manner of performing it, we refer the reader to the u Notes of a Physician," &c. ; Southern Medical and Surgical Journal, No. 5, pages 311 and 312. 183G.] On Fracture of Inferior Extremity of the Radius. 433 On Fractures of the ln(< rior I '. qf the Radius: By G. Goyraud, M. D., of Aix. A frequent consequence of a fall on the hand is a painful swelling of the wrist, hand, and lower extremity of the forearm. This tumefaction is ac- companied by a deformity consisting in an unnatural projection of the lower extremity of the ulna ; a change ot form in the forearm, which is rounded in- feriorly ; inclination of the wrist outwards and generally backwards, and of the hand in the contrary direction. Generally the only treatment consists in emollient applications. The swelling slowly declines, and the motions are not free for a long period. Six months after the fall, the wrist-joint has not recovered its suppleness. As the swelling disappears, the projection of the lower end of the ulna is more" apparent: inequalities are felt on the palmar surface of the inferior extremity of the radius. Eventually the joints regain their mobility, but the deformity remains throughout life. This accident has been considered by some to be a diastasis of the inferior radio-ulnar articulation, by others as a sprain ; by Petit and Boyer as a dis- location of the wrist : but no external violence could separate from each oth- er the lower ends of the radius and ulna ; no sprain could change the direc- tion of the hand ; and, if the possibility of luxations of the wrist are admitted, (which Dupuytren doubts,) still they must be very rare, whilst this accident is very common. It can only be accounted for by a fracture of the radius. Fractures of the carpal extremities of the radius are generally oblique from above downwards, and from the dorsal to the palmar surface. Out of forty- seven instances of fractured radius, forty-three were in this direction ; two others were oblique fractures from above downwards, and from the palmar to the dorsal surface ; in one other the inferior fragment was fractured vertical- ly, and in another there was a star-like fracture into many pieces. In the most common variety, the obliquity was of various degrees, sometimes near- ly transverse. In the common oblique fracture the inferior fragment is forced, by the violence of the blow, and the action of the muscles passing from the forearm to the hand, from below upwards and from before back- wards. The superior fragment is drawn towards the interosseous space by the action of the two pronator muscles. The consequence of this displace- ment is a diminution of the breadth of the inferior part of the forearm and in- terosseous space ; a depression on the external side of the radius, some lines above the wrist ; an inclination of the carpal articulatory surface of the ra- dius outwards and backwards. Cline and Cooper have attributed the pro- minence formed anteriorly above the wrist to the displacement of the inferi- or extremity of the upper fragment by the pronator quadratus ; but M. Goy- raud is convinced, from numerous dissections, that the inferior fragment is displaced, producing the prominence. The more oblique the fracture, the greater the displacement : in transverse fractures the violence only causes the displacement, and this may be so great as to simulate luxation of the wrist ; an error which may be strengthened by the fact, that, after reduction, there is no tendency in the parts to become again displaced. The carpus follows the direction of the articular surface of the radius, so that the articu- lation of the wrist takes a direction separating it trom the inferior extremity of the ulna, which consequently forms a projection remarked by Petit and Boyer, who believed it to be a consequence of luxation of the wrist. The hand would follow the same direction, if it were not for the internal lateral ligament of the joint, which prevents the hand turning outward; the flexor muscles, rendered tense by the wrist being thrown backwards in the com- mon oblique fracture from behind forward, draw the hand forwards ; in the fracture in the opposite direction, the extensor muscles draw the hand back- wards. In the great majority of cases, the hand is fixed in the state of ad- duction and a little inclined forwards ; sometimes, but rarely, backwards. If the violence has ruptured the lateral ligaments, or separated the styloid pro- cess of the ulna, the hand and wrist are in a state of abduction. 55 434 On Fractures of Inferior Extremity of the Radius. [Dec. These oblique fractures of the radius are extremely frequent : they gener- ally are caused by falls on the palm of the hand, but sometimes on the dorsal surface, the hand being strongly bent forwards. The indications of this frac- ture are an unnatural projection of the lower end of the ulna, a depression on the radial border of the forearm some lines above the wrist-joint, a little increase in the dorso palmar diameter, and a little diminution in the radio- ulnar diameter of the forearm, at a point corresponding to the depression on the radial edge ; pain in the lower extremity of the radius, augmented by pressure at this point, but not by the motions of the joint ; pain also beneath the lower end of the ulna, from the dragging or rupture of the internal late- ral ligament. In the commonest oblique fracture from above downwards and behind forwards, the wrist is inclined backwards, its axis forming an angle, more or less marked, with the forearm. From thence a depression on the dorsal face of the forearm, over the radius, and ten or twelve lines above the wrist, and a large prominence, convex from above downwards, on its palmar surface. The hand is bent forwards ; and this inclination is more considerable in proportion to the deviation of the wrist. In the rare fracture from above downwards and before backwards, the wrist is bent forwards and the hand backwards. The inequalities arc felt before the swelling begins, and w7hen it is partly dissipated. Transverse fractures with great violence, and separation of the epiphyses, may be mistaken for dislocations ; but, as Dessault remarked, in luxations the styloid process of the radius loses its re- lation to the carpus ; in the other two accidents it is no longer in the same line as the radius, but it preserves its relations with the hand. Crepitation is often [absent, from the want of mobility in the fragments and from the swelling. To sum up : the diagnosis is formed on the change in the direc- tion of the axis of the wrist and that of the hand ; the swelling characteristic of fractures ; the pain seated not in the joint, but in the lower end of the ra- dius, and the unusual projection of the lower end of the ulna. The absence of rotation in the end of the radius during pronation and supination has been dwrelt on ; but, from the large surfaces of the fracture and intimate connex- ion of the two bones, must not the motion of one be necessarily communica- ted to the other? This fracture is without danger : it leaves behind a de- formity previously described, but M. G. has never known it produce obliter- ation of the interosseous space, nor loss of the motions of pronation and su- pination, which Dupuytren describes as a consequence of its being over- looked. Under such circumstances, the joint remains for a long time almost without motion. Treatment. To reduce the fracture, the forearm must be bent and placed in a position between pronation and supination ; an assistant produces coun- ter-extension by seizing the lower part of the forearm, whilst another ex- tends the limb by drawing the hand gradually outwards, and slightly incli- ning it towards the ulnar border of the forearm. The surgeon pushes the flesh of the two sides of the forearm into the interosseous space, and then puts the broken surfaces into apposition. The fracture is easily reduced, but retained with difficulty in its situation. The apparatus employed by M. Goyraud consists of two splints, about the breadth of the lower end of the forearm, one of which is from eighteen to twenty lines shorter than the oth- er, and its inferior extremity cut off obliquely ; two graduated interosseous compresses ; and two pads, one between three and four inches long, and the same thickness as Ihe middle of 1 he graduated compress ; the other an inch in length, and like a wed^o, its base being about as thick as the anterior in- terosseous compress. The interosseous compresses are applied on the two faces of the forearm, parallel to the inti rosseous spare, and descending to an inch above the joinl ; below ibis point they are replaced by the pads, the larger one over the dorsal aspect of the wrist, and the Wedge-like pad on the paJmarside, with its basenexl to the graduated con id its apex to the carpus. The 1 'orsal graduated compress and 183G.] Surgical Observations, tyc. 435 pad, is to descend to the posterior surface of the metacarpus; the shorter splint is placed over the palmar compresses and pad, its oblique extremity being inferior, rndthc acute angle of this extremity towards the radial edge of the limb, so that it is applied with the interposition of the cuneiform pad a- gainst the superior part of the prominence formed by the os pisiform and os scaphoides. A tight roller confines the whole. The advantages of this me- thod are the following : As the interosseous space terminates an inch above the wrist.joint, the long graduated compresses generally used to prevent the bones coming in contact are of no use; but, by substituting pads whose sur- fac3 corresponds (as these do) to the shape of the lower end of the radius, this bone is evidently acted upon. The effect of the oblicpie extremity of the splint is to change the direction of the line formed by the prominence of the os pisiforme and scaphoid process, which is almost horizontal, into an o- blique line running from above downwards and from the ulnar to the radial border of the limb ; that is to say, to fix the hand in the state of abduction, and to oppose more certainly the reproduction of the displacement ; an indi- cation which Cline and Sir A. Cooper attempted by the weight of the hand, winch they allowed to hang out of the sling. During the last two years, this treatment has been adopted by M. Goyraud in eleven cases with complete success. British arul Foreign Review. Journal Hebdomadaire des Sciences Medicates, No. (5, Fevrier 6, 1836. Surgical Observations : By Professor Chelius, of Heidelberg. [In the first number of a new series of the Heidelberger Klinische Anna- len, recently published under the name of " Medicinische Annalen," this em- inent surgeon has given an elaborate and highly interesting Report of Ins Surgical and Ophthalmologic al Clinical Practice in the Heidelberg Hospital, from 1830 to 1834 inclusive. We regret that our limits will only permit us to give a brief notice of some of the more important surgical observations contained in it ] 1. Amputation. Professor C. mentions that, out of twenty-nine cases of amputation, he lost only two patients. The circular incision was in every instance put in practice, and ligatures employed to secure the bleeding ves- sels ; in no case torsion. Two alone required the removal of the dressings for after-hemorrhage ; in all the rest they were allowed to remain untouched as long as possible ; in some till the third week, at which period the wound was found perfectly closed. 2. Lithotomy in the Female. After discussing fully the merit of different plans that have been proposed, Professor C. adopts the method of incising perpendicularly downwards, (a modification of Bromfield's operation ;) and for the following reasons : The urethra, throughout its whole extent, lies immediately upon the anterior wall of the vagina, as is likewise the case with the bladder. By the incision so directed these two points alone are impli- cated ; the execution of the operation is simple, nor is it likely to give rise to any considerable loss of blood. The extraction of the stone will be attend- ed with the least possible difficulty ; and, should the large size of the stone demand it, the incision can be commodiously prolonged. Owing to the ex- act apposition of the vagina to the urethra and to the neck of the bladder, there exists a constant parallelism between the wound of the vagina, of the urethra, and of the cervix vesicae ; the urine finds a ready way of egress, and no danger need be apprehended from infiltration. From being able, in case of need, to carry the incision along the neck into the body of the bladder, every risk from pinching or tearing the cervix vesicae is removed ; lesions much more apt to produce subsequent incontinence of urine than the mere section of the neck! As disadvantages resulting from this mode of operation, are enumerated the danger of vesico-vaginal fistula and permanent fissure of the urethra. 436 Surgical Observations. [DcC. The first of these objections must be opposed by the various arguments ad- duced in support of the vesico-vaginal section generally. In this respect the conditions here are much more favorable than in the instance of recto- vesical lithotomy ; for here the vagina is empty, and the entrance of foreign matters into the cavity of the bladder, as fasces from the wounded rectum, rendered impossible. Nor is any inconvenience to be apprehended from the remote chance of the influx of fluid during the flow of the catamenia. The second objection is supported neither by anatomical nor physiological grounds, and is directly refuted by Professor C's. own proper experience. Operation. The grooved staff is introduced with its handle sustained ver- tically by the assistant, and its concavity pressed up against the pubic arch: in this manner the parts to be incised are more securely fixed, the entrance of the vagina somewhat widened, and the finding the groove on the staff fa- cilitated, and, lastly, the section downwards of the urethra and vagina accom- plished without trouble. The incision may be performed with a probe-poin- ted bistoury introduced to the requisite depth along the groove, and then made to cut its way outwards, dividing in its course the neck of the bladder, urethra, and anterior wall of the vagina, to the full extent wanted : or it may be executed by means of the lithotome cache of Frere Come. Should the incision of the bladder be too small, it must be enlarged by means of the probe-pointed bistoury, conducted along the left index-finger. Reports of three cases are related wherein the above plan answered. 3. Scrotal Calculus. This case is remarkable from the multitude of con- cretions removed, amounting to twenty-seven in number. The patient was fifty-five years of age, and attributed the origin of the complaint to a fall upon the perineum, about twenty years previously. 4. Bronchocele, (Struma Lymphat lea.) Professor C. is of opinion, that in every case of this disease where the nutritious vessels are much enlarged and easily to be felt, their obliteration by means of ligature is equally indica- ted, as in the aneurismal form of the affection ; for, although the diminution of the swelling in Struma lymphatica, after the supply of blood has been checked by tying the superior thyroid arteries, does not proceed with such rapidity, nor to the same degree, as in the vascular goitre, still however such a decrease in the bulk of the tumour will be obtained, that the inconvenien- ces it had created will be in a great measure lessened or altogether re- moved. The operation is of the simplest description. The rule given is to make the incision correspond, in direction and situation, with the course in which the arterial pulsations are most distinctly perceptible to the finger of the operator. This will most frequently be found to be between the omo-hyoi- deus muscle and the point at which the vessel is entering the gland ; often, however, between its origin and the same muscle. An advantage attending this method is, that, if it should not fulfil the desired end, diminution of the morbid growth, other means can, with greater confidence, be put in practice. Four cases are reported in which it proved of great service, and in no one was it productive of the least bad consequence. 5. Erectile Tumours. Creosote was tried as a topical application in sev- eral cases of this affection, and especially Ncevus maternus in infants. The only effect its continued application seemed to produce was the formation of a superficial dry crust, which came away, leaving the tumour in statu quo : indeed, in one case, the volume of the nawus appeared to have augmented under the use of the creosote. From its jnefficacy, he was obliged to have recourse to caustic, which he pronounces unfailing in its effects, and prefera- ble to the knife, from the danger of mortal hemorrhage from the latter. 6. Removal of an Abdominal Tumour. This is another addition to the eepulchretum of operations in that cavity. The tumour was of a fibrous texture, of considerable magnitude, attached by a pedicle to the uterus. The patient never recovered the shock of the operation, which she outlived 183G.J Surgical Observations. 437 seventeen hours. It is justice to state, that its performance took place at the earnest solicitation of the patient, in opposition to the advice and opin- ion of her medical men. 7. Tetcaugiectasia Lipomatodes. Under this strange name is detailed the history of a singular case of mixed tumour, partly erectile, partly lipomatous, occurring in the hand of a tailor, chiefly between the thumb and the meta- carpal bone of the index-finger. As its presence interfered with the use of the needle, Professor C. determined to try the effect of tying the radial ar- tery. Soon after the operation, so great was the amendment that he was again able to resume his handicraft. It is worthy of remark, that, in conse- quence o? the supply of blood being diminished, it gradually lost its erectile character, assuming more and more that common to lipoma. 8. Stricture of the (Esophagus. For the permanent cure of stricture of the oesophagus, Professor C., taking advautage of the principle introduced by Ducamp for strictures of the urethra, employs an oval ivory dilatator, at- tached upon a common oesophagus bougie, about an inch and a half from its extremity. An ordinary oesophagus bougie is first inserted, to ascertain the existence and situation of the stricture. Should this fail to make a passage, a thinner bougie must be used. Where the coarctation is considerable, it is sometimes necessary to use middling-sized urethra bougies. The bougie is left in ten or fifteen minutes each day, gradually exchanging it for one of lar- ger caliber, until the dilatator is permitted to enter, which patients are found to endure quite as well as the ordinary sounds. Under this plan there is ra- pid improvement ; and, after the lapse of a few days, a second thicker dila- tator may be substituted for the former, until perfect dilatation is effected, and deglutition rendered free. For some time after the cure it is advised to in- troduce the instrument once every five, eight, or fourteen days, to prevent relapse. All instruments for the cure of stricture are always to be intro- duced by the mouth. British and Foreign Review. Heidelberg Medicinisclie Annalen, Band. i. H. i. 1835. 438 Medical Society of Augusta. [Dec. Part III MONTHLY PERISCOPE. Medical Society of Augusta, 9th November, 183G. The Society convened at 7 p. m. Dr. Bowen, the essayist for the evening, not having his essay present, the members were called on for medical intelligence. Whereon, Dr. Antony rela- ted a case of typhoid fever, in which salivation had supervened on the use of forty grains of calomel, in 8 grain doses, three hours apart, with 1 gr. aloes in each. This occurred about the sev- enth day the disease having hitherto observed an intermittent type, and in the early stage had, from the symptoms of a tenden- cy to cerebral congestion, required the free use of the lancet once, an emetic, and continued use of nauseating portions of an- timonials, previous to the use of the calomel, but could not bear quinine. The salivation continued several days, the calomel had operated as a purgative, without evincing any change of hepa- tic secretion. During the continuance of the salivation, the fe- ver gradually assumed a remittent, and finally a decidedly con- tinued type, and typhoid character ; during the progress to which, and within three or four days, the salivation, which was at first severe, gradually decreased and finally ceased altogether by the fourth day after salivation. The tongue was covered with a thick brown fur, thickened, with crimson colour of the apex, edges, and under surface. Litmus paper applied to the tongue, which was moist with saliva, promptly assumed a pale pink colour. Pulse small, week and fluctuating through the twenty- four hours from 90 to 100, with frequent intermissions. Con- tinued coma, eyes half open, without expression ; countenance hippocratic; jaw fallen ; constant and considerable typanitis. Carbonate of soda was administered in doses of 10 grains every two hours, and every four hours 15 drops of chloride of soda, as suggested by Drs. Graves andChomel, in g i. mixtura camphora, for forty-eight hours; during which time, the epigastrium hav- ing been previously vesicated, blisters were also drawn on the legs. At the end of this period, the thickness and redness of the tongue had greatly abated, the saliva no longer produced the pink colour of the litmus paper, the intermissions of the pulse were less frequent, its tone decidedly improved, the tympanitic condition of the bowels was entirely removed, and the bowels, which had been disposed to looseness, became less relaxed. IJnt the thick fur on the tongue, the coma, the want of expres- sion, the falling of the jaw, with dry skin and cold extremities, continued. Calomel G grains, with com p. powd. of ipicac 3 grs. were now directed every three hours, alternated with I ss. port- 1830.] Medical Society of Augusta. 439 Wine and I ij. decoct, cinchon., with serpentina infusion. By the next day, the calomel secretion from the liver was evident. The use of the calomel was however continued for two days longer, with the effect of a gentle evacuation of very black se- cretion about every three or four hours. During this time, per- spiration made its appearance on the face, and gradually extend- ed, with increasing warmth, to the rest of the surface ; the ir- regularity and weakness of the pulse were corrected, and at last she awoke from her coma as from a sleep, knowing nothing of what had passed for the last twelve days. Her mouth now be- gan to swell and evince the salivating effect of calomel, and soon became very sore, with/ the prompt abatement of the febrile symptoms. This case was given, as one amongst many, mainly in illustration of the fact, that mercurial salivation has little or no agency in arresting the progress of fever. Attention was also called to the fact of the abounding acid in the saliva, and the tympanitic state of the bowels, in connexion with the other typhoid symptoms, which were so promptly corrected by the alkali and" chloride of soda. Dr. A. remarked that this dis- play of acid and tympanitis had been frequently found during the season in connexion with these symptoms, and which had been very uniformly corrected by corbonate and chloride of so- da. He also alluded to the fact of its almost universal preva- lence some years ago, in an epidemic influenza which prevailed in Augusta, as was plainly evinced by the taste of the perspira- ble matter being nearly as sour as that of lemonade ; and in which the pulmonary and the typhoid symptoms were much more promptly relieved by the addition of a little clean ashes, or carb. sod. or potass, with linseed and seneka infusion, than by all other means without the alkali. Dr. A. stated, that during the past summer, he had deliv- ered an ancncephalus, wherein the whole brain and mudulla ob- longata were deficient. How much farther down the spinal column the deficiency continued was not determined, from want of opportunity to continue the examination. The child lived in the full and regular -performance of the functions of circulation and respiration, (witli the exception of occasional short intermis- sions of the latter.) for (he full term of twenty-seven hours. It was very strong and remarkably sensitive to the touch, so as to exhibit, when touched, somewhat of that convulsive effort pro- duced by cold water thrown on one asleep. Dr. Bowen stated a case of intermittent fever, to which he had been called, in which the pulse intermitted every eighth pulsa- tion. The patient was then under the operation of what the family called " sandhill physic," a specimen of which the Doctor had not been able to obtain, and therefore could say nothing of its botanical character, but observed that its operation was very similar to that of tartrate of antimony. The regular inter- 440 Medical Society of Augusta. [Dec. mission of pulse continued through the use of purgatives and di- aphoretics This case was treated with calomel, nit. potass, and tartrate of antimony ; with arsenite of potass. A fine relaxation of skin was procured and the chills arrested. The patient relapsed, and sulph. quinoe was resorted to, but was abandoned because of the increased dryness of the skin and fever. He died on the twen- tieth day from the attack. The privilege for autopsy could not be obtained. Dr. B. gives this case on account of the remarkable facts of the great regularity of the intermissions of the pulse, and the great dryness of the tongue at the same time that the skin was in a fine state of relaxation. The spleen was obviously very much enlarged. For several months previous to the attack, complained of considerable pain in the precordial region. Dr. B. did not think an intermitting pulse a necessary accom- paniment of great hepatic derangement ; and therefore thought this symptom dependent on some alteration of the heart, the prime mover of circulation. Dr. B. proceeded to give another case illustrative of the oper- ation of lobelia. This article he said was given to a boy 10 years old, laboring under a bilious fever, at one o'clock in the afternoon. Soon after taking this dose, he was found to be in a stupor, with that general helplessness and extreme flexibili- ty, which immediately precedes death, the eyelids half closed, eyes rolled back, and great difficulty of breathing. In this situ- ation he continued for nearly twelve hours, when he vomited and was relieved. Dr. Dugas then related a very extraordinary and interesting case of chronic hydrocephalus, which he had treated by tapping. This was a male child, born without accident, and enjoyed ap- parent good health until one month old. His head was then perceived to increase in size more rapidly than is usual in health ; and subsequently, the cranial bones separated, the eyes became spasmodically turned downward, and at four months of age the child experienced slight general spasms, which in a few days amounted to convulsions. He appeared in other respects per- fectly well, was fleshy and had been subjected to no treatment whatever. The circumference of the head was now 21 inches, and the fluctuation could be distinctly felt at the forehead, which was puffed up by the contained fluid. In this condition he had found the patient, on the 25th of June, laboring under convul- sions which had commenced several hours before. Dr. Antony happening to be present, it was at once determined in consulta- tion, to draw off a portion of the effusion ; but having no more suitable instrument at hand, Dr. D. made the puncture with a couching needle, penetrating about one inch deep, in the left an- gle of the fontanelle. On withdrawing the needle, an ounce and a 18 30.] Medical Society of Augusta. 441 half ( ^ iss.) of limpid yellowish fluid oozed out, and no more could he obtained. The head was then bandaged; the convul- sions continued during the operation, and two or three hours af- ter. On the 5th July, the operation was repeated with the same instrument, and the application of a cupping glass, when ^ij. more were drawn. Aug. 12. Head had very much enlarged, and on the use of a very small trocar, made expressly for the purpose, I vij. of fluid were removed. Aug. 29. Head larger than previous to the last operation. Drew off 5 xi. Sept. 12. Head full, but not distended strongly. Drew off I xv. Sept. 30. Head again filled. Drew off I xiiss. Oct. 16. Drew off I xiv. Dr. D. remarked that the convulsions subsided shortly after the first operation, and did not return, except very slightly, a short time before the third and fifth puncture, although the accumula- tion continually increased. Indeed his general health appeared unimpaired until the 15th October, when he became dull and stupid. The stupor gradually increased and he became insensi- ble of the nipple when put into his mouth. On the 16th he ap- peared as if in a profound sleep, and had swallowed nothing for two days. After the removal of the 1 xiv. on that day, he again readily noticed and swallowed several teaspoonfuls of milk poured into his mouth. He expired quietly on the 18th October. The operations were never attended with the least change of pulse, nor symptoms of prostration the only visible effect being the subsidence of the tumefaction, and of the tendency to spasm. Iodine, calomel, bandages, &c. were prescribed, but never attend- ed to, from the unwillingness on the part of the mother to annoy the child, as she thought, unnecessarily. The fluid was, after several of the operations, exposed to heat, without coagulating in the least. The Dr. then gave the following full and minute account of the autopsic examination: Autopsy. The cranium was opened longitudinally, by an in- cision made in the membranes connecting the two sides of the frontal and the two parietal bones. The brain was found ex- panded like a sack, lining the dura mater, and filled with fluid, which did not escape until the brain was punctured. The con- volutions were entirely unfolded, and the walls of the sac thus formed were about a line or two thick. The corpora strata and thalami were not affected, and the third ventricle was nearly normal ; the fornix, velum interpositum and plexus choroides existed; the septum lucidum was not found. The corpus cal- 96 442 Medical Society of Augusta. [Dec. losum could not be recognised, although the cerebral substance forming the walls of the sac was as firm as usual at this age. Cerebellum normal as also the medulla oblongata and encepha- lic nerves. The membranes presented nothing peculiar, save a great want of blood in the vessels of the pia mater. The inner. surface of the cerebral sac resembled very closely a healthy mu- cous coat of the stomach. It was in some places covered with thick flakes resembling dense mucus ; some of these were yel- lowish, some brown, others of a cream color and like thick pus. The yellowish patches were at the bottom of that portion of the sac corresponding to the anterior lobes of the brain, and were not very unlike the appearances left after the absorption of apo- plectic effusion. The left hemisphere being the first opened, permitted the escape of the fluid contained in both, after which, on looking into the right cavity through the hole of communica- tion with the left, a kind of longitudinal septum, though lacerated, was seen hanging from the upper part of the sac and reaching- its floor. It resembled the cineritious substance, but was so pulpy as to be readily torn and thus to prevent a satisfactory examination. It may possibly have been formed by flakes anal- ogous to those already alluded to. On examining that part of the sac which corresponded to the external marks left by the punctures, the cicatrices of the seven perforations were distinctly seen in the cerebral substance, which at this, place with its other membranes slightly adhered to thc- dura mater. The contained fluid measured sixty-four ounces, was limpid and of the colour of pale urine. The above case, although unsuccessfully treated, may, by con- firming the practicability and harmlessness of tapping the brain. lead to its more frequent trial. The plan has proved successful in one or more instances, and therefore merits more attention than it has hitherto received. In this case the brain was punc- tured seven times and sixty-three ounces of fluid drawn off, yet not the slightest unpleasant effect ever followed the operation. Dr.. Joseph A. Eve, then made some observations on irregu- larity and intermittence of the pulse, which he was disposed to attribute to sympathy with the liver generally, when not depen- dent on organic affection of the heart at least this was the con- clusion to which he had arrived from observing intermittence frequently attendant on, or accompanying hepatic disease. He related the case of a lady of bilious temperament, and previously the subject of hepatitis, who, after long continued and repented exposure to cold, was attacked with a most intense pain in the region of the liver and other symptoms of hepatic disease ; and whose pulse during the attack was extremely irregular and in- termittent, and reduced to a mere thread were it not that it did not correspond with the muscular strength, voice, expression of 1 836.] Medical Society of Augusta. 413 countenance, and tlint he had seen cases somewhat similar, he should have supposed, judging by the pulse alone, that she was then moribund. Notwithstanding the pulse was scarcely per- ceptible and like that of a person in articulo mortis, recognising it to be a < i litis, lie did not hesitate to prescribe a large blister to the side and purgation with calomel and aloes, after the operation of which, the pulse gradually recovered its natural tone and rhythm and the patient was restored to health. Dr. Antony remarked, that intermitting pulse, as well as pal- pitation, was a very frequent attendant on chronic bilious habits'; very often observable and generally yielding more or less prompt- ly to the correction of the habit, by evacuating the bile and im- proving the hepatic secretion by slow purging with calomel and aloes. Dr. P. F. Eve gave the following case, evincing the danger- ous effects of hygeian pills. He had been called on the 5thinst. to a married lady, whom he found laboring under a most severe attack of acute dysentery. She had been complaining of irregular action in the bowels for two or three days, and during the day on the evening of which he was called in, she had had about 20 operations, attend- ed with distressing tormina and tenesmus, the discharges being chiefly blood and mucus. She said she had taken no medicine whatever, and had no appetite for food or drink. After stating, however, his surprise at the want of a satisfactory cause for such serious effects, his patient admitted she had taken only six hy- geian pills. The box was on examination found marked "Mor- rison's Pills, No. 2" This proved to be the most violent case of dysentery he had ever seen. It resisted laudanum in large doses by the mouth and anus, a large blister over the abdomen, (there being no fever,) sixty grains of Dover's powder and three grs. of acetate of mor- phine in twelve hours, combined with absolute repose in the horizontal position, (the patient usi '-pan,) diet, thus induced. Some medicines, as emetics, cathartics, enemata, &c, produce their effects by a direct and local impression on the part or organ to which they are applied thus sal epsom in solution stimulates the inner surface of the intestinal canal and can.:e; an increased secretion therefrom this mode of opera- tion, however, is limited a very large majority of therapeutic agists display their effects in parts distant from that to which they ar ; first addressed. There are three modes in which medicinal action may be com- municated from the part first impressed to others more remote : the 1st, by continuity of tissues ; the 2nd, by the sympathies; and the 3rd, by absorption into the circulation, the remedies being thus conveyed directly by the blood to the organs over whose func- tions they exercise a specific influence, or for which they have a peculiar elective affinity, as diuretics for the kidneys, abortives for the uterus, &c. With respect to the first of these modes of communication, there is perhaps little diversity of opinion among physicians all agree that irritation of much intensity, whether spontaneous or artificially produced, has a natural tendency to extend itself to contiguous parts, especially in the same tissues, and few, if any would dispute the physiological fact, first inculcated by the illus- trious Bichat, that if the mouth of an excretory duct be irritated, the irritation is propagated along the duct into the gland itself, causing an augmentation of its secretion, as exemplified in the effects of masticatories in promoting the flow of saliva, stimu- lants to the mouth of the lachrymal gland producing an effusion of tears, &c. This, however, is the least important medium of 1537.] Essay on the Modus Operandi of Medicines. 451 communication, and is comparatively of but limited application, in explaining medicinal operation. As to i! . the propagation of the action of medicines through the medium of sympathy, there is, I believe, perfect una- nimity among therapeutists no one disputes the very impor- tant agency of sympathy in communicating affections from one part of the economy to another. It is principally through the sympathetic and antagonistic relations that exist between the different organs and parts of the system, that impressions, mor- bific and curative, are transmitted through the organism: upon these relations depends the principle of revulsion a principle of almost universal application in explaining the operation and ef- fects of medicines. The sympathies direct and inverse, consti- tute a bond of union, by which all the organs and particular sys- tems in the general system are bound together, in one consentient and harmonious whole by virtue of which the affections of one part are conveyed to and felt by others, by which the organs feel and suffer together. The cerebro-spinal and ganglionic systems are the seats and media of the sympathies; as they are the organs of sensation, we cannot rationally conceive an idea of sympathy independent of them, therefore we shall employ the terms sympa- thy and nervous communication as synonymous. It is with re- ference to the third mode of operation, by absorption into the circulation, that there is some discrepancy of opinion among med- ical authors some denying this medium of communication al- together and accounting for every thing on the principle of sym- pathy whilst another party contend for both these modes of operation. The principal authorities in favor of sympathy exclusively, are Professor Chapman in our own country, and Drs. Addison and Christison in Europe on the other side of the question might be arranged a large majority of the most respectable medical writers, European and American. We will state as succinctly as possible, the theory of Dr. Chapman, in his own words, and then adduce some of the prin- cipal facts and arguments in proof of the absorption of medi- cines into the blood. " The theory I shall propose of the operation of medicines, (says Dr. Chapman.) alleges that they all act by exciting a local action which is extended through the medium of sympathy." 452 Essay on the Modus Operandi of Medicines. [Jan. " Conformably to the theory I have adopted, whenever a me- dicinal substance is applied to a susceptible portion of the body, externally or internally, an action is excited, which is extended more or less according to the diflusibility of the properties of the substance, or the degree of sympathetic connection, which the part may maintain with the body generally. Thus a set of ac- tions is raised, every one of which is precisely similar ; provided they are confined to the same system, by which is to be under- stood parts of an identity of structure. If, however, the chain runs into other systems, it loses its homogeneousness of charac- ter, the actions being modified by the peculiar organization of the parts in which they may take place. These arc principles of universal application. In every case, whether it respects the operation of remedies, or the production of disease, the spot pri- marily acted upon is a point, from which is diffused the radiated impression." "This is a mode of action peculiar to living matter, and is re- markably distinguished from all other processes. An impres- sion is made and extended without mixture or combination, or in any degree disturbing the order and constitution of the part in which it takes place." Inasmuch as we do not deny the influence of sympathy and the communication of medicinal action through the medium of the nerves, it is unnecessary to state the arguments in support of this position. The transmission of the effects of some medi- cines and poisons, is too instantaneous to admit of any other mode of communication than that through the nerves the sud- denness of their effects precluding altogether the idea of absorp- tion into the blood, such as prussjc acid, &c. Without considering with Dr. Chapman the stomach to be "the throne of the vital power," it enjoys the most numerous and the strongest sympathies with the organs generally, inso- much that when the stomach is languid, the whole system lan- guishes* and on the contrary, when this organ is excited by food or drink, the whole system participates in the excitement. As soon as food is received into the stomach of a person i e- ble and faint from fasting, strength and animation are imparted before the first process of digestion commences, which can only *"Vcntriculolan*ruido omnia langnent." 1837.] Essay on the Modus Operandi of Medicines. 453 be accounted for on the principle of sympathy the vigor thus restored, would however soon subside, were it not rendered more permanent by the subsequent conversion of the aliment into chyle and its absorption into the blood. But to multiply arguments to prove a fact so evident, so well established, and so generally acknowledged, would be a useless task. Professor Chapman's denial of the operation of medicines by absorption, is founded on two opinions that are in direct op- position to experiment and observation: First, that "chyle, however diversified the materials may be out of which it is formed, whether animal or vegetable, has essentially an identity of nature." And, secondly, " that it is incompatible with animal life, that such active substances (medicines) should be received into the circulation, since milk and other bland fluids have been known, when injected into the vessels, to occasion immediate death." It has been satisfactorily proven by the experiments of Dr. Marcet and others, that chyle resulting from the digestion of an- imal food, differs essentially from that derived from vegetable, in composition, appearance after standing, and in disposition to putrefaction, which takes place in three or four days in chyle from animal, and in not less than as many weeks in that from vegetable diet. With respect to the second assumption " that no substance in its active state can be received into the circulation," it is a fact abundantly proven, that many medicines can be injected into the veins, and that thus introduced into the blood they evince the same specific tendency or elective affinity for certain organs, precisely as when received into the stomach, except that their effects are evinced with much greater rapidity and in much smaller doses. Castor oil, rhubarb, emetic tartar, ipecac, &c, have been the subjects of these experiments, to the safe perform- ance of which, two precautions only are necessary that the substances be gradually introduced into the circulation, and that they be not too viscid or thick to pass through the pulmonary capillaries, by which the circulation would be prevented and fatal consequences result. Bichat thought that a bubble of air introduced into the veins, would be destructive to life, but more recent experiments have shewn, that if introduced slowly no injury may be apprehended. These experiments have been 454 Essay on the Modus Operandi of Medicines. [Jan. nsidered more interesting in a physiological point of view than of imp >rtance in practice, as a physician would scarce- ly think of injecting medicines into the veins, which could be so much more conveniently administered by the mouth or in ene- mata. But that terrific scourge which has of late years called into requisition all the resources of the profession, and the ut- most efforts of human skill and ingenuity? has proven not only the safety, but the nr utility of the copious transfusion of saline medicines directly into the blood. It is thus proven most conclusively, that medicinal substances may enter the blood and that through that medium they are conveyed directly to the or- gans with whose excitability they are in relation. It is true the artificial introduction of medicinal substances into the blood, and their operation when thus introduced there, do not prove their absorption into the circulation in other movies of exhibition still they go far in corroboration; but they are not necessary to the establishment of the fact. Medicines administered by the mouth and by the endermic and iatraleptic methods, have been frequently detected, not only in the secre- tions and excretions, but in the blood itself. Camphor has been found in the blood of the vena cava. Mercury has been detect- ed by Jourdan and others, in the urine of patients who had taken it; and Dr. Colson has detected it in the blood itself by introdu- cing plates of polished brass, which came out coated with mereu- rv. Another proof that mercury is absorbed into the blood and passes out by cutaneous exhalation, is, that a gold watch worri in the pocket of a person whose system is under its influence will exhibit a white mercurial coating. Iodine has been discovered in the blood and in many of the secretions and excretions, even in the milk of persons that had taken it for sometime. Children are often affected by medicines their mothers have taken, as though they were taken by themselves. This is a fact so well known, that some physicians give to the mother the medicine designed to operate on the child. Professor Dunglisson in his "Genera! Therapeutics," relates a case in which the most alarm- in^ degree of narcotism was produced in an infant by a large dns-' of morphine administered to the mother. Is this to be at- tributed to sympathy between mother and child? A very fa- miliar example is the effect of sulphur in imparting its odour to the perspiration and in turning silver coin, knives, &c. worn in 1837.] Essay on the Modus Operandi of Medicines. 455 the pockets of persons who have taken it, of a black colour. Spirit of turpentine is soon manifested in the urine by its smell, &c, and affects the kidneys much more in small doses than in large, because when exhibited quantities it proves pur- gative and is not absorbed. Sulphate of quinine has been detec- ted in the urine by M. Piorry, half an hour after its exhibition. Calomel given in one large dose, say 15 or 20 grains, will gener- ally irritate the small intestines and operate actively as ahydro- goguc cathartic whereas, when administered slowly in divided doses, until 40, 50, or 60 grains have been taken, allowing time for its absorption, the evacuations will consist of thick dark bil- ious matter, and longer retained without purgation, the mouth and salivary glands will become affected. What imagination vivid enough to explain all these phenomena by sympathy ? Passing by the very obvious effect that the food of cows has upon their milk the smell, taste and colour of many medicinal and alimentary substances are, constantly, observed in the urine, perspiration and breath some, as garlic, &c, even when ap- plied to the surface. Dr. Chapman supposes that these substan- ces are all perfectly assimilated, and their characteristic quali- ties completely lost, before they enter the blood, and that their elementary particles thrown beyond the sphere of the circula- tion, claim kindred, reunite again, atom to atom, in the secretions, and exhibit afresh all their pristine properties in this new existence. This fanciful supposition is too far-fetched, too un philosophical too absurd, to deserve a serious refutation. That the presence of medicinal substances is more of; en recognised in the secretions and excretions than in the blood, depends upon their greater dilution in the latter fluid. The secretions and excretions are the out- lets provided in the economy for the elimination of all foreign matter from the blood hence they are found frequently more concentrated in the former than in the latter. Dr. Christison does not deny a fact so often and satisfactorily demonstrated, as the absorption of medicinal substances into the blood, but still he contends that all medicines operate through the nerves alone. If the rapid and instantaneous transmission of the effects of some remedies be proof of the agency of the nerves, certainly the very slow operation of others is as strong against it, and affords pre- sumptive evidence mat their effects are propagated through some more circuitous route, or by some more gradual process ; 456 Essay on the Modus Operandi of Medicines. [Jan. that is, by being communicated through the medium of the blood to the organs acted on, or by modifying the exciting power of the blood itself. The methods of medication, by applying medicinal substances to a part of the surface from which the cuticle has been removed by a blister, and by friction or inunc- tion, prove the absorption of medicines into the blood. If iodine be applied to the surface for a length of time, the mammae testi- cles or some other gland become absorbed: who will attribute this to sympathy ? A miner employs quicksilver in collecting mi- nute fragments of gold and becomes salivated : is this to be at- tributed to sympathy between the palms of the hands and the sali- vary glands ? Nitro-muriatic acid rubbed on the surface causes the liver, previously torpid, to secrete bile. Nitrate of silver taken inter- nally, imparts a blue colour to the skin. Not only may the smell of alcohol be perceived in the blood, but it has been found in the ventricles of the brain of a man who had died suddenly after drinking a quart of rum ; and it is stated on good authority, that the blood of a drunkard was so impregnated with this in- flammable fluid as to ignite and burn on the approach of a can- dle. "Is the chemistry of the animal fluids, (says Dr. James John- son,) to be placed entirely to the account of the nervous sys- tem ? We have turbid urine, with deposition of uric acid. A few drachms of soda change the state of the renal secretion, and render it clear: Is this from sympathy, alone, of the nerves of the stomach with those of the kidneys ? Were it necessary innumerable instances might be adduced wherein the operation of medicines cannot be satisfactorily or rationally accounted for, unless by admitting their absorption into the blood. From a careful and candid examination of all the phenomena displayed in the operation of medicines, it appears to us the una- voidable conclusion is, that while the effects of some are com- municated more directly through the medium of the nerves, others are first absorbed into the circulation, but that, except when the impression is most sudden and evanescent, whether the sanguine or nervous system be primarily affected, the other becomes secondarily involved that is, if the nerves be first im- pressed, the impression extends from them to the blood vessels 1837.] Remarks on Hypertrophy, fyc. 457 and consequently to the blood ; and if the medicine be received into the blood, it not only affects the nerves of the vessels, but is conveyed through that medium to the brain and nerves every where throughout the body. As in all physiological and pathological processes, we observe the joint operation and involution of the nervous and sanguine systems, in those that are curative also, they are both mutually and reciprocally involved. The modes of operation of medicines may be summed up as follows: 1st. By a direct and local impression. 2dly. By sympathy of continuity. 3dly. Through the medium of the nerves, or sympathy direct and inverse. And 4thly. Through the medium of the blood. It would be an agreeable task did our limits admit, to institute an enquiry into the nature and effects of the impressions which medicines make on the system, which we believe are of three kinds, besides those whose operation is mechanical or chemical, viz : debilitation, sedation and excitation that is, by abstracting stimuli, by diminishing excitability, and by stimulating or increa- sing excitement ; but we respectfully submit to the society the remarks already made, as time will not permit us at present to enter upon the consideration of that interesting and important subject ARTICLE II. Remarks on Hypertrophy, fyc. : By M. Antony, M. D. As truth is the foundation of all moral, so is it of all scientific excellence. And in no branch of science is tins virtue more de- sirable than in medicine. This is a science which, when its claims arc duly considered, demands the most unerring judg- ment, not only for the well doing of its professor, but on account of the important interests of humanity. Not only comfort, but human life rests its hopes on those truths which are the physi- cian's data for sound reasoning. Without these, the practition- er must be as the mariner in the raging tempest, with helm in hand, but without sun, stars, log. or compass. And as the latter 458 Remarks on Hypertrophy. [Jail. most probably guides his barque to the wrecking shoal, so does the former without the sound premises of truth, guide to destruc- tion the frail casket of humanity. These reflections have been suggested by contemplating the love of novelty and the spirit of ultraism which pervade the profession in the present age. One of the great causes which drove our own immortal Rush to untenable ultraism in the sim- plification of disease, was the falsehood of nomenclature, arising out of the errors of classification. Two elements are essentially necessary to nomenclature, without either of which, the very name given is pregnant with mischief. The first is, a name which shall itself declare the nature of the tiling named, and the second is the real facts of the nature of the thing to which the name is applied. Nomenclature, therefore, so long as it contains these elements, is most convenient and unobjectionable : In a word, it declares to us the philosophy of the thing. The name of a disease or a disorder, or any unusual physiological or pa- thological phenomenon, must, in order to answer the purpose of nomenclature, declare the nature and condition of that disease or disorder, or unnatural occurrence; and the knowledge of the facts- which justified the name must furnish us with the whole of the causes, and the present condition of the phenomena. It must declare the state of the system, or that part of it concerned, and the causes operative in the production of that state. If then a name of phenomena, which result from one cause or set of cau- ses, be given to those phenomena which have resulted from ano- ther, we find ourselves at once plunged into all the dangers of erroneous diagnosis ; or if we fail to discover our error here, we are soon overwhelmed in the more immediately dangerous one of erroneous prescription ; for our prescriptions must generally bear a relation to causation, as well as to the present phenomena. We perceive in the Clinical Lectures of M. Lisfranc,* the term hypertrophy, used synonymously with metritis. For ex- ample, " Chronic metritis, or simple hypertrophy of the uterus." The state which M. Lisfranc alluded to by this name, is well defined to be a mere increase of healthy tissue in distinction from schirrous and the white tissue resembling, but very different from it. This state " is generally very insidious in its progress, ''See Southern Medical and Surgical Journal, page 303. 1837. J Remarks on Hypertrophy. 459 especially about the critical age," but less so as we approach the greater irritability of earlier life. " Touching is always a pain- ful operation, and the consistence of the uterus is found normal, though rather soft. To the feel, it gives the same impression as an uterus in early pregnancy, or shortly after abortion, and is sometimes as large as the head of a six months' fetus," and sometimes much larger, and generally, perhaps always main- tains very nearly the shape of the uterus when enlarging in the different months of pregnancy. But so soon as the name "hy- pertrophy" is given to it, the value of those truths which entitle it to some name is lost, because hypertrophy means a state of deviation from ordinary physiological, or rather anatomical con- dition, consisting of an increased growth of the hypertrophied part, differing however in causes and condition from what we should call metritis. It cannot therefore fail, if confided in, to lead to much mischief in all diagnosis, and therapeutics, and consequently in prognosis. If compared with hypertrophy (of the heart for example,) it will be found essentially different. Nor is it unimportant to mark the distinction ; for there is some- thing of obscurity, nay much, in the pathology, (if I may so speak of hypertrophy,) which repels enquiry into the cause, and its manner of producing its effects. And without mere accident, the indications of cure must be defective in proportion to the error in etiology. This is, but for chance, just as sure as that effects depend for their production on their causes ; which should be con- sidered, as it is, self-evident. It is therefore our purpose in this paper, to illustrate more plainly and definitely, the subject of hy- pertrophy. Hypertrophy should be distinguished from swellings the ef- fect of recent, subacute, or chronic inflammation. These cause swellings, acute or chronic, in certain parts, attended with in- creased sensibility, redness, &c* as the necessary consequents of a law of irritation, whereof increased fluxion is the result. The greater the constitutional irritability, the quicker these swel- lings are developed, according to the same law ; and the quicker they are developed, the greater is their sensibility. Hence, what have been by M. Lisfranc called hypertrophy of the uterus, are generally very insidious in their progress about the critical age, and are, cet. par. less so in earlier life. But the slower the pro- gress of the case, the less is the sensibility exalted ; consequent- 460 Remarks on Hypertrophy. [Jan Iy, the tenderness to the touch does not so readily characterize the disease. The acute case of this kind affecting a viscus, is a proper phleg- monous inflammation and will be found more rapid and strong- ly marked not only in early life, under the same circumstances otherwise, but also in the sanguineous temperament, because in this the hematosin of the blood is greater in proportion to the other ingredients, and the circulation therefore produces greater excitement in just proportion, as evinced by the peculiar irrita- bility of that temperament under any exciting cause. This true phlegmonous inflammation of a viscus, is one extreme ; and as we consider this nature becoming, in obedience to the whole in- fluencing circumstances of the case, as age, temperament, &c, &c, more and more chronic, it approaches the other extreme, as in advanced life, phlegmatic temperament, &c. And thus are produced chronic phlegmasia? : but they are all phlegmasia) still. We would illustrate hypertrophy in the following manner : All the actions of health are merely series of excitements. But so long as these actions do not exhibit the characters of disease, they arc properly considered physiological. If by any means these excitements become so increased as to cause an increase of growth in any organ or tissue, stopping short however of morbid phenomena, except increased size, such increase of growth should be called Hypertrophy. This is a word of Greek etymology, Meg and to*j, and literally means super-nutrition, unnatural, or excessive accretion. Nor is there good reason in necessity or elsewhere for altering the literal signification. It is fairly applicable to the whole system, or any of the organs which enter into its composition, or any particular organic system. A muscle is enlarged by use to double its natural thickness. This is sometimes observable in the features of the face, often in the legs of dancing masters and pedestrians, and almost always in the biceps flexor cubiti and other muscles in the arms of axe-men, blacksmiths, &c. This is a growth of the natural structure, effected in the same manner that the arterial system, by acting, increases its power of action during the first half of life, until it exceeds the veinous resistance, and throws the ple- thora from itself into the veins. Exercise of a faculty exalts and perfects that faculty. It is so, not only in the corporeal, but al- 1830.] Remarks on Hypertrophy. 401 so in the mental faculties. This enlargement of muscle may be considered a hypertrophy. It is an enlargement of the natural structure beyond what is natural or ordinary, and which, as a pe- culiar effect, has its peculiar cause. This cause is action. For if instead of giving the organ increased action, its actions be re- strained by avoiding exertion, or by compression, as by a band- age, &c, the organ not only fails to be exceedingly developed, but actually becomes atrophied. The brain of Baron Cuvier may be considered as hypertrophied, and by the same cause, great exercise, as every one must acknowledge who is acquain- ted with the immense intellectual labor of that man. The heart becomes hypertrophied in the course of a long time, from the occasional, though more or less frequent excitement it undergoes from the exhilarating passions, &c, and more quickly when produced by causes which are more steadily in operation, whether mental or physical ; as by the exciting passions, or by daily liberal potations of wine and other fermented liquors. Hence the great frequency of hypertrophy in apoplectics and paralytics. Here then is a very obvious difference between hy- pertrophy and that swelling which is produced by the fluxion consequent on irritation ; but the difference is still farther re- markable : this tends to phlegmonous inflammation, and through it, to some of its terminations, according to the peculiar circum- stances of the case ; as suppuration, schirrous, gangrene, &c. ; whilst hypertrophy has no tendency to either of them. These states may be still farther distinguished by the reme- dial measures appropriate for each. If you would palliate hy- pertrophy, or prevent its ill consequences ; or if you would hope for its removal you would rely on withholding its peculiar causes ; and even where applications might be practicable, go to the ex- treme opposed to its causation ; that is, not merely suspend ex- ercise, but compress the organ, or otherwise promote the action of the absorbents of the part : and here is the sum of resourses in a remedial point of view. But in the case of phlegmonous in- flammation, when the increased action has been the effect of vascular irritation, we have at command the various antiphlogis- tic means which operate mainly by lessening the vascular action of the centrifugal powers (the heart and arteries), as well as promoting the action of the centripetal, (or absorbents,) the re- moval of local irritants, &c, all tending to resolvent effect. 462 Remarks on Hypertrophy. [Jan. Here will be found causation which is approachable with thera- peutic means ; and we should examine, study and detect, that we may attack it. These considerations lead us to the conclusion, that M. Lis- franc's cases of hypertrophy of the uterus, are to be considered more properly phlegmonous inflammations of that organ; and that they are in that state and period in which they exhibit swel- ling, with more or less increased tenderness, heat and redness, and that they demand the removal of all causes of irritation in the part, as well as all obstructions to a free transmission and return of circulation. These may be very chronic, according to the peculiarities of the general system, the habits of the individ- ual, the previous treatment of the case, &c. &c, and may tend to any of the other terminations of inflammation than that in resolution ; as suppuration, or the white tissue so much resemb- ling schirrus. We need not expect to compare it in all respects with a phlegmon situated in the cellular tissue for example, for like the liver and the lungs, the tissue of the uterus is very pe- culiar, and this peculiarity, like that of the other organs just named, is calculated to come into the chain of cause and effect, and produce its proportion of peculiarity in the resulting phe- nomena. Thus we see these tumors last sometimes for years, and sometimes for almost an age and again, we see them de- generate into those conditions which have their other names, and thus are produced ulcerations, enormous white enlargements, &c. &c. It is not a little remarkable, that a man of M. Lisfranc's intel- ligence and experience should have allowed an error thus intro- duced, as it appears to have been, by a mere name, to have gone its wayward course in all the succeeding details of medical phil- osophy, and finally into a practice most inert and deficient in some respects, and most imprudently bold in others, when con- sidered in relation to true cause and pathological condition. There is, as we have often observed heretofore, no error more prolific of mischief, passive or active, than that of connecting ef- fects with causes which did not produce them. To this error we must consider M. Lisfranc indebted for his failure in relation to therapeutics in the disease in question. He has described a true sub-acute or chronic inflammation of the uterus, under the ap- pellation of "simple hypertrophy," which means merely "% 1837.] Remarks on Hypertrophy, 463 increase of healthy tissue :" and so little has been known of gen- uine hypertrophy, that the word has carried with it in its appli- cation to metritis so much of its own deficient etiology, as to obscure the view of causation in this latter affection. Thus it is that his prescriptions appear certainly to be the result of partial observation of this disease, with an eye jaundiced by hypertro- phy, and not that legitimate deduction from the whole premises which constitute the fundamental philosophy of the case ; for these include at least the whole causation, and the true patholog- ical condition. We have before alluded to the treatment rationally determined for genuine hypertrophy ; we will now endeavor to show the difference between these affections by exhibiting the demands of true metritis. It is passing strange we say, that even the action of some of his remedies had not informed M. Lisfranc more of the causation, as well as the pathological state in this disease. But whilst he considers, and very correctly too, that absolute rest is amongst the influential means of effecting a cure, and that the patient should not be allowed to walk even to her sofa, nor move roughly in bed, he at the next instant declares "these precau- tions are recommended in order to prevent the irritation kept up by the friction of the uterus against the adjoining parts." Well may his discerning annotator ask the question, " Is this friction really produced, as M. Lisfranc believes, by ordinary move- ments V No. Were this the cause of the existing irritation, the prescription would then bear a good relation to it. But this being not the fact, the prescription, though in part necessarily demanded by the rationale of the case, is inefficient alone, being only secondary in importance at most. Hence the necessity for the next error, depletion for its revulsive effect, which although sometimes perhaps correct, is not generally so, because there is an abiding cause, the removal of which is demanded by the fair reasoning in the case, and with which, the effects will almost always cease; especially if the other appropriate, more prudent and safe auxiliaries be simultaneously and consecutively in ope- ration: and not only so, but it would be in opposition to all sound reasoning to expect a given effect to cease, whilst its causes con- tinue in operation. We have thus instanced one or two of the therapeutic errors arising out of views of the causation but too limited. This 464 Remarks on Hypertrophy. [Jan. train of errors continues on the same principle to the prescrip- tion of and reliance on antispasmodics, if the nervous system be found to suffer the use of tepid baths tepid enemata, because the bowels tend to constipation, and the fecal collections increase irritation tepid vaginal injections three times a day with linseed fomentations a small elastic canula introduced with caution for the administration of injections, to prevent wounding the dis- eased parts dry cups moxas blisters and issues, as revul- sives to the pelvis regimen, as avoiding coffee, reducing the quantity of food to half the general allowance exercise at the menstrual period leeches to the os tinea?, to stimulate the ves- sels and bring about the removal of superfluous matter frictions with iodine douches de vagin, &c. &c. Does M. Lisfranc or any one else believe that this metritis is produced, continued and increased, by no particular cause or causes ? Did it merely arise from an increase of the healthy growth of the part by nutritious accretion? Or if according to his description of the facts of the case, which constitute chronic metritis, irritation exist, did that irritation arise spontaneously, making the first link in the chain of morbid phenomena, and there- fore only needing revulsive powers? Surely this cannot be be- lieved by any one. Even hypertrophy must have its causes; but they are in good relation with their effects, which exhibit no more of the characters of inflammation than did Mr. Daniel Lambert, whose adipose tissue was so hypertrophied that al- though but five feet eleven inches high, he arrived at the enor- mous weight of 704 pounds, with a girth of body of nine feet four inches and of the leg of three feet one inch ; and who, though convivial, was temperate in all things, being a cold water drinker, and eating only of one dish at a time. He scarcely knew what indisposition was was cheerful, intelligent, free in respiration, not disposed to drowsiness, was able to walk up stairs with great case, and believed, says his biographer, that he could walk a quarter of a mile. So also must metritis have its causes, and these must be in good relation with their effects. What then arc these effects which make up the phenomena of the disease, whether acute or chronic? These phenomena are swelling, tenderness to the touch, pain and heal, (if acute,) and doubtless redness, & tending to some of the terminations of inflam- mation. And here, we doubt not, may be found the true source 1837.] Remarks on Hypertrophy. 465 of those ulcerations of the os tinea) and cancerous degenerations for which M. Lisfranc has so freely and frequently amputated the os tincse, to be that the disease, being considered hypertro- phy, has been subjected to a treatment, (if any at all,) but par- tially adapted to its necessities. Here the nobler talent of the surgeon should have been displayed, in preventing these or curing them when produced, instead of amputating. Any tyro can amputate a leg, but the best surgical talent is often needed for the cure of that lesion which seems to render amputation necessary. Differing essentially then from hypertrophy, chronic metritis is explicitly this, that the circulation through the blood vessels, both veins and arteries become obstructed by the undue pressure of the displaced uterus on them. This being the case, no anato- mist who will contemplate the immense and curious distribution of arteries to this viscus and its appendages,* and the corres- ponding veins and lymphatics, will be surprised at the appear- ance of that irritation and tumefaction which must be consequent to such obstruction. Nor will any surgeon be astonished at the increase of size, tenderness to the touch, &c. &c, which are ac- knowledged characteristics of this disease. With this view then of cause and effect in this case, what curative indications are ra- tionally suggested ? They are 1st. To remove the impediment to the free transmission of blood and lymph. 2d. To correct the effects of this obstruction. In the fulfilment of the first indication, we are unavoidably led to enquire into the cause of obstruction of circulation, that we may direct our attention to its removal. Had cold been the cause of this obstruction, then indeed most of the means prescribed by M. L. would have been in relation therewith ; as revulsion, avoiding irritating causes, &c. &c. Nor would these have been less applicable to such a case produced by lacerations and other kinds of violence inflicted on the substance of the uterus: but these causes are rarely in proximate connexion with chronic metritis their effects being generally acute, although there may be rare instances of its existence from this cause. Yet if JVI. Lisfranc has had these or similar causes in view, in the chronic metritis described by him, under the name of "simple hypertro- phy," he has greatly erred in omitting a cause, twenty, perhaps *See Tiedeman's Plates. 59 466 Remarks on Hypertrophy. [Jan. a hundred fold more common, which omission must, as it actu- ally does in his details, extend a most important influence throughout the whole of the subsequent views taken in the case. In truth, there is generally, on fair and thorough investigation of these cases, no such cause alleged by the patient. If she state that she has taken cold, it will generally be ascertained that this statement is founded merely on the fact of some menstrual irreg- ularity commonly a retained, suppressed, deficient, retarded or painful menstruation, of which she believes cold the only compe- tent cause ; but to which she had suffered no particular expo- sure. On diligent enquiry it will be found that she suffers bar- renness, fluor albus, &c. ; spinal irritation, in the lower lumbar or dorsal vertebrae, sacrum, or whole column will be very com- monly found in connexion with hysteria and other nervous phe- nomena nervous symptoms with the nervous temperament, he- patic with the bilious, and pulmonary with the sanguine ; and these variously mixed and diversified according to the mixtures of temperaments, and the joint or collateral influence of other accidents, &c. ; but these are to be looked on as effects or symp- toms, and not as causes. Whilst therefore they need corrective means, we are still impelled to the investigation of cause. On farther inquiry it will be found that she has suffered menstrual irregularity in some respect, preceded by abortion, difficult la- bour, too soon quitting child-bed, over exertion, a fall, the use of eorsettesf &c. and that she suffers pain about the sacro- vertebral junction, the sacrum, the ganglion impar, the round or broad lig- aments, burning, or obstruction, or incontinence of urine, or con- stipation from obstruction of the rectum, or tenesmus or dysen- teric distresses from irritation of the part, &c. These and the like, point to the fact of uterine displacement, and justify the touch. On this mode of enquiry, the displacement will be found to exist, and the uterus generally lower down than natural, with its lower orifice towards or at the vertibule, or fossa scaphoides ; and often in cases which have been long existing, accompanied with various degrees of tenderness, mobility, &c. This fact dis- covered, we have at once a cause adequate to the production of all the phenomena, primary or secondary a cause immediately proximate to the effect, the removal of which is the object of our first indication ; a cause at once calculated to produce, under or- dinary circumstances, just such effects as we observe, and a 183G.] Remarks on Hypertrophy. 467 cause, the removal of which will be speedily followed by the a- batement of all the local phenomena. The replacement and retention of the uterus in its proper site become therefore the legitimate prescription ; nor is there within the whole range of remedial means, one more uniform in accom- plishing the intended object. So soon as the prescription is ful- filled, if the case be not very chronic in its nature, the arteries which arc abundant, are enabled to effect a free transmission of the blood ; and the veins and absorbents commence the work of resolution. This is all accomplished with surprising rapidity, on the good retention of the uterus and a well regulated regimen. Frequently in the course of a week or two, have I observed these enlargements of the uterus, which had been of many months' duration and of considerable size entirely disappear. But most commonly the process is tedious, requiring many^ weeks, and sometimes many months for its entire removal ; and occasional- ly the assistant means of alterative medicines, as iodine, mercu- rials, antimonials, guaiacum, &c. The bilboquet pessary, made of soft elastic material, we have proven by the experience of the last twenty years, to be the best retentive mean for the uterus ; not operating, as Lisfranc be- lieves, by promoting absorption on the principle of compression ; but simply by retaining the uterus so as to liberate the vessels, and allow them their free action. It is true, that from the great enlargement of the uterus, and the extension of the disease to the circumambient attachments, the uterus is sometimes so immova- ble, as to require very considerable pressure by a pessary made more firm and impacted between the perineum and the os tincae ; but even this cannot act mainly by promoting absorption on the principle of pressure ; as its pressure is only exerted on one point. Thus have we imperfectly accomplished the hasty sketch of the nature of hypertrophy and of metritis, which we designed ; and we hope that the practical bearing of the errors in nomenclature and reasoning, may at least be so apparent, that humanity may not suffer from such errors. In conclusion, it is but justice to remark, that so far as the ob- servations we have made bear on the instructions of M. Lisfranc, the writer has been actuated by no motive or feeling apart from those directed to the cause of truth and humanity. It may be 468 Remarks on Hypertrophy. [Jan. objected that the arraignment of unpublished doctrines and in- structions of an individual for the purpose of exposing and cor- recting the errors of the same, is unjust and illiberal. So far as we are informed, M. Lisfranc has never published the instructions above alluded to, in a book ; but they are doubt- less published annually in a more impressive and effectual man- ner that is, to an immense class in his course of extemporane- ous clinical lectures, and with an influence of character calcula- ted to inspire the fullest confidence in the truth and accuracy of every .word which falls from his lips. These instructions are taken down by most of the industrious, faithful and zealous hear- ers, and thus are disseminated those instructions, in a way best calculated to give them their full influence, whether good or bad, on the practical details of the profession. We hold him there- fore, at least, not less accountable for error thus inculcated, as it is alike calculated to retard science, and operate injuriously to humanity. Nothing is more calculated to regulate and improve genius than scrupulous watching and diligent chastisement; for, as with the percussion of flint and steel, its brightest scintillations are excited by attrition. 1837.] Treatise on the Radical Cure of Hernia, tyc. 4G9 Part II. REVIEWS AND EXTRACTS. Treatise on the Radical Cure of Hernia by Instruments, fyc. $c. By Heber Chase, M. D., Honorary Member of the Philadel- phia Medical Society, &c. pp. 195. Philadelphia, 1836. The American public has been much agitated on the subject of Trusses, recently invented for the radical cure of Hernia or rupture. Two or three years ago, a Mr. Stagner of Kentucky, it is said, accidentally relieved himself permanently of a rupture, by placing a piece of wood between the spring of a truss and the skin covering the protruded bowel. He subsequently modeled a block for which he obtained a patent, established agencies in several States, and realized from his invention an immense for- tune. We at a distance from these operations, anxiously looked for a professional notice of this truss, in some of the periodicals of the day ; but it was in vain. During the winter of 1834-5, several of Stagner' s instruments were placed in our hands by an agent, and after their application in six or eight cases without benefiting them in the least, they were laid aside, with the con- viction that further improvement was needed to effect what was promised by them, viz. : a radical cure. One of our patients, the Rev. Mr. Reid, then of this city, added a new spring to Stagner's block, for which he obtained a patent, and submitted it to the Medical Societies of Georgia and South Carolina. The following are extracts from the report made by the commit- tee appointed in this city. " The committee have had placed in their hands the certificate of two of Mr. Reid's patients, and the statements concerning the application of the Truss to five others, making in all seven cases. From some of the patients residing out of the city, we have been able to examine and collect the partic- ulars of but 5 cases out of 7, to whom the truss has been applied. Mr. M; who was ruptured on both sides, believes himself permanently cured on one. He has left off the truss for more than 24 hours, and notwithstanding consid- erable efforts were designedly made, no protrusion took place." " Mr. Martin, now in his 95th year, and well known as the oldest inhabi- tant of Augusta, has been afflicted with hernia for more than 40 years and, after having tried every truss that he had ever heard of, expresses his entire satisfaction of the relief afforded, and thinks he yet may be cured by wearing the one applied by Mr. Reid." * Mr. S. after wearing the new truss about six weeks, writes ' I am now satisfied of the benefit it will afford the afflicted. It has given me relief, and I am now quite easy while wearing it \ and would recommend it to any per- son afflicted with hernia." " The negro man Isaac, belonging to Mrs. Rowell, has already been pre- sented to the Society, and all have had an opportunity of examining him per- sonally, and of judging of the operations of the truss in his case." " The fifth case, which we have investigated, is that of the Inventor and Patentee himself, who has been afflicted with inguinal hernia on both sides, 470 Treatise on the Radical Cure of Hernia, fyc. [Jan. on one for more than 35 years, and on the other for several and, after ex- periencing the defects of the trusses, which had been recommended to him, is now relieved, by the one which lie has invented or improved." "Of the five patients that we have examined, one believes himself entirely cured on one side ; and all are satisfied of the truss' maintaining its proper situation independently of any other apparatus and of the entire relief it af- fords. " The greatest improvement, however, which occurs to the committee, is, that this truss operates in maintaining its position without the aid of belt, strap, buckle or any other appendage whatever, the chafing and disagreeable effects of which, cause patients so generally to complain." " We believe Mr. Reid entitled to full credit for all he claims in his patent ; that the Independent Spring Truss is an improvement ; that it operates and retains its situation, when applied, independently of any other apparatus ; that it does prevent the protrusion of the abdominal contents ; that it thus affords relief, and that if any other truss will produce a permanent cure, this one will." Mr. Reid's truss was also approved by the Medical Society of Charleston. In a recent conversation with Mr. R., he admitted that during a visit to the north, he had experienced some difficulty in having his instrument properly made, but that he had finally succeeded in Baltimore his agent here, however, is still unsupplied with them. The name of Dr. Hood has also been associated with that of Mr. Stagner, as an inventor of improvements to the truss for the radical cure of hernia. And finally we have that of Dr. Chase, who seems to have devoted himself almost exclusively to the sub- ject of hernia, and the product of his labour and inventions is contained in the work, the title of which is placed at the head of this article. Dr. Chase's publication has forcibly impressed us with one idea that he is honest in the improvements now presented to the public. Unlike hundreds around him, he has come forward and candidly submitted his inventions to his professional breth- ren, the proper, if not the only tribunal capable of pronouncing a correct decision upon them. The same credit we have given to the Rev. Mr. Reid. En passant, what would be the effect of placing Chase's block upon Reid's spring ? Might not the " In- dependent Spring" and the "Surgeons Truss" be combined with advantage ? The Treatise on the Radical Cure of Hernia by Instruments, is dedicated to Drs. R. Coates, Ashmead and Parish, members of the committee of the Philadelphia Medical Society, appointed to investigate the subject of the radical cure of hernia. It is design- ed for those affected with hernia or rupture, and the language is adapted to the comprehension of every one it is a popular and at the same time a scientific work. It is embraced in eleven chapters, and illustrated with numerous figures. Chapter I. contains a minute and popular description of the 1837.] Treatise on the Radical Cure of Hernia, fyc. 471 various ruptures occurring in the human body. We have read this chapter with much pleasure. The description of inguinal, scrotal, femoral and umbilical hcrniae, is decidedly the best we have ever seen. His observations concerning the careless man- ner in which trusses are daily applied and constantly worn, are confirmed by every practitioner. It is true, " a large majority of those who die of hernia, or are subjected to severe surgical operations for its relief, are persons in the constant habit of wear- ing the trusses heretofore employed." His remarks too about patients wearing the truss day and night, will be responded to by every one knowing the importance and even the absolute neces- sity of keeping the intestine within the abdomen, when a radical cure is proposed. Chapter II. is taken up with the symptoms of hernia not stran- gulated. Chapter III. contains the directions for reducing hernia. We would suggest in addition to the means mentioned in this chapter by the author, the good effects resulting from the evaporation of ether. As an application for reducing strangulated hernia, it cannot or is not so liable to be abused, in the hands of common people as cold directly applied. It never produces mortifica- tion. Chapter IV. is on the retention of hernia by trusses. Inclu- ded in which we have the different kind of trusses heretofore in- vented, and the different parts composing the truss page 52, line 12, the word "ruler" should be rule. The most important section of this chapter is the one on the materials for pads or blocks. We agree with Dr. Chase in condemning the india- rubber or gum-elastic, as a substance entirely inapplicable for this purpose. We have seen a case where it produced not only a blister but an ulcer. Our author, of course, selects a block of wood. Chapter V. is the history of the progress and present state of the improvement in the construction of wooden truss-blocks. In this, we have mentioned, the names of Stagner and Hood, and also an account of our author's association with the latter. It concludes with a description of the wooden blocks invented by Dr. Chase for the radical cure of inguinal, femoral and umbilical hernia?. Chapter VI. on complete trusses containing the explanations and figures of the application of Dr. Chase's truss for the differ- ent kinds of rupture. Chapter VII. contains the modus operandi of the instruments for the radical cure of hernia. This is the most interesting and important chapter in the work before us. In what manner does the instrument operate in effecting a radical cure of hernia ? Mr. Stagner and Dr. Hood attributed it to adhesive inflammation, ex- cited by the pressure of their instruments upon the neck of the 472 Treatise on the Radical Cure of Hernia, c. [Jan. sac. Dr. Chase thinks, that though the pressure of his truss pro- duces redness of the skin in the great majority of cases, it would be premature in him to attempt to decide, at present, how much the production of local irritation accelerates the radical cure, in the treatment of hernia by wooden blocks. The committee ap- pointed by the Philadelphia Medical Society, expressly state that the excitement of local irritation was a matter of " secondary importance" And Dr. Chase addressed a letter to Dr. Reynelf Coates, the chairman of said committee, on this subject. Dr. C. in his reply, has reviewed the different modes which have been proposed for the radical cure of hernia. His conclusion is, " that in most cases of the radical cure of hernia by means of trusses, the neck of the hernial sac is obliterated either by adhesion or more rarely by absorption. In reading the lengthy answer of Dr. Coates, we were not a little surprised to find no notice of the method recently proposed by Gerdy of Paris, for the radical cure of this affliction. We allude to the operation of pushing the skin into the place occupied by the herniary tumour, and per- manently securing it by exciting adhesion. Several successful cases from this new operation have been reported in the journals of Paris, and we think they have been noticed in Johnson's Re- view. Chapter VIII. on the manner of applying the different instru- ments, and some precautions necessary to be observed in using them. The remarks contained in this chapter are judicious and excellent. We learn from it that Dr. Chase has applied his truss with good effect, on a child only six weeks old, and frequently to those of the age of six months. Chapter IX. is taken up with cases and the results obtained by the use of the improved instruments. The cases contained in this report are not selected, but are those only which have been most regularly noted. They number 32, and to judge from the entire and complete success obtained in many of these cases, all must now admit of the radical cure of hernia, and that Dr. Chase's truss is decidedly the best yet invented to effect that object. This chapter concludes with a tabular statement of 100 cases of hernia. Chapter X. is occupied with the diseases mistaken for hernia. This is not an uninteresting chapter. Not only patients, but too often for the good of the profession, men professing to be doctors, if not surgeons, are deceived on this subject, and many an one has worn a truss who never had a rupture. Chapter XI. the last, is on the subject of hereditary hernia ; and from the author's experience he believes this to be a cause predisposing to this affection. In concluding this lengthy review of Dr. Chase's Treatise on the radicul cure of hernia by instruments, it is unnecessary to add more to what has been already said, to recommend it to every 1837. J Remarks on Chronic Fluxes of the Bowels, fyc. 473 one afflicted with rupture, and to the profession generally. We are pleased that our author has placed this subject in its proper light before the public, and doubt not but that he will be amply- rewarded for all his labour and expense. We hope moreover, he will continue his investigations, and that his success will en- courage others to similar undertakings. Not indeed in writing popular treatises on medical subjects, but that talented and enter- prising men may direct their undivided attention to one object in medicine, so that after due and thorough investigation, it might be properly estimated by the profession. P. F. E. Augusta, December, 183G. Remarks on the Chronic Fluxes of the Boiuels: By N. Chapman, M. D. Not a little diversified are the symptoms of this pathological condition, though in nearly all instances the bowels are very irritable, and consequent- ly excited by the slightest causes. The stools may be small and of mucus, sometimes tinged with blood, or containing fragments of lymph, or are glairy or gleety or exceedingly copious, and of a light clay colour or dark and granulated like coffee grounds, or resembling greasy water, and of a cadaver- ous odour or are seemingly of putrid chyme, or pulpy, mixed with ingesta, very frothy, and of divers hues, though usually of an ashy or slaty aspect, and are attended by more or less tormina and tenesmus or straining, or come a- wav at once in a gush, or by a sudden ejection or squirting without any un- easiness. The mode of evacuation depends much on the character of the stools slow and difficult when they are small and tenacious, and the reverse if large and watery. Little appetite exists, or it is very capricious, and the food taken is seldom thoroughly digested. The tongue is heavily furred in the centre and at the root, with florid tip and edges, or red and raw throughout, as if scalded; or with scattered superficial ulcers on it, and the inside of the cheeks and lips, or down into the fauces or it is pallid, attenuated and flaccid. The skin is dry, furrowed, and of a dingy white or sallow, or leaden hue the eyes sunken, with a shrivelled and meagre expression of countenance. Tenderness of the abdomen is felt on pressure, though not uniformly, and it is tumid or the contrary, lank, relaxed, or even collapsed. Borborigmus is very troublesome. The pulse is often contracted, hard and accelerated, with an irregular febrile movement, especially in the evening but it may be natural, or very diminutive and feeble, with low temperature of the surface, or while the extremities are cold, the belly is preternaturally hot. Emacia- tion advances rapidly, with corresponding debility, till finally the individual sinks from absolute exhaustion, death being preceded by oedema of the low- er limbs, apthae of the throat and mouth, redness and ulceration around, or within the verge of the anus, and the Facies Hippocratica strongly marked. The duration of an attack is very various, from a few weeks to months or years, subject, when long continued, to alternate remissions and exacerba- tions. Chronic fluxes may be an original affection, or the consequence of an acute attack, protracted by neglect or ill management and when of the former or primary nature, are assignable to many of the causes of the latter, opera- ting less actively. 60 ( 474 Remarks on Chronic Fluxes of the Bowels. [Jam They are undoubtedly induced by malaria, whether the vitiation of the at- mosphere be owing to the effluvia of vegetable or animal decomposition, or other offensive impregnations scarcely less so by the excesses or variations of temperature, particularly moist, austere weather, and by the occupancy of cellars and other damp confined places. As much, perhaps, may be ascribed to the direct irritation of the prima? vise from aliments or drml^3, such as tainted or tough indigestible meats, sour or mouldy bread, or crude or decayed vegetables or fruits, the intemperate use of ardent liquors or bad water, putrid, or charged with adventitious mat- ters. They result, too, from the long persistence in purging w7ith drastic arti- cles, as is practised by some for the removal of diseases, and above all drop- sy, of which I have seen repeated instances, and by whatever indeed is cal- culated thus to worry the bowels into a state of exasperation, or to destroy their tone, or otherwise throw them into derangement. It is in this way, I' have little doubt,- that the horrible abuse of mercury throughout a consider- able extent of our country concurs in the production of similar mischief. Nothing is more irritating to the alimentary tube, the liver,, and to the wmole of the abdominal viscera, than this very article, unless cautiously regulated and when we advert to the indiscriminate and exorbitant employment of it by confessedly too many of the practitioners in the region to which I have alluded, the conjecture advanced, seems scarcely to require any confirma- tion. Nor must the exanthemata be omitted in the enumeration of causes. These have their origin in the mucous membrane of the alimentary canal and the translation to the skin not perfectly taking place, leaves behind an irritation productive of this effect, as is strikingly exemplified in scarlatina, measles, &c. Chronic eruptions of different kinds receding from the cuta- neous surface, occasionally operate also in the same mode, two instances of which I have seen. Certain sections of our country ere singularly liable to the disease, and it prevails to a great extent, especially at or near Richmond and N. Orleans- Cases of it I have annually from each of these cities, and am assured that it Is one of the most terrible of their maladies : no age, sex, or condition of life is entirely exempt from it, though it rarely occurs before puberty. What occasions it, is not ascertained : nothing peculiar about Richmond exists to which its production can be referred, but at New Orleans the popular notion connects it with the use of the turbid waters of the Mississippi. Never ha- ving seen a case in the early stage, I am not able to describe it from any knowledge of my own, but I learn that it usually commences with the symp- toms of dyspepsia. As it has come before me, the disease was far advanced, and only distinguishable from more common diarrhcea, by less emaciation, the flesh and integuments being rather flaccid than wasted, and by a peculiar sallowness of skin, more of the light lemon than the orange hue, and by the number and copiousness of the discharges, which invariably resemble pale clay or Fuller's earth dissolved in a quantity of water.* Chronic fluxes are moreover of a secondary nature, from the extension of irritation to the bowels of other diseased organs,, as the stomach, liver, spleen, pancreas, kidneys,, uterus, the lungs and I have seen it occasioned byhae- morrhoidal tumours or ulcerations at the termination of the rectum. 1 Diarrhoea of a somewhat different kind appears to be hardly less frequent among our Eastern population, especially that of Boston, the source of which is as little intelligible. But the individuals whom I have attended with it, in their passage through this city to the South, all concurred in sta- ting that the attacks were ushered in as dyspepsia, followed after a long in- terval, by the bowel affection, then cough and other pectoral symptoms, ma- rasmus, hectic fever, &c. 1837.] Remarks on Chronic Fluxes of the Bowels. 475 No perplexity can prevail in the recognition of diarrhoea. It were highly important, however, in a therapeutic and practical view, could we discrimi- nate the several states of the bowels on which the discharge depends but I am apprehensive we cannot do this with any uniformity or precision. Nei- ther the symptoms nor the appearance of the stools may be relied on under all circumstances. Generally, however, inflammation is denoted by pain in the abdomen, hot skin, corded, frequent pulse, and by slimy, membraniform, or bloody dejections. But on the contrary, how often is there pain without phlogosis, and ulcerations and other lesions are to be met with, where no ex- pression had been given by this or any more distinctive sign of their exis- tence ] Genuine mucous or serous discharges, though ordinarily indicative of sim- ple irritation or phlogosis, are occasionally found in every variety of case and even the most copious effusions of blood, the common product of phlogo- sis, maybe owing to merely a turgescence, or perhaps relaxation of vessels. Gleety stools usually denote a subdued state of previous inflammation though not always, they sometimes proceeding from an ulcerative condition. Chymous dejections are more uniformly significant of an imperfection in the digestive powers of the colon, or in other words, the process of foecation. Evacuations thin, greasy, and of a cadaverous odour, mixed with sanious, purulent, or fibrinous matter, are to be deemed, in my opinion, the least un- erring criterion of organic mischief. But this test is also fallible, having seen -extensive lesions of the same kind, with stools of the earth-like solution I Jiave just mentioned. In a disease so various in its character, and occasioned by such diversity of causes or conditions, the grounds of prognostication must necessarily be vague and uncertain. Not much more can be determined, than that in pro- portion to the duration and severity of the attack, the degree of constitu- tional disturbance, emaciation, and debility, is the prospect of a cure or oth- erwise. What is to be deduced from the aspect of the stools, I have previ- ously stated. Cases with mucous or gleety discharges are usually the most curable, and those earthy or watery, and of cadaverous smell, the least so. From autopsic inspections, evidence is afforded of inflammation in its sev- eral gradations, in the mucous coat especially, confined to a part, or embra- cing a considerable extent, and sometimes every variety of organic injury, from the simplest to an entire change of structure, the most common of which, however, is ulceration. This consists of a single ulcer, or a few on- ly, though often innumerable. Cases have repeatedly been examined by me, where it was as impossible to count them as the stars in the firmament. .Large portions of the bowels are, indeed, sometimes found cellulated like a honey-comb. The ulcers are of various sizes, from that of the head of a pin to an inch or more, and have a close similitude to the venereal chancre. Connected with these or independent of them, mere vegetation, or fungous excrescences are occasionally to be met with. I once opened a subject who died of the disease, where a fungoid growth in the colon was discovered, nine inches in length, two in breadth, and half an inch in thickness. But in oth- er instances, the mucous surface seems to be scalded, as it were, here and there a vesicle or superficial sore, or more decidedly apthous, in the whole, analogous to the state of the tongue, mouth, and fauces, which I have no- ticed. An extreme attenuation of the intestinal parictes is a further occurrence. Bonnet tells us that he has seen the bowels as thin as a cob- web ; and, in one instance, I found the ileum and part of the colon so wasted away, that with a delicate arachnoid peritoneal covering, a few fibres of the muscular tissue were only left, pallid and widely separated. This atrophy oftener happens than is suspected. Moreover, though sometimes the mucous coat may appear sound, tubercles are concealed in the cellular texture under it, by which it is irritated to undue secretions, precisely as such extraneous bo- 476 Remarks on Chronic Fluxes of the Boiuels. [Jan. dies in the same tissue of the lungs provoke their mucous surface to inordinate discharges. But though some of these lesions are usually to be detected, it can scarcely be doubted that the intestinal fluxes may prevail independently of them or any others appreciable. JVJorgagni has transmitted the history of several cases without the slight- est phlogosis, the individuals sinking, as it were, in a very short time, from the exhaustion of excessive serous effusions, in one of which, forty pounds of limpid fluid were evacuated in a day. The same kind of testimony is borne by Louis, who states that he had several times found the mucous coat only changed by becoming preternaturally pale, flabby, and relaxed. Confirma- tory of all this, it is reported by Andral, that he has frequently noticed the mucous membrane of the intestines, especially in children, perfectly white, with its natural thickness and consistence, both in acute and chronic diar- rhoea. But it is highly probable, in most ol the instances where the bowels have been represented as exempt from organic derangement, that the irrita- tion productive of the discharge was sympathetic only derived from contig- uous or remoter parts, one or more of the abdominal viscera or the lungs, these organs, or some of them, being often found deeply affected. Of the diarrhcca which I have represented as incident to sections of our southern country, the prominent appearances are, so far as 1 know, softenings of the mucous texture, an infinity of ulcers, and, perhaps, diminution in the size of the liver. Three subjects only have I had opportunities of inspecting, and such were the lesions chiefly observable. The liver in two of them was exceedingly reduced, and of a dingy white in another, the stomach exhibited a partial ramollescence, and, in the third, with extensive ulceration, principal- ly of the ileum, the mesenteric glands were enlarged and indurated. The pathology of the disease might, perhaps, be sufficiently collected from what has now been detailed, and my further reflections on it will, therefore, be very brief. Touching the immediate seat of the affection causing these fluxes, there is some division of opinion. By some, it is insisted that constipation is uniform- ly dependent on phlogosis of the small intestines, purging only occurring when the colon becomes implicated. True in the main, this is erroneous as a universal proposition. Even irritation of the stomach, much less of the up- per portion of the intestinal tube, simply from ingesta, is productive of it, as is particularly exemplified in Licntery. Louis maintains that the seat is most frequently in the ccecum, next in the colon, and least in the rectum. It would seem, according to our own dissections in this city, to be in and about the ileo-ccecal valve, in the largest proportion of instances. The discharge in all the profluvioe was once considered as constituting the disease itself, occasioned either by a depuration of certain peccant humours through the solids, or a colliquation of the latter into a fluid. But such hypo- thetical crudities are no longer entertained, and to them has succeeded the doctrine, that all these discharges are owing to a vitiation of the secretory process, immediately dependent on some change of condition in the organ, and which change may be functional or structural, and of divers gradations and kinds. Granting the general correctness of this doctrine, it still remains to inquire more precisely into the conditions affirmed. That a vast increase of a discharge may take place from the mucous mem- brane, independently of any apparent lesion, is shown by the post-mortem evidence I have cited, and as certainly, from the cutaneous cellular and se- rous tissues. As the skin sweats, so may these eliminate their respective fluids in excess. But, here there is usually some excitement and tume- scence of vessels. The discharge happening from metastasis, the same con- dition probably exists. Thus, when the skin, under the influence of cold, ceases to perspire, and the bowels assume vicariously the office, there is in them an exaltation of action, corresponding to the loss sustained by the der- moid membrane. Exactly what the one loses, the other gains, to be added 1837.] Remarks on Chronic Fluxes of the Bowels. 477 to its natural portion of excitement. This may be deemed irritation only and of the connexion of these fluxes with phlogosis and organic lesions, no one doubts. Do they, however, occur in the absence of these several states'? The theory of haemorrhage and dropsy will equally embrace the present case. Like the sanguineous or serous discharges, that from the mucous coat, may be referred either to an active or passive state. But, perhaps, a still more pertinent illustration may be had in the analogy of colliquative perspiration. A haemorrhage or hydropic effusion, or such cutaneous transpiration, is met with in the lowest prostration of vital energy, and so is diarrhoea, each caused by relaxation of the exhalents, and all requiring for their cure astringents, tonics, or other means of invigoration.* Establishing this distinction as a leading principle, its exceptions and limi- tations will hereafter appear in the treatment of the disease. But previously to entering on this, I wish to remark, as a conclusion, from all I have said, that the discharge itself is merely an effect of an abnormal condition of the bowels, the ascertainment and rectification of which, constitute the real objects of cure. To determine, however, the exact pathology of the case, we have seen is very difficult, and, so long as it remains in such obscurity, the practice must be somewhat tentative and empirical. Nevertheless, in the want of more perfect information, we may be guided, in part, by the character of the stools, and still more, by the general state of the system. The pulse being tense or corded, with pain and tenderness of the abdo- men, aggravated by pressure, florid tongue, and not extreme weakness, we can scarcely err by a resort to venesection, the propriety of which, indeed, is attested by ample experience. To Sydenham, in his account of the diarrhoea of measles, we are indebted for this great practical improvement, and which is not the least of his valuable contributions. Claimed recently as a discovery, it may have been overlooked or disregarded by others, though not by the practitioners of this city. From the time of my connexion with the profes- sion, such, at least, has been the plan of treatment of every description of in- flammatory bowel affection, chronic or acute. Nor, will a single bleeding, however copious it may be, always, or even generally suffice. Chronic in- flammation, though not so immediately dangerous, has a much stronger hold of a part than recent, and accordingly proves more difficult to dislodge or sub- due. Not discouraged, then, if no very striking advantage accrues from the first bleeding, in such cases, let it be repeated every two or three days, while the pulse and strength warrant the continuance, and we cannot fail ultimately to be well satisfied with the consequences. Certainly, in some instances, I have bled from ten to fifteen times, taking away four, six, or eight ounces of blood, each operation, and found it essential to the cure. Topical bleeding is a very important auxiliary to venesection, sometimes superseding altogether the necessity of it, where the means of accomplishment, which is seldom the case in country practice, can be conveniently obtained. The inflammatory state having been overcome, gentle emetics of ipeca- cuanha, exhibited occasionally, may be useful. They are not prescribed here as evacuants, though not always without advantage in this respect, as to ren- ovate, by instituting a series of new actions, the condition of the whole ali- mentary canal. Nor in their immediate operation, by arresting the peristal- tic motion, are they without good effect, and perhaps not less so by inducing a determination to the dermoid surface. In the management of this disease, it is of the last importance to restore to the skin its healthy functions, for, till this is accomplished, no decided and permanent impression will be made. Great benefit accrues Irom the frequent use of the warm-bath with this view. To command, however, its full effect, where the skin is dry and the capiUary *The work of Andral on Pathological Anatomy, has a chapter on this sub- ject, abounding in facts and the most interesting views, which may be con- sulted with the greatest advantage. 478 Remarks on Chronic Fluxes of the Boicsh. [Jan. circulation torpid, some stimulating1 article should be added to the water, as salt, and, on the patient entering his bed, he is to be rubbed with a flesh- brush, till a universal glow is diffused over his body. The bath being not readily commanded, a stimulating pediluvium or friction with fine warm salt, may be employed as a succedaneum and further to promote the effect, a small dose of Dover' s powder will prove serviceable. During the day, a pill may be given, every two or three hours, composed of a small portion of tor- refied rhubarb, ipecacuanha and opium. The ipecacuanha, on every ac- count, is singularly valuable in this disease, though there are some who pre- fer the antimonials, and especially the cerated glass of antimony, with opi- um a preference, I suspect, without any just foundation. These medicines having been tried unavailingly, we may next resort to alum, which is much prescribed in the form of whey. My mode of directing it, however, is in the dose of two, three, or four grains, to a quarter of a grain of opium, several times in the twenty-four hours. In some instances, a small portion of ipecacuanha may be added, and especially if the skin continues dry, and the bowels harassed by griping or other uneasiness. By Mosely, a combination of alum and white vitriol, called by him the vitriolic solution, has been greatly extolled in chronic dysentery and diarrhoea. Of this, 1 can- not say a great deal, from my own experience, having been discouraged from any extensive use of it, by its very disagreeable taste and nauseating effects. Entitled to greater regard, is a union of alum and the sulphate of iron in equal portions, say a grain or two of each, occasionally repeated, with or without opium, as the indication maybe. The acetate of lead, with opium and ipecacuanha, has strong claims to attention, and the camphorated mixture, with nitrous acid and laudanum, is of late strongly commended, though, [ think, undeservedly.* In some in- stances, particularly where the liver is concerned, the nitro-muriatic acid internally or as a pediluvium, or by frictions, has certainly proved of service. It ought, however, to be cautiously used, and its effects carefully watched. Even when endermically applied, I have known it, in several instances, to bring on the most distressing dysenteric affections. Contrary to common opinion, by which they are forbidden, I have seen the vegetable acids eminently beneficial. Diluted vinegar I allude to especially, though lemon juice sometimes also answers. Much the most, on the whole, however, may be expected from the use of mercury. This is an indispensable remedy, when the case is associated with hepatic derangement, and even if such do not exist, it proves servicea- ble. Calomel or the blue pill is given in minute doses with opium, and some- times ipecacuanha and prepared chalk, to attain the alterative, and not the salivant effect. By the unanimous voice of practitioners, blisters are declared to be of the greatest utility at this conjuncture, which are applied to the abdomen or the extremities, and may be alternately put on the ankles and wrists. The prin- ciple on which they act, in the latter instance, is that of revulsion. Chronic fluxes, with such discharges as to constitute merely a gleet of the bowels, are most successfully managed by the balsamic and terebinthi- nate preparations. The copaivae I have often used advantageously ; also the spirit of turpentine, and sometimes, even more so, common rosin, in the dose of four or live grains several times a day. Cubebs, repeated in the same dose and manner, I have known to be serviceable. The bowels being ulcerated, which may be suspected from the appear- ance of the discharge, the balsams and terebinthinates are thought also pe- culiarly adapted. Not a little has also been recently said of the nitrate of * This is called Hope's mixture, from the author of it, and is prepared as follows the dose of which is a table-spoonful, several times a day : R . Mist, camph. 5 viij., acid, nitrous. 3j., tinct. T. tieb. git. xl. 18#7.] Remarks on Chronic Fluxes of the Bowels. 479 silver, as well as the sulphate of copper. But, whatever may be their utili- ty, the principle on which they are applied, is surely erroneous. It having been found that ulcers of the external mucous surfaces when touched by ei- ther of these articles, are disposed to heal, it is presumed that given internal- ly, they might have a similar effect, by coming in contact with the intestinal ulceration. This is sheer nonsense, and it is really inconceivable how the notion came to be entertained, that the fourth of a grain, which is the ordina- ry dose of these articles, covered up as they are in some other matter, in a pill, the only mode of exhibition, could thus operate, and especially on so wide a spread surface as usually exists in the case. Not much is to be expected from any treatment in this ulcerated state. Except in two instances, never have I seen a cicatrix in the bowels, exten- sively as post mortem examinations are conducted in this city. But facts of the kind are leported by Latham, of London; and among the French, by Petit, Billard, Andral, and Troillet, the latter of whom has presented an ex- ample of ulceration, where there were marks of incipient, advanced, and com- plete cicatrization. Next I am to make a few remarks on that species or variety of the disease supposed to depend on debility or relaxation of the intestinal exhalents. It may be the final stage of the inflammatory flux which I have already de- scribed, and it is to be met with, as a primary state of the bowels, among very emaciated and infirm people, either from age or other causes, or as" symptomatic of consumption, &c. These cases, however, are exceedingly deceptive. Much general weakness may exist with a high degree of local irritation or phlogosis, or even ulceration. To determine this point, previ- ously to entering on the treatment of the case, is of great consequence. Being satisfied, however, that no such conditions exist, the indication be- comes simple, pointing directly to the restoration of the tone of the prima? viae, and to this end, the whole catalogue of tonics and astringents is some- times exhausted. The use of them, however, is hazardous, and for the most part inefficient, so that they are comparatively seldom employed by me, and uniformly with the circumspection which a distrust of their propriety cre- ates, though undoubtedly, a state of the bowels may prevail, to be cured by this description of means. Experience teaches this, and we have the fur- ther evidence of their efficacy in similar atonic affections of the mucous sur- faces of other parts, as of the urethra, vagina and lungs, gleet, leuchorrea, and some varieties of bronchitis. Nevertheless I repeat, that the course must be experimental in a considerable degree. There is one source of il- lusion, which ought not to be overlooked. It happens that the evacuations may be suddenly checked, and relief presumed to be effected. The remedy here excites the muscular coat of the bowels into spasmodic contractions, preventive for a time of the escape of the fluid, soon followed by tumidity of the abdomen, a distressing sense of distension, often some colicky pain, and ultimately the discharge bursts forth with increased violence. An occur- rence of this sort, ought to be received as an admonition of the impropriety of the practice, and of course to its discontinuance. But the effect being otherwise or really beneficial, then any or the whole of the astringents, mentioned under a preceding head, may be recurred to, and these not suc- ceeding an appeal must be made to some of greater power. An infusion of galls alone, or in various combinations, particularly with prepared chalk and laudanum, is much prescribed in this atonic state of the bowels. The Syrup of galls made in the following mode, is also occasion- ally directed. Two drachms of the powder of galls, are to be infused in a gill of brandy sweetened, and then set fire to the liquor, and let it burn out, of which a teaspoonful is the dose. Nearly of equal power is the kino. It may be given in powder, or watery solution, or in tincture though it is most effi- cient in tincture, with prepared chalk and laudanum. The dose is a table- spoonful occasionally. Nearly of similar properties is the catechu, which may be exhibited in a similar manner. 480 Remarks on Chronic Fluxes of the Bowels. [J an, As a mere astringent much has been said of logwood. It is given in de- coction or infusion. The tincture of rhatany, however, has a still higher reputation, An infusion of the bark or flowers of the pomegranate is wor- thy of trial. Equally so is the cinnamon, and particularly the clove tea. I have also, sometimes witnessed very good effects from the compound tinc- ture of rhubarb with laudanum in small and repeated doses. By our own country we are supplied with several active astringents. The only one, however, I have employed, and which 1 think is equal to any of the vegetable astringents, is the dewberry root, Rubus irivialis, in decoc- tion. Combined with astringency it has an aromatic flavour, which recon- ciles the stomach to it, and hence is rarely rejected. The bowels, however, are commonly very much ulcerated, and under such circumstances little is to be hoped. As a palliative, an opiate injection occasionally renewed, is here more effectual than any other remedy.* Regarding the diarrhasa in those districts of our own country, formerly mentioned, I have to make only a single suggestion. The preceding reme- dies, so far as I have remarked, are equally adapted to it, the one or the other to be selected according to the existing condition. But since it seems to originate in local influences, the propriety of an immediate removal beyond their noxious sphere is obvious. This is the medical management of primary fluxes, having hitherto only referred incidentally to the secondary form of the affection. But there is no difference so far as concerns the bowels, the main object being to detect and remove the parent disease, whence is derived the intestinal irritation, of which the discharges are the consequence. The treatment, however, of the lesions of the organs to which I allude being foreign to the present occasion, I shall not at present expatiate on the subject. It must suffice to mention singly, which I am induced to do, as perhaps less apt to attract attention, that these fluxes are far more frequently than suspected to be found in con- nexion with some irritation at the extremity of the rectum, operating either as the original or aggravating cause and that whatever may be its nature, it is very important to get rid of it without delay. We come now to the consideration of regimen, on the due regulation of which every thing depends. As to diet, it is usual to select those articles supposed from their astrin- gency to bind the bowels, which I think is a mistaken notion, derived from the false doctrine that the discharge constituting the disease the great pur- pose in the cure is to restrain it. The indication, on the contrary, is to soothe irritation by the blandest nutriment, thus making it harmonize with the oth- er parts of the treatment. It is customary, as having this property, and by which they are so well adapted, to commence with the mucilaginous or far- rinacious matters that of gum arabic, the slippery elm or the benne, and tapioca, sago, sallop, arrow root, rice, flour, &c. Gruel and thin broths, though usually proscribed, from an apprehension of their running through the bowels, I have found, on the same principle of allaying irritation, very appropriate. We direct them in cholera morbus, and why not in the pre- sent case ] Milk, on some occasions where the stomach is not sour, an- swers very well and perhaps no article more uniformly agrees with the pa- tient than buttermilk. f * But the application of a blister over the abdomen, so long as merely to produce rubescence of the skin, will sometimes mitigate the irritation, and temporarily suspend the discharge. f Milk may be given alone, or thickened with some of the farinaceous matters mentioned above, the best of which is wheat flour, thus prepared : Enclose in several folds of linen half a pound or more of it, drawn tight into a ball, and then boil it for several hours in a pot of water. On cooling it be- comes hard, and must be grated into a powder. 1837.] Remarks on Chronic Fluxes of the Bowels. 481 Digestible solids, as mutton, or fowl, or game, or oysters, raw or slightly- roasted, may subsequently, on the abatement of irritation, be allowed and lhave seen benefit from an occasional indulgence in a small portion of ham or salt fish under similar circumstances. Crackers or stale leaven bread are only proper. Fruit I have sometimes known to be appropriate, particularly peaches. The dew or blackberry has a large share of popular confidence in this respect, to which it is not more entitled than strawberries. These, and I may add oranges, habitually and almost exclusively used, have cured the disease. Mentioning on a former occasion some cases to this purport as regards the latter, the physician-gen- eral of the British forces in Canada, who happened to be present, informed me that his wife, having suffered from diarrhoea for a long period, during which she had visited Europe and received there the best medical advice without avail, was finally cured by living entirely on oranges, to which she was prompted by an irresistible instinctive desire. Yet generally fruits dis- agree, or prove as injurious as the common vegetables. The best drink at first is rice or barley-water, or some similar article, and brandy and water or port wine in the advanced atonic stages. Neither much food nor drink should be permitted at a time, it being very apt at once to run through the bowels, nor the latter be very cold for the same reason. Many of the cases of diarrhoea, and especially of long standing, may be considered as materially dependent on dyspepsia, and hence all the dietetic rules in relation to that affection are to be observed, together with a recur- rence to the ordinary remedies for its removal. No one questions the necessity of preserving an equable temperature on the surface in the intestinal affections, and among the best means of secur- ing it is a flannel roller, while at the same time by its compression, further and more decided effects are attained. Equally important is it carefully to protect the feet these, when cold, hardly ever failing to revive or exasper- ate the affection. Exercise has been greatly insisted on as a curative measure : but whe- ther it operates for good or evil, will depend on its being properly timed. During the continuance of any activity of phlogosis it must be avoided ab- solute rest, even in the recumbent posture, having the most beneficial influ- ence under such circumstances. It is indeed, in many instances, the sine qua non, or without which every thing else will prove nugatory while in an opposite or atonic condition, taken in any mode it is eminently serviceable, though more so on horseback, and particularly if it be extended to a long jour- ney. More than one of our watering places, the White Sulphur and Warm Springs of Virginia especially, are deemed very efficacious, and hence may be worthy of trial. Even, however, if all these expedients fail, we are not to abandon the pa- tient. As a last resort, a sea voyage to some temperate climate should be re- commended. This is a very important measure, and will sometimes succeed when all others have proved unavailing. It is matter of great moment to remove these fluxes. Exhausting as they may be in their immediate effects, they are connected with pathological conditions, which become aggravated by delay, leading too often to the sad- dest catastrophe. Looking at some of the results only, "the bowels," says a late writer rather quaintly, "being unfaithful to the stomach, and, instead of playing fair, let go their hold of the pabulum vita before the lacteals have pro- perly performed the process which that grand organ has prepared for them, nutrition must be deficient, and the consequences of inanition ultimately take place. Nor," continues he, " does the mischief stop here. Locke tells us that people with relaxed bowels have seldom strong thoughts or strong bodies. To a certain extent this may be true, and it is one of the numerous instances illustrative of the ultimate dependence of our moral on our physi- cal condition. Am. Journal of Medical Scie?ices November, f 482 Editors1 Remarks on the forgoing article. [Jan. Editors' Remarks on the foregoing article. The age and experience of Professor Chapman, have furnished him with the means of giving, in the foregoing communication, a most copious and excellent account of the phenomena of Chro- nic Fluxes of the Bowels. This would have been no easy task for one less experienced and familiar with their varying charac- teristics. As we desire that every practitioner should study and be familiar with those characters, as well as every thing else valuable in the subsequent details, of which we honestly con- ceive there is much, we have given the entire treatise. But whilst we are unable to boast an extent of observation equal to that of Dr. C, we still feel not only the right, but the duty, as southern practitioners, of exercising judgment on his opinions of a disease, almost exclusively of southern origin ; or rather, hav- ing in its nature much of that pathology which is peculiar to* southern climates. Our observation leads us to confirm the views of Dr. C. on many of the causes of this disease, and agree with him, that al- most all things which will irritate the primse viae excessively* and especially if habitually indulged in, may produce chronic fluxes of great obstinacy. But these when they become chronic are generally connected with dyspepsia. They arise most com- monly from the abuse of ordinary articles of diet, good in them- selves ; or from articles unsuitable for human digestion and nu- trition. But we must necessarily pass over much of the discussion which this essay demands, and come to the few points on which we designed to comment in this note. In speaking of the use of protracted purgation with drastic articles, he remarks, " It is in this way, I have little doubt, that the horrible abuse of mercury throughout a considerable extent of our country, concurs in the production of similar mischief Nothing is more irritating to the alimentary tube, the liver, and the whole of the abdominal viscera, than this very article, unless cautiously regulated and when we advert to the indiscriminate and exorbitant employment of it by confessedly too many of the practitioners in the region to which I have alluded, the conjec- ture advanced, seems scarcely to require any confirmation." The indiscriminate or exorbitant use of any thing, even the most wholesome article of diet, must doubtless always be wrong. But the whole aspect of the paragraph is such as to impress the reader with the idea that a large proportion of the practitioners of the south, (for this is the region alluded to,) are unacquainted with the judicious use of mercurials, or that they are so empiri- cal as to employ them indiscriminately: and it stands before the 1837.] Editors' Remarks on the foregoing article. 483 reader as a beacon against the use of calomel, the most common form of mercurial medicine pointing it out as not only unsuc- cessful but as a common cause of diarrhoea. However extensive may be the inroads made on southern prac- tice, by the fashionable ultraism of the so styled physiological doctrine, which, thanks to a kind providence, has passed by as a meteor, having arisen, attained the zenith of its glory and fallen in half an age, thus compelling its author to procrastinate the hope of its farther cultivation and renewed approbation to ano- ther age; still practitioners who arc habituated to observation of southern diseases, have most commonly some independence -of mind which they freely indulge: they 'daily observe that this medicine is not to be judged for them, by practitioners who are not habituated to observe its effects on the human system, under the modifying influences of a southern clime. They well know that instead of considering that " nothing is more irritating to the alimentary tube," that scarcely any medicine is better calculated to arrest diarrhoea, especially with the assistance of such an anodyne power as will so retard gurgation as to allow it to ope- rate on the secretions of the prima? viae and of the liver. In cholera infantum, the first dose is often found competent, with- out the aid of anodynes, to arrest the morbid discharge,, and in- deed all discharges for a time, and until a new and salutary evac- uation is effected by an entire change of secretion. And this is a case in which a kind of local irritation is generally consid- ered as existing, from which a more general morbid action may be expected to arise. Calomel certainly possesses great ener- gy : But it is also certain that in moderate doses, and in cases of moderate excitement in the intestinal canal, unattended with very high general excitement, its power is not calculated so to co-operate with the morbific causes as to increase, in proportion to the power abstractly considered, the quantum of morbid ex- citement, but to produce a new one. in the primre viae, which new action tends to the subversion of the old. They are not prepared so far to reverse the order of cause and effect as to believe all that has been said about the gastritic and enteritic origin of all fevers and so forth; or that the various- ulcerations in the first passages which are observed in autopsies, and which there is good reason to believe often exist sometime before death, are always indicative of a primary irritation there ; but that these are more generally dernier effects of disease primarily located elsewhere. They have learned, in short, to free this medicine from its dreaded irritating powers, and this done, frequently to relieve effectually by its use the most irritable stomach and bowels, by correcting that hepatic action on which these depend and apply it to the irritated conjunctiva, and all cutaneous excoriations and chronic eruptions, with the effect of promoting the action of the absorbents so as to procure an early removal of the existing irritation. 484 auditors' Remarks on ilie foregoing article. [Jan. In saying these things, we mean to refer to that judicious use of this article, the knowledge of which is usually obtained, only by close observation and much experience in the diseases in question ; and with a mind not trammelled by false theories of the origin of disease, as in gastric or enteric irritation ; or the nature of the green, blue, black and other secretions, produced by the peculiar action of calomel ; or of its modus operandi ; as considering that this medicine only irritates the first passages, and without going elsewhere, issues from this highway its sove- reign mandates to distant parts, through the medium of an invis- ible and indemonstrable and unknown agent called sympathy. The doses alluded to are of such size as carefully to avoid too prompt and rapid purgation, but at the same time as large, and often repeated as may be necessary to effect the desired altera- tion of secretion. We are free to acknowledge that this article has very consid- erable cathartic power operating not unfrequently in large do- ses, as perfectly as a hydrargogue, as the compound powder of jalap ; but nature has placed such a guard around it, by giving it a salivating power, as to prevent the frequent habitual use of it as a prompt purgative or a laxative. Whilst therefore we per- fectly agree with the learned and experienced professor in con- sidering that its "indiscriminate and exorbitant" use maybe a competent cause of chronic flux of the bowels, we are compelled to differ so far, as to the fact of its being a frequent cause, as to conclude that the want of its use in a proper manner is by far a more common cause. And this opinion is founded on our views of the pathology of these affections, in connection with the results of its employment in their treatment. The professor seems evidently to have labored in this essay under two difficulties, which he should have determined most conclusively before either prescribing for, or treating on these cases. The first is a clear and definite diagnosis between the different varieties of chronic fluxes. This must necessarily have relation to cause, as well as the subsequent considerations in the- rapeutics. It happened that during a few weeks residence in New Orleans, we witnessed the effect of the water of the Mis- sissippi in producing twelve cases of flux from the bowels, in a family consisting of the same number of persons, and perpetua- ting the same against the efforts of two of the most accomplished practitioners of the place, for several weeks, and indeed until they were corrected by crossing the lake and obtaining an entire change of water. Here was a simple purgative power, for which that water appeared to be notorious, at least so far as re- lated to its use by those not habituated to it. It was not unlike that of a moderate dose of salts taken several times a day. This was in December and January. Again: In autumn doubtless this simple disease would have been complicated by that dyspep- tic state of the primae via: which sometimes attends hepatic tor- 1837.] Editors' Remarks on the foregoing article. 485 por or other obstructions. Those however of the liver, skin and uterus are the most common. Again : This complicating cir- cumstance may, and doubtless does more or less, in miasmatic regions, prove sufficient alone for the production of a chronic dyspeptic diarrhoea, instead of constipation so that scarcely any article of diet is properly digested on account of deficient hepatic secretion ; or in other cases there often appears a diarr- hoea or other form of al vine flux, arising from that irritation of the first passages produced by excessive fullness in the beginning branches from obstruction of portal circulation in the liver, &c. Hence the "sallowness of skin, of light lemon hue the invariable resemblance of the discharges to pale clay, or Fuller's earth dis- solved in water," &c. All these and other varieties do exist, and should, we say, be clearly distinguished before the pathology is declared, and still more, before the prescription, can be rational- ly made. We cannot enter in this place on a formal therapeutic treatise on the various cases, as we have already protracted this article greatly beyond the intended limits. But we feel that we shall not be able to stop our remarks short of citing the professor and his readers to another cause of embarrassment under which he has been compelled to labor. It is this. After declaring that "no perplexity can prevail in the recognition of diarrhoea," he says, " It were highly important, however, in a therapeutic and practical view, could we discriminate the several states of the bowels on which the discharge depends but I am apprehensive we cannot do this with any uniformity or precision." The state then has afforded a perplexity and want of decision which ex- tended its confusion into all his subsequent philosophy. He appears in his pathological investigation not to have duly distinguished between the acute and chronic state not to have considered that chronic in medicine is not, as in chronology, de- termined by days, weeks, months or years; but rather the state of the disease, and the word should therefore be in its technical use, considered chiefly as qualifying the nature instead of marking the time. Its use however is not strictly apposite, as it really has in this sense no other relation to time, (from which it comes,) but that the state intended to be described is most commonly in con- nexion with more or less considerable duration. Nor does the professor seem to call in to his aid much of the influence of sea- son, climate, sex, age or temperament ; some of which almost always give peculiarity of caste to the resulting phenomena. But so soon as he arrives at the part for which all the rest was intended, by the dint of long observation, and the assistance of Sydenham, light seems to have shone forth on the subject, and very considerable accuracy to be arrived at, both in diagnosis as to state, and therapeutics. In speaking of the cause of this affliction, we should have re- 486 Obstetric Institute of the U?iiv2rsity of Pavia, fyc. [Jan. ferred the professor as well as his readers to one which has of late become more common than all others together the exorbi- tant and indiscriminate use of Lobelia, No. 6, and Composition Tea. Review of the Practice of the Obstetric Institute of the University ofPavia : By Dr. Ant. Trezzi. One hundred and one females were admitted to the institute during the year 1833-4, of whom sixty-eight were in their first pregnancy, and were delivered of one hundred and two children, there being twins in one instance. Ninety-eight of these children were born at full term. There were ninty-five natural labors, of which thirteen only were difficult ; of the six remain- ing, four required manual assistance, one the use of forceps, and one the cesarian section. The presentations were as follows : ~ . , (1st. position, 72 Occiput, 2nd.Pdo. I .... 18 Breech, Face, Shoulders, 2nd, , do. - - 3d. 4th. do. do. - : 1st. 3d. 4th. do. do. do. - - 1st. 2d. transverse position, oblique do. 2d. position, 1st. do. 2d. do. right, left, do. - 1 1 2 1 1 1 1 1 1 Uterine Phlebitis preceding delivery. One of the females experienced on the 30th January, a chill, loss of appetite, lassitude, head-ache, thirst, lateral uterine pains, especially on the right side, pains increased by pressure, and at- tended with uterine contraction presenting nothing peculiar. The active movements of the foetus were sensible and sometimes painful ; the cervix was long, soft, indolent ; os tincae closed ; pulse frequent, full and vibrating. She was immediately bled and purged with oil ; the antiphlogistic treatment was vigor- ously pursued, but without more than temporary relief; the uterine phlebitis gradually progressed until the 16th February, 1837.] Obstetric Institute, of the University of Pavi a. 487 when she was delivered without assistance. The infant was apoplectic and could not be restored to life. She experienced some relief after delivery, but very soon presented every symp- tom of intense puerperal fever, which terminated fatally on the nineteenth. Autopsy twenty-six hours after death presented the thoracic viscera healthy ; in the abdomen a puriform effusion had taken place, as also adhesions of the omentum and intestines to the walls of the cavity ; inflammation of the uterine connexions, particularly in the right side, where these parts adhered by a purulent plastic lymph. The spermatic veins were very much developed though healthy ; the uterus being opened, those vessels at their entrance into the uterus were found filled with pus ; the cellular tissue surrounding them in their way through the broad ligaments was also infiltrated with pus ; the suppuration howev- er was confined to the larger venous trunks. The same morbid conditions were found in the other side, but in a less degree. Among the Natural Labours, the difficulties encountered were: from spasm of the uterus, uterine inaction, resistance of os ex- ternum, and presentations of the breech and feet. There were five instances of uterine spasm, especially of the cervix, which yielded to blood-letting. In another case, the waters having come away, three bleedings, emollient poultices to the abdomen, and oleaginous injections per vaginam, became necessary. The child was born apoplectic, but was saved by umbilical bleeding. The delivery was natural. One of the cases of face presentation was sufficiently remark- able to be further noticed. When the head descended to the in- ferior strait, the position was the following : The forehead oc- cupied the centre of the strait, the vertex rested against the right ischium and the chin against the left, the left temple under the arch of the pubis and the right in the sacrum. The right tem- poral region, yielding to the uterine contractions, slided over the perineum and escaped at the inferior commissure of the vul- va, whilst the left remained stationary. All the right side of the head having passed out, the clavicle resting against the left side of the pubic arch, the head rotated from right to left, the vertex, then the occiput, successively escaped from behind the right side of the arch ; and the head thus liberated assumed the position of the second occipital presentation ; the remainder of the body soon followed. The labour continued thirty-two hours ; the child was apoplectic, but was restored; his forehead, eye-lids, nose, and upper lip were very much bloated ; the other parts of the face normal. The delivery was effected without instrumen- tal assistance. This case although extraordinary evinces the great resources of nature in completing her greatest work, and Professor Lova- 488 Obstetric Institute of the University of Pavia. [Jan. ti took occasion to impress on his pupils the necessity of with- holding the use of instruments as long as possible ; and also to allude to the error of those who believe assistance indispensable in all cases of face presentation. This quastion has been argued in the Academy of Medicine of Paris, M. Capuron admitting the possibility of spontaneous delivery with such presentations, if the foetal head be small and the pelvis very large. Cesarian Operation. The cesarian operation was performed by incision in the linea alba. Many obstetricians have advised the incision of the uterus to be made as high up as possible; but this viscus being always affected more or less with lateral- obliqui- ty, the section of its anterior wall would always be oblique in- stead of vertical ; moreover, the section of its upper part would favour the introduction of portions of intestines between the edges of the wound, as well as extravasation. Professor Lovati there- fore prefers making the incision lower down, in order to avoid these dangers as well as to facilitate adhesion by the application of the bladder over the wound. In the case before us Baudelocque's Pelvimeter indicated the following dimensions : Antero-posterior diameter, 5 inches 2 lines. Left oblique do.. 7 7 Right oblique do. 7 9 Further examination proved the vertebral angle to project ve- ry much into the pelvic cavity ; the sacrum presented no cur- vature ; and the pelvis was strongly inclined downwards. The section being made the child was removed alive, the placenta was expelled through the wound by the uterine contractions, the wound was well stitched, but the patient expired twenty-fou? hours after the operation. The external wound was found well united ; at its superior angle a portion of the omentum was found adhering by plastic lymph; a noose of small intestines, red, and covered with puru- lent matter, adhered in the same manner to its left lip -r the peri- toneum in general was inflamed; the uterus was voluminous and open on its left side ; its incision was oblique from left to right, was four inches long, beginning two inches below the fun- dus and extending to the point at which the peritoneum passes from the uterus to the bladder, and slightly open. The uterine cavity was empty ; the os tinea? soft and dilated. The follow- ing were the dimensions of the pelvis : /Antero-posterior diameter, 2 inches 4 lines. Left oblique, do. 3 4 . Right oblique, (^Transverse, T r . .. C Antero-posterior, Inferior strait, j Transve'rse> do. 3 9 do. 4 2 do. 3 8 do. 3 4 1S37.J Medical Education in South Carolina. 489 The bones of the pelvis were small but not altered in their form: the sacrum was perfectly flat; the coceyx very much curved and its point inclined to the left; the promontory not prominent ; the left acetabulum turned inwards towards the sa- crum. The length of the incision not being more diminished by the contraction of the uterus, might be urged as an argument against M . Lovati's method of making it as low down as possible, for inasmuch as the distension of the uterus is especially produced at the expense of its fundus, so will the contraction be greatest in this portion; indeed observation teaches us, that incisions made in the upper part arc found to lose half their length by the subsequent contraction of the organ. Annah Universali di Mcdicina. Gazette Medicale. We have received and read with much pleasure " A Memo- rial on the State of Medical Education in South Carolina ; deli- vered by James Moultrie, M. D., in the Representative Hall, December 5th, 183G." Medical education is a subject that has engaged us heart and hand for some time passed, and we are truly gratified to see it advocated as it has been by such a man as Dr. Moultrie. We hope the effort made by the Medical College of Georgia, to call a Convention of Delegates from all the Medical Colleges in the Union, to devise some general plan of reforming the system of Medical Education in the United States, although unsuccessful, may yet prove not to have been altogether unproductive of ben- eficial influence in promoting the interests of the profession. It would be an easier task to say very much than too much in commendation of the paper before us suffice it to say the man- ner and matter are worthy the learned and talented author. We have only space for a few of the concluding pages, but we re- commend our readers to obtain and peruse the whole memorial, which has been published in Charleston by Burges and Honour, No. 18 Broad-street. "It cannot be doubted, but that the establishment of medicaJ uistitutions in the United States, has been of much service to the country. It may be questioned, however, whether their multiplication has been followed by good always unmixed with evil. We might even go farther, and say, that it is to be lamented, that this has not seldomer been the case. If they have served to cheapen education to keep our resources in the country to make us in- oJ 400 Medical Education in South Carolina. [ Jar^v dependent of foreign nations and render the vocation accessible to many a worthy candidate who otherwise would have sought, or been driven to seekr some occupation less suitable to his nature they have operated not less as in- ducements to multitudes who otherwise would never have dreamed, or should never have been permitted to dream, of embarking in the pursuit; and who, bnt for the facilities thus offered, would have turned their thoughts to some other occupation, more compatible with their circumstances or capabilities. Uncontrolled, as they have been, by the wholesome restrictions of legislative enactments, our colleges of medicine, actuated, too unfortunately for science, by a spirit of aggrandizement, have thrown open their portals with but too little discrimination to all who have thought proper to enter them ; and the consequence has been, the nurture of a generation, which, in the main, have conferred little honor either on themselves or their Alma Mater. The diplo- mated quacks far cut number the legitimately initiated ; so that the catalogue of the former has been swelled to an incredible extent, and thus mischief and evil have been perpetuated and disseminated, in opposition to public confi- dence and expectation, by the very means which were originally intended to prevent their promulgation. A question very naturally arises, then What is to be done? I fear, how- ever, that no reform will ever take place, either immediately or remotelyr Which is to have its origin in the institutions themselves. All may be placed Upon an equality with respect to plans of instruction, requisites for gradua- tion and so forth ; but unless the same equality can be made to obtain with respect to charges, and proper security be given against the continuance or t epetition of the present systems of underselling, and of simplifying when the progress of the science calls for a stilt further subdivision of labor, than ha^ yet obtained in any of them, in order to facilitate graduation and procure large classes, every effort to this effect will be made in vain. The necessity for preliminary instruction is so little apprehended, and the means of afford- ing it SO' imperfectly provided, at the same time that the pecuniary state of a large proportion of our population is in so humble a condition, that for a long time to come this latter consideration will largely operate as a reason in favor of those institutions, which shall continue to avail themselves of it. For this reason, the plan of allowing regular salaries as a basis, in addition to the usual fees, of the medical faculties, as pursued in France, appears, under all circum- stances, the best that can possibly be devised. It insures to the government the right of enforcing, both on professors and students, a compliance with whatever regulations are deemed proper to be adopted for the good of the public, as well as for the institution, and of providing, by law, a surveillance, and the institution of a concours, the effect of which cannot fail to be ulti- mately beneficial. It would be but half accomplishing the work, however, to stop even at this. As professorial celebrity, ceteris paribus, must depend upon the success of the efforts to secure the attainment of ante-professorial requisites and these, again, upon college acquirements, and college acquirements upon academic discipline and instruction it is evident that the remedies for present evils should be applied deeper still than this, [t should go beyond the mere re- sults. And to effect this, we must go back to the primary links of the length- ened catenation. We must begin, as it is said, from the beginning. And while we endeavor to correct the ills attendant upon the present laxities of our professional seminaries, try to lay the foundation for a simultaneous and entire revolution in the disciplinary exercises of our academics and eollr -gos. These must be made to take ihrir proper relation^ to r ert, in their natural order, the influ< i Medicine has been too mu lated branch of human knowledge. It. has been too much considered I in myste- ry. It has been too commonly viewed as a subjeel bj p< rial irfquiry, with fixed, secret, and determinate Jaws, and surrounded by circumstances be] 1837.] Medical Education in South Carolina. 4D1 ordinary ken ; and too seldom as a science of observation and induction, complex and comprehensive in its nature, having its basis, extensively laid in the truths of the more common and popular. To become acquainted with these truths has been considered, by those, too, who should have known better, a matter, to say the least, of very questionable utility ; and it has even been urged as an objection to it by others, that it detracts too much from time which should be devoted to objects more professedly professional. This idea should no longer be permitted to prevail. - It is time that such rea- soning should cease to be listened to. It . is unquestionably true, that no one can study the extremes of any general system at once. He cannot at- tend to the exercises of an academy, those of a philosophical seminary, and those of a professional institution, simultaneously* He cannot seize them at a grasp. But besides that this is attempting what is not only impracticable and should not be encouraged, we know from experience that, when properly conducted, the results which are aimed at are perfectly attainable. What has been reached in Germany, France, or Italy, can easily be reached in the United States, and should be attempted ; and I would fain leave the de- grees of perfection at which we may arrive, to be discussed by those who deem it a matter of sufficient importance to limit or restrict them. Of one thing 1 feel assured, that we have less cause to fear the maximum will be overreached, than that we shall fall short of the minimum. The principle can hardly be considered a questionable one, as to what or- der should be pursued in the culture of the human understanding, or the stu- dy of the different departments of philosophy. There is a time for all things ; and this maxim is as true in reference to the education of the powers of the mind, as to any of the events to which it has been applied. Each faculty has its allotted period of development, in the fulfilment of which there is a time of opening, when education exerts its most successful and happiest effects ; a time of maturation ; and a time of decay ; and to interrupt or disturb this order, is either to impair its natural vigor, or to occasion it to fall far short of the end for which it is destined. The effect of such a perversity of method can only be to introduce discord into the mental constitution, or to touch notes, upon the same instrument, which have no natural or harmonious re- lation. And this principle, and these remarks, are not less true of the order in which, in reference to any particular avocation or profession, the sciences are studied. The understanding of some, notwithstanding they have been generally represented as constituting a circle, is necessary to the knowledge of others. If we begin with those at, or after, graduation, which should have been accomplished before it, what can be expected but disappoint- ment or failure 1 How can we look for any other result than the formation of a being of diminutive stature ? Can the judgment or the understanding be at ease amidst the objects of any particular department of human knowl- edge, whilst it is distracted by the presentation of numerous others ? Can either be free to examine their respective principles, and mutual influences and relations ? It would be but a needless expenditure of reason, to argue about the connection of the sciences, with those who have not the acquired perceptions to understand the very terms of the proposition. But can it be doubted that upon the putting of the same question to different individuals as for example, whether the study of botany, zoology, and comparative anat- omy, are of any value to that of physic different answers would be returned according to the modes and measures in which each has been instructed? That with a German or Parisian, it will be one thing with an American another? And yet, who wouM , Knowing these differences, to pro- nounce which has the belter right, or better reason, to determine ? Which would be the more competent witness in the courts of an enlightened philos- ophy 1 There, we hear of no misgivings as to want of time ; no whining as to the length of art or shortness of life. It is here only, where they are least understood, that we find the greatest nnwillingnesp, and hear I h 492 Medical Education in South Carolina. [Jan. of the apprehension of difficulties. Obliging every one to begin where he should, and to adopt, throughout, the course which an enlightened experi- ence has shown to be the best to be pursued upon the whole, it seems to be the object of the best European systems, to open all of the capacities of the intellect, and to fill them with all of the tieasures of knowledge, which a self- correcting and self-improving philosophy, has been able to gather from the ample fields of nature and of art ; and to leave it to aftertimes, or the dictates of accident, or the steady operation of the natural laws of the constitution, to settle the mode in which they shall be employed practically and individually. Discarding, as impracticable, the unphilosophical conception of a mode of in- struction to be endlessly adapted to individual peculiarities, strengthening those faculties which are already too predominant, and suffering those to lie idle which are already too much endangered by the activity of their more powerful neighbors, in other words, fitting a man, as the plirase is, for the profession to which he is inclined, or adapted, by the force of his genius a system which never has been, and never can be, carried into general or suc- cessful execution it appears to be their object to carry out the more tangi- ble or feasible expedient of disregarding those peculiarities wherein the facul- ties are already sufficiently active to struggle for themselves, if not to require restraint, and to supply the objects in the proper order, and with the corres- ponding exercises to each and all of the powers of the understanding ; ad- justing the extent and degrees of each, by that common admeasurement which trial, actual trial, has shown to be both practicable and proper. That the standard which is adopted should sometimes prove too exalted for some, is what may have been anticipated, perhaps, from the accidental, as well as natural, inequalities of the race. But this is their misfortune, not a fault of the system. The inherent inequalities of the race can never be wholly era- dicated or removed. Modification is all that we should aim at. It is all that we can accomplish. What nature lias sown, philosophy must reap. Where she has established distinctions, intending them to be permanent, art may vary, but she can never wholly set aside or supersede the law. To those who fall below the level, the higher occupations in life should be as a tree of forbidden fruit, which they may be permitted to behold and approach, but upon no account either to pluck or eat. But, after all, there is no system which can be considered perfect none we can imagine which is wholly free from difficulty or objection. Of all those that have been adopted, the models of France arc the freest from cith- er. One of their fundamental excellencies is, that while the votC6 of the fa- culty are allowed to predominate in the judgments or decisions of the con- cours, thereby rendering the grounds on which they arc made wholly profes- sional, the judicious exercise of the governmental authority, which is also an element therein, preserves them from the pernicious influences of motives which are private, personal and mercenary. The chief, if not only liability to abuse from this circumstance, is the opening it leaves for political influ- ence and intrigue, than which, in the republic of letters, there is nothing more to be deprecated. It may be, however, that we arc not yet, in this country, in a situation for 1hc entire adoption of the concours a fact of which I am far from being con- vinced. It may be that the degree, as well as the extent, of mental culture in this State, does not warrant its immediate adoption that the mass of our physicians, us well as of the community at large, have not that fulness and readiness of knowledge, or of practical interchange of thought, necessary to sustain if. Hut we can at least prepare lor it. We can do much, in anti- cipation, by fostering those; preliminary branches of study, and encouraging those primary institutions, from which are to spring up the elements of its completion. We may make the departments ol human learning harmonize more thoroughly than they have hitherto done We may adapt them more effectually one to the other, and incorporate into all the same leaven of im- 1837. J Medical Education in South Carolina, 196 provcmcnt. We may bring them all under the Bame authorized inspection, and make them but different states and stages of one unique and entire whole. 1 know it lias been said thai Germany is indebted for the eminence of her scientific and literary institutions, in a great degree, to the spirit of rivalry ompetition which prevails among* individuals. Of the truth oft his. how- ever, I may he | I to doubt. Germany owes every thing to the hab- its of application, and emulation after distinction, w hich has been, by a course of well directed and uninterrupted discipline, long identified with the intellec- tual existence of her sons. The tendency of such a spirit, amidst corpora- tions where pecuniary interests are involved, is to make them venal; and 1 would appeal to the experience of Germany even, for the truth or confirma- tion of this observation. That of our own country will corroborate it. France has wisely shunned it. She, prudently and patriotically, confines the exercise of this principle to individuals ; and the Results have shed a lustre on her name, which will prove as enduring as her existence. Profiting by these examples, the plan which I would propose, then, under existing circumstances, would be this : Let the Legislature take the whole subject of education under its paternal care ; and let the system be regulated in accordance with the views and principles which have been exposed. Let the medical department be made a branch of that system, and a college be es- tablished by its authority ; and let all other grants be abrogated, or expire naturally, at the end of the term for which they were given. Let there be granted by it, for the erection or purchase of a suitable building, a suitable sum of money ; and let the professors, in addition to the compensation now received for then- tickets, bo also suitably salaried. This last would make amends for the reduction of the members of the class, which in the outset of the undertaking, and from the higher requisitions of the applicants, may be expected to be made in their incomes ; in return for which the State might receive the amounts accruing from the matriculation and graduation fees, to be expended in necessary repairs. It is well known to this society and to the public, that since the disagreements which have eventuated in the establish- ment of the second Medical College of the State, and the unparalleled en- couragement and success which have attended the labors of its Faculty, the liberality both of that body and of the municipal authority of Charleston, has been not only rendered nugatory, but unless a speedy re-action take place in favor of its unfortunate competitor, these must soon be scattered to the winds. The outlay is composed of perishable materials, and like an organized body requires composition to sustain decomposition. Something may be done perhaps towards the prevention of further losses, and the reclaiming of the materials which remain, and the appropriation of them towards this object. I have no authority for even hinting it, but from the zeal and public spirit which I know to be the sole actuating motives of the trustees and faculty of the other school, 1 am disposed to think that arrangements might also be made with the authorities of that seminary, for the devotion of all that they possess, and all that they are capable of doing, towards the accomplishment of what seems to me so desirable and glorious an undertaking. The proper equiva- lents being given, the Legislature might thus at once possess itself of a fund, which would go far towards the immediate execution of this plan, with per- haps but little additional expenditure on their part. The details of such an arrangement I forbear, however, to enter into now. They may safely be left, should the scheme seem feasible, to future adjustment or agreement. But it may not be inappropriate to remark, that the two latter considerations the giving of salaries and erection of a college edifice by the State were parts of the scheme submitted years ago to the consideration of the Legislature and of the community by Dr. Cooper, in the Address to which, in the commence- ment of this inquiry, I took occasion to allude. These preliminaries being established, ! should in the next place say, I I 494 Anatomy of the Nerves of the Perns, fyc. tyc. [Jan. the period of lecturing be extended to six or eight months, and let each stu- dent be compelled to attend three or four courses. Let there be a substitute provided for the concours, or the concours itself be established, in which each applicant for a professorship shall give a 'practical or demonstrative proof of his abilities and competency to fill the situation. Let the number of professor- ships be increased, and the order determined, by conference and council of the faculty, in which the studies shall be pursued. Let there be several exami- nations also of the student in the course of his studies, in which he may be re- manded to further preparation, or be advanced to others that are ulterior ; and a final one, in which the ordinary written testimonials shall be included. The carrying out of this plan would render it necessary, perhaps, that some distant day be fixed upon, in which no other diploma than that of this college should be considered valid, or should entitle its possessor to practice within the jurisdiction of the State so as to avoid inflicting injury or injustice upon those who already prc-occupy the field. The crisis we have reached in the mental progress of our affairs is an inter- esting and important one ; in which the public mind is at once in that state of solicitude and fortunate equipoise, the most favorable, as it seems to me, for establishing what is right and sound ; in which much moral and intellectual good may be accomplished ; and in which, if rightly managed or guided, its onergics may be directed and impelled to the performance of a work compat- ible with the enlightenment of the present generation, and worthy the perpet. nation of that which is to come. Anatomy of the nerves supplying the cavernous structure of the renis, and their connexion with ike hypogastric plexus of the sympathetic : By Professor Mueller, of Berlin. After 1 had discovered the fact that the xirtcriae hclicincc the branches of the arteria profunda penis producing crectionwcre different from those branches of the same vessel which served for nutrition (see this Journal, No- vember, 1835, p. 179,) I put to myself the question, whether the nerves of the penis were of the same or different properties, whether they belong to the system of nerves of animal life alone, or whether they also included or- ganic fibres'? Do those nerves upon which the sexual gratification depends, differ in their nature from those which produce the accumulation of blood in the corpora cavernosa ] I have been so fortunate as to find, both in man and the horso, that the nerves of the cavernous bodies are made up both of branches proceeding from the organic as well as the animal system, whilst the nerves of animal life alone provide the nerves of sensation of the penis. Since, by the discovery of the arteriae heHcine in the corpora cavernosa penis, the immediate source of erection is found to be in these bodies them- selves, 60 will it be also proved, if such a connexion exists between the ncr- vus sympathicus and the nervi cavcrnosi, that the sympathicus perforins the principal part in the phenomenon of erection. \ have observed that by far the greatest number of the nerves which penetrate the corpora cavernosa in man, derive as considerable fibres from the organic as from the animal ner- vous system, and that the same takes place throughout the nerves supplying at least the posterior half of the corpora cavernosa of the horse, whilst the anterior half is supplied only by nerves arising from the animal system, and entering anteriorly to the pubes viz. the branches of the nervus pudendus 1837.] Anatomy of the Nerves of the Penis, fyc. 495 given off whilst passing along the dorsum of the penis. Therefore the pos- terior nerves, which penetrate the corpora cavernosa behind, and enter the symphysis pubis, are composed as well of branches of the nervus sympathi- es, proceeding from its plexus hypogastrics, -as of the branches which come from the nervus pudendus communis. Upon the side of the urinary bladder in the horse, and proceeding towards its neck, are many fine twigs of the plexus hypogastrics, which often join one another on their way, and separate again, forming a net work. In this part of the plexus hypogastrics, upon the side of the middle and anterior part of the bladder, lie several email ganglions, separated from one another, more or less, but often by a considerable space ; they measure from one-half to two or three lines in diameter. From these ganglions, twigs pass into the urina- ry bladder, by which means the gray nervous fibres destined for the corpora cavernosa pass from the hypogastric plexus thither, and they then unite again in the same reticulated manner. Before these nerves arrive at the posteri- or surface of the pubes, they unite in the neighborhood of the neck of the bladder with branches of the nervus pudendus. Through this anastomosis are formed many strong nerves the posterior cavernous nerves; it is of these alone that I now treat. Many of the nerves formed in this manner, of which, in the instance now before me, I reckon four large and two smaller, pass under and behind the symphysis pubis, and penetrate the corpora cavernosa, in part accompanying the arteria profunda penis, and partly in other places. I remark particularly, that neither the posterior cavernous nerves, nor the anterior branches of the nervus dorsalis penis, form any swellings in their passage through the fibrous coat of the corpora cavernosa. In man, a much greater portion of the cavernous nerves are in connexion with the hypogas- tric plexus, and the number of twigs wliich come from the nervus dorsalis penis alone, is much smaller than in the horse. Hitherto, only the-cavernous twigs of the nervus dorsalis have been known. The demonstration of this communication in the horse is so easy, that the principal points may be clearly made out in a few weeks ; but the preparation of those of the cavernous nerves, which anastomose with the hypogastric plexus in man, requires an extraordinary degree of patience, and a satisfac- tory demonstration of them, together with the hypogastric plexus, can only be perfected in the course of some months. The larger of these cavernous nerves can be found easily before and under the symphysis pubis, after these bones have been very carefully cut away ; but the difficulty is, to demonstrate their connexion with the plexus hypogastrics. In the summer of 1834, I was following out the twigs given to the penis by the nervus dorsalis, which I, as well as other anatomists, thought were the only nerves this organ received, and by this means I discovered, upon the root of the penis, a considerable number of gray nervous fibres, which passed forwards in a kind of lace- work between the vasa dorsalia from the right and left side, in order to unite themselves almost immediately to the branches of the nervus dorsalis ; some, however, pierced the root of the penis directly. As I prosecuted the dissection of these gray fibres backwards, I was quite as- tonished to find that the stems did not arise from the nervus dorsalis, but were continued in a diverging direction backwards to the sides of the com- mencement of the prostate gland, and underneath the venus plexus situated here one of these nerves is especially strong in this place. Before the prostate gland, these nerves are continued in a weak and still finer plexus of organic fibres, wliich partly lies concealed in the fleshy coats of the pars membranacea urethrse, and in part passes backwards between the prostate and the M. levator ani. This plexus stands also in connexion with branches of the nervus pudendus, within the fleshy coat of the membranous pnr; the urethra ; but the greatest number of the twigs <>f this , organic nervous system. 496 Anatomy of the Nerves of the Penis, fyc. [Jan. These, then, arc continued (divided into many filaments) backwards be- tween the side of the prostate and the levator ani ; still hanging together in a plexus, and passing upon the side of the bladder, where the fibres are very fine and soft, until they at length reach the plexus hypogastrics, with winch they unite. Close behind the prostate, and by the side of the cervical portion of the bladder, there are in these plexuses, many ganglions, some longish and some more rounded (ganglia pudenda seu prostatico-vesicalia) ; to which, also, may be traced some line filaments from the third or fourth sacral nerves. These ganglions cannot well be considered to belong to the hypogastric plexus, since they arc widely separated, and are only connected with it by long and weak filaments. From these ganglions, twiggs pass into the neck of the bladder and the prostate gland; but the greater number pass forwards to form the cavernous plexus. The preparation of the nerves in question will be conducted best in the following manner first, the cavernous nerves must be sought after upon the root of the penis, in that part where the greater number of them sink into the corpora cavernosa, that is, immediately before and under the symphysis pubis. Some gray nerves may be very soon found before the symphysis, and lying between the dorsal vein and arteries ; these are to be followed backwards after the root of the penis has been separated from the pubes, wrhich must then be sawed away this must be done very carefully. When the stems of the cavernous nerves are arrived at, they must be followed through the fibrous mass which envelopes the venous plexus, underneath and behind the symphysis, until they reach the commencement of the prostate, where they begin to subdivide still finer, and form the plexus which has been already described. It will be advantageous to allow the pre- paration to macerate for some time in spirit, as," by this means, the fine nerves will be more easily distinguished from the surrounding parts. Now, before the most difficult part of the dissection, it will be better to commence the plexus hypogastrics, so that the plexus of the cavernous nerves may be prepared from behind forwards. The preparation of this union is very diffi- cult, and requires the greatest patience ; for although the connecting fila- ments between these two plexuses are numerous, they are very fine and weak. The nervi cavernosi, consisting of many fine branches, and one large one, will then be found to spring from the plexus cavernosus, which is composed of the roots proceeding from the nervus pudendus on the one hand, and the plexus hypogastrics on the other, and which lies partly between the levator ani and the prostate, and partly in the fleshy coat of the membraneous portion of the urethra, but is strongest on the anterior part of the prostate gland. All these stand in connexion with one another, and pass partly under the symphysis ossium pubis, partly immediately before it into the corpora caver- nosa ; sometimes accompanying the arteria profunda penis, but sometimes through peculiar passages in the fibrous envelope. Some twigs unite with the nervus dorsalis itself, others with the cavernous nerves of the opposite side, and others again with branches of the nervus dorsalis of the other side, and by these means a plexus is formed which accompanies the vasa dorsalia, and from this also twigs proceed, which, penetrating the fibrous coat, range in the corpora cavernosa. Some of the filaments of the plexus cavernosus on the otlicr hand, uniting with twigs of the nervus dorsalis, pass over the corpora cavernosa, and descending into the furrows formed by the two roots of these bodies and the corpora cavernosa urethrte, are distributed into the last named body. The nervi dorsales penis are, in distinction to all these nerves, quite white : they pass on the side ofihe arteria: dorsalis forwards, and send many, for the most part fine, twigs into the corpora cavernosa. Their anastomosis in the .niddle line, through communicating branches, occurs generally in such a manner that fil imente proceeding from the plexus cavernosus participate in 1837.] Observations and experiments upon the Cozcum. 497 forming it. By far the greatest number of the branches of the nervi dorsales are destined for the glans ; a small number only is distributed to the integu- ments and prepuce. Upon these it is that the sensation of the parts de- pends. London Medical Gazette, 23d April, 1836. Am. Journal. Observations and experiments upon the function of the Ccec.um : By Dr. Schultz, Professor of Physiology in the University of Berlin. The objects of the learned Professor in making his experiments were to as- certain first, the function of the ccecum ; second, the digestibility of the different articles of food; third, the manner of the dissolution of the fleshy fibres in the stomach, according to microscopical observation ; fourth, the degree of acidity in the stomich and coecum; fifth, the degree of alkales- cence of the food in the stomachs of ruminating animals ; sixth, the nature of the acids in the stomach ; seventh, the coagulation of milk by the saliva, sto- mach, &c. ; eighth, the saliva; ninth, the nature of the bile. He maintains that there are two digestions, one in the stomach, the other in the coecum, and that the latter is more especially active when vegetable food has been ingested. From the first experiment he learned that the de- gree of acidity in the ccecum is not always the same, that it is not always pre- sent, and that the food may even become alkalescent. From the second, that this acidity was neutralized by long fasting, and thus allowed pure bile to enter the coecum and neutralize its contents. ' From the third, that there is always bile in the course of the small intestines. From the fourth and fifth, that all the bile secreted by the liver during fasting, is by no means con- tained in the gall bladder, and that that part is very small compared with the large quantity that flows int6 the intestine during the empty state of the stomach. From the sixth, that though bile is always flowing, it never pasl ses the coecal valve during fasting, but collects on the upper side of it ; it is only after perfect acidification, and at the beginning of the peristaltic motion of the intestines, that this bile flows into the coecum. From the seventh, eighth and ninth, that the degree of acidity and alkalescence of various parts of the digestive canal, vary with the length of time that has passed after feed- ing, and the degree of perfection of the gastric digestion, as also with the length of time which animals have fisted before freding. From the tenth, that the quantity of digestible matter which is contained in the food has a great influence upon the degree of acidity in the ccecum. From the eleventh, that in carnivorous animals, when the coecum and colon are but little devel- oped, the. food is for the most part digested by the stomach and small intes- tines, and the acidity in the coecum is in general very weak, since the food, when it is here collected, contains little or no digestible matter. The general results from the whole of the experiments we give in the au- thor's own words; they are of the highest interest and importance. " Results of the experiments upon the coecal digestion. It may, therefore, be gathered from my observations and experiments, that the food in the ccecum becomes not only a seconjl time sour, but that the acid chyme is there neu- tralized by the access of bile, in the same way as in the duodenum ; so that after the employing of the intestines very different reactions may be pro- duced according to pleasure. On account of this twofold consumption of bile in the stomach and ccecum, there is an antagonism between the two diges- tions ; for when the bile is consumed by the digestion in the stomach, the coecal digestion cannot be perfected, and, on the other hand, when the bile flows into the coecum, the neutralization of the acidity in the duodenum can- not take place. In those animals in which the coecal digestion is most per- fectly developed, this antagonism appears to be so arranged, that each diges- tion has its particular period of action, so that when the one is in action, the other is either lessened or at rest. In ruminating animals, it is verv evident 63 4Q& Observations and experiments vpon the Caecum. [Jan, that the gastric digestion takes place more particularly during the clay, and the coecal at night, so that I think the gastric may very properly be called the diurnal, and the ceecal, nocturnal digestion, "In carnivorous animals, however, the ccecum is so little developed, that the stomach alone furnishes nearly the whole process of digestion. These animals, therefore, have a preponderating diurnal digestion. This agrees with the fact, that carnivorous animals rest for the most part during 'h J day, and at night become hungry, and seek their prey, and are, therefore, noctur- nal animals, since their digestion takes place during the day. "As the formation of the feces follows the perfected caeca] digestion, her- bivorous animals are accustomed to discharge the greatest quantities in the morning and evening, a- d but very little di ring the day, and the healthy course of digestion. There appears to be something similar to this in man, in those ages where the ceecal digestion is most developed; in childhood, on the contrary, when the d:gestive apparatus resembles that of carnivorous an- imals, repeated discharges of excrement take place at indefinite periods of time. " The use of the valvula cccci in c Felt, " li w consider cinder this point of view the antagonism between the gas* trie am! coecal digestio i, it followfe, that, if both be excited at the same time, they will reciprocally disturb a^ch other, and that for perfect digestion, and the proper formation of the blood, they must take place at different periods of time. My experiments show that, for the completion of the coecal digestion, the bile flows through the small intestine into the coecurn, and the whole intestine becom ts th ir (by more or less alkaline; but they also show, that if, during the coecal dig sstion, the stomach be put in action, the flowing of the bile to the coecurn is stopped, and its digestion consequently hindered, since the chyme cannot be neutralized, and all the contents of the canal as far as the excrement become sour The formation of the blood in the lower parts of the canal is hereby disturbed, and the .gastric digestion is also rendered imperfect; so that the two digestions cannot take place in their integrity at one and the sums time: The completion, therefore, is indispensably neces- sary to perfect digestion in general, and it becomes very important so to reg- ulate the periods tor eating, that the activity of the stomach may not disturb the digestion in the coecurn. "If now, the coecal digestion be considered more particularly as a noctu- ral digestion, the meals should be so regulated, that,, when this begins, the stomach may no more be put into action, or at least not overfilled. It is gen- erally admitted that, a mm digests a moderate meal within three or four hours My experiments, however, upon carnivorous animals, which digest much more quickly than the omnivorous, to which class man belongs, show, that six or seven h >urs are r squisite for the digestion of a moderate meal, and that when dogs are allowed to eat as much meat as they will, twelve to four- teen hours are hardly sufficient for perfect digestion. The animals must even then bo allowed to r ist, for if they are made to exert themselves, the digestion is still further d< live.!, at least half the "time longer. The obser- vation:; which I mad i upon myself during intermittent fever agree with this fact, and ir maysaf ly be assumed, that six hours are necessary for perfect digestion, thr is till-all sour chyma has disappeared from the stomach. If now it be ad nitl i ', that; in the common mode of life, the noctural digestion begins about from s wen to eight o'clock in the evening, the last meal ought to b ! bv this time it may be for the most part digested in the stomach. Ingm r re, one should not eat after four o'clock in the afternoon, and -v- Is should be altogether avoided : for,in proportion to the la hour and the' quantity eaten in the evening, the more will I !i coec i1, and th o the gastrin digestion, be disturbed, seeing that both n place nearly at the same time. "Tint this nil i is nol ible in youth, (as long as the gastric diges- tion lesemMoa tin' of c trnivorous an'm l-\ and for the most part, finishes the process or digestion alone,) as in riper year?, follows from what has been al- ready observ d. "The more the feionis disturbed by con'inued large and late evening meals, the less perfect willbeths preparation of the blood, and the more will the need of its nourishing prts,*or hunger, be feU, particularly in the even- ing when th ! stomach is empty. This is the reason why those people who should eat leas >ning are most hungry at this time, and heie mere particularly does the feeling of hunger no! correspond with the period of di- gestion ; for th i more such people eat in the evening, the more imperfect is their sanguification, and the greater the consequent hunger, since the food goes almost entirely unchanged through *he alimentary canal, and the nour- ishment it contains is lost to the body. The only means, therefore, by which this hunger may be properly appeased, is that by which the digestion may be restored, and sanguification amended, and that is, notwithstanding hunger. 500 Observations and experiments upon the Ccecum. [Jan. to abstain from food in the evening, that the gastric and coecal digestions may not reciprocally disturb each other. " The source of hunger will ever increase, by continually appeasing it by late evening meals, and in this way, therefore, it is as easy to starve from too much eating as from fasting ; and no doubt in this way has many a person eaten himself to death, and most probably will still. We find in general that the meagerest and most sickly persons are the greatest eaters, and, on the contrary, the well-nourished and powerful eat less. That in the different condition of the digestive organs of different people, and according to the quantity of food which is taken during the day, there may be various chan- ges and exceptions to this general rule, is self-evident. Where the youthful condition of the digestive organs is still vigorous, and the coecum not as yet much developed, it is not necessary to be so particular about the smallness of the evening meals ; and where there is in general but little taken during the day, and the quantity of food in the coecum, therefore, small, more may be eaten in the evening, as there still remains a quantity of bile sufficient for the perfection of the coecal digestion. The longer the fasting after meals, the more bile can flow into the coecum after the ending of the gastric, digestion, and the less fear need there be of evil consequences." London Medical and Surgical Journal, October 1, 1835. Am. Journal. 1837. J New Treatment of Primary Syphilitic Ulcers, Cyc. 501 Part III. MONTHLY PERISCOPE. New Treatment of Primary Syphilitic Ulcers : By Dr. Carust. This very simple method consists in exposing the affected parts a minute to the vapour of vinegar, twice a day, and then covering them with dry lint, until the cure be complete. The healing progressed very rapidly, but only in primary ulcers, whether old or recent ; the secondary are never benefitted by it. After the cicatrization, the D>ctor administered anti-syphilitics to destrov the constitutional effects. H^ rep >rts already eight suc- cessful cases. // Filiatre Sebezio. Gazette Medical?.. New method of wealing Strictures of the Urethra, : By M. Jo- bert de Lamballe, Surgeon at the Hopital Saint-Louis. Having ascertained the existence and situation of the stricture with an elastic bougie, the instrument is to be smeared with sweet oil, and then covered with finely pulverized calcined alum ; if the stricture be considerable, the bougie is again to be dipped in oil and coated a second time with the alum in order to increase its quantity. The bougie thus doubly coated, is to be introduced and carried up to the stricture, care being taken to dilate the ori- fice of the canal so as to convey within as much of the coating as possible. Having reached the obstacle, the instrument is to be gently pressed against it and secured in its place in the usual manner. In some instances two hours will suffice to overcome the obstruction and to render urination practicable. But if re- lief be not obtained thus readily, it will, in most cases not be de- ferred beyond twenty-four hours. It will be necessary to repeat the application daily until the instrument can be carried into the bladder. M. Jobert relates cases which go to prove that the most in- veterate strictures yield to this treatment. The inflammation excited is but slight and the increased discharge soon ceases. This remedy acts by increasing the secretion and thus relieving the mucous membrane. The mucous membrane of the urethra, like the pituitary membrane, is tumified by inflammation, but re- turns to its normal thickness by an increased secretion as the lat- ter does by that attending coryza. Journal Hebdomadaire, 10th September , 1836. Epilepsy treated by Indigo. M. Noble, Physician in chief of the Royal Hospital at Ver- sailles, recently sent to the Academy of Medicine a detailed ac- 502 Epilepsy Treated by Indigo. [Jan. count of the use of Indigo in Epilcnsv. The following are his results. Three individuals were subjected to the treatment. The first was a youth 18 years oi'age, who. had been subject to epilepsy twelve years, and who was never more than eight or ten days without experiencing one or more well characterized paroxysms. Having been subjected to the use of indigo, he had had no return of the disease for two months at the time of the communication. He had taken the remedy in doses of a drachm daily, which were gradually increased to four drachms. This increased quantity produced at first slight vertigo*, dimness of vision, and finally involuntary contractions similar to those resulting from the use of strychnine. These symptoms ceased on the discon- tinuance of the indigo, but were always reproduced when the was again increased to three or four draehms. The second individual was a girl 20 years of age, who had been epileptic since her fourth year of age. She menstruated at eighteen, since which time her paroxysms, that had previously occurred once, -twice, or thrice daily, had increased to a frightful degree, especially about the menstrual periods, and, since her ad- mission to the hospital, she had never experienced less than ten or twelve paroxysms in twenty-four hours. On being submit- ted to the indigo treatment, in doses increased from one to four drachms, the freo^.ency of the paroxysms rapidly diminished. They even ceased entirely on the sixth day of the treatment, which howrever was continued a month. The last case related is that of a female in her fiftieth year, and who had had epilepsy twenty years. She had been several rs in the institution under M. Noble's direction, and had not only weekly attacks, but occasionally four or five in a day. Treated as the above two cases, the paroxysms have never re- turned since the fourth day, although she still experiences the same uneasiness and stupor which usually followed each paroxysm. She is yet under treatment, but the dose is not now carried be- yond two drachms. The two last individuals experienced no involuntary contrac- tions, but were affected with much diarrhoea whenever the dose reached four drachms. The diarrhoea ceased on suspending or merely diminishing the dose. Neither of the cases presented any other functional disorder. They will tend to confirm the efficacy attributed to this remedy, although they do not prove, as do those reported by M. Idelcr. that the disease will not re- turn. They are nevertheless sufficient to authorize further at- tempts, especially when the disease returns at short intervals. , [Ibid* 1837.] Solid Carbonic Acid. 503 Solid Carbonic Acid. The Gazette Mvdicah de Paris of the 8th of October last, con- tains the proceedings of a meeting of the Academy of Sciences, on the 26th September, 1836, from which we derive the following extract, announcing the interesting discovery of the means of solidifying carbonic acid. M. Tiiilorier, after relating a series of experiments made wTith Uquid carbonic acid, proceeds as follows to state the particulars of his more recent, discovery : "When, in 1832, 1 directed for the first time a current of li- quid carbonic acid on the bulb of a thermometer, the glass vessel in which rested the bulb was almost, rilled with a white powder of a peculiar character, and whose grains were finer than those of snow ; it ivas solid carbonic a'cid. Many persons have seen this substance, which was so abundantly foi med as to prove an obstacle to the frigorific effect of the current on the thermometer. ] will now state why the nature of this substance was not soon- er detected. The iirst apparatus 1 used for the- production of liquid carbonic acid, served both as a generator and receiver; that is to say, that the liquified gas would float over the solution of sulphate of soda resulting from the chemical action. The ex- tremity of the tube through which issued the liquified gas," being near the surface of the saline solution, I was led to think that the liquified gas carried with it aqueous particles in the form of snow, and it was in order to avoid this inconvenience that I determined to convey the liquid carbonic acid into a separate receiver. The necessary apparatus had just been completed when the committee met to repeat the various experiments I had made with the liquid carbonic acid. On turning the cock, I perceived with much surprise that this substance formed as abundantly as it had done before; and when one of the committee observed that it could be nothing else than solid carbonic acid, I wras already convinced of the fact, for I alone knew positively that the appa- ratus contained nothing but carbonic acid. I may then state that the committee determined with me the fact of its solidifica- tion, and 1 trust that their justice will acknowledge my claims to a "discovery unconnected with the ordinary processes of the labor- atory, and which required mechanical means of the greatest pow- er and utmost precision, as well as a degree of scientific zeal, which the committee have appreciated/' After the reading of this statement, a vessel filled with solid carbonic acid, resembling snow, in the middle of which was a block of solidified mercury weighing upwards of a pound, was presented to the academy. The frozen mercury was broken in- to pieces with a hammer, and presented a crystalline fracture. 504 Proceedings of the French Academy of Medicine. [Jan. Extracts from the proceedings of the French Academy of Medi- cine on the 4th October last. Treatment of Itch. M. Malapert objects to the usual method of treating Itch, as disagreeable and uncertain. He therefore sought for another, and thinks the causlics will combine the advantages of prevent- ing the disease from being translated to the more important in- ternal organs, and of radically effecting its cure. He prescribes them in the form of frictions or of lotions. The caustics he enu- merates are potass, soda, muriate of mercury, sulphuric acid, and sub-carbonate of potass, but gives the preference to the mer- curial preparation as the most certain and expeditious. Accor- ding to M. Malapert, the mean duration of the treatment with a solution of mur. hyd. (12 grs. to 3j. water,) is fifteen days. Essay on the relation existing between the symptoms of primitive and secondary Syphilis : By M. Martins. The first question proposed by M. Martins is which of the symptoms of the primitive disease are most commonly followed by secondary syphilis? The consecutive affection sometimes follows gonorrhoea, though rarely, and its complication with or- chitis or buboes adds nothing to the danger. Chancres lead to it much more frequently, especially if they be accompanied, pre- ceded, or followed by other symptoms of infection. The most common of the sequela? are papular eruptions, whereas the most rare (in adults) are the pustular forms of the disease. The more inveterate forms, or syphilitic tubercles and ulcer- ations follow gonorrhoea as often as chancres; and more than one half the cases of secondary syphilis are first manifested in the face and scalp. Nothing is more uncertain than the period at which the second- ary symptoms may appear; they are however more tardy after gonorrhoea than after chancres. One half of the cases succeed- ing chancres occur in the course of seven months. Among the causes which predispose to secondary syphilis, M. Martins ranks heat as first ; but admils that extremes of temperature have al- most as much influence. Taliacotian ()j>rrations. M. Blandin presented to the Academy, two individuals on whom he had practised the operation of "Autoplastic," one of 1 837.] Proceedings of the French Academy of Medicine. 04 them, a lad about 12 years of age, had nearly the whole of the left side of his face torn away by the accidental discharge of a gun. The buccal cavity was laid open so that the saliva con- tinually dripped out. M. Bland in detached a bit of skin from the forehead and formed with it the lost side of the nose ; with ano- ther brought down from the temporal region, he replaced the cheek and left commissure of the lips. M. B. remarks, that he retained the temporal artery in the latter flap, notwithstanding the opinion of Diffenbach, who advises that large arteries should never be used in such operations. The other individual was a man, perhaps fifty years of age, whose upper lip had entirely been removed with a cancer. M. Blandin replaced the lip with skin derived from the anterior part of the neck. Lithotrity. M. Segalas presented a child two years old on whom he oper- ated for the stone, by lithotrity, when only 33* months of age. The cure required six sittings and was completed in six weeks. The case is one of interest, the child being younger than any hitherto subjected to the operation. Gazette Medicate de Paris, Cancer of the mouth removed successfully by a new process : By M. Roux, of the Hotel Dieu. The tumour was situated between the tongue and the right branch of the inferior maxillary bone, and extended from about half an inch in the rear of the last molar tooth, to half an inch on the left of the mental symphysis. Its upper surface, ulcerated, greyish, fungous, and bleeding on the slightest touch, was ele- vated a little above the level of the teeth ; but the jaw was not affected. None of the teeth on that side were missing, and none were pressed aside ; the two incisors alone were slightly moveable. The tumour was separated from the root of the tongue by a deep fissure. The tongue was perfectly sound, but pressed to the left, and elevated towards the soft palate, so as to render speech almost unintelligible. By the finder introduced beyond the tu- mour, it was ascertained that it did not extend quite to the root of the tongue, and that it terminated abruptly by a vertical sur- face. The parts beneath were depressed so as to project below the lower edge of the branch of the maxillary about a half inch. M. Roux having previously ascertained, by experiment on the dead body, the extent in which the branches of the inferior max- illary could be separated without injury to its ligaments, after the division of the symphysis, and finding that it could be carried to This must be a typographical error. 06 Period for Hare-lip Operation, $c [Jan, an inch and a half or even to two inches, resolved on the opera- tion, which he performed on the 4th of May. The patient being seated in a chair in front of the surgeon, a vertical incision was made through the lower lip, on the median line, and extended to an inch below the chin. A fine saw was then introduced between the incisors, and the jaw severed at the symphysis. The branches of the bone were now by gentle la- teral traction, separated about two inches at the symphysis, the soft parts readily yielding, and held in this position by the hands of an aid standing behind the patient. The surgeon then, with a convex scalpel, detached the tumor from the internal face of the jaw-bone and from the root of the tongue. During the last inci- sion, a pretty large artery coming from the tumour was opened, but immediately tied. A double hook (airigne double) carried into the posterior part of the tumour, served to draw it forward,, and the operator making tractions, with its handle between the teeth, detached the posterior adhesions, leaving it connected only inferiorly. The tumour was now readily separated from the Subjacent muscles, which were found perfectly normal. Another artery was opened and tied. The tumour being thus entirely removed, the bones were brought together ana maintained by a silver wire carried around the four incisors ; the soft parts were united by the twisted su- ture ; and no other application made. With the exception of small fragments of bone coming away from the internal face of the mental portion of the inferior maxillary, there were no un- toward circumstances attending the cure of this case. The bones united kindly, and the patient was discharged on the 4th of July following. The mouth had healed, but the tongue ad- hered to it in such a manner as materially to impede pronunci- ation and mastication. There was no evidence of a disposition in the disease to return. The lymphatics of the neck were nat- ural. Journal des Connaissances Medico-Clnrurgicales* Period for Hare-lip Operation. The Boston Medical and Surgical Journal for 14th December, 1836, furnishes us with some observations on the operation for hare-lip, by Dr. Peirson. In this essay, the author, after array- ing and inspecting the opinions and practice of the principal sur- geons, from the time of Cclsus to the present, on the subject of the age of the patient best suited to good success, concurs finally with the late Dr. Rand, senr., of Boston, on recommending the operation immediately at birth. This concurrence of opinion is founded on the facts of observation, of himself and others, as well as the reasoning against other periods of life, as the time of den- tition and after that is over, the most ungovernable period of life, in which there is not a sufficient development of the reasoning 1837.] Period for Hare-lip Operation. 50? faculty to overrule the pcrvcrsencss of disposition, or the dread of pain and so forth. After stating the success of Dr. Rand's last case, in which "the child was put to the breast a few days after (the removal of the pins on the fourth day), sucked as well as any child until she was weaned ;" and became a fine healthy, handsome girl, with scarcely a trace of a scar in her lip. He proceeds: " I cannot help concurring with these views, and recommend- ing the operation at the very earliest age, provided the child is in good health and well constituted. Many of the objections made to this operation at this early age arc certainly groundless. It is not true that there is not consistency and firmness enough in the lip to bear the pressure of the pins or sutures. And com- pared with any other period, anterior to teething, I do not believe the danger of convulsions or death is any greater. There is, doubtless, a degree of danger, which must be encountered in all such operations during infancy ; but ought this to weigh against the parental distress and anxiety, the risk of defective nutrition, the imperfect ossification of the maxillary bone, and the defective pronunciation, which are the probable, or certain consequences of delay?" Dr. P. then gives two cases in point. In the first he operated for a simple fissure of the lip, on the next day after birth. The operation was performed in the usual manner, with hare-lip pins. Three days after, the pins and all the dressings were finally re- moved. On the eighth day after birth, the child was put to breast, and nursed as well as any infant. The cicatrix became so ef faced, that there was scarcely a perceptible deformity left He states as one of the advantages of this early operation, the fact that the deformity being in the first instance kept secret, the parents were saved from annoyance by the officious enquiries of their friends and neighbors. This is a matter of no trivial con- sideration with most parents; but there is a more valuable fact than this in the case, and it is that the deformity was so com- pletely removed as not to lead to the discovery of the part after- wards. In his second case, which was last February, he operated on a child born the previous day. The fissure in this case extend- ed through the superior maxillary bone and soft palate. In three days the union was completed and the pins removed. In this case, the child was well nourished by feeding, but could not suck on account of the extent of the fissure in the palate. He considers the early operation peculiarly important in this case for facilita- ting the ossific union of the palatine bone. Dr. P. then advances other reasons in favor of the operation the next day after birth ; as the fact of the removal of the fissure preventing, by the regular and moderate pressure of the lip on the part, the projection of the anterior part of the maxillary bone 598 Bad Surgery, $c. [Jai. through the fissure; a circumstance-which not unfrequently oc- curs at and after dentition; also the fact that the infant is more generally free from all diseases during the first week ; and that " it is perfectly practicable to keep the mother ignorant of all the circumstances, until she can be informed that the steps necessary to remedy the deformity have been completed." On the subject of the mode of performing this operation, the Dr. asks, "can it be said that the mode of performing the opera- tion is better settled than the time? Dr. P. for many good and insuperable reasons adopts the use of thejstraight silver pins with polished steel heads (points?) and the twisted suture ; and the scissors are preferred to the bistoury for removing the sides of the fissure. The difficulty which commonly occurs in the use of the scissors, of holding the edge of the lip to the instrument, he overcomes by adopting the expedient of Dubois and Roux, of passing a thread through the angle of the lip by means of a curved needle. In all ordinary cases, he advises the removal of the pins after 72 hours, as he considers that nothing is gained in point of longer co-aptation of the edges, as the ulceration which is apt to take place around the pins after this time prevents their effects, as well as increases the mark which they leave on healing disa- greeably large. After they are removed, the uniting bandage should be applied, and the retracting powers of the cheeks prevented from action, as far as practicable. Bad Surgery. The following is a very striking illustration of the old plan of treating fractures of the thigh of a good patient, with a box for extension and counter-extension. We are free to acknowledge, that whilst we practised in these cases on the Dessault and the Physic plan, that our sympathies wen; ah. ays more or less excited, by the actual suffering which the treatment alone inflicted; and occasionally we have had the mortification to witness, in those patients who were most amia- ble, and patiently submissive to orders, most extensive ulcerations at the points of pressure. Nor were these the worst of the evils, but, as is too often the case with people in other matters, we found ourselves like great men in bad things ; and as was the fact with the celebrated Boyer and Deschamps, in the case of the illustrious La Fayette, we were not unfrequently chargeable with that mal-surgery which entailed on our patients lameness and deformity for life. Whilst the case is important in a bio- graphical point of view setting forth beautifully as it does the extreme amiableness of him whom Americans so much revere, it is no less useful in exhibiting a proper comparison between the old plan of treatment, which is yet chiefly in use, nnd the treatment 1837.] Want of the Sagittal Suture, $c. <$<;. 509 by weight and fulcrum as illustrated by a number of cases in the 5th No. of the Southern Medical andSurgical Journal, page 281. We are of the opinion that, one of the causes, (and not the least,) which tend to retard not only surgery, but medicine generally, is the concealment of bad practise, or ill success. When we had the honor of beholding this great and virtuous lover of freedom, this bosom friend of our own Washington, as our " nation's guest," so bright was the halo of glory that shone from his heroic deeds, that no thought entered our mind but that his decripitudc marked his sacrifice on the altar of American liberty. Had it then been known as publicly as his misfortune was, that it was the result of bad surgery, surely the inventive genius of freemen would not have rested short of a remedy which would have saved from such afflictions. 44 Maltreatment of a Fractured Leg in Gen. Lafayette. M. Jules Cloquet, relates the following instance of bad surgery on the part of the celebrated Burgeons Boyer and Deschamps. 44 During his last illness, Lafayette related to us more than once the partic- ulars of the treatment he underwent in 1803, for the fracture of a thigh, caused by falling from a height ; Deschamps and Boycr, whose memories I respect, and under whose care I was educated, were called in, and enclosed the limb in a machine constructed so as to maintain it in a state of continual extension. Lafayette having promised his surgical friends that lie would pa- tiently endure the pain and inconvenience necessarily attendant on the treat- ment, did not give utterance to a single complaint, and did not betray the least sign of being in pain for the whole of the twenty days which elapsed be- fore the apparatus was for the first time removed ; when it was removed, however, his surgical friends could not conceal their consternation ; Des- champs turned pale, and Boyer appeared thunderstruck. The bandages of the upper portion of the apparatus had, by their pressure, cut deeply into the flesh, and exposed the femoral artery, while the skin of the dorsum of the foot was rendered gangrenous by the inferior bandages, so as to lay bare the ex- tensor tendons of the toes. More than five weeks were required to heal these wounds, and when the cure was completed, an almost complete an- chylosis of the hip joint had taken place, so that he was lamed for life." [Boston Medical and Surgical Journal. Want ofth* Sagittal Suture. Mr. Wallace, surgeon in the British navy, lias lately had the opportunity of examining the heads of four negroes from the western coast of Africa, in all of which the sagittal suture was wanting. This can hardly be thought an accidental occurrence, and leads to the con- clusion, though exceedingly remarkable, that sucli is the usual cranial confor- mation in this race of blacks. Ibid. Cinnabar Fumigations. Dr. Venot employs with success the following mode of fumigating venereal ulcers of the throat with cinnabar. After soak- ing sage-leaves in strong gum-water, the sulphuret of mercury is sprinkled over them, and they are dried in the sun ; they arc afterwards smoked in a pipe instead of tobacco, and the vapour is thus directly and conveniently ap- plied to the diseased surface. Several cases are reported to prove its rfnea- oy. Jwr, rf# Med. Pra'iqve dela Snr. Boy. d Bordeaux, Ftvrier, 1836. 510 On the nature and mode of action of Cantharides. [Jan, On the Nature and Mode of Action of Cantharides : By Dr. Domenico Nardcx of Venice, and Dr. Tommaso Pullino of Alba. [We regard as most valuable every fact that tends to illustrate and estab- lish the physiological and therapeutical action of medicines on the animal sys- tem ; and we are rather disposed to direct attention towards the more ex- tended and closer investigation of the properties of our old remedies, than to hunt after new ones of doubtful efficacy. We have yet much to learn res- pecting our best known medicines, and certainly respecting that which is the subject of the following pages which contain the more essential parts of two long memoirs.] First Memoir. By Dr. Nardo. 1. Cantharides, when chewed, have not that acrid taste which has been, assigned to them, solely from analogy. 2. They will act in an entire state or in powder. 3. The green portion is the only active part of the fly. 4. In this green portion alone is found the cantharidin. 5. There is no other poisonous principle existing in the fly. 6. The green principle is analogous to that found in the involucra of other insects having no vesicating powers. 7. The other principles, as the black and yellow substances, are produced by other insects, and are modified by the process followed in their extrac- tion. 8* Cantharidin is a neutral body, unchanged by acids or alkalies ; soluble in cold sether, creosote, oils and fats, and in boiling nitric acid and alcohol. 9. It has neither smell nor taste ; but, if a small quantity be laid upon the tongue and pressed against the palate, it produces after a time a scalding sen- sation. The same thing occurs if it be dissolved in aether or oil, which, by aiding its absorption, increases its powers. 10. A very minute quantity of cantharidin is sufficient to excite vesica- tion : for its farther action is arrested the moment that the elevation of the epidermis by the serum removes the absorbents from their contact with it. The vesication, therefore, is not increased either by a larger quantity or lon- ger application of the cantharidin. 11. Cantharidin does not vesicate by irritating or producing any sensible inflammation ;(]) its action upon the cutaneous system appears to be limited to the lymphatics, or to a slight stimulus confined to the cutaneous layer be- low the epidermis, so that the nervous and sanguiferous systems do not suffer at all during the process of vesication. (]) 12. 13, 14. Cantharidin applied to the denuded cutis induces a serous ex- udation, followed by an atonic suppuration ; and acts in the same way that it does on the outer surface, its action is most speedy and painful upon parts most supplied with sebaceous and mucous follicles. 15, 16. Cantharidin is not decomposed when absorbed, and its absorption ceases as the vascular action of the cutis is excited. 17 20. Being carried through the system in an undecomposed state, the cantharidin is eliminated like other foreign matter ; but, if the quantity be great, it accumulates in certain parts, and produces its effects according to the nature and susceptibility of the organ. Its stimulating effects upon the urinary passages, and its boasted aphrodisiac powers, are not peculiar pro- perties, but result from the effects of its primary action. Thus, carried along with the urine, it attacks the prostate follicles, producing a state approaching to vesication ; and the urine, by increasing this irritation, produces the symp- toms of priapism, ischuria, &c. Its poisonous action upon the alimentary canal is produced in an analogous manner, but gives rise to more extensive sympathies. 1837.] On the nature and mode of action of Cantharides. 511 21. Camphor has no power as an antidote to cantharides. [Dr. Nardo lias given cantharides in various kinds of dropsy, but could never perceive any effect from them. The effects as an aphrodisiac are very uncertain, and usually are only exhibited when they are taken in dangerous doses. The author rather prefers in paralysis of the bladder and incontinence of urine, a weak injection of cantharides.] British and Foreign Review. Antologia Medica. Second Memoir. By Dr. Pullino. 1. Two grains of cantharidin, given at once to a middle-sized rabbit, pro- duced paralysis, coldness, and death in three hours. 2. A grain and a half dissolved in milk caused the same symptoms, and death in an hour and a half. 3. The same dose with m. xv. of cherry-laurel water caused instant death. The rabbit had five hours previously taken m. xx. without injury. Heart empty and flaccid, stomach pale. 4. A fourth rabbit took two grains in solution, with the same symptoms and convulsions of the hind legs. It then took a few drops of ammoniated aether, and one grain of acetate of morphine, at two doses. It revived, but was not lively, and died in twelve days. Stomach reddish here and there ; menin- ges injected. 5. Two dogs of the same age and size, took, the one ten grains of cantha- rides in decoction ; the other twelve grains in powder. The former was paralyzed, and died ; and, on examination, presented no inflammation of the stomach. The other tried to vomit, was distressed, writhed, and moaned. He was killed in six hours, when the poison was found undigested, and the stomach reddish. 6. Three more rabbits were killed with cantharidin, and two with cantha- rides. The stomachs of those that drank after taking the poison were unin- jured, and the inflammation in those that did not drink was too slight to ac- count for death. 7. The author took two grains of cantharidin at two doses, fasting, and felt a universal shivering and chill down the spine, skin pale, head oppressed, and in one minute the pulse fell five beats. Urine copious in a quarter of an hour afterwards. 8. A fortnight subsequently, he took two grains at four doses. After the second dose he felt a dull pain in the head, and at the next a little vertigo, the skin being cold and clammy. The pulse, after violent, action, lost seven beats in a minute. Urine scalding and copious, although but little fluid had been drunk. In the afternoon he took some alcohol, and then ten drops of ammo- nia in water, when the vertigo ceased and the urine by midnight no longer scalded. Unusual weakness next day. 9. The following are notes of some cases of disease in which cantharides were exhibited : (1.) Pleuropneumonia . After two bleedings, the pain continued with bloo- dy sputa of unhealthy consistence. Three grains of cantharides in solution, gradually increased to ten, were taken daily. Continued sweats, urine not increased ; sputa healthy, pain gone in sixteen days , eighty-five grains ta- ken. (2.) Carditis. One hundred and twelve grains taken in twenty days ; urine scalding at first, very copious and turbid afterwards; (3.) Beating of arteries of the left side of the head preventing sleep ; had been treated by many bleedings. The patient took one grain of cantharidin in four doses at short intervals. Vomiting, pulse small, rapid, rigors, ver- tigo, torpor of lower extremities, and other signs of depression. iEther, opi- um, wine and generous diet, produced a cure. (4.) Intermittent Fever threatening suffocation. Bleeding during the pa- roxygm, and quinine, were followed by ardent and continued fever, dryness ol2 Influence of the Nerves on the Muscular System, f Hydrocephalus, with Operations. 515 the calomel. The turpentine having no effect, ordered oleum ricini 5ss. to be given in two doses, one half at 9 o'clock, the oth- er at half-past ten if necessary. Sept. 3d. Medicines operated five times in the course of the night, but was succeeded by pain, griping and tenesmus and it was thought too by pain in the head, which might have been oc- casioned by crying or perhaps by cold. The latter, however, was not indicated by any marked febrile symptoms. Ordered enemata of starch and laudanum. Two of which were admin- istered and two drops of laudanum per orem. Several doses were given before relief was obtained. The child became quiet in the afternoon and slept tolerably well. Resumed the diuretic mixture. Sept. 4th and 5th. Child quite comfortable nursed well . bowels acted on once or twice each day apparently free from irritation and pain. Diurectic mixture continued in doses of six drops every two or three hours. Sept. Gth. In the morning the child had convulsions the head gradually enlarging and strabismus increasing. Directed calomel gr. vi. to be given, which operated but three times du- ring the afternoon and night Sept. 7th. Calomel operated once during the day. Child continues much the same as yesterday. Drops continued. Sept. 8th. The little patient remains the same, except thai the head is rapidly increasing. Diuretic mixture continued. Sept, 9th. Child tolerably comfortable in the morning. At mid-day had two or three convulsions these occurred again in the evening. Child rather fretful when awake, but sleeps much. Ordered calomel gr. vi. to be given, and the laced cap upon the head, which had been substituted for the bandage, to be loosed. The diurectic drops have been continued as usual about xxxvi. drops in twenty-four hours. Sept. 10th. The calomel operated but once during the night. Directed sub. mur. hydr. gr. iij. mixed in ol. ricini I ss. which operated freely five times in the course of the day and night. Sept. 11th. Child somewhat better. Increased the dose of the tine. dig. and sp. sweet nitre to eight drops every three hours. Sept. 12th. Child continues better evidently improved by the cathartic. Drops continued as yesterday. 516 Case of Hydrocephalus, with Operations. [Feb. Sept. 13th. The little patient continued tranquil all day. The drops which were given as yesterday, acted freely as a diurec- tic. Sept. 14th. Child's head had attained precisely the same size it was before the operation, but the strabismus had almost entire- ly ceased, and the child seemed in other respects much better. At one o'clock repeated the operation near the place it was per- formed before, and drew off seventeen ounces of serous fluid, con- siderably more than a pint. Child bore it well. Cried hearti- ly, and evinced very little inclination to syncope. Drops con- tinued. Sept. 15th. The child had a convulsion in the morning, but has been in other respects quite comfortable during the day. Medicine continued. Sept. 16th. Continues much the same as yesterday. Sept. 17th. Had a convulsion in the morning was fretful during the day. Had another in the evening, was very restless, cried much, and required to be held in an erect posture. Di- rected twelve drops tine, camph. opiata to be given, which pro- cured some rest. Sept. 18th. Directed sub mur. hydr. gr. vi., which operated three times in the course of the day and evening. Had a severe convulsion about one o'clock, but was tranquil in the evening, pulse and skin in good condition. Sept. 19th. Child fretful and cried much in the morning. Directed tine, camph. opiata to be given, which procured relief. The bowels were acted on once during the day. The child urin- ates freely under the use of the drops in the dose of eight every three hours, as before. Skin in good condition. Sept. 20th. The little patient has had a more tranquil day - has been free from convulsions bowels and skin in tolerable or- der. Drops continued. Sept. 21st, 22d, and 23rd. The child during this period in statu quo. Case marked by no peculiar symptoms of irregular- ity or uneasiness. Diuretic mixture continued as usual. Sept. 24th. Had a convulsion in the morning with some fe- ver and apparent derangement. Ordered sub mur. hydr. gr. viij. Other convulsions during the day. Calomel operated but twice. In the evening gave pulv. con. jalapii, gr. v., sup tart, potgr. xv., which produced two more dejections. 1837.] Case of Hydrocephalus, with Operations. 517 Sept. 25th. Child very fretful cried much, apparently from pain. Directed tine, cam ph. opiata, gtt. xv, which gave relief. Sept. 26th, 27th, 28th and 29th. No material alteration in the child during the last four days. A 11 the emunctories of the body seem to have been pretty well open, and no other medicine given save the diuretic mixture. Oct. 8th. No material alteration in the child since the 29th ult. until yesterday, except that the child's head had gradually enlarged, and during the last three days had become very turgid. It was much less irritable, and for the last two days ceased to cry entirely. The bowels as usual were constipated. One or two doses of calomel only had been given, and the drops con- tinued. Yesterday morning (7th,) it was taken with cascading and vomited much through the day. A little magnesia was given it once or twice with only partial relief. In the night the vomiting returned severely, and was then relieved by xv drops of elixir paregoric. The bowels being still constipated, gave this morn- ing (8th,) sub mur. hydr. gr. vi, which operated once in the evening. At 4 o'clock, in presence of Dr. Waring, I again op- erated upon the head, which was now very turgid, and enlarged to nineteen and a quarter inches, measuring over the os occipitis and os frontis, and nineteen and three-fourth inches measuring under the chin and over the posterior part of the ossa parietalia, near the apex of the lamdoidal suture. The quantity of serous fluid which was now evacuated amounted to fourteen ounces by weight. The puncture was made three-fourths of an inch fur- ther back than the former some small blood vessel was woun- ded, in consequence of which the serum was tinged with blood ; perhaps a table spoonful was discharged, the flow of which, however, ceased before the serum was all evacuated. The child which had been so senseless and so constantly inclined to sleep for three days before the operation, did not appear to suffer at all from it. It was evidently more sensible, animated, and brighter afterwards. Although there was not much strabismus previ- ously, it looked better about the eyes after the operation was performed. Oct. 9th. The night though a tranquil one, was passed with- out much sleep. To-day the child seems brighter and better sleeps very little has had four voluntary stools, or else the effect 518 Case of Hydrocephalus, with Operations. [Feb.. of the calomel taken yesterday morning. The diuretic mixture resumed this afternoon, winch had been suspended during the last thirty hours. No material alteration in the child during the 10th, 11th and 12th, except that the head seemed to be filling up rapidly. On the thirteenth, the child had several convulsions was fretful and sometimes cried severely bowels somewhat constipated had been acted on but once during the day. Di- rected the laced cap to be removed and the child's head bathed in cold water the cap to be reapplied, but not so tight as be- fore. Ordered, sub mur. hydr. gr. vi., which operated but once next morning. Drops continued. Oct. 15th and lGth. The cathartic operated several times freely, producing at first dark, afterwards mucus and stringy or fibrous stools. Head rapidly swelling. To-day, (16th,) has some fever, is fretful and apparently in pain has had several- convulsions and although two discharges from the bowels, or- dered a dose of cal. magnesia to be given, (say a small tea-spoon- ful) at 6 o'clock in the evening. Oct. 17th, 18th, 19th and 20th. No material alteration in the child, except a gradual enlargement of the head, not only from its rapidly filling up, but apparently from natural growth. The child nurses heartily is fat, and grows well. The only incon- venience which it seems to suffer, is, occasional slight convul- sions, and constipation of the bowels. The head had again be- come quite turgid, its circumference now (20th,) being nineteen and a half inches and twenty and a quarter inches, measuring under the chin. At four o'clock I repeated the operation, and drew off thirteen and a half ounces of serous fluid reapplied the laced cap directed the diuretic mixture to be continued as before, and sub mur. hydr. viij. grs. to be given every fourth day, to be followed with sup. tart. pot. if necessary. On the 21st, the mother and child returned to the country to remain a fortnight. Nov. 3d. From the account given by the mother, it appears the child continued in statu quo, until Wednesday the 31st of October. Previous to that time, it was comfortable, nursed well, and she thought had lost no ground. It however had fits occasionally, or was convulsed and the overseer, Mr, A thought it quite ill. On Wednesday, as before stated, it became very much worse. Its head had now become quite enlarged, so is;*?.] Case of Hydrocephalus, with Operations. 519 as no doubt to occasion much compression of the brain. Fever ensued, and the convulsions were increased. On Friday afternoon, my boat left the plantation for town, in which the mother and child took passage. Distance by water, about fifty miles. The latter, however, was so ill, that the over- seer thought it inexpedient for the child to come, but as it had been directed, permitted the order to be complied with. While on the passage, and when about half-way to town, the child died. About twelve or fifteen hours after, I made a post mortem ex- amination, the head at that time was nineteen and three-fourth inches in circumference, measuring over the os frontis and os occipitis above the ears, and twenty and a half measuring over the ossa parietalia and under the chin ; just a quarter of an inch larger each way than at the last operation. I first plunged in a small trocar and drew offwhat water would readily flow. I then made an incision through the scalp and through the meninges of the brain, in the direction of the longi- tudinal sinus, and along the sagittal suture, by means of which, I evacuated the balance of the serous fluid in all two pounds and a quarter. The autopsy in this case, exhibits the following interesting and singular phenomena. The medullary substance of the brain was very small in quantity, being separated into two parts at the ventricles, and attached to the parietes of the cranium the substance of which was found principally upon two sides, and upon the base of the cranium, arising with a thin edge near the top of the parietal bones, and descending thence to the. base, not more than six or eight lines in thickness in any part. The pa- rietal bones were separated about two inches along the course of the sagittal suture, and with the os frontis and os occipitis, formed very large openings at the fontanelles. The dura mater and the other cerebral membranes (viz. the pia mater and tunica arachnoidea,) were very thick and strong, especially at the ante- rior fontanelle. The falciform process extended to the base of the brain, having a round opening in the centre, of about one inch in diameter, which of course admitted of a free communi- cation of the serous fluid from one side to the other. The ten- torium cerebelli had also an opening in it similar to that in the falciform process, which admitted of a free ingress and egress of serous fluid, so that all parts of the cavity of the cranium were 520 Case of Hydrocephalus, with Operations, [Feb. subject to dropsical effusion. The cerebellum was somewhat smaller than usual, but in other respects it appeared quite natu- ral and healthy. And upon the functions of this organ no doubt depended the exercise of the powers of life, for so long a timer and the apparent health and flesh of the child. The pressure upon this organ as well as the cerebrum, previous to each oper- ation, no doubt wras the principal cause of the convulsions. And had the operation been repeated on the Wednesday or Thurs- day preceding the child's death, it is probable its life would have been prolonged. But that a sound and healthy action would have been produced, or that a cure could have been effected by a rep- etition of the operation, is not at all probable. The oftener the operation was repeated, the more rapid would have been the accumulation the more distressing the symptoms, and conse- quently the greater the necessity for relief. The first case which came under my observation, in which the operation of paracentesis capitis was practised for the cure of Hydrocephalus, and the first of the kind of which at that time I had any knowledge, was the case read before the Medical Socie- ty of South Carolina, on the first of July, 1818, by Joseph Glo- ver, M. D. of this city, and subsequently published by the Soci- ety in pamphlet form. In this case the operation was repeated eight times, with great relief to the patient and with great hope of success seven times by the Dr. and once by myself. The first operation was performed on the 3d of March, and the last on the 21st of June, 1818. The subject was a female child born on the 21st of November, 1817. Six and three-quarter pints of serous fluid were drawn off in the course of the several opera- tions. The case terminated fatally on the 21st of June. After death, three pints more were subtracted from the inter-cranial sac formed by the dura and pia mater. Reviewed in the Ar- chives Generates de Medecine, a Paris. In the London Medical Repository and Review, for January 183G, another instance of tapping for hydrocephalus is reported, by Mr. Sym, with an unfavorable termination. Noticed in the Archives Generates de Medecine, Mars, 1826. It is stated in the London Medical Gazette, for April, 1830, that Dr. Conquest had, in t\yo cases, performed the opera- tion of puncturing for the cure of hydrocephalus, with success in both. 1837.] Case of Hydrocephalus, with Operations, 521 Professor Gracfc of!3crl in, repeated this operation eleven times in the course of six months, upon the head of a child, (a hoy be- tween four and ten months old,) which resulted in a perfect re- covery. Reported in Gracfe and Walter's Journal der Chirur- gie, and copied into the Archives Generales de Medccine, a Paris, Mars, 1832 Into the London Medical and Physical Journal and into the American Journal of Medical Sciences, Nov. 1832. This operation was subsequently performed for the cure of hydrocephalus, by Mr. Russel of Aberdeen, with a successful issue an account of which may be seen in the Edinborough Medical and Surgical Journal, July, 1832. Mr. Russel says, " with the exception of Dr. Conquest's two cases, I am not acquainted with another in which the ventricle has been punctured for the relief of water in the head. In the cases of Rossi and Dr. Vose, the water between the membranes only was evacuated.,, In the London Lancet for June, 1835, a case is recorded in which the operation was twice performed by Francis Cooper, Esq., upon the same subject, and a large quantity of water evac- uated, but with an unsuccessful termination. In the Southern Medical and Surgical Journal, for December, 1838,* a case is stated by Professor Dugas, of the Georgia Med- ical College, in which " the brain was punctured seven times, and sixty-three ounces of fluid drawn off, without the slightest un- pleasant effect from the operation," yet the case unfortunately terminated fatally. From the formidable character of this disease, and the gener- ally fatal termination of it yielding to the power of no article of the Materia Medica reasoning a priori, one could scarcely come to the conclusion that the trocar would prove so important a remedial agent. Although a majority of the cases which have hitherto been reported, terminated fatally, as might have been reasonably expected, yet, if the operation of parancetesis capitis has proved successful in a single instance, it is a fact which ought *Just as this article was about to bo closed, and placed at the disposal of the Editors of this Journal, (though not originally written for publication,) and just in time to be here noticed the seventh number of the Journal came to hand, containing a description of Dr. Dugas' interesting case, which, in many of its features bears so strong a resemblance to mine, as perhaps to lessen in some measure the interest, which might otherwise have been felt, in the details which are now presented to the public. 66 523 A short account of Master S. K. G. NeUis, $c. ' Jtr.n ^SwV.yVIO^ A. Stcfc oftiuMd/rnu-Md (icrtih D. Jnferwr JD^phT^niAte^rTertM F. Sflwje ^Tfery . CTon/ryJ*f1fcrij JTX;tlfepaJtt .Artery LPyforicfl/rfcri/. :K. Superior MwtiStrieArX ~L Bight Hepatic d"' M. Bight Gv.**rt>f*f>hM &> H.SuptncrByhtColic d. O . RznalJlrtima P . iS'pwtn'ji.tic do 9 Jk/erwr .Mesenteric 1 JVumJ&en.ttwXf/.hojfrap'iie-Pw* M,.U V , Ck.rUU. 1837.] Hysteritis Chronica with Cases. 529 ARTICLE IV. Hysteritis Chronica with Cases: By Isaac Bowen, M. D. Although the disease under consideration is a chronic affec- tion, as observed in this and tropical climates, still the fever which accompanies it, is a cauma, sometimes, however, in minia- ture, as will appear from its description and treatment. The penultimate and final syllables of the class of diseases, to which hysteritis belongs, viz. itis, is derived from the Greek word ae(aai, which is a ramification ofsw, and implies not merely slug- gish action, but " violent and impetuous action." It is imperfectly described in Good's study of medicine, under the name ofhysteritis simplex, but the best description which I have seen, is to be found in " Dewees' Treatise on Females," un- der the appellation of " irritable uterus." I could not pretend to give a better account of the diagnostic symptoms than is laid down in that excellent volume ; but as my observations have been in a climate many degrees warmer, where the cornplaint occurs oftener, and as I have sometimes varied from his treat- ment, although perhaps not essentially, it will not be considered fastidious, that I should attempt to describe the disease as it ex- ists in this climate. Another reason is, that the complaint is oftener mistaken in the southern States for prolapsus uteri, than in Philadelphia, and oftener still for gravel. The reason of such mistakes is, undoubtedly, because it has many symptoms in com- mon with those maladies. The attack ofhysteritis chronica is not, like many other local inflammations, often, if ever, ushered in by a chill, although it frequently comes on quite suddenly, and is attended with more or less fever. Sometimes the fever is so slight that it can scarce- ly be noticed, except by the increase of frequency and fullness of the pulse, and flushed face in the afternoon. The uterus lies somewhat lower in the vagina than usual, is enlarged, particu- larly at the neck and os tincae, and is so sensible to the touch as frequently to cause the patient to distort the countenance by the operation. In severe cases, the whole uterus is enlarged, but .generally the inflammation only extends to the mouth and neck 67 #30 Hysterias Chronica with Cases. [Feb. of the organ. One lip is generally more swollen than the other. There is an obtuse pain in the back, which often extends to the hips, and sometimes produces the sensation of heaviness or grav- itation. The os tincoc is sometimes open, so that often the point of the finger can easily be introduced, although not without, pain to the patient. . f The stomach usually sympatizcs with the ute- rus, so as to give rise to a train of very harrassing, dyspeptic and nervous symptoms." (Eberle.) The part of the uterus, which is inflamed, may be known by the region in which the suilering is felt. Astruc says, " Cette douleur de la matricc estrapportee par les malades a differcns cndroits du bas ventre, suivant le plus ou le moins de proximite de ccs cndroits avee 1c siege dc Pin* flammation, ou suivant la communication plus ou moins grande, qu'ont ces endroits avec la partie enflammee de la matricc, soit par les vaisseaux sanguins, soit par les ligamens de la matricc, soit par les expansions du peritoine, qui attachent la matricc par les cotes. C'est ainsi que les malades.se plaignent de la douleur des lombcs quand ^inflammation occupc la partie postcricure du fond de la matricc ; de la douleur du nombril, quand l'inflmma- tion occupe la partie anterieurc du meme fond, dejjla douleur du pubis ou de Fanus quand l'inflammation est au col de la matrice en devant ou en derriere, de la douleur dc l'une ou de l'autre des aines, des hanches, des cuisses, quand rinflammction est a Tune ou a l'autre des parties laterales dc la matricc, d'ou naissent les ligamens ronds,&c." (Maladies des Femmes Tom. 3. liv. 2. p. 20.) The same symptoms have since been described by ma- ny writers, both European and American, but not differing es- sentially from tills author, who wrote about eighty years ago.- Menorrhagia or leucorrhcca frequently accompanies or precedes this disease. The bowels arc generally costive, or alternate with looseness and constipation. The pulse is preternaturally full, and is at its acme in the early part of the afternoon, at which time a hectic flush may be seen upon the face. The patient com- plains of pain in the hinder part of the head, and sometimes in the anterior part ; the tongue is of a pale white colour, and as De- wees justly remarks, " towards evening it reddens and becomes clearer." When the irritation extends to the neck of the bladder, it products strangury and sometimes an inability to urinate. The patient is much the most easy in a recumbent supine pos- ture, with the lower extremitjefc slightly drawn up. as the pros- 1837.] Hysteritis Chronica xoith Cases. 531 sure of the other viscera docs not interfere so much with the. uterus. As it regards the cause of this disease, there exists some ob- scurity. In most of the eases, which have come under my obser- vation, the patients have assigned cold as a cause. This may often have its eilects, where other causes catenate in the com- plaint. In man} cases which I have attended, menorrhagia has preceded chronic inflammation of the uterus, and in some -for a long time. I think the relaxing state of the climate, together with the sudden changes which often take place, has a predisposing influence ; so that the exposure which females often undergo on account of thin clothing, tends to throw the blood upon the in- ternal organs with mure force than natural. This being fre- quently repeated, may produce the effect upon those females who are very susceptible. In slight cases, the uterus is capable of impregnation. No disease can require the antiphlogistic method more steadi- ly applied, than the one under consideration. Tonics of no de- scription will agree with the patient, until the disease is com- pletely at an end. The first step to be taken is the abstraction of a sufficient quantity of blood to relieve the pain, which is seated in the head. In cases that are not severe, fourteen ounces or less of blood will be sufficient ; but frequently if the health is not restored in a few weeks, smaller quantities must occasionally be taken. In gener- al the application of a blister above the pubis, will be an excel- lent auxiliary ; but sometimes one applied to the sacrum will have a better effect, particularly if the posterior part of the ute- rus is principally affected. As a local application, cupping or leeching will have a powerful influence, and, in some cases, su- persede the necessity of blisters. When these topical applica- tions fail to restore a sound state of the uterus, a seton, inserted in the inner side of the thigh or in the sacrum, will be highly ben- eficial, and sometimes perfect a cure. Demulcents applied to the os tincce, by introducing them into the vagina, will produce a very fine effect, and ought never to be neglected. For this pur- pose, a mucilage of llax-seed will generally answer the purpose, but I have always found that made of the root of comfrey (sym- phitum officinale) preferable to any other mucilage I have used. Many physicians, on account of the fallen position of the utc- 532 Hysteritis Chronica with Cases. [Feb, rus, have thought the intervention of a pessary proper, mistaking the real nature of the case for prolapsus, or procedentia. This fact cannot be better illustrated than by inserting the words of Dr. Dewees on the subject. He says, " the irritable uterus is however more frequently confounded with prolapsus uteri, than with any other complaint, as the local symptoms of the latter are a miniature representation of the former. And as the womb is almost sure to descend more or less in the irritable uterus, this precipitation has been supposed to be the cause of all the incon- veniences experienced ; and hence, the frequent failures of the pessary, when it had been applied for the relief of the prolapsus. Nay, sometimes serious and permanent injury has been done by this instrument in these cases, without the practitioner being ex- actly aware why mischief should be caused by a machine that has been so often successful in cases so apparently alike." Nevertheless, I have in some instances made use of a pessary r or rather poultice formed by filling a little bag with the muci- lage of symphitum officinale, and applying it as a pessary. I have often found this mode of applying mucilage preferable to- that of administering it by injections. After a proper reduction of the system by venesection, opium or the sulphate of morphia, will tend greatly to diminish the painful or uneasy sensations, which are felt in the uterine region, and calm the whole system. I have found the extract oflettuce to answer a better purpose, given in doses of three grains, than opium, because it did not affect the head at the same time that it gave quiet and repose to the patient. During the whole progress of the complaint, the patient ought generally to remain in a recumbent posture. It was thought by Frederick Wilhelm von Hoven and Bocr- haave that this disease was sometimes of a typhoid nature, be- cause it could be successfully treated with camphor and opium, which they very properly considered stimulants ; although some other physicians would make a different decision, by considering them contra-stimulants. The first says, " Bey der esthenischen Gebarmuttercnt-zundung ist allein die asthenische Methode an- gezeigt, und die Hauptmittel sind innerlich das Opium und der Kamqher, und aiisserlich Kataplasmcn, Fomentationen von aro- inatischcn Krautcrn. Einreibungen hingegen von dem fliichti- gen Linament, Vcsicataricn, wnrme Bader keunen nur mit der 1837.] Hysttrilis Chronica with Cases. 53:4 grosten Vorsicht angewcndet werdcn." (nt2undung der Cc- barnuuter erster Band, scitc2i)0.) When we take into consideration thai tonics never fail to do mischief, we may naturally conclude that the above opinion of the Professor of Wurtzburg, is erroneous. All medicines which increase the tension of the fibres are injurious. In conclusion of the above plan of treatment, it is necessary to state that it will be important to attend to the state of the bowels, by giving occasionally mild purgatives, in order to over- come the constipation that often attends hysteritis chronica. For this purpose magnesia and epsom salts will be a good selec- tion. Case 1. On the 20th of February, 182t3, I was called to at- tend Mrs. L., who was laboring under an affection of the uterus. She had been previously attended by a physician, who had ad- ministered the arsenite of potass as a tonic, which had produced an aggravation of the symptoms. On examination, digito j)er vaginam, the mouth and neck of the womb were found consid- erably enlarged, flabby, and somewhat sensible to the touch. The organ was completely prolapsed from its natural location, with the os tincce nearly or quite resting upon the perineum. Conformably to the advice of a highly reputable physician, a pessary was introduced to retain the uterus in its natural posi- tion. The pessary remained until the twenty-second, when it was withdrawn, and after a few hours re-introduced. On the twenty-third, the patient complained very much of the pain and irritation which it had caused, and declared that she could not any longer bear it. I became confirmed in the justness of her com- plaints, and, accordingly, withdrew the instrument. After the abandonment of the pessary, injections of the mucilage of sym- phitum officinale were thrown into the vagina, and a blister ap- plied over the prccordia which seemed strongly to sympathize with the uterus. After that had healed, it was applied immedi- ately above the pubis, which naturally produced a better effect. The symptoms of the disease were now less violent, and as the uterus was prolapsed again, a linen bag in the form of a pessary, filled with the mucilage of comfrey-root, was introduced, after reducing that organ. This article was used instead of the al- thaea officinalis or guimauve, recommended by Astruc in his iS Maladies des Femmes.'' It seemed to act as a soothing poul- 534 stertHis Gtironicit with Cases. [Feb lice, and on account of its lubricity, was easily introduced and withdrawn i y i! it. After venesection had been resorted to, the pulvis Doveri, in doses of live grains, was found a very useful auxiliary, but after, sometime was increased in dose in order to procure repose. At length one grain of opium alone was given, As th'e opium had some tendency to afieot the head, the inspissated juice of lettuce was substituted in doses of three grains. This seemed equally to calm the irritation ofthe uterine Eegioflj without producing any unpleasant effect upon the senso- jium. Under this treatment, the patient gradually although slowly ipproxfmated toward health, and was completely restored by the introduction of a seton. Case 2. In the month of June, 1832, I was consulted by a lady, who said she bad been for a long time troubled with a dis- ease, which her physicians called the gravels, but she had not experienced any relief from the treatment, which they had di- rected, and she thought they might have mistaken her complaint. By interrogation, I soon discovered that she was suffering under chronica hysteritis, and directed her as much as possible to remain in a recumbent position, and to use mucilaginous injections per vaginam, &c. I afterwards learned that she was relieved by those means. Case 3. In the month ofSeptemher, 1832, I was consulted by Mrs. F., complaining of uterine irritation, who had been using a pessary without experiencing any relief. On examination, digltd per vaginam, I discovered an enlargement oftheoset cervix uteri, with tenderness to the touch. Some arterial ex- citement, with flushed face, occurred in the evening. After ven- esection to the amount of twelve ounces, I ordered injections of the mucilage of flaxseed, as the root of the symphitum officinale could not be obtained. Her case was gradually ameliorated. Case 4. March 6th, 1833, 1 was called to visit Mrs. B., who was complaining of misery in the pelvic region. She said she had been troubled with 'prolapsus uteri, for more than a year, and had at the time an infant several weeks old, that her physi- cian said, after her delivery would be the most favorable oppor- tunity, for reducingthe prolfep sus* that she had since used a pes- sary, but thought, it bad done her injury, and had accordingly fallen out with her physician. On examination :n.nn, the uteius was found 1837.] HytteritU Chronica with Casts. 5&5 considerably lower than natural. 'I'll- i upon the os tineas gave sacli pain as to can >rtion of the countenance. As was to l,c supj.- enlarged and considerably inflamed, rtorfice were tnuch flushed in the evening, and she complained at that time with some pain in the head, She was for a few days restricted to a Uv diet, a recumbent position, and mucilaginous injeoti< n; per nagtnam. In a w< although contrary to my ad vie-, she was seen " battant le pave et courant Ics boutiques." Case 5. June 11th, a negro woman came to my office saying that she was not well, but that her master and mistress thought she complained without a cause. On interrogation. I was suspicious of an irritable state of the uterus, but refused to do any thing for her relief without permission of her owner. The same day she brought word, that her master desired me to prescribe for her. On examination, 'digitoper vUginum,vC\y suspicions were con- firmed. '! he inferior parts of the uterus were considerably en- larged, and quite tender to the touch. I advised mucilaginous injections per vhginam, and the recumbent posture as mueh as practicable. As these cases are generally slow of recovery, her master was not satisfied with the treatment, and called in another physician, who introduced the pessary a much better mode of making a large bill and of adding fuel to the fire, but it evident- ly proved detrimental to the patient. She was, in consequence sold for less than her real value. Case G. April 2, 1834, I was called to visit Mrs. P., about 45 years of age, who had been for several years complaining of hysteritis chronica. The inferior parts of the uterus were en- larged and tender to the touch. She said she had consulted sev- eral physicians, who generally agreed that she would find much relief from the use of a pessary. Afterwards another was called in, whoconcurrred with his predecessor's m the use of a pessary. Accordingly a silver one was introduced, (I think about twelve o'clock M.) and at two or three \\ M. the pain it occasioned was so intolerable, that she was compelled to send for her phvsieian to take it away. Her face was much flushed and head painful. On examina* tion per vainnam. the uterus appeared mueh enlarged and very 530 Rf marks en Pneumonia BiUosa, $c. [Feb. Sensible to the slightest impression* of the finder. I immediately abstracted sixteen ounces of blood from the arm, put her upon a low diet, advised mucilaginous injections per vaginam, and. strict- Iv enjoined the recumbent posture. Her case gradually im- proved, so that she was able to qui! the bed, and attend to domes- tic concerns. I do not know that she is entirely well at this time, but she has received great benefit from the course advised. From my own experience in uterine diseases, I doubt if simple prolapsus, i. e. unaccompanied with hypertrophy, or uterine irrita- tion, and enlargement of some part of the organ, often takes place. Vvrhen it does become irritable or sensible, in consequence of its fallen position, I have no doubt that a pessary, made of comfrey- root in the manner described in the first case, would fulfil every necessary indication, unless the disease had produced general ar- terial excitement. Augusta, January 11, 1837. ARTICLE V. Remarks on Pneumonia Biliosa: By Ignatius P. Garvin, M. D., of Waynesborough, Georgia. Although the inhabitants of malarial regions are in a Great measure exempt from those subacute and chronic inflammations of the respiratory organs, which arc common and so fatal in higher latitudes and in a purer atmosphere, yet they are by no means free from a liability to the more acute forms of pulmona- ry disease. During the winter and early part of the spring, a very severe and often fatal form of thoracic inflammation, pre- vails to a considerable extent. The ordinary fevers of these sections in acclimated subjects, when compared with this form of disease, are but trifling indispositions, and a large proportion of the deaths which occur amongst the adult population, happens during these seasons, and from this cause. This modificotion of pulmonary inflammation from some symptoms which usually 1S37.] Remarl:s on Pneumonia B'dioan. 537 accompany it, lias received the name of bilious pneumonia. Yet as the hepatic disorder is by no means the primary modify- ing cause, and as it is to the gastric irritation which always ex- ists, and to the symptoms thereby sympathetically produced, that the disease under consideration owes most of its peculiarities, the term gastric pneumonia, would seem more consonant to sound pathology. It is to be regretted that a disease so violent in its nature so fatal in its consequences, and of such frequent occurrence, should not have excited such attention among the physicians of the South, as would have induced some of those most experienced in its management, to furnish their views of its nature and treat- ment. Some of the older European writers have noticed this modification of disease, but their works are in the hands of but comparatively few7 members of the profession. The elementary works, with but one excepti on that we can call to mind, at this time, arc silent upon the subject. Eberle has given it a brief no- tice, but it is neither so full nor so minute, as the importance of the subject demands. The writer is not so vain as to imagine, that the imperfect observations which are to follow, will supply this deficiency in our medical literature, but they are offered with the design and hope that they may elicit the views of others bet- ter qualified for the task. No age or sex is entirely exempt from the attacks of bilious pneumonia, yet females and children, probably from less expo- sure to the inclemencies of the weather, seem to be less liable than males. Negroes seem to be less subject to its attacks than the whites, though they are more liable to the simple form of pneumonia partly from greater exposure and partly from their physical constitution. The peculiarity in their organization seems to consist in an inferior sensibility in the cutaneous sur- face, and a less degree of activity in the capiliary circulation, and consequently in the same degree that it exempts them from the diseases generated by heat, renders them more liable to those which are produced by cold. Individuals who have labored under malarial fevers, during the autumnal months, seem to be more liable than those who have escaped, and these last if they have been constantly exposed to the action of malaria, seem to be more subject to an attack than those who have resided in a dry and healthy Location* - , the 5eason when febnfic exha- 6ft 538 Remarks on Pneumonia Biliosa. [Feb* lations are most rife. This greater liability among the sufferers from fever, seems to result from the disordered state of the di- gestive organs, which seldom recover their usual healthy tone, immediately upon the subsidence of the fever. It is a fact that but very few of those who suffer from severe attacks of autumnal fever, entirely regain their usual health and strength for some months, and this proves that the organs have not during that period, recovered their healthy tone, else ordinary strength would sooner be restored. Even in milder cases, a protracted conva- lescence of these organs occurs to some extent. When, there- fore, an individual, with his digestive organs thus predisposed to disease, is attacked with pulmonary inflammation, it is not at all surprising that the symptoms which characterize bilious pneu- monia, should present themselves. We think it highly probable, that the previous fever which generates this predisposition to gastric disorder, also leaves a predisposition to inflammation of the respiratory organs. The impetuous flow of blood through the pulmonary vessels, during the continuance of the fever, and of that excited condition of the circulatory organs which often continues for some time after its subsidence, necessarily produ- ces a pulmonary irritation, which though it may not be of suffi- cient magnitude to excite much attention, nevertheless renders the lungs more than ordinarily liable to inflammation. The ordinary causes of simple pulmonary inflammation, act- ing in combination with such circumstances, as tend to produce gastric irritation, or upon a system where such irritation already exists, are the usual causes of bilious pneumonia. Eberle at- tributes the disease to the combined action of atmospherical vi- cissitudes and malaria. It is highly probable that it is sometimes thus produced, yet such cases must be comparatively rare, as miasmatic exhalations do not occur to much extent, during the season when the disease most frequently appears. Some of the older writers state that it has prevailed as an epidemic, but such an occurrence has not come under our observation. Bilious Pneumonia is usually ushered in by chills or rigors. In some cases there are premonitory symptoms, such as usually precede an attack of fever, whilst in others, the chill or ague is the first notice of the invasion of the disease. In some instances the patient has labored under catarrh, or intermittent fever, for some days previous to the attack, and under these circumstan- 1837. J Remarks on Pneumonia Biliosa. 53'J ccs, the pneumonic symptoms come on more gradually. The cold stage is not usually of great duration, and as it subsides, the patient experiences pain in some part of the thorax. The pain is of a dull, obtuse character, and suffers considerable ag- gravation from the cough which accompanies it. During the first few hours the c< dry, but soon there is a scanty discharge of tenacious mucus, often stained with blood, and expectorated with some difficulty. The breathing is hur- ried, though the patient does not usually complain of any pecu- liar difficulty in respiring. The stomach is irritable, and vomi- ting is a frequent, though not an invariable occurrence. The matter rejected from the stomach is in some cases mixed with bile, but in others, it appears to consist of the depraved gastric secretions alone. The bowels are usually torpid, until laxative medicine is administered, and then it frequently happens that diarrhoea appears. Sometimes this symptom is present from the commencement of the disease. Soon after the development of the disease, the middle of the tongue becomes covered with a brownish coat, whilst the tip and edges are clean and red. The appetite entirely disappears, and the thirst is very considerable. In almost every case there is pain in the forehead, but the mental faculties are rarely disturbed during the earlier stages of the dis- ease. The skin is hot and dry, and the pulse frequent and full, though it rarely offers much resistance upon pressure. Its fre- quency is seldom less than 120 beats in a minute, except during the remission. Indeed we consider this frequency of pulse as almost characteristic of the disease, as we have very rarely found it so frequent in the unmixed form of pneumonia. There is usu- ally a morning remission, more or less distinct, as the gastric or pneumonic symptoms predominate. In some few cases, there exists from the commencement of the disease, a degree of cere- bral congestion, evinced by a red, swollen face, and stupor, which entirely masks the ordinary symptoms. When the pa- tient is roused, though apparently rational, yet he generally de- nies the existence of any pain. Yet we will gen-rally find upon enquiry, that the patient has a slight c il has scarce- ly been noticed previous to the inv i n, and the puJse pre- sents a frequency which can only be accounted for on the pre- sumption of some other considerable irritation. When in such a case, the cerebral congestion is removed by the application of MO Remarks cm Pneumonia BiUosa. [Feb proper remedies, the usual symptoms of bilious pneumonia speed- ily manifest themselves. The most common duration of the disease is from seven to ten days, yet we have seen a fatal termination occur in forty* eight hours, and other cases, where it continued to a much longer period. It sometimes happens when the pneumonic inflamma- tion is inconsiderable in extent and degree, that it will subside before there is much reduction in the gnstric disorder; but most commonly they proceed pari passu. It rarely terminates sud- denly and by a sensible crisis, the symptoms in most cases sub- siding gradually. The gastric disease which exists in bilious pneumonia may also accompany bronchitis, or pleuritis, and it not unfrequently happens, that the modification under consideration, is blended with some degree of these affections. When this occurs, the disease will present symptoms differing somewhat from those usually exhibited by bilious pneumonia. Yet to distinguish be- tween these various modifications, is not of much practical im- portance, as in all these cases our treatment is to be governed by the same principles. As cases of bilious pneumonia present many shades of modifi- cation, from the various degrees of relative intensity of the pneu- monic and gastric disorder, a corresponding modification will be found necessary in the treatment. In a large majority, indeed we may say in every case, in the early stage of the disease, ven- esection may be practised with safety and benefit. We are aware that a different opinion prevails to a limited extent, but we feel nt that in the sentiment we have advanced, we shall 1) ! sustained by the great body of the profession. The lengths of the stage in which bleeding will prove beneficial, va- ries according to the relative intensity of the gastric and pulmo- nary disease. When the former predominates considerably, this stage is much shorter than where the contrary obtains. Indeed in the former case the use of the lancet may be omitted, with less hazard, than one not familiar with the disease might. suppose. Yet we would by no means advocate its omission in such cases, as its judicious use even there will materially expe- dite the cure. It is impossible in this, as in many other diseases, to affix the precise limits to. the stage in which venesection may be beneficially practised. It is, we believe, never shorter than 18.37.] Remarks on Pneumonia Bdiosa. 541 one day,aad sometimes continues through several. In most ca- ses one full bleeding will suffice. The blood should be suffered to flow until a decided reduction, and softening of the pulse are effected. In some instances, a repetition of the remedy will be necessary, but wc are persuaded that such cases are rare, or in their nature approach very nearly the simple form of pneumonia. We are under the imnression that negroes in general do not bear considerable sanguine depletion so well as whites, and when from any cause we are unable to apply this remedy in their ca- ses, we feel more confident of success from our other remedial means, than we would in the case of a white man, under similar circumstances. Whilst a few may be disposed to consider us as advocating too general irt to the lancet, there will probably be many others, who will dissent from an application so moder- ate. In simple pneumonia, we have no fears in relation to its free use. With Gregory we believe, that " the danger of a large bleeding is less than the danger of the disease," yet in the com- plication under consideration, we are fully satisfied, that very large and repeated abstractions of blood, are likely in many ca- ses to prove highly injurious, and have tended much to bring the remedy into disrepute. Although bloodletting is a remedy of so much power in the simple forms of thoracic inflammation, and is so necessary in most cases of bilious pneumonia, yet it rarely affords such full and prompt relief to the pain in the latter, as in the former, nei- ther does it seem to exert much influence upon the gastric symp- toms. We are therefore compelled to resort to other means to arrest the progress of the disease; and among these the most im- portant is calomel. From the acknowledged action of this medi- cine upon the liver, and from its beneficial effects in the disease in question, we doubt not, have sprung those pathological views, which have given to it the epithet bilious. But as we hold that the gastric irritation is the primary modifying cause, and that the hepatic disorder is only incidental, and yet unite with those who hold the opposite opinion, in recommending the use of calomel, it may be well briefly to explain our views of its modus operandi in such cases. We believe that in this disease, the liver is usu- ally in a torpid condition, at least that its functions are partially suspended, and that this suspension is not the product of hepatic irritation. This peculiar state of the liver is the result of the 542 Remarks on Pneumonia BiHosa. [Feb, concentration of the vital powers in the stomach. Under these circumstanc< inistered in large portions, docs not increase the irrii iting in the stomach, for we know that externa tees it has no such effect, but it is absor : carried in some form or other into the circulation", and then excites those organs on which its principal powers seem to be expended. The liver in particular it stimulates powerful!}', and from the great size and vascular structure of that organ, its effect is strongly revulsive. If its use be too soon discontinued, the benefit will prove transient, and the organs will speedily relapse into their former condition. Under no other view of the state of the liver could we feel fully justified in expecting benefit from the use of mercurials ; for if that organ was in an irritated state, how could we rationally expect, that the addition of more irritation, would remove that which already existed. We are aware that the opinion has been advanced, and has its advocates, that when the liver is irritated, calomel will remove the irritation, and when it is in a sluggish condition, that it will excite "it. Such an opinion reminds us of the man in the fable, who blew hot and cold with the same breath, and for an exhibition of this faculty was summarily ejected from his quarters by his indignant host a treatment well worthy of the notion in question. We. are aware that the "physiological doc- trine'' affirms that hepatic is a necessary consequence of gastric- irritation, and consequently that the symptoms of hepatic de- rangement must be the result of irritation. In conformity to this theory, they reject the use of mercurials in such cases, yet the most ample observation, in almost every quarter of the globe, by men of various powers and conflicting views, has demonstra- ted that they are the most effectual remedies we possess in this particular state of the digestive organs. Either the theory of Broussais is founded in error, or all observation is to be disbe- lieved and forgotten. Many arguments and facts might be ad- duced in favor of the view we have taken, did the occasion per- mit so considerable a digression. Whether the views we have advanced in relation to the modus operandi of calomel in such cases be correct or not, ample observation has proven it to be one of our most important remedies in the; treatment of bilious pneu- monia. After bloodletting, and in small doses combined with ppium or Dover's powder, and repeated at intervals until the l'S.'tt.] 7i evacuations shew that it has exerted its peculiar stimulation upon the liver, it will powerfully c ixtinction of the gastric dison most of its peculiaril ve rare- ly know., h often follow its use, to fail in being succeeded in a few hours, b; ided amend- ment. In. this, as in all ol we desire its stimula- ting action upon the liver, we should prescribe it in doses of such six", as will not pass rapidly through the bowels, but act if at all, merely as a laxative. After the small doses have been contin- ued for some hours, the bowels should be gently acted upon by castor oil, or some other mild laxative, if the calomel itself has effected no evacuations. This course may be repeated daily, should the violence of the symptoms demand it, until the gastric disease seems subdued. Salivation is not of such frequent occur- rence in the disease under consideration, as it would be in fever under a similar administration of mercurials. Blisters are also important remedies in bilious pneumonia, but their application must be delayed until the excitement is materi- ally reduced, else little or no benefit can be derived from their use. When, however, this reduction is effected, we have no more powerful means of removing the inflammation, some degree of which always remains, even after depletion has been carried to its fullest extent. Some difference of opinion exists as to the pro- per place for their application. Dr. Mefiadec Laenhec, in a note to the work of his illustrious kinsman, asserts that "good practi- tioners nevrr apply them in the first instance to the chest, but to the legs, thighs, and inside of the arms." Notwithstanding the declaration will bring us under the censure of this learned anno- tator, we feel no hesitation in expressing the opinion, that the chest is the very best place for their application, and this we be- lieve is the sentiment of a great majority of the good practition- ers in our country. Even the great author to whose work this sentiment is appended, though not very favorable to blistering, points out no place as preferable to the chest. We are persua- ded that but few persons will be found to agree with another sen- timent contained in the note from which we have just quoted, which is, that when blisters fail to act as derivatives in cases of pneumonia, "they still operate beneficially by exciting tempo- rarily the powers of the system j and thereby rendering admit- 544 Remarks on Pneumonia Biliosa. [Fob. sible further bleedings." Our observation has satisfied us, that where they fail to act as derivatives, they very rarely fail to prove injurious. Before the inflammatory action is sufficiently reduced to permit the application of blisters, considerable benefit may be obtained by a long continued use of warm poultices to the scat of the pain. Drastic purgatives arc seldom admissible, but laxatives are important auxiliaries in the treatment. Such articles as act without producing much intestinal irritation, will be found most beneficial. Emetics are recommended by Eberle and others, but except in a few instances, and in the forming stage of the disease, we have found but little benefit from their use. In many cases, they are highly pernicious. We have known the nausea and vomi- ting induced by an antimonial emetic, to continue during the whole course of the disease, in defiance of every application for their relief. Tartar emetic, given in the mode recommended by Laennec in simple pneumonia, though truly a "heroic" remedy in that form of the disease, will generally be found inadmissible in the complication under consideration, as it always increases the gastric irritation, and thereby enhances the difficulties and dan- gers of the case. Expectorants are usually considered valuable remedies in pneumonic disease, but as we are compelled to exclude antimo- nials from the treatment, our choice of expectorant remedies is reduced within narrow limits. During the early stage of the disease, mucilaginous drinks, such as flax-seed tea, gum arabic solution and infusion of slippery elm, should be used as freely as the stomach will permit. In the latter stages, particularly when the gastric disorder is abated, much benefit may be derived from the decoction of polygala seneka. The preceding remarks briefly point out the general course of treatment, which we have found most useful in bilious pneumonia. We might have added to the list of articles which are sometimes prescribed in such cases, but we have been content to indicate those means of cure which are of primary importance, and those which are most likely to prove injurious. 1837.] Cliomal on Typhoid Fewrs. G45 Part II. REVIEWS AND EXTRACTS. Chomcl on Typhoid Fever. In a former number* we referred our readers to the third num- ber of the British and Foreign Medical Review, and to the first number of the Eclectic Journal of Medicine, for Professor Cho- mel's observations on this important subject. Since observing the applicability of these observations to the fevers amongst us, during the past autumn and first half of winter, we have conclu- ded, that, lest many of our readers should not be able to make the reference, we would give a condensed view of the same, which we take pleasure in doing, in the summary contained in the first and second numbers of the Eclectic Journal. " Fever, Typhoid or Continued, described by Chomel. The term typhoid fever, is that used by M. Chomel, in his Lecons Cliniques, published two years ago, to express the continued fever of English writers, and includes both their synochus and synocha, as well as typhus. Whilst he regards fe- ver to be a disease of the whole system, he admits its local complications or lesions. Of these some ate constant, viz. alterations of the follicles of the in- testines and of the mesenteric glands. The follicles are known anatomically by the name of the glands of Brunner and those of Peyer : the first are scat- tered, the second are in groups. At what time these follicles are first changed, or in what order, we cannot well say. The earliest state at which Chomel had an opportunity of examining their diseased state was on the seventh day, or that on which death took place. Out of fifty-five cases noted by Louis, the most recent was on the eighth day. They are seen at this time, like opaque spots, through the distended and almost transparent intestine at vari- ous parts along its course. The larger patches are seen in the ileum and termination of the jejunum, being most numerous towards the ileo-ccecal valve and in the upper part of the large intestine. Death during the second "period of fever allows of our seeing the follicles changed by ulceration of the mucous membrane, which is the result of the morbid state of the follicles, as it commences over the follicular patches and is confined during this period to these parts. In ninety-two cases closely observed by Chomel and Louis, ulceration commenced from the eighth to the twelfth or fifteenth days from the first attack. The ulceration proceeds from the ileum upwards. More rarely do the isolated follicles ulcerate. In some cases during this second period, the mucous membrane covering the patches becomes of a dark colour, separates from the subjacent tissues, and is observed to be perforated with a largo number of holes, giving it a reticulated appearance : these holes are the orifices of the enlarged follicles. Beneath this the sub-mucous tissue is found, or a thin layer of white deposit. If death occurs at a later period, there is sometimes no trace either of the ulcerated or reticulated patches, but merely ulcers, whose edges have no traces of the whitish deposit. The duration and symptoms of the disease will indicate whether these ulcers be the accompan- iment of typhoid fever. M. Chomel thinks that in the present state of our knowledge, the ulcers which are formed in the intestines after an acute dis- ease are the result of lesion of the follicles, and not a primary affection of mucous membrane. *See Southern Medical and Surgical Journal, vol.i., page 417. 09 546 Chomel 07i Typhoid Fevers. [Feb, The ulcers are of two varieties the first with very slight depression be- low the mucous surface and without any appearance of inflammation ; the second are deep, with prominent edges of a slate colour, and extend even so- far as to sometimes perforate the peritoneal membrane. The disease of the follicles may after a time disappear either by resolution, or by cicatrization of the ulcers, and the mesenteric glands, which were enlarged, resume their natural size. There are three other diseases in which diseased follicles have been found, viz. Cholera,* Phthisis and Scarlatina. Of the forty-two subjects dead of the typhoid fever, and examined by M. Chomel, all were found to exhibit follicles more or less diseased. The connexion between the symptoms and the diseased state of the folli- cles has been carefully studied by M. Chomel. Headache was observed in all but one of the forty-two fatal cases ; but as it precedes the lesions we can- not well admit any connexion between them. Stupor, an important symp- tom, cannot be referred, as some suppose, to the formation of ulcers of the in- testine and the absorption of pus, any more than to the exhaustion of the constitutional powers. But between diarrhoea and diseased follicles there seems to be a closer connexion the former being present in forty out of fifty- two cases of the latter. Among the changes not c- nstantly met with are alterations in colour and consistence of the mucous :. mbrane of the stomach and intestines. Soft- ening of the gastric mucous membrane occurred in fourteen cases. But we cannot attach much importance to this fact, since, of twenty-four subjects dead of pneumonia, and examined by M. Chomel, there was softening of the stomach in eight. Similar appearances and proportions were observed in peritonitis, small-pox and other diseases. Softening of the mucous coat of the intestines is not common. Neither the colour of the stomach nor intes- tines is distinctive. Vomiting and sensibility of the epigastrium were not greater where there was softening than where there was none. Sanguineous infiltration was not distinctive of the fever. Next to the follicles, the spleen is most frequently diseased, being either enlarged, as in the acute stage, or softened, as in the more advanced and sometimes harder and drier. The liver was sometimes softened. Louis observed this in about half of his cases. Organs of circulation. The heart in seven cases out of thirty was soft- ened, a state coincident generally with a similar state of other organs. In* seven other cases out of the number thirty, the walls were flaccid. The softening was attended with paleness. Sometimes the inner membrane was of a lively or deep red ; but in no case were there inflammatory depositions. The red condition often observed of the inner membrane of the aorta was probably owing to imbibition of the red particles dissolved, since it was in general in proportion to the putrid state of the blood. The blood is often deficient in fibrin. Air has been found in the blood-ves- sels, particularly in the veins. Petechias and ecchymoses were observed during life in cases, so that the decomposition of the blood probably com- menced before death. In the lungs, congestion of the posterior and inferior parts was noted in eighteen instances out of fifty-two : in eight cases, there were marks of pneumonia, and in two, pleuritic effusion. The hrain, although its functions arc most disordered, suffered fewest ap- preciable organic changes. Delirium present in half the cases, is not ex- plained by the pathological changes. (Edema of the meninges and bloody * For a very full and authentic account of the follicular changes in cholera as observed by himself, we would refer to J In' paper by Br. Horner, in the American Journal of Medical Sciences, for May, 1835. 1837.] Chomel on Typhoid Fevers. 347 points are found, it is true ; but these are met with as often in cases where there has been no affection of the cerebral functions as when they have been present, and also as frequently in other diseases as this. In thirty-eight care- fully observed cases there was Injection (venous) of the meninges - - - - in 4 CEdema of the meninges ------ "7 Genera] but slight softening "6 .Serous effusion in the ventricles (from a tea-spoonful to a des- ert-spoonful) -- "12 Bloody points -------- " 5 Increased density "2 Healthy state "15 Causes of Fever. The exciting causes of the one hundred and sixteen cases which came under M. Chomel's notice are given, as far as could be as- certained by inquiry. But unless the physician have the added testimony of the friends and companions of the sick person, he cannot receive with much confidence the statements of the latter, liable as they are to be distorted from the real facts by ignorance, bad faith, or forgetfulness. In the respect of causes, hospital records are therefore less valuable than those of private prac- tice. The following is the table exhibiting the results of M. Chomel's in- quiries : 5 patients attributed it to sudden cold when heated, 6 to deficient or bad food, 4 to mental depression, 5 to debility from other diseases, 3 to the action of a purgative taken for some indisposition, 1 to excess in drink, 5 to excessive fatigue, 2 to a violent physical shock, 1 to the effects of the sun, 5 were exposed to circumstances favorable to contagion. 37 Of the remaining seventy-nine, in the whole number of one hundred an3 sixteen cases, no cause could be ascertained. However much we may be disappointed at this deficiency of information, we cannot but see in it addi- tional proof of the good faith of the author, and his freedom from any bias of system. The age at which this fever most frequently attacks is, according to M. -Chomel, between eighteen and thirty. It is rarely observed after forty, and perhaps in no case after fifty-five. Under ten years of age it is rarely met with. Of the whole number of patients more than two-thirds had lived in Paris less than two years, and only two were natives of that city. We well re- member, when attending at the Charite, being struck with "the uniformity of the question proposed by M. Lerminier to patients with this fever of how long they had lived in Paris'? M. Chomel, in common with most of the French school, is opposed to a belief in the contagion of typhoid fever. To describe well the symptoms and progress of this fever, it must be divi- ded into different periods or stages, into the details of which we cannot be supposed to enter on this occasion. The preliminary symptoms of dimin- ished activity of the mind and ienses, feebleness, loss of appetite, foul tongue, altered expression of countenance, &c, are well known. But in a great majority of cases recorded by the author, the attack was sudden. There were no premonitory symptoms in seventy-three out of one hundred and twelve cases; although we must take this statement with the customary al- lowances required for hospital patients, whose accounts of their attack, never 048 ChoTJtcl on Typhoid Fevers. [Feb. very clear, are rendered still more confused by the fever. The disease is divided by M . Chomcl into three periods, of a week in each, in which a pecu- liar set of symptoms are said to be exhibited. First Period. Marked change in phosiognomy,- diminished intelligence, apathy, muscular debility and consequent supination, constant wakefulness, or dreams so vivid as to induce in the patient the idea that he has not slept ; headache, generally confined to the forehead; thick and glutinous secretions from the mouth and tongue ; lips and edges of the tongue red, with a small white border on each side, sometimes preceded by otl>er appearances of this organ. A3 the mouth dries, there is a uniform red colour of the whole mu- cous membrane, the lips crack, and the teeth have a brilliant look. There is anorexia, sometimes with nausea and vomiting ; dysphagia, great thirst, diarrhoea, almost universally, amounting to from four to eight evacuations daily ; in many cases gaseous distension of the intestines evidenced by per- cussion. A gurgling sound is heard when the lower part of the abdomen, and particularly the right iliac region, is pressed with the hand ; a state pro- bably connected with a morbid condition of the ileo-ccccal valve ; and most common in the second and third stages. Generally, there is increased sen- sibility on pressure of the bowels, but often not unless strong pressure have been used : it may be confinpd to the right iliac region, to the whole hypo- gastric or epigastric regions, or it may extend over the whole abdomen. During the first days there is, generally, an active circulation, with marked inflammatory symptoms ; pulse full, and sometimes resisting and frequent ; skin red. These symptoms diminish towards the end of this period ; the pulse becoming more rapid, but softer, and the skin, which was covered with abundant acid perspiration, becomes dry and hot. The urine is scanty, high- coloured and fetid. Early epistaxis is common, and is a valuable diagnostic symptom ; the bleeding is rarely copious, but often occurs several times. The state of the lungs is important in diagnosis ; often from the first there is a general sibilant rattle over both lungs more evident inferiorly and poste- riorly. The cough is rarely in proportion to the rattle ; the expectoration is scanty, viscid and transparent. Obstruction of the nostrils by dried mucus or blood, and extreme meteorism often produce dyspnoea. Death rarely oc- curs during this period. Second Period. The eruption which is peculiar to typhoid fever usually appears between the seventh and ninth days. It consists of small rose- coloured spots, disappearing on pressure, from half a line to two lines in di- ameter, round and hardly elevated ; scattered over the abdomen, sometimes on the breast ; more rarely on the thighs, arms and forearms. Their number varies ; in order to be characteristic, there should be at least fifteen or twen- ty. They do not all appear at the same time : their duration is uncertain ; they ordinarily disappear in two or three days; in other cases they remain twelve or fifteen days ; but it is probable these are successive eruptions. Out of seventy cases occurring in 1830-1-2, where attention was paid to this point, there were only sixteen in which the eruption did not appear. Of these fifty-four cases presenting the eruption, there were none in which it appeared before the sixth day, and in two cases it appeared as late as the thirty-sixth day of the disease. This agrees with the larger number of cases noticed by Louis. This eruption, so common in typhus, and so unfrequont in other acute diseases, is distinguished from petechia? and flcabite/, by its co- lour disappearing entirely under pressure, and returning as soon as it is re- moved. A similar eruption was observed by Ilildebrand, in the typhus of camps ; and in 1H14, M. Chomel had an opportunity of verifying his obser- vation in Paris. The extent of this eruption in some epidemics, gave rise to the term petechial fever. Sudamina are sometimes observed at a later pe- riod, but they are not so intimately connected with this disease as the erup- tion just described ; they are small, demi-hemispherical, transparent vesi- cles ; when viewed obliquely, they have a brilliant appearance, but when 1837.] Chomcl on Typhoid Fevers. 549 looked at perpendicularly to their a:; is, they escape observation. We can understand from this, why they have been so seldom noticed or mentioned by authors. Th iy arc readi lished bythetouch appearing at first on the sides of the neck* and is tfie folds of the arm-pit and groin, and extend* ing thence, in some c&ses. to toe trunk and limbs. The symptom is of some importance, aa re frequent In this disease than in any other with which it m ij be confounded ^ on the hips, Bacxum, heel, and back of the hairy scalp. Si tybe caused by pressure; but it sometimes occurs spontaneously and inner surface of the thigh, or upper part of the foot; and may follow the application of sinapism or a blis- ter, or the irritation of urine and feces. Debility and stupor may remain as in the first period, in the least serious cases ; but in the most serious&rms, the prostration of strength is complete^ and the patient lies on his back an inert mass. The muscles of the throat partaking of the debility, deglutition becomes impossible ; the liquids being rejected through the mouth or nose. Dysphagia may depend on inllammation about the epiglottis, or on ulceration of the mucous lining of the fauces and oesophagus. Involuntary discharge of is regarded as another symptom of muscular debility: though we are ri' d - ure of the correctness of this view, especially when a retention u'eged to be evidence of paralysis of the bladder. If the respira- tory muscled share in the deficiency of muscular power, the patient i3 in a c of suffocation. It is not uncommon, at the same time, to find subsul- tus tendinum, convulsive twitchings of the nose and upper lip, and carpology. General and permanent rigidity of the limbs is almost always a fatal symp- tom. In mild cases the headache ceases, and to constant wakefulness suc- ceeds drowsiness, from which it is impossible to arouse the patient, except for a few moments. This is the Coma somnolent urn of authors, and often lasts many days. When this stupor is so great that the patient cannot be roused by any excitement, he generally dies in a few days in the same state. Instead of stupor, some have delirium, coming on in the evening or at night, or constant ; and either violent or of the tranquil and muttering kind. Deafness, in most cases independent of stupor, is very frequent. The senses of sight and taste are commonly weakened. The pulse is small, weak, trem- bling, jerking, or intermittent ; generally from 100 to 120; in others, from 80 to 90; in a few, it falls as low as 40 or 50 at the termination of this peri- od. There is an increase of fever in the evening, sometimes hardly percep- tible, at others violent, and more rarely preceded by rigors, and terminating by sweating, than in the first stage. The skin is of a more acrid heat, drier and rougher; thirst less urgent; the nostrils having become impervious to air, the patient breathes wholly through his mouth, and the mucus covering it becomes dry, and changes from a brown to a brilliant black colour: this has been mistaken for effusion of blood. Diarrhoea continues; sometimes less frequent. Hemorrhage from the bowels, which, if abundant, speedily destroys the patient: this symptom is important in the diagnosis, as it is much more common than in other diseases. Meteorism continues or increa- ses ; abdominal pains are not complained of, except in the mildest cases ; the breath and perspiration have an offensive smell, peculiar to fever. Of 42 fatal cases, 9 deaths took place during this stage. Third Period. The symptoms either improve and lead to convalescence or become aggravated, terminating in death. Thus, thirty-two patients, out of forty-two who died of fever, died in this stage; and, of ninety cases of re- covery, convalescence commenced in one only during the first period ; and when the symptoms were severe, there were no instances of improvement before the end of the second. Improvement of expression, and attention to what is passing, are often the first signs of amendment ; or the comatose state is exchanged for peaceful sleep, on waking from wltich the patient part- ly recovers his intelligence: he is able to move himself a little ; the tomrue and mouth become moist ; meteorisrn diminishes ; the evacuations are of a 550 Lhomel on Typhoid Fevers. [Feb. more yellow colour, less fluid and foetid. Sometimes, at the moment when the first amendment of the symptoms commences, solid and formed stools are passed ; sometimes black, dry, and in prodigious quantities ; they had pro- bably lain hidden in the cells of the colon. The patient becomes aware of the passage of his evacuations ; respiration more free ; skin more supple or moistened. At this period it is not unusual for abscesses to form in parts of the body, which do not appear to have been irritated ; and the patient or his friends become alarmed at that which is a sign of beginning convalescence. The face becomes thinner, and the features and expression more marked. Of 66 favorable cases, the convalescence commenced by one or more of the previous symptoms on the following days : In 1 patient, the 8th day after the attack. 1 9th. 4 patients, the 12th. 3 " from the 12th to the 14th days. 10 " from the 15th to the 16th. 15 from the 17th to the 20th. 14 " from the 21st to the 25th. 11 " from the 26th to the 30th. 8 " from the 31st to the 40th. It will be seen by this table, although the days on which the improvement commences are very variable, yet that, in fifty cases out of sixty-eight that is, nearly three out of four, the improvement commenced from the fifteenth to the thirtieth day. In fatal cases, the stupor augments, expression more changed ; the mouth is drier, or, if moistened, it is only by the secretion of grey, viscid mucus, mixed with blood, and foetid. Respiration more difficult, stertorous ; some- times, towards the last days, crepitation is heard posteriorly and inferiorly, which is replaced by complete absence of respiration. Pulse more feeble ; heat diminishes ; skin dry, covered with cold, glutinous sweat ; emaciation general and rapid ; eyes hollow ; features drawn down with a fixed expres- sion, (facies hippocratica.) If the patient can speak, it is with difficulty and with a trembling voice ; the answers are unintelligible, even if the words are understood. The exhaustion of strength is complete, and the comatose de- bility is speedily followed by death. In some few cases, either at this period or during convalescence, the patient is suddenly seized, if his sensibiJity is sufficiently excitable, with extremely acute pains in the abdomen, sensation of sinking, alteration of expression, nausea and vomiting ; and the symptoms of typhoid fever give way to those of partial or general peritonitis. The pulse is small and thread-like, the abdominal pains are excessive. This sud- den attack of peritonitis, depending on no apparent external cause, is owing to perforation of the coats of the intestines and effusion of faeces into the pe- ritoneal cavity. It is almost inevitably fatal. Two out of forty-two fatal cases died from this cause. Erysipelas of the face is a very fatal complica- tion : it was observed in four cases out of 130, and all four died. The con- valescence from fever is not rapid ; in some cases it is extremely prolonged. Satisfying the appetite, which is often voracious, frequently leads to very se- rious consequences. CEdema of the lower extremities sometimes follows fever ; so does mental derangement in some few cases, but it generally dis- appears when the patient resumes his previous habits of life. JVI. Chomel's testimony is adverse to the doctrine of crises and critical days. Of ninety-four cases, there were two in which copious perspiration was fol- followed by benefit ; and two others where an abundant discharge of fecal matter coincided with an amelioration of the symptoms; in the remaining ninety, nothing similar was observed, so that these four cases can only be regarded as rare exceptions. The only phenomena which really appeared to precede improvement were abscesses, in six cases out of eighty. The list given of the days in which improvement took place, shows that it hap- pened many times in each day between the 15th and 30th. 1837.] Chomel on Typhoid Fevers. f>f>l We find that our limits will not allow of our completing the analysis of M . Chomel's excellent work. This will be done in our next number, in which will be found, also, a notice of the use of chlorides in fever. We must not close this article, however, without acknowledging our obligation to the Bri- tish and Foreign Medical Review, No. Ill, for its admirable digest of Cho- mel's work. Varieties of Typhoid Fever. The sketch of fever which has been given embraces all the symptoms, but in no one case do they all meet ; some symp- toms excluding others, or being constantly united. The concurrence of par- ticular symptoms constitutes varieties of fever, to which distinct names have been given by authors, as if they were distinct affections. 1. Inflammatory Typhoid Fever. This is frequent, particularly in winter : those of a sanguine temperament, and from twenty to thirty years old, and subject to hemorrhages, are liable to it. When well marked, the peculiar symptoms occur early ; such as fulness and frequency of the pulse, hot skin, dryness of the throat, thirst, loss of appetite, oppression, and other general symptoms common to inflammatory affections ; but, besides these, there are constant headach, muscular debility, disposition to hemorrhages, dry tongue, diarrhoea, typhoid and miliary eruptions. The form changes generally to the adynamic and ataxic about the seventh or eighth day, sometimes earlier. In two cases only out of forty-two fatal ones did the inflammatory form con- tinue throughout the disease, and in one of these cases death was produced by perforation of the bowels. During five years, during which these cases were collected, M. Chomel saw no other instances of inflammatory fever which were fatal, and he has never met with inflammatory fever which was not a variety of the typhoid affection. 2. Bilious Typhoid Fever. Most frequent in summer and autumn. In two cases out of forty-two fatal ones, there were bilious symptoms at first, giving way to more serious ones. Five others were cured where these symptoms continued throughout. The symptoms are yellow skin, especi- ally around the lips and alae nasi ; frequent nausea, and vomiting of bile ; bi- lious stools ; bitterness and dryness of the mouth ; yellow or greenish coat- ing to the tongue ; tinnitus aurium ; depravation of taste, smell and touch. The duration of these symptoms is seldom beyond the seventh to the fifteenth day. 3. Mucous Typhoid Fever. This, like the bilious, seems to depend much on localities: it is seldom well marked in Paris. The symptoms are great debility; pale or swollen face ; muscles soft; mouth pasty; breath, saliva, perspiration, and urine, of an acid odour ; stools mucous or glairy : after a short period it is replaced by the adynamic or the ataxic form. Two out of forty-two fatal cases had these symptoms. 4. Ataxic Typhoid Fever. One of the best marked, most frequent, and most generally fatal forms. Ten out of forty-two were ataxic : four of these were unmixed throughout, and death ensued on the eighth, ninth, and twelfth days ; two were preceded by the inflammatory, and two by the adynamic symptoms. This variety is distinguished by a remarkable disturbance of the functions of relation ; as delirium, cries, threats, efforts to strike or es- cape ; sometimes by mild delirium, heaviness, alteration or perversion of the senses, twitching of the tendons, convulsions, rigidity, &c. In other cases there is a remarkable discordance between the symptoms : thus, whilst the pulse is rapid, the skin is not hot, or one part is cold whilst the rest is very warm ; or, whilst the face expresses a disease almost inevitably mortal, the pulse is hardly affected. Frequently the delirium is not in proportion to the other symptoms, either less or greater. Sometimes a sudden improvement leads the practitioner to doubt his diagnosis : the benefit is, however, tempo- rary only. In some cases the patient is perfectly restored to his senses be- fore death. Ataxic symptoms do not belong exclusively to fever, but may co- 552 Chomel on Typhoid Fevers. [Feb. exist with visceral inflammation, puerperal, eruptive and other acute disea- ses. 5. Slow Nervous Typhoid Fever. The symptoms are a general indif- ference, great lassitude, heaviness, dejection; slight headach; pulse fre- quent and weak; constant wakefulness; no thirst, although the mouth is dry ; if there is delirium, it is not violent, and consists of a confusion between thought and action ; the patient mutters ; in unfavorable cases the strength diminishes, and the stupor increases, with other adynamic symptoms ; in favorable ones, the patient gradually throws off the drowsiness or suddenly, as if awaking from sleep. 6. Adynamic Typhoid Fever. The most frequent form, adynamic being marked in twenty-six out of forty-two fatal cases: in ten of these, adynamic symptoms were present throughout, and in sixteen at the termination only. The predominant symptom is muscular debility, which may gradually simu- late paralysis. These patients, with every appearance of strength, can nei- ther lie down nor rise up in their beds without help, or even turn on one side. Towards the termination they lie immovable, and after many hours are found in precisely the same position in which they had been left. There is com- monly great mental debility, commencing with early stupor. In bad cases, or at an advanced period, the patient does not answer questions which are put to him, and his unmoved features show that he lias not understood them : after a loud question he may direct his eyes momentarily towards the speak- er. Headach diminishes as adynamia increases, and is replaced by wakeful- ness, or constant unquiet dreams. The mouth is covered with a thick layer of dry mucus ; great meteorism ; often no sensibility on pressure ; stools gen- erally foetid and involuntary ; sloughing of the parts pressed upon ; urine and sweat foetid; petechia?; skin at first warm and dry, afterwards cold; pulse feeble, trembling, at first rapid, latterly slow. This state sometimes lasts long. Diagnosis. This is sometimes extremely difficult. It is prudent not to give a decided opinion during the first three or four days ; for, when the symptoms are not very decidedly marked, they differ little from the precur- sory fever of many eruptive diseases, as small-pox, scarlatina, measles, of some catarrhal affections, or latent visceral inflammations. The long dura- tion of the febrile condition is an important characteristic. Whenever febrile symptoms, which cannot be referred to any appreciable lesion, last eight or ten days, there are strong grounds to presume that the glands of Peyer are diseased, and when, on the other hand, a febrile disease, the nature of which is doubtful, it is not this affection. Between the sixth and twelfth days, symptoms which clear up the diagnosis generally appear, such as me- teorism, typhoid eruption, stupor, epistaxis, hemorrhage from the bowels. At a later period still, there is less difficulty ; for, even if the symptoms du- ring the first and second periods have been absent, those which belong to the third remove all doubts: these are intestinal hemorrhages, sloughing, invol- untary stools, and other marks of adynamia. Prognosis. Few diseases are so fatal. Out of 147 cases in the clinical wards of the Hotel Dicu, between 1828 and 1832, forty-seven died, or one in three. Though a mortality of one in three is a very large proportion, any inferences unfavorable to the treatment of fever should for many reasons be made with caution and charity. The mode in which patients are distributed to the various hospitals in Paris, is brought forward as one excuse for such fatality. All the hospitals being under the direction of government, a central hoard of medical men is appointed to examine the patients who apply for re- lief, and to distribute them among the different hospitals. This board meets near the I [otel Dieu, so that the sevi resl cases of fever are often sent there, as it is the nearest plaice. M. Chomel is also the professor of clinical medi- cine, and the most serious cases are sent to the clinical wards. These rea- sons would account for a greater apparent mortality than under other circum- 1837.] Chomel on Typhoid Fevers. 55^ stance?, if we did not find that during several years, whilst M. Chomcl was physician to La Charito, the mortality in about the same number of cases was rather greater. M. Louis founded his " Recherches sur la Gastro- enteric" on 138 cases of fever treated by M. Chomel, and out of these there were fifty deaths.* The average of one in three seems to be therefore inde- pendent of these local causes. Fever is less dangerous in patients under eighteen years of age, and more dangerous after the age of forty. No appreciable difference is observed in regard to sex. Previous feebleness of the system does not appear to act un- favorably. Two out of four patients who attributed fever to moral causes of ^repression died. Of sixteen patients who admitted that they had taken stim- ulating drinks at the commencement of the attack, three only died, M. Chomel concludes that those cases are most dangerous where the attack was sudden. The tables given, however, indicate the opposite, the mortality being rather less than one in three where the attack was sudden, and slight- ly above one in two where there were premonitory symptoms. (P. 433). There is probably some numerical error. If during fever there is a decided remission, followed by an aggravation of the symptoms, the termination is generally fatal. There is less danger when the form of the disease does not change : the ataxic is in such cases the most fatal. Complicated cases are very fatal: thus, of thirteen cases of inflammatory adynamia," eight died. Many symptoms, when they become intense, are important in the prognosis. When delirium is early and violent, it is very unfavorable. Of forty-two fatal cases, twenty-two were violently delirious. When it consists in a dreaming state from which the patient can be roused, there is less danger. Of eighty patients who recovered, twelve had this mild delirium. Involun- tary evacuations, when passed without consciousness, constitute a bad sign. Of thirty cases, in which this symptom was present, thirteen died. Constant and general twitching of the tendons is highly unfavorable. In five cases with general convulsions death was speedy. Coma is one of the most fatal symptoms; it should be distinguished from stupor, in which the patient's at- tention can be roused. Of seven patients with intestinal haemorrhage six died. M. Chomel does not think deafness unfavorable. The expression of the face is important : when emaciated and shrunk, (facies Hippocratica,) death is at hand ; whilst improvement in intelligence of expression is often the first sign of amendment. If the pulse exceeds 120 or 130 it is bad, when 150 or 160 death is near. When it becomes slow after having been rapid, without symptoms of improvement, it is a fatal symptom, unless proper means to relieve the patient are not employed. Perforation of the intestines, and erysipelas of the face, are generally fatal complications. The danger of inflammation of the lungs is in proportion to its extent and to the general condition of the patient. When it occupies a considerable portion, or the whole of one lobe, and is not arrested, it is fatal, even before it passes into the second and third stage. Circumscribed pneumonia is often discovered in those who have extensive suppurations on the sacrum, and is dangerous. As pneumonia is often latent, considerable attention should be paid to the lungs. In three patients inflammation of the larynx and epiglottis took place, and was fatal. The injurious effects of sloughs on the sacrum, heels, &c, have been exaggerated. In seven cases, only three died, and in those which recovered the extent of the ulcers was truly alarming. Abscess in the external parts was observed in six, all of which recovered. They were not found in parts subjected to pressure. Treatment. M. Chomel employs the rational mode of treatment, in which the disease is treated according to the symptoms which may be pre- sent, and not according to any uniform plan. By this mode, none of the * Recherche:; cur la Gastro-enterite, &c par P. Louis-.- Vol. 1. p. be. 70 554 Chomel on Typhoid Fevers. [Feb. specific modes of cure is excluded, though none is exclusively adopted. The antiphlogistic, the antiseptic, the tonic plans are not individually adhered to in every case, but are applied according to the" form which the fever may assume. This is called rational treatment, as it supposes that the practition- er reasons on every case ; it is also called symptomatic, from the attention which is necessarily paid to symptoms. In the simple uncomplicated forms, M. Chomel prescribes refreshing drinks, such as lemonade, orangeade, solution of syrup of currants, pure water taken at short intervals, emollient fomentations and poultices to the abdomen, if it is painful ; washing the body with vinegar and water, or simple baths, if there is much heat; mucilaginous lavements repeated many times daily ; cold compresses to the forehead, if there is much headach, and warm or mustard poultices, if there is any tendency to drowsiness or forgetfulness. He also commences by taking some blood from the arm, as he agrees with M. Louis that this has a favorable influence on 4he duration of the disease. If the headach is intense, or if there is much abdominal pain, leeches may be ap- plied behind the ears or to the anus. If the stools are scanty, mild laxatives, such as whey with tamarinds, neutral salts, &c. If there is diarrhoea, it should be restrained by mucilaginous drinks, gum or rice water, small lave- ments of starch. Free air and absolute cleanliness are indispensable : great care should be taken that the urine and fa)ces passed involuntarily should be immediately removed. When amendment commences, the emollient drinks may be exchanged for aromatics and gentle bitters : diet improved, such as vegetable jellies, weak broth, wine and water, &c. When the symptoms are more urgent, this expectant treatment is replacechby a more vigorous one. Treatment of Inflammatory Typhoid Fever. This requires the antiphlo- gistic treatment according to the age and strength, but by no means with the same vig*or as in simple inflammations ; for it must be remembered that ady- namic symptoms frequently follow inflammatory ; there is therefore a neces- sity of husbanding the powers of the patient. Another reason for the same caution is, that inflammation frequently springs up in the most debilitated subjects. Therefore, after taking blood once or twice, generally and locally by leeches, these means must be laid aside, and complete abstinence, with the remedies just mentioned,, trusted to. The only cases where general bleeding is indicated in the second and third periods, would be when inflam- mation attacks patients who are not greatly debilitated. Great caution is required in all such cases. Treatment of Bilious Typhoid Fever. The bitter taste in the mouth, great thirst, &c, cause the patient to request cooling drinks, ripe fruits, &c. which should be allowed. M. C. has not found emetics and purgatives so useful, nor bleeding so dangerous, as the physicians of the last century state. Emetics may be used at the commencement of a sudden attack, if the sto- mach appears to be loaded, but cooling drinks and fruit generally relieve the bad taste in the mouth. Mucous Typhoid Fever. This is treated like the simple, except that acid drinks are given instead of emollients, and slightly bitter and aromatic infu- sions of indigenous plants, such as are made no use of in this country except by the poor, and therefore not at all equivalent to our pharmaceutical bitters and aromatics. Treatment of Ataxic Typhoid Fever. The treatment of this variety is ve- ry difficult: the antiphlogistic, tonic, and antispasmodic plans have all had their exclusive supporters. The treatment however must vary. If inflam- matory symptoms are present, the antiphlogistic treatment, and if Hie ady- namic, tonics must be recommended. When there is no precise indication, the expectant treatment is to be followed. Treatment of Adynamic Typhoid Fever. When there is stupor, unusual ppottration of itrength, weaknose of the pulse, faintness in the sitting posture. 1837.] Chomel o* Typhoid Fever$. 655 and involuntary passing of stools and urine,' we must use bitters and aromatics, such as bark, chamomile, and Bage in draughts, lavements, baths, and exter- nal applications ; with wine, camphor, and ether: if the symptoms increase, the doses must be] _ . Spain given instead of those of France. Extract of bark, by the mouth and in lavements, in doses of one to two ounces a day, is given by M. Chomel in preference to quinine, if the stomach will bear it, as he doubts whether the sulphate of quinine contains all the tonic powers of bark equally with its febrifuge and antiperiodic princi- ples. In this state tonics and excitants, instead of aggravating the lesions of the intestines, exercise a favorable effect upon them. The intestinal ul- are analogous to cutaneous ulcere sets, which are im* proved by g applications. In three instances where the patients died during the tonic treatment, the ulcers in the intestines were evidently cicatrizing. The tonic treatment was followed in nine patients, all of whom when it was commenced were in an alarming state of prostration, and six of these recovered. It is important that tonics should be given before the strength is too much exhausted, and yet not during reaction. The exact time must be determined' at the bed-side, as no exact rules can be laid down. If delirium or other signs of cerebral congestion exist, wine should not be given, as it almost inevitably aggravates the symptoms. M. Chomel com- monly gives wine in spoonfuls, at first once or many times daily, increasing the quantity as debility increases. The lighter wines he gives with other drinks, in the proportion of a 'fourth, a third, or half; the stronger wines pure. In some cases the benefit is immediate: the pulse rises, the heat of the skin increases, and the expression improves. Ether is particularly use- ful when it is necessary to raise the powers rapidly, but. its action is transient ; it should bo given with bark. Camphor is only employed by M. C. in lave- ments with bark, when debility is great. Bark in infusion, decoction, or still better only macerated in water, and sweetened with syrup of lemon, is one of the best drinks. Also infusions of serpentaria, cascarilla and sage. ^ The tonic treatment is rarely necessary in the first stage, and should never he tried then except with great reserve. In the second and third stages we may employ it with more confidence and energy. Several excellent cases are detailed in which success followed this treatment in apparently hopeless cases. M. Chomel mentions the application of revulsives and of warm and cold baths, but states nothing decidedly as to his own opinion of their effi- cacy. Treatment of Particular Symptoms and Complications. Haemorrhages are rarely so profuse as to require special treatment. Epistaxis may render plugging the nostrils necessary, and if the discharge of blood from the bow- els is great, cold or iced water in draughts, lavements, and external applica- tions, extract of rhatany, &c. should be tried. Great care should be taken to prevent the formation of sloughs : when the fever has listed any time the parts pressed on should be examined, and if there is that redness over the sacrum which precedes sloughing, the patient should be so supported as to lie on the side or even on the belly. When the eschar has formed, it should be covered with diachylon plaster; when it has fallen, tlie wound should be dressed as an ordinary ulcer. M. C. has not tried Dr. Arnol bed. The treatment of local inflammation- attacking a d difficult. Local bleeding, particularly cupping, must be cautiously emplo; if the strength will permit. !'> lition forbids it, and the tonic treatment must b .. whilst the local disease is combated with epispastics, as blisters and rubefacient plasters. In erysipelas of the face, the blood should be directed towards the feet by sinapisms, or very hot flannels covered with oiled silk. All the cases of perforation of the intes- tines which have fallen under M. Chomel's immediate observation have been fatal. Perfect rest and abstinence were the treatment adopted, but if other f the digestive organs. Maignault and Beclard have attempted to prove that, although the stomach is not spasmodically contracted, still that the oeso- phagus is thus affected, by fits, during vomiting in the dog ; and every one who has experienced vomiting in his own person must have felt that these reverse spasmodic efforts of the muscles of deglutition commence in the pha- rynx. These gentlemen were further of opinion that, in the act of vomiting, no antiperistaltic movements take place in the stomach, but that this organ presents a state of equable tonic contraction, and that it is only by means of the fitful contractions and expansions of the oesophagus, aided by the action of the abdominal muscles, that the stomach is emptied of its contents. While acknowledging our obligations to the French investigators, we must admit that there are many phenomena attending the act of vomiting which prove their theory to be at least insufficient. If the oesophagus and abdom- inal muscles are the only parts active during vomiting, how is the phenomena of faecal vomiting to be explained? I consider this morbid state sufficient proof in itself that an antiperistaltic action both of the intestinal canal and stomach does exist, while, on the other hand, no one can deny that there may and do exist contractions of the abdominal muscle?, diaphragm, and oe- sophagus, without any vomiting. This is evident in the case of the horse, rabbit, hare, guinea-pig, and several other herbivorous animals, which can- not be made to vomit even by the strongest emetics, although the strongest retching and contractions of the abdominal muscles take place, and although they possess the same organs as the dog, which vomits on the slightest occa- sion. It is the more important to investigate the cause of this difference in animals-, as it will lead to the explanation of the much greater facility of vom- iting in children than in adults. The cause of these differences lies in the particular shape of the stomach in different animals, a circumstance, as far as I know, hitherto unnoticed by comparative anatomists; and the same cause operates in producing the dif- ference in the facility of vomiting in the infant and the adult; since there ex- ists the same analogous difference of form between the stomach of the child and the adult man, as between the stomach of animals which vomit with facil- ity* su^h as the dog and cat (and we may say carnivorous animals in general)* and the stomach of those which vomit not at all or with extreme difficulty, as the horse and rabbit, (and herbivorous animals generally). Before proceeding further in the enquiry, I think it necessary to state that my experiments and observations lead me to decide positively in favor of the existence of antiperistaltic motions of the stomach during the act of vomiting. Boyle, Chirac, and the recent observers in France, hastily concluded that. because they could discover no convulsive movements of the stomach that therefore there were no antiperistaltic movements of any kind : they found the stomach contracted and motionless. I admit that there are no convul- sive movements, but I cannot concede that in the dog, for instance, the sto- mach is at rest during the act of vomiting. On the contrary, I maintain that decided antiperistaltic movements are perceptible, but these are not stronger than the ordinary peristaltic motions of the same organ. They are, more- over, not very distinct in the middle portion and fundus of the sicmach, but 1837. J On the Physiology of Vomiting, fyc. 501 only at the two extremities near the cardia and pylorus. The whole pyloric portion is strongly contracted -when the cardiac portion expands ; and, while this is going on, there is no perceptible motion in the fundus and larger cur- vature, and assuredly no convulsive one. But, it may be asked, what consid- erable effect can so slow an antiperistaltic motion have in vomiting? The answer is briefly this that, by this antiperistaltic motion, (no doubt assisted by the abdominal muscles,) the direction is given to the food which is to be ejected by the act of vomiting, or which is to be forced from the intestines into the stomach in the case of fascal vomiting. If the abdominal muscles alone acted on the perfectly passive stomach, the food might, by this pressure, be driven into the intestine as well as into the oesophagus; if, then, the contents of the stomach are to be ejected in a particular direction, it is requisite that the cardiac and pyloric portions should possess a distinct active motion. I now return to the various forms of the stomach occasioning the differen- ces in vomiting; and here I may take for granted as understood what I have detailed in the work "De Alimentorum Concoctione" concerning the forms of the stomachs of carnivorous and herbivorous animals. It is demonstrable that a child's stomach is as different from that of an adult as a pole-cat's is from that of a rat; and, if the difference between the form of a child's sto- mach and that of an adult has not been sooner recognised, it is only because their very different functions and importance in the preservation of life had not previously been suspected ; for this difference will not fail to strike every one as soon as his attention is directed to it. But, to make these differences still more conspicuous, I will introduce an outline of the form of a child's sto- mach, and that of an adult. The stomach of a child is more of a conical form, drawn out lengthwise, and gradually narrowing towards the two extremities, inferiorly towards the pylorus, superiorly towards the cardia. The oesophagus is inserted into the fundus at the left extremity, and at a distance from the pylorus ; the small curvature is stretched out lengthwise, the large curvature is less developed, and runs almost parallel with the small ; in short, the stomach of a child re- sembles that of the carnivorous mammalia. The form of the stomach of the adult is very different : it is more circular ; the oesophagus is not inserted into the left extremity, as is the case with the child's, but into the middle between the left extremity and the pylorus. The pylorus itself is drawn back towards the cardia, and both brought very near to each other; on this account, the small curvature is very short, while the large curvature, on the contrary, is disproportionately extended, forming not only the entire lower circumference of the stomach, but also surrounding that part of the fundus situated between the cardia and the left extremity ; so that the large curvature alone forms about four-fifths of the whole circum- ference of the stomach. It must, also be added, that the fundus does not pass into the pyloric portion gradually and gently, as is the case with the child's, but that the latter is separated from the former by a sort of neck or contraction, sometimes more, sometimes less, strongly marked. In conse- quence of this the left part of the stomach assumes an almost circular form, and the whole very much resembles the form of the stomach of the rat or rabbit, although in a less marked degree than in these animals. To each of these different forms of the stomach, an entirely distinct mo- tion, peristaltic as well as antiperistaltic, has been given. In the child's sto- mach, where the small curvature is extended almost parallel with the large one, the food is expelled with nearly equal power by the undulating motion of both curvatures, and forced towards the pylorus by the peristaltic and to- wards the cardia and oesophagus by the antiperistaltic. In consequence of this, vomiting in children is very easy, because the oesophagus is situated at one extremity of the stomach, towards which the food is forced, at the same time thai the pylorus closes and the cardia opens. But the pepjsess is very different in the stomach of the adult : in thi*, the small curvature is so much 71 5G2 On the Physiology of Vomitijig, tyc. [Feb. shortened, and the large one. so much extended, that the food is not equally propelled from both sides, but the motion is almost confined to one s-ide, and is effected principally by the large curvature, which embraces almost the entire circumference of the contents of the stomach ; by this partial action, the contents of the stomach are moved rather in a rotary direction, which completely stops towards the contracted pyloric portion, turning round in the fundus from the left side to the right when urged by the peristaltic motion, and from the right to the left when by the antiperistaltic. In consequence of this, during the act of vomiting, the antiperistaltic motion does not direct the food towards the cardia and oesophagus, but merely communicates to it a motion contrary to that given by the peristaltic; and herein the reason is to be sought why, notwithstanding the pressure of the abdominal muscles and the diaphragm, the contents of the stomach are so difficult to be voided, and. that, in many herbivorous animals, where the small curvature is still more shortened, the evacuation is impossible. The evacuation of the contents of the stomach of an adult can be effected only by a strenuous effort, produced by the strong pressure of the diaphragm and abdominal muscles, at the same time that the oesophagus-opens and shuts alternately; the stomach itself would be incapable from its antiperistaltic motion alone to discharge its contents upwards. In this respect there exists a completely different state of tilings in the pyloric and cardiac portions of the stomach. The pyloric portion from the point where it is so much reduced in diameter, exhibits a more regular or intestine-like form of both curvatures, and the contents are on that ac- count easily urged forwards into the duodenum ; but, in the other direction, the contemporaneous motion of the two sides ceases beyond the contracted part, becoming, as already stated, rotary, in the cardial portion. These details satisfactorily explain the differences so often referred to be- tween children and adults. The former can discharge the contents of their stomachs by the antiperistaltic motion alone, without any perceptible assis- tance of the abdominal muscles ; and the least pressure from these will in- crease the discharge. Animals whose stomachs are cylindrical, and in which consequently, the ordinary relation between two curvatures entirely ceases, such as frogs or fishes, can, as it appears, with facility empty their "stomachs by means of the antiperistaltic motion alone, without any cooperation of the abdominal muscles ; and it is thus that they often throw up pieces of food merely on account of their inconvenient position in the stomach, and swallow them again in a more acceptable direction ; even dogs after having swal- lowed a piece of bone frequently adopt a somewhat similar method. The human stomach in the earlier stages of its formation puts on the cylindrical form of the stomach of fishes and amphibious animals ; in the embryo it ap- pears only as a slight enlargement and elongation of the oesophagus in the abdominal cavity, with the cardia directed upwards and the pylorus down- wards, as is the case with frogs. The stomach assumes its horizontal posi- tion only at a later period when the curvatures become developed. There are naturally an endless number of transitions and intermediate sta- ges of development, between the cylindrical, conical form of 1 lie stomach of the infant and that of the adult; and these numerous transilieiis will be ac- companied by as many degrees of facility or difficulty in vomiting. What appears to me particularly interesting in a medical point of view is, that t ho round stomach of the adult is frequently seen in children oi a diseased or merely of a disordered condition at a much earlier age than usual, and that such children also generally vomit with much more difficulty. I have had opportunities of making this observation in several post-mortom examine- tions of scrofulous children; and in one instance was able to describe before death the probable form of the stomach, from the i^w raordinary difficulty with which the child vomited. On the other hand, the fundus ofthe stomach of adults is not always found to extend, in a like degree^ beyond the insertion ofthe oesophagus towards, the left side. There are human stomachs * 1837.] On the Physiology of Vomiting, <$>c. 5tf3 the fundus so much developed, as to be with difficulty distinguished from those of herbivorous animals : and others, again, which approacli nearer to the form of the dog's stomach from their imperfect development. The question naturally here suggests itself What is the cause, not only of these difference^ but of the changes in general, to which the stomach is subject at different periods of life 1 To me it appears that the cause is prin- cipally to be sought in the nature and quantity of the food. The cylindrical form of the stomach in children continues only while they arc fed on milk, Consequently on purely animal food ; as soon as they receive vegetable food in any quantity, the fundus begins to develop itself. On that account, even in the first year, a strong development of the fundus is found to have taken place in such children as have been weaned immediately after their birth and fed on soft pap made of flour, potatoes, or bread. The influence of the food on the form of the stomach is distinctly observable in older persons. The stomachs of such persons who live principally on potatoes and other vegeta- bles are found to resemble most those of herbivorous animals ; while the fun- dus in individuals who live more on rich animal food is less developed. I have shewn in my paper, "De Alimentorum Concoctione," that the stomach of dogs and cats (animals purely carnivorous,) will assume the circular form after they have been fed for some time on messes of potatoes, meal, and bread ; but that their stomach will retain its original oblong form if fed on animal food alone. On this account, the round form 6f the stomach observed in the domesticated carnivorous animals is never found in wild animals of the same class, such as, for example, the pole-cat. Man, as an omnivorous animal, certainly possesses the type of the more rounded form of the stomach ; but the extent of the development until it at- tain the form of the stomach of animals purely herbivorous, will, however, in a great measure, be determined by the degree of preponderance of vegetable over animal food ; and the development may be increased till it become mor- bid. The reason why. vegetable diet should develop the fundus to such a degree that the stomach assumes the circular form, (and the rotary motion be inconsequence given to its contents,) is, I believe, the following: 1 have shewn elsewhere, in speaking of animals, that vegetable food is of much more difficult digestion, and consequently is retained much longer in the stomach; The food requires to be moved, about longer, and not immediately propelled into the intestine ; hence the rotary motion, by which it is agitated in the stomach without being directly emptied into the pylorus. By this action the digested part of the vegetable food is gradually separated by layers on the surface of the mass, and is conducted into the pyloric division, in order to be passed into the intestine, while the undigested part continues in rotary mo- tion in the centre of the stomach. In carnivorous animals the process is very different: the animal food, being soon digested, is directly propelled towards the pylorus by the united action of both curvatures, and does not require to undergo a prolonged rotary motion ; whereas, if vegetable food be received in a stomach so constituted, it will necessarily pass into the intestine in a raw or only partially digested state. On the other hand, herbivorous ani- mals cannot perfectly digest animal food unless the form of the stomach un- dergo a change, as, by long detention in the organ, the food, instead of being digested, becomes putrid. The attempts-, therefore, which have been made in some places to feed sheep, horses, and oxen, on fish or other animal mat- ter, must ever fail. The enquiry whether the stomach of these animals might not be transformed by gradually accustoming them to animal food, is foreign to the present subject. But, even with dogs and cats, experience shews that purely vegetable food does not succeed, as it almost invariably renders them subject to the mange, (raude.) But, to return to the cause of vomiting in children and adults. ' Although the form of the stomach plays the principal part in vomiting, there seems to be another agent strongly co-operating with it, namely, the sensi- 564 On the Physiology of Vomiting, fyc. [Feb. bility of the organ itself, particularly in respect of the nausea or sickness which produces the motions of the stomach in the act of vomiting. This is the reason why I do not assert that lunatics, who generally vomit with so much difficulty, experience this difficulty only because they have a herbivor- ous stomach ; in such a case, we must consider the state of the brain as well as the sensibility of the stomach ; the torpidity of the brain being often such as not to admit the perception of nausea : these persons, perhaps, frequent- ly do not vomit because they do not experience nausea. We have been endeavouring to shew that the food is detained longer in the stomach of the herbivorous form, because it is kept longer in action there, without passing directly into the intestine, and that this form is adapted on- ly to the more indigestible quality of vegetable food. If a stomach so consti- tuted be suddenly filled with animal food, this food will be detained longer by the rotary motion than is necessary for the purpose of digestion, and the consequence will be, that the whole process will be disturbed, and the food, instead of being digested, will undergo a chemical decomposition. From this we may also conclude, that nothing will disorder the stomach sooner than-sudden repletion with animal food after long use of a diet in which the vegetable preponderated. Excess of vegetable food is much less injurious in such cases, as indigested vegetable matter is, in the intestine, not so easily decomposed, and excites peristaltic motion more than animal food. It fol- lows that we ought carefully to avoid sudden change of diet from vegetable to animal. To this may be ascribed the greatest part of the gastric diseas- es prevalent in the summer, and still more in autumn, when the stomach, af- ter having been accustomed to vegetable diet, is suddenly charged with large quantities of animal food. The only remaining question is, whether we can produce excessive retch- ing by larger doses of emetics, as a substitute for the want of peristaltic ex- pulsory motion in persons having stomachs of the herbivorous form ? On closer observation, however, we shall be induced to believe that large doses of emetics in such cases would fail in, producing the intended effect. There are persons in whom very powerful emetics would sooner produce death than vomiting, as is the case with rabbits. In such cases, I think, the greatest as- sistance will be afforded by such means as will facilitate vomiting, by in- creasing the pressure of the abdominal muscles on the stomach, such as fil- ling it with fluids particularly gelatinous fluids, or any thing calculated to in- crease the elastic tension of the parts : perhaps, after all, the best means of facilitating vomiting in stomachs of such a conformation will be starch-flower or arrow-root boiled to a paste, as formerly recommended by Hufeland. Hufeland and Osann's Journal. Mdrz, 1835. 1837] StiUingut Sylvatica in Scrofula and tinea. 505 Part III MONTHLY PERISCOPE. Stilhngia Sylvatica in Scrofula and tinea. Wc have just re- ceived a familiar letter from our highly valued and scientific friend, Dr. Wm. M. Lee, of Indiantown, S. C, from which we take the liberty of extracting the very important observations it contains on the medicinal properties of the Stilling ia Sylvatica. Every practitioner will feel deep interest in facts which tend to enhance his usefulness, in attempts to cure these diseases which have so often resisted every effort of the physician. " You request some information in relation to the medicinal properties of Stillingia Sylvatica. I have not kept any register of the cases in which I have administerd it ; but two occur to my mind at this time interesting : One of Scrofula, the other of Tinea Capitis. The former was a lady who had been under the care of several physycians, with little or no benefit. I endeav- ored to ascertain from herself and husband, what kind of medi- cines had been given her, but received no clear and satifactory information ; although I am inclined to think she had used either the nitric or sulphuric acid. When I first saw her, her face was disfigured by plasters of citrine ointment covering unsightly ulcers, supposed by her friends to be cancerous in their nature, and considered incurable ; as some healed, others would suc- ceed them. The first glance satisfied me that the disease was scrofulous. To restore the general health, I prescribed 4 grs. Pilul. Hydr. every alternate night, and during the day three wine-glassfuls" of the decoction of Stillingia, prepared by sim- mering a double handful of the recent root in four pints of water down to two. The effect was almost magical. In a very short time, perhaps a fortnight, the ulcers began to dry up, and were not, as formely, succeeded by a new crop. In the course of two months they were all healed, the general health greatly improv- ed; and except from the cicatrices, no one would suspect that she had ever been diseased. The case of Tinea was in a negro infant, about six months old, belonging to a gentleman with whom I then boarded. I never saw a more aggravated case. The scalp was almost one mass of disease. An infusion was made by pouring two pints of boiling water upon 1 oz. of the sliced roots of Stillingia. The dose was a tablespoonful It was tried by the consent of her owner, as an experiment, and in three or four weeks, my success was complete. No external means were used except daily ablution. Asa therapeutical agent, T consider the Stillingia infinitely superior to the expensive and often inert Sarsaparilla." 568 Medical Society of Augusta. [Feb. MEDICAL SOCIETY OF AUGUSTA. Wednesday, Jan. 4th, 1837. After the annual election of officers, which was held this eve- ning, the essayist for the evening being absent, the discussion of the regular subject was postponed until the next meeting. On the call of the meeting for the relation of facts of practic- al importance, Dr. Antony related a case of accelerated men- struation. Until the last two years the habit of this patient had been regular menstruating at four weeks, and for five days at each period, and at the usual rate. But since that time, the pe- riod, had gradually accelerated to three weeks, shortened in du- ration to three days, and attended with more than usual pain. She was eighteen years of age, and had been married about a year and a half, lie first saw her four days previous to her three weeks' period. Finding the cause of her irregularity to be a gradually increasing prolapse of the womb, this organ was removed from the fossa scaphoides, into which it had descended, and placed properly in the upper part of the pelvis, and in the axis of the superior strait; and the patient, placed on her side with her hips elevated by a thick pillow. On the second day after, being two days before the expected menstrual discharge, (according to the three weeks' period,) a bilboquet pessary, made of soft elastic materials, was so applied as to occupy the [place in the vagina before the lower part of the rectum, from which the uterus had been removed, and sustain the organ in its proper site. The patient was allowed to leave her bed at pleasure. No other treatment was was prescribed, nor any particular regimen; but the patient directed. to wear the pessary until after the close of the approaching menstrual, which was her Novem- ber period. The result was most happy. The menstrual flux was retarded to the precise time of four weeks from the first day of the last period, and continued without more uneasiness than attends ordinary healthy menstruation for the term of five days, at the ordinary rate of flowing in health thus securing to her for this period at least, a perfect restoration to regularity in every respect, which had not been the case for the last two years. The next day after the decline of the menstrual flux, the pes- sary was removed. So complete had been the correction of every irregularity at this period, that it was resolved to rest the case for the next period, on daily replacement, with the use of vaginal lotions. These were used every day, after a few hours refreshment from bed in the morning, after which recumbence for eighteen hours, with the hips on a pillow was enjoined. On the twenty-seventh day from the beginning of the November pc- riod, the menses made their appearance and continued four days 1837.] Medical Society of Augusta. 567 only being a deviation from health, of acceleration one day, and duration one fifth less, but attended with no peculiar distress. She was at this time on the same treatment as the last month, and it was intended to reapply the pessary immediately pro- ceeding the next period. He gave this case as one fairly illustrating the efficacy of a plan calculated to ensure the positive restoration of the uterus in its proper place, over any other plan without this. The patient was of -full and round habit, in the vigour of youth, and carrying in the face the aspect of high health. Under all the circumstan- ces, therefore, styptics or astringents, as well as tonics, were counter-indicated. Dr. Dugas said, as menstruation had been referred to, he would give the Society the results of a case, wherein the menses had not appeared for six months. He had sinapisms- prepared of equal parts of mustard and flour, made into a paste with water, and applied them over one half of each breast simmultaneously, alternating the places of application on each mamma, and repeating them frequently for three days ; at the end of which the menses made their appear- ance. Dr. A. said he was happy in hearing of the favorable result of a practice so suited to the convenience of females, and from which he had expected so much, and found so little success. On theiirst announccmnet of this remedy, he had subjected some six or eight cases to the use of sinapsisms, in the same manner, com- mencing about two days in anticipation of the monthly period, and continuing the repetition as often asthetendernessoi" the sur- face would bear, for three or four days, with no better results than partial success in. one case only. He hoped, however, that as our remedial resources were very limited in such cases, the favorable result obtained by Dr, Dugas, would afford encourage- ment to the members to give further trial to the remedy, and re- port the result to the society. Dr. D. said he had succeeded fully with this remedy in but one case ; but that in all the cases in which he had used-it, mens- trual pains and other symptoms of approaching discharge had been produced, without the actual flux , thus manifesting the power of the remedy on the uterus through the mammas; but that at subsequent periods in the same cases, he had not found the same results. Dr. A. confirmed by his own experience the observation of Dr. D., relative to the evidences of uterine excitement thus pro- duced, notwithstanding the finally unfavorable issues which had followed his use of this remedy. Dr. P. F. Eve asfced if cither Dr. D. or Dr. A. had, on fail- ing with this application of sinapisms, ever applied them to the uppei and inner part of the thighs? 368 Medical Society of Augusta. [Feb. Dr. Dugas said he had constantly done so, and with consider- able success. Dr. Antony said he had often used sinapisms in this latter way, before and since their applicatiou to the mammae had been recommended, but with such limited success in proportion to their severiiy and disagreeableness to the patient, that he had measurably abandoned the practice. Dr. E. A. Eve said he had used sinapisms in both ways, but always in connexion with other means, and with a reasonable proportion of good results in his cases ; but could not say what part of such results was fairly attributable to the use of sinapisms, as he had in no instance depended on them alone. Dr. Jos. A. Eve observed that cases of this kind were so va- rious in their nature that this remedy could not be expected to succeed in all cases, but whilst it would prove serviceable in some, it would be productive of much mischief in others ; as exciting measures only are properly adapted to those cases in which there is a want of excitement in the uterus ; and contrary means, as rcvellents to the sacrum, &c. in the opposite state of the organ. He considered that before truth can be arrived at in this practice, we must know more of physiology, relative to the association or nature of the connexion of action which exists between the mam- ma) and the uterus whether the sympathy, (if he might so speak,) between them were direct or inverse- whether excitants applied to the mamma) acted on the principle of revulsion, in les- sening the excessive excitment of the uterus, or as a direct stim- ulus to the latter by its association with the former. Dr. Dugas was not prepared to say whether sinapisms to the mamma), act as revulsives, or as direct exciters of the uterus, but was much inclined to the latter opinion. Pregnancy, even in the first weeks, he considered, irritates the mamma) so also on the approach of the menstrual period, the mamma) become irritated. He considered that in these and such cases, the uterine irritation is directly extended to the mamma) ; therefore he was not dispos- ed to consider the modus operandi to be by revulsion. Dr. J. A. Eve repeated that until we can determine the mode of sympathy between the two parts, it is impracticable to deter- mine the modus operandi. If direct, then the sinapisms to the mamma) can only prove useful in cases where more action is required in the uterus, and injurious, if operative at all, in cases of too high excitement in this organ, and vice versa if the sympa- thy be inverse. He considered that the only way to determine the relation of these parts is, by physiological observation. In pregnancy the mamma) doincreasc,but the great excitement in the womb would seem. to keep back the excitement in the mamma). But after pregnancy ends, the excitement of the uterus is daily re- duced, and the breasts become developed from excitement and fluxion, nnd lactation commences. He pave as an evidence 1837.] Medical Society of Augusta. 56$ favorable to the opinion that the sympathy was reverse, the fact that some women keep from conceiving as long as they please, by keepingup lactation, and that the former (conception) is retard- ed by the latter more or less in all women. If a woman miscarry, or if, in consequence of the death of her child or any other cause, except bad health, she do not lactate, she generally conceives in a short time after parturition ; whereas, when a woman nurses her child, it is not usual for her to conceive in less than twelve or eigh- teen months. Many more arguments, he thought might, be deriv- ed from an observation of physiological and pathological phe- nomena, in favor of the existence of an antagonistic relation or inverse sympathy between the Uterus and mammae. Dr. E. A. Eve considered that lactation did not disprove uterine excitement, but tended tc relieve it when it existed. Dr. Antony advanced the opinion that the physiology of the con- nexion of the uterus and mammae was very peculiar, and not to be explained on the common principles of excitement alone. He Was not sure if there was not a peculiarity in the vascular con- nexion of these parts, (alluding to the anastomoses of the mam- mary with the hypogastric arteries,) sufficient to account for the peculiar phenomena, which are presented by these organs, in the differrent states in which they are synchronously or successvely found relative to each other. He instanced the accession of lactation after delivery, when the contractions which the ute- rus undergoes, necessarily, close up the great vascular sin- uses which constitute, at least, much of its increased bulk in pregnancy 5 and by which contractions the lochial discharge is constantly moderated for several days, and until it ceas- es almost entirely, whereon the mammae swell and become painfully irritated, until free secretion takes place. Here, he asked, might it not be reasonably supposed that the prompt sup- pression of the free and copious transmission of the* blood through the uterus, as well as of the red lochia, would tend to the increased fulness of all that part of the sanguifer- ous system most immediately connected with the uterus, and therefore, of the hypogastrics which anastomose with the mammary; and hence these organs enlarge and become irrita- ted from unusual repletion ? Again. In pregnancy, the uterus and its appendages labor under a greater or less (but considerable) irritation, which causes an in- creased fluxion to the part. And here he felt bound to depart from some opinions which had been advanced, and to conclude their stead, that the mammae do not ordinarily evince irritation in the very first weeks of pregnancy ; but that, if altered at all, they actually become more soft and flabby than usual, and that this evidence of withdrawal of excitement and repletion is man- ifested not only in the mammae, but also in every feature of the face, making what are called the "shrinking of countenance," "the 78 570 Medical Society of Augusta. [Feb. loss of looks," " the sharpening of features," &c. &c, which makeup the prominent early symptoms of pregnancy. And that these phenomena are owing to the focus of irritation exist- ing in the uterus and its appendages, and which irritation, tho' lo- cales tothegeneral system,is still suflicientlyextensive.as by a well established law of excitement, to cause so considerable a fluxion to the part, as to produce those external phenomena, so much re- sembling a chill, and in which, the heart and large arteries arc unusually charged with blood. He had observed that it is not, generally, until after four weeks from the last menstrual visita- tion, prior to conception, that the mammae become sensibly en- larged; and even then the ratio of enlargment is in inverse pro- portion to the degree of uterine irritation enlarging more rapidly the less the uterine irritation, and remaining longer relaxed un- der the circumstance of greater. He was disposed to trace the manner of connexion still farther, by calling the attention of the society to the facts of abortion, Or of premature labor from uterine irritation; an occurrence by no means unfrcquent. Here, he had found that, as after ordinary delivery, the mamma) filled very soon after the irritation was removed from the uterus, which had hitherto kept the mammae more relaxed than ordinary, at least in proportion to the period of pregnancy. The same principle, he considered still farther illustrated, by the very conspicuous revulsion from the mammae, in those serious cases of hysteritis, and its complica- tions with puerperal peritonitis, in which lactation, after being regularly established, is caused to cease almost instantaneously; and which cessation is looked to as an evidence of most destruc- tive and monopolizing intlammation The breasts here become soft and flabby. There is nothing in this case to excite the least idea that the change is, from any repellent effort produced in the mammas ; for, at the period of confinement at which these dis- eases are most likely to occur, we use, with perfect safety, the most powerful repellents to the breast, which we can bring into operation, as litharge plaster, &c. Still farther facts, he said, might be adduced in evidence of the agency of direct vascularity. In unmarried or unimpregnatcd females, who labor under retarded or deficient menstruation, the mamma; are found to swell and sometimes lactate at the men- strual period. Why, he asked, should this fluxion and irritation arise, in this distant part in preference to any other, but for vas- cularity ? This is ordinarily the very next change in the sys- tem, to deficient menstruation, and stands as a kind of monitor to point US to future dangers (under continuance of the cause,) of hepatic derangements in the phlegmatic, pulmonary in the san- guineous and strumous,, nid nervous in the nervous temperaments. If this be not the true physiology and paihology of the instan- ces advanced, we have to conclude that these are to be acknowU 1837. J Medical Sqci iugusia. 57 i edged laws of female nature, that her deyelopements cease in some resp -ds short of that which lakes place in males that her increment must so eixcedc as to amount to surplusage^ period-1 ically, tor thirty her life, for die purpose of her being prepared for her offices, in the perpetuation of the species, and that she must menstruate for that period, more or \c^, if not pregnant nor laetatin.r: or suffer disease. So is it another law peculiar to her nature, t<> undergo this change of determination of the fluids, and theexclt i'her system, to lit her for the same purposes ; and thus is beta t ion produced for the nourish* ment of the offspring, when uterine excitement can no longer continue. In obedience to the same law the determination leaves the uterus when no longer needed there, but is necessary at the breasts for the sustenance of the offspring ; and when this, in turn, is no longer necessary, itreturns to the uterus, again to pre- pare it for a renewal of its functions. He would here leave the physiology of the case under consid- eration, and give his practical views of those menstrual irregular- ities whose treatment had been so .mexpectedly brought under consideration. The pathology on which he practised in these cases might be considered a vci'y mechanical one, but nevertheless he would five his views of it, and the practice founded thereon. He believed that a common error of pathologists was to look with too much abstraction, on the principles and state of action or excitement for the full solution of every problem in pathology. As in other cases, lie was not disposed to conclude that, in menstru- al irregularity, excitement dlojie was all that is to be considered. He wished to avoid being too exclusive on either side. He was not disposed to deny that momentary and transient causes which demand, in consequence of their nature, no special effort for their removal, may and do produce menstrual derangements which continue after the first causes have passed away. Such are certain strong mental impressions, cold, &c. But if the gentle- men would contemplate the very peculiar vascularity of the uterus, the distribution of the spermatic and uterine arteries to the uterus and its appendages, the wonderfully varied anasto- moses and inosculations with their own branches, with the branches of their fellows in the symmetrical arrangement, and with those of each other, with veins, 0c together with the cor. responding veinous arrangement, it will not be difficult to con- ceive of the great liability to obstruction to which many of these vessels arc exposed: arid they would be able to realize, for themselves, the fact that these derangements constitute by far the most common aadse <>f menstrual irregularities. These im- portant anatomical facts may be easily contemplated, by a visit to the anatomical boards, or opening the large. folio of Tiedeman, on the arteries, at the xxvii table. In view of the vascular arrangements of this part, he had been 572 Medical Society of Augusta. [Feb. n i I.. . in the habit of considering that obstructions of different orders of vessels, and these in various degrees might be fairly looked to as the cause of a very large proportion of menstrual derangements. In amenorrhoea and dysmenorrhea, the easy and sufficient dis- charge of function is prevented by the tortion or compression in some degree, which the arterial branches entering the uterus suf- fer inconsequence of some degree of obliquity or depression of the organ to which they are destined. All acquainted with the anatomical connexions of the uterus, or its functions, must be aware of the fact of its great and necessary mobility with the sur- rounding part.-?. This is an indispensable part of the design in the arrangement of its attachments to allow the great functional exspansibility of the uterus. Keeping in view this fact, in con- nexion with the abundantly tortuous course of the arteries pas- sing through these loose media of connexion, no effort of the im- agination is needed to perceive not only the probability of such tortion or compression, but the almost unavoidable necessity for its occurrence, on the existence of any considerable obliquity or depression. But the truth, he considered, did not rest its sup- port on the great probability which is, on contemplating these cir- cumstances, found to exist ; but the seat of the principal distres- ses or sensations attending these cases seemed to him, plainly to indicate the fact, by referring to the parts of the vessels im- mediately at and posterior to the obstructed points, that is to say, about the round, broad and posterior ligaments. Thus he considered that the necessary distribution to the vessels, within the uterus, for the purpose of menstruation, whether it be a pe- riodical discharge of blood, or a peculiar secretion (and he was decidedly of the opinion that the former was the fact,) was pre- vented, whilst pain from unusual fulness attended at the points of mechanical obstruction. He considered that the only cause of the difference between amenorrhoea and menorrhagia, so far as regarded their pathol- ogy was that, in the former the arterial, and in the latter, the veinous branches suffered the obstruction; and that thus were pro- duced the differing phenomena in the latter case, as excessive dis- charge, less pain, &c. In farther evidence of the truth of this opinion, he would state that on due investigation, he had rarely, if ever, been disappointed, in finding the displacement alluded to as cause of vascular obstruction : and that the two diseases yielded with like promptitude to the same treatment, so far as this was dictated by a reference to cause ; the chief dif- ference being in the treatment of some of the symptoms in each, for the removal of present distress, as the pain, for example, in the former, and the haemorrhage in the latter. The same theory of causation, he considered, equally applica- ble to accelerated and to retarded menstruation ; in the latter case arterial, and in the former veinous obstruction, existing. 1837.] Literary Sacrilege. 573 All these things, he considered, entirely consistent with the anat- omy and physiology of the parts concurred, as well as the ill success and* great uncertainty ordinarily attendant on other means, without such as are adapted to the cause in this view. So great has been this uncertainty, that not long since it was a point of serious doubt amongst the profession, whether there was, in- deed, such a virtue amongst medicines as emmenagogue ; and this doubt still exists in the minds of many excellent practition- ers, from the evidence afforded to the negative side of this ques- tion, by their continued failures in protracted experience. Al- though he was himself on the affirmative side of this question, still, his experience had been attended by results much of the same character during the first eight or ten years of his practice ; and even to the present time, so far as he depended on the ad- ministration of emmenagogue medicines alone. But for the last twenty years, he had been pretty generally able, any time prior to alteration of uterine texture, to succed in retarding accelera- ted and accelerating retarded menstruation, to the proper peri- od, by the same general course of treatment, with wThich he had been most successful in procuring ease in painful, and abundance in deficient menstruation. This treatment had mainly consist- ed of strictly preserving the uterus in its proper site, proving thereby not only the truth of the cause, but its identity in both cases. He was fully aware that there were cases of menstrual irregularity in both ways from other causes, and in these cases, he had met with reasonable success in the use of ordinary em- menagogue powers for difficult, deficient or retarded menstrua- tion; such as camphor in large doses, asafoetida, savin, &c. &c, and incases of haemorrhage, styptics, as acet. plumb., pulvis, alumina? comp., ergot, &c. But he had found these cases of rare occurrence. His trials of the sinapisms had been made in such cases as from long continuance, and probably vascular disorganization, had refused to yield to his ordinary treatment; and he was, therefore, happy in being able to hope that they would, in gener- al use, be found more successful than they had proved in his cases. But whilst their use might in some measure stay the progress of mischief for a time, still they might not be expected alone to effect a final cure in any of those cases, depending on the mechan- ical obstruction, to which he had alluded. The Society then adjourned to the next Wednesday. The following account of Sir Edward Home's flagitious con- duct, with respect the invaluable manuscripts of the late John Hunter, is taken from one of the daily papers in New York. Comments are unnecessary every honest man and friend of science will unite, in condemning to everlasting disgrace, a rob- 7-i Literary Sac r lit [Feb. bcr so base as to steal from tli'e t omb of the dead his hard earned laurels. Literary S.vchi!,ec,i:. Some two. or tl . a statement ap- peared in tho London papers, that? the late emuimi Surgeon, Sir Ever ard Home, Jiad derived all ilie valuable portions of Jus celebrated Lectures on Comparative Anatomy" from the manuscripts of the great John Hunter, which had been confided to him for a special purpose by the Directors of the College of Surgeon?, and then, to conceal the robbery, destroyed the manu- scripts. The statement was copied into many papers in this couutry, but here, too, it was not belived, and the charge was unhesitatingly pronounced an infamous libel. The charge appears to have been made the subject of a parliamentary in- vestigation, and the London Courier gives the i'oiio wing as the substance of the testimony given by tne accuser, Mr. Ciift, who was at one time, me believe, an assistant of Sir Everard Home, and afterwards conservator of the books and manuscripts in the museum of th of Surgeons. "The museum of the late John Hunter was purchased by Government in 1800, who gave for it in all the sum of X*'-2700. This museum was given by Government to the College of Surgeons in trust for tho Public. To then- care were also cimlidod Mr. Hunter's papers and manuscripts referring to the collection. Without any one interposing to prevent it, these manu- scripts were allowed to be separated from the collection, and were taken in a cart to Sir Everard Home's house, who was considered the only person who could made a catalouge of the collection, and who expressed his inten- tion to do so. Year after year, however, was permitted to pass away with- out the preparation or the catalouge, and without any supervision of the manuscripts from which aleue an account of the museum could be derived, ami -without the slightest care being taken to ascertain that these valuable documents were in safe custody^ when one day in July, 1824, that is, twenty three years after the collection had been iri possession of the College of Sur- geons, Sir Everard Home informed Mr. Clilt, the conservator of the muse- um, that he (Sir Everard Home) had just been employed in burning all the papers! Mr. Clift thus describee the relat ion oi' th. e.v.i .-uudinary circum- stance before a Parliamentary committee : Sir Everard Home began by tel- ling me that an accident had very nearly occurred at his house ; that it had been nearly on lire ; that, the engineers came, and the firemen insisted in taking possession of his house. They saw the flames coming out of the chimney. He did uot wish to admit them, but they insisted upon being ad- mitted. I asked how it happened, and then he told me it was in burning those manuscripts of Mr. hunter. V> hei\ did thi: c; nversafion pass ? On four road to Kew. That was the first intimation you ever had of the des- truction of any of the manuscripts ! Yes. I said to him 'I hope Sir Eve- rard, you have not destroyed those ten volumes relating to the gallery it He said 'yes.' And then 1 mentioned perhaps? twenty fibers that J had a per- fect recollection of. Will you go on and describe the state of your feeJmgs. and what passed ! 1 can hardly describe then', because \ felt that all those hopes that I had entertained, were entirely frustrated i nd destroyed. I con- sidered that my life had been spent iti the service1 oi' that collection, and I hoped to live to sec t hose papers honoliciaily employed. When I had made inquiry respecting the principal of them, and lie told me they were all gone, 1 said to him, ' Well, Sir Evnard, there is only one more thing to be done.' He said ' W'hal is that .'' I said -To burn the conecnon.4 Tn the course of this conversation did you a k Sir Everard what had led him to take this step ? I knew that that week Sir Everard had received back from the printer the last proof of his second volvmo of ' Lectures on Comprrative Anatomy,' and that lie had used fchoge papers \ cry largely in the composition of that work. Can you state, from the knowledge you obtained of i he manuscript,!? 188"/. j An inquiry inU itpnjoJLciicorrhcea. 5*75 while you bad accosi tot!; Sir Everard II >m i bad lately u jed tlicir contents inthe e n of the volumes which he issuea under his own nam;'!' l Yes.' [Then. follows! ao< ki ol ;lu letters and mmu- Fcrip- . : a ^viewer observes:] *A range . iinperft* \ I is admitted lo be, investigated with the orig id tha woujdotful U^oustry: of this extra- ordinary mm, would proba giveu a new aspect to the sciences of anatomy and physiology in this . aad there, is not wanting evidence that tli ' ! T himself, really had anticipated discoveries which hi .c.kuduringfame to men of other countries.' "] An Inquiry info somi Points of ike History of Lit'.corrhcsa. By Dr. M*RC LftSsrrwE. Th il facts which form (he basis of the present essay were col- lected in the Venereal Hospital of Paris. 1 \'ie author insists on the necessi- ty of employing- the speculum, as the only means of acquiring a correct knowledge of the disease. In several females, who stated that they never had any leucorrhoea, he found a discharge from the os uteri, on employing th? speculum. The cases which he has collected of -uterine discharge are the most important, and the connexion which he has found to exist between the matters secreted and the condition of the os ut sri are worthy of a short analysis. Of 19.3 cases of uterine discharge which were examined with a speculum, there were twenty-three in which the os uteri was dry, and the vagina was equally free from any matter which could be traced to a uterine origin. In forty eases, there was only a single drop pendent attheos uteri. In the remaining 130, the discharge was more abundant. This discharge is not necessarily stopped during pregnrncy. In a large proportion of cas- es in which the menses were somewhat retarded, the discharge is also found wanting. The fluid is either watery or more or less viscid, and in the latter case of various characters; sometimes transparent, at others opaline, streaked, opaque, white or yeilow. The condition of the cavity of the ute- rus is neccsarily unknown ; but its orifice may be either healthy or surround- ed by a rosy circle ; this circle may be of a deep reu colour or bloody, or the redness may be granular without erosion ; or, lastly, the circle may be erod- and ulcerated, with a. smooth or granulated surface. The fact of all these cases having been assembled in Use the Venereal Hospital renders it doubt- ful how far these discharges may be dependent on a syphilitic cause, or orig- inate in simple chronic inflamation. But, as illustrating the connexion be- tween the condition o! the parts and that of the discharge, the facts are still of some interest. From a numerical comparison, the author found that the waters and transparent albuminous discharges existed in the majority of cases in which Ihe orifice was healthy, in one half of those where it was sur- rounded by simple redness, and only in a fourth of the cases in which there was vivid redness or ulceration. The opposite maybe said of those dis- charges which were . -emitransparont and opaque. However, the nature of the discharge is not soiely dependent on the condition of the ori- fice, nor does a similar condition always produce a similar discharge ; for an ulceration of the cer\i\, which coincides most frequently with the opaque, coincides occasionally with the aqueous or albuminous discharges, and those which are opaque and striated are sometimes met with when the cervix is perfectly healthy. It is probable that the aqueous and albumuious dischar- ges belong properly to leucorrhma ; whilst the addition of streaks of pur- ulent opaque white fluid, depends rather on an inflammation which is either simple or syphilitic. So little that is important can be concluded from the author's examination of the vagina audits discharges, that it is scarcely worthy of notice. British and Foreign Review. Archives generates Mcdc- rinc, tome x. Fevrtsr, 1 83< i S76 Chloride of Soda in Intermittent Fevers, fyc. <$c. [Feb* On the use of Chhride of Soda in Intermittent Fevers. By Dr. Gouzee, First Physician of the Millitary Hospital at Anvers. Dr. Gouzee was induced to try this medicine, first recommended by Dr. Lalesque, as its cheapness would render it (if efficacious) very valuable to the poor inhabitants of marshy districts, as a substitute for quinine. The dose prescribed was a half a drachm of chloride of soda in four ounces of distilled water, to be taken by spoonfuls between the fits, and so that the last doses should be swallowed shortly before the next paroxysm was expected. The patients were restricted to a light diet, and confined in their beds, or at least their chambers. Ten cases are reported of ague: in two the intermittent yielded immediately ; two others were cured after a slight return ; m One there were four attacks, gradually diminishing; in two cases the severity of the paroxysms abated, but it was thought necessary to have recourse to sulphate of quinine ; in two others no effect was produced, and in one the disease was aggravated. Dr. G. thinks these cases prove the febrifuge properties of the chloride of soda to be less marked than those of sulphate of quinine, and therefore that it should not be trusted to except in the slighter cases, and where the patients are readily susceptible of the effects of medi- cine, as women and children. British and Foreign Review. Revue Medi- cate. Fevricr, 1836. On Incontinence of Urine. By M. Mondjere. M. Mondiere has employed the extract of nux vomica in cases of noc- turnal incontinence of urine, with beneficial effects. The case in which its efficacy was most strongly shown is that of a young woman, aged twen- ty, who* from the age of six years, had constantly voided her urine involun- tarily during the night. The use of twelve of the following pills put an end to the incontinence : they were continued until twenty-four grains of the ex- tract had been taken, and** during the year following this treatment, there was no return of the disease. Other successful cases are mentioned. Extracti nucis vomicae, gr. viij. Ferri protoxidi, gr. j. M. riant pil. xxiv. British and Foreign Review. Gazette Medicate. Ao, 10. 1836. Formnlafor an artificial Chalybeate Water. fy . Ferri Sulphatis, 3 ss. Sacchar, albi, 3 iss. Misce, et divide in chart, xij. eeq. D. S. No. 1, ty. Sodce Carbonatis, 3ss. Sacchar. albi, 3 iss. M. et divide in pulv. xij. acq. D. S. No. 2. One powder from each of these packets is to be dissolved in a small quan- tity of water, then mixed and drunk whilst effervescing. Each draught con- tains about a grain of the carbonate of the protoxide of iron, dissolved in water impregnated with carbonic acid gas, with a little Glauber's salt and carbonate of soda ; the carbonate of soda being designedly a little in ex- cess. This is a good substitute for ferruginous mineral waters, where the natural ones cannot be obtained. British and Foreign Review. Summa- rium des Nuesten in der Heilkunde. 1835. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. I.] MARCH, 1837. [No, 10. Part L ORIGINAL COMMUNICATIONS, ARTICLE I. Cases of Traumatic Tetanus. By Jos. F. Lee, M. D., Ab- beville District, S. C. (late of John's Island, S. C.) There is, perhaps, no disease that falls under the attention of the physician more generally fatal in its termination than Te- tanus. So generally fatal has it been considered, that Dr. Thomas, a West India practitioner, of high standing, when speaking of this disease, observes : " When Tetanic affections arise in con- sequence of a wound, puncture or laceration, they are almost sure to prove fatal, as I never, but once, met with a recovery, under such circumstances, during a very extensive practice, and Jong residence in the West Indies." Any plan of treatment, therefore, calculated to produce a different result, in a disease of so formidable a character, should be hailed with joy by the med- ical philanthropist. Cold water "in Tetanic affections is no new remedy. It has been employed for centuries past. Hippo- crates, himself, was an advocate for the use of it. It appears, however, surprising, that an agent of such extraordinary pow- ers in this disease, should not be more generally used ; and, fhat the warm bath should in most cases be substituted for it 73 578 Cases Traumatic Tetanus. [March, My object in the following communication is, to relate two cases, and the only two cases of Tetanus that have fallen under my notice within a few years, in which a favorable termination was effected by the cold affusion with other auxiliaries. I am fully aware that I advance nothing new in the treatment of the disease ; my sole object is, to endeaver to rescue, from undeserv- ed neglect, one of the most potent remedies in the management of it. The first case that was treated by the cold affusion, was in December, 1829. The patient was a negro woman, about forty years of age. She had received an injury on the internal mal- leolus of the ri^ht foot. The wound was considered of a trifling nature, and neglected until the incursion of Tetanic symptoms. I was now sent for. I found her, on my arrival, laboring under opisthotonos, and upon inquiry into the cause of the disease, the wound, as before stated, was shown me. A warm corn poul- tice was directed to be applied to the wound, well moistened with Spts. Turpentine, and to be renewed three times- in the course of the day. She had taken, before my arrival, a dose of the ol. ricini which 1 was informed, had operated well. Carded cotton was next applied the whole length of the spinal column^ moistened with Turpentine and set fire to, which had the effect of producing a very extensive eschar. The cold bath was directed to be used every two hours, com- mencing immediately. The manner of using the cold water wa^ as follows: The patient was placed in a large tub, and a bucket of cold water dashed over her ; she v/as then wiped dry and placed between blankets. Fifty drops of laudanum was giv- her in warm brandy toddy, and directed to be repeated every three hours. On my visit the next day I was informed by the master of the woman (before I saw her,) that he considered the woman much better, that the interval between the spasms was much longer, and the paroxysms much less violent than they were the day before ; and that the woman herself was so satis- fied of the salutary effect of the cold affusion, that she had called for it herself. Upon seeing the patient, I was convinced of the correctness of the statement received from her master. I did not see her again for two days, on account of the distance of my residence, and then found her progressing as well as could be wished. The soreness of her .back from the cautery distres- 1937.1 Cases of Traumatic Tetanus. 579 sed tier at this time very much. Her pulse was, as is common in the disease, but little affected. I did not see her again after this visit, on account of the distance, but directed, should the spasms recur in a violent degree, to be informed of it. I did not again hear from them. About three weeks after, I saw the master of the woman, who informed me that she had gradually- improved under the cold affusion and laudanum, and he spoke in the most rapturous terms of the cold water. At this time, she only labored under debility. He was advised to administer to her Peruvian bark three or four times a day, which completed the cure. The second case, was a girl, about twelve years of age, a slave also. She complained, on my arrival, of great stiffness in her back, some difficulty of deglutition, with a distressing pain shooting from the sternum to her back. Her master was with me, and I unhesitatingly pronounced it a case of Tetanus, which he had not suspected, and had given her a dose of Glauber's salts, which he informed me had operated well. Upon inquiry into the cause of the disease, I was informed that she had run a splin- ter in her foot about two weeks before, and that it had not been extracted. A crucial incision was made over the punctured place, with a view to extract the extraneous body, if possible. The foot was carefully examined, but no splinter was found. A poultice of corn flour and Turpentine was applied as in the former case,and twenty drops of laudanum were administered to her every three hours in brandy and water. The cold affusion to be used every two hours. On my visit the next day, I found her with confirmed Tetanus. The poultice that had been ap- plied the day before, had caused the discharge of a fishbone about an inch in length. In consequence of the successful termina- tion of the former case, I was loath to omit any part of the treat- ment pursued in that, hence I resorted again to the use of the Cau- tery to the spine as in that case. The cold water and laudanum were directed to be seduously used, and on my next visit, which, in consequence of my being attacked with fever, was not until a fortnight had elapsed, I was gratified to learn that after five days the symptoms had entirely subsided, and that at this time she only labored under debility. Bark and wine were directed for her, and in a few weeks she was permanently restored. 680 Remarks on Spinal Irritation. [March, ARTICLE II. Remarks on Spinal Irritation. By M. Antony, M. D. The publication of Teale's Book on Neuralgic Affections may be considered a new era in medicine. To the experi- enced practitioner, worn down with unprofitable cares exercised for a series of years, on unaccountable, not to say indescribable, distresses, this little book was as a cool stream to the weary pil- grim in a thirsty land. It pointed at once, most plainly, to the immediate cause of the obvious and distressing phenomena, and to the most effectual means for their removal. It dispensed a cheering light over many dark places in medicine, and brought to view a new link in the chain of morbid phenomena, and in that part too, the knowledge of which was calculated to effect great amelioration of human miseries, hitherto uncontrolable. And not only so, but to the inquiring mind, the local irritation, thus clearly and beautifully displayed, cannot fail to reveal an- other truth, which is, as this is but an effect, there must be another cause in the series of phenomena, which must have re- sulted in this effect, and therefore points to the necessity of far- ther research in the train of previous phenomena in the direction suggested by the very nature of this phenomenon : for there must be & proportionate relation, at least of proximate cause and effect. Therefore, an effect well understood, as morbid irrita- tion, or sub-acute or acute inflammation, points by its own nature, as it is understood in relation to its manner of production, to its own appropriate causation, with almost as much certainty as the letters and words on this paper at once declare, or point to the fact that a pen in hand has been engaged in their causation. But when the weary and thirsty plilgrim comes to the cool fountain, clear and decisive reasoning is necessary to lead him to the exercise of that self-denial, without which, his refreshing fountain becomes to him the minister of death. Like a well proportioned and delightful atmosphere, it is invigorating and health-giving, imparting at once to the imagination, a steady brilliancy, and to the reasoning faculty a clearness, and an en- ergy competent to its due control, But if charged with an addi- 1837.] Remarks, on Spinal Irritation: 581 tional dose of the vitalizing principle, it gives to the inhaler the bright scintillations of the former, which exhibit to his sen- ses delusive visions of wealth, honor and glory ; whilst it forces the latter into a wild and intoxicated luxuriance, out of all pro- portion to its own formative laws, and no longer capable of exer- cising its own wonted sovereignty. Such appears to us to be the course which every good thing in medicine is destined to take. Such has been that of the humoral doctrine such, that of excitement ; such, the course of nosology, and such, that of the simplification of disease. To counteract one imprudent extreme, another has always been ap- proached. So free is the human intellect and, most unfortunately too, so partial, (should I not say selfish ?) that, whilst its inherent vanity is wholly captivated by novelty, or enamoured of its own beautiful creations, it lavishes, prodigally, on them its whole treasures with one hand, whilst with the other it tyranically re- jects all the premises which should in sober justice influence the result. And such, it apppears" to us. is the course to which the doc- trine, (if I may so call it.) of spinal irritation is destined. A new medicine which, on its first introduction, has made some favor- able impression, is directly considered and praised as a catholi- con, until, by its universal, use it has numbered its thousand victo- ries over human life. Novelty becomes supplanted by familiar- ity and observation, it loses its charm and the medicine is doom- ed to exile for a century, then brought from the rubbish of gener- alizing error and allowed its proper rank. Thus, is spinal irri- tation wrested from its proper rank in the concatenation of pa- thological phenomena, and made a first and only efficient cause of all accompanying and succeeding phenomena. But there is a difference between therapeutic, and patholo- gical errors ; that whilst a little time serves amply to expose the former, the latter are more disguised, and a greater grasp of intellect is necessary for their detection. Because spinal irritation is, indeed, the true cause of the most conspicuous phenomena, as is evident on the soundest principles of physiology, and proved by their correction by its removal, it so captivates the thoughts not sufficiently chastised by time and experience, as (although itself an effect,) to be considered the pri- mary and efficient cause of all, to the neglect of all concomitant or antecedent, phenomena, and even its own etiology. Inquiry, 582 Remarks on Spinal Irritation. [March. I say, stops here at the detection of the fact of spinal irritation, satisfied that here is the real here, the first independent and sole cause. The indication of its removal, and that alone is there- fore plainly drawn from the premises. And so stongly does the spell hold its sway over the rational mind that, although no evi- dence of the fact of spinal irritation can be apprehended, it is still believed so intimately connected with the other phenomena in the relation of cause, as to have its existence inferred from these. Here, are the errors I would expose. The discovery of the connexion of spinal irritation with many distressing phenomena, and its suggesting the means for their re- lief should not thus limit its utility. To the enquiring mind, I say this local phenomenon, so clearly and beautifully displayed, cannot fail to reveal another truth. Could this spinal irritation have occurred without having its own peculiar and appropriate cause ? Certainly not, as there is no effect without competent causation. If then it have a cause, is it abiding ? Or has it been momentary, and, therefore, left only its effects to be corrected. If the former, surely nothing can justify the neglect of such abiding cause of any train of phe- nomena, when our object is the removal of that train. As well miS4 Remarks or Spinal Irritation. [March , of substance, the spinal centre, at the central extremity of these nerves, has become the seat of inflammation from the primary source. Pursuing this plan of enquiry farther, we shall con- clude that pregnancy alone, and considered abstractly, could not have produced the spinal phenomena, because if this were the case, it would occur in every instance, which is not the fact. The mind is then led to enquire for other, or additional cause, as we have not yet in view a competent one. On examining for its detection, we may find a peculiar irritability of temperament, suf- ficient to render a cause, ordinarily inoperative, productive of the morbid action. If this be all, we shall proceed to di- rect our attention to the moans necessary for the correction of this morbid irritability. But this, which, when found, may be considered a predisposing cause, may not exist in the present case. On farther investigation, we may find an active one, in an undue pressure or bearing down of the gravid uterus, afford- ing more or less obstruction to the circulation through the tor- tuous and meandering branches of the uterine, spermatic or other arteries, which would be additionally calculated to serve as a cause, not only, of local irritation in and about the uterus, but also of an unusual determination of blood to other parts ; and as well to the vessels of the neurilema,or of the nervous substance at the spine, as elsewhere ; and more probably than to some others, as this is, mainly, a non-resisting organ. With these facts, and the evidence of their existence found in considering them, even as abstractly as possible, from the fact of spinal irri- tation, shall we not find cause of farther prescription, such as taking off the obstructing and irritating uterine pressure, by horizontal position and other means, if necessary, and correct- in"- the oxtraordinary irritation of the uterus, by general and lo- cal depletion, abstinence, &c? But again. We find an assem- blage of those distressing nervous symptoms, of which women often complain, in common with amenorrhoea. On farther in- vestigation, we detect a spinal irritation at the sacrum or lower lumbar vertebra, and perhaps about the sixth or seventh dorsal. We shall surely, under these circumstances, not hesitate to cor- rect the spinal irritation ; but if we consider the other phenom- ena, presented by the case, we do not find the suppression of an habitual discharge from the uterus, which, according to a fixed law of her nature, shall take place, unless pregnant or lactating, 2 837.] Remarks on Spinal L I J^5 during about thirty years of her life, and tho want of which, dom, if ever, fails to produce i rcsscs, even ^ out spinal irritation, and which we are compelled to remove, by prescriptions directed to uction of "natural discharge ? And again. We find an intermitting fever attended with some degree of irritation about the spinal marrow. As spinal irritation seldom, if ever, exists idiopathieally, shall we not rather look to it as an index, pointing to other disorder ? In this case, an enquiry is ne- cessary into the pathological condition of the general system, or the various organs, under the existence of an intermitting fever. And here, we find that the liver and the spleen, sometimes* are laboring under an obstructing torpor, which prevents that free transmission of blood through them which the great portal sys- tem demands. This is a fact, that we know to exist ; and if we did not, it is susceptible of plain proof. Now, suppose a given quantity of blood m the system a1 ment of consid- eration, as 24 pounds, and that one u, or 2 pounds, pass the portal system whilst the other 22 do the other circulation. The abdominal fulness evinces the obstruction. If, now, we al- low any obstructing cause in the route of the portal circulation, the liver is the only organ where we may suppose it located. Let us suppose that this obstruction is such, as to transmit only half the ordinary quantity of blood, in a given time. The una- voidable consequence and proximate effect of this,, must be an increased fulness of the portal vessels. This accomplished to its utmost, and the next consequent must be their refusal to im- bibe or receive, more than half their natural quantity in a g:' time, or one, instead of two pounds, and consequently, if the health were perfect in the former state, there is, to say nothing about, the quality of the blood, a redundance of about four per cent. Following this inquiry, we perceive, therefore, local phe- nomena, and especially in non-resisting parts, and consequently a cause of irritation or of oppression. We would not exclude by an ultra humoral philosophy the whole nervous pathology. Obstruction in a part, is generally fol- lowed by irritation and inflammation of that part. This is, howev- er, various in kind and degree, according to many circumstances: we will name but one as necessary for our present illustration, and that is, the different irritability of the different parts. ' * 7-1 W6 Remarks on Spinal Irritation. [March, liver is an organ of very remarkable peculiarities having in its structure, a large proportion of its bulk, made up of vein- ous branches from the great portal, and an arterial arrangement, only proportioned to the support of its 'secerning organism, whilst it is less supplied with irritability, as its irregularities arc more frequently and easily induced than most others. Therefore should we conclude that, however great and acute an inflamma- tion in some other parts might be from a given offending cause, it will be proportionately less in this, and consequently less effec- tive of secondary and distant effects it would be more chronic, or of that character at most which is designated by the term sub- acute. Hence, when phlegmonous inflammation does exist and continue in this organ, it is slow in arriving at the suppurating stage, and instead of doing so at all, it more frequently termin- ates in schirrous degeneration. Not so, however, with the uterus, with whose irritations the lower fourth part of the spinal marrow is first found in relation. This, although as peculiar an organ in some respects, and indeed, much more so, is very differently in- nervated. Consequently it is much more susceptible of the vio- lent and acute forms of inflammation. But an observation on the connexion of some of the diseases of this organ will be useful in satisfying the enquiring mind of the fact, that both the principles above alluded to, assist in causing spinal irritation from the or- gans. It is a fact of observation, that the spinal irritation, and consequently, the great sum of neuralgic symptoms, are gener- ally found to be more considerable in cases of difficult, suppres- sed, retained, or retarded menstruation, whilst with accelerated, or excessive, it is generally in a small degree and extent, and of- ten not existing at all. In all these cases, therefore, we are bound to direct attention to the first seat of obstruction and of irritation. Let the partisan in medical doctrines have his choice of the horns of the dilemma, still is he bound to look to it as cause whether it be the local irritation alone acting through the medium of the nerves, or merely the effect of the sanguine plethora, already described. And in case of the combination of both, he must look to the remo- val of the obstruction to circulation, as well as (he subduction of irritation in the primarily obstructed and irritated part. Fortu- nately for the practitioner, it is often the case that the means test adapted to the correction of one of these primary difficulties 1837.] Remarks on Impeded Respiration. fiST is tributary to the relief of the other. For example, a uterine flux contributes to the reduction of its irritation ; and as irrita- tion increases obstruct! Auction of the former often con- tributes in no mean <3 s removal of the latter. Not so much so, however, in tl ! of the liver whose innervation is less conspicuous, and irritation, consequently, more sub-acute, or chronic. In this case, expeciallv in that grade of action com- monly attended by spinal irritation, the irritation in the primary organ is not such, but that mercurials are generally found, not only safe, but peculiarly happy in so increasing the secerning ac- tion as to cau^c the burthen of labor awaiting the actions of the viscus to be dispatched, and the obstruction removed. The same principles and reasoning, which we have applied to the case of spinal irritation, in connexion with hepatic derange- ment, is alike applicable to rheumatism. Here we shall find cause of local obstruction and local irritation. ARTICLE m. Remarks on some of the causes of impeded Respiration : By L. A. Dugas, M. D., Professor, &c. in the Medical Col- lege of Georgia. There are no functional derangements, the immediate causes of which, should be more clearly and distinctly understood by practitioners, than those of respiration, yet, until a few years since, the attention of the profession had been called perhaps less to this than to any other class of diseases. It is to the tow- ering genius of Laennec, we owe nearly all our knowledge on this interesting subject, and, although, much has been contributed by his immediate followers to carry out his principles, the desired bourne of perfection has not yet been reached. There still re- mains much to be done in diagnosis as well as in treatment, ere we shall be enabled to detect the true cause of many cases of impeded respiration, and to snatch th victim from impending suffocation. xrks on Impeded Inspiration. March, The art.' -0j action of a piece of mechanism, should come toils examination with a thorough ion these boar to each other in the accomplishment of regular and unimpaired action. So with :ologist ; before he can inquire into the cause* of morbid functions, lie must be acquainted with those functions in ir normal condition, and with the structure which contributes to their performance. Anatomy teaches him that the parts be- longing to the apparatus of Respiration, are lungs pervaded, not only by air passages, but also by bloodvessels, lymphatics, and nerves; that the air passages result from the subdivisions of larger conduits coming from a distance, and so disposed as to sub- serve other functions than those exclusively of respiration, viz: voice ; that these lungs are expanded and contracted by muscles situated about the chest, the abdomen, and the larynx ; and lastly that the action of these muscles is subservient Jo a 'pecu- liar influence transmitted by appropriate nerves. Physiology will teach him that the performance of healthy respiration requires healthy pulmonary tissue, unobstructed circulation in the blood- vessels and lymphatics, the free admission of atmospheric air through the conduits and into the pulmonary cells, unimpaired action of the muscles of respiration, properly so called, and finally a normal supply of nervous influence, both to the lungs themselves and to the muscles presiding over their motions. With this knowledge before him, the pathologist will at once perceive that the process of respiration may be impeded by le- sions, not only of the parenchyma of the lungs, but also by lesions of each of the tissues entering into its structure; by lesions of the air passages* by lesions of the serous membrane lining the thorax ; by lesions of the muscles of respiration, whether situat- ed about the chest, abdomen, or larynx ; by lesions of the cir- culatory apparatus ; and finally, by lesions of innervation in ei- ther of the parts just mentioned. Although our knowledge of the respiratory derangements con- sequent on 'affections of the pleura, of the pulmonary tissue, and of the circulatory system is considerably advanced, we cannot say as much with regard to those dependant or vitiated innerva- tion and on the condition of the larynx. The effects of vitialed innervation are, or may be presumed to be, manifested in the con- dition of the air cells, which may cease to be permeable to the 1837.] Remarks qnlmpeded Respiration. 689 air, but principally in the action of the muscles of respiration. Smart) is and the action ofmai of them < A ! ?*>es exceedingly diffi- cult to determine to what extent impediments of respiration de- pend on their imperfect or total want of action. I am not aware that the attention of any path > - been strongly directed to this inquiry with regard to any other than the muscular fibres supposed to bronchial ramifications. The perfect- ed means of invc. . instituted by Laennec enabled him to ascertain beyond doul cases of impeded respiration are entirely unattended with any lesion of the pulmonary paren- chyma or of its tubes. Hence, we find him admitting the exist- ence of the muscular fibres alluded to, and explaining the, mor- bid phenomena on the principle of spasm of these fibres. He seems to have taken but little account of the condition of the ex- ternal respiratory muscles. The free and easy expansion and contraction of the chest, are necessary to free and easy respiration ; and in this alternate increase and diminution o'f the capacity of the thorax, we find concurring the muscles of the chest, properly so- called, the diaphragm, and the abdominal miisclesv Now it is evident that cessation, or even a diminution ofthe-actioa of either of these sets of muscles must tend to lessen the freedom and ease with which the capacity of the chest is alternated, and, conse- quently, with which respiration is effected. The impaired action of the whole would be fatal. May not then, many of the cases of asthma, regarded as dependant on spasm of the minute air passages, be with some propriety at least, referred to spasm or vitiated action of the muscles termed respiratory ? That there is such a disease as spasmodic asthma, independent of any pul- monary lesion, is no longer a matter ofdoubt. It only remains to locate the scat of the spasm, and to determine the diagnostic signs. But there is yet another apparatus, the integrity of which, is of the highest importance in the respiratory process. I mean the larynx, which, in order to subserve the vocal functions/is so disposed as to leave its comparatively small aperture more or less under the dominion of muscular power. The ingress and egress of air through the larynx, may therefore, be seriously affected by the action of the muscles about, the glottis, whether voluntary or spasmodic. 590 Remarks on Impeded Respiration. [March, Respiration may also be impeded by the diminution of the caliber of the larynx, and especially of the rima glottidis, oc- casioned by abscesses, false membranes, or by the mere thick- ening of the mucous lining. The thickening of this mucous coat may depend either on congestii mmation, or infiltration, all of which may be acute or chronic. It is one of these conditions of the laryngeal membrane to which the attention of the profes- sion was called by Bayle i servations on oedema glot- tidis, (Diet, des Sc. J\icd. T. 18,) but which have, I apprehend, been too much overlooked by practitioners. Of all the causes of impeded respiration we have enumerated, there are none whose -diagnosis is more important than those occurring in the larynx. It is peculiarly important in these cases, because they are fre- quently fatal, and because they require local as well as general treatment. We have stated that the diagnosis of the difficulties of respiration dependant on lesions of the pleura, pulmonary pa- renchyma, and heart, might be readily established by ausculta- tion and percussion. Withregard however to the lesions of in- nervation, and to those of the larynx, the physical signs afforded by auscultation and percussion can only be negative. They will enable us merely to ascertain that the disease is located neither in the lungs, pleura, or heart. How then shall we distinguish the vitiated innervation or spasmodic state, from that resulting from other causes ? The question is of difficult solution. Yet should not all cases resulting from spasm alone present more or less of the intermittent character so peculiar to nervous affections, and vice versa, should not the absence of intermittency establish the existence of a more permanent lesion ? Indeed I do not hesitate to regard intermittency in cases of impeded respiration, whether termed asthma or otherwise, as a positive indication of spasm. If these premises be admitted, it will only remain to distinguish the several forms of thickening of the laryngeal membrane from each other as well as from the existence of an abscess in the la- rynx. This is extremely difficult, inasmuch as they not (infre- quently exist simultaneously, and that in the progress of an ab- scess the symptoms may simi those of congestion, inflamma- tion, or infiltration of the mucous membrane. The lesion of the mucous membrane, in order to impede respiration, must be about the rima glottidis and vocal cords; hence the alteration of the voice accompanying this disease. The effects of congestion are 1837.] Remarks on Imp . :. 'ion. M]- usually more or less i loss so and attended with more or ma progresses rather slowly and is unattended with any excitement whatever. The followin will serve to illustrate two of the most dangerous forms of laryngeal obstruction; viz. by oede- ma and by abscess. JVed, a negro man aged about 40 years, was in good health when in 1835, he experienced some uneasiness about thethroajt, attended with h and difficulty of breathing. Having no other symptom of disease, he paid but little attention to his situation for several days. The disease however gradually pro- gressed ; the difficulty of breathing incr ' and the sensation in the larynx was such as to induce him to think there was some- thing in it strangling him. He also complained of intense pain in the nasal bones. On examination nothing could be perceived either in the fauces or nose to account satisfactorily for the symp- toms. 1 was called to sec him about a week after the invasion of the disease, and on the occasion of his having a slight convul- sive attack, which appeared to 'rom suffocation. I found his'pulse very small and feel rface cool; respi- ration resembling that which attends asthma or croup; voice ex- tremely hoarse; deglutition difficult; muscular power barely sufficient to allow him to walk and sit about the room ; great depression of spirits; 'other functions normal. The pain in the nose was intolerable, and the sensation of the larynx extremely annoying. No treatment had been instituted before. An emetic was now prescribed, but before it had 'time to act he fell back with another violent convulsion, during which suffocation seemed inevitable. He however recruited sufficiently to swallow a large dose of spirits turpentine and oil, but without benefit. Respiration became more and more impeded, and he soon ex- pired in convulsive throes and violent attempts to tear open his throat with hi iqgers. I had early explored the chest by. auscultation and percussion, and satisfied myself that there was in the lungs no impediment to the ingress of air, and consequently that the obstruction was in the larynx; the uneasiness felt at this region also pointed it out as the seat of disease. Several physicians having been called in, I proposed laryngotomy, but it was thought too late and I met with no concurrence. I nevertheless, when death approached, 592 Remarks on Impeded Respiration. [March, attempted the operation, but the movements of the fiuyi so rapid that I found it extremely difficult withe abandoned it. The autopsic examination being made a few hours a the lungs were found in a normal condition ; the tr; I la- rynx contained a considerable quantity of frothy mucous-, but evinced no traces of inflammation. The lining membrane and sub-mucous cellular tissue, from the cricoid cartilage to the epi- glottis, were in a state of complete serous infiltration, and so much thickened that the rima g] ' irely closed. The epiglottis was double its nor The whole of the diseased surface presented the pallid aspect peculiar to oedema. Nothing was found in the nose. The other organs were not examined, it being perfectly evident that death had been caused by the partial occlusion of the larynx. The occlusion being produced gradually and partially, life was destroyed by degrees. The debility resulting from insufficient respiration may be regarded as the immediate cause of death. The other case to which we have referred is that of a man about 40 years of age, who entered the city hospital, in No- vember, 1836, with dysentery. He was treated by calomel and opium in small doses, and soon relieved of his enteritie nflbction. But he soon became profusely salivated, and his gums assumed a gangrenous- appearance. The disease of the mouth resisted several weeks every means instituted, but finally healed. He was then taken with every symptom of cramp, hoarseness, diffi- culty1 of respiration, &c. &c.; ami presenting every symptom of croup for several days, was treated accordingly. The diffi- culty of breathing increased, and the fatal issue seemed in- evitable. He was found dead in his bed, having expired sud- denly during a momentary absence of his nurse. Autopsic ex- amination evinced that lie died from suffocation produced by the bursting of an abscess in the larynx. This tube was filled with pus, and the abscess found to proceed from a carious state of the cricoid and arytenoid cartilages. There was no oedema nor in- flammation of the mucous membrane elsewhere lungs sound no otter organ* examined. The pathologic. d specimens of these two cases arc preserved in our college museum. The history of the two above cases shows the great importance of correct diagnosis in the treatment of diseases, for had the di- 1837.] Remarks on Impeded Re upi ration. 593 agnosis been perfectly established in cither instance, life might have been saved. Had the true nature of the affection been known in time, laryngectomy or tracheotomy would unquestion- ably have been immediately performed. But unfortunately the cases were both regarded and treated as croup, a disease not ve- ry often fatal, and consequently one in which the operation is rarely performed In the treatment of this disease, and of those which from their resemblance to it are often mistaken for it, the hope that relief will be obtained without recourse to the knife, is indulged so long that laryngotomy is rarely proposed until it is too late for it to be beneficial. Hence the small number of cases in which this operation has proven successful. The wrant of suc- cess has doubtless in many instances been owing to the small- ncss of the aperture made. Some surgeons have recommended the use of a trocar, but the canula of no instrument of this kind in ordinary use, is sufficiently large. The correctness of this belief may be tested by endeavoring to breathe exclusively through one of these tubes placed in the mouth. It will soon become ev- ident that it will not permit free respiration. The opening intc the larynx or trachea should be made as large as prudence will permit, and kept well dilated. It is difficult to determine how long an individual may exist when affected with impeded respi- ration. The necessity for oxygen varies exceedingly in differ- ent individuals, and perhaps in the same person at different peri- ods. The energies of life are seriously and rapidly impaired by an insufficient supply of air. It is of the utmost importance therefore, that whenever bronchotomy becomes necessary, it be performed before the system has materially suffered from this species of inanition. The operation is extremely simple, and if performed with but a moderate degree of care, can scarcely ever be attended with serious consequences. If practised above the thyroid gland, no vessel of magnitude can be encountered; be- low this body a little more caution is required. When we con- sider the many instances in which individuals, especially chil- dren, have been permitted to expire from suffocation without any attempt to avoid the fatal issue by laying open the wind-pipe, it is at once a matter of surprise and regret that practitioners should still be so reluctant and dilatory in the performance of this simple operation. I am fully convinced that I have had cog- nizance of at least live fatal eases of impeded respiration, in which 75 54 On the Congestive Fever of Chattahoochee, fyc. [March, life might have been saved by timely resorting to laryngotomy. The history of only two of them has been presented because no post-mortem examination was made in the others. The object of these desultory remarks is merely to awaken the attention of practitioners to the investigation of the causes of impeded respi- ration, to the importance of correct diagnosis, and to the urgent necessity of a more frequent resort to laryngotomy or tracheot- omy. I have unreservedly stated the errors of my practice, and of that of some of my distinguished friends, with the hope that they may be a warning to others in similar cases. ARTICLE I\\ On the Congestive Fever of Chattahoochee : By William J. Johnson, M. D. of Fort Gaines. I would beg to call your attention and that of physicians gen- erally, to an alarming species of congestive fever which prevails to a considerable extent among the negroes on most of our Chat- tahoochee plantations. In order for you to arrive at just and cor- rect notions of the nature and character of the disease, I will first describe its symptoms and pathology, and afterwards detail some eases which have come under my own observation, together with the plan of treatment generally adopted, that the patient cannot distinctly articulate his words. In most cases it is so thick and invnlublc that the patient cannot be un- derstood. One would suppose at first sight that the patient had been stunned by a blow. The eye is generally vacant, heavy, watery and suffused. The vessels of the conjunctiva arc gen- erally tinged and red as if the patient had been intoxicated or lost much sleep. The tongue is moist and thickly coated with a slimy white or brownish fur. The bowels arc torpid, and on this account I have always found it exceedingly difficult to pro- cure alvinc evacuations, and when procured they are most intol- erably foetid and as thick and nearly of the colour and consis- tence of tar. The symptoms become more and more aggravated. The stu- por and delirium continue to increase with an augmentation of sensorial oppression. The respiration becomes more anxious. The pulse seems as if it were nearly or quite obstructed. The skin colder and more flaccid. The countenance vacant, gloomy and unmeaning. The patient becomes suddenly insensible to pain, not appearing to feel the application of the most potent and active stimuli, such as pinching and the pouring of boiling hot water on the surface. The patient now presents a cadaverous appearance, having the eyelids thrown back and the balls immo- vable and fixed. He picks at the bed clothes and constantly mut- ters to himself. These symptoms frequently terminate the pa- tient's life and suffering within twelve hours from the commence- ment of the attack. I consider this as one of the endemial scour- ges of our climate. It usually prevails during the summer and autumnal months, particularly the latter, when the cool and damp evenings succeed to the oppressive heat of summer. My own observation of the symptoms, together with the postobit ex- aminations I have had the opportunity of making, impress me with the belief that the cerebral and hepatic organs are most frequently congested. The first shock in this fever seems to be communicated to the brain and nervous system, and the heat of the surface being reduced the blood retires into the deeper seated veins, from whence it is impossible to invite or force it, not- withstanding venesection, the warm bath, frictions, vesicatories, rubefacients, capsicum and the most active stimuli, both inter- nally and externally, be resorted to for that purpose. The bal- ance or equilibrium of the circulation is entirely destroyed after 59G On the Congestive Fever of Chattahoochee. [March' the following manner. After the blood has retired into the deep seated veins, it must be returned in preternatural abundance to the right side of the heart, the powers of which had been previ- ously oppressed from the first shock to the nervous system, and it cannot throw offor rid itself from the superabundance of blood, and hence its action continues to be disturbed, and hence the re- turn of venous blood from the brain, liver and other organs, must necessarily be so retarded as to engorge the vessels of those parts, and indeed when the shock has been severe, almost to stag- nate in them. The idea of the blood staimatin^ in the veins of a living animal seems to be a novel one, but I am sustained in my statement by the immortal Haller. This admirable physiologist has positively declared that the blood may actually coagulate in the veins of living animals. The treatment in this disease vcrv naturally resolves itself into the three following indications of cure : 1st. To restore the lost balance of the circulation. 2d. To give calomel with a view to its specific action ovor the secretory glands. And 3dly. If the febrile excitement can be established to moderate it and treat the disease as any other disease of ex- citement ; but unfortunately I have seldom had the pleasure of seeing the reaction take place, and when it did it was only par- tially, and I have almost always had the mortification to sec a fatal collapse succeed to it. As it appears among us, I am per- suaded that it is the most fatal, the most alarming, and the most unmanageable complaint of which I have any experimental or professional knowledge : It would be one of the greatest desid- erata in medicine for this part of the country, could a success- ful plan of treatment be devised for its management. Had I my choice of professional achievements, either as respects the present or future good to this section of my country, there is none I would prefer to a knowledge of an infallible remedy for this miserable and distressing complaint. The plan of treatment I have generally pursued, in relation to the first indication, (to wit.) to restore the lost balance of the cir- culation, has been 1st. To open a large orifice in each arm, and if the blood will flow at all, to bleed the patient ad deliquium ; but it is seldom, perhaps not once in i\[ty cases, that the surgeon can be successful enough to obtain blood. After the orifice has been made, the blood will drop and sometimes slowly trickle net 1837.] On the Congi stive Facer of ChnWihoochca. Wl for a few moments, when it will obstinately refuse to drop or fl< m. I generally allow the arms to be corded and the orifices kept open until I can immerse the patient in a hot salt bath, while at the same time I give internal stimuli, such as camphor and aether, capsicum, cognac brandy* ammonia, turpentine, &c, and make use of gentle frictions and rubbing with flannel, and from time to time, I tease the orifice by patting the vein above the el- bow to make it bleed if possible. When the patient is removed from the bath, I order frictions with flannel cloths dipped into an ointment composed of capsicum, turpentine, brandy and hogs- lard, or sweet-oil and afterwards- sinapisms to the extremities and spine. I have sometimes prescribed emetics in this com- plaint, but generally with no manifest advantages. It has been suggested to me that a solution of tartarized antimony in warm cognac brandv, would overcome the congestion, bv the shock the emetic would communicate to the system and by the stimu- lating effect of the brandv combined. I intend to try this remedy with the first case that presents itself to me. Having tried all the means above stated with no good effect, I next resort to the use of calomel, given in large doses and at repeated intervals, and endeavor to assist its operation with stim- ulating enemas ; but the powers of the system seem to be so sud- denly exhausted and so perfectly torpid, that like the stage of collapse in cholera, medicine does no good. The following cases will show the suddenness with which it makes its attack, and the obstinacy with which it refuses to be conquered. About sun-rise on the morning of Sunday, in the month of August, 1S35, a negro boy, aged 30, belonging to one of my patrons, was attacked with pain in the head and shivering. He was ordered to bed and w rapped up warm, and a bowl of hot sudorific tea was given him. The boy complained no more and lay in bed perfectly quiet until eight o'clock, when his master became alarmed, he said, at his breathing, approached the bed and called out to him. The boy returned no answer. He threw the covering from his head, and was still more alarmed at the boy's appearance. His eyelids were thrown back; his eye balls immovably fixed; his extremities cold and clammy, and his pulse slow and struggling. The boy seemed to notice nothing. 1 was immediately called in with Dr. Hcnson. We und Dr. Brown with the boy's arm corded and an ori- i*;j7.] On the CvngestiveFeterofiJhalttihoockee. 699 lice made, from which occasionally a drop of black blood would ill II . I saw that it was one of those violent attacks of congestive fever which were so prevalent in this section. Advised the plan of treatment pursued in similar cases; but before we could use the bath he died. These three were cases in which it had been impossible to establish a reaction. The two following will show that even after a partial reaction has taken place, that the pa- tients arc not free from danger. Case 4th. Caroline, a servant girl belonging to Thomas Tow- son of Randolph County, aged 19, had never menstruated, though well grown and active. At the time the catamenial discharge should have established itself, she was attacked with acute artic- ular rheumatism. All plans of treatment were adopted for her relief, but to no purpose. Emmcnagogues were given in order to establish the menses, as it was my opinion that if this could be accomplished, a cure of the rheumatism might reasonably be expected. She took nearly every article of this class without any manifest relief for a great while. At length the symptoms gave way and she appeared much better, insomuch as to be able to work in the field. No appearance of the catamenia had yet been seen. She imprudently allowed herself to be caught in a shower of rain, and still more imprudently lay down in her wet clothes, after she arrived at home. The next morning she a- woke with excruciating pain in the head and neck. She was neglected for awhile on account of the indisposition of her mis- tress, until her case became alarming. I was called in, and found her labouring under all the symptoms of congestive fever. I bled her from the arm ; applied some cups to the spine ; made use of frictions over the spine with hot turpentine oil and capsi- cum ; applied sinapisms to the inside of the thighs and a blister plaster around the rheumatic joint ; ordered the warm bath, ene- mas and cathartic medicines. Under this plan of treatment she seemed to grow better; became sensible; spoke rationally, and to all appearance was out of danger. I advised the use of spir- itus mindereri in hot teas, and left her, thinking the next day to find her better but unfortunately I laboured under a false delusion. I found the girl much worse than ever, and in fact she died not many hours afterwards. This might be called a case of repelled rheumatism, as that disease is known to attack the muscular fi- Bres u( delicate organs and membranes, but the bvmptoms so 000 Gn the Congestive Fever of Chattahoochee. [March closely approximate these of the common congestive fever in this climate, that I am compelled to class it with those complaints. The question might be asked May not all these cases of con- gestive fever arise from some obscure repelled disease? If so, 1 defy any physician to make a correct reply as there are no symptoms, unless they are latent ones, to warrant such a be- lief Case 5th. Thadcus Hervcy, a respectable young lad, aged about 14, was a pupil of Mr. Le Grand's, rector of the Fort Gaines Academy. I attende*.! the school with the examining committee on Friday evening, and was pleased to see him look so well and so readily answer questions put to him. I parted with him in apparently good health, and was astonished the next day at being sent for in great haste to see him, as I was informed he was dying. I hastened to him and indeed found him exceed- ingly ill. He was labouring under all the symptoms of conges- tive fever. I bled him and gave him an emetic of tartarized an- timony. He threw some putrid, half digested substance from his stomach, which I found on examination to be chesnuts. He was insensible to the venesection and to the operation of the emetic. I then cupped him and applied sinapisms to his extrem- ities and a blister over the cervical vertebra. He still continued to be collapsed, and I endeavored to force down him a bowl of hot negus, with other stimulants, but was unable to do it. I then called in Dr. Brown, and we determined on giving him cal- omel, as usual in such cases, together with enemas, cupping and stimulants. By persevering in this plan of treatment, we suc- ceeded in opening his bowels and unloading them of a large quan- tity of dark offensive vitiated bile. After this he became sensi- ble and expressed himself better. There was a pretty consider- able excitement in the arterial system, and we treated him for several days on the depletory and evacuant plan. His friends entertained the strongest hopes of his recovery; when on a sud- den he complained of acute pain in his head went delirious and seemed for a time to be labouring under an attack of phrenitis. These symptoms were attended with convulsions and other ner- vous symptoms. Blisters were reapplied to the head and be- hind the car, but notwithstanding this he went into a fatal slate of collapse frottl which he never recovered. The pupils of his 3 wen widel) dilated and insensible to the stimulus of light, 837.] Topography and Diseases of Talbot County, c. 601 picking at the bed clothes, low muttering, delirium, incoherent speech, subsultus tendinum, involuntary evacuations, were the symptoms which closed the scene with him. tn this case the congcstion%was evidently seated in the cere- bral vessels, and the brain was unable completely to recover from the shock at first communicated to it, by the inordinate fulness of its vessels. ARTICLE V. Topography and Diseases of Talbot County, Ga. : By Edward Delony, M. D. The centre of this county is about 32 , 30 ' north latitude. It is bounded on the east by Flint River, on the south by the County of Marion, on the west by the County of Harris, and on the north by the County of Meriweather. The south, or lower part of the county, bieaks off suddenly into very poor sand hills, and on the north the whole extent of the line runs on a highly elevated country, known as the Oak Mountain; the western sec- tion is composed of broken lands, wTith numerous rocky hills. 1* he interior of the county is generally broken ; there are some districts, however, of level, handsome country. The soil is gen- erally good, some large portions of it are exceedingly fertile. In the upper part of the county the soil is a stiffmulatto, in the low- er it is grey and light, requiring much less rain for agricultural purposes ; that in the upper part of the county is best adapted to the culture of corn, though the cotton crops yield abundantly and richly repay the industrious farmer; that in the lower part, however, is better adapted to the production of cotton. The whole interior of the county is well watered with fine bold streams some one or two of considerable size all of these streams abound, more or less, with marshy grounds, perhaps- more so than is common in other sections of country as broken as this is. And there is vet a great quantity of forest land: of 76 602 Topography and Diseases of Talbot County. [March, the whole county, nearly three-fourths are a growing forest of stately oaks, still the haunts of the bounding deer. The lands which are cleared, or rather cultivated, are covered with abundance of dead trees, left standing in the fields, which have been chopped around sufficiently to cause their death. These trees, from their continued decom position, deposit a considerable quantity of matter around, which seems to increase the fertility f the soil and render vegetation more luxuriant in- their vicin- ity. The population of this county at this time is not accurately known. There are some sixteen or seventeen hundred voters ; a number equal, perhaps, to that of any other county in the state, and will soon be greater. Our citizens are generally industri- ous, active, enterprising and in good circumstances ; few, very few, who know the want of the necessaries of life. Their habi- tations are generally wanting in comfort, most of them having fceen put up in a hurry by settlers, moving into the coun>1?y and commencing in the woods, with but little time to devote to ele- gance, convenience or comfort about their dwellings. Our coun- ty is now, however, assuming a new aspect, and the rude abodes of the emigrant are fast giving room to the elegant and beautiful mansions of the established and prosperous farmer. Our population, almost entirely, is composed of citizens from She older counties of the state, hence a predisposition, in many of them who have settled among us, to attacks of the diseases which prevail in those districts of country from whence they emi- grated, and the unhealthy constitutions which we find among many of them, usual in such sickly sections. Until recently, however, the inhabitants of Tahbot County have been generally healthy, at least until about two years past, when bilious diseases began to make their appearance. Before this time, such attacks seemed to be more casual than otherwise, and were no doubt dependent on a condition of the system, con- tracted before emigration to the county. The increase of bil- ious diseases with us, may be very properly attributed to^ an in- crease of those causes, usually attendant on a newly settled fer- tile country, (viz.) the opening of lands after the usual fashion in Georgia, with an abundance of deadened timbers left standing ki the fields the accumulated obstructions in the streams, cau- sing an increased quantity of stagnant water, and a greater over- 1S37.] Topography and Diseases of Talbot County. 60 3 flowing of the low marshy grounds, &c. ; to these may be added innumerable minor causes, having a similar influence, &c. But the frequently peculiar character which our summer and fall diseases assume, cannot be attributed to local causes, certain uncontrolable atmospherical laws and influences over which we can have no control, seem to exercise a superior power in giv- ing them character and novelty of appearance. Let it not be forgotten, however, that whatever character or peculiarity un- der which they may appear, they arc bilious diseases ; an eye single should be continually directed to this important truth let other symptoms indicate what kind of treatment they may, whether the use of the lancet or the brandy bottle. The bilious fever cannot he correctly or successfully treated, without the aid of calomel. My chief reliance is in the lancet, calomel and good port wine remedies that have stood the test of ages passed, and whose reputation will be established and confirmed by the experience of future generations, while the ephemeral imposi- tions of the day, lobelia, No. 6, and composition tea, will be for- gotten, with the base charlatans that now employ them as means to impose upon the credulity, destroy the lives and rob the pock- ets of a too credulous and unwitting community. So far as my observation extended, the bilious diseases which made their appearance during the last summer and fall, wore decidedly a different garb of symptoms from those which pre- vailed the year preceding, I very well recollect how frequent- ly I was compelled to bring to my aid the use of the lancet, be- fore I could subdue many of the attacks which came under my care. In these it was used in the outset, sometimes repeatedly: but during the last summer and fall, I did not unsheath my lancet in a single case of bilious fever, during the whole sickly season ; nor did I meet with a solitary case in which the loss of blood could be admissible and yet I did not lose a patient with this disease. I say this not as a boast of my good success, but as the strongest evidence and argument in justification of the opinion which I have formed of the character of the diseases of the last season, and the correctness of my treatment founded on that opinion. The diseases of the last season were evidently of a typhoid character. Assuming as they did, this low grade of symptoms. they were rendered much mora obstinate and dangerous ; and GOi Topography and Disease? of Talbot County. [March, this danger was increased by the supervention of a highly irrita^ ted state of the bowels, which made its appearance in a great many cases some two or three days after the attack. This pe- culiar symptom I attributed to the great abundance of rain which fell during the spring and summer months, and which was con- sidered the cause of a prevalence of bowel complaints to some considerable extent during that time. In fact, some more or less disposition of this kind manifested itself in almost every case which occurred, especially in the early and middle parts of the season, at least which came under my observation; and I would here take occasion to remark, that if such was the character of the diseases throughout the state, I do not hesitate to say, that the physician who resorted to the use of the lancet and the too popular tartar-emetic plan of treatment, during the last summer, was an unsuccessful practitioner. In my general plan of treatment, 1 found it necessary to com- bine opiates with my remedies. T hree or four evacuations from the bowels during the day arjd night, I found entirely sufficient, and deemed it unnecessary and unsafe to carry them further. These I procured by ,the administration of about 30 grains of calomel every night at 9 or 10 o'clock, combined with a sufficient quantity of Dover's powder to prevent its running oil' too soon by the bowels ; this was carried off next morning with castor oil. When the irritation of the bowels was found severe, and the Dover's powder with mucilage insufficient to its relief, the appli- cation of a blister plaster over the abdomen always had the de- sired effect. If during the day or night there occurred much fer vcr or thirst, and this was rarely the case at night, an occasional draught of effervescent soda water was found a sufficient febri-. fuge and remarkably agreeable to the stomach. If, however, I desired a more effectual febrifuge, I directed the saline mixture. When there was a sense of heat at the extremities and about the forehead, I permitted my patients to use cold water and vinegar combined, as freely as seemed pleasant to them, and this was fre- quently done ; for although in some cases the accession of fever was considerable, yet the pulse was small, quick and frequent. The quinine and wine were never omitted when the skin was soft, with a sufficient abatement of the febrile paroxysm, espe- cially in those cases which were marked by a regular distinct Chill. JS37.] Topography and Diseases of Talbot County, (>;> By these general means, my patients seemed to do well, and although the portions of calomel and Dover's powder were repea- ted every night, as long as the alvinc discharges appeared unfa- vorable, yet not one of my patients was salivated, and their convalescence was speedy. Extreme cases of course required a more particular treatment, and the general plan above de- scribed was, in some peculiar cases, a little varied. Here I wrould fain close this article ; but my task is not done. From uncontrolable circumstances connected with the settle- ment of this section of country, as perhaps with that of all others, the fairer portion of our population is more frequently afflicted with diseases, which, if not more alarming in their character, are at least far more obstinate and disagreeable in their nature, than that which we have already commented upon: I allude to pro- lapsus uteri and jluor albus. It has been twelve years since I commenced my professional career, and I have never met with so many cases of these diseases in all the balance of my prac- tice, previous to my residence in this county, a term of three years. I was somewhat at a loss to account for such a greater number of those cases which I met with here, than I had else- where ; but on reflection and observation, I became fully satis- fied in my owrn mind as to the causes of their origin. Our pop- ulation in this county, is composed generally of emigrants from the older sections of Georgia, many of this number having re- moved from the most sickly parts of the state, brought writh them all those predispositions and effects which such a situation was calculated to produce on the human system, a shattered consti- tution, liver disease, indigestion, general debility and relaxation of the whole systcrn. Hence the predisposition, (if in fact those diseases do not already exist.) in females, to prolapsus uteri, fluor albus, &c. But the question will be asked, why under such cirr cumstances, are these diseases more prevalent in this section of country? The answer is at hand : the causes are more numer- ous, as observed in a former part of this article the settlers in our new country undergo more frequent and severe exposures to vicissitudes of weather they have been, and are now, fre- quently compelled to settle in the woods, without even a shelter for some days, more than is afforded them by their travelling tents. Their first object is to throw them up such temporarv log buildings as the hurry of the time will permit These build- fiOG Topography and Diseases of Talbot County. March, ings, open as they are on every side, exposing their inmates to all kinds of severe weather, arc extremely uncomfortable, and are generally occupied some three, four, or five years : hence, from the severe exposure of females beyond the strength and durability of their more delicate constitutions, result the frequent attacks of inflammatory diseases to which they are liable, the frequent inter- ruptions and obstructions of the catamenial flow, with all its dis- agreeable train of symptoms, general debility, fluor albus, pro- lapsus uteri, &c. &c. How much more severe, and how much more fruitful of such complaints, must these exposures be to fe- males of previous bad health and enfeebled constitutions females who have borne children and who feel the effects of repeated la- bours and of age, at a time when they should be least exposed. It is unnecessary to comment upon the effects which such cir- cumstances are calculated to produce; hundreds have been hur- ried to an untimely end. Independent of these, female emigrants to a newly settled coun- try, especially the poorer classes, have more arduous duties to perform and much greater fatigues to undergo, such as their delicate frames were not formed to encounter ; hence also the frequent occurrence of abortions and miscarriages another fruitful source of prolapsus uteri and fluor albus. These diseases have proved obstinate and unyielding in their treatment, no doubt in many instances, in consequence of the wretched condition of the constitution and a continued exposure to the causes which brought them into existence. From the circumstances connected with our population and the diseases consequent thereon, as hinted at in the foregoing re- marks, I have anticipated other complaints to which they are particularly liable: various inflammatory attacks, such as pleu- risies, inflammation of the lungs, throat, bowels, &c, and among children, croup, catarrhs, bowel affections, &c. &c. I am fully aware that I have presented nothing new to the profession, but if my remarks shall tend in the least to lessen those distressing diseases, that so frequently and painfully afflict the most interesting part of society, by directing attention more for- cibly to their causes, my labour shall have received most ample and grateful compensation. 1837.] On Pneumonia of the Old. 007 Part II. REVIEWS AND EXTRACTS. On Pneumonia of the Old: By Sf M. Hourmann & Deciiambiue. [This is a continuation of the researches made at the Salpc- triere on the diseases of the aged. The previous memoirs on the natural changes of structure and functions of the lungs, on the pulse, &c, we have analysed. 1. Anatomical characters. Pneumonia is the most frequent and dangerous of the acute diseases to which the old are subject. Its diagnosis, so evident in the adult, is difficult, as the affection is often overlooked from the apparent mildness of the general symptoms ; or obscured from the utter prostration caused by the attendant adynamic fever. The changes it produces are pecu* liar. Independently of inflammation, the vessels of the lungs' of the old are always more or less congested, so that it is always" difficult to establish the existence of pneumonia, in its commence- ment or even progress, in the dead body, if the symptoms during life have not been carefully observed. I. Simple congestion. There are three degrees : in the first, the lungs, which arc intensely red, both crepitate and swim com- pletely ; they contain a great quantity of bloody, frothy serum ; there is no change of consistence : in the second degree, their co- lour is deeper: in the third, they are livid, the lobules are nearly confounded; there is an increase of volume; their cohesion is diminished ; a blackish fluid with bubbles of air escapes from an incision ; they slightly crepitate, and float less high in water. Dried sections of congested lungs show that the cells are still per- meable, but contracted in proportion to the congestion ; this is much less marked when the cells are torn and irregular. Ccete* ris paribus, the arborizations on the sides of the cells diminish in proportion to the rarefaction of the tissue, as might be expected from the previous observations on structure. II. Congestion with imperviousness of the pulmonary paten- chyma. There are two varieties : one in which the granular ap- pearance, regarded as peculiar to pneumonia, is absent, and ano-- ther in which it is well marked: 1st form. The pulmonary tissue is of a dark colour, often blue or black, and a section is homogeneous, and remarkably polished ; sometimes it is elastic like caoutchouc ; at others easily broken up. On cutting the lung, a fluid or viscid liquid escapes, often reddish, but not frothy. Compression increases the suppleness and elasticity of the first portions, and, if after compression they arc dried, the cells reap- pear, without having experienced any other change than con- traction, which is seen by a lens to be produced by congestion >{ the vessels running in the intervals, separating the cells, thick- COS On Pneumonia of the Old. [March, ening the membranes dividing them, and less evident in the cells themselves. 2d form, (lied hepatization.) The granulations arc cither regular, well marked, and much larger than in the pneumonia of adults, or less defined, running into one another. Generally there is less friability than in adults ; the lung being resistant and easily cut into thin and flexible slices ; it is not so heavy, nor does it sink so deeply. This lightness may be owing to the rarefaction which the lungs undergo with age. III. Suppuration of the Lung. There are two varieties ; one without granulations, and the other granulated. In the first form mere are two varieties : (1.) lines or patches of a greyish white colour are seen in the middle of the congested lung, which ap- pear to be pus beneath a fine membrane ; on making pressure with the nail, the pus can be deplaced, and made to pass into the pulmonary tissue as far as the surface where it appears to tran- sude ; the texture then regains its suppleness, and on drying it the cells reappear. (2). The texture appears like granite, be- ing a singular mixture of red and dull white ; the pus being de- posited in spots of one or two lines in diameter. Pressure with the nail does not displace it, but it is removed easily on the point of a lancet, and is of the consistence of coagulated albumen, and never fluid. When thus extracted, it is evident that it is con- tained in irregular cells whose walls are of a deep red colour. It is never prolonged into the small bronchial ramifications. Suppuration with granulations {Grey hepatization) is much more frequent. The granulations are larger than in the adult, though less than in the red stage* The granulations may disap- pear and be replaced by small abscesses, but extensive abscesses of the lungs are excessively rare. The lung is extremely fria- ble, the slightest pressure reducing it to a pulp, from which pus flows in abundance ; it also escapes from a simple incision. In some lungs there were small groups of grey granulations, not mixed with red, and surrounded by healthy tissue. This was the general description of changes in pneumonia, but there were some peculiarities worth noticing. The diseased lung, espe- cially if it belonged to the first type, generally was consider- ably increased in size. The disease, whether consisting of congestion, hepatization, or suppuration, occupied generally a very large portion of the lung, so that it was extraordinary how life could have been carried on. In one body, the right lung and inferior lobe of the left were throughout in a state of grey hepat- ization, whilst the upper lobe of the left lung was gorged with blood and frothy bronchial secretion. The granulations were often in groups towards the posterior border of the lung. The deposition of semi-concrete matter without granulations was never observed except in lungs of the third type, and in these rfed or grey granulations were never observed. They only ex- isted in^ungs of the firs! and second type, and in these they va- 1837.] On Pneumonia of the Old. 600 ried, being regular and distinctly circumscribed in tbe first, which is characterized by the regularity and rounded form of the cells, and irregular and almost confluent in the second, where the cells are of a more irregular figure. From these facts it may be inferred, 1st, that the pus, which is capable of being displaced by the pressure of the nail, is sea- ted externally to the air-cells; otherwise, instead of its passing into the interior of the parenchyma, it would escape in isolated drops from the incised surfaces. It is in a situation analogous to that of the air in intervesicular emphysema of the lungs. The sanguineous congestion which attends it (as desiccation proves,) consists of engorgement of the vessels ramifying between the cells. 2d. The granulations, on the contrary, appear to be sea- ted in the cells themselves, as they are rounded or irregular ac- cording to the peculiar change in the anatomical structure of the cells, and are not observed in the third type, where the cells are completely disorganized. Compression and desiccation give further proofs of this fact ; for by these means the granulations cannot be changed, and the cells cannot be made to reappear, except in those cases where the grey granulations are not fria- ble; where, when compression is employed, small drops of pus escape from the nearest bronchial tubes, and the granulation dis- appears; thus again proving its situation. The impossibility of removing the red granulations and those grey granules which are friable, by means of compression, &c, shows that they are not merely produced by cells distended with fluid, but that they are solid. The next enquiry is as to the nature of these changes. 1. Hepatization without granulations. M. Piorry has demon- strated that, owing to the diminution of the vital contractility of an organ, and in proportion to its spongy parenchyma, the blood abandoned partly to the laws of gravity may, notwithstanding the motions of circulation, accumulate in dependent parts, and stagnate there. This can be constantly verified at the Salpe- triere. It renders it difficult to judge whether congestion is ac- tive or passive. Friability is not a proof that the congestion is active ; for, although it is an effect of inflammation, yet it is suffi- cient that a patient, or even a corpse, should lie some time on one side to produce both congestion and friability of the correspond- ing part of the lung. Even among old asthmatics, who prss the last days of their life in a sitting posture, the base of the lungs is very commonly congested and friable. The idea of inflamma- tion must not, on the other hand, be rejected from the situation of the lesion, as granular pneumonia undoubtedly occurs in some instances at the posterior edge of the lungs. The congestion may be determined to be of an inflammatory nature when it oc- cupies the anterior surface on the whole extent of the organ, particularly if no obstacle to the circulation exists in the heart or great vessels, But, under such circumstances, MM. H. and 77 610 On Pneumonia of the OlcL [March, D. have only seen the first degree of congestion, and never im- permeability without granulations. The nature of this hitter change must then be judged by the symptoms ; and, in many cases, their sudden attack and acutencss left no doubt of the in- flammatory nature of the lesion. When suppuration and friabil- ity are united, there can be no doubt that they are the effect of inflammation.. The deposition of semi-concrete matter is also a-n inflammatory change. 2. Impermeability with granulations. Both. the red and grey granulations are undoubtedly the result of inflammation, as is proved by their situation and mode of formation. From the preceding remarks it appears established that. among the old, there are two kinds of pneumonia. The first, marked by congestion and impermeability without granulations, followed by the secretion of pus in the interlobular spaces, is seated exter- nally to theJ}ronchial canals in .the laminated tissue separating them. The second kind occupies the canals themselves, and is- owing either to a granular engorgement of their sides, or to a de- position of pus in their cavities. If the cavities are very irregu- lar, granulations cannot be formed. The first kind of pneumo- nia may be called intervesicular, and the second vesicular. Frequency of Pneumonia in the Old. The difficulty of dis- tinguishing the disease renders rigorously exact statistics impos- sible, but the following calculation shows that it is the most fre- quent and dangerous of the acute diseases of the aged. Of 0c6 cases of all kinds occurring in the Hospital of the Aged during the periods of these investigations, there were 1 10 dissections in which there was merely congestion of the base of the lungs pro- duced after death, the patients having had no symptoms of pneu- monia, but dying of other diseases ; 370 patients were cured af- ter having had symptoms of congestion, recognized both by aus- cultation and percussion ; but, it is true, at the dependent part of the chest, and almost always after prolonged decuhitus, so that the inflammatory nature of the congestion might sometimes be contested : fifty-three patients recovered from pneumonia attend- ed by such marked symptoms that it was impossible to doubt its nature; fifteen patient? had well marked svmptoms, but no ex- amination could be made: in eighty-ei^ht fatal cases, dissection displayed sanguineous congestion of the lungs reaching the de- gree of complete impermeability or of suppuration. Of these eighty-eight cases, there wrnre eighteen only of non- granulated or intervesicular pneumonia, and purulent infiltration in five. The remaining seventy had well marked granulations or vesicular pneumonia ; so that the vesicular was in proportion to the intervesicular pneumonia as four to one. With regard to situation, if those cases are omitted where it was not observed, and where the base of the organ only or the whole lobes were invaded, it appears that the non-granulated engorgement (inter* \S37.] On Gangrene of the Lungs i?i the Insane. 611 vesicular.) occupied constantly the posterior border, whether with or without suppuration, and that the granulated form (ves- icular pneumonia.) occupied the anterior border twelve times, and theup >steftor twenty-tire times. Of these twenty-five cases there were fifteen of pneumonia of the inferior lobe, eight of double pneumonia, and only two confined to the upper lobes; whilst all of the twelve cases were of the superior lobes, except two divided between double pneumonia, and pneumonia of the lower lobe. This will be considered fully under the head etiol- ogy- State of the Bronchi. In all cases of pneumonia of the old, the bronchial tubes are red from the epiglottis to their minute ra- mifications, the tint augmenting- as they approach' their termina- tions. There are but few old women whose bronchial mem- brane is not reddened, whatever may be the kind ' of death. The quantity, often enormous, of mucus which fills the trachea and even obstructs the larynx is worthy of notice. It is thick, viscid, opique, of a dull white or grey, sometimes yellow or greenish, and occasionally bloody. This latter colour was chief- ly remarked in the months of April of the two years during which the investigations were conducted. State of the Pleura. Of sixty cases of vesicular pneumonia, there were marks of pleurisy in thirty-eight. Of these thirty- eight, there were eighteen in which the left pleura was inflamed, coinciding sixteen times with pneumonia of the same side, and twice with double pn2umonia; fourteen times the pleurisy was in the right side, in thirteen of which there was pneumonia of the right side, and in one on the left. Six times there was double pleurisy ; of these there was double pneumonia in five cases, and pneumonia of the right side only in one. Archives Generates de Jledecine. Mar,, 1833. On Gancrren* of the Lungs in the Insane: By J. Guislun, M. D., Senior Physician to the Hospital for the Insane atGand. M. Guislaix's attention was called to this disease by observ- ing that the breath of a patient, who obstinately refused his food, smelled exactly like the cavity of the chest of a former patient whose lungs were gangrenous; and. after death, the same lesion was discovered. He thus connected together the obstinate refu- sal to take food, fetor of the breath, and gangrene of the lung; and subsequent experience proved that the two former were symp- toms of the latter. Fetor of the breath is also the consequence of prolonged abstinence, and of pulmonary suppurations, but the smell from gangrene of the lung is altogether peculiar. The ob- stinate refusal to eat, Al. G. considers as an occasional cause of gangrene ; it occurs in one-ninth of the insane, and, in more than 61% On Gangj-ene of the Lungs in the Insane. [March# a thirtieth part of these patients, no care or management will conquer the repugnance. They live twenty, thirty; fifty, sixty days w'thout any food, drinking only cold water; some last the first days of the week and eat on the others. In but few instan- ces does this arise from a notion that the food is poisoned ; it is generally owing to some caprice of the will, dependent on a pain- ful impression. Various fancies confirm this ; a child when sul- ky, and a woman when jealous or spiteful, will not eat: even animals, after Josing their master or companion, occasionally re- fuse all food, and starve. To the debility arising from impover- ished blood M.G. attributes the pulmonary disorganization, and he illustrates the influence of a supply of poor blood on the lungs by the effects of the rigorous fasting which some religious com- munities undergo, the defective and insufficient food of prisons and some charitable institutions, and prolonged abstinence after acute diseases, in producing numerous chronic pulmonary com- plaints, which (if curable) will only yield to nutritious food and tonics. The following case illustrates the progress and symptoms of this disease. Case. In the late political disturbances, an intelligent wo- man, aet. fifty-four, leading a retired life, was much affected by seeing some armed men fighting below her window. The shock was followed by mental alienation, and she refused to take food. During nine days no persuasions of her family, who put before her food of all kinds, could induce her to eat. From the altera- tion in her features, her emaciation and melancholy, her family were alarmed, and she was placed in the Institution, the 4th February, 1831, a month after the disease commenced. During this time she had only taken a little milk-soup and weak broth. By the colour of her face only, M. G. recognized her refusal to take food It was of a brick-red ; the cheeks, end of the nose, and lobules of the ears were of a deep brown,; pupil dilated; sclerotica of a brilliant whiteness, approaching blue; hair, pre- viously unctuous, was dry, and its colour deteriorated, as well as that of the iris. By force alone, a cup of milk or broth was occasionally taken ; but she passed from a state of melancholia to mania ; the emaciation frightfully increased, and the face be- came brown, and the lips, hands, and feet livid as in cyanosis. The smell of the breath was unbearable; expectoration brown, reddish, and streaked with clear blood in considerable quantity, but without pus. The face was so changed that she appeared like a decrepit old woman. She gradually sunk, but during tho last few days took the food which was given to her. Examination of the Body. Brain and membranes, and ab- dominal viscera, healthy; gall-bladder filled with black bile, and tho spleen and mesenteric vessels full oi very dark blood. In taking out the left lun?, M. G.*a fingers penetrated its substance, ISft7.] On Gangrene of the Lungs in the Insane. 613 and there was an insupportable smell. Its posterior surface, towards the upper lobe, was very black, with green ami brown- ish spots: the tissue beneath was so degenerated as to be broken down with the least force: it was infiltrated with a black fetid cruor, like that exhaled from a mortified limb, with here and there purulent flocci. A spherical mass of five inches diameter was reduced to this putrid condition. The bronchi were filled with a reddish, frothy, fetid f]i;id. Right lung not afFectcd. M. G. has examined thirteen patients who died of inanition, and in nine of these there was gangrene of the lungs. In one case both lungs were affected ; the left lung in seven ; and the right in two. Once the gangrene was confined to the anterior surface, but in all other cases to the posterior and upper part, nearer the spine than the lateral region of the thorax. The pul- monary tissue around the gangrene was injected, but it appeared to be rather the effect of the irritation than the cause of the mor- tification. In no case was there pain, cough, or dyspnoea ; the temperature of the skin was rather cool than hot, and the pulse slower. In all the patients who abstained from food for any length of time, the peculiar hue of the skin was observed which was described in the above case, together with the appearance of premature old age. In no case was the stomach found to be inflamed ; it presented no morbid appearance. Physiologists all agree in stating thai, in ordinary cases of starvation, the stomach is inflamed, as if reaction took place : but, among the insane who voluntarily starve themselves, there is no such reaction, no pain, no cardialgia, and, as they affirm when convalescent, no sensation of hunger. There is none of that debility which comes on invariably in the other cases. Thus, maniacs enter the hospitals after having fasted twenty, thirty, forty days ; they walk about, and exercise themselves in different ways, and, although extremely emaciated, live for months, or even years, only swallowing from time to time some mouthfuls of broth. Not only is there no sensation of hunger, but food is either not at all or very imperfectly digested One patient who had thus refused food, took some at eleven o'clock, and committed suicide at seven; the contents of the stomach were found to be unchanged. The absence of prominent symp- toms in this gangrene of the lungs is owing probably to the same want of sensibility as is seen in the digestive organs. The lungs do not transmit to the brain the expression of their sufferings ; L-nd there is none of that oppression in breathing, violent cough, and dangerous general symptoms which are observed in ordina- ry individuals suffering from the same local disorganization. The torpor of the par vagum will explain the absence of symp- toms both when the lungs and stomach are affected. It also ex- plains the enormous doses of medicine which are tolerated by the insane, and the obstinate torpidity of their bowels. The 614 On Gangrene of the Lungs in the Insane. [March. nerves of sense arc equally torpid. They bear without incon- venience the extremes of heat and cold, and the actual cautery hardly is felt: loud sounds in their enrs do not disturb them, and they can look at the sun without blinking. - In this inert state of the stomach, very light food is alone suit- able. j\ either wine nor soup agrees ; but milk, either bv itself or with the yolk of e.ugs, is very useful: on this food M. G. has pre- served life for two years. Sometimes whey or barley water should be given at first. The patient's obstinacy more than once has given way after taking a few spoonfuls of milk or broth. It is an important practical fact that the privation of food hns a bad influence on the minds of the insane ; they become more and more taciturn, and melancholia often passes into mania. In general a restorative diet produces an amendment* Too much conciliation is injurious. Persuasion is useless and loses time, and energetic measures are necessary at the least opposition, Very frequently, in a few days, such measures com- pletely remove the disgust for food. The following cases are valuable as regards prognosis, corroborating the opinion of La- ennee, that gangrene of the lungs is not always beyond the pow- er of medical skill. Case. Marie de L , ret. twenty-eight, whose father, uncle, and two brothers were insane, was in a state of confirmed mel- ancholia. After two months she refused all food: after three days' abstinence, force was employed, and. by means of a tube passed down the oesophagus, a very little liquid food was given. The peculiar colour of the face appeared; the strength declined, and, after two months of complete abstinence, she had fetid ex- pectoration of a reddish and thin brown colour, without previous cough or dyspnoea. She then spontaneously began to eat, and gradua'ly recovered her health and sanity. Two years after- wards she was readmitted; she refused to eat and had symp- toms of pulmonary disease, of which she died. There was gan- grene of the left lung. Case. A young man affected with melancholia refused all nourishment: if force was used he swallowed the food, but im- mediately excited vomiting by thrusting his fingers into his pha- rynx; and, when that was prevented, he managed to vomit by contracting the abdominal muscles. He continued these practi- ces for manv months, and gradually sunk. Face of a brown colour, lips livid, breath smclled unbearably ; a pint daily of red- dish expectoration. When almost at the point of death, he sud- denly determined to take some milk and broth after a threat to burn his pole with a red-hot iron. Gradually but very slowly he improved, and eventually was completely restored to bodily and mental health. Gazette Mtdicak de Paris, 16 Janvier, 1836. 1837.] Case of Aneurism of the Thoracic Duct. 615 Case of Aneurism of the Thoracic Duct: By Dr. Albeks, of Bonn. The patient, a man of fifty-one, died of abscess of the liver. On examining the body after death, Dr. Albers found, in the re- gion of the solar plexus, amongst several hard cartilaginous tu- mours, an elastic soft one, with a half-transparent tegument. It was knotty, and about the shape of a fig. At first he took it for an hydatid; but it was soon discovered that it was bound by membranous bands in several places, and that a canal led into it, both above and below. It contained a quantity of fluid lympht in which flaky matter was suspended. The internal surface of the tumour was smooth and uniform. A sound could be passed up the canal, both superiorly and inferiorly. In the latter direc- tion its course was followed, and it soon became evident that the tumour was an aneurism of the thoracic duct. Its parietes were thicker and firmer than those where the duct had not lost its nor- mal caliber. Dr. Albers has only seen one similar case. viz. a dilatation of the cystoma chyli, found at the examination of a dropsical pa- tient. It is singular that the thoracic duct is not oftener affected by the diseases of the surrounding organs How often it is com- pressed in the scrofulous and consumptive, by enlarged glands, tumors, &c. ! But these compressions are not attended by cor- responding dilatations, as is the case with arteries and veins. Dr. A. has seen a case in which the thoracic duct, in the middle of its course, had been reduced by pressure to such a small cali- ber, that it would not admit even a bristle. In another case the canal was altogether obliterated ; but in neither was the caliber of the canal below the narrowed part altered by the compression. (See alsoRokitanski, Austrian Annals, vol. xvii. p. 441.) The cause of this absence of dilatation hfeases of compression lies, doubtless, in the nature of the fluid, in the weakness of its cur- rent, and also in the fact that there must be more branches of the thoracic duct anastomosing with the venous system than is gen- erally supposed. A proof of this is, that in children in whom the caliber of the duct has been materially narrowed, no emacia- tion has followed in consequence. Wutzer ha-s discovered a branch of the thoracic duct leading into the vena azygos. The most frequent cases of dilatation of lymphatic vessels are those in which thev contain tuberculous, scrofulous, and cancerous matters. Numerous descriptions of such cases are found in the works of Cruveilhier and Cars well. Hannoversche Annate n, B. ii. H. I. 1830. (51 6 On External Application of Croton Oil, fyc. c. [March, On the External Application of Croton Oil in Affections of the Larynx : By Dr. Romberg. The following cases prove the peculiar efficacy of this species of counter-irritation in affections of the organs of voice; a facf. observed by many. Case i, A fisherman, a3t. 34, lost his voice after exerting him- self greatly in saving some individuals from drowning. There was no reason to suspect any disorganization of the larynx. - Blisters, vapour baths, &c. were tried without effect. Frictions of croton oil were directed over the larynx, to be repeated as soon as the eruption declined. On the twenty-first day of tins treat- ment he began to recover his voice, and regained it completely. Case ii. A girl, aged 18, suffered during seven weeks with hoarseness, succeeded by aphonia, the consequence of a sudden chill. Leeches. emetics, and irritating frictions produced no re- lief; but, after the third application of croton oil, an eruption ap- peared, and she immediately regained her voice. Case hi. . A woman, ast. 38, complained for twelve months of a sensation of pressure in the pharynx, as if the neck were squeezed, rendering deglutition difficult: there were no other symptoms. Many remedies wTere tried without benefit. Three drops of crotou oil were rubbed in, and, after the third applica- tion, an eruption appeared on the neck, nucha, chest, and face, which was followed by erysipelas. The patient entirely recov- ered. Dr. Romberg never found that the external application of cro- ton oil had a purgative effect, but he never applied it to the ab- dominal integuments. Dr. Otto reports, in the same journal, the case of a woman af- fected with sciatica, for which frictions with croton oil were made on the thigh, and the whole body became red and covered with vesicles. Dr. Otto never observed its purgative effect when thus applied. Wochenschrift fur die gesammte Hei/kun- de. 1835. Expectoration of Bronchial Polypus, independent of Croup : By Professor Casper. Dr. Cheyne has described two kinds of bronchial polypus, un- connected with croup; one of which appears to be but a coagu- lum of blood, and is associated with haemoptysis; the other symp- tomatic of a chronic disease, of an inflammatory character, af- fecting secreting surface : this inflammation, however, never reaching to the extent observed in croup. The following case 1837.] New Casc9 of Ccesarian Operation. 017 appears to lead to the conclusion, that inflammation and the for- mation of a false membrane observed in croup arc by no means necessarily connected. In tin's view of the subject alone is the action of many remedies explicable. Dr. Casper justly main- tains that the clanger of croup is not simply dependent on the me- chanical impediment produced by the false membrane, but that it is to be ascribed likewise to a specific inflammation, which, in respect to its symptoms and its resistance to the usual remedies, stands in the same relation to common inflammation as do many forms of abdominal inflammation, &c. A girl, twelve years of age, of a lymphatic scrofulous consti- tution, was affected, on the 2d o[ May, by inflammatory catarrh, which yielded to a few leeches and a mixture containing nitre. She left her bed on the fourth day, and expectorated occasional- ly and without difficulty. On the afternoon of May 7th, a vio- lent cough and suffocative paroxysm unexpectedly occurred, and the patient expectorated a whitish-yellow polypous body, which appeared externally very like Concrete fat, was of a firm and tenacious character, was with difficulty torn, and corres- ponded to the ramifications of the bronchi. During the follow- ing twelve days, two and twenty similar substances were ex- pectorated. The first ten were accompanied with violent cough and paroxysms of suffocation; the expectoration of the remain- ing twelve was very easy, long after the patient had left her bed, when she Was quite free from fever, had a good appetite, slept well, and had only a slight hoarseness of voice. This hoarse- ness had existed mnny years previously, and still continues. Two of these bodies were generally expectorated daily ; one in the morning, and the other towards midnight. The health of the patient being otherwise good, very little medical treatment was employed. Wochcnschrift fur die gesammte Heilkunde. No. 1. 1836. New Cases of C^sarian Operation : By Professor Stoltz, of Strasbourg. This is the most serious and dangerous of all obstetrical op- erations ; in which both the abdomen and uterus are extensively opened for the extraction of the fetus. Whatever be the origin of this operation, it is certain, that from the sixteenth century to our own times, it has been many times performed and frequently with success. It is certain, also, that this operation has been performed frequently upon the same woman. The number of successful cases is now so consideraBle, that it is no fonger a question; whether it be possible to save the life of both mother and child, it is no loir. irded as necessarily fatal to the mother. Nevertheless, its most enthusiastic advocates* ac^ 78 616 New Cases of Ccesarian Operation. [March knowledge, that in the great majority of cases, the mother per- ishes; and yet, the proportion ot" favorable cases is much great' er at the present day than formerly. Baudelocque, for example, who, in the second and third editions of his treatise, declared it scarcely possible to save one woman often, proves, in his me- moir published in 1799, that at the most, one of three now dies. The difference is immense. We may reasonably hope that the danger of this operation may still further be diminished, either by determining the most appropriate time for performing it, or by discovering means to counteract the immediate dangers and accidents of the operation itself, and new means of combatting more successfully the frightful consequences of such extensive incisions. In this first part of his work, M. Stoltz, after some general considerations, details, very particularly, four cases of the Caesa- rian operation, not before published, two of which were crowned with complete success both the mother and child being saved. He proposes subsequently to examine the true indications and counter indications to this operation. Case 1. Jeannette Half, aet. 26, a dwarf of delicate consti- tution, lymphatico-sanguine temperament, eyes and hair brown ; was, at the eighth month of her first pregnancy, admitted to the Civil Hospital of Strasbourg, Nov. 12th, 1834. Her parents are healthy ; her mother has had nine children, of which she was the sixth, and was delivered with the forceps, on account of the ex- traordinary size of the head the others were delivered without aid. She was early attacked with rickets, and at ten years of age her growth was arrested, being as large at that age as now. Height 44 inches from the top of the head to the coccyx 26 from the coccyx to the heels eighteen. Her head is large, limbs short and slightly curved near the joints, the vertebral column perfectly straight, the body well proportioned. The pelvis is small but well proportioned, inclination 58 * There is no de- formity, but only a want of development. External measurement. From one to the other anterior- superior spinous process seven inches six lines. From one to the other iliac crest eight inches. From the middle of the base of the sacrum to the superior part of the symphisis pubis, five inch- es nine lines. From one to the other trochanter ten inches three lines. From the middle of the crest of the ilium to the tuberosi- ty of the ischium six inches three lines. The labia slightly prominent, orifice of the vagina narrow, vagina contracted and short; the finger readily touches the sacro-vertebral angle; deducting fr< m this length, (that is the sacro-sub-pubic diameter.) a half inch, there is obtained two inch- es and four or six lines for the antcro-posterior diameter of the superior strait. The fundus of the uterus had reached the epigastrium and wa* 1837.] New Cases of CcrsuriaiL Operation. 619 ordinarily prominent. The functions of respiration and diges- tion were uninjured, because there was no want of space. The motions of the infant were vigorous. The inferior segment of the uterus made a slight projection into the vagina, and the head of the foetus was moveable. M. Ehrmann, on examination, coincided with M. Stoltz in his estimation of the case. They accorded in their opinion of the impossibility of delivery by the natural passages and of the in- dispensable necessity of the Caesarian operation. On the night of 19th of December, labour pains commenced. In the morning the pains are of short duration and not very in- tense; the motions of the foetus on the left side strong. The va- gina moist, the lower segment of the uterus relaxed and fluctua- ting ; the neck completely effaced ; the orifice undilated, directed backwards and to the left side. Behind and above the pubis, the head was discovered large and very resisting. During the day, M. M. Ehrmann and Stoltz, endeavored to introduce the entire hand into the vagina, the better to explore it neither could in- troduce more than four fingers, on account of the narrowness of the vulva and vagina; which was a sufficient proof of the state of the parts above detailed. It was then determined to resort to the operation, when the os tincae should have dilated to the ex- tent of an inch and a half the patient consenting to the opera- tion. M. Stoltz operated in presence of many physicians, commen- cing by evacuating the rectum and bladder. The patient being conveniently placed, an assistant on the right side causes the fun- dus to become prominent upon the median line of the belly, by means of two fine, large, flat sponges: these sponges being first moistened in warm water, were applied upon the sides of the su- perior part of the abdomen and maintained there by pressure. A second assistant, placed at the foot of the bed, between the thighs of the patient, caused a prominence of the inferior part of the uterus by applying his two hands upon the hypogastric re- gions, at the same time drawing the skin tense. The operator, on the left of the patient, having assured him- self that no folds of intestine arc between the abdominal walls and the uterus, with a convex bistoury, makes, an incision thro' the skin, commencing two and a half inches from the pubis and extending alonjr the linea alba two and a half inches above the umbilicus, leaving this on the left of the incision : to avoid wound- ing the epiploon, which sometimes covers the uterus, the inci- sion is made first through the skin, then through the adipose tis- sue, which is seven or eight lines in thickness ; at the centre of the wound, he divides the aponeuroses of the abdominal mus and in like manner the peritoneum, carefully raising it up first. with the forceps, as in opening a hernial sac ; the escape of a definite quantity of serosity, announces the opening of tli fi*20 New Cases of Ca-sarian Operation. [March, tonial cavity; then with a concave blunt- pointed bistoury, he opens the peritoneum and the aponeurosis, first at the lower, then nt the upper part to the whole extent of the external wound. He then extends the incision at the two angles, so as to make its length about seven inches. As the section of the skin is cxtend^ ed, the edges of the wound are separated, and when the belly was opened the wound formed an ellipsis of about lour inches at its shorter diameter, exposing the anterior face of the uterus, of a rose colour, marked by serpentine capillary vessels highly in- jected. r\ he external pressure, upon the abdomen above and below had augmented the spontaneous separation of the lips of the wound. Notwithstanding the care taken to keep the uterus and the abdominal parjetes in close contact and the efforts made to force the uterus into the wound, a portfon of intestine escaped on the left side and inferior of the wound, which was easily re- turned and its escape prevented by greater pressure from the assistants. To ascertain if the uterus had rotated upon its axis, the oper- ator introduces his left hand under the right lip of the wound near its superior angle ; it had suffered no rotation. With the convex bistoury, lie divides the uterus layer by layer, upon the median line ; as tjiey arc divided, the uterine fibres retract. The uterine parietes were four or fwc lines thick. The last layer is torn rather than cut, and exposes the membranes of the foetus, cov* ored with the decidua rellexa. The operator then with the fin- ger for a director, passed between the uterus and the membranes, extends the incision in the uterus with the curved guarded bis- toury. Before rupturing the membranes, the operator instructs the assistants to keep the uterus firmly closed upon the wound, by their pressure, to prevent the effusion of the waters into the cavity of the abdomen. On opening the membranes with the bistour three or lour ounces of water escape; the right side of the fetus then presents with the left hand, the accoucheur seizes the feet, which are backward and to the right side, and brings them out with case and then delivers the bod}' and head without any difficulty, it being necessary only to disengage the aims as in natural delivery by \\\v, feet The infant immediately began to cry, the chord was tied and cut; the infant was strong and well grown, eighteen inches in length, and weighed five pounds and three quarters* Alter lite extraction of the foetus, gnat attention and address were necessary on the pari of the assistants to prevent a hernia 3 patient his arm, or even his life, that the lancet should bcexpjmged from the catalogue of instruments* The same observation Is applicable to the use of calomel. If some practitioners have never learned the importance of regular secretions, to the well-being of the human economy, and the pe- culiarly happy virtues and best manner of using this medicine in relation to these functions ; or if others have used it imprudently and produced the worst consequences, it does not follow that the' teachable should not learn, and the experienced and judicious avail themselves of its proper use in combatting the ills which beset humanity. The powers of cinnabar fumigations have been abundantly proven and acknowledged. The next point is so to learn its use as not to abuse it. The experiments of Dr. Venot are, we think, to this point. The three cases he men:ions in verification of its efficacy, serve also as proofs of its safety in prudent hands* Should it be found safe and useful, only in chronic, or in vene- real ulcerations in the throat, (a disease so often resisting all other remedial means, and the embarrassments and perplexities of which must have been deplored by most practitioners of ex^ perience) it will eminently merit a respectable rank in our ma 624 Cinnabar Fumigations. [March, teria mcdica. But it will doubtless be found, on experiment and observation, prudently and carefully made, to be both safe and efficacious in a considerable variety of chronic affections, a- mongst which are found those which too often baffle the other- wise best efforts of the practitioner. We are pleased to find the use of cinnabar in fumigation, the only practicable manner of using it on account of its insolubili- ty, become a subject of observation in the profession. We give, as well in point, the following extract from our res- pected friend, P. Melvin Cohen, M. D , of Charleston, S. C, in which its safety and success in the only two cases he has sub- jected to its use are detailed. We hope to hear of farther suc- cesses attending its use in inveterate cases. "CHARLESTON, S. C, February, 1837. To the Editors of the Southern Medical and Surgical Journal : Gentleman. In the last number of your interesting Journal. I notice an article on the utility of Cinnabar Fumigations, and the method of using them, by Dr. Venot. I have recently treated two interesting cases of ulcerated sore throat, in patients of a cachetic habit; in both of which great benefit was derived from the use of cinnabar. In the first and most alarming* case, which baffled every oth- er remedy, and in which the patient's life was in the most immi- nent danger, a perfect cure has been effected. The second is still under treatment, but rapidly convalescing. From the sig- nal success which has attended the use of cinnabar fumigations in these two cases, I cannot too strongly recommend its use to the profession in all cases of chronic cynanche maligna. The mode in which I administered it was more simple and equally as efficacious, as that recommended by Dr. V. On an iron plate heated to redness, P. Cinnabar was sprinkled, and the vapour inhaled through a tin tube passing into the mouth. Practitioners need not be deterred from using cinnabar in this form, as the oppression and dyspnoea caused by it are transient, whilst the benefit is permanent. Very respectfully, gentlemen, vour obedient servant." To the skiBbf those scientific and distinguished practitioners, Dos. B. B. and Thomas Y. Simons, of this city, am 1 indebted for the success of this case. H337.] '., iputation alike. SJioulder, $c. 62U imputation at the Shoulder, Sudden death from ingress of air into the veins. Tins operation was performed by M, Roux, for the removal of the right upper extremity that had been severely burned and was in a state of sphacelus. The preliminary incision, extend- ing from the acromion to two inches below this point, had been made; the external and posterior flap was formed, and the op- erator had raised it and was opening the capsular ligament in order to turn out the head of the humerus, when the patient's vi- sage was seen to become pale ; he appeared as about to faint, notwithstanding he had lost but a few drops of blood. These symptoms not being deemed alarming, the surgeon merely has* tened to complete the operation; the joint was opened, the ves- sels compressed and the anterior and internal flap was made. But the syncope continued ; two or three convulsive motions seemed to indicate a return of sensibility, but in despite of the usual means resorted to in such cases, life could not be restored ; the man was dead. It was after the incision for the posterior flap that the symp- toms of syncope were observed. Some thought, on seeing the convulsive contractions of the limbs and sudden flexion of the head, that an epileptic attack was coming on. Others, who were nearer, heard distinctly a hissing noise, similar to that produced by air penetrating an air pump : indeed M. Roux himself heard this sound but thought it produced by the joint. Autopsy, twenty-four hours after death. The anterior wall of the thorax and abdomen wTas removed with the utmost care, the pleural membranes and pericardium being left entire, and no veins of size being divided. On opening the pericardium, the mht ventricle presented to the touch a peculiar softness and elasticity indicative of contained air. The surface of the heart being carefully examined, distinct globules of air were seen di- viding the blood contained in the coronary veins. It was now determined to endeavor to collect and analyze the air presumed to be within the heart, but previous to opening this organ, it was desirable to examine some of the lar^e veins. The inferior cava was accordingly carefully dissected and yielded the same sen- sation as the right ventricle. A portion of it was included be- tween two ligatures, after being filled by pressure on its contig- uous parts. Water was then poured into the abdomen, in order to see if any bubbles would escape on opening the vein. As the incision was made a considerable number of bubbles were seen to arise. The thorax was now in the same manner converted into a trough, filled with water, and containing a receiver placed over, the heart; inthis manner eleven cubic centimetres of air were collected on opening the right ventricle. A few bubbles 79 G-2G On the Cure of Intestinal Fistula3, $c. [March, were lost. The examination was now continued ; no air was detected in the veins of the neck, superficial or deep seated ; the axillary and sub-clavian veins of the right side were filled with blood. The left lung was entirely bloodless, unusually light, crepitating, and without emphysema. The right lung contained a little blood, but resembled in other respects the left. The ab- domen presented nothing worthy of remark ; the contents of the cranium were morbid in several respects, but indicated nothing calculated to induce sudden death. The gas obtained from the heart, was on analysis, found to be atmospheric air. This case is interesting, inasmuch as it demonstrates that the air must have penetrated by a vessel of very small calibre, the accident having occurred during the dissection of the posterior flap. The compression of the large vessels, on making the ante- rior sections, would have prevented it on this side. In Delpech's case, the fact was more readily understood, for the vessels were morbidly dilated. Theautopsic examination in this case seems conclusive. It is true that gas is frequently found in the vascu- lar system. We have, however, recently repeated the exami- nations made to enlighten this subject, and we have almost in- variably found air in the heart, especially in the right ventricle, also, though in less quantities, in the cava and jugular veins. But we have never been able to collect.it in sufficient quantity to be analyzed. We have in no instance, however, found the heart and cava to present the peculiar elastic tension, nor the coronary veins the admixture of air and blood, observed in the above case. British and Foreign Review. Journal dts Con- naissances Medico- Chirurgicales. On the Cure of Intestinal Fistulce by the Actual Cautery : By Dr. FlNGERIIUTH. The success attending the employment of the hot iron in the cure of artificial anus, already recommended by DiefFenbach, is confirmed by two cases related by Dr. Fingerhuth. In both, abdominal inflammation, caused by violent blows, had been followed by external abscess, to which succeeded discharge of faecal matters. Various cauteries were employed to destroy the membranes lining the fistula?, and to convert them into gran- ulating surfaces, but without producing their complete oblitera- tion. The fistulous openings, although somewhat diminished by imperfect granulations, showed no tendency to become closed. Cauterization was then adopted by means of an iron, correspond- ing in diameter to that of the fistula;, and the temperature of which was scarcely elevated to that of red heat. Luxuriant granulations soon covered the cauterized parts, the fistula? dimin- ished, and the surfaces being again destroyed by a heated iron corresponding in size to the apertures which remained, they were eventually cured. Wochcnsch rift fur die gesammte Ileilkunde. 1837.] On the Cure of Erectile Tumours. 027 On the Cure of Erectile Tumours: By Frofcssor Lallemand, of Montpellier. M. Lallemand was led, by observing tbe rapid cicatrization of an incision made in an erectile tumour during the partial re- moval of the lower jaw. and by reflecting on the complete oblit- eration by inflammation of portions of the corpus cavernosum and spongiosum, (to which erectile tumours are precisely analo- gous,) to attempt the cure of an erectile tumour, which from its situation could not be removed, by incisions and immediate union of the edges of the wounds. This tumour occupied the upper lip and extended into the nares ; the first step consisted in remo- ving, with two strokes of the scissors, a portion from the centre, of eight or ten lines in breadth : the wound bled freely, but the bleeding was immediately stopped by bringing the edges of the wound together, and fixing them with needles, around which thread was twisted as in the hair-lip operation. The wound healed favorably : the needles were removed on the fourth and fifth day, and the thread was detached on the twenty-fifth, lea- ving a solid cicatrix. In about two months afterwards, M. Lallemand removed ano- ther portion in a similar way. As a proof of the success of the first cicatrix in partially obliterating the erectile tissue, it was ob- served that the blood merely oozed from the incision nearest to the first cicatrix, whilst it gushed freely from the opposite side ; and the needles were passed with difficulty into the erectile tis- sue, near the old cicatrix. The needles this time produced more abundant suppuration, but the wound healed, and its cica- trix, as well as those produced by the needles, looked like fibrous tissue. As the division of the nares, as well as the adjoining mucous membrane, remained tumefied, and as the needles pro- duced a similar obliteration of the erectile tissue as the incision, M. Lallemand introduced them alone ; and they produced the change he expected. In a third case where incision was also employed, the effect of the needles in* transforming the erectile into fibrous tissue was still more apparent, so that he employed in the next case needles alone. An erectile tumour of three inches in length, two in breadth, and three lines in thickness, situated over the left scapula of a child of three months old, had been subjected to compression without advantage, and had doubled its size since birth. As the child was irritable, and very delicate, and the tumour was large, M. Lallemand was afraid to treat it by incision: he therefore introduced into the lower part of the tumour twelve fine pins, and covered the space which separated them with numerous circum- 02S Oil the Cure of Erectile Tumourp. [Mavciv.. volutions of waxed thread. The child cried but little. Three days afterwards he made a similar application to the upper part, and attacked successively the whole circumference, leaving the pins for about seven or eight days, or even more, until they had produced sufficient inflammation. This occupied about forty days, and he was about to attack the centre, when he found it violet, tumid, and very hot; the general health was disturbed,. and he suspended all treatment. To his surprise, the central part suppurated and collapsed, and in a fortnight was complete- ly changed into a flat cicatrix. As some points of the circum- ference had escaped inflammation, it was necessary to repeat the introduction of the pins. After two months and a half of treat- ment, during which time 120 pins were introduced, the whole was converted into a pale fibrous tissue: not a teaspoonful of blood was lost, and the health of a delicate child was only slight- ly deranged for a few days. Compression cures in a similar w.ay, by producing inflamma- tion : when compression is impossible or useless, this plan should be tried: it should also supersede the removal of the tumour,. even when such an operation might be performed without dan- ger or deformity. The stationary condition of such tumours does not warrant their not being operated on. The kind of op- eration must depend on the seat and extent of the disease. Where, as in the first case, the tumour arose from the alveolar border of the lower jaw, nothing better could be done than a re- moval of a portion of the bone, leaving undivided its lower border. to prevent deformity, &c. Where the disease is very exten- sive, and occupies prominent and moveable parts like the lips, as it did in the second case, excisions and needles should be em- ployed; but, where the erectile tissue is not free and moveable, the cure is best performed by exciting acute inflammation in it. Pins of a medium size are better than needles, as they can be cut with scissors, or their ends covered with forceps : the waxed thread is useless. Nitrate of silver, and probably nitrate of mer- cury frequently applied, keeps up the inflammation, which is the essential agent. Archives Generales de Medecinc. Mai, 1835.. [Although our countryman, Dr. Marshall Hall, is fully entitled to the credit of priority in treating erectile tumouw according to the principle advocated by M. Lallemand, (See Medical Gazette, Vol. VIII. 679,) it does not appear that the French Surgeon was acquainted with the practice recommended by Dr. Hall. At any rate the clear way in which he explains the steps by which he was led to substitute the insertion of needles for extir- pation, renders his paper both valuable and instructive. Consid- erable credit is due to Mr. Abernethy for having recommended the simpler treatment by wet compresses and pressure, at the time when complete extirpation with the knife was practised general- ly. It is cunou" that ho con sidi r< d the incrj a ;e of these tumours 1837.] On certain Modi) alment of Hernia. depended on inflammation, and that they were to be cured by subduing it.] British and Foreign Medical Revt On certain Modifications in the Treatment of Hernia: By JI. hdy. Professor G trdy recommends the following plan of applying tlie taxis when the hernia) tumour is so large that it cannot be grasped and pressed in its whole circumference ; for in such ca- ses the partial pressure does not become concentrated at the her- nial opening, but pushes the whole mass in front of the ring. He seizes between the extremities of the fingers of each hand that portion of the tumour nearest to the ring, at about an inch from the orifice, and, pressing the fingers together, he isolates this small portion from the rest of the tumour ; he compresses it in its whole circumference, and by lateral movements he endea- vours to return it. It generally requires only slight efforts to succeed, and the tumour is a little diminished ; he then leaves the fingers of one hand applied to the ring, to prevent the reduced intestines from again protruding, and with the other hand seizes another portion in the same manner, and, abandoning the open- ing, he performs the same manipulation, but with greater facili- ty : he continues in this manner until the hernia is so far reduced that he can grasp it with the hands, so as to compress it in its whole circumference, and thus reduce it as he would treat a smaller hernia. By this manipulation he has many times reduced hernias which have resisted the common methods^ even when practised by experienced surgeons. M. Gerdy also recommends the following modifications in the operation which he has practised as surgeon to the Hopital^Saint- Louis. After making the first incision through the integuments with a knife, he often completes the first part of the operation with straight probe-pointed scissors. The advantages consist in his operating more quickly, as he uses no director ; in being able to distinguish better the parts raised on one of the blades of the scissors; in being more certain of cutting what he has seized, whilst, with a bistoury, the movement of the patient or assistant, or his own want of address, may cause the incision to be deeper than was intended. Scissors cut, as well and clean as a knife, and, as it is only required to divide cellular or thin fibrous lay- ers, there is no fear of that contusion which scissors are said to cause, the importance of which has been exaggeral M. Gerdy wTas induced by the following operation to invent a new form of knife for dividing the stricture. In operating for strangulated hernia, he found, after opening the sac, that the stric- ture was so narrow as to prevent iiis passing a director with the" bistoury. He did not dare to pass a probe-pointed bistoury, flat, for fear of wounding the intestine. He then benl at a right ui- 630 On the Treatment of White Swellings, $c. [March, gle to an extent of two or three lines, the end of a silver director, and introduced its point. When he had passed the limits of the stricture, he depressed the body of the instrument perpendicular- ly to the trunk of the patient, so that the bent end of the sound was crooked round the posterior part of the ring, which lie seized as by a hook. Then, whilst drawing the director gently towards him, he introduced into its groove a straight and acute bistoury, without fear of wounding any thing, as its point was lodged in the angle of the bent director, and the division of the stricture was easily effected. In consequence of this operation, M. Gerdy constructed a straight bistoury, about two lines wide in its whole length, terminated by a small cylindrical tongue, rather flattened, about one line in length, and united at a right angle to the end of the blade. The point of union was carefully rounded. No- thing can be more simple than the way in which it is used. The end of the tongue of the bistoury is introduced, guided by the finger, between the stricture and the strangulated mass : it passes as easily as a probe ; the handle is then depressed, and the curved end of the bistoury passes up behind the ring. If, on de- pressing the handle, the instrument is instantly drawn towards the operator, it is impossible to wound the epigastric artery, even if it is in the wTay. To make more sure that the artery is not between the hook and the ring, the finger, whilst the operator draws the instrument to him, may be placed in the ring to ascer- tain if the pulsations arc to be felt. The bistoury is then to be elevated, so as to divide by pressure the ring and corresponding portion of the sac. British and Foreign Medical Review. Ar- chives Gcnerales de Mcdecine. Avril, 18,36. On the Employment of Muriate of Barytes in the Treatment of White Swellings: By M. Lisfkanc. The "Gazette Medicale" reports a clinical lecture of M. Lis- franc's, in which he relates the results of his experiments with this medicine, which has been long known, but has been recently brought into notice by M. Pirondi, of Marseilles. Six grains of muriate of barytes are dissolved in four ounces of distilled water, of which one spoonful is taken every hour, except one hour before and two hours after each meal. In or- der to tolerate the medicine, the patient must abstain from wine and meat, taking only water and vegetable food. The bottle should not be exposed to the sun, or the salt will be precipitated, and the last spoonfuls contain a greater quantity: to avoid this, it should always be shaken. Sometimes the medicine produces slight pain in the stomach or a feeling of weight; but, if other symptoms do not follow, the stomach gradually becomes accus- tomed to the remedy, and the pain ceases. If, on the other hand, nausea, vomiting, or even some slight symptoms of poisoning 1837.] New treatment of diseases produced by Lead. 631 come on, the medicine should be suspended, and cautiously re- sumed. The climate has some influence ; for, although at Mar- seilles two drachms have been given, M. Lis franc lias never been able to increase the dose in Paris beyond forty-eight grains, and often he has been unable to reach that. The unpleasant symptoms have been removed by whites of eggs. Numerous patients have been submitted to this treatment, and the following are the conclusions which M. Lisfranc has arrived at. 1. Generally the white swelling has been much amended, and sometimes cured. 2. The benefit has been greatest amongst the scrofulous. X. In some very few cases the muriate alone has cured. 4. After a certain time, the disease having become stationary, it was necessary to employ another method. At a later period, the renewed use of the muriate has produced ex- cellent effects. 5. It may be employed both in the acute and chronic stage of white swellings. 6. Serious accidents have never resulted from its use ; the slight symptoms before men- tioned have always yielded readily. 7. A frequent effect is a diminution in the frequency of the pulse ; this falling from sixty or eighty to forty or fifty, or even to twenty-five. 8. In some circumstances the medicine, continued at the dose of twelve grains during the month, has produced as much amendment as in other cases where the dose has been gradually augmented. 9. Where the patients have been slightly inconvenienced with the medicine, it has been most useful. 10. Compression and lo- cal abstractions of blood have been often combined with this treatment, and with extreme advantage. M Lisfranc considers muriate of barytes, given according to M. Pirondi's method, as a truly valuable acquisition to surgery, ("une vraie conquete chirurgicale.") Gazette Medic ah de Par- is. New Treatment of Diseases produced by Lead. The liver of sulphur has been proposed since 1777 by Navier, as a counter-poison to lead ; but he did not confirm its efficacy by actual experiment, and Orfila having shown its inapplicabili- ty, it fell into oblivion. In 1811, M. Chevalier, having con- vinced himself that sulphurct of lead had no action on dogs, whilst carbonate of lead was injurious, inferred that hydrosul- phuric acid might be advantageously employed as a counterpoi- son to the salts of lead; and four years afterwards, being in a manufactory where two men were attacked with violent lead colic, he gave them about a pint of hydro-sulphuretted water, which he found in the laboratory, with immediate relief. He subsequently found similar benefit in his own person. M. Ratier has since confirmed these facts by many trials at the Hospital of La Charite, and gives the following directions. Three indi- cations p"" ' ' ''-'ri^-J 632 New treatment of diseases produced by Ijead, [March, 1. To neutralize the poison, by giving internally a quantity of hydro-sulphuretted.water, proportioned to the known or sup- posed quantity of the salt or oxide of lead absorbed. 1\] . Raver has used the " eau d'Enghein," but either of the following'artifi- cial preparations may be substituted : (No. 1.) Take nineteen pints of water, and add one pint of water saturated with sulphuretted hydrogen, in which twelve grains of carbonate of soda had been previously dissolved. (Xo. 2.) Dissolve five grains of sulphuret of potash in a pint of water. The more recent the colic, the more marked the effect. Many obstinate attacks have yielded to this treatment only. 2. To relieve constipation where it exists. For this purpose, M. Raver prescribes forty-eight grains of scammony and the same quantity of jalap in twelve pills, the patient to take from two to six until they operate. If the constipation continues, a lavement, containing an ounce of senna and two or three ounces of castor-oil. 3. To relieve pain and to procure sleep. For this purpose, one grain or one and a half grain of extract of opium is given at night. By these means, M. Rayer lias rapidly relieved the effects of the salts and oxides of lead, sometimes on the second day, often on the third or fourth, and rarely beyond the sixth. He has never seen a relapse. M. Lefebvre has communicated by letter the particulars of four cases of colica pictonam in his manufactory, all of which yielded to the sulphuretted hydrogen treatment alone. Half a drachm of sulphuret of potash was dissolved in a pint of water, half of which was taken in two doses each day. Three were cured in two days, and one in one day. From the injurious effects which white paint made by carbo- nate of lead has on the healths of painters, as well as occasional- ly on the inhabitants of recently painted houses, it has been pro- posed to substitute carbonate of zinc for the lead. From a re- port of commissioners appointed by the Academy of Architec- ture in Paris, it appears that the paint made from carbonate of zinc is not unwholesome, and that it preserves its brilliancy and whiteness. At present, however, it is more expensive than car- bonate of lead, which would prevent its general adoption ; but, as M. Chevallier suggests, it may be very useful in painting the rooms when- sulphur-baths are given, or privies where sulphu- retted hydrogen is evolved, which blackens white-lead paints. [The general circulation of information tending to the preven- tion of complaints produced by employments to which large bo- dies of men are necessarily exposed, is one of our most useful and gratifying duties. Indeed, the value of precautionary mea- sures promisi nrity will be gratefully acknowledged by 1837. J Inflammation of the Testicles, <$<\ 10 Parturition of a Child at full lime, <\-c. [Marclif The relaxed skin situated in the lower eyelids was operated on. in the same manner as a case of entropium. The wround healed by the first intention, and the deformity was removed. As the deformity of the neck could be conveniently concealed by the patient's dress, it was not removed by the knife. The pa- tient was simply advised to apply to the part strong astringent remedies : and, in order to increase the tone of the whole skin, to use mildly astringent baths, as cool as possible. British and Foreign Review. Wochcnschrift fur die gesammtc Heilkundc, No 15. 1830. Parturition of a Child at full time and of a blighted foetus. Mr. L. Owen Fox records in a late number of the Lancet, (17th September, 1836,) an example of this. The mother, aet. 30, had previously had two children. Mr. F. was called to her 28th May, and shortly after his arrival a large healthy child was born, and the uterine efforts continued very severe, but the pla- centa was not expelled. After wTaiting a short time, he passed his finger along the cord to the uterus, when he discovered a soft mass, not unlike distended membranes, protruding from it. During a strong pain he made slight extension on the cord, when the placenta, together with the mass, immediately came away. On examining the latter, he found it to consist of a small male fetus, about five inches in length, surrounded by about three ounces of fluid. The integuments of the foetus were softened, and presented just such an appearance as might be expected from long maceration; it did not give off any unusual odour. On in- quiry Mr. F. could only learn that his patient expected to be confined at least three months before the event happened. [American Journal. Erratwn. Tagc 592, line 26th, erase the words "every symptom of ip." SOUTHERN JIEDICAL AND SURGICAL JOURNAL Vol. I.] APRIL, 1837, [No. IT Part I. ORIGINAL COMMUNICATIONS, ARTICLE I. An Essay on the question, Ought not the use of Pessaries to b& now abandoned? Read before the Medical Society of Au- gusta, Georgia, by Paul F. Eve, M. D. Professor of Surgery in the Medical College of Georgia. In answering the question, ought not the use of pessaries to be now abandoned? we propose to consider, 1st. In what cases are these instruments now employed? 2d. What is their mo- dus operandi? And ?rd. What are the reasons for or against their application ? First then, in what cases are pessaries now employed? Pes- saries are instruments composed of various materials, as wool, lint, sponge, wax, glass, different kinds of wood and metal, and are of different sizes and shapes ; they are introduced into the vagina to support the uterus when it has descended from its nat- ural situation. There are commonly reckoned two degrees of uterine displacement; one known as prolapsus and the other as procidentia. To these have been added a simple relaxation of the sustaining parts of the womb, and which degree is embraced under the first division or prolapsus By this term then, pro- lapsus uteri, is meant any descent of the womb within the vagi- na, from a simple relaxation of its sustaining organs to its mouth, resting upon the internal face of the perineum ; and bv prociden- 81 sn j^ssay, yc. LAPnl tia, a projection of the os tineas beyond the os externum. By these technical expressions we wish only to indicate different decrees of the same affection. It is an interesting and important question and intimately con- nected with the subject under consideration, to decide what is meant by a descent of the womb from simple relaxation of its attachments. Dr. Horner in his Anatomy, states the length of the vagina to be from four to six inches, and also that it is muck shorter in women who have borne children than in virgins. H. Cloquet in his work, sets it down from six to eight inches. We may clearly infer from this that we are not to judge of prolap- sus simply from the os tineas being more or less distant from the os externum. When we consider the loose attachment of the uterus, the nature of its ligaments, and the character of the oper- ations now performed upon its neck, I think it may be safely as- sumed that the womb often descends an inch or more, as in the first months of pregnancy, &c, without its being manifested by any unpleasant symptoms. I believe the finger applied to the os tincae in the unimpregnated state, can produce a displace-, ment to the extent of an inch, and in females who have borne many children, particularly in warm climates, to a much greater degree. A physician not aware of this mobility of the uterus, or who does not admit it, finding it existing upon an examination per vaginam, may set it down as the pathognomonic symptom or absolute sign of prolapsus uteri. I find upon inquiry of several physicians, that pessaries are now restricted by them to procidentia, some few employing them in certain cases of prolapsus ; but their most strenuous advo- cate in all cases of uterine displacement, is the Professor of Ob* stetrics in the Medical College of Georgia.* Anxious to obtain all the information I could on this subject, I addressed a letter to several distinguished gentlemen of the profession, and made a personal application to every physician in our city. The result of these enquiries has been very satisfactory to me, and has tended much to strengthen my conclusions, that pessaries have been greatly abused, that a revolution is now actually occurring * Dr. Joseph A. Eve, Professor of Materia Medica and Therapeutics, was originally included with Professor Antony as entertaining similar views with regard to the pessary he, however, declares that, in his practice, he usee these instruments inleM than one tenth of the c&s?e? of prolapsus uteri. 1SS7.] An Essay, $c 04* in their use, and that in all probability they will soon be entirely abandoned. Dr. Samuel Henry Dickson, the Professor of Theory and Practice of Medicine in the Medical College of the State of So. Carolina, expressly says in his reply, " pessaries ought to be employed very rarely if ever. While I entertain any hope of a cure, I should regard them as absolutely forbidden." Dr. Hugh L. Hodge, Professor of Obstetrics in the University of Pennsylvania, though an advocate for pessaries, writes, "they are often productive of mischief." Dr. Cunningham, Professor of Theory and Practice of Medi- cine in the Medical College of Georgia, states that he once em- ployed pessaries, but that for the last five years he has become convinced from experience (and I may add an experience of 28 years,) that they are injurious in prolapsus uteri. He has aban- doned their use entirely. Drs. Dugas and Ford, both professors in our Medical College, report that they have never applied a pessary. They have re- moved them in supposed cases of prolapsus, for which they think them not necessary, and can only be required in procidentia, even for which, however, they do not recommend them. Dr. Hook, during a practice of many years, has employed pessaries in prolapsus, but thinks them uncalled for in the great majority of cases. He would restrict them to about one-tenth of the cases of prolapsus and to procidentia. Dr. Carter has applied pessaries in about half a dozen cases, but without any advantage. He says he has repeatedly removed them when applied by others for prolapsus, and the patients have recovered by the use of other means. He has abandoned them entirely. Dr. Robertson has never applied a pessary, but has been called to remove them, and did so with decided advantage to the cases. He thinks they ought never to be employed for prolapsus uteri, Dr. Kennon has used pessaries for procidentia, sometimes with and at other times without any advantage. He says they ought lo be restricted to procidentia. Dr. Bowen applied once a pessary with such decided aggra- vation of symptoms that it was soon withdrawn. He has known them applied by others, but generally without advantage to pro- lapsus uteri. He censures their application in this affection. 644 An Essay, c. [April, Pessaries, says a modern distinguished writer and practitioner, " effect a forcible distinction of the vagina ; the elasticity and con- tracting disposition of this canal they tend to destroy, while by their irritation they keep up an active congestion in the uterus itself. These are the necessary results even of the judicious em- ployment (so to speak) of pessaries, but of their rash and pro- miscuous application the consequences are truly harrassing and sometimes destructive." They certainly cannot restore tone to the vagina, but on the contrary they tend necessarily by their presence to destroy it. They do not shorten the ligaments of the womb, nor do they promote the attachments of the uterus and vagina to the surrounding parts. They increase and never diminish the discharges from these organs. How then can pes- saries cure prolapsus uteri? There is one degree of uterine displacement for which it is gen- erally supposed pessaries are still required ; I allude to proci- dentia. Here it would seem their good mechanical effects in keeping the womb within the vagina more than counterbalances their irritation, &c. of the soft parts. But is it necessary even in these cases to resort to pessaries ? If an instrument be re- quired, I hesitate not to assert that Hull's Utero- Abdominal sup- porter, or some similar external application will be found far more preferable, and decidedly more efficacious than the pessa- ry, and moreover, free from all its objections. Whether this in- strument will answer for simple prolapsus, can alone be deter- mined by experience. Before abandoning the use of pessaries, it would be well to en- quire if we have a substitute for them. Sound policy would, in- deed, teach us to retain even a doubtful remedy until we obtain a better. Prolapsus uteri is not a rare disease in this climate. The physicians whom I have consulted, and whose names have already been mentioned, have treated cases of uterine displace- ment. If pessaries had been useful they certainly would not have abandoned or restricted their application, and if the practice which they now pursue for this affection were not successful, they as certainly would not continue it. The ample experience of Professor Dickson also attests the fact, that prolapsus is not only best cured without pessaries, but that these instruments ought rarely if ever to be employed in the treatment. With these facts before us, Ave are now prepared for -the rr?a- so is for and against the use of pi sarics, 1837.] An Essay, $c. 649 The only reason why these instruments are still employed and recommended in practice, is that they do keep the uterus within the vagina or even in situ, if well adapted to the case. But this they do at such an expense that they arc highly injurious and properly forbidden by a great majority of physicians at the pre- sent day. 1st. Pessaries ought not to be applied for procidentia uteri, because we have a much better substitute Hull's Utero- Abdom- inal Supporter. 2d. They ought not to be employed for prolapsus uteri, be- cause they can never cure the disease. Their operation is purely mechanical ; negative to counteract relaxation of the soft parts sustaining the uterus, but positive in their injurious and destruc- tive effects to these parts. 3d. They are not necessary other means succeed best in curing prolapsus. Experience on this subject among physicians of this city is as 11 to 1. 4th. They are highly injurious and destructive if long contin- ued. They promote vaginal relaxation, excite fluor albus, may produce prolapsus uteri itself, and by irritating the os tincae oc- casion ulceration or even cancer, the most fatal of all female dis- eases. They may also call forth afflictions of the surrounding soft parts in the bladder, rectum, &c. 5th. They are in their application exceedingly unpleasant to both physician and patient. The very idea of a pessary is revolt- ing to the female. They are to her a source of great moral as well as physical suffering. 6th. They interfere with the periodical menstrual discharge from the uterus. 7th. "They interrupt sexual intercourse." 8th. Their use may lead to immorality. For these reasons I think the use o^ pessaries ought now to be abandoned. 62 050 Medical Statistics, $c. [April, ARTICLE II. Medical Statistics : being Tables, c. relating to the mortality of Augusta: By L. A. Dugas, Professor of Anatomy, &c. in the Medical College of Georgia. In presenting the result of my examination of the Records kept by the City Sexton, during the preceding nineteen years, I feel that the work is in many respects deficient. Imperfect as it isr however, I am deterred from withholding it by the reflection, that it contains all the facts in our power to obtain on the sub- ject, that the tables and deductions, so far as they go, are correct, and that the deficiencies are attributable not to any want of la- bour on my part, but to the rude and careless manner in which the records have been kept. Enough is collected to evince the importance of such statistical observations, and to call the atten- tion of the authorities to the regulation of the manner in which such facts may be collected. The age in which we live is one of positive research ; one in which facts are loudly called for, and theories laid prostrate. Let us then not be reluctant to contri- bute to truth, by yielding up our store of/ac/s, however scanty it may be. Table No. 1, exhibits the state of the population of Augusta, as taken by order of the Ceneral Government, in June, 1830. The character of the gentleman employed for this purpose, (Mr. J. S. Beers.) is a sufficient guarantee of its accuracy. It will be remarked that the census was taken in summer, when a large number of inhabitants leave the city ; that the whole population was then 6710, of whom 3052 were whites, and 3658 coloured. Among the whites the number of males was 1680, whereas that of females was only 1372, a disproportion of sexes not existing among the blacks, of whom 1800 were males and 1858 females. The disproportion observed, exists only with regard to adults, a circumstance to be attributed to the mercantile character of this community, which gives employment to a large number of young men as clerks. - The present population of Augusta is estimated to be about 7500. We regret that the census recently ordered to be taken by the City Council is not yet completed. 1837.] Medical Statistics, $c. GoT Tabic No. 2, presents the number of deaths, (still-borns inclu- ded,) that occurred in Augusta in each year from 1821 to 1836. It is, as well as all the subsequent tables, derived from the records kept by the city sexton. Table No. 3, is a statement of the mortality in each month, during a period of sixteen years, from which we are enabled to deduce the following tables. Tables No. 4, 5 and G, exhibiting the average number of deaths in each month. From these it wiil be perceived that there is but little difference in the mortality of the months of July, Au- gust, September and October, and that the fatality of these is nearly double that of the other months. In taking the average from the column of whites, the number of deaths is greatest in October, whereas if it be taken from the blacks, July will present the greatest mortality. The two last averages, however, differ very slightly, and prove conclusively, notwithstanding the opin- ion recently advanced by a southern writer of distinction, that the causes of disease in our climate, without regard to season, operate with equal intensity on the white and black race. On referring to Table No. 2, it will be seen that in sixteen years, there were among the whites seventeen hundred and eighty-one deaths, and among the blacks only sixteen hundred and twenty- nine ; but the relative proportion of the two races during that time is not known. That this proportion must have changed very materially, I think more than probable. It is well known that the number of free negroes and of those who hire their own time, has very materially increased of late years. The number of artisans, (who are generally negroes,) has also manifestly in- creased; moreover, on examining the Table No. 2, I find that during the first eight years of the series, the deaths were, whites nine hundred and forty-six, blacks seven hundred and five. Whereas the eight last years show the majority of deaths the reverse : whites eight hundred and thirty-five, blacks nine hun- dred and twenty-four. I am aware that the gentleman to whose opinion I just alluded, is not alone in support of the doctrine that our prevailing fevers are more fatal to the Caucasian than to the African race ; but I doubt very much that facts alone, without prejudice, have ever furnished sufficient data for its establish- ment. I am unwilling to admit, without better evidence than we possess, that the mortality is greater among the whites than fiSS Medical Statistics, <$-c. [April. the blacks, when situated and living under similar influences. With regard to the statistical observations of this city, it should be remembered that the white population is such as to render it extremely susceptible of disease. A large number of the inhabi- tants are only temporarily located, and each business season is ushered in by an accession of strangers. The mercantile com- munity is almost entirely changed every live years not so with the blacks. These are generally permanent residents. Their masters may remove, but they prefer remaining with their friends, and usually request to be sold at home. They do not spend one season at the north, another at the south, a third at the east, and then go to the west ; thus continually being exposed to changes of climate, customs, &c. These are reasons why they should withstand the climate better than the whites. But I repeat, I am not prepared to admit the fact. The following table will show the most fatal as well as the least fatal months in several cities. (Diet, des Sc. Med. torn. 34, p. 362, et seq.) Maximum mortality. Minimum mortality. St. Petersburgh, May, October. Stockholm, August, January. London, January, June. Paris, April, July. Berlin, March, November. Vienna, March, ^ October, Montpellier, August, - May. Padua, January, June. Milan, December, April. Table No. 7. Number of deaths in each month during a pe- riod of four years, (1833, '34, '35 and '3G,) with averages deduced from~the column of whites, from that of blacks, and from the total. Table No. 8. It is much regretted that this table, showing the ages of those who died in Augusta, during a period of nine- teen years, is incomplete as respects the coloured population. During this period 21 15 whites died, the ages of 1941 of whom I found recorded; leaving 174 unknown. The records having been more carefully kept for four years past, I am enabled to give the ages of the blacks who died during this period. It should be noted, however, that their age is generally extremely uncer- 1837.] Medical Statistics, $c. 053 tain. Their desire to claim the privileges of the super-annuated leads them to great exaggeration, and it is rare that their mas- ters, keeping no record of their ago, can state it accurately from memory. This will probably explain why the number above fifty years of age is so much greater in the table of blacks than in that of whites. It is well known that longevity is in general greater in the higher than in the lower classes of society ; We should therefore not admit, without more positive information, the vulgar belief that negroes live to a much more advanced age than whites. N Tables No. 9, 10 and 11, represent the average number of deaths per annum at different ages, deduced from the foregoing table (No. 8.) The first is the average taken from nineteen years* and the two others that taken from the four last years ('33, '34, '35, '3G,) still borns and casualties included. Table No. 12, exhibits the proportion of deaths at different ages to the population, as established by the census of 1830. It is the result of a comparison of table No. 8. with said census, and refers to whites alone. The ages of the blacks being stated in the census differently from those of the whites, the same esti- mate could not be made with regard to them. Fractions are omitted. If the proportion of deaths per annum to the present popula- tion [7500] be deduced from the mortality of 1834, '35, '36, (those recorded as still-born being excluded, as never having ex- isted,) it will appear that it is as 1 to 40.32. In this estimate, whites and blacks are of course included. It is a matter of some interest to compare this with the mortality of other places. Ac- cording to Emmerson's Tables, (Am. Jour, of Med. Sciences, No. 1, 1827, p. 138,) the mortality of the coloured people in Philadelphia is astonishingly great, 1 in 11), whereas that of the whites is comparatively small, 1 in 50.8. The aggregate would give an average of 1 in 34.0. The following is a table taken from Dr. Gregory's Dictionarv. The data on which it is founded are not stated. Proportion of inhabitants dying annually In London, - - ' - 1 in 20 3-4 " Edinburgh, - - - 1 " 20 4-5 " Dublin, - - - 1 " 22 " Stockholm, - - 1 " 19 651 Medical Statistics, fyc. [April, " Vienna, - - - 1 " 19 1-2 " Rome, - - - - 1 " 21 1-2 " Amsterdam, - - 1 u 24 " Norwich, - - - - 1 " 24 1-2 u Northampton, - - 1 26 2-5 M Liverpool, - - - 1 " 27 " Manchester, - - - 1 " 28 " Savannah, (Georgia,) - 1% 317-10 " Wirtemburgh, - - 1 ' 32 " Sweden, - - - - 1 " 35 u Kingdom of Naples, - 1 " 37 1-3 " Parish of Brandenburgh, - 1 " 45 " Pays de Vaud, - - 1 " 45 " Philadelphia, - - - 1 <; 45 " Ackworth, (Yorkshire,) - 1 " 47 " Salem, (Massachusetts,) - 1 " 47 " Island of Madeira, - 1 " 50 " Corfe-Castle, Dorset, - - 1 " 50 1-3 M. Friedlander, in his very able memoir on mortality, (Diet, des Sc. Medicales, t. 34, p. 391.) states the proportion of deaths to the population, to be in London 1 in 21 Dublin 1 in 22 Edinburgh 1 in 21 Amsterdam 1 in 22 Berlin 1 in 26 Vi- enna 1 in 20 Montpellier 1 in 28 Rome 1 in 23. According to Heberden, the proportion in London was in 1700, 1 in 25 in 1750, 1 in 21 in 1801, 1 in 35 and since, 1 in 38. In an article on the "Health of Charleston," (Southern Litera- ry Journal, July, 1836.) Dr. Logan quotes the following table from an Edinburgh periodical. The number of deaths compared with the population was: In London in 1828, 1 in 55 " St. Petersburg " 1828, 1 in 48 Geneva M 1821, 1 in 43 Berlin 1827, 1 in 34 Paris M 1829, 1 in 32 Rome M 1828, l in 81 Amsterdam, M 1828, 1 in 29 Stockholm, U 1827, 1 in 26 Vienna, u 1821, 1 in 25 The discrepancies evinced by these tables establish sufficient- ly the difficulty attending their construction, and consequently 1837.] Medical Statistics, 4'c- fl5* the little degree of confidence to which they are entitled. The London bills of mortality are proverbially inaccurate. In Swe- den they are better regulated than in any other country. Can we then for a moment credit the statement of such an immense difference in the mortality of London and Stockholm? In ma- king such estimates, authors should always state the sources of their information. Fortunately for us, Dr. Logan has stated the manner in which he determines the mortality of Charleston. He tells us that "Charleston is decidedly one of the healthiest cities on the face of the globe." I do not deny it. But how does he prove it ? By a reference to the above table, and by stating that in Charleston in 1835, 1 in 45 1-2 died. Certainly no one can presume to establish the mortality of a city upon the facts of one year alone. This may have been the manner in which some have made their estimates, relating to London and other places. Were we to adopt this method, we might, by selecting particular years, make Augusta either the most insalubrious or the most healthy city on earth. Table "So. 13, is a summary of the number of deaths from each of the most prevalent diseases. The records are extremely im- perfect prior to 1833, and indeed totally deficient from 1826 to 1833, the sexton having kept no account of diseases during that time. From 1833 to '36 inclusive, the records have been kept with much more accuracy. This table exhibits a large number of deaths from scarlet fever in 1833, prior to which year this disease was scarcely known amongst us. It then prevailed epi- demically to a dreadful extent, but has since gradually disap- peared. This table also presents ten cases of Asiatic cholera among the blacks, all of which I believe originated on the river, or occurred in boat hands shortly after their arrival. Under the head of fever are included those reported as bilious, malignant, typhus, intermittent and nervous fevers. The small number of deaths from fever is worthy of notice. It is believed that the fatality and indeed frequency of these affections, are rapidly de- creasing. The small number of cases of cholera infantum will also attract attention ; but I have no doubt that most of those reported as dysentery should have been placed under the former head. In 1833, as well as in 1835, the infantile affection was unusually rife, and it is in these two years we find the largest proportion of dysentery reported. f>56 Medical Statistics, fyc. [April, In the column of " casualties," are included burns, drowning, murders, and external injuries. The great proportion of deaths from old age recorded as occurring among th: blacks, is the re- sult of error, as has already been hinted. Table No. 14, exhibits the relative proportion of the sexes among the deaths in 1833, '34, '35, and '30, by which it will be seen that the- mortality of the males far exceeds that of the fe- males. Table No. 15, contains the place of nativity of those who died of consumption and of bilious fever during the same period. It is worthy of remark, that whilst the deaths from phthisis are al- most equally divided by *he northerners and southerners, that those from bilious fever should be much more numerous among the natives of the south, than among the natives of northern lati- tudes ; 46 southerners, and 17 northerners. If to this majority we add the number of blacks, who are all southerners, the result will be truly surprising. TABLE No. I. Census of Augusta, taken by order of the General Government, June, 1830. *n "J ^ M a *d H 1 TS >*J g *J HI P o o o o O c S o sr 3 3 3 3 5 3 B 3 3 3 5,3 Ol O Ol ft K & 8 S 3 3 g Whites. V\ o O o o- S c o o s o ^ o 250 240 o 19G M0 c o 4*. B* s 8 o 8 8 3-S w O 1 Males, 154 418 333 128 42 15 3 1 1 1680 Females, 159 151 176 279 199 94 46 22 5 1372 1 3052 a "3 3 3 3 i* g Cu 3 3 B 3 K 8 Slaves. o o o 443 M 413 387 390 5i 326 339 8 107 V Males, 2 ~ 1708 Females, 470 437 1 126 1 1763 3471 Free col.m. 30 23 16 14 92 Females, 26 24 J9 16 10 95| 167 - b/10 1837.] Medical Statistics, <$ 657 TABLE No. II. Whites Rlacks Tut.l 9(J 2-J7 82 231 76 185 78 1G8 82 208 99 216 97 231 92 182 104 193 L83U 1831 1832 1833 1834 1835 1836 TABBE No. Ill TfoHl 164 284 230 272 177 225 209 3410 < S 1821, Jan. 5 12 17 Feb. 8 8 16 March, 5 11 16 April, 6 4 10 May, 7 8 15 June, 12 8 20 July, 24 15 39 Aug. 11 10 21 Sept. 11 7 18 Oct. 25 8 33 Nov. 8 4 12 Dec. 6 4 10227 1822, Jan. 5 7 12 Feb, 9 4 13 March, 11 6 17 April, 6 6 12 May, 2 9 11 June, 14 8 22 July, 25 6 31 Aug. 23 5 28 Sept. 20 10 30 Oct. 16 10 26 Nov. 13 7 20 Dec. 5 4 9231 1823, Jan. 7 3 10 Feb. 3 4 7 March, 3 5 8 April, 7 6 13 May, 6 7 13 June, 10 4 14 July, 25 13 38 Aug. 14 7 21 Sept. 9 10 19 Oct. 13 5 18 Nov. 4 2 6 Dec. 8 10 18185 1824. Jan. 7 7 14 Feb. 6 7 13 March, 5 o 7 April, 8 4 12 May, 6 4 10 June, 9 8 17 July, 12 13 25 Aug. 6 11 17 Sept. Oct. Nov. Dec. 1825, Jan. Feb. March, April, May, June, July, Aug. Sept. Oct. Nov. Dec. 1826, Jan. Fob. March, April, May, June, July, -Aug. Sept. Oct. Nov. Dec. 1827, Jan. Feb. March, April, May, June, July, Aug. Sept. Oct. Nov. Dec. IS2S, Jan. Feb. March, April, 11 6 5 9 5 6 4 2 6 12 17 22 12 18 12 10 9 6 8 12 10 12 6 10 7 12 12 13 13 4 7 10 9 18 13 11 14 15 12 11 3 4 7 10 83 2 9 4 7 6 8 6 3 5 4 8 7 9 8 12 6 3 9 11 7 7 14 11 10 5 8 5 9 6 7 3 10 6 10 17 14 6 7 4 7 7 6 7 2 13 15 9 16168 11 14 10 5 11 16 25 29 21 26 24 16-208 12 15 19 19 17 2S 1 20 12 20 17 22-216 19 11 10 20 15 28 30 25 20 n 16 18-231 10 10 14 12 658 Medical Statistics, tyc. [April, < a t^ > S 3 3 K > 5 5 m c 2 JO c o May, 9 5 14 Sept. 16 20 36 June, 5 13 18 Oct. 14 15 29 July , 9 5 14 Nov. 5 15 20 Aug. 13 8 21 Dec. 5 6 11230 Sept. 12 11 23 182 Jan, 8 a 10 Oct. 9 9 18 Feb- 10 10 20 Nov. 6 13 19 March, 20 24 44 Dec. 3 6 9 182 April, 12 24 36 1829, Jan. 5 9 14 May, 7 12 1 Feb. 3 4 7 June, 6 17 23 March, 3 7. 10 July, 10 10 20 April, 1 9 10 Aug. 10 Ii 21 May, 6 5 11 Sept. 15 11 26 June, 5 9 14 Oct. 16 7 23 July, 10 9 19 Nov. G 9 15 Aug. 20 14 34 Dec. 7 8 15273 Sept. 12 13 25 1834, Jan, 3 8 11 Oct. 14 11 25 1 Feb. 8 4 12 Nov. 8 8 16 March, 1 9 10 Dec. 7 6 13- 198 April 4 9 13 1830, Jan. 4 5 9 ' May, o 9 11 Feb. 3 6 9 June, 8 9 17 March, 2 8 10 July, 6 3 9 April, 8 6 14 Aug. 8 5 13 May, 13 11 24 Sept. 10 21 31 June, 5 6 11 Oct. 16 10 26 July, 4 15 19 Nov. 6 8 14 Aug. 7 3 10 Dec. 4 G 10177 Sept. 5 6 1L 1835 , Jan. 7 11 18 Oct. 11 6 17 Feb. 9 5 14 Nov. 4 8 12 March 2 7 9- Dec. 5 13 18- -164 April, 3 11 14 1831, Jan. 6 13 19 May, 8 4 12 Feb. 6 11 17 June, 7 9 16 March, 8 6 14 July, 18 18 36. April, 2 7 9 Aug. 20 17 37 May, 9 10 19 Sept. 15 9 24 June, 10 5 15 Oct, 11 7 18 July, 11 19 30 Nov. 3 7 10 Aug. 18 11 29 Dec. 2 15 17225 Sept. 27 11 38 183C , Jan. G 12 18 Oct. 34 19 53 1 Feb. 7 7 14 Nov. 15 12 27 March , 6 9 15 Dec. 6 8 14- -284 April, 15 3 18 1832, Jan. 12 9 21 May, 2 5 7 Feb. 12 6 18 June, 7 7 14 M arch , 5 7 12 July, 6 8 14 April, 9 6 15 Aug. 15 10 25 May, 4 8 12 Sept. 5 8 13 June, G 7 13 Oct. 19 14 33 July, Aug. 3 12 15 Nov. 10 8 18 12 1G 28 Dec. 9 11 20209 1837.] Medical Statistics, fc 659 TABLE No. IV. Average Mortality of each month ; deduced from a Series of sixteen years, (from 1821 to 183G,) Whites and Blacks in- cluded. January, 14,06 J.^v, 23.80 August, 23,68 September, 22,49 October, 25,12 November, 15,03 December, 14,74 February, 13,12 March," 14,06 April, 14,49 May, 13,80 Juno, 17,71 TABLE No. V. Average Mortality in each month, among the Whites alone. January, 6,56 February, 6,50 March, 6,06 AdhI, 7,18 May, 6,62 June, 9,12 July, 12,43 August, 13,75 September, 12,56 October, 15.56 November, 8,06 December, 6,87 TABLE No. VI. Average Mortality in each month, among the Colored alone, January, " 7,50 July, 11,37 February, 6,62 August, 9,93 March, 8, September, 9,93 April, 7,31 October, 9,56 May, 7,18 November, 7,87 June, 8,62 December, 7,87 TABLE No. VII. Number of deaths in each month, during a period of four years (1833, '34, '35 and '33,) with averages deduced from the column of Whites, from tliatof Blacks, and from the total, January February, March, April, May, June, July, August, September, October, November, December. White Black Total Whites, Blacks, Total, rrerafo, avenge, average 24 33 57 6 8* 14* 31 26 60 84 64 . 15 29 49 78 7* 12* 194 34 47 81 84 HI 90* 19 30 49 4| 74 12* 23 42 73 7 104 174 40 33 79 13 9.} 19* 53 43 96 13* 10| 24 45 49 94 11* 12* 234 62 33 100 15* 94 25 25 32 57 6i 8 w* 22 40 62 SJ 10 154 mo Medical Statistics, tyc. [April, TABLE No. VIII. Ages of those who died. Whites, 1 Under! 5 years From 1 | | 5 to 10[l0tn20|20to30l M) to 40 40 to 50159 to 00|GO to 70 TOtoSO over 80 1 Tot.i] 1818 18 6 7 5 8 8 5 3 3 63 1819 39 6 6 18 12 5 7 4 1 3 3 101 1820 36 12 4 30 12 15 1 1 o 116 1821 46 9 3 27 12 8 9 o 3 1 120 1822 45 8 10 21 13 7 7 7 1 119 1823 34 8 8 18 11 9 4 1 2 95 1824 25 6 8 14 10 7 4 1 3 78 1825 30 14 10 20 16 7 3 3 1 107 1826 49 3 3 18 14 6 3 3 1 103 1827 46 9 8 22 16 15 6 5 5 3 1 121 1828 36 o 7 12 6 7 4 5 1 1 83 1829 45 4 4 10 16 4 7 5 1 99 1830 31 4 3 18 7 1 1 1 1 70 1831 61 15 14 18 17 8 6 3 3 3 151 1832 33 56 o 8 15 20 9 4 3 o 101 1833 16 13 i 12 15 8 4 3 127 1831 32 r,yr 17 6 3 3 1 4 74 1835 44 \ 6 15 14 11 6 0 3 105 1837.] Medical Statistics, <$ 001 1836 II 7(53 13S 133 ID 320 1* 249 10 130 91 I 57 36 13 102 1011 Blacks, Uiidei j yean Fr nn > to 10 0to20 20 to no 30 to 40 10 to 50 >0 to GO *o. of deaths, 1 CO 1 i z ,2 i !l Disease stated, P|P Disease unknown. ~ - 1 * 2 CO 1 CO I t"- CO Tf 1 CO Sundries, i w - V 1 CO CO CO - 1 " Mortification, 1 Dyspepsia, Casualties, -* ~ *< a a|- 1 co Still-born, co i> m j o 1 2 J 1 El 2 g Old age, 1 1 OS ' t^ i j o "'- n Childbed, ~l * H 11 *^ -^ Rheumatism, CO -> Worms, -v "1" i 1 1 1 i 1 CO _ OD Intemperance, CO 1 7 "1 jo Palsy, ~ pf Dropsy of Brain, "~co" Q mi TP 1 1 o f^ Dropsy, CO 1 1 * ~c7 1 co ~00 i p .w CO CO 1" W ^ Liver affections, JS | .... J3 Asiatic Cholera, 41 1 c 1 V^ Cholera Morbus, Of 35 M i in <-- 1 1 % Cholera Infantum, "1 ^ Sore Throat and Quinzy, ~ " 1 c* 5T Hooping Cough, -1 ~l Croup, CO co CO 00 | "r M Affection of the Lungs, ! "1 1-1 rr | SO P> Pneumonia and Pleurisy, " l' JO. o -ar 1 Consumption, 3 "l "1 -| Brain Fever, 1 __:! * i Fever, 8ft ^ | CO J2 w col as ! on 1^3?.] On the Physiological effects of Caoutchouc, fyc. 603 TABLE No. XIV. la 1833 there died (Whites,) Males 76, Females 4G, sex unknown S In 1831 do do 15, do 31, do In 1 B35 do do do 53, do 47, do In 1635 do do do 7G, do 31, do In 1>33 do (Blacks,) do 64, do 66, do 15 In 1831 do do do 56, do 33, do 6 In 183.5 do do do' 65, do 51, do 4 In 1836 do do do 55, do 44, do 3 435 355 33 TABLE No. XV. Place of nativity of the Whites who died of Consumption and of 'Bilious Fever, in the years 1833, '34. '3 5 and '36, OF CONSUMPTION. North of the Potomac, 9 Europe, 817 Georgia, 4 Other Southern States, 913 OF BILIOUS FEVER. Xorth of the Potomac, 7 Europe, 1017 Georgia, 28 Other Southern States, 1846. ARTICLE III. A paper on the Physiological effects of Caoutchouc as an ender- mic application for the purpose of Counter Irritation. Read before the Philadelphia Medical Society, November, 1836: By Heber Chase, M. D. of Philadelphia. Gentlemen. The short space of time which has elapsed since my escape from the walls of Alma Mater, together with my at- tention having been directed to other and more engrossing pro- fessional occupations, has rendered the investigation of the sub- ject of the paper which I have the honor of offering you on the present occasion, less extensive than might be desired : the facts however, though not numerous, may be considered striking, and perhaps not wholly unworthy of attention. The application of remedial substances to the skin is by no means of modern date. Its origin was coeval with the history 064 On the Physiological effects of Caoutchouc, <$-c. [April, of surgical means for the relief of disease, and it has, I believe, at all times and in all ages been regarded as a powerful auxiliary, in combatting a very large class of diseases tojvvhich the human family is heir. The long list of agents suited to this species of external treat- ment, ranked under the general head of revulsives, and divided by writers and teachers into various classes, embracing the chain from the potential cautery down to the mildest irritant which produces an erythematous blush, may, and I dare say in your opinion does afford the practitioner an ample field from which to select remedies for every state and condition of disease under which our patients may chance to suffer. I purpose, however, to call your attention to the employment of a new remedy which may be placed in this class, and thus to add another to the above named list, viz. : Caoutchouc or India Rubber, used as a revulsive or counter-irritant. I shall in these remarks enter so far into the commercial his- tory of the article, as to give some idea of the resources in ob- taining it, and the vast quantities^ now consumed. I shall also offer a slight notice of the different modes of preparing it, in order to give the practitioner a few hints in selecting the genuine arti- cle, and such of its varieties, as are best adapted to the dhTerent forms of disease. India rubber trees are found very abundant on the north coast of Brazil, in the province of Para they are about sixty feet in height, and from eighteen to twenty-four inches in diameter, and are almost devoid of branches, except towards the top. They grow indiscriminately among trees of all kinds, and in a thick dense forest. The milk (as it is there called) is procured by the Indians ; and over this tract of country there are no less than from ten to twelve thousand persons employed in collecting it. Young specimens of this plant may be found in the botanic gardens near this city. It is asserted that the health of the tree is improved by the abstraction of its juice, and that upon this, its longevity greatly depends. The quantity of gum elastic obtained from each tree varies generally from one hundred to one hundred and fifty pounds. The specimen of the sap or milk of the caoutchouc now ex- hibited, was originally of a cream colour, but from the action of r837.] On the Physiological effects of Caoutchouc, fyc. 60& the air and light, has become of a darker hue. This specimen belongs to the Philadelphia College of Phnrmacy, and was brought from the province of Nicaragua in Central America, in 1831. A part of the specimen as then imported was analyzed.* Originally, they were in the habit of felling the tree for the purpose of obtaining the juice, but more recently it is procured by tapping (a process similar to that employed by our farmers for obtaining the juice of the maple or sugar-tree, for the manu- facture of sugar.) The juice of the Seranga or India rubber tree, is caught in small clay vessels and is then poured off into small vats. The first notice of the employment of caoutchouc was in 1770, by Dr. Priestley, in a note to his treatise on the theory and prac- tice of perspective, in which he says, M since this work was printed off, I have seen a substance excellently adapted to the purpose of wiping from paper the marks of a black-lead pencil. It must therefore be of singular use to those who practice draw- ing." There are now exported annually from the province of Para alone, 1500 tons of India rubber. At present there are. I believe, in this country, but two estab- lishments for the manufacture of this article. One is located at Roxbury, Massachusetts, and is called the "Roxbury India Rub- ber Company." The other at Lynn, Massachusetts, and is styled the "Boston and Lynn India Rubber Manufacturing Com- pany." The former of these, (the Roxbury company,) posses- ses a capital of 8500,000, which is all employed in the manufac- ture of this article in its numerous forms. This company was established about seven years ago, and from that period up to within a few months, the caoutchouc was dissolved in spirits of wine, or spirits of turpentine, and then laid upon cloth of suitable fabric, and allowed to become hardened. The cloth here seen by the society, is from the agencies in this city. The several pieces, as will be observed, are of different texture; and from this are manufactured various articles for surgical purposes, as well as for those of dress. The process for dissolving the caoutchouc is as follows : Large vats capable of containing several pipes, are rilled with *8se Journal of the College of Pharmacy, No. xii, for 1832, p. 2OT. 84 666 On the PJiysiological effects of Caoutchouc, fyc. [April the India rubber cut in pieces: upon these is poured the solvent, and after the lapse of a few days, the preparation becomes fit for use. It is then spread upon the cloth. The proportion of the solvent employed to the caoutchouc is kept secret by the pro- prietors, and its original discovery was accidental. There is, however, an article in the market which is entirely worthless ; it is rendered so by the change which the prepared caoutchouc undergoes after being laid upon the cloth. Here is a specimen, of the article under consideration : it presents an un- even appearance on the surface, adheres to the fingers, or when brought in contact with itself, if not obviously liable to this ob- jection when purchased it soon becomes adherent on pressure or exposure to warmth, and consequently unfit for use. Within a few months past, a gentleman connected with the Roxbury company, has invented a machine for rolling the caoutchouc into sheets, by which process it is said, the sheets may be extended with perfect facility, to any degree of tenuity re- quired. The pieces of rubber are placed between rollers, and carried through a sufficient number of setts to reduce it to a ne- cessary thickness. While under this process, it is brought in contact with the cloth and made to adhere, by a part of the same machine through which it has passed. This is a very beautiful preparation, and it is one that promises to be of great utility ; at present it is obtained with difficulty, but will no doubt be exten- sively employed hereafter. The experiments of Dr. Mitchell of this city, upon caoutchouc, have shown, that when this substance is submitted to the action of ether for a short time, its susceptibility of extension is greatly increased ; that ba^s of several feet, may be inflated by the breath to such an extent, that when filled with hydrogen and placed at liberty, they will ascend against their own gravity. It may be doubted whether mechanical apparatus is capable of producing the same extreme expansion without the aid of a sol- vent ; but the dilation of caoutchouc bottles has been carried very far by the action of hydrostatic pressure, by Mr. Rehrer, a sur- geons' instrument-maker in this city. Another form of caoutchouc to which I wish to call the atten- tion of the society, is in the India rubber sheet. This, as I ex- hibit it to you, is also brought from Brazil, and is prepared in the following manner. The juice of the I-Ioeva Caoutchouc, or /.] On the Physiological effects of Caoutchouc, 1 eris paribus, by a considerable difference, that of pads composed of softer materials. If there could be any ex- ceptions to this rule, it would be in favour of pads formed of very firm, but highly elastic materials; but the only substance of the latter character now employed in the construction of truss-pads, is gum elastic; and against the direct application of caoutchouc to the skin, there are strong physiological objections." While digressing thus from my main subject, I will remark, that during the last six months I have employed India rubber cloth to a very considerable extent, in the treatment of hernia. Instruments covered with this material, the prepared side turned next to the spring of the instrument, serves not only to protect the spring, but is invaluable, and altogether indispensable to pa- tients under treatment, while visiting the sea-shore, or bathing under any circumstances whatever, when throwing aside their truss would endanger the retention of the bowel. I had these instruments prepared last summer for several gen- tlemen, who visited Philadelphia from the south, in order to be treated for this disease : and I have now three patients from the Island of Cuba, two of whom were labouring under double rup- tures, who prefer instruments of this character for constant use, during the treatment. The only objection that has been found connected with these instruments, is the unpleasant odour arising from the employment of some of them ; but hereafter this will be obviated entirely, from the fact that the cloth oan now be 1837.] On the Physiological effects of Caoutchouc, ction de Medeciite dc la Socteti Acadcmiquc de la Loire In fir ie urc. 680 Ccrebro-Spinal Fluid. [April, good deal ; but that, said M. Magendio, is an inevitable effect of the presence of a foreign body in the vertebral canal.] Third Experiment. The cerebrospinal fluid supports a certain pressure in the interior of the rachis, and that pressure is not without having some in- fluence on the functions of the nervous system. We sh;)]', therefore, endea- vour to see how far this influence can be demonstrated ; and for this pur- pose we shall inject a certain quantity of fluid into the vertebral cavity, and, as a necessary consequence, augment the pressure of the fluid on the con- tained nervous mass. The water we employ for injection is at the tempera- ture of 25 Reaum. We must also take care that the point of the syringe does not touch the nervous substance of the spinal marrow, which, as you know, possesses a very high degree of sensibility. I now introduce the tube of the syringe into the original opening made into the dura mater, and throw in not a very large quantity of water. The animal has already lost the pow- er of vision, and he has now fallen into a state of complete prostration. These phenomena are, as you must be aware, easily explained by the pres- sure which the fluid exercises on the whole cerebrospinal axis. You m^y observe the same fact in diseases of the nervous system : as soon as ever serous effusion takes place, the patient is thrown into a state exactly similar to that of the animal now lying before us. The prostration, however, dis- appears with its cause ; remove the fluid artificially introduced, and you re- store the functions of the animal ; if you leave a free issue, the movement? of respiration are sufficient to remove it. Here then, you see how the intro- duction of scarcely half a small syringe full of fluid was sufficient to deter- mine a state very nearly approaching apoplexy. Fourth Experiment. We have just seen the effect" which would result from any considerable augmentation of the cerebrospinal fluid ; but let ua now consider the influence of changes in its temperature. H itherto we have employed liquids at the same temperature as those of the animal experiment- ed on ; we shall now try the effects of a fluid of a different temperature on the same animal. [Here M. Magendie injected some water at the temperature of 5 Zeait- mer; but a few drops were scarcely thrown in when the little dog began to moan, as if suffering excessively, and was seized with a convulsive shudder- ing, very similar to that of a person in intermittent fever.] Thus you see how the study of experimental physiology may lead to pa- thological applications ; and this is the only manner in which we should pur- sue the study of phenomena which, beyond all doubt, are nothing but physi- cal phenomena, that, nevertheless, throw the greatest light on the nature and cause of those denominated exclusively vital. I confess that experiments on the living animal have many inconveniences attached to them, and are opposed by many humane men ; they are, besides, extremely expensive, but they are indispensable to the advancement of the science, and the interests of humanity. Now, gentlemen, with regard to these experiments relative to the pheno- mena connected with the existence of the cerebrospinal fluid, you have seen how the evacuation of this fluid commonly plunges the most furious and ac- tive animal into a state of complete prostration a condition which continues until the fluid has been reproduced. We have also examined the movement of ascension and descent observed in this fluid, and seen it fall anfi mount in the cavity of the vertebral canal according to the movements of the respira- tory apparatus. Finally, we have demonstrated, in a direct manner, the well-marked influence of the fluid's temperature on the functions of the ner- vous system. These facts are highly interesting to the practical physician, for unless he has acquired correct notions on the seat, nature, and modifica- tions of the cerebrospinal fluid, it is impossible for him to estimate the phe- nomena of serous effusion in the ventricular cavities of the brain, or in the membranes of the pin:i' marrcv. You caw the change almoet injrtantane- 1 9S7.J Ccrcbro-Spinal Fluid* 6* I ously operated by the removal of a portion of the fluid through the opening practised in the spinal membrane. Before that was done the animal appear- ed lively and active; after the operation he exhibited an insurmountable tendency to sleep. This result is seen in all animals, without exception, and would, probably, also occur in man, for in certain diseases of the nervous sys- tem its removal is absolutely necessary. It is a fact which observation and experience have placed beyond all doubt, that augmentation of the fluid, and the consequent pressure, produce serious results. We see constant exam- ples of this in the animal economy, and should hence ever keep in mind that the functions of the cerebro-spinal axis are suspended as soon as ever the nervous pulp becomes pressed on by an increased quantity of fluid. This is a physiological fact of the highest interest. I repeat again, that day after day our hospital practice affords examples of the same phenomena being developed in man which I showed were produced in animals by com- pression, from an increased quantity of fluid. Thus you perceive how ne- cessary it is to make yourselves acquainted with the normal state and pro- perties of this liquid. You also witnessed the phenomena which resulted from elevation or depression of temperature of the fluid, independently of any change in its quantity. You saw the animal in which we injected water at a temperature of 5 thrown into a state very similar to that of a person la- bouring under the cold fit of intermittent fever. Finally, you saw the man- ner in which the functions of the whole nervous system were modified by the introduction of fluid at an elevated temperature. I shall not insist at further length on the importance of your studying these facts, both in a physiologi- cal and a pathological point of view. You are, I hope, fully convinced of this. Let us rather pass to matter more immediately connected with our subject. [Here the Professor desired the assistant to bring in the body of a dog on which experiments precisely like those described in this lecture had been performed, and which died yesterday evening.] Here, gentlemen, is a pathological fact of some importance to notice ; you may observe, in the animal before us, how the relations of the cerebro-spinal axis have been modified; the nervous pulp is no longer in contact with its normal fluid ; the whole surface is covered, as you see, with a purulent ef- fusion, similar to that produced by inflammation of the membranes, or of the nervous substance itself; in a word, the cerebro-spinal fluid has been trans- formed into a purulent liquid. Hence any change in the nature or qualities of the fluid may be attended with dangerous or even fatal consequences. If you remember, during the course of this lecture, we injected a small quan- tity of fluid tinged with ink, and connected with a glass tube, in order to de- monstrate the alternate ascent and descent of the fluid, according to the res- piratory movements : it was a similar change in the quality of the fluid, brought into contact with the cerebro-spinal axis, which produced the pa- thological phenomenon I have just shown you. The alterations, as you may observe, are less manifest in the vertebral canal, because the greatest part of the fluid was thrown up towards the brain ; however, you can dis- cover a thin layer of altered fluid lining the whole surface of the spinal mar- row. Here an important question, connected with the history of the cere- bro-spinal fluid, presents itself. Is the composition of the fluid identical with that of serum, or is it a fluid sui generis 1 The liquid, in its normal state, is transparent, and inodorous : its taste is slightly saltish ; the idea prevailed, for a length of time, that it was pure serum ; at length, however, more exact observations were made the fluid collected from the living and from the dead animal was submitted to the test of chemical analysis, and the latter means soon demonstrated the difference of its cfcmposition from that of se- rum. One of the most remarkable poiat6 of distinction consisted in the pre- sence of an animal matter, in considerable quantity, which the chemists re- gard as osmazome a rubotancr not to be found in ccrum. Since the latest C>&2 Cerebrospinal Fluid. [April, analysis of M. Conerbe, tending to show the exact composition of the brain, we have acquired the conviction that this fluid differs essentially from serum in its composition. M. Conerbe has lately communicated to me a note up- on this subject, and although his experiments were performed on a small quantity of fluid, his skill and accuracy of investigation have enabled him to determine the composition of the cerebro-spinal fluid in a positive manner. He says, that when a portion of the fluid has been evaporated on a glass- plate, the microscope demonstrates the presence of cerebral matter in very feeble quantities ; it seems, in fact, partly composed of a kind of net-work, containing irregular globules, analogous to those which enter into the com- position of the nervous pulp. This, however, is a fact which should not, in the least, astonish us ; you can all understand the possibility of the cerebro- spinal fluid containing some cerebral or nervous globules, for the fluid em- braces the nervous substance on all sides, and may easily carry off with it some of the particles of the brain, or spinal marrow. The density of the cerebro-spinal fluid, compared with that of water, is 1,0110,00; when pure it is colourless, limpid, and inodorous: it acquires a slightly salt taste when abstracted for any length of time from the body. The residue, obtained by evaporating the fluid, is tenacious, elastic, and of a yellowish colour, and contains a deposit similar to that left by the brain. It also contains an animal matter, which is insoluble in ether, or alcohol, but is dissolved by the alkalies. It contains cholesterine and albumine, the chlo- rate of sodium, and phosphate of lime, with the salts of potass and magnesia. Finally, a new element, whose precise nature is not yet exactly made out. Thus you see that the analysis of the chemist whom I have mentioned, has brought to light two new facts of a remarkable kind. The first, and most important, is the fact, that the composition of the fluid bears some analogy to that of the brain itself; the second fact is the presence of the fatty matter of the cerebral substance being contained in the residue of the fluid. From the above observations we are fully justified in concluding that the cerebro-spinal fluid is not identical with common serum, but is a fluid sui generis. Having established this point, we come to a question not less interesting, though more difficult, viz. What organ or organic apparatus produces this fluid ? It is not a serous membrane, for the fluid differs, in the first place,, essentially from serum ; and, in the second, it is not contained in the cavity of the serous membrane, but that of the vascular one ; hence we conclude it is this latter membrane which produces the cerebro-spinal liquid, as a secre- tion from its vessels ; you shall presently see the facts which prove this, and you will be convinced that the secretion lakes place from the pia mater. Keflect on the way in which serous membranes separate fluids they tran- sude rather than secrete ; besides, in a normal condition, the serous mem- branes never present any trace of vessels from which secretion could take place. In cases of inflammation, when they seem to be vascular, the arte- ries really exist beneath the membrane, and you can always detach a serous surface from the false membranes by which it is covered, without any rupture of continuous capillaries, such as we observe in cases where a mucous tissue may be engaged. So far as concerns the secretion of the cerebro-spinal fluid, the pia mater seems evidently the organ which separates it from the blood : unlike the se- rous tissue, the pia mater is highly vascular, and if you take the trouble to examine the cerebro-spinal axis of the animal before us, you will convince yourselves that a modification of capillary action in that membrane has pro- duced the fluid called pus, instead of its normal transparent secretion. It is still more difficult to connect the fluid contained in the ventricles of the brain with a serous membrane. In spite of what Jiichat has said, we persist in the opinion, that the ventricles are not lined with serous membrane ; yet those cavities are often filled with fluid. It appears to me probable that this fluid il not secreted in tho place where it is found after death, but gradually accu- mulates there from the surface of the brain, or spinal marrow. 1S37.J Cerebrospinal Fluid. G )3 If you expose the dura mater in a living animal, incise it, and introduce a coloured fluid into the subarachnoid cavity, you will find that it mounts from the spinal marrow to the cavity of the cranium, and from this latter passes into the cavity of the ventricles; hence there is evidently a means of com- munication between the external and internal fluids, and a possibiJity of the former, by a change of place, being transformed into the latter. In most animals there is no free communication between the surface of the cerebel- lum and the fourth ventricle, and, consequently, no opening, or membrane, like those we find in man ; the transmission of the fluid takes place through a kind of sieve-like apparatus, which permits its passage. This passage docs not take place in certain pathological conditions ; in certain others it is very evident. We also possess very convincing proofs of the fact, that, in the human sub- ject, this fluid may pass from the external surfaces of the cerebro-spinal axis to the internal cavities. I have had frequent opportunities of verifying this fact in one case, in particular, that of a man cutoff by inflammation of the pia mater lining the spinal marrow. I found the whole cavity of the rachis nearly filled with pus, and, on further examination, observed that the latter fluid had passed up from the vertebral canal, as far as the cavity of the fourth ventricle. Hence it seems highly probable, that the fluid secreted at the surface of the brain and spinal marrow makes its way into the ventricle of the cerebellum, and thence passes into the different cavities of the brain ; and, in support of this opinion, I could cite several cases in which the symptoms cf cerebral effusion were considerably ameliorated by derivation practised along the traject of the spinal marrow. Thus you see we have every reason for adopting the opinion, that the cerebro-spinal fluid is secreted by the pia mater on the surface of the nervous centres, and then passes, by a mechanism unknown to us,, to the cavities of the brain. Let us now resume the consideration of other facts connected with the fluid. When we introduce any foreign substance whose nature is easily recog- nised, such as a salt, into the current of the circulation, we find a portion of the substance deposited in the cerebro-spinal fluid. There are two animals now in the laboratory which have just been destroyed by an experiment of this kind. A solution of prussiate of potass was thrown into the veins, but I am at a loss to account for their death. The foreign substance introduced was not a very active one, we might even have thrown in 20 grains without expecting any inconvenience from the injection. However this may be, even in five minutes after the introduction of the prussiate of potass, if the cerebro- spinal fluid had been drawn off, the usual tests would have demonstrated the presence of the salt in it. Fifth Experiment. Thus every substance which is in our fluids may be brought into contact with the whole surface of the brain and spinal marrow a fact, gentlemen, of the highest importance in a therapeutical point of view; for, if it be true, and we have just demonstrated the fact, that various sub* stances pass from the circulation to the cerebro-spinal fluid* a great number of medicaments must follow the same law, and be capable of being brought into immediate contact with the nervous substance. [Here M. Magendie proceeded to examine one of the two dogs above- mentioned, in which a solution of prussiate of potass had been injected ; but as the result of the examination was not conformable with what he assured us he had frequently obtained, he announced his intention of again repeating it on the living animal. The fluid drawn off from the vertebral cavity was perfectly clear and transparent.] The phenomenon just alluded to, gentlemen, depends on the circulation of the blood ; a foreign substance is mixed with the circulating fluid, and carried to all parts of the body ; it necessarily arrives at the smaller arteries of the pia mater, and by them is thrown into the cerebro-spinal fluid. Hence, it 8841 Cerebrospinal -Fluid* [April, you replace the solution of the prussiate of potass by opium, alcohol, or ex- tract of nux vomica, the momtnt these latter substances come in contact with the surface of the brain and spinal marrow, you are struck with the poi- sonous symptoms immediately dcveveloped. YVhen we come to treat of these questions we will show you that the surface of the spinal marrow, and particularly its posterior surface, is the part which feels most quickly the action of substances thus introduced into the circulation an action that'may readily give rise to fatal consequences. Thus you see how authors who neglect the cerebro-spinal fluid, or are un- acquainted with its existence, properties, &c, not only overlook an important fact in anatomy and physiology, but. also render themselves incapable of com- prehending several pathological phenomena of the utmost importance. A Knowledge of this fact is absolutely necessary for every one who investigates cerebral disease ; without it, we constantly fall into uncertainty and hypothe- sis, the fruits of our ignorance, and we do nothing but multiply the already immense number of pathological questions, without contributing anything towards their solution. You will frequently hear pathologists assert, that ef- fusion has taken place into the cerebral substance on the same side as the hemiplegia, or on the opposite side, according as the influence of the com- pressing cause may be intercrossed or not ; but it is probably the condition of the cerebro-spinal fluid which determines the nature and seat of the para- lytic symptoms in a great variety of cases. It is very possible, that while an effusion of blood exists at one side of the brain, there may be an effusion of the fluid at the other ; the latter, then, should account for what the older pathologists called serous apoplexies ; and, perhaps, in this respect, their ideas were much sounder than many modern writers appear to think. The increased quantity of the fluid, beyond what is consistent with the cerebral functions, will cause alterations of movement and sensibility exactly similar to those which result from an effusion of blood. These considerations might be carried much further ; but the objects of our course do not permit us to dwell too long on facts which are purely pa- thological. However, I shall not terminate the lecture without showing you an experiment, at least in confirmation of what I have just advanced, and showing you the effects produced by the introduction of a foreign fluid into the vertebral canal. Sixth Experiment. [Here the professor had a small guineapig brought in.] I told you before that it was difficult to open the sac containing the cere- bro-spinal fluid in these little animals, and that the puncture should always be made between the occipital foramen and the first cervical vertebra. I now divide the muscles of the neck, but the little animal does not present the pe- culiar trembling motion generally produced by their section. The cavity is now opened, and I hope you will distinguish the jet of the cerebro-spinal fluid ; it issues forth rapidly, as you see, but somewhat tinged with blood, and in small quantity ; indeed, the fluid is generally not very abundant in the guinea-pig. The tincture of nux-vomica has the remarkable effect of producing tetanic contraction of the muscles, and it is this substance which we now propose introducing. [Here the Professor injected a very small quantity into the opening he had practised in the vertebral canal. Scarcely were a few drops thrown in, when the animal was seized with violent convulsive movements, and fell dead before the tetanic symptoms had time to develop themselves.] You see the sudden and violent effect of this medicament when brought into immediate contact with the surface of the cerebro-spinal axis ; a few tetanic coninjleions have barely appeared, and the animal has ceased to exist. It is unnecessary for me to dwell on the various consequences that might be drawn from the experiment which I have just shown to you. 1837.] On Schirrous and Cancerous degenerations, fyc. (>R5 Remarks on Schirrous and Cancerous degenerations of the Uterus: By Dr. Stefano Bamalari, of Chiaviri. With good right may modern surgery boast of possessing means capable of conquering diseases which, on account of their nature and situation, were considered by our predecessors as exceeeding the resources of art and aban- doned to their fate as incurable. The ligature of the iliac artery, of the subclavian and of the carotid, for the cure of aneurisms, the useful precepts resulting from incessant anatomical in- vestigations, for the different operations of which the numerous varieties of hernia admit, the perfection of the greater part of operative processes, the invention of new methods, are to be numbered among the happy discoveries with which surgery has been enriched in the present age. Of not less benefit than these, and those of former times, is the operation designed to remove the morbid disorganizations of the uterus, an operation practised, the first time, in the beginning of the present century. There were already recorded, in the annals of the science, operations per- formed and crowned with success on the prolapsed uterus. It was reserved for the most sublime Italian genius, for our immortal Monteggia, first to pro- pose to extend the knife to parts so concealed and to make known the possi- bility of obtaining fortunate results. If Monteggia does not for the first put his suggestion in practice on the li- ving subject, it is because a suitable occasion does not present itself, for so exact is the picture he draws of this disease, and so precise and useful his instructions, that he is properly considered not only to have discovered the possibility of performing such an operation, but supported by substantial ob- servations to have scientifically proposed it. Ossiander of d'ottinga, is the first who performed it on the living subject, and after this epoch similar observations were repeated in various parts of Europe; in the intoxi- cation caused by frequent good success, it was tried in extreme and des- perate cases, whence not few were the operations performed that had an unfortunate result, and the operators that undertook them weFe disappointed in their expectation. It happened therefore with this, as with many other useful inventions and discoveries in medicine and surgery, that the opinion of practitioners was divided with respect to the utility of such an operation ; there arose not a small numher of modern writers to discredit it, and to de- clare the operation to be most daring and very seldom successful. Seeing authors yet disagreeing with respect to this important point of prac- tical surgery, I think the cultivators of this science ought to make known the facts which occur in practice, and which may be of some utility in illustrating this still controverted subject. Moved by such a principle, I render, as of public right, the history of an operation of this kind which I made; and it is my design to demonstrate it, the excision of the neck of the uterus to be not only a most useful operation, but the sole mean capable of curing a disease which in its nature inevitably produces the death of the patient. Maria Vaccari, a widow of Lavagna, aged 47 years, of sanguineo-bilious temperament ; visited by me the first time the 20th of June, 1835; informed me that she had been many years ago affected with puerperal metritis and that she had had five births. It was eight months since the commencement of her disease, which made its appearance with irregularity of menstruation, debility, anorexia, sense of pain in the vagina, hypogastrium and loins at irregular intervals she suffered leucorrhrea and monorrhagia; the day pre- ceding that on which I visited her, she sustained a frightful loss of" blood which ceased spontaneously; there was great prostration of strength, ca- chectic habit, continued fever, with very marked evening exacerbation^, map. 686 On Schirrous and Cancerous degenerations, <$c. [April, petence, a sero-sanguineons discharge from the vulva of most offensive odour. On manual examination, there was discovered a tumour at the neck of the uterus, hard, knobby, painful to the touch, extending over all the inferior lip of the os tincae, readily dropping blood. Introducing Recamier's speculum, I observed this tumour to be of a dark-red colour, of an irregular surface, of the size of a hen's egg, and of considerable hardness. The surrounding parts were in a sound stale, except the posterior wall of the vagina, which was ex- coriated and inflamed. The invalid consented to subject herself to an operation, which was per- formed by me, the 30th of June, in the presence of my distinguished friend, L. Sanmichele and A. Solari, surgeon. The patient being situated as is usual for the operation of lithotomy, the assistants being conveniently arranged, I introduced Recamier's speculum, and conducted it so that the superior smaller extremity joined the superior part of the vagina, and the tumour which was quickly turned back was con- tained in the hollow of the instrument which I trusted to an assistant. This being done, I prescribed a strong injection of tepid water to wash the parts on which the operation was to be performed ; then with the left hand I took the double hooked forceps and with the right the curved scissors ; 1 held the tumour fast with the first and with the latter, by several cuts, made the exci- sion. The operation, which was not very severe, occupied a very short time, and the patient assured us that she had suffered very little. The dressing was with simple dry lint. The extirpated tumour being examined, presented all the characters of can- cerous tissue ; in the interior it was divided by various whitish bands, shining as cartilage, and shewed some points of fusion, containing a humour of vari- ous color and consistence, and the walls, where such fusions appeared, were softened. Nothing remarkable occurred during the cure ; the febrile reaction was light; frequent washing, dressings often renewed, consisting of soft lint, and two applications of nitrate of silver perfected her recovery. The natural opening along the neck of the uterus remained pervious, and Mrs. Vaccari regained her original state of florid health. Having visited her four months after the operation was performed, every thing convinced me that I had found her in a state of permanent restoration to health. It is not my intention here to extend a treatise upon cancerous degenera- tion of the uterus, others who have preceded me have, by their labours, left little to be desired : I will not then enumerate the opinions advanced on can- cer and schirrus, nor agitate questions so often discussed ; whether cancer- ous affections be local or constitutional diseases ; whether they ought to be considered as critical or metastic maladies, according to the idea of Ques- nay, to which Scarfa still appears to adhere ; but my design is, in making 6ome remarks on cancerous and schirrous affections of the uterus, to restrict myself to true experience, the great instructress in all things. In many cases of cancerous ulcer of the uterus examined in hospitals, and in those that have occurred to me in my private practice, I have constantly seen that the disease first attacks the neck of the uterus, the so called os tin- cae ; therefore, supported by these facts and many others related in the works of the most correct observers, I doubt very much whether this disease can, in its commencement, invade the fundus and the body of this organ. The cancer of the neck of the uterus does not present itself with the aspect of can- cer, with schirrous base, as that which occupies the glandular tissue of the mamnrue, of the parotids, but assumes the appearance of cutaneous cancers, and has the greatest analogy to cancerous affections that attack the dermoid tissue of the face ; similar to this* it has its origin in the integument, on which small tumours or knots arc developed, which ulcerate, extend in depth and size, unite together and render, in a shorter or longer time, the neck of this J 637,] On Schirrous and Cancerous degenerations, . 18^.] Case of Excision of the Elboic Joint. 689 Tiie operation was performed in the presence of my colleagues, Drs. Bar- Ion and Randolph, the house physicians, Drs. Kirkbride and Gerhard, and * large class of medical students. The operating table was covered by a mattrass, and she was placed on it With her face downward?, by which the back part of the r.rm could be more readily commanded. The operation was performed according to a plan pro- posed by Moreau, and afterwards successfully practised on by Mr. James Byrne, surgeon to the Edinburgh Surgical Hospital. The figure II gives an outline of the first incisions. The transverse cut was made by passing the point of a strong bistoury above the olecranon process, and parallel with its inner edge, by which the skin, cellular texture and tendon of the triceps mus- cle were divided. It extended to the radial side of the tuberosity of the hu- merus, and at such a distance from the inner one as to avoid the ulnar nerve. J then cut upwards and downwards for the space of an inch and a half from ejther end of the transverse incision, so as to form two flaps, which, when dis- sected off the joint, fully exposed the olecranon process. The soft parts, in- cluding the ulnar nerve, were drawn aside by curved spatuke, and then, by means of a common amputating saw, the process was readily removed. The condition of the joint was now carefully examined, and all the articu- lating surfaces were found to be in a state of caries. I first divided the lig- amentous connexions, and then, with the aid of nippers and the oblique cut- ting pliers, the head of the radius and the diseased surfaces of the ulna and humerus were perfectly removed. After securing two branches of the artic- ular arteries, the joint was neatly cleansed, exposed to the air for a short time, until the oozing of blood ceased, then the flaps were laid down, main- tained in their position by 6Utures, and afterwards dressed in the ordinary way. The chief difficulty which I experienced in this operation was in avoiding the ulnar nerve. In the natural condition of the parts, as for example, in op- erating on the dead subject, the nerve can be easily placed without the reach of the knife ; but when the soft parts are altered in their nature, when the structure becomes thickened, dense, and unyielding, it is necessary, in order to avoid wounding this important nerve, to observe the greatest precaution. The operation being severe, gave no inconsiderable shock to the nervous system, which was evinced by stupor, difficulty of articulation, deglutition, and respiration. These symptoms were removed, however, in 24 hours, by sinapisms to her extremities, and stimulating enemata. On the 7th, the symptoms were improved the pulse 34 in a minute, and the skin cool and moist. On the 9th, the wound was dressed, and exhibited a healthful appear- ance. On the 10th, secondary haemorrhage supervened, preceded by intense pain in the joint. The flow of blood was arrested by compression,* but not until she had lost about sixteen ounces. Neither the bleeding nor pain ia the wound was renewed, but she occasionally Buffered excruciating pain about the umbilical region, which, however, was always speedily relieved by lauda- num injections. July 25th the patient is walking about her ward, with her arm in a eling, and secured by angular splints. Hectic fever and cough have disap- peared; appetite good; strength returning, and her health in all respects rapidly improving. July 80th patient has a considerable degree of motion in the joint, tie wound is nearly healed, and she has every prospect of having a useful arm and good health. Being poor, and lacking comforts at home, she was per- suaded to remain in the hospital until her health wis entirely recruited, and her arm so completely restored, that rhe would incur no risk in resuming her rough and laborious duties. 87 690 Case of Excision of the Elbow Joint. [April, -- - - M i ,. . Dec. 4th, 1836, this patient called at the Pennsylvania hospital, was ex- amined by Drs. M'Crea and Kirkbride, and found not only in good health, but her arm very little deformed, considerable motion in the new joint, and perfectly able, according to her own account, to work in the hard way to which she had been accustomed. The result of this operation, which, so far as I know, is the first of the kind performed in the United States, is in every respect gratifying. It is the more so, as our amputations in the Pennsylvania Hospital have terminated, in so many instances, fatally. During the last two years, we have lost at least one in four cases, by the formation of metastatic abscesses, either in the brain, lungs, or liver. It has been reported by the surgeons of the .Hotel Dieu, that more than half their amputations terminate, in the same discoura- ging manner. Nor ought this effect to excite our wonder, since by lopping off a considerable portion of the body, the equable action of the system is, in some degree, destroyed, causing thereby more or less disturbance in its func- tions. The objections to this operation consist in the difficulty in performing it, and the great suffering which it causes. These objections, however, are more than counterbalanced by placing the life of the patient in less jeopardy and by the preservation of a useful limb. Of fourteen cases of diseased elbow joint on which Mr. Syme operated, eleven perfectly recovered. IS 37.] Medical Society of Augusta. 001 Part III. MONTHLY PERISCOPE. MEDICAL SOCIETY OF AUGUSTA, February 22nd, 1837. The Essayist read the essay which constitutes the first article in the present number of this Journal. We refer our readers to the essay for the question for debate. The essayist states that he has conversed with all the physi- cians of Augusta, and that they are as seven against pessaries to one in favor of them it will appear, however, that of the mem- bers of the society, a large majority were only opposed to the indiscriminate use or abuse of pessaries, and not to their judicious employment. Dr. Bowcn stated he had known pessaries, in one or two ca- ses in the practice of other physicians, do harm that he had him- self applied pessaries in many cases and certainly without inju- ry he could not say but that these cases might have been re- lieved as well by other remedies; recommended a bag of com- phrey to be introduced into the vagina, to serve as a pessary, to maintain the uterus in place when irritated or inflamed this he considered to act both as an emollient poultice and a support : esteemed the woollen pessary employed by Dr. Antony superior to all other kinds or forms. In conclusion, believed that pessa- ries are sometimes productive of good and ought not to be aban- doned. Dr. Antony observed, that he differed widely from the essay- ist on so many points, that much more time was required than could be allowed him, in the debate, to express his views. He conceived that very important principles were jeoparded by the essay, and that he disliked to enter upon their discussion, unless he had at least several hours 'before him. He regretted that this subject had been chosen for this even- ing's discussion a question which he conceived directed pecu- liarly to his own views arid practice, and which had, one way or another, been so often before the society that every member ought, by this time, to have become fully possessed of his opin- ions and testimonials on the subject. Nor would he say a word, but from the dictates of a sense of duty to those present,' who were here for the purpose of being taught, and whom it was his duty to guard, as far as opportunity oh. . ,aist the reception of unwholesome doctrines which, if received, must necessarily lead to practical errors, cither active or passive ; the result of either ot which could be entitled to but little choice with those * The medical class. 602 Medical Society of Augusta. [April, whom they might be called to serve. He would therefore use the present occasion for observing, that the essayist was radi- cally wron^in many particulars touching the question under dis- cussion. He was wrong in forestalling the minds of his hear- ers by what may be considered, begging the question, which he does throughout, on what he is called to argue. He was wrong in considering the pessary as an exclusive treatment, in opposi- tion to and separate from all other plans, or parts of treatment. He was wrong in treating on it as applied indiscriminately to all cases of uterine displacement. He was wrong in so gener- alizing pessaries, as not to distinguish between one kind and ano- ther. He was wrong and unjust in advancing the opinions and expressions of his correspondents, or of those with whom he had conversed, which opinions were evidently in relation to the pes- saries in general use, as applicable to all possible forms and con- structions of pessaries ; particularly such as they had never seen, and perhaps never heard of. Essays and opinions he said, were written, and opinions expressed, relative to such pessaries as were contemplated at the time of offering such opinions; for he would not accuse practitioners of offering condemnatory opin- ions, or any others, the least decisive, on such as they had nei- ther seen nor used. Nothing, therefore, could in his estimation be more unjust to those whose opinions had been brought for- ward by the essayist, than to take these opinions and apply them to an apparatus which could not have entered into the minds of those who had advanced them. The essayist was wrong in ap- plying even the experience of practitioners with some pessaries, to the use cf others which, in construction, materials, mode of operation, &c, are essentially different. He was wrong in en- deavoring to withhold from suffermg humanity the wholesome influence of the truths of extensive experience, by interposing his own opinion, which is professedly v/iihoutany experience in the use of the practice. He was wrong in denying the compatibil- ity of their use with what Li^franc considered hypertrophy, but which he (Dr. A.) considered chronic metritis ; and in asserting their positively injurious and destructive efl ects on those parts ; effects of which, with his own alleged entire want of experience, he could not possibly be allowed to have any idea except mere supposition. Dr. A. said that he, whom the essayist regarded ns the most strenuous and almost only advocate of pessaries, does not employ them in every case; nor does he depend exclusively on them in any. With respect to the pessaries in general use, he was prepared to say that having, on ample experience, found them altogether inadequate to the fulfilment of the indication, h* had long since abandoned them-^-that he would not, for practical purposes, give one cent for sli the pessaries in the museum, be- cause he knew they could effect very little, if any good, except possibly in some cases of procedentia, where they might palliate 1537.] Medical Society of Augusta. (VJ3 the distresses by retaining the uterus within the vulva. He em- ployed a woollen pessary only, and whieh was so constructed as to retain with great certainty the uterus at its proper site during its use ; and whieh, although the essayist might be never so much surprised at the statement, when properly impacted yes, im- pacted between the uterus and fossa scaphoides, has the power of gradually restoring the uterus to its proper site, when, from chronic metritis or other causes, it has become so fixed below, as to defy the efforts of the fingers for replacement, to say nothing of the powers opposition. And that, in such cases of great immo- bility of the uterus, a two day's use of a small pessary, well im- pacted, was often found sufficient to prepare room for a larger one, and so on, until one of three or four inches could be received, which was sufficient, with females of ordinary stature, to retain the uterus at its proper place, and allow an efficient action of the absorbents for the removal of swelling, or M. Lisfranc's " simple hypertrophy." But, he continued, the essayist might be still more surprised to learn, that so far from "obstructing the menstrual flux," his choice time for their application was immediately in anticipation of and during the period, and with the happiest effects in restoring and regulating the discharge generally rendered more or less irregular by that state of things which so much demands the use of pessaries. And the essayist would surely be astounded to hear, with his dreadful apprehensions about chronic metritis, that he had often used them with the best effects, made of wool of the coarsest fibre, selected for this quality, for the very pur- pose of producing a- general irritation of the relaxed and debilita- ted vagina, the effect of which was, on recovery, (the uterus be- ing kept strictly from descending into it again.) to leave the va- gina of much smaller dimensions, and more effectually resisting the descent of the uterus by its better contraction the main purpose to be effected in all cases, and which cannot be in some, by other mean>\ He granted that authors had been very defective on this dis- ease, not only in regard to the treatment, but also the diagnosis ; hence it was, he said, that but a few years had elapsed since even the physicians of this place, for whom he had high respect as general practitioners, rarely distinguished a case. And whence it was, that on removing to this city eighteen years ago, and de- claring the existence of a few cases, so little had females heard of such cases, that it appeared to be for a time the current belief that a new disease had appeared amongst them ; and as to the practitioners, many of them denied r.ny thing like a frequent oc- currence of prolapsus in any, and positively denied the possibili- ty of it in unmarried ferm!e\ be i ^marked, that those ramifications which make an infinite number of convol around themselves, run back- ward, forward,, and in every direction, forming a great number of areola? and anastoi with all other vessels about them, and with themsel' ?e have just described, are, in the ordin- 'i- vacant state of the uterus, extremely delicate; as they must be to be indosed in so small a space and dense a body as ihe uterus ; but become, by the tern nancy, a line or more in diameter. It is believed by Madame Boivin, that the greater redness ob- servable at the fundus than in the rest of the uterus, is owing to the stronger and more direct impulsion of blood from the larger and higher parts of the aorta, through the branches of the sper- matic, by which that part is mostly supplied. The veins of the uterus, like the arteries, form spermatic and uterine trunks. The spermatic vein is much larger than the ar- tery. It ramifies as in the male, and forms a very large plexus, which constitutes on the forepart of the psoas muscle, what has been called the corpus pampiniforme, Many of the veins which form the body, originate near the ovaries, but a considerable num- ber arise also from ihe tubes and the uterus. But the most im- portant veins of the uterus, are the branches of the uterine veins. These are extremely numerous, and form a plexus on the side of the uterus, from which two or more uterine veins proceed in the course of the artery, and join tho hypogastric. All the veins of the uterus are greatly enlarged during pregnancy, some becom- ing large enough to receive a common-sized quill, and others, the end of the little finger. These latter have received the name of uterine sinuses. Pax ton says., "the veins of the uterus follow the arteries very much in their course, but are more tortuous, and become so large in the progress of pregnancy, as to receive the term uterine sinuses.'' The elder Baudelocque says, "the most considerable of the openings which constitute the reticulated ap- pearance of the lining membrane of the uterus, lead to winding cavities called uterine sinuses."' Cruikshank said the lymphatics .of the uterus become, by pregnane rge as a goose-qoill, ?I6 On Menstrua! Ir regularities. [May, - > i . , . . . . i ., i ii i > and appear so numerous, that the uterus seems to be nothing but a mass of these vessels. The vessels of the uterus are said to be enlarged in like man- ner during the menstrual discharge, though not to such an ex- tent. Now the truth is, the uterus is a very peculiar organ not less wonderful in its anatomy than in its physiology. Its fibrous and vascular structure have constantly perplexed anatomists; and to the present day, they are undecided as to the muscular or non-muscular structure of its substance but they have latterly determined distinctly its fibrous organization, from observations during gravidity ; and conclude that as they could not be sup- posed to be produced de novo, during each pregnancy, and non exist again in the unim pregnated state, that they really exist at all times in the uterus, but in so compact a state, as to be un- distinguishable. The same extent of doubt or indecision has existed about the lymphatics in the uterus. This question has likewise been decided by observations on the gravid state, by which Cruikshank, on finding them become as large as goose-quills, and so numerous, said that the uterus seemed to be nothing but a mass of these vessels. (Were it in place here we should have occasion to use this fact of anatomy, to the explanation of some interesting points in obscure pathology ; but it would be devia- ting from the particular purpose of this essay, and could only be proper in a treatise on the pathology of schirrous degenerations, as they arc called, or chronic metritis; or on the secondary af- fections from prolapse of the uterus.) The same difficulty might have been before the anatomists relative to the vascular arrange- ments, at least in regard to their extent. Nor could the neurol- ogy be decided, to its true extent, until the observations were extended to the pregnant stair. Here every thing becomes magnified, as by a powerful lens the mystery of organization made clear, and the nerves in the organ found extremely numer* ous. " Les nerfs des organes genitaux sont extremement nom- breux."* The same difficulty, we continue, still exists to some extent relative to those winding canals called uterine sinuses ; and their very existence denied by some, because forsooth they are not always visible as such, in the vacant uterus. *Boivio. 1837.] On Menstrual Irregularities. 717 The secret of this matter is just this: that all these parts are most wisely and beautifully arranged by perfect wisdom, (acting by the impulse of the final cause, the perpetuation of the species,) to answer the demands of both the pregnant and vacant state of the uterus. The vessels anastomose and inosculate and abound with flexions and tortuosities, as in no other part, in order that their purposes may not be lost to the necessities of the uterus in any state that when necessary, they may all transmit blood copi- ously through all their branches, as the uterus enlarges in preg- nancy, and be extended by the growth of the foetus not only without injury, but even, by straightening their course increase the facility of circulation just in proportion to the ratio of increase of the foetus, as it advances in growth. And the vacancy of vir- ginity, or that which follows childbearing, a sufficiently abundant passage for the blood exists by way of the anastomoses, under that contraction of the contractile fibres of the uterus which closes or obliterates for a time many of the branches whereby circulation through the substance of the uterus is abundantly ef- fected during pregnancy. The absorbents too, become conspic- uous, according to the increasing demand for their function, and recede again from view when this becomes unnecessary. But it is a fact of observation, that the vessels of the substance of the uterus become evidently enlarged on the approach of the men- strual period no matter whether general or local plethora, or lunar influence, or something yet unnamed, tend to cause the menstrual returns. This is observable, not only in the appear- ances of the part under the knife, as witnessed abundantly by Mauriceau, Madame Boivin and many others, but also by the touch. The experienced touch will readily detect, if there be no disease of the substance of the uterus, by the appearance of the organ to this sense, the period for menstruation, or the length of time that it has passed, &c, and the characters it exhibits are those which declare an increased fulness of blood ; which must, of course, arise from an increased fulness of its vessels. It is farther illustrated by collateral symptoms; as when a woman approaching the menstrual period, is troubled with pains in the head, loins and pelvis, finds herself relieved the instant the men- ses appear symptoms and circumstances which would, in re- lation to any other part, be taken as satisfactory evidence of in- crease of blood in the part from which the haemorrhage came: 71 8 On Menstrual Irregularities. [May, as when headache is relieved by epistaxis, <&c. A very similar state of the os tines? is indeed observable on the approach of the menstrual period, as is presented early after conception. It is a state of increased vascular repletion, evinced by tumefaction and sometimes tenderness. This increases until the uterine sinuses, (a most wise and beautiful, arrangement, but not without its an- alogy in the system.) begin to pour out their contents through the largest reticular openings of the lining membrane into the cavity of the uterus. Thus is menstruation effected, by the dis- charge of pure blood. "Procidit autum sanguis velut a victima, et ceto coagulatur, si sana fuerit mulier.'1* " La qualitedu sang des menstrues ne parait pas differer de celui qui circule dans tout \e systeme, lorsque la fern me est saine, bien conformee, et qu'elle fait usage des moyens que la sante et la proprete exigent."! This blood of menstruation here becomes immediately incor- porated with the non-coagulating mucus, which ever (in a heal- thy state.) lines the uterine cavity, and is distilled from the os tinea?, when it mixes again with the secretions of the next pas- sage, the vagina, before it finally escapes the vulva, and thus com- pletes the formation of its whole character as a menstrual dis- charge. Were this the proper occasion, there would be little difficulty in proving that so far as regards the uterus, the menstrual dis- charge is simply a periodical haemorrhage, to which nature, ever strictly and most wisely economical in all her purposes and oper- ations, has adapted the organization; notwithstanding the con- trary opinion has been given by high authority. With the preparation of mind which the foregoing summary of anatomy and physiology is calculated to afford, for a due re- ception of those etiological views which were the object of this essay, I shall now proceed to state my views relative to the pa- thology of " obstructed menstruation ; and this may be done in lew words. It is most true, that a certain impression made on the system by cold, has the power of obstructing the menstrual discharge. * Hippocrates. jBoivin. Also, when speaking of having had opportunities of seeing the uterus of many young females who died during the menstrual epoch, she said, the internal face of the uterus was "converte d'une couche de sang- cTun rouge vif. LHM.] On Menstrual Irregularities. 1lO This is most easily and commonly done by cold, if moisture be combined ; as by wetting the surface, wearing a damp linen, ta- king off flannel from the skin, wetting the feet with cold water, &c. These are causes which give men, and women at other times, and sometimes in connexion with menstrual obstructions, pleu- risy, rheumatism, catarrh, &c. &c. On the subject of the man- ner in which cold operates on the susceptibilities of the system in the production of these effects, we cannot be allowed room on the present occasion. The result, no one denies. The treat- ment is as simple as the pathological facts. The same treatment timely adopted, that is ordinarily recommended for the restora- tion of perspiration when suppressed by cold, will generally prove competent to the purpose desired here, that is to say, the restora- tion of the menstrual flux. It consists ofpediluvium,semicupium, sudorific ptisans, as of sage, pennyroyal, thyme, catmint, savin, camphor in large doses, opium with antimonials, local relaxing applications, &c. &c. When the symptoms are more severe, and an inflammatory action discoverable, a full antiphlogistic treatment in proportion to the state of the system becomes ne- cessary. Should the time have passed at which nature's tenden- cy to this topical depletion exists, (for there is some influence which determines a periodicity,) and the means used, come short of the desired end, the evils of the present suppression on the system are to be guarded against, by depletion, &c, if need be, and the next menstrual period awaited. When this occurs, a diligent course of such treatment is to be again adopted, which, if no organic injury shall have been sustained, by the uterus or some other part, will generally be found adequate to the end in view. Should other diseases occur consequently, they are to be treated according to their specific character, always bearing in mind the peculiarity of cause which produced them. Is it pleu- risy, bronchitis, hepatitis, colic, &c. &c? With all the appro- priate treatment these specifically require, they may change lo- cation, but may not be expected to be cured, without the correct tion of the prominent and peculiar cause, the obstruction of the menses. The lighter parts of the treatment here advised in cases of obstructed menstruation from cold, operate by effecting alike in the skin and uterus, that state of action which favours the free and easy transmission of their appropriate discharges. This 720 On Menstrual Irregularities. [May, cause, (cold), is that which is generally alleged by the patient at (he onset in giving the account of her case ; which on close and pointed enquiry will be found not to be the fact in a very large majority of cases. Her declaration is however made in the spirit of truth, for knowing no other ordinary cause, she really believes she suffers these effects from cold, without knowing when or how it was applied; or she perhaps ascribes the case to some trivial exposure which made no particular impression on the system, merely because it may have been the only irregu- larity of temperature to which she may have been exposed. There are other causes which operate in a very similar manner to cold, in causing this obstruction. Amongst these we may name the severe influence of fear. But there is another cause, by far more common than all oth- ers collectively, and which operates on principles entirely dif- ferent from others to which I have alluded, and will generally be fpund to have produced the various irregularities, and some- times the entire obstruction of menstruation. This cause is some degree of pro'apsus, of the uterus ; a cause from which, when we contemplate the attachments of this organ and the functions for which it is peculiarly adapted, we are rather surprised on find- ing any exempt. This displacement is produced by a great va- riety of causes.* And amongst the naany, I will name one which is perhaps more apt to deceive in the case than any other. It is the violent bearing-down; pains which sometimes attend cases of obstruction from cold, as a well known cause of the beginning of the case. But 1, would be careful not to limit the reader's mind to this cause of prolapsus. The other causes should be easily detected by the practitioner ; or when no particular cause which appears adequate can be remembered, still it does not fol- lpw that it has not existed. Every practitioner who even dares prescribe for the diseases peculiar to females, should be able to detect the existence of prolapsus, in any degree, by his familiar- ity with the symptoms it produces. * See various authors on this subject, and then make great allowance for the superficial views of most writers on prolapsus. It i& not a little surpri- sing that a source of so much affliction and danger, and a prolific cause of so? many secondary diseases and dangers to females, should have been so disre- garded by authors and systematizers, when they know that many of their readers look to their words as the ullima thule, or as the truth, and the whole of the truth in medicine ; and think that it is medical heresy to doubt their statements, or to say that there are more truths than they have given. 1837.] On Menstrual Irregularities. 721 Perfect regularity only is compatible with perfect health. Menstrual irregularities are, however, frequent and various. They are mainly : Jst. Difficult, or painful menstruation, 2nd. Deficient menstruation, 3rd. Retarded menstruation. 4th. Obstructed menstruation. 5th. Excessive menstruation. (6th. Accelerated menstruation, 7th. Protracted menstruation. The first four of these are believed to be dependent on arterial, and the last three on veinous obstruction, when arising from any displacement of the uterus. Most women will, on being asked if their monthly visitations are regular, answer affirmatively, notwithstanding some one, or many of these features, or species of irregularity, exist ; and it is an examination not at all to be relied on under such an answer, without specific interrogations on all of these features of irregu- larity. Some women really believe that any occasional return of menstrual discharge, no matter how various in quantity, man- ner, &c, cox^stitutes regularity of this function. Others, and in- deed a large majority in good society, and even amongst the blacks, are compelled by their native modesty and diffidence on this subject, to avoid every word which they can. The most they can say is the monosyllable yes, or no; and the latter is of- ten avoided when it should not be, lest it should lead to the ne- cessity of farther expression on the subject : indeed the answer is often expressed by a nod or shake of the head the former being an affirmative and the latter a negative reply. Nothing is more common, on direct interrogation to the point, than to find, after this affirmation, by which the patient expects to prevent all fur- ther direction of attention to this subject, that she suffers unusual distress in some way, before, during, or immediately after the menstrual discharge ; or that it is deficient in quantity, or exces- sive in the rate of flowing, retarded several days, or even a week or two beyond the lunar month, from the beginning of the last flux ; or that it appears some days, or a week or two earlier than the lunar month from the commencement of the former pe- riod ; or that, although flowing at the proper rate, the continu- ance of the flux is extended some days bevond the ordinary lim- 91 ?22 On Menstrual Irregularities. [Mayr itation in pristine health that it ceases for a time and recurs after short and irregular intervals, &c. That which is common- ly the first and ordinary interrogatory in these cases, that is tc* say, " are your monthly visitations regular V is therefore not only useless, but very liable to mislead. I will define each of the usual species of irregularity, in order that by bearing them in mind, a greater degree of precision and accuracy may be con- veniently and certainly arrived at, both in the detection and the diagnosis of disease. 1. Difficult menstruation. This is a case in which the pain, or other unusual distress attending the monthly period, is the chief or leading feature of the case, or the particular point of deviation from the healthy flux. 2. Deficient Menstruation. This may be either from partial retention or suppression. In this case the leading feature is a< deficiency in the quantity of menstrual discharge during the pe- riod ; of which there are two varieties : First, from too slow a rate of flowing or, secondly, from, too early a cessation, although* the flux be sufficiently free whilst it continues* 3. Retarded menstruation. In this case the leading feature is the retardation of the flux from half a day to two or three weeks, after the end of the lunar month. 4. Obstructed menstruation. Under this head is included all those cases in which there is no coloured discharge ; whether from undue retention at puberty or after childbirth; or from stop- page occasioned by other causes. 5. Excessive menstruation. In this case there is a greater quantity discharged each month than is natural. Of this species there are likewise two varieties: first, from too long a continu- ance of the monthly flux, or its occasional recurrence ; and se- condly, from so transcending the ordinary rate as to cause the loss of an excessive quantity each month. 6. Accelerated menstruation. In this species the leading fea- ture of the case is the too early accession of the menstrual dis- charge, varying from a few hours to many days. 7. Protracted menstruation. In this the quantity discharged each month is natural, but requires a longer period than in the healthy state of the individual, differing from a few hours to ma- ny days even the whole lunar month. It is not unusual for two or more of these species to be com- bined in the same -case. 1837.] On Menstrual Irregularities. 723 j - i , j When we contemplate the manner and extent of the vascular arrangements of the part,* no difficulty need be felt in determin- ing the mode of operation of this cause in the production of the irregularities in question. Whether the menstrual be considered a, true sanguineous discharge, or a peculiar secretion, no one will contest the fact that the blood from which it comes is brought to the uterus by the arteries, which are chiefly the uterine branches of the spermatic, and those of the hypogastric, generally noticed under the name of the uterine arteries. The former of these enter the uterus laterally, near its upper part, after passing through the lateral, or broad ligaments formed on either side by duplications of the peritoneum ; the latter, approaching at the cervix and distributing themselves, as they pass upwards, to the whole substance of the uterus. The functions of these proceed with beautiful regularity and exactness during the continuance of the uterus in place, or its extension upwards in the progress of gestation. But no- sooner do we contemplate the flexure of the latter on themselves, as it must almost necessarily be by the descent of the uterus ; or the compression of these, or of the for- mer, by the bearing-down of the uterus, with, or without ante* version, retroversion, or some lateral obliquity, than we see a competent cause of arterial obstruction and a resistance of great- er or less extent, to the free transmission of blood to the extreme branches of each or either, and into the uterus; and consequent- ly a failure of that free diffusion of blood in the organ, by which alone can the menstrual discharge be afforded. The consequence of this obstruction of some of the ramifications- must necessarily be an increased fullness, and in many instances, a painful disten- sion of others into which the obstructed blood may pass. Hence arise the pains of the first, second, third and fourth species the scantiness and tardy appearance of red flux, &c. And hence also arise, other effects which, in their nature, produce series of other troubles and dangers, as spinal irritation about the junction of the last lumbar vertebra and the sacrum, or the whole of the sacral portion of the rachedian centre. Hence arise also congestions, tending to hemorrhois, fistulse. abscesses, recto-vaginal ulcera- tions, pulmonary or hepatic affections, cerebral oppressions tend- ing to epilepsy, catalepsy, chorea, mania, &c. Of these, I could cite some hundreds of cases directly in point, and well illustra- ting some one, or several of these views. I will give three or * See Anatomy ; also, Tiedman's Tables of the Arteries. 724 On Menstrual Irregularities. [.May, four by way of illustrating some of the more difficult views, or some of those most liable to be doubted by those who are unac- quainted with this part of pathology. The first case I shall give, was one of a coloured woman, who had laboured many years previous to my seeing her, under the following, which is a very common succession of these species : first difficult or painful menstruation, then deficiency, and finally, total obstruction. When I first saw her, which was as far back as the year 1821, she had not had the least appearance of men- strual discharge for the four last months ; but in its stead, as I believed, and certainly, at or about each period for menstruation, a copious purulent discharge from the rectum was effected. I saw her soon after her fourth discharge of this kind. This case had been for several years under the management of the late Dr. Brux of this city, after whose death it was placed under my care. Consequently I was dependent on her own account for the chief history of the past part of her case. On examining the uterus by the touch, I found it extensively prolapsed, and con- siderably swollen. I replaced it and enjoined suitable position for a few days, or until the purulent discharge should cease. Daily the ordinary distresses of prolapsus returned, in conse- quence of her necessity of rising from bed to obey the calls of mature, and allow the free evacuation of purulent matter per ano. On the cessation of this discharge, I applied a pessary made of soft materials, and of such size and shape as to retain the uterus at its proper site. After several days, this was re- moved and a strong solution of alum was used twice a day, as a vaginal injection after replacement. About a week before the next menstrual period, another pessary was applied and worn through the period, which instead of producing a purulent dis- charge as a the last four months, was attended with a pretty good menstrual discharge. The same treatment was con.tinned about two months longer, when the patient was discharged well, and in the enjoyment of a fine increase of corpulence, and has been ever since, an able washer-woman in this place. The second case I shall give, was one of recto- vaginal open- ings, two in number and one of them of considerable size, and which afforded a free transmission of fecal matter through the iower part of the vagina, and out at the vulva. This had been a well marked case of prolapsus for about three years, which was 1837.-] On Menstrual Irregularities. 72f> brought on suddenly to some extent, by a fall down the stairway. The patient was a coloured woman. On tiie touch, I found a prolnpsc in which the os tincce was resting with considerable pressure on the rectum at the fossa naviculars, when the recto- vaginal openings existed, and through which the intestinal evac- uations made their escape almost continually, instead of forcing the sphincter ani. I replaced the uterus, and applied a pessary, and committed the case to the charge of a nurse for the present. Forthwith, the evacuations passed the natural way. On the removal of the pessary, position, astringent vaginal injections, with gentle relaxation of the bowels. After a few days another soft pessary was applied, in anticipation of the menstrual peri- od. The menstrual flux, which had become almost entirely ob- structed, now appeared, almost to a satisfactory extent On its cessation, the injections and position were again resorted to, and she was committed to the nurse again. A few days in anr iieipation of the next period, I found on examination that the openings had closed. Another pessary was applied and general advice given for the future management of the case. Soon after this I met her in the street, when she declared herself entirely weh. The following year, on being called to her again, I found that her proiapse had returned, and again deranged her menses by greatly lessening the discharge ; and no less than three dis- tinct fistulee existed around the anus. She had become extreme- ly emaciated and desponding, and utterly refused to allow the use of the bistoury. I abandoned the case and she died eight or ten days after, of mortification. The third case which I give was of an unmarried woman, in whom the menstrual discharges had been deficient and very pain- ful from the beginning, about five years before I saw her. This deficiency increased until she came under my care, when the monthly evacuation was in but very small quantity and only for a few hours. The pains were extremely severe, extensive spinal irritation, and a regular recurrence of epilepsy every month, fol- lowed by great insensibility, and indeed entire loss of conscious- ness for many hours and sometimes for a day or two. In addi- tion to these monthly returns of epilepsy, it occasionally occurred at different times in the month, on the appearance of colic pains or headache ; to both of which she was very subject. On examination of the uterus immediately after the supervene 726 On Menstrual Irregularities. [May, tion of the state of insensibility which followed the fit, the uterus was found prolapsed to the lower part of the vagina proper. It was replaced and a small pessary applied, which, in her state of insensibility, could only be done with the assistance of her friends. Not more than fifteen minutes elapsed after the replace- ment, and application of the pessary, before she aroused from her insensibility and was perfectly comfortable, conversed free- ly, and after about two hours left her bed. She was unconscious of the application or presence of the pessary, until informed of it on the succeeding day. Her menstruation was slightly increased in the rate of flowing, and continued nearly two days. Several months elapsed before these epileptic returns could be entirely arrested; but they were finally, by the monthly application of a pessary the day previous to the expected menstrual difficulty, with various success in the correction of the menstrual irregu- larity : sometimes the discharge amounting nearly to the natu- ral quantity, and at other times only a scanty discharge for 24 to 30 hours. Hepatic derangement existed, which demanded oc- casional mercurial purgations by small doses. The spinal irri- tation was treated by blisters and sinapisms, by which means it was kept measurably corrected ; but never more than a month or two at a time, without appealing again to its appropriate rem- edies. She had an occasional hacking cou^h. Various other O CD remedies were used in turn, without conspicuous benefit. For the next three years, a pessary was applied at the approach of every menstrual period, and astringent injections used in the in- termediate part of the month, by which the pains of prolapsus were prevented, and those of the menstrual period gradually moderated, but never with the entire restoration of sufficient menstrual discharge. The hepatic symptoms decreased so that in the last of those three years not more than one mercurial pur- gative was required on their account, and her general health was habitually comfortable, suffering only more or less headach for a few hours every month. Thus she continued, until, from the circumstances of her family, she was obliged to leave the city for several months ; and when she returned was so situated that she could not make it convenient to be subjected to a renewal of the regular treatment, on which she depended for the perpetua- tion of the degree of health she enjoyed. This circumstance, ad- ded to a hope on her part that she would continue better with- 1837.] On Menstrual Irregularities. 727 out treatment, caused her case to be neglected as to uterine treat- ment. After a few more months, the menstrual obstruction be- came complete ; which she still suffered without treatment, be- cause her pains did not now increase with the decline of men- strual discharge, and she allowed herself to hope that the sys- tem had become accommodated to the deficiency, and that she would henceforth remain well, without menstruating. But an obstinate and increasing violent and harrassing cough was soon established, and pulmonary ulceration supervened* of which she expired about 16 months after. This case afforded a clear dis- play of what might have been considered merely metastases, by anyone not aware of the great source of all the troubles in the case. In the first place, the injuries sustained by the encephalon ; in the second, by the spinal irritation ; third, by the liver ; and fourth and lastly, by the lungs. The fourth and last case we shall give here, was one of reten- tion, after giving birth to a still-born child. Many months after her accouchement she came under my care, without having menstru- ated, and was labouring under chronic derangement of intellect, with aggravation of the, symptoms at every monthly period. She had suffered extreme difficulty and bad management during parturition. On examining the condition of the uterus, it was found prolapsed, and a replacement effected and a pessary ap- plied during sleep, by the assistance of a. female friend. Em- menagogues were added to the pessary treatment in this case, both of which were monthly employed for about three months ; during which the discharge became established, nearly natural in all respects.* Her intellect improved and the distress of head, of which she gave the strongest intimations, mitigated. Her powers of speech, of which she was entirely deprived, began to return, and she is now able to use a number of words very dis- tinctly and accurately. When I turned aside to illustrate by a few cases which I thought would be useful, I was about to shew that the four first species of irregularity, viz. difficult, deficient, retarded and obstructed menstruation, depend on arterial obstruction, for it is evident that these arise from a deficiency of arterial function in the or- gan in these cases. * The same emmenagogue powers had been previously used for several months without success. 728 On Menstrual Irregularities. [May, We have said that no one will contest the fact, that the blood from which the menstrual discharge is produced is supplied by the arteries of the uterus. Alike impossible is it for any one to deny the fact, that the blood in the uterus, or flowing to it, is borne away again in the healthy state, by the corresponding veins; but in this disease, these are in as much danger of com- pression as the uterus. Now we find three other species of ir- regularity which are not less evidently the result of a deficiency of venous function at the part. These are excessive, accelerated and protracted menstruation. It is most easy to comprehend the modus agendi of this cause in these cases. We have only to al- low the possibility of the uninterrupted continuance of arterial distribution in and about the uterus, whilst the returning veins suffer obstruction, from distortion, compression, &c, as the arte- ries in the former four species, and we find at once a state of things which must produce excessive, accelerated or protracted menstruation, or even that copious discharge which has received the name of flooding. This view is unavoidable when we con- template the abundance, the office, and the situation of the venous branches, plexuses, anastomoses, sinuses, &c. &c. An interest- ing case, finely illustrating this pathology, has just passed from my care. The woman, in the absence of her menstrual period, exerted herself severely in lifting a heavy weight. The effort was soon followed by increasing pains in the back, pelvis and thighs. At the end of two days, a copious hemorrhage was af- forded by the uterus. On seeing her, the prolapsus was at once, determined by the history and symptoms of the case. On the touch, the uterus was very sore and considerably swollen. The vestibule, to the upper part of which the uterus had de- scended, was also quite tender. The uterus was replaced as nearly 'to its proper site as the swellings would allow, and the patient placed on her side, with a pillow under her hips. Doses of the compound powder of alum and kino, were left to be taken hourly, should the hemorrhage not cease, or should it recur in my absence. The following night I was compelled to visit her again, on account of recurrence of profuse haemorrhage, after having almost entirely ceased, from her having risen from her bed. The styptic powders had been taken for several hours, without the least effect. From her having been up, and the recurrence of the pain and flooding, it was the belief that the uterus had 1837.] On Menstrual Irregularities. 729 again prolapsed, which was on examination found to be the fact. It was again replaced, with the good effect of checking the hae- morrhage. Powders of the acet. plumb, with pul v. ipecac, com p. were left for use in the event of another recurrence, which was the case on again leaving her bed the following day. Several doses of the powders were administered without any obvious in- fluence on the discharge. The uterus was again replaced and a pessary introduced and properly adjusted. The discharge con- tinued in a very inconsiderable degree for three days, at which time the pessary, having become very offensive, was removed, and a strong styptic lotion used with the womb syringe twice a day, with strict regard to position. -Constipation followed the use of the compound powders of acet. plumb, and Dover's pow- ders. The haemorrhage gradually decreased for several days and then entirely ceased. The lotion was continued once a day for a week longer, and the patient continuing well and impro- ving in strength, was allowed to leave her bed, and has now continued well three weeks. I have not been informed whether she has menstruated since her recovery ; but presume from her recent very excessive haemorrhage she has not. Thus have I attempted to give a hasty sketch of my views on the various menstrual irregularities, with a few of many hun- dreds of cases which are well calculated to confirm their truth. 1 might have made up this article by detailing many cases, and giving their pathology and treatment, but for the knowledge of the fact, that but few readers are disposed to follow out the de- tails of numerous cases alone in search of truth ; and to have blended with them a sufficiency of explanatory matter, would have protracted this essay, already far exceeding the intended limits, to a much greater length. My purpose has not been to draw off the attention of the rea- der from those cases of menstrual irregularity which are known to be fairly ascribable to cold and similar causes; but to ex- tend it to another and a far more fruitful, but generally neglect- ed, cause of these distresses. It will be seen by the very nature of the cause alluded to, and the anatomy in connexion, that the treatment for the whole of the seven varieties I have given, must be very much the same. The same treatment which would remove arterial compression would remove venous also. It may at first view be considered 02 730 An Essay on Gangrcnopsis. [May, paradoxical to say that the same remedies which would be cal- culated to promote menstrual discharge when deficient, are also well calculated for decreasing it when excessive that treat- ment, well adapted to the acceleration of retarded menstruation, is also rationally depended on for retarding accelerated menstru- ation, &c. And this opinion of unreasonableness will be the more confided in, on the recollection of the fact that such is not ' the case with those irregularities which result from cold, &c. But the problem is solved, the instant the peculiar nature and power of this cause are contemplated, in connexion with the anat- omy and physiology of the part concerned. The same treat- ment which removes arterial, is also cnlculated to remove venous compression in like situations. When all the premises are fair- ly reasoned from, the conclusion is unavoidable, even if abun- dant observation on these cases did not set the truth beyond dis- pute. But the truth is, that the popular doctrine of exclusive excitement, has swept like a torrent over a large portion of the medical world, carrying before it, for the present, every vestige of humoralism, so that it has become almost sacrilege to say that the blood circulates in the sanguiferous system, or that variations of its constituents have any thing to do with a' change of excite- ments. But it were puerile, it were base, to suppress a truth of nature, or allow her truths the purest of all to be obscured by the false glare of theory, erected on partial premises, which, although it attract the vision for a time, must soon flicker and expire like the exhausted taper. Nor is it less objectionable to conclude that the boundaries of the science have been set that its ultimate limits have been reached, and that no more truths of deepest interest exist but those which have been arrayed before us. Such an exclusion is alike calculated to inspire an unjust confidence in errors of expression or of omission, and dampen philosophical research for farther truth to say nothing of the noxious vanity which infests the minds of such exclusives and such systematists. Every honest practitioner must acknowledge his repeated em- barrassments and disappointments, in depending on what are called emmenagogue powers alone, in the first four varieties of these cases, and on styptic powers or astringents, for the final cure of the thrrr* last. After vainly hoping for the discovery of bettrr emmenagogue means than his science had afforded himr 1837.] On Menstrual Irregularities. 731 he has doubtless been brought to wish, that he might never again be required to prescribe for such a case. He has also, if much experienced, found cases in which the local symptoms demand medicinal powers which the state of the general system forbade, and vice versa, &c. There is here offered such an etiology which will be found applicable to a large proportion of cases, and which will enable them to remove from their way most of the impediments hitherto insuperable. ARTICLE III. An Essay en Gangrenopsis, read before the Medical Society of Augusta : By Edward A. Eve, M. D., of Richmond County. Before commencing the essay which it has been my duty to provide for the present occasion, I would premise, that my hav* ing selected the question, "Is Gangrenopsis a separate and dis- tinct disease, or is it identical with Salivation?" is not from a supposition, that 1 have any novel or important views on the subject, but rather because, from the very slight notice I have seen of this disease in systematic works, and from having heard some respectable members of our profession say they have ne- ver seen it, I fear it is less recognised by the medical community, than its actual importance deserves: And it is for the purpose of eliciting the knowledge of such as may have had experience with this affection, and of directing to it the attention of such oth- ers, as either may never have met with it, or passed it by unno- ticed, or "en mas?e" with salivation, and the various cankerous affections of the mouth, that I now agitate the subject: And if by so doing I shall call inquiry to it, and produce the ulterior ef- fect of conducing to a more systematic and efficient practice m this truly loathsome and deplorable disease, I shall feel satisfied that I have chosen a subject, about which the imagination can. 7 32 -47i Essay on Gangrenopsis. [May, exercise no pleasing cogitations, and from which, if any satisfac- tion be derived, it must be that of a reflective character, the con- sciousness of performing a duty. As all that is known of this disease is of a very vague and indefinite character, being treated of in medical journals' under different name?, and the same being applied to different diseases, I will be compelled in giving its pa- thognomonic characters, to be governed more by the little 1 have seen of its actual existence in our own climate, than by the con- fused though in some instances very learned treatises, I have read in the medical journals of our country. The confusionv however, appears more in the aggregate of these treatises, than when taken separately, and seems to arise evidently from differ? ent diseases being treated of by authors under the same name. To give an analysis of these essays, particularly those by B. F. Coates, of Philadelphia, Samuel Jackson of the same place, as well as Richter of Berlin, would be highly interesting, were it not that it would be travelling beyond my prescribed limits. Among the great variety of names by which this disease has been described, I would prefer to designate it by the term Gangre- nopsis, first proposed by Dr. S. Jackson, derived from yayy.caiva, gangrene, and oi'is, the iace. From what I have seen of this af- fection, and I think I can gather some coincidence of opinion from some treatises I have read, I would pronounce this affection a putrescent, or sphacelating fever, attacking children for the most part between two and eight years of age, forming one of the varieties of our bilious autumnal fever, or in oilier words, it is a low grade of bilious remitting, or intermitting fever, which seems to have a strong tendency to terminate in gangrene of some part, generally of the face. Although this disease selects the face as the point, of attack, sufficiently often, to entitle it with some justice to the appellation of gangrenopsis; still, lest those who are more than usually sensitive about the perverted action of calomel, may be indue ribute it to tlje use of that min- eral, from its spending its violence on that part, for which mer- cury has peculiar affinity, it may be well to state, that the gan grenous development of this disease is by no means confined to this part, but occurs in parts sufficiently remote and distinct, as altogether to remove such a suspicion; as, indeed, wherever the excitement seems invited, by any extraneous or accidental irritation, there the disease seems first to develope itself. I have 1837.] An Essay on Gangrenopsis. 733 known the soft parts covering the lumbar vertebrae affected with this gangrene ; probably produced by the irritation consequent on the pressure on this region, from lying on the back. I have known blistered surfaces affected in the same way. This dis-r ease is also said not unfrequently to develope itself on the labia pudendi of young girls, where, from the want of strict attention to cleanliness, acrimonious accumulations may have made these parts a centre of irritation. The principle contained in the maxim, " pars dolens trahit," which seems to preside in the above instances, can be used with equal propriety to account for the force of this disease being directed to the mouths of children from two to six or eight years old ; as the process of dentition going on at this age can reasonably be supposed to make a focus of ir- ritation sufficient to concentrate the action of the disease in this location. The part of the cheek in which this mortification most usually makes its first appearance, is the part most liable to be bitten in convulsions from worms and intestinal irritation from other causes. And in lying on the side, as children frequently do, with the cheek resting on the hand or arm, the internal sur- face of the cheek being pressed against the molar teeth, may prove another source of injury or irritation to this pnrt : and it is perhaps in proportion as this part is more liable to be injured or irritated, that the force of this disease is directed to it oftener than to any other. As the symptomatology given by Dr. Jackson in his excellent essay on this subject, accords so well with my own observation, I will extract it for our present purpose, in the place of giving an original sketch. "Whenever in the course of our attendance on children debilitated by fe- vers, we perceive the least swelling of the cheek, it is time to take the alarm. According to our very limited experience, a little cineritious spot will be found on the inside oflhs cheek. This, as Van Svvieten observes, is nothing less than a true gangrenous eschar. If the case is not seen till it lias made a progress of two or three days, the face will be found pale, the cheek tume- fied, hard and shining, the mouth distorted, the lower eye-lid cedematous, the saliva sometimes profuse, in some cases not at all increased. In some cases the odour of the mouth is altogether peculiar. At this time the gums and teeth are to human eyes, entirely unaffected, but the gangrene will even now be found to have made alarming ravages in the cheek ; and spreading sooner or later through the contiguous parts, the gums are seized, the teeth become loose, and necrosis involves the socket. The farther progress of the spha- celation can be more easily conceived than described. There is no general inflammation of the mouth, none very evident even at the margin of the gan- grene, the parts seem to pass immediately from life to death. The spot of 731 An Essay on Gangrenopsis. [May, gangrene appears cineritious, or even whitish, but in the progress of the dis- ease the dead parts are nearly black. The patient appears to suffer very lit- tle, he lies quiet, desires to be left to himself, in fact he appears both in body and mind to have passed into another slate of existence." Having now m a very brief and concise manner given the symptoms nnd pathognomonic characters, by which we may in- dividualize this disease; we will next endeavor to give our rea- sons for believing it not to be identical with salivation. In the first place, if we observe the regular occurrence and progress of the symptoms, we can I think even in this way distinguish such a difference as will tend, in a great measure, to destroy the iden- tity of this affection with salivation: In the early stage of this disease, or even after the gangrene has been making ravages for several days, there is no tenderness of the teeth and gums, which it is well known is recognised as one of the earliest symptoms in salivation, and in a great many cases, the odour from the mouth of a patient affected with this malady, is very different from the breath of a salivated person, and seems to resemble more the stench of a grave-yard, or that arising from any putrifying ani- mal matter, and indeed while salivation is a highly inflammatory and painful affection, gangrenopsis seems to be attended with neither pain nor inflammation. And in the next place, we have many well authenticated cases on record o( this disease, in which little or no calomel had been given ; and those most in the habit of treating this disease, aver that they find a liberal use of calo- mel the most efficient mode of treatment. We have many well authenticated cases, I have in my very limited experience seen some, where this disease has occurred, in its most malignant form, after a very moderate quantity of calomel had been given, perhaps a single purge, or a lew doses combined with such ac- tive cathartics as would carry it off speedily. Now when we take into consideration how much greater quantities of calomel adults frequently take, almost with impunity, notwithstanding their greater susceptibility to salivation than children, we scarce- ly can think it a fair course of etiology to attribute the severe af- flictions these unfortunate little sufferers experience, to a few grains of calomel, notwithstanding the great resistance they seem generally to offer, to the salivating influence of mercury. But as still stronger proof, and sufficient we think to satisfy the most sceptical, Dr. Jackson has recorded two well marked and very 1837.] -in Essay on Gangrenopsis. ?35 severe cases of gangrenopsis, one of which ended fatally, in which not a particle of any mercurial preparation whatever had been taken by the subjects. In one of these cases, a little girl of four or five years of age, after gangrene had commenced, he gave a hundred and fifty grains of calomel. This child, although she suffered severely from the disease, was cured, and the eschar healed perfectly, leaving no deformity. Dr. Milton Antony of this citv, has not only seen cases in which no mercury had been given, previously to the gangrenous development, but has found it the very best mean for arresting the disease. Dr. A. related to me a history of a family, of which, very recently after having removed to a marshy situation in the neighborhood of this city, three members were attacked with this disease. As incipient gangrene had made its appearance in some of these, when they were first seen by him, he as well as the physician in attendance with him, abstained from the administration of calomel; the fe- vers continued, and in about a usual period for such a crisis, these patients perished with gangrenopsis. Several others of the same family, were taken apparently with the same fever this fever has diagnostic characters by which it may be recognised before the gangrenous development in these cases calomel was em- ployed liberally, and they recovered in good time, whether be- fore they passed through the gangrenoptic stage or not, lam not able to say at this time, having forgotten what the Doctor stated on this subject. 1 understand also, that Dr. L. D. Ford of this city, has witnessed more than one case of gangrenopsis, that su- pervened on fevers, in the treatment of which no calomel had been used. I regret not having had an opportunity to converse with him, since I have had this subject under consideration; if present, I hope he will give the result of his experience with this disease; and also let us have the benefit of his views of its pa- thology, and the relation it bears to salivation. The few cases that I have seen, although highly interesting in a practical view, a narration of them here would be irrelevant, as they would have no direct bearing on the question in point as calomel, although in some instances in very moderate quantities, had been given previously to the development of the cheek disease. There is one, however, which from one circumstance connected with it, may not be altogether unprofitably referred to. This case oc- curred in the autumn of 1831, the subject of it was my nephew, 736 An Essay on Gangrenopsis. [May; a boy about eight years of age, the gangrene supervened on a severe attack of bilious fever. As it was a regular case in eve- ry respect, I will only state the fact that bears upon the ques- tion before us ; which is, that fever remained unabated even after the gangrenopsis was developed. I was at this time but little acquainted with this disease ; Dr. Antony and my brother at- tended this case with me, and it was at the suggestion of the former, in this dreadful dilemma fever raging and gangrene al- ready making rapid ravages in the cheek that calomel was given with the happiest results, apparently both as regards the fever and the local mortification. It must be acknowledged, however, that the very earliest opportunity was embraced for the most vigorous exhibition of general tonics, as well as the most unremitting application of antiseptics and stimulants to the gangrenous parts. If in passing, I will be indulged in digressing so far as to venture one remark of a practical nature, it would be, that while I fully appreciate the good effects of calomel jn the above cases, as well as other cases of this disease in which it has been errvployed, I still do not believe that it acts as an an- tidote, or dfjerfs any directly curative agency on the gangrene ; but acts ffftermediately by arresting the fever and removing that condition of the system which precludes the administration of quj-ninV, and such other tonic and antiseptic remedies as are most potent in correcting the gangrenous diathesis which characteri- zes this*" fever. From the evidence that a candid, though hasty and imperfect investigation' has brought before my mind, I aver that I am de- cidedly of the opinion,%at calomel has no direct agency in pro- ducing gangrenopsis, and .that this affection exists as a disease distinct from salivation. And as reasons for this decision, I will repeat, that if we examine the symptoms, those diagnostic char acters which give individuality to a disease, we will find tho which characterize gangrenopsis Widely different from those which indicate salivation, which fact alone gives a separate exis- tence to gangrenopsis. A great part of the treatment also, found beneficial in the one, wouM-be highly detrimental in the other. And now, in conclusion,' as farther reasons for this decision, I will recapitulate but two arguments, one from the positive and the other from the negative side of the question ; and I have no doubt that every unprepossessed mind will perceive the force of nil >se Kc37.] Of Antimonial Suppositories, $c. 737 the reasoning. The one is, that mercury is frequently given in very large quantities without. producing this affection, showing that it has no direct agency in generating it ; and the other is, that gangrenopsis frequently occurs where no mercury what- ever has been taken. Part II. REVIEWS AND EXTRACTS. Of Antimonial Suppositories as a mean of restoring the He- morrhoidal Flux. The physicians of past ages have, perhaps, too much exagger- ated the importance of haemorrhoids in the scale of pathological phenomena, while those of our own time are fallen into the con- trary extreme. It cannot be denied, that the suppression of the hemorrhoidal flux, when habitual, may be productive of general disorders a- mong men, almost as serious as the suppression of the menses in women. Moreover, it is as generally admitted, that with cer- tain persons who have, not only regularly, but at indeterminate periods, a draining or hemorrhoidal flux, the existence of this pathological condition is attended with a state of general good health y although it may remain for a long time uncertain and variable, provided the hemorrhoids do not manifest themselves as soon as usual. Observation shows also, that persons who have had hemorrhoids for a long time, suffer generally if this flux en- tirely ceases. And it often happens that there is a call for its restoration. Many means have been advised to effect this indication. The warm local baths, mustard foot baths, leeches to the part, suc- tion applied to the lower part of the large intestines, purgatives and cupping glasses to the part. Of all the means which we have made use of, only one has succeeded in any satisfactory manner. This is the application of cupping glasses. Tnis mean was entirely forgotten, when a student of the Medical Faculty of Paris restored it to honour, and I am able to bear wit-, ness to its effects on him. 93 738 Of Antimonial Suppositories, fyc. [May, He had had hemorrhoids till the age of twenty years, and al- ways enjoyed good health. This 'flux now ceased", when he be- came subject to violent pains in the stomach, and continual disor- ders of the digestive organs. He consulted M. Andral, while attending the Hospital de la Pitie, and this physician made use of every mean advised by authors for restoring this flux. Noth- ing succeeded and the disease remained stationary. The young patient then conceived the idea of applying a cupping glass to the part. During this application the circumference oi the anus en- veloped the hemorrhoidal tumours, which Tor eight days were- swollen and painful. From this time his health was re-estab- lished. A month after this he experienced a slight return of gastric disorder; and one day, while attending my visit to the hospital he spoke tame of the relief which he had obtained the previous month from the sufferings which he now began to feel again, and offered to let me witness the prompt appearance of the hemorrhoids under the operation of the cupping glass. I accepted the invitation with alacrity, and at the same time I placed him upon the bed of one of the patients, and in the pre- sence of more than forty physicians and students, 1 applied a cupping glass to the fundament. A minute did not elapse when the tumours made their appearance, and becoming united, they acquired the size of a small pigeon's egg ten minutes after the application of the instrument. The same means were made use of the following day, and the hemorrhoidal flux continued for a week and wras followed by a cessation of the disorders of the stomach. M. Andral also saw this young physician, and can testify with me to the great rapidity with which the tumours be- came swollen. After this, I had only one opportunity of locally applying cup- ping glasses for recalling the hemorrhoidal flux. This was with a female afflicted with erratic rheumatism, which to me appeared to be caused by the suppression of habitual hemorrhoidal flux. I succeeded in puffing up the hemorrhoidal vessels by means of the cupping glass ; but the tumours disappeared soon after the application of the instrument. What prevents my using this remedy more frequently is this. In the first place, patients, es- pecially women, have a great aversion to it. Secondly, I have conceived that a much more simple remedy, and the employment of which can never be the subject of serious objection, will an- swer the same end, I allude to antimonial suppositories. As I had never succeeded with aloetic suppositories, I thought by substituting in the place of aloes one of the most energetic irritants, I might attain the desired end. Now, tartrate of anti- mony, applied locally to the skin or mucous membrane, creates an inflammatory action very powerful and persisting, I therefore preferred this article. I mix with a drachm of butter or lard from two to six grains of tartrate of antimony. The supposito- 1837.] Of Antimonial Suppositories, <$c. 739 ry, being introduced within the sphincter of the anus, melts quick- ly, and the tartrate of antimony remaining in contact with the mucous membrane, excites a lively local irritation, a species of tenesmus, as a necessary consequence. When the suppository contains only a grain, or half a grain, of the tartar, it can be re- tained for twelve hours without any necessity for going to stool ; but when a greater quantity of it is made use of, the patient ex- periences a heat at first slight, but afterwards scorching and at- tended with painful pulsations at the part, there is a necessity of frequently going to stool. The arterial pulsations increase at the same time that the circumference of the anus protrudes, and pustules similar to those excited by tartar emetic on the skin, now appear ; bluish tumours arise, hard and painful, permitting occasionally a large quantity of blood to transude. These are the true hemorrhoidal tumours, perfectly evident with those who have had them already and only apparent with those who have not had them. I have often advised this remedy, in consultation, in my pri- vate practice and in the hospital. I have taken notes of only six patients who have used it. With five of these the hemorrhoidal flux was re-established; in the sixth, who had never had hemorr- hoidal tumours, I wTas unable to excite them. I will briefly re- late these six cases, as they afford some practical interest. Case 1. A man 36 years of age, had had an hemorrhoidal flux until his thirty-fourth year. The flux appeared at irregular pe- riods four or five times a year. At each time it lasted at least five days. He took a cold, which at first seemed to be of little importance ; but during the continuance of the cold, haemoptysis came on and the hemorrhoides disappeared. The cold still con- tinued, and the hemoptysis was repeated and lasted for several days without any means being able to arrest it. Soon after this, symptoms of phthisis pulmonalis were manifested and he con* eluded to enter the Hospital Dieu. There was considerable emaciation and slight hectic fever. Resonance less at the upper part of the right lung, both before and behind ; murmur in inspiration scarcely perceptible in ex- piration it was very strong; slight broncophony; rale sub-crepU tant sufficiently frequent : some humid crackling and a trace of pectoriloquy; expectoration muco-puriform and often streaked with blood; but little appetite. These were the symptoms of tubercles beginning to be formed in the lung. Nevertheless, ha- ving regard to the suppression of the hemorrhoids, I conceived that there might exist in the respiratory organs a point to which there was an undue flow of blood, similar to that which latelv existed in the pelvis, I determined on recalling the hemorrhoids. I made an application of a suppository of tart, antim. It exci- ted a glow of heat around the anus, and the following night, large hemorrhoidal tumours appeared, which continued six davs and 740 Of Antimonial Suppositories, fyc. [May, discharged abundantly. A great amelioration of the thoracic symptoms took place; the expectoration immediately ceased to be bloody and was much diminished, so that, five days after- wards, he coughed but little and respired almost as strong as usual. Soon after this, the piles appeared without solicitation, and the threatening symptoms which had been manifested in the breast, were completely dissipated. Indeed, I do not imagine that I cured phthisis pulmonalis. but merely an obstinate conges- tion of the lung, which probably would have ended in inducing tubercles. Case 2. A cook, aged 50 years, entered the Hospital Dicu, in order to be treated for a chronic disease of the stomach. This man stated, that three years previously to his entering the hos- pital, he had been afflicted with piles, which returned every month, and which at that time became suppressed. Since then he had lest his appetite, the little which he did eat gave rise to pains in the stomach, attended with obstinate constipation. He had made use of local bloodletting, opiates, laxatives, mag- nesia, &c, in vain. I thought that the hemorrhoidal flux ought first to be re-established if possible. For this purpose, I applied a suppository containing the tart, antim. The first suppository gave rise to a diarrhoea and tenesmus, but no tumour. The next day, another suppository containing three grains of the tartrate antimony to the drachm, (a little stronger than the previous one,) was made use of. This caused very sharp pain at the anus, and on the third day we found that very large and painful hemorr- hoidal tumours had arisen. These tumours remained swollen for several days, without applying any suppository, but did not discharge. His health was improved, but was not completely established. A month after this, a new application of the sup- pository caused the piles to discharge, and at the same time his stools became bloody. This discharge continued for six days and then ceased. The health of the patient became much im- proved, and after using the waters of Vichy for three weeks, his cure became confirmed. I have not since seen the two patients whose cases I have just related, so that 1 am unable to say what their present state of health is. Case 3. A woman, aged 40 years, was attacked with obsti- nate erratic rheumatism. I imagined that by provoking hemorr- hoids, she might obtain some relief, I therefore applied two an- timonial suppositories. The tumours appeared ; continued two days and then disappeared; but the rheumatism was not miti- gated. This case, apparently of no consequence, proves that hemorrhoids can be excited in those who have never had them. Case 4. A young man, aged 30 years, contracted a gonorrhoea, which was treated and cured with emollients and balsams. Soon after this he experienced all the symptoms of syphilis. The velum palati was destroyed by a large ulcer; the nasal fossa 1837.] Of Antimonial Suppositories, fyc. 711 and even the larynx, were not exempt from alteration. The prot. iodide of mercury, bathing with a solution of corrosive sub- limate, and local cauterization with nitrate of silver, improved the character of these disorders. As the patient had formerly had bleeding piles, which returned many times yearly, but had disappeared during the last year, I applied for two days in suc- cession the antimonial suppositories. The piles appeared again and discharged abundantly but there was no abatement of the disease. Case 5. In September, 1835, while attending the hospital, a patient aged 45 years, came under my care. He had a very se- rious attack of sub-acute hepatitis. Hepatic enlargement was very distinct, and there also existed an effusion of the peritone- um and the cellular tissue of the pelvic organs. As he had a high fever, I took blood from the arm, but without any relief. I also applied leeches to the right hypochondrium and over the whole seat of disease, but without any mitigation of the malady. The patient had had in the course of his life three or four attacks of piles. Knowing how much importance modern practitioners attach to hemorrhoids, especially in diseases of the liver, I deter- mined on exciting in the pelvic vessels a derivation which might be salutary. The application of an antimonial suppository, produced on the second day very painful hemorrhoidal tumours, which discharged much blood. Nevertheless, the disease in- creased in a frightful manner and the patient died. Case 6. M. R., aged 52 years, during his whole life had been subject to bleedings from the nose, which returned many times during the month, particularly in the spring. His father, who died at 2 years of age, was subject during his life to hemorrhoids, which flowed regularly every month. The epistaxis had now been suppressed for 3 years, during which time he was subject to affections of the head two or three times a year, especially in the spring. He also had a species of cerebral excitation similar to that which marks the commencement of drunkenness. The application of leeches to the part moderated these symptoms considerably, but they soon retarned and gave much uneasiness. The regularity of the hemorrhoids in the fa- ther, caused me to think that a monthly congestion in the rec- tum would be of great service. During one year, M. H. applied for three days every month, an antimonial suppository. This application excited a violent irritation, and an eruption which evidently did not differ from the ordinary eruption produced by antimony. The inflammation lasted only a few days. Although hemorrhoids, properly so called, did not supervene, the cerebral affections have not given any uneasiness, and his whole health would have continued to improve, if the patient had patience to continue the use of the means. 742 Discovery of a work attributed to Hippocrates. [May, Let us recapitulate the facts contained in this brief account. Antimonial suppositories in six cases, in order to provoke he- morrhoids. In five the hemorrhoids appeaaed two days after the employment of the means. Four were truly hemorrhoidal ; one was not. In the four first, the eruption was persisting ; in the other it lasted only two days. In one of the patients it was impossible to produce the tumours. Of the six patients, three were cured, probably in consequence of the appearance of the flux. One of these three might have been cured, although the hemorrhoidal tumours, properly so called, were not produced. Three experienced no alleviation, although the hemorrhoids were reproduced easily and abundantly. It would be too hasty to draw general conclusions from so small a number of cases, I wish only to make known to the faculty a therapeutic mean, by which they can fulfil indications which may sometimes be presented to their notice. Journal des CoinnaissancesMedico-Chirurgicalcs. Discovery of a work attributed to Hippocrates, and hitherto sup- posed to be lost. The Gazette Medicale de Paris, (24 Dec. 1836,) contains an elaborate and exceedingly interesting article from the pen of M. E. Littre, on the discovery of a Latin translation of the Hebdom- adal Treatise attributed by some of the ancients to Hippocrates, the original of which (in Greek) was lost at the destruction of the Alexandrian Library. M. Littre was led to this discovery by his researches preparatory to the translation of the works of the father of medicine. The treatise is found in one of the ancient tomes of the Royal Library of Paris, where it had remained con- cealed for centuries. The volume contains no date by which its age can be determined; but judging from its barbarous Latin and from its imperfect execution, its antiquity is undoubted. M. Littre's researches into the history and tenor of this work have led him to the following conclusions : 1st. The Hebdomadal Treatise, though lost in Grepk, still ex- ists in Latin ; it was referred to by various ancient authors, from Philonius to Moschopoulos. 2d. Galen, who is high authority in this matter, considered it erroneously attributed to Hippocrates ; and the inspection of the work tends to confirm this opinion. 3rd. The Hebdt madal Treatise is a work on fevers, founded on two opinions, viz. that all nature is governed by the number se- ven, and that the vital principle is a compound of elementary heat and cold, the variations of whose proportions constitute fe- brile affections. 4th. Two considerable passages, the one con- tained in the Treatise on Critical days, and the other constituting the second part of the eighth section of the Aphorisms, belong to this work. This fact had never been suspected until the exami- 1 837.1 Discovery of a work attributed to Hippocrates. 74$ nation of the Hebdomadal treatise. 5th. We possess in Greek, and as specimens of the original, the two passages alluded to ; also a passage quoted by Philonius, detached expressions and an entire sentence related by Galen, and a sentence contained in iEtius. The dialect is Ionian, and the style, as far as it can be discerned by these fragments, is studied and obscure, though not entirely devoid of elegance. 6th. This work is from the same author as the Book of Principles, and probably also the Treatise on the Heart. It is interesting not only for these reasons, but also because of the care with which it unfolds the treatment of certain acute diseases, and especially of ardent fever or causus. The following is a translation of JVT. Littre's analysis of the work. "Such is the constitution of the world and of its parts, that all things are regulated by the number seven." With this position the author of the treatise enumerates all the phenomena which seem to be under the influence of this number : the moon's phazes ; the seven winds; seven seasons ; seven ages of human life; seven principal parts of the body ; seven requisites for ex- istence; viz. inspiration of cold, the exhalation of heat from the body, sight, hearing, smell, deglutition of water and food, and lastly, taste; the articulation of the seven vowels. The author goes on to slate that the earth itself has seven parts; the head, or the Peloponesus, the residence of great souls ; the neck and chest, which correspond to two countries whose names are omit- ted by the scribe ; the thighs, or the Hellespont ; the feet, or the Bosphorus and Thracia ; the long intestine and the lower belly, an obscure word which appears to be Cimmerian Bosphorus, and the Pal us Moeotides. After having thus established the predominence of the number seven, and having remarked that the knowledge of the world is necessary to the understanding of diseases, he explains his opin- ion of the nature of the soul, which according to him was a mix- ture of the elements of heat and cold. Then follows a compari- son of the animal body with the world. The innate heat repre- sents the sun ; the fluids of the body, water ; innate cold corres- ponds to the air ; and the flesh and bones, to the earth. The body, like the year, has a period of growth, one of ma- turity and one of decay. It must necessarily be under the in- fluence of the year itself, and be modified by its periods When winter brings cold, it makes the leaves drop from the trees, and compels animals to take refuge in their retreats. The heat of the body, dreading the cold, secures itself by rushing to the centre. This heat acts on the humours, or rather on the humour, for, according to the author, there is but one humour, which has received many and inappropriate names ; as there is but one humour in the world so there is but one humour in the body ; all those fluids termed bile, phlegm, urine, &c, result from changes of heat into cold and of cold into heat, as do all the fluids of the 744 Discovery of a work attributed to Hippocrates. [May, earth, wine, vinegar, milk, honey, dew, snow and hail, which are derived from one humour, water. He adds, however, that this heat, when its influence is salutary, cures diseases ; it therefore preserves and destroys the body, cures and produces fevers. But they are produced by heat in a different manner when the temperature of the world becomes mild. The season of flow- ers and of fruit brings animals from their retreat, and recals from Egypt those that were driven thither by the cold. The sun sets in motion the humours, which in their turn enkindle fevers, un* less evacuations be produced or occur spontaneously, or that the influence of the season be combatted by a cooling regimen. Summer brings high fevers, ulcerations and eruptions ; for then the humours of the body are heated, active and venomous. Still later, tert;an, quartan and quotidian fevers come on. It is there- fore necessary that the physician should not only be acquainted with fevers, but also know to what extent the body is subject to the influence of the world ; the practitioner will never err, if he will oppose these influences. As long as the heat and cold of the soul remain in a state of equilibrium, health is the consequence, but fever manifests itself as soon as this equilibrium is disturbed. If the onset of the fever be cold, the very excess of this cold, by reaction, brings on heat and perspiration. If the onset of the fever be hot, cold and chill will succeed. Whenever the chill and perspiration occur on a critical day, the disease will cease ; but if, on the contrary, they occur on a non-critical day, they will necessarily recur again. The author endeavors to explain the rationale of these crises by considering the heat as attracting from the centre to the surface and vice versa. If the patient be deprived of the proper regi- men, the flesh attracts the humours, and ardent fevers are devel- oped. To these accidents physicians have erroneously applied the epithets ofdeirium, coma, peripneumonia, hepatitis, &c. Fevers terminate on the 7th day, or on the 9th, 11th and 14th in the second week, on the 21st in the third week, on the 2th in the fourth week, on the 35th in the fifth week as it does on the fifth day, on the 42nd in the sixth week, on the 49th in the sev- enth week as it does on the 7th day, on the 56th in the eighth week, and on the 63rd in the ninth week as it does on the 9th day. The diseases that exceed this period become chronic. Quotidian, tertian and quartan fevers, may have a crisis in the 5th, 7th, 9th and 14th month, as other fevers do on the 5th, 7th, 9th and 14th days. The humours drawn into the viscera and into the veins by the heat of the soul remain sometime without undergoing coction. When the coction has been accomplished, the crisis takes place on a critical day. The phlegmonous humours undergo coction slowly, but the bilious more rapidly. Observation teaches that a crisis is frequently brought about by a very slight evacuation. 1^37.] Discovery of a work attributed to Hippocrates. 745 The author explains the pathology of ardent levers, ofpletfK- sy, of pcripnoumony and piquartan fever, and it is here that may be found the passage quoted by ^Eiius, on ihc subject of the last fever. We here give his treatment of quartan feVeft In the first plaee, make the patient sneeze repeatedly ; rub his inferior extremities up to the middle of the thighs, and the superior up to the shoulders, so as to make them red and hot ; rub the body and the head with a mixture of laurel, myrrh, castorcum, cassia, ni- tre, rosemary and pepper. The blood being thus warmed, cover the patient with clean, soft and heated garments; place near him vessels filled with hot water, and allow him to go to sleep. All this must be done before the paroxysm. The author gives the treatment of some other forms of fever; and here we remark the correct observation, that at the onset and during the progress of fevers, the practitioner must be guarded against the inflammations that may supervene. " They are dan- gerous," says he, "in proportion to the degree with which the disease has exhausted the vital heat, for then it requires but a breath to extinguish it." The remark is a good one, in despite of the explanation. The author details at considerable length the treatment of ar- dent kver, a disease much dwelt upon by Hippocrates and the Greek physicians, and which appears to be one of the forms of the bilious fevers of hot climates. I will not here attempt to substantiate this opinion, but will in my translation of Hippo- crates, present the symptoms of this I'vvc.v and compare it with those familiar to us. The basis of the treatment recommended by the author is antiphlogistic ; mild diuretics, cooling medicines, an elevated head, a darkened room, silence, quiet, friciions to the extremities with warm oil, sternutatories, which according to the author, tend to diminish morbid heat, cataplasms to the swollen precordium, &c. His general pathology rests on two principles: the first of which is that the number seven, which rules all nature, which determines the movements of the principal heavenly bodies, which presides over the development of the human body, also determines the course of diseases and fixes their limits ; the se- cond is, that the soul, the vital principle, is an admixture of ele- mentary heat and cold, and that diseases result from the inequal- ities which supervene between these elements The special pathology of the He' domadal. Treatise, is limited to a few fevers. The signs of these diseases are not enumera- ted ; but, at the same time that the author omits details consid- ered in our days of the utmost importance, he does not (Jirgrt to refer the origin of those fevers to the composition of the vital principle he has created. He dwells more particularly on treat- ment and prognosis. Ofdiagnosis, piognosisand treatment, the first is alwavs neglected for the two latter in the Hippocratio 94 740 Operation for Empyema New Febrifuge. [M ay. works. Whilst the d stinctive characters of diseases are exposed in an imperfect and confused manner, (hey are the objects ofno research, of no scientific deductions, of no importance in ,|le es- timation of the author, he very carefully details the trea.meni, and turns ail hmattention to the study, not of the seat and nature of he disease, but ol the signs l,y which crisis or issue mav be lore- ol l. 1 he therapeutics and prognosis were much more studied than nosology .tself. Tins preference of prognosis and neglect of diagnosis is characteristic of llippocralic medicine. The author of the Trent,*, bestows onc-fourlh of it on the consideratton of the signs which precede the crises of diseases J hese signs applicable to fee, rs and acme diseases, are deduced from the colour of the whole body or of any of its parts, from he tongue, the eyes, dreams, the urine, the alvine evacuations, the voice and respiration. Operation for Empyema. *f:jL*fBEY presented to the Academy of Sciences, one of the individuals on whom he bad succ. ssfully' performed an operation of this kind. Louis Giarie. a soldier of the imperial army, re- ceived in the last Russian campaign, a hall which pencl rated the chest ana remmned lodged in the inferior p,rt of .he right lung in the midst of a purulent collection. He was four veals aft, ,"- wards put under the care of Baron Larrev, who found a fistu- lous opening; hut th,s side of the dust beina collapsed, it was impossible lo remove .he l,all through the orifice i had made and ,1 became necessary to rem,, a ,,.,,,; of ri|, j:|, | pointed knife, such as is used in lreplin,r. The ball was. like all .hose ol .he Russians, vary large, weighing one oi nee where JS ours weigh but six drachms, but was seizfd and < Zr'Ju d - The cure was .protracted, though as complete as possible, and he subject still enjoys perfect health. The loss of substance the lung has caused a contraction of the chest on that side the projection of the heart and mediastinum to the ri ;he skin, the dermis and the epider- mis; Mafpighi discovered in the negro a third, situated between tho^e, the corpus tnucosum; "Albinus and Meckel specially stu- died this corpus muenxum; Mitchell detected two strata in the epidermis; and finally Cruikshank and Gaultier distinguished also others in the corpus mUGosum. Notwithstanding these brilliant discoveries, continues M. Flou- rens, the structure of the corpus mUcosum was far from being known; hence it is we find the attention of the most celebrated anatomists directed to its investigation, since Gaultier; in France, Blainville, Dntrochet, Beclnrd, Breschet and Roussel de Vau- zeme ; and in Germany, Weber, &c. The researches of Jf. Flourens, have led him to detect be- tween the dermis and epidermis, exclusive of the corpus papil- lire, of which he will subsequently treat, four distinct layers: the first applied to the dermis, the second on which rests the pigment urn, the pigmentum itself, and the fourth (or rather third membrane, for the pigmentum is a layer and not a membrane, as has been correctly observed by M. de Blainville,) placed between the epidermis and the pigmentum. Ibid, p. 82$. Living Caterpillars in the Human Intestines. M. Dumeril and M. de Blainville reported to the Academy of Sciences, on a memoir presented by M.. Rebineau Desvoidy on the above subject. The facts are thus related by M; Lechin. a physician of Len^ny : A female, aged 57 years, was left af- fected with abdominal dropsy after an attack of (evew On the 3d of March, 1836, she took (5 drops of croton oil, and in the substances rejected by emeses. four living caterpillars were per- ceived at first and subsequently ten others. 7\vo of these were carried of]" alive by the physician, but List on the way : two oth- ers were sent by him to a professional acquaintance, who trans- ferred seven of them in alcohol to M. Desvoidy, of which four have been forwarded to the Academy by this Xatural'st. 31. Roblneau perfectly recognised their ideality with the cat- erpillars termed hv Linueus pi/mfis rin uinalis. by Fabricius crambus. and by Latreilie ouJf>ssa. - The history of these insects being well known. M. Robineau | s that the ggs were deposited in adipose food and introduced with it into the womau's 748 On the Uterine Syphon, <$-c. [May, digestive apparatus ; that here the larvae were developed and nourished. Ibid. On the Uterine Syphon, SfC : By Professor MoifTADf, of Lyons. It not un frequently occurs that accouchements become diffi- cult from the rigidity and dryness of the foetal head and uterine passages, consequent either on the too early escape of the amni- otic fluid or on a state of irritation, such as to deprive this fluid of its usual lubricating properties. The pains then dimmish, the parts become swollen and inflamed, and delivery is distressingly procrastinated. Having observed a. considerable number of such cases both in my service at the Charite of Lyons and in private practice, I have resorted to the following expedient, with uniform success. The operation is perfectly simple, and this is perhaps the reason it has hitherto escaped the attention of practitioners ; but its simplicity cannot diminish its value, since its usefulness is fullv established. The instrument is a silver canula. from five to six inches long, slightly curved, terminated by a flattened oval extremity, very thin and perforated on both surfaces by a great number of small holes; the other extremity is constructed so as to receive the end of the canula of an ordinary syringe. This instrument, which I denominate an uterine syphon, is well oiled and directed so as fo introduce the flattened extremity between the foetal head and the uterus, winch may be done with- out difficulty and without pain, and, with a syringe, tepid olive oil is injected so as to anoint the head and passages. The ca- nula is successively carried around the head, the passages soon become soft and yielding, and the head escapes without difficulty, I might relate a great number of cases on this subject, for the accouchements susceptible of relief by the syphon arc of frequent occurrence. 1 will at present give but two. Casel. Mrs. L. had been in labour more than twenty-four hours, when I was requested in consultation with her physician. The pains were severe, but the waters had long since escaped. I proposed injections by means of the syphon, but yielded to the desire of the attending physician, who preferred the forceps. The application of these, however, was attempted in vain; in- jections were used and the head immediately passed out. Case 2. Mrs. C. had strong pnins, and was extremely ner- vous; the waters had passed off three days before; the parts were dry and apparently inflamed ; according to the midwife, the pains had been strong for several hours, hut had effected no change in the position of the child. Injections were made around the child's head, and it almost immediately came through with the greatest case Ibid, 771. 1837.] On Laceration of the Urethra. 749 M. Montein als > recommends the inj cii >n, by me'aiis of the syphon, of a tincture of er^ot into the uterus, as preferable in many instances to its administration by the stomach. The pre- paration he uses is made by digesting half an ounce of ergut in three or four ounces of alcohol and keeping the bottle well slop- ped. Of this, one or two ladle spoonfuls may be mixed with tepid water and thrown into the neck of the uterus; to be re- pealed if necessary. If the aelion be too powerful, it can be moderated by sedative, and subsequently by demulcent, injec- tions. M. Montain relates two cases in which this medication was signally successful. Laceration of the Urethra from a fall tm the Pennxum, with consequent reten lion of wins, for which the opera/ion if puncturing the bladder was verform ed: By Thomas F. Betton, M. D. The rarity of the following case, and the conflicting; opinions of manydis tinguished surgeon?, as to the propriety of the operation selected for its re lief, have induced me to present it to the medical public. Without the mos' remote wish to presume to decide on so important a question, the case with all the facts, as they occurred, shall be given. Ir is not my desire to write a paper, but merely to state the case candidly, and wi'h the view to el,,,;4 farther information on this, to me, an exceedingly interesting topif Gist. On rtie23h of October, 1834, Mr. 1 1.' R. fell from a ladder direct- ly astride of a cart- wheel, through a space of four or five teet. The acci. dent happened berween 10 and 11 o'clock, a. m. 1 was sent for that night at 12 o'clock to see him, in conjunction with his attending physict***, l)r ShehnerJine. He was then labouring under all the symptoms of retention of urine. The introduction of the catheter had been fruitlessly attempted, previously to my arrival; and his physician had used in vain all the mean* usual in such cases, as a warm bath, fomentations to the abdomen and peri- naeum, leeches to t lie perinseum, anodyne enemata, etc. From the nature of the accident, and subsequent symptoms, laceration of the membranous por- tion of the urethra was to be suspected, and such indeed proved to be the case, Cn attempting to introduce the catheter, the peculiar fee] indicating that ac cident, wis plainly distinguishable. There was a peculiar sensation, as if the end of the instrument had passed over a piece of tense cat-gut, which was easily perceptible, but which I am at a loss to compare with any thing analogous. The poriiueum was much bruised and ecchymosed, and the pat tient, as m'ght be expected, greatly distressed. 29th. 9 o'clock, patient more distressed than at our previous visit, in con, sequence of the distension of the bladder, the fundus of which had ascended as high as the umbilicus. As a 1 our endeavors had proved unavailing, noth- ing remained but to evacuate the water contained in the bladder by some ar- tificial means. Further advice was obtained, and the operation "above the pubes being decided upon.it was performed at one o'clock of the same day, twenty-six hours after the accident. It was done in the following manner: Hiving previously shaved the pubes, I mode an incision in the abdominal parietes of about an inch in length, the base of whk h rested on the symphysis pubis, passing between the pyramidal muscles, il i to the fascia lining the abdomen. As is well known to. the anatomist, a pc? ion of the bladd -r isnot invested by peritone- um, and by keeping the trocar as gIobc as possible to the pubes, and direct- ing it towards the axis of the viscus, the peritoneum is not in danger of being wounded, when the bladder is much distended. These rules were observed 759 On Laceration of the Urethra. [Mny, in the present care, and a female silver catheter left in the aperture.- The patient was greatly relieved. 30th. Patient easy. Ordered minute portions of calomel, rhubarb and opium, With mucilaginous drinks. Urine f'ews freely I y the catheter. 31st. Some tenderness of abdomen ; 100 leeches were ordered to he ap- plied. Continue remedy. Nov. 1st. From some exertions made during the eight, to our great re- " greU the catheter slipped out, despite of its tapes. The wound in the blad- der/had healed, and it was necessary to puncture i! sgain, which was tfone at half-past 12, p. m , to his great relief. 2d. Seems easier, but has pome fever; gave him a very weak solution of sub. h. magnes. cum. vin. antimon. etepts. ail her. nit. 3d. The solution has acted en the bowels. Discontinue and substitute neutral mixture. 4: h. Succeeded in presirg the catheter without any difficulty by the nat- ural passage, very mi ch to my satisfaction, as it affiirds me some hope of the patient's life, although his situation has suddenly become, since yesterday, much more dangerous. The catheter in the artificial opening was removed, and the orifice cics d. No infiltration n'o the celluli r tissue i f the abdom- inal partete's had taken place; the irritation of the u nine had excited adhe- sive inflammation, and thereby condensed the sides ot the incision, so as to form a cana1, which, but for the closing of the orifice in the bladder, would have required no canula. H s strength is sinking, and he was ordered miik punch with chicken water. ' His spins also seem depressed, and 1 ferr.bis recovery is hopeless. In fact, on my vifitmgh'm next morning, after a lapse of about fi teen hours, lie was no more. His-skilful and attentive physician, who had visited him very late at nigh4", and di.1 not live very far from him, informed me that he appeared to have, ded from mere exhaustion and debil- ity, added to anxiety of mind. Stimuli were freely administered, but they were productive of no good. Autopsy. The membranous portion of the urethra was found lacerated for about the space of two and a half inches, a. great deal ol Mood effused in the cellular tissue of the perinBBum The wounds in the bladder had healed entirely, and that viscus, throughout, was perfectly sound. The peritoneum < and intestines very carefuHyand minutely examined, evinced not. ihe slight- est mark of disease, so that we could find no apparent cause for his death, save the general shock Jtfl a man whose mind was naturally active and anx- ious. The morbid specimen is in my possession, and it will gratify me to show it to any one desirous of examining it. A case precisely similar to the above in every particular, except the attempt to tap the bladder from the rectum, is related in Dr. Parish's Surgical Ob- servations, p. 24\ and had great influence in inducing me to venture to pub- lish the one occurring under my own rot ice. That the accident is not of frequent occurrence must Ik1 from the circumstance of its having occurred only twiee in this vicinity. i lapse ol many years ; at least I have been able to meel with but one on i shed by Dr. Par- rish. In the case of Mr. It no attempl was made to tap the bladder by the rectum, as it was deemed most advisable to perform that operation above the pubes. This operation, ii done, ca& be productive of no ill con- sequent s ; the peritoneum is not liable to he wounded, if t ho bladder, as it must be to render the operation urgent, he exceedingly djstended with wa- ter: the operation is performed in a sound portion of the yisc_us, the irritation of the urine exc iye inflammation in, and condenses the eel )61ar tis- sue ot tie- a! domm ' p ir etes, forming ihe track of the canula, and no risk of inriltrat'on is incurred. Care must be taken that the canula be neither too k>ng nbr too short, but a (- mtion of this kind it is un ." to make here, as it must arise uaturally in the mind of every' surgeon. The wound heals Siery readily, and the chances of a fistulous opening being le;tare very few. 1837.] On Laceration of the Urethra. 751 h> i v in such cases is d u ' id we should nevi r allow ourselvesai .- wards to rcgr.pt that the operation had not been performed soo Observations ott the preceding case by Dr. Isaac Hays, Rapture of the urethra from externa] injury, ol which the rrecedin affords an int< res in . , though by no < . ry rare occurrence, Jias been either entirely I by authors of ^y<' ma-tic ir surgery, or so cursori ', as to furnish the | ractitioiier v i li but >c\v principles to ^u'd,' him m the n n1 ol the accident. A brief sketch, therefore, ot' i s principal nd of Hie best ma: hod ohrea>ing i, may n>' prove uoacc p'.a'de to rs, and may, perhaps, aid m saving th'e'm from tli!" m >rtificat.ion of fail ire in thi ireffbr'.s to afford relief, and their pa- tterns from unnecessary suffering and even losstiflife. T,ie most frequent rauses ol the accidenl in qy< stion are, falls astride pome firm body, as a bar, edge 0f a boat, pommel of a -saddle, &c., a Jdek on the perinaeum, injuries of the pi lvis, &c. The immediate efinseyuencrs arei severe pain in, and effusion of blood i To th ' perinaeum, prod icing usu illy tumefaction of this part, and sometimes pro- fuse haemorrhage through the urethra. A catheter cautiously itf'roduced in- to the canal ju t named, when it reaches 'he seat rtf rupture, gives the sur- geon the impression of its being out of the canal, fbr its point is wholly un- supported and falls from si I.1 to *.d\ On withdrawing the catheter or stilet afresh haemorrh ige gjNerally ensues If the solution ofcontinui y be com- plete, and sometimes even \vhep partfa), gj*eat difficulty may ba experienced in conveying- a catheter into the blad !er, and in soms cases this will be im- possible. After the la| s i <>:" some time, the patient experiences an urgent desire, with inability to ; iss his urin*1, and this fluid either escapes by lie breach in the urethra, and insinuates itselfin'o the cellular tissue of- the peri- neum and scrotum, enormo isly distending thesn parts and causingthem to slough, if proper m^ans of re' c\' he not adopted, or there is an absolute reten- tion of urine, the bladder becomes visibly and painfully distended, and if this organ is not emptied by the introduction of the catheter or by puncture, it ulcerates or sloughs, th? urine is effused into the peritoneum; or perineum andscrotum, constitution il symptoms manifest themselves", and the patient di 's after great suffering. Tiie treatment of th. se cases seems to us very obvious. When the ca- theter can be introduced into the bladder; this sho aid be d me.* Venesec- tion, leeches, "he warm ba h. poultices, saturnine lotions, and 7\\s/, will then generally complete the cure. But if the perineum and scrotum .be much distended with blood; it is generally most prudent to make a/reeinct6ion into the former part to - . is fluid; and if there be also infiltration of urino, this operation will be always necessary. Where much difficulty is experienced in introducing the catheter into the bladder, the attempt should not bo persevered in, by which the injury is open increased, without, the object being attained; but a free opening must be made into the peruueum, by which a ready exit for the urine, biood and matter is at once secured, and an extension of the mischief prevented^ It is justly remarked by Mr Earfc, that 'kin many of tb , wh< re there is no external wound, and where the patjent is ignorant of the nature of the in- *Dr. Macfarlane states that when the lncerahon of the uret bra is not so extensive as immediately to give rise to extravasation, lie has succeeded in preventing it in two cases, by introducing a large elastic catheter into the bladder and retaining it for several days until the dinger was warded off b+ the sides of the lacerated opening becoming consolidated. (Clinical Re- ports, p. 139.) Where there is little or no extravasation of blood this will no doubt be sufficient. 752 On Laceration of the Urethra. (.May, jury, and the danger to be apprehended, it is of;en difficult, to persuade him or his friends of the necessity for such an operation. Much decision and firmness are required on the part of the surgeon, who should act at once, or he may be too late to prevent extensive or even fptal effusion of urine. No possible danger is to be apprehended from the performance of the operation, which places the patient in a state of security, and enables nature to set about her process of reparation. The wounds always heal readilv, if proper- ly treated, and the external incision be of sufficient extent." London Medi- cal and physical Journal, April, 1828, p. -U7. The operation is best performed by placing the patient on a table in the same position as for lithotomy. An incision should be made along the line of the raph.1 of the perineum, and the coagulated blood removed. A cathe- ter introduced through the glans penis may then be passed into the bladder, the urine evacuated, and the instrument fixed in its situation by a T bandage. Simple dressings are to be applied to the wound, which usually heals without difficulty, and the canal is restored. This upc-rat/on is far preferable to the puncture of the bladder, either above thepubes or from the rectum. The latter is, indeed, often impracticable in these cases, as is fully exemplified by a case presently to be related, and it should never be attempted. The former, though much less objectionable than the latter, is attended with more danger than that we have recom- mended, and is calculated only to relieve one of the consequences of the in- jury without directly contributing to its cure ; and in many cases would not supersede the necessity for a free incision into the perineum. These observations will be illustrated by the following cases : Case 1. The subject of this was a man 25 years of age, wh*n received a vi- olent contusion in the perina?um, by falling with his thighs separated upon the end of the axletree of a carriage. The severe pain which he felt, did not at first prevent him from continuing his work, but he soon had retention of urine, and in a little while there appeared at the bruised spot a tumour, which in- creased rapidly. The swelling extended to the penis and scrotum, and ties last was swelled so considerably that, in the evening, it acquired the size of an adult's head, and was already of a black colour. In this state the patient was admitted into the Hotel Dieu, 10th January, 1790. As he had not made water since morning, and as he suffered much, the bladder was first emptied by means of a catheter, which passed easily, and which was withdrawn after the operation. Dessault then made an incision from the left side of the an- terior part of the scrotum along the perineum to the spot where the urethra was ruptured, and which left naked the vagina] coat of the left testicle. The cellular tissue was found infiltrated with urine, and there was much coagula- ted blood along the canal of the urethra. This incision afforded much relief. Mild dressings w ere applied to the wound. The urine at first flowed through, the incision in the perineum ; on the sixth day a few drops passed through the urethra The wound'gradually healed, so that on the 29th day the urine principally passed through the urethra The "cicatrix, however, contracted this canal, and it was necessary to dilate it. by the introduction of a catheter. The urine ceased to flow through the artificial opening on the 58' h day, and the patient left the hospital cured on the 85;h day. DessauWs Surgery, Vol. II. Case 2. "A man 20 years of age, fyll from a height across a ladder upon the perineum. Much swelling and tension of the parts from the anus to the scrotum succeeded, with great discoloration. Leeches were applied and the bleeding encouraged by warm fomentations ; afer which a poultice was em- ployed and a saline purgative given, which operated largely during the day. In the evening he took an opiate draught with tartarized antimony, which procured alleviatfon of his pain, and produced some sleep. The next day he had much tension of the abdomen, and was unable to void his urine. The catheter was introduced without much difficulty, and a large quantity of 1837.] On Laceration of the Urethra. 753 urine, dear nnd untinged with bload drawn off, and the operation was repea- ted as often as the patient expressed much uneasiness from distension of the bhd ler. A similar plan was pursued with little variation for seven or eijrht days, during which the symptoms were not materially arrested. The dis- coloration at this time had extended to the se.rotum and penis, which were al- most buried in the swelling, and which had now become somewhat aei'ema- tous. in the bight of the eighth day, during a pressing effort to make wa- ter, he was seized with a pain of a much more acute kind than what he had before experienced, and on attempting to pass a ca'heter it met with consid- erable resistance, and could not now be got into the bladder as usual. - " Unavailing attempts. were agam made to introduce ca'heters ot different sizes and curves but the obstacle could not be surmounted. The point of the instrument seemed, when it had arrived a little beyond the bulbous part of the urethra, to quit the canal and get into a pouch on the left side of the raph j "The man's health was now becoming much disordered from constant pain. The pulse was rapid, tongue furred, much thirst, universal heat on the skin, appetite lost and sleep disturbed. It was determined to pass the cafheter as far as possible, and to make an incision upon its poin\ which might be felt externally on the left side of the seam in ptriruto. This was accordingly done to the extent of more than two inches, through the integ- uments, much in the same direction as in li hotomy. A large mass of coia"- uiated and grumous blood was pressed out by the fingers, which was fol- 1 wed by a discharge of watery fluid to the extent of a quart at least, of a strong urinous smell, ar.cl highly tinged with blood. The catheter might then be distinctly felt and seen, having found it's way through the newly formed aperture in the membranous part of the urethra. The patient's suf- ferings became immediately relieved. A largs quantity of water drained off during the night, which reduced the parts nearly to their ordinary dimen- sions. On the following day, when the dressing was removed, the patient was directed to exert an effort to make water, when the whole contents of the bladder escaped through the wound. 44 A flexible elastic gum catheter was then introduced, and left in the blad- der, through which the man voided his urine, which, however, came away partly by the external opening, but chiefly by the catheter, till the wound began to heal. The urine then gradually resumed its natural course, rnd he perfectly recovered in about a month from the time of the accident, wi4h- out any other bad symptoms." London Medical and Physh al Journal^ Sep. tember, 1812. Case 3. 44 A man aged 42, fell across the edge of a door upon his perineum. Considerable bleeding took place from the ureter1, and effusion into the scro- tum and perineum opposite the bulb. When admitted into St. Bartholo- mew's Hospita', he had not passed any urine for many hours. An attempt was made by the dresser to pass a catheter, without success ; and Mr. Stan- ley, who was passing through the ward, was requested to see him. After some time he succeed d in passing a small Plastic gum catheter into the bladder, and some water mixed filth blood was drawn off. Mr. S. distinctly felt the rupture in the urethra in passing the instrument, which was directed to be left in the bladder. Mr Earle saw the patient the following day, and found a tumour of the 6ize ot a large walnut rather to the left of the bulb. The scrotum was black with effused blood, but not much distended. Urine mixed with blool con- tinued to flow through the catheter. He was largely bled from the arm, and twenty leeches were applied to the perineum. 44 He continued to go on favourably for some days, but on the 2oth the ca- theter slipped out, and the patient attempted to reintroduce it, which caused some return of arterial bleeding. He had suffered during the preceding night with severe rigors and fever. Mr. Earle introduced a large catheter S3 734 On Laceration of the Urethra. [May without difficulty, in doing which the laceration in the urethra was distinctly felt about the bulbous part. The shivering and fever returned at night, ar.d the patient removed the catheter, which was followed by considerable he- morrhage. 'On the following day he was very i!1, with frequent deposition to shiver, and the tumour in the perineum had increased in size. A free incision was made through the tumour, and extended downwards towards ihe anus. The membranous part of the urethra was distinctly fJt, but not opened, as the lacerated opening communicated directly with the upper part of the incision, and afforded a ready exit for the urine. The wound bled freely, and gave the patient much relief From this time he was able to pass water without the assistance of the catheter, partly through the wcu id, but principally through the natural passage. The wound suppurated kindly, and speedily healed. "It was necessary for some time to pass bougies, to counteract the effect of the contraction ax the cicatrized portion of the urethra." Ibid, Airi/t 18-28. Case 4. "A man, aged '3d, was admitted into St. Bartholomew's Hospi- tal, September 13th, 1&27. He stated, that on the previous evening, he had fallen about fifteen feet and struck the perineum across an iron bar. Vio- lent haemorrhage took place from the urethra, and the scrotum and integu- ments became distended with blood, accompanied wil h severe pain. H^ sent for a surgeon, who made many attempts to pars a catheter without success. He was bled, and leeches were applied to the part ; but he passed an'ght of freat misery, and the following day was admitted into the hos i'al. His ladder was at this time to be felt above the pubes; no urine had passed since the accident, (sixteen hours,) nor for some hours befon*. His counte- nance was anxious, and expressive of much suffering; pulse 100 and full; perineum and scrotum much distended; and of a dark livid colour; there was no external wound. Mr. Earle cautiously introduced a full-sized silver catheter* which pursed readily down into a cavity filled with coagulum, between the rectum and membranous part of the urethra. The finger, introduced into the rectum, readily detected the point of the catheter in this situation. Mr. E. imme- diately made a free incision opposite to the bulb of the urethra, and extend- ed it parallel to the rupture to the extent of two inches. A quanlity of co- agulum and fresh blood escaped, and the catheter became apparent, passing- through the ruptured opening at the upper p^rt of the bulb. Mr. Karle at- tempted to introduce an elastic gum catheter from t Irs part into the bladder, but not readily succeeding, he desisted from any effort. The finger, intro- duced into the wound, passed into a large cavity filled with coagulum. It did not appear that any urine had been effused. He was place;! in a warm hip-bath, which encouraged the bleeding from the wound, nnd loosened some of the coagulum. Whilst in the bath, some urine flowed through the wound. He now became very faint, and was removed to bed ; and the bleeding waa restrained by the application of lint and cold cloths. Urine mixed with : lood continued to dribble away. He passed a tranquil night, without any return of bleeding. On the 15th, he pissed about half a pint of urine voluntarily through the wount', which relieved h;m much. On the 17th, he experienced difficulty in passing h:s water through the wound, and the dresser endeavored to remove a coagulum which presented itself. This was followed by a return of ar'crial blec d'rg, which continued to flow through the greater part of the nigh*, until the patient was alarm- ingly faint, requiring the administration ol brandy and ammonia, with opi- um. On the 18th, no urine had passed, but the bladder was not d stended. He continued very faint, with a feeble intermitting pulse. On raising him upon 1337.] On Laceration of tho Urethra. 7W a night-chair, he was able to pass water through the wound. Suppuration now began to take place, and no farther alarming symptoms occurred. Oc'o'j?r 2J. A good sizel metallic bougie, No. 12, was introduced. On reading the (situation of the woun'l, it met with some resistance, which was readily overcom?, and the instrument passed or! without difficulty into tho bladder. On withdrawing the bougie, the patient passed sonic water through, then itural passage. "The boug'e was introduced every second diy. The wound in the peri- neum How r ipidiy healed, and was closed by the 8th of October." Il>id. Case 5. A gentleman, in consequence of tjjs horse taking fright and run. ning away, Ion bis stirrups and seat at the same time, and was forcibly thrown forward on the pommel of the saddle, whore he remained <*ome time, t ie horse piu.iging and galloping violently. The gentleman being a good horseman* several tunes attempted to regain his sea', but was as often thrown forward; when finding himself much injured he threw himself on the ground, whence he was carried home. The surgeon who saw him first, found that there was a very considerable contusion a'ong the course of the urethra, and that, the peni3 en! scro'.um were much tumefied; the latter, indeed, filling fast wir>- extravasated blood and urine. The patient was bled, look an ape- rieet, and" a saturnine lo' ion was applied to the injured parts; several at- tempts were made to explore the urethra, but in vain. In the evening the appearance of the parrs was still more formidable; the scrotum at this time \va> enlarged to h s ze of a ch 1.1's head, and perfectly black. Under these circumstance?, iMr. Cline, w o was then called in, ten hours aft^r the acci* dent, made a lateral incision in the perineum, (as for lithotomy, but with* out the usual guide of staff or sound) and having punctured the bladder, urine issued from the wound. An opiate was then administered and the patient put to bed. I a the morning the appearances were more favorable, 'the urine flowed through tha wound, and the scrotum had not increased in size. All inim 'dire danger had subsided, and it was hoped that when ab- sorption of the fljid contained in the scrotum took place, that an opportunity m gat present itself of discovering the passage into the bladder by the ure. thra ; all attempts at which, under the present circumstances, proved com- pletely abortive. Ti;e-o expectations were verified by the event. The pa- tient was enjoined a strict regimen, due attention was paid to the bowels, and an opiate gra ;rally administered at night'. In the course of a fortnight, the absorbing prozess pr 'settled a curimis fmennmerfn. T>ie whole surface of the abdnmsn% nni imm the pubis in Vie dim, displayed extravasated fluid in all Us shahs upwards. No untoward svmptom had occurred, the urine continued to piss by the puncture. A portion of the urethra was discovered, and eve- ry day morn of that passage was found ouf ; till at length, before a month had expired from the time of ihe accid ev, a few drops of water discharged itself through the urethra, and afterwards continued to pass through that channel ; the external opening was allowed to heal, the parts wore reduced to their nVural size," and in another mouth the patient was entirely well. lbia\ May, 1809. Case 6. The subject of this case was a lad sixteen years of ag-e, admitted into SL. Thomas' Hospital, 1"> h July, 1826, with retention of urine, accom- panied with severe scalding pain in the perineum, and earnest desire to empty the bladder. " On examina' ion, the bladder was found distended and rather painful, and I ha perineum much swollen and very tender: from this part the cuticle W s partially abrad yd, as it was also from the inside of both thighs, where ecchymosis to a considerable extent had taken place, producing great d's- coloration, in which the scrotum and penis participated. Tlio lad walked with ranch difficulty, bending forward the body and" separating thsle^pa, and J>o complained that this exertion aggravated the pain* V. 759 On Laceration of the Urethra. l_May, "On inquiry, it was ascertained that, at 6 p. M.t while standing on form rr.ils to take down the blinds from a window, his foot slipped, and he fell, the legs crossing- ihe railing-, and the whole weight of the body and force of the fall being concentrated upon the perineum. Ke immediately felt an urgent desire to void urine, but was unable to pass a single drop, and, rot having passed water since the morning, the repeated ineffectual attempts produced considerable pain. The swelling and pain in thep rineum came on at the same time, and, continuing to increase, he was brought to the hospital ; and an attempt was made to introduce a catheter, which however passed no fur- ther than the bulb of the urethra, and there appeared to enter a carry, in which the point, readily moved in every direction: during this operation, a small quantity of blood escaped. Mr. Travers was now sent for, who on his arrival repeated the attempt with no better success ; and he therefore re- solved upon laying open the perineum and endeavoring to find the continu- ation of the urethra, as no doubt was now entertained as to the fact of lace- ration having taken place. "July 16th, at half-past 3 a. m. The lad being placed on a tabic, in the same position as in the operation of lithotomy, a d.oep incision was made along the line of the raphe of the petineum, and a large quantity of firmly coagulated blood removed. A catheter was then introduced at the glans penis, and the poixit of the instrument was seen in the wound, surrounded by the torn urethra, which appeare I to have been completely divided at the bulb, one-third of its length from its termination in the spongy portion of the urethra. Alter a short but attentive examination, the continuation of the canal, having a clean cut edget was found retracted about hah an inch, and thrown to the left side. Into the vesical portion a silver female catheter was passed till it entered the bladder, when two pin's of clear urine were drawn off. No urine appeared to have escaped previously ; nor did a droo pas?, notwithstandi g the repeated efforts of the patient by Mr. Travers' direc- tion, preparatory to the introduction of the catheter. The female catheter being withdrawn, a gum elastic catheter was introduced along the whole line of the urethra. Simple dressings were then applied to the wound, and retained in position by the T bandage, to which the catheter was attached. The lad was now removed to bed. 44 10, a. M. Ho has slept one or two hours. Has but little pain. The bladder is not distended, but there is slight tenderness of the hypogastric re- gion on the left side. Neither faeces nor urine have been passed since the operation. The face is flushed ; pulse 110, full and firm ; tongue white and dry, slight thirst. Ifr. 01. Ricini %ss. statirn suraend. ; et post duas horas repetend. nisi tlvus prius respondent. 44 2, p m. The bowels have been freely relieved, and he has passed half t pint of clear urine, r ither high coloured ; since which the pulse has become leas rapid and his general appearance more tranquil. "For two days a little urine escaped through the wound, but on the 19' h, the whole pafsad through the catl. e'er, and the wound was healthy and gra. nulating. On the *22d, the catheter became partially plugged, and, no' with- standing the injection of warm water, the obstruction daily increased, and by th? middle of August none of the urine escaped 'hrough i\ hut took its courr e principally through the urethra, by the side of the instrument ; wh;lea small \v completely cicatrized, except at a p:n's po:nt opening?, through w uch twej or thr >e drops of urine, at The moss es- enp j during the day. T.^e stream of urine from the urethra is as large, and pass >s as freely as before the op ration. 14 By ih; applicition of lun at caustic to the openmg, it heilod in a few days; and on October 25th he waa discharged." Ibid* Jan 1827. Cmsp7. "A^'ox, muscular man, aged 41, admitted in'o St Thomas* Hospita', 10th Aug isr, 18*26, with retention of urine, of 48 hours duration, the consequence of an injury to the perineum. "It appeared, r h it on the evening of AtlgustStb, he was occupied in the ch line of a vessel lying off Rotherhithe, when, by some accident, he lost his hold, and fejl about six or seven tee*, with one leg on each tide of :he edge of a bo it, so that the perineum was severely bruised : considerable swelling and tension were the immediate consequence ; but having passed his urine two or fliree hours before, he felt no desire to evacuate the bladder During the night he slept we!', as usual, and was quite easy till the morning of the 9 h, whn, on attempting 'o make water, h^ found that merely a small quantify of blood passed from the urethra, unmixed with urine. The retention con- tinuing, and *he desire to void the urine becoming more urgen% in the even- ing he applied to a snrgeo", who attempted to introduce a catheter, but was foiled by the arrest of the instrument at the bulb of the urethra. About half a pin* of blood flowed 'h rough the catheter. The surgeon then directed the application of twelve leeches and a poultice to the perineum. On August 10th, !he urgency was srill greater, and the lower part of the abdomen bo- cam painful; hut his health was not disordered, and he was able to walk three or four hundred yards to consult an h^r surgeon, who applied six- leeches. On *h ! evening of the 10 h, he was brought to the hospita1, when the permeum was found en ire, but much swollen and tend r to the touch s the penis and scro um, and the inside of both thighs discoloured by effused blood; and the hi id ier evidently much distended, producing considerable pain in the lower part of the abdomen. The desire to emp'y the bladder was very grea\ an I gave an anxious expression to the countenance; the pulse was hut s?'ghtly q'uekened. "Mr. Green, nfrer a'temo'ing to introduce a catheter without success, (pro hieing on'v a flow of blood,) directed -he pa'ientto be placed in the same posture as in the operation of lithotomy, and then made ail incision in the line of the rapht of the perineum, the knife passing into a cell of blood, part- ly fluid, par ly co gul ited, extending towards the arch of the pubes. On in- troducing 'he catheter from the glans penis, it passed into this cell, protru- ding win it th^ ragged edges of the ure'hr >, which was lacen'ed to the ex- ten' of arnnch. probably < lose to the prostate gland, as no diffi ul?v was ex perienced in pissing the catheter on to the bladder. If was a'so "distinctly seen that the triangular ligament was partially lacerated. Three pin's of urine, highly tinged with blood, wore drawn o ~ and the silver catheter left in 'he bladder, an I fixed i i i*s si uation >y a T >and ge. 44 A g ist 11 h. II is passed a comfort ible night, and is easy and qui'e free from pun, eteeptaag :ha smirting of the wound. Pulse, sixty. five, fall, soft, and r'gtil r; the tong io is fou', and he has slight thins*; tiie bowels have been moved twice ; the urine passes through the catheter in tolerable quan- tity it is, however, mixed with b'o"d : a sma'l portion passes from the wound in the perineum. The tenderness of the abdom n has subsided. uThe urine continued to be bio dy till the 14th, after which it became na tural. The bowe's were rather CO *ive, and he was ordered to take ()1. Ri. cini 5 ss. pro re nata. S^rec the urine continued to pass by the wound till the 19tb, after whri :b Use whnk passed through the catheter. ,'oS On Laceration of the Urethra* [May, "August 20th. The catheter having become partially plugged, it was re- moved, cleaned, and again introduced. The wound is healing rapidly, tho granulations at the bottom having inosculated. September 4 h. The granulations have filled the wound, and are now on the same level as the per.neum. Cicatrisation to soma extent, has taken p'ace at U12 extremity of the incision, and the same process is going on at the edges M As the vessel to which he belonged was on the eve of sail'ng for Rgi, and as the captain was unwilling to go without him, the patient was allowed to leave the hospital; havi jg first exchanged the silver for an chstic gura catheter, which he was directed to wear till the wound was quite healed." [Pnd, Mmj, 1837. Case 8. "A robust man, 40 years of age, whilst in the act of mounting a horse, (4 h March, 1837,) was, in consequence of the strap of the stirrup gi- ving wa -, thrown upon the ground ; whilst 1 lag upon h:s back, with h's b >t entangled in the stirrup, he made several violent but ineffectual efforts to re- g iin h:s footing. The bystanders asserted, that whilst the patient lay on Hie ground, he was trod 01 by the horse; but {here was no mark of external contusion, not even the slightest scratch or bruise. Being disengaged from the horse, he was able to walk a considerable distance, to his home; wh m he arrivtl there, he discovered that blood was flowing profusely from his penis. Dr. 1). F. Condie, the narrator of the case, saw the patient, about half prist nine, p m. A full stream of bright coloured blood was flow i ig from the orifice of the urethra, and the amount of blood which had been discharged was considerable. He was dieted to goto b-d, to have cloths wrung out ot cold water applied around the penis, and to the pubes, and to take a dose of sulp. magnes. in divided portions. Eirly the next morning, (9:h,) the patieut was found in great agony, from a coas'ant desire, without the ability, to void his urine. The bladder was grea'ly distended : he had never before been affected with a s'oppage of urine, and had, a few minutes previous to the acciderr, passed it in a full and fr.je stream : during the night he h:id discharged, at. intervals, a small quantity of b'o>d. A catheter was readily passed uito the bladder, and through it was immediately discharged about a pint of blond, mixed wi h a small quantity of urine, followed by a few coig- ula: th; discharge ceasing, the catheter was withdrawn, and found to be completely filled with roagul t *d blood, br. C. attempted to introduce an- other of the same size and curvature, but without success; after en'ering the urethra about an inch, the instrument appeared to escape from the natu- ral canal, when its further progress was immediately arrested ; by a sligH change in the direction of the point of the instrument this first impediment was, without much difficulty, overcome, and the catheter could be passe dor, until it arrived at the arch of the pubes, where it was found to enter an un- natural opening at the inferior part of the ur thra ; its point being felt al- most immediately beneath the skin. The patient was put. into a warm bath ; o: i im gr. i. given, and cloths wrung from warm water app!i d over the blad- der. With the assistance of Drs. R. Coates and J. H Barton, attempts were ae-ain made to introduce the catheter, varying the size, form, and diree- ton of the instrument, in every possible manner, but with no better s: c-M ss; and every attempt produced considerable haemorrhage The attendan e Were satisfied 'that the urethra had been torn across at two different places ; one about an inch within the eX'ernal orifice, the other at that part of the canal corresponding to nearly the centre of the scrotum About twenty hours had now elapsed since the occurrence of the accident. The patient complained of m ;ch pain in the bladder, which latter was greatly distended, and rismg considerably above the pubes. The propriety of an operation to evacuate the bladder was suggested, 'as, however, the general system of the patient had, as yet, suffered but little, his pulse, strength, and spirits con- tinuing good, this, taken in connexion with the very doubtful resuJJ. of any op- 1837.] On Laceration of the Urethra. 759 erafi/tn that could be ff.rfarmed, and the earnest en'rea'ies of the patient to delay as long as was possible, induced us to wait, the appearance of ;he case on the next day, before coming to any decision. In the mean time, the warm bath, warm fomentations over the pubes, and internally opium gra. i:j. were directed.' During the night the patient passed a considerable quanti- ty of very dark coloured blood, mixed with urine ; and the next, morning the distension o! the bladder was somewhat reduced, and nearly all uneasy sen Bations were gone the scrotum and penis were somewhat swollen, and to- gether with the perineum, were of a dark colour, from an injection of blood in the cellular tissue. The patient being costive, directed an enemata. During the day, he continued to pass, at interval.-, a large quantity of blood and urine, and during the night f the 7th, after a violent effort to empty the bladdi r, a coagulum escaped from the urethra, two or thr^e inches in length and nearly of the thickness of the little finger ; it was fo, lowed by a very i o- pious di charge of extremely dark coloured, somewhat foetid urine. "8th. Nearly all swelling and uneasiness of the bladder removed: the urine passes i>tT in voluntary Bowels being costive, directed a dose of castor oil. The patient appeared from this time to be gradually recovering from I he ef- fects of the accident, until the 14fh, when he complained of tenderness along the course of the urethra, with heat and smarting in the act of passing his urine. Skin hot, pulse quick and frequent, thirst considerable. In the course of the day, the pain in the urethra greatly augmented ; on examina- tion, found the fatter, particularly in the perineum, swollen mid hard : the scrotum was also greatly enlarged, tense and painful, presenting many of the appearances of hydrocele : directed twenty-four leeches to the urethra, and a dose of sulph. sodee. From continued neglect on the part of the patient, the leeches were not applied until the 17th. The pain, hardness and swell- ing of the urethra, were greatly relieved by the topical depletion. In the evening, the discharge of ur.ne was again entirely suspended: the bladder somewhat distended, bowels costive ; directed the leeches to be repeated to the same extent as before, and the patient to take, occasionally, a dose of the compound powder of jalap ; the scrotum and region of the bladder to be kept constantly fom ntedwith cloths wrung out of warm water: from these the patient, evperienced very great relief ; and, on the morning of the 19 h, he passed a coagulum, four inches in length, and about the thickness o* a com- mon quill, perfectly white, and rounded at the extremities ; the coagulum was followed by about a quart of dark coloured urine: swelling and pain of the urethra, and distension of the scrotum, greatly diminished; in which state they continued, the patient, passing his urine naturally, until the evening of the 21p\, when the inability to evacuate the bladder, with the pain and swel- ling of the scrotum, again returned: every attempt to introduce the catheter was ineffectual. By the 22nd, the tumefiction of the scrotum extended half way to the knees ; a very considerable swelling was also discovered in the perineum, soft, and without pain On' attempting now to introduce the ca- theter, the instrument, after continuing in the course o/ the urethra for a few inches, suddenly dipped down within the scrotum, and from thence gave die- charge to a very considerable quantity of thick, ropy, deep coloured urine. At this period of the case, Dr. Hewson had the kindness to see the patient with me; it was concluded, that in order to give a free passage to the urine, an incision should be made into the urethra, at the anterior part of the peri- neum: this was accordingly done, and through this opening, the urine con- tinued to he entirely discharged, until about the 30th. From the period of the operation, the swelling and inflammation of the scrotum very rapidly di- minished, and were entirely removed by the end of the month, at which time the patient was able to walk out. The urine was now occasionally passed by the natural outlet ; and by the 13th of April, the opening in the perineum was entirely closed, and the patient discharged cured." iV. A. Medical and Surgical Journal, OcU 1827. 760 On Laceration of the Urethra. [May, Ca?e 9. A man, aged 22, on the evening 0f 17th July, 182-3, received a violent kick on the perineum from a man's foot. "A profuse hemorrhage immediately took place from the urethra, and lie nearly fainted from the ex- cessive pain which 'ho blow occasioned. On the following morning, the 18th, he was brought to St. G urge's hospital, having been unable to make water since the accident, and suffering much uneasiness from ihe dimension of his bladder. There was a good deal of discoloration a! out the perineum, from ex'r.nasat.ion of blood ; but very li:tl swelling', and not so much ten- derness as might have been expected. Tnc house-surgeon passed a silver catheter into the bladdor, and drew off a pint and a half of urine, mixed with dark coloured blood. The i jb lorrhage had previo. sly ceased, and there w s now only a slight oozing of blood from the urethra " He was directed to have some hot'se-physie ; to keep the contused par's constantly wet with compresses soaked in cold spirit lotion ; and a flexible gum catheter was placed in Ihe bladder, in order to prevent any effusion of urine from taking place through the ruptured per ion of rhe urethra. "In the evening, it was found that no water I ad be en voided through the cathe:er, the eyes of it having b -en Hocked up w i-tjn coagi laied blood ; and there was a good deal of pain at d distension aboul the W dder in consequence. The instrument was therefore taken out and . oduced, and twelve ounces of urine drawn off. '.Inly 19th. -The water had flowed freely t; eter dur ng the night ; and tins morning early he took a Senna d] ch operated well. In the last portions of urine voided to-day were a f< Irops of blood He said he was free from pain ; he had no fever, and there was scarcely any swelling in the perineum. "In the evening, he complained of pain in the head, and had made no water since the middle of the day ; he had a dry, furred tongue, and a small, weak pulse. A fresh catheter was passed, but there was no urine found in the bladder, and only a few drops of blood came away. He was ordered a draught with thirty drops of laudanum and a drachm of tSp. Mther. Sulph. comp. "20;h. Had a restless nigh1, but did not complain of pain. H? h"d made no water, and was much in the same state as on the preceding evenirg. 'I he catheter was again passed, but no urine was found in the bladder There was no particular heat of skin or thirst, or urinous smell about his person, as is sometimes the case where the secretion of urine is suppressed. He was directed to be put into the warm balh, ?nd to take the following draught every two hours: 1^. Pulv. Ipecac, co. gr. v.; Fo^asse Nitr. gr. x. ; Pulv. Tragse. co. 3ss. ; Aqua Piment. gjss.; Sp. M'h. Nitr/3j. M. fiat haustus. u In the evening he became comatose, and the skin over the whole body completely jaundiced ; and on the following day, at 1 1 o'clock, he died. About two hours before he expired, the catheter was passed, and two ounces of dark-co'oured offensive urine were drawn off. "At the examination of the body after death, the urethra was found to have been extensively ruptured between the bulb and the prostate giand ; and the cellular structure surrounding that parf, and in the perineum, was loaded with a profusion of dark-coloured coagulated b'ood, but without any admixture of pus or urine in it. The bladder was quite empty, nnd in a per- fectly healthy state ; nor Could any disease be observed in the kidneys, or in any of the viscera of the abdomen. The gill-ducts were not obstructed. "In this case the suppression of urine probal ly depended on nervous sym- pathy, or consent, between the kidneys ard .he urethra. It came on at the expiration of nearly forty-eight hours after the receipt of the acciden% at a time when every thing appeared to be going on in the most favourable way, and destroyed the patient at the termination of about forty hours. * London Medical and Physical Journal, May, 1827. 1537.] Medical Society of Augusta. 761 Taut III.-MONTHLY PERISCOPE. MEDICAL SOCIETY OF AUGUSTA, Addendum to the Argument on the Abolition r>f Pessaries. L\ our notice of the proceedings of the Medical Society of Augusta, on the 2'2(\ of February,* l>y inadvertence, which cs- Capad our noiice in reviewing the proof which we did not com- p:ire with the essay, we made the essayist say, ''that he had conversed with all the physicians of Augusta, and that they are as seven against passaries, to one in favor of them." We should have said "the united testimony often physicians of our city, I may say of all but one or two, goes to establish the fact, that pessaries are now seldom required, and that they are inj irioui when appl'ed for prolapsus uteri." The statements made by the essayist will be seen on reference to the second p:ige of the essay, or (>44 of the journal. It should be recollected that having no stenographer, we have been obliged to take down the proceedings ns made to his arguments in the debate. We omitted these, because we recollected no particular argument ofiered in them, beyond those contained in the body of the essay, which we considered covered all the ground the essay"st wished to occupv. Rut as we are now ad- vis xi to the contrary, it affords us pleasure to make amends for this omission, by publishing the following replications of Dr. P. P. Eve. In reply to Dr. Antony, the essayist said, if he had begged the question throughout, as slated. Dr. A. was unnecessarily solici- tous about guarding the medical class against the reception of unwholeso no. doctrines. ''Begging the. question throughout an essay, he said, was certainty a new m de of instilling doctrines into the m:n Is of students.'* 2d. He had not, a* Dr. A supposed, considered the pessary as an exclusive treatment, but had laid particular stress on the penological condition of the parts in uterine displacements, in relief of which his object was to exclude that instrument. 3rd. He acknowledged he had supposed tint Dr. A. applied * See Southern Medical and Surgical Journal, Vol. 1, p. 691. 90 762 Medical Society of Augusta. [May, pessaries in almost, every case of uterine displacement. It" in error here, he could, lie said, plead for excuse Dr. A's. declara- tion that he had treated upwards of a thousand cases of prolap- sus uteri wit!) the pessary an 1 that the rep'acement and reten- tion of die uterus in its proper site is the lei;imatc prescription, and the bilboqnet pessary the best retentive means. 4th. He said Dr. A. had overlooked the fact that he had men- tioned in the second paragraph of the essay, the difF rent mate- rials, form, &c, of which pessaries had been and are still m-ade even that of wool.* 5th. He was unconscious, he said, of doing; his corrrspon 'ents the injustice ascribed to him by Dr. A. ; for he had proceeded up- on the presumption that they had heard of 'wooden pessaries" since wool is one of the oldest materials of which these instruments were maclp.f 6th. With respect to the fact that authors bad been verv de- fective on this disease (prolapsus utrri), and that the pro ft ssion appeared to know less, both of the diasjn >sis and treatment of this disease than aim' st any other affciion, the essayist sail he could not but think that Dr. A. was brought to this conclusi n by the very peculiar views he entertains on this subject. With all due deference, he said, to his extensive experience in this disease, he could not believe Dr. A. alone correct, and all other practi- tioners wrong in the treatment of prolapsus uteri. 7th. In answer to Dr. A's. remarks on the interruption of sex- ual intercourse, and the immorality consequent on the fr< quent use of the pessary viz. that the first is forbidden by the condition, of the patient, and the second is prevented by tin4 tendency of the disease to alia v. and finally destroy all appetency for vene- real imiulirence, the essayist deduced the f >ll >wing[ dilemma that Dr. A. is in error in calculating that 9-10 of le mates die of ibe (fleets of prolapsus uteri; or that sexual intercourse is not forbidden in this d'sease. If nine-tenths of women labour und< r prolapsus uteri, and even die of its effecls and this dsease forbids sexual indulgence, the world surely would soon be d( p^pulated.J We would syn paihize. lie said, not only with ihe pitiable cr nei- tion oj heaven's best gift to man, but must mourn over our own sad and solitary condition on earth. In reply the essayist said he had stated that the result of his * There will be found on the reference here made, no account of \hcform of a wool'en pessary ; on which its superiority greatly depends. A. . f Docs the essayist believe, that his correspondents had present in their minds, when writing, wo- lien pessaries, of an hour.-glaFs Fhrpe .' A. | See first part of the last paragraph on page ( 95, Southern Medii al and Surgical Journal* where " this sentiment," alluding to the u^o of the pessary lending 1o immorality, is said to have "operated most severely on those af- flicted, and forced its thousands into a course of submission to one degree of physical evil after another," &c. A. 1837.] Georgia Medical Society. 703 inquiries, was a conviction on his part, that pessaries had been greatly abused. He had given the testimony (if more than leu physicians, nearly in their own language, and had thereby estab- lished the tact, that pessaries are P >w seldom required, and that thev are inj irious when applie I fr pr lapsus ut ri. And that the evidence here, is as ten to one. or at most, to two. Finally, Chat in the treatment of uteri le displacements, pessaries are not necessary other means succeed best. Experience on this sub- ject among physicians of this city, is as eleven to one. Georgia Medical Society. This is the oldest Medical Society in the State of Georiia, ha- ving been originally chartered m the latter part of the last, or the first of the present century. It holds its meetings in the C.ty of Savannah, where its members most I v reside, with the exception of corresponding members in different parts. For- merly this society held interesting sessions with regularity, and pressed on in the investigation of medical science with much ar- dor. IJut in consequence of the want of convenient means for Communicating the results of their labors to the world, their ben- efits were limited to their own community, which was not a little profited thereby, and the professional character of the place elevated to the rank of the most respectable, which it has e the advancement of a scit nee so dear to humanity and phil- nuthr py. From our high estimation of the professional abili- ty s o' that community, we, as journalists, look to the Georgia Medical Society, lor much to enrich the pages of the Southern Medical and Surgical Journal. We hope they will not only lupp'y us with their well written essays, but also with the inter- esting debates on the subjects before them, and eases of interest which will, from time to time, be presented by the members. Extraction of a Bone from the Notes. The following case was communicated to us by our friend Dr. A. Cunningham. We consider it valuable because it is cal- culated to afford us a useful hint for the better management of some d seases of the rectum. We have occasionally met with strictures and other disorders of the rectum, arising from the re- tention or, and mechanical injury from, some extraneous sub- stance in the rectum, in which the afll.ction was mo&t severe and pro:raeted. We have also not long since, seen accounts of a number of cases, in wh;ch wood, bone, &c, in the rectum had produced the most distr< ssing (fleets. "The following ca.se is worthy of record in your journal, if for nothing more than to shew what the system is capable of en- during; and in what way it sometimes runovi s ex:raneous matte r which the process of digestion was unable to modify. "A negro man, aged about 50 years, formerly very hit rn- prrate. had for the last ten or fifteen years, been subject to both anal and perineal fistulyc having the space around the anus as far as each ischium, present a series of cicairicc s and fistulous 0 enings. A little way down the back part ofihe scrotum, and i i the raphe scroti, is a fistulous opening through which a portion tfthe mine escapes. I counted three strictures along the ure- t irnl cana . On the projecting point of the right isclvum,the patient direct- ed my at lent on to a p'ece of b ne which had come through the fkin about two-tenths offttl inch, and of a dirty dark brown co- 1 >iir. An attempt to extract it with the thumb and finger, gave him considerable pain. < *n dividing the adjouvng skin, I easily drew out a piece of b ne of the following shape, measuring one in h and efght tenths in length, and three in breadth. It appears to be a portion of hone which is sometimes found in a piece of beef-steak, which has been cut with a saw. 1837.] Hydatids developed in the Gums. 765 The pntient states that some six or eight months ago, he first felt somethin i within the anus which he was unal)le to void w.th his natural evacuations. M ly we no! presume that this, piece of bone entered some of the fistulous openings above the sphincter ani, and from thence passed along it to the ischium? The patient has experienced so much relief since the extraction of the bone, that he has thus far preferred the enjoyment of his present ease to a lvsort to the knife, die, for permanent relief." Hydatids developed in the Gums: Reported by M. Lefoulon, Surgeon Dentist at Paris. On the 15th of July las?, I was consulted by Col. de C., aged 56 years, who had always hitherto enj >yed good health. He stated that about twj years ag >, the third molar tooth of the right side, in the lower jnw, was extracted by a Parisian dentist on account of an o'd cries whicli became exceedingly painful. The operation was attended with nothing peculiar, and was fol- lowed by no inconvenience until three months after, at which time he began to feel at the rejrion from which the tooth had been removed, a small tumour, situated in the gum and which was painful whenever irritated by food during mastication. The tu- mour gradually mereased, until it piojected into the mouth, pre- venting it from bring closed and impeding mastication. It is in this state I ex imined I iin, and found that the tumour was oblong, in the direction of the j iw bone, and about the size of a partridge eg:*. It was hard, with the exception of its middle portion, in which a slight fluctuation could be felt; a considerable pressure was required to give pain; the mucous membrane covering it had undergone no change; the fourth molar tooth was pressed backwards and outwards, arid the second forwards and inwards; the second was also carious and highly sensitive to the touch. I proposed the immediate extraction of the decayed tooth, as preliminary to doing any thing for the tumour, whose nature I did not understand. The operation was performed, when, to my astonishment, the tumour was no longer to be seen, having been lacerated and emptied by the extraction of the tooth. A!y surprise increased, when I found floating in the basin in which tl.e pitient had rinsed his mouth, three small globular and per- fectly transpirent bodies. They were about the s'ze of a large pea, of a gelatinous consistence, and contained a liquid as limpid as water. I at onee recognised them as hydatids (acephalocvsts) and exhibited them to several physicians who concurred with mo with regard to their nature. On examining the mouth. I ascertained that the tumour was evidently formed in the gum in a state of hy pert rop' y; that the interior of the sac was lined bv a whitish membrane, somewhat 7G3 Inoculation of Morphine. Medical College, c]c. [May, resisting, and presenting every appearance of a cyst, No acci- dent followed ; the wound healed kindly ; and Col. de C. has sin^e experienced no pain. This case is one of interest, for I have met with none like it. and it would have been difficult hi' any one to determine its charac- ter a priori. I kn w of n > cases of hydatids fou id in the mouih, save those of the tonsils. Jour/utl Hebdomadaire, p. 151. 1836. Inoculation of Morphine. M. Lafargit, lias been and is still engaged in a series of ex- periments on the inoculation of various medicinal agents. He has ascertained not only that the narcotic eff-cts of morphine are readily developed, locally and generally by this process, but al- so that itoccasi >ns a papular eruption at the point at which it is introduced, which presents characters different from those occa- sioned by the inoculation of other substances. M. L. considers this method of introducing narcotics preferable to other endermic modes, because much more speedy and certain. The peculiar eruption alluded to is, uniformly, produced by all the preparations of opium ; and hence may assist very materially in medico- legal investigations. After relating his experiments, M. L. comes to the following conclusions : "Whenever a suspected fluid does not, on being inserted under the cuticle, develope the peculiar papular eruption already described, it does not contain opium, (or its preparations) : whenever the eruption is produced, the presence of opium should be strongly suspected." M. L. has ( x- perimented with tartarized antimony, crotnn oil, strychnine. &c. [Bulletin de VAcadbmie de Medcane, p. 40. 163(5. Medical College of Georgia. At the annual Commencement of the Mcd'cal College of Geor- gia, held on Wednesday, April 19th, ihe degree of Doctor of Medicine was conferred upon the following graduates, viz: B. L. Thompson, of Crawford vi He. Oa . Thesis, Modus Op- erandi of Medicines, Bryant Walton, of Putnam County. Ga., Cause and Pathology of our Autumnal Fevers. Joseph Tay- lor, jr. of Anderson, S. (\, Opium. Win. L. Al'riend, of Greene County, Ga., Pneumonia. James M. Darnall. of Jasper Coun- tv, Ga., Pathology of Remitted Fever. S. H. Sanders. of Butts County, Ga., Typhus Fever. C. W. W< st. of Liberty Co.. Ga. Detection of Arsenic. John G. Byrd, of Augusta, Ga.. Remit- tent Fever. Joseph Shannon, of Augusta, Ga., Injuries of the Head. Oliver Walton, of Lincoln County, Ga., Pathology of Svphilis. I ). F. Adkins, of Warren County, Ga., Enteritis. ' Jo- seph M. Gardner, of Augusta, Ga.. Pleurisy, A. R. Kilpitrick, of Burke Countv,Ga., Prolapsus Uteri.' C. L. Holland, of Mon- ticello, Ga., Peritonitis Puerperalis. And on application, John 1837.] On Lithotripsy Anomalous Menstruation, <$c. 767 H. Pope. jr. M D., a graduate of the University of Pennsylva- nia, was admitted aleundemgradum. A highly interesting and impressive Address was delivered to the Graduates by Professor L. D. Ford, and which was also lis- tened to with manifest pleasure, by a very large and respectable audience of both ladies and gentlemen. We are much plei-ed with the interest that oar .Medical College is now exciting in our community, and with the influence it is beginning to exercise over our State. We feel persuaded that its advantages, its splendid Museum, extensive Laboratory, increasing Library, Ac* need only to be known, to be propeily appreciated by the med- ical student. We are happy too to learn, that at a meeting of its Trustees, it was contemp'ated to create two new Pn)ressorsh:ps: one of the Institutes of Medicine and Medical Jurisprudence, and the other of Physiology and Pathological Anatomy. We doubt not that competent gentlemen will receive these anp )intments, which will increase the numbrrofPr )fess >rs in our Medical Ceilege t<>8. The- number of students atten ling the lectures in this institu- tion the past season wis 47, being a considerable increasj over that of any former period. Lithotripsy. At a meeting of the Royal Academy of Medicine, in Paris, M. Segalas introduced a child thme years of ag\ on whom, when vet two years ami nine mm h< old, ho performed the operation of hibotricy. The entire time of cure wis six weeks; in which period the instrument had been in'roduced and used six !imes. This is probably the youngest subject yet operated upon in this manner, and will form an evcenrion to the prevailing rule, that naither lit.otricy nor lithotripsy can he norformed at so tender an age. Anronos Dr. G bson inform- u?, that all the rasps m^n'ionod in his com- nvmication to ?h j American Journal of the M 'dical Sciences, for Au-. 1833, as having been opora'ed on by him, are entirely cured. Mr. List op, in his Elements of Surgery, a copy of which we have ju't re- ceived, and shall put to press, for insertion in the Library, expresses himself as no* verv sanguine i" suppoing that the breaking up of the stone in the bladder will ever supersede lithotomy. At. the same lime he admits that, this operation is very advisable in certain cases, and may be resorted to with evory prosooct of a safe, speedy and successful conclusion. Eclectic Jour- nal ol Medicine. Anomalous Menstrua/ion. - M. Bourgeois lias met with a curious exam- ple of this. A young 1 idy of 15 or Hi years of age, commenced some time since to menstruate trom the extremities of each ol her ten fingers. At the second menstrual epoch, the hemorrhage was renewed from the sam place and at the period when M. B. communicated the tact to the Medical Society of Paris, the menses had not appeared in the natural manner. Boston Jour- nal. Treatment of Influenza. The London Lancet, in speaking of the late pre- valent epidemic influenza, thus alludes to the treatment. "In the severe cases, the most effectual treatment was found to consist in the administration of an aperient, containing two or three grains of pro- 76S Iiiti-orluction of the Catheter, $c. <$*c. [May* tochJoride of mercury, generally combined with aloes. This, in all case*, was foun I essentia] ; and here we may no'ice H13 Riga*) relief which all such cases as small po*\ scarlet fever, under treatment, at this period, derived at their commencemen', esp-'ci illy from pnrgatives, or which pro'ochloride of mercury, and rlmbarb or jalap, followed by castor oil, &c, were the most use- ful. *A saline mx'er^, composed of tar*^r ome'ie and smorn*- ing in number to abont 600. This comparison led bin to fo*m a conchsion decidedly favorable to ex* ration, and he hW, since then, adopted this as lifs ordinarv practice, reserving the o'h'T mod ^ for tfie few discs wlrcb rppear peculiarly adapted for its application ; the pronpr'ion of wbic.K "crord'nfftt M. Koux, does not exceed one in twenty. Eclectic Journal . in l!i tcntjon ofl] rine ioUterus, StrananlninH I l.-nn.i. 436 504 504 504 504 505 314 381 129 62 318 64 435 704 404 404 . 625 313 . 64 525 . 376 46 . 121 767 . 737 711 . 457 24 . 65 148 . 150 179 weight and fulcrum, 281 580 . 24 415 509 150 185 129 557 556 Benedict's opinion on operation for Cancer, Blighted Foetus at term, .... Blainville, M. de, on False Membranes, . Bone, extraction of, from Nates, Bow en, Dr. 1. on Hy stent is Chronica, . " on Ergot, .... " Editors' note on. Brodie, Sir B., Clinical Lectures of, on Epulis, Bronehocele, by Professor Chelius, " Case of, successfully treated by Dr. W. M. Broussaisin. ..... Bruit do Soufflet, mechanism of Lee, Caterpillars in the Intestines, ..... Catheter, introduction of ..... Catcract, operation for . " Dr. Middleton's plan of operation for, Cantharides, nature and mode of action of " 1st memoir on, by Nardo, " 2d memoir on, by Pullino, . Carusi, Dr. on Syphilitic Ulcers, Carbonic Acid, solid, ...... Cancer of the Mouth, cure of, .... " Remarks on Professor Benedict's opinion of operation for . ' of Lip, resection of lower jaw for Cautery, Actual, in Fistulas, ..... Carcinomatous tongue, Ligature on, by Dr. Donnelan, Carmichael on Sleep, ...... " on the Blood of the Vena Porta, . Cases with observations, by Dr. Robertson, Caoutchouc, physiological effects, of, by Dr. Chase, Ccecum, experiments on the functions of, ... Ccrebro-Spinal Fluid, ...... Cervical Vertebra?, fracture and depression of, by Dr. Strobel, Caesarian Operations, new cases of . Ceanothus Americanus, medical properties of, by Dr. M. Antony, Chapman, Dr. on Chronic fluxes of the bowels, Chorea, . Chase, Dr. H. on Caoutchouc, ..... " on Radical cure of Hernia, notice of, Chalybeate Water, artificial, ..... Chloride of Soda in sore nipples, .... Chomel on Typhus Fever, . Cholera in Savannah, Dr. Kolloch on, " Sulphate ofCtuininc and Lactucarium in, Cholenferous Insects, ..... Chloride of^Soda, use of in fevers, . Chronic Fluxes of the Bowels, Dr. Chapman on, " Editor's Remarks on,l Cinnabar Fumigations, ...... " Dr. Cohen's letter on, Clinical Lectures of Sir Brodie on Epulis, ('l.i\ of dirt-eaters, analysis of, by Professor Cotting, Convulsions, Puerperal, Dr. M. Antony on, " Tartar Emetic in, . , Corigeen, or Irish Pearl Moss, . . . . ( 'oehlea. use of in hearing . Cohen, Dr. Philip Meivin, Letter of, on Cinnabar Fumigations, Cory/.a, venereal, . CoUcaPktonum, treatment of, .' . . 1 1!> Consumption, pulmonary, influence of professions on, . . 122 ( !opaiba, Tincture of, . . . . . . . 381 Getting, Professor J. M. Thermometrical observations of, 7(i, L33 2 " Extracts from a Geological Survey, &c. . ... 76 " Analysis of Clay, bj ...... 988 Creosote, physical properties of, ...... '>!> " chemical properties of, . . . . . .39 " preparation of ....... 3!) " physiological action, of, .... .40 " medical employment of, ...... 41 " mode of administering, . . . . . .42 Croup, sulphate of copper in . . . . . 383 " new remedy for, ....... 12(5 Croton Oil in Laryngeal affections. ..... 616 Cranium, extensive fracture of, by Dr. I. M. Antony, . . . 134 " Note on the same by Dr. M. Antony, 13(5 Cruveilhier's Pathological Anatomy, notice of . . . .98 Cystotomy and Lithotrity, parallel between, ". . ... 375 Datura Stramonium, poisoning by, ..... 382 Delony, Dr. E. Topography of Talbot County, by .... 601 " Letters to the Editors, ...... 257 Delirium Tremens, Digitalis in, . . . . .64 Diagnosis, by Rostan table of, . . . . . . 231 " Rostan on, ....... 166 Dignified consistency, . . . . . , . . 120 Doctor, notice of the ........ 233 Doctors, mortality of ....... 422 Donnella n's case of Carcinomatous tongue, . . . . .60 Dugas, Dr. L. A., Medical Statistics of Augusta by, . . . 650 " Strictures of the Urethra treated by excision 293 11 On Colica Pictonum, . . . 402 " " On Impeded Respiration, . . . .587 " On Idiopathic Mortification, ... . 265 " " On Rheumatism, . .... 15 Case of Hydrocephalus, .... 440 " " On Purulent Ophthalmia, . . .81 Dupuytreu on Chorea, ....... 108 Dupuytren's Clinique Sub-cutaneous Fibrous Tumour . 366 " " Cataract with Carious Teeth, . . 368 " Dislocation of Thumb, .... 368 " " Schirrous Mamma1, .... 360 " " Case 1. Disease of Spine, .... 205 2. Disease of Spine, . . . 806 11 " 3. Disease of Spine7~ .... 336 " " 4. Disease of Spine and Hydrocele, . 327 " 5. Empyema caused by Disease of Spine, . 227 " " 6. Disease of Spine and Coxalgia, . 227 " " 7. Vicarious Menstruation, . . . 228 " " 8. Wounds of Abdomen, . . 228 " " 9. Concussion, &c. of Brain, . . 228 " " 10. Abscess of Mamma-, . . 239 11. Predisposition to Disease, . . 908 12. Varicose Veins. ... 230 Editorial Remarks on Lisfranc's Cliniquc, .... 370 Elbow Joint, excision of, ...;.. 088 Elementary Medical Instruction, by Dr. Coates, . . . 237 Empiricism, Remarks on, by Dr. Joseph A. Eve, . . . .70 Empyema, operation for, ....... 257 Epilepsy, treated by Indigo, ....... 501 Epulis, . . . k 249 Ergot, Observations on, by Dr. M. Antony, .... C5 misplaced action of, by )r. I. Bowen, .... 145 'Erectile Tumours, cure of, \ 627 " by Professor Chclius, ..... 436 Eve, Dr. Joseph A.; on Professional Qualifications, &c. . . 705 " " On Empiricism, ...... 70 " On the Modus Operandi of Medicines, . . 449 On Revulsion, 388 " " On Medical Education, .... 216 Eve, Dr. Edward A. on Gangrenopsis, ..... 731 on Idiopathic Fever, .... 139 Eve, Dr. Paul F., Operation for Polypus by, . . . . . 78 " " Essay on Pessaries, ..... 641 Surgical Cases by, .... 261,385 Expectant method, ....... 249 Fever, Typhus, Alum in, ....... 318 " Chloride of Soda in, . . . . . . 103 " Intermittent and Remittent, pathology and treatment of, by Dr.. L. D. Ford, 335 " Bilious, Quinine in, by Dr. D. Hook, .... 360 " Congestive, of Chattahoochee, by Dr. Johnson, . . 594 Febrifuge, new, ........ 746 Flannel in Hot Climates, . . . . . . 254 Ford, Dr. L. D., Analysis of Hydrant Water of Augusta, by . .22 " " On Intermittent and Remittent Fevers, . . 335 Fractured Os Femoris, treated by weight and Fulcrum, by Dr. M. Antony, 281 French Medical Institutions, account of, by Dr. Lee, . . . 234 Fumigations in Whooping Cough, ...... 320 Cinnabar, 509,623 G. Gangrenopsis, Essay on, by Dr. Edward A. Eve, . . . 731 Gangrene of the Lungs in the Insane, ..... 611 Galvanism, Medical application of, ..... 183 Garvin, Dr. J. P., on Puerperal Pcritonotis, . . . . .5 " on Pneumonia Biliosa, .... 536 Gerhard on Diagnosis, notice of, ...... 29 Georgia Medical Society, ...... 763 Gout, Magnc tism in, ....... 416 Goitre, cure of, by extirpation, ...... 61 Grant, Dr. George R., on Retained Placenta, .... 193 Grade, cases ol'Goitre, by ....... 61 Groin, Tumour in, with worms, ...... 675 Gray Sulphur Springs, Medical properties of, . . . . 162 H. Harelip, period for Operation, ...... 506 Hemiplegia, remarkaole cose of .... .448 i Hemiplegia cured, ...... irrhoidal Flu*, Antimonial Suppositories for .restoration of Hemorrhois, notice of Dr. Salmon's] markBon, us iii the i:< afcmi ml > f Heart, moti< nsarj i . * . . ..... * and pulse, action of, " pulsation ofin Foetus, . Heustis, Dr. J. W.j remarks by, on Spinal Irritati< a. " " " Medical Relic; Hind's Lithographic PI [ [ippoerati i fa work of, . . Holfoway, Dr.G. K., cat Sarcoma, by Home, Sir Everard Literary Sacrilege, Hooping Co ts in, Hook, Dr. D. on Quinine in Bilious Fever, . Hypertrophy, Remarks on, by Dr. M. Antony, . Hydrothorax, case of, Hydatids in the Gums, .... n Pills, composition of, " antidote for, Hydrocele of the Neck, by O'Beirne, remarks on Hydrocephalus, case of, by Dr. Whitridge, " case of, by Dr. Dugas, I. Illustrations of Surgery, by Dr. Doane, notice of Intermittent Fever, Chloride of Soda in, Intemperance, morbid effects of, . Influenza, treatment of, Indigo in Epilepsy, .... Itch, treatment of, . 410 7:57 363 . 629 104 . 104 106 . 63 322 . 321 69 . 742 207 , . 573! 320 . 360 457 . 637 76& . 382 120 . 17 513 . m 0 i<>i . 570 181 767 . 501 255 K. Kennedy, Dr. on Tartar Emetic in Obstetric Practice, L. 34. 100 Lactcals, offices of .... Lafayette. Dial-treatment of fractured leg of Lactucarium in Cholera, .... Labour, tedious from rigidity, Tartar Emetic in " " " note on by the Editors " Irritable or Violent, Tartar Emetic in Leucorrhoea. enquiry into, Inula Helenium in, Lee, Dr. J. F., Cases of Traumatic Tetanus by Lee, Dr. Wm. M. on Acupuncture, Lead, new treatment ofthe disease of Leeches Medicinal, Editorial remarks on Lithotomy in the female, by Professor Chclius, Lithotripsy, ..... Lithographic plates of fractured bones, by Dr. Hinds Light stimulous of Life, Chances of ... Listranc, on Encysted Tumour of Wrist, Li* franc's Clkiique Anatomy, " Introduction of speculum uteri, " General symptoms of uterine disease, . 254 . 509 255 . 35 , . . . 37 . 37 575 . 704 577 129 G31 116 435 767 62 382 377 408 390 300 301 Lisfranc's Cases of uterine diseases speciilum, " Piseases of the uterus, " Chronic metritis, or simple hypertrophy " Hypertrophy ot'uterus, with transformation, &c. " Tumours ofthe uterus, " Miliary polypi of os tineas, " Tubercles of the uterus, " Ulceration of os tincae, " Leucorrhcea, .... " Amputation of os tinea), . of carcinoma of os tinea?, " Editorial remarks on, Louis M. on Expectoration, .... " on Blushing, .... Lymphatics and Veins, offices of ... 370, 302 302 303 305 305 306 306 307 309 310 211 430 409 409 254 M. Mammae Obstructed, Tartar Emetic in Mania Puerperal, Tartar Emetic in Magncsian Aperient, analysis of Magnetism, Animal, editorial remarks on Medical Society of Augusta, proceedings of, . Medical Education, by Dr. Moultrie, " by Dr. Eve, Medical College of Georgia, commencement, . Medicine, Retrospection in, Metritis, Chronic, ^^ Mercury, MeWlic, iAs, Middlemore's ope i ongenital Cataract, M'Junkin, case of Monjfcrosity, by Mixture, Freezing, its me in Prussic Acid process Morphine, Inoculation w^ Moore, Dr. R. D., on Secretions, Morrison's Pills, .... Mortality, comparative, of Males and Females, " " of married and unmarried, Muscular System, influence of Nerves on, Muriate of Barytes in White Swelling, . 438, 566, 691 101 102 121 187 761 489 261 766 412 313 429 59 294 382 766 201 190 421 433 512 630 N. Nerves, Cerebro-spinal, plates of, Nervous System, physiology of, Neuralgia, Frontal, " of stomach, Nellis, Master S. K. G., short account of Nipple Shield, (Pratt's) . North London Hospital, O. Odoriferous Exhalation from Skin, Opium, correctives of Orchitis Chronic, mercurial inunctions in, Osteo- Sarcoma, case of, . 703 678 416 128 522 58 701 446 128 633 207 Parietal bone, fracture of Penis, arteries concerned in erection of, " Anatomy of . 155 422 494 INDEX. Peritonitis, Puerperalis, Phrenological A nalysu PhUoBoph) of i [ealth, Phloridzine, Phthisis, pathological anatomy of, Piorrj . notes mi the blood by, . " on diluents, Pneumonia Bifiosa, . . : Senilis, Polypus, Bronchial, . " removal of from base of Cranium, Pulsation, local, case of] Pus in the blood, method of detectin r- stP26' 1 od j\VKl3ul [" FEB 6 62 1 ' Library Bureau Cat. No. 1137 Southern journal Vledioal and |3*3 Surgical fS al 1383 Southern Medical and Surgical Journal Vol. 1, 1836