Southern Medical and Surgical Journal, 1847

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SOU T II E K N

MEDICAL AID SURGICAL JOURNAL

EDITED T.Y

PAUL F. EVE, M. D.,

AND

I. P. GARVIN, M. D.

Medical College of Georgia.

\ Je preyirfs Ic bicn ou je le trouvc."

VOL. HI. 1847. NEW SERIES.

Augusta, (a.

JAMES McCAFFERTY,

PRINTER AXD PUBLISHER.

1847.

SOUTHERN

MEDIGAL AND SURGICAL

JOURNAL.

Vol. I] NEW SERIES. JANUARY, 1847. [No. 1.

PART I. ORIGINAL COMMUNICATIONS.

ARTICLE I.

Remarks on the use of Quinine in Intermittent and Remittent
Fevers. By L. A. Bugas, M. D., Professor in the Medical Col-
lege of Georgia.

Having received during the past season a number of communica-
tions requesting my views on the use of quinine in the treatment of
our autumnal fevers, I beg leave to reply to them through the medi-
um of this Journal.

The fevers of this section of our country, being almost exclusively
paroxysmal, it may be. well to premise, very briefly, my views of
their pathology, by which it will be perceived tfiat I regard them as
essentially different from those continued fevers more commonly en-
countered in colder latitudes, and which have been denominated
Typhoid, Typhus, Follicular enteritis, Dothenenteritis, Jail fever,
Ship fever, &c.

Our paroxysmal fevers are either intermittent or remittent at their
onset; but, if not arrested, the former may, more or less early, be-
come remittent, or the remittent assume the intermittent type ; thus
showing them to be only different degrees of the same disease.
They both present the same paroxysmal phenomena, that is to say,
have regular periods of recurrence or exacerbation, and of declen-
sion ; they are both preceded and accompanied by a general disturb-
ance, more or less marked, of all the functions of the system, but
more especially of those usually termed nervous, as those of sensi-
bility and muscular motion. Lassitude, pains in the limbs, back and
head, loss of muscular strength, are premonitory and persistent in
both. The activity of the circulation, however great, is not continu-
ous as in the phlegmasia?, but partakes of the same paroxysmal char-
acter as the other phenomena. Indeed it may be established as a

1

Quinine in Intermittent and Remittent Fevers. [January,

maxim, that no inflammatory disease ever assumes the paroxysmal
character, inasmuch as all inflammations pursue an uninterrupted
course, whether they terminate in resolution, suppuration or gan-
grene. Wherever inflammation is exposed to occular observation,
it is never seen suddenly to disappear and to return at stated inter-
vals, or otherwise ; but it runs a uniform course which cannot be
suddenly modified by the efforts of nature nor by any agent with
which we are acquainted. Pure inflammation of internal parts, as
pneumonia, pleurisy, acute articular rheumatism, enteritis, &c, ob-
serves the same course ; there is nothing paroxysmal in these diseases ;
the febrile action is not attended with daily or periodical exacerbations,
but gradually progresses to a certain point, and then gradually declines
with the subsidence of the inflammation. Periodicity or the paroxys-
mal peculiarity is characteristic of the neuroses properly so called
of diseases of the nervous system, which modify the functions of
remote organs, and which may be dependent upon congestion, but
certainly never upon inflammation. We know of no organ, whose
inflammation could furnish us any rational explanation of the varied
phenomena of intermittent or of remittent fever. Let us however
look to the nervous system for the solution of the problem of these
fevers, and all becomes perfectly plain. The languor, lassitude, gen-
eral and local pains, tremor, modifications of the capillary as well as of
the general circulation and of the secretions, and, above all, the abrupt
transitions from a normal state to one of great perturbation, and from
this again to comparative health, together with the periodical returns
of the morbid manifestations all indicate manifestly great disturb-
ance of that pervading system whose condition is reflected in every
part of the body the nervous system. There is no other system
whose impairment could by any possibility yield us the phenomena
above related; still less is there any single organ that could by any
modification of its condition, produce such general perturbation of
the acts of the economy. Intermittents and remittents then are un-
questionably the manifestations of deranged innervation ; and if
arrested sufficiently early will be attended with but little injury to
any organ. A continuance or frequent repetition of this derange-
ment, however, may more or less seriously implicate the parenchy-
matous and secerning structures, inducing inflammatory action, and
may even terminate in fatal congestions.

With these views of the pathology of paroxysmal fevers, we are
ed naturally to the use of such remedies as are calculated to arrest

1847.] Quinine in Intermittent and Remittent Fevers.

or to modify the perversion of innervation. Theory alone would
indicate a resort to any agent known to blunt the nervous sensibili-
ties, and thus to diminish their mobility or tendency to perturbation.
Narcotics would present themselves in the first line. Every one
knows that opium, morphine, camphor, alcoholic liquors, sulphuric
ether, &c, are valuable remedies in intermittent fevers. Indeed, a
favorite prescription with me in such cases is a combination of 2 parts
of sulphuric ether, 1 part of tincture of camphor and 1 part of tinc-
ture of opium, of which I give a tea-spoonful in a wine-glass of cold
water two hours before the expected paroxysm, and half this quantity
again at the expected hour of attack ; the patient remaining in bed
during the effect of the remedy. This rarely fails in uncomplicated
cases of intermittent fever ; if it does not completely succeed the first
day, it will the next. I have frequently averted, or favorably modi-
fied even a paroxysm of remittent fever by the administration of a
full dose of morphine {\ to J gr.) half an hour before the expected
exacerbation. But the efficacy of narcotics is not so fully borne out
by experience as is that of quinine, an agent which as yet holds a
position unique in the materia medica. The most striking peculiari-
ty of quinine is its power to prevent the return of periodical affec
tions, and this appears to me to be effected by blunting the susceptibili-
ties of the nervous system. The senses whose acuteness of perception
we can most easily observe, are manifestly blunted. Audition is
very soon impaired, and so is vision, if the dose of the remedy be
large. The effect of quinine on the heart, in our fevers at least, is
unquestionably to diminish the force and frequency of its action, and
if the quantity administered be large, a general relaxation, attended
with a profuse cold sweat, will be produced, resembling and therefore
mistaken by the inexperienced for a collapse of fatal tendency.
Having tried it in cases of pure phlegmasia, in pneumonia and acute
articular rheumatism, for example, without any aggravation of the
febrile action, I cannot regard it as a stimulant.

There is, I believe, no difference of opinion in relation to the value
of quinine in the treatment of intermittent fevers. I will, therefore,
now confine my remarks to Remittent fevers, comprehending under
this term, bilious, malignant, congestive, and country fevers. These
are usually preceded by premonitions, which if properly attended to,
would enable us to avert their development with great ease. It is,
however, exceedingly rare that medicai aid is invoked thus early, and
the physician is generally called in only during the first or second

Quinine in Intermittent and Remittent Fevers. [January,

strong paroxysm ; often much later. The paroxysm, when once fully
developed, will usually run its course despite of any efforts we may
use to check it. I therefore generally direct merely a foot-bath, and
the free us&of cold drinks, as water, lemonade, or soda water, until the
period of remission. Should there be, however, such a determina-
tion to some vital organ as to threaten serious injury before the
equilibrium of the circulation be restored by the subsidence of the
exacerbation, I abstract blood with cups to the spine, sometimes
(though rarely) deplete from the arm, and urge the use of revulsives,
as hot and stimulating pediluvia, and sinapisms to the spine, epigas-
trium, feet, &e. ; if the head be congested, the affusion of cold water
to it, continued until the pulse be depressed, and repeated as this
reacts, is the most efficacious application I know of. Saline enemata,
especially if the bowels are full, should not be omitted, as cathartics
will very rarely act during the stage of excitement. If the conges-
tion be attended with cold clammy skin, a small and feeble pulse,
and prostration of the vital energies, I advise, in addition to the re-
vulsives, large and repeated doses of the above-mentioned combina-
tion of ether, laudanum and camphor, until reaction take place.

The exacerbation having subsided, our treatment should be direct-
ed to the prevention of its return, and my invariable rule is never
to permit the occurrence of another paroxysm after I see the patient.
But, it will be asked, can this rule be carried out? I answer that it
can in the great mcjority of cases, and that in those in which we fail
to accomplish all we desire, we yet so modify the state of things that
success is almost certain on the day following. If we be fully im-
pressed with the belief that the fever being once arrested the patient
will rapidly return to health, the importance of the rule cannot fail
to be appreciated ; and that such is the fact will not for a moment
be denied by any one who has ever tried the practice we recommend.
I repeat, that if all our efforts be directed to the prevention of another
paroxysm if we resolve never to allow a patient to have another
exacerbation after we see him, the cure of remittent fevers will al-
most invariably be effected in a day or two.

In the accomplishment of our resolve, quinine must be regarded as
the sheet anchor of our dependence, for although we may resort to
other means, these can never be but of secondary value. Nor is it
necessary in ordinary cases to use such large quantities of the quinine
as are recommended by some. The quantity I use in one remission is
usually from 15 to 20 grs., but I have sometimes given 30 or 40 grs. ;

1847.] Quinine in Intermittent and Remittent Fevers.

never more. It is rare that less than 15 grs. will prevent the expect-
ed paroxysm. Whatever be the quantity we may estimate as neces-
sary, this should be given in such a manner as to have the system
fully under its influence an hour or two before the time of the previous
exacerbation, and to continue its influence a couple of hours after
this time. If the period of remission be eight hours, we may admin-
ister 2 grs. hourly if it be five hours, we may give 3 grs. hourly
if three hours, 5 grs. hourly and if only one hour, we should give
20 grs. at once, and smaller doses subsequently, if necessary, to insure
success. According to my observation the number of doses is a
matter of but little moment the quantity given in a remission is all
important. This will depend upon the violence of the attack, the
number of paroxysms that have occurred before we see the patient,
and the kind of treatment to which he may have been previously
subjected. As a general rule, the quantity should be increased as
the period of remission is shortened, and in proportion to the number
of paroxysms that have preceded its use. I am inclined to think also
that it requires more quinine to prevent a paroxysm in one who has
been depleted or acted on by emetics and cathartics than in one who
has previously been subjected to no medication. The convalescence
is certainly more rapid when no debilitating process has been insti-
tuted, and health is almost immediately restored if the disease be
arrested with quinine on the occurrence of the very first paroxysm.
There is some choice in the mode of administration, for the sulphate
of quinine will act more slowly if given in powder than in solution,
and still more so in pills than in powder. Whenever, therefore, a
prompt effect is necessary, the solution should always be preferred.
If the stomach will not retain it, it may be thrown up tlse rectum
with a little flax-seed tea or thin starch, in about the same dose as if
given by the stomach. In this way it acts remarkably well, and, in
the treatment of children, who evince great reluctance to its taste,
this mode of administration is peculiarly happy.

But the query is often made : would you give the quinine in cases
of remittent fever in which the head is evidently affected, when
there is intense cephalalgia, or coma, or delirium ? in cases in which
the stomach seems implicated the patient vomiting frequently and
rejecting every thing he takes ? in cases in which the bowels are too
loose, or very easily disturbed ? in ca*es in which the liver is either
torpid or secretes inordinately? incases in which one paroxysm
runs into the succeeding so completely as scarcely to leave any re-

Quinine in Intermittent and Remittent Fevers. [January,

mission of consequence? I answer, unequivocally, yes and that
the stronger the tendency of the disease to localize itself, the more
urgent is the necessity to arrest it ; for this tendency will increase
with every paroxysm, and cease as soon as their return be checked.
Let us always bear in mind that the paroxysms are not occasioned
by the affection of the head, stomach, bowels, or liver, but, on the
contrary, that these are the consequences of a deranged innervation
and of the paroxysmal condition, and our duty is plain. Let us not
be alarmed by the bug-bear inflammation and vitiated secretions, nor
be deterred from the use of quinine because some still believe it a
stimulant, and our success will very soon eradicate every vestige of
former prejudices on this subject. It was not without much difficulty
that I succeeded a few years ago in persuading a planter, who had
long been in the habit of looking on bilious fever as occasioned by
the presence of vitiated or superabundant bile, and who consequently
treated his negroes with emetics, cathartics and mercurials, that if
he would use quinine at the outset, his hands would be in the field in
a few days, instead of losing from ten to fifteen days whenever at-
tacked by fever. And yet, after he had fully satisfied himself of the
advantage of the proposed change of treatment, his first observation
on meeting me was always " what becomes of the bile? I am afraid
that it is still in the system and will again do mischief!"

In order to illustrate some of the positions I have assumed, I will
relate a few cases in which the remission was very slight, and the
tendency to localization imminent.

On the 12th of October, 1841, I was called to see a lad about 10
years of age, and found him in the height of the second paroxysm of
a most violent attack of remittent fever. The pulse was full, strong
and active ; the heat of the surface intense ; he complained of violent
head-ache, yet was incessantly tossing himself about the bed in wild
delirium ; his stomach and bowels were quiet. I had but a few
days previous seen a patient about the same age, and in the same
neighborhood succumb (without quinine) in the third paroxysm of a
similar attack, and I had every reason to apprehend a similar issue in
this case, if another paroxysm were permitted to occur. It was now
2 o'clock, P. M. and the next paroxysm was expected to commence at
8 in the evening. He had taken a cathartic the day before I saw
him. I immediately opened a vein, to prevent increased injury to the
brain, and abstracted blood pretty freely ; then applied a blistering
plaster over the dorsal region of the spine, and commenced the use

1847.] Quinine in Intermittent and Remittent Fevers.

of quinine in doses of 2 grs. every hour. At my evening visit (7
o'clock,) I found him quiet, free from delirium, and with very little
fever. Ordered (he quinine in doses of 1 gr. hourly through the night.
The next morning I found him sitting up, without fever, and wishing
something to eat. He had no return of fever, took no more medi-
cine, and was perfectly well in a few days. I would remark that the
delirium entirely suhsided only, after he had taken several doses of^
quinine. I have since given it during delirium, without bleeding,
and with equally good effect.

On the 28th October, 1841, I was requested to visit a gentleman,
about 45 years of age, on the 5th day of a severe remittent fever. I
found him with high fever, lying on his back, and so comatose that it
was with considerable difficulty that he could be made to notice ques-
tions, to which he would then make incoherent replies. His surface
was moist with perspiration, though warm. His pulse was frequent,
and somewhat strong, but not sufficiently so to warrant bleeding at
so advanced a stage of the case, and especially as he was of intemper-
ate habits. He had taken two or three cathartics and the onset of
the next paroxysm was expected in three hours. The case was such,
that death must of necessity attend the supervention of another par-
oxysm. Under these circumstances I ordered 5 grs. quinine in
solution every hour, and remained to watch the effects, for I was not
at that time as well acquainted with them as at present. Indeed I
had not before ventured ihe use of quinine under a similar determi-
nation to the head. The administration of each dose, was attended
with manifest improvement, so that when the time arrived for the
recurrence of the paroxysm, my patient was perfectly lucid, had no
stupor, and but little fever. I then left him, with orders to take 1 gr.
of the quinine hourly, for twelve hours. On the following morning
he was sitting up, without fever, and had none afterwards. A mild
laxative was all he took during the rapid convalescence.

During the same month, I attended a girl 8 years of age, whose
remittent fever was marked by great gastrin irritation, so as to cause
her to reject every thing she took ; quinine solution administered per
rectum as readily controlled the disease in this as it did in the above
cases.

More recently, I saw a gentleman who had been seized at 9 o'clock
A. M. with a chill, which was soon followed by the most intense
head-ache, intolerance of light, pain in the back and limbs, as well as
at the epigastrium. Being of a sanguineous and plethoric habit, I

8 Quinine in Intermittent and Remittent Fevers. [January,

bled him ; then applied sinapisms to the spine and epigastrium, and
prescribed a beverage of cream of tartar and cold water. In the
afternoon I found that the fever was still high, that he had vomited
repeatedly, was much distressed with nausea, and had been gently
purged. The sinapisms were ordered to be repeated, the cream of
tartar to be discontinued, and small quantities of iced water to be
used to relieve thirst during the night ; doses of 5 grs. quinine (in
powder) were left, one to be taken in very little water at 4 o'clock
the next morning, and repeated every two hours thereafter. I visited
him at 8 A. M. and found that the fever had continued high during
the night, and remitted only towards morning. He had taken 15
grs. quinine, and now had but little fever, although the nausea still
persisted, and had caused him to reject the quinine twice, but which
being repeated was finally retained. During this day the febrile
exacerbation was much less intense, and he was kept on the use of
iced water with a little lime water added to it. On the following
morning, the nausea still being troublesome, and, apprehending that
the quinine in solution or in powder would be rejected, I gave it to
him in pills, 4 grains every two hours until he had taken 16 grains.
These were retained, the nausea gradually subsided with the fever,
and in the afternoon he was convalescent. He suffered a little from
debility, but without further treatment, he was out in a few days.
In this case head ache and gastric irritation instead of being increas-
ed, subsided under the use of quinine.

We are frequently called to cases in which we cannot ascertain
the periods of exacerbation and of remission because of the ignor-
ance of the patient cr of his attendants, or because those periods
are not very strongly defined. In such cases we may safely pre-
sume that the remission, if there be any, will occur in the morning,
as this is most usually the case in these affections. And, under this
presumption, I always prescribe about 20 grs. of quinine to be given
in 5 grs. doses at intervals of two hours, commencing at the dawn of
the next day, without regard to any incidental circumstances. This
last injunction is added because without it, the attendant may upon
some trivial change assume the responsibility of omitting the remedy
at the only time when it might be given with decided advantage.
I have known several cases to terminate fatally by such omission to
carry out the prescription ; the excuse being that the patient had too
much fever, or head-ache, or nausea, &c. We not unfrequently see
cases so late that the life of the patient depends entirely on our abil-

1847.] Quininein Intermittent and Remittent Fevers.

ity to prevent another paroxysm. No circumstance then must be
allowed to interfere with the use of the only certain preventive with
which we are are acquainted. If it cannot be given in one form it
must be given in another ; if the stomach rejects it, throw it upon
the rectum. At all hazards, give it. If by this course you happen
to give the quinine before the remission have been fully established*
it will not increase the fever, but on the contrary lessen its intensity,
and consequently hasten the establishment of the remission. We
frequently induce a very decided remission in cases in which it has
previously been very slight, by the administration of quinine a short
time after the fever has reached its acme of intensity, as may be
seen by reference to the cases just related.

Having thus far restricted my remarks to the use of quinine in
fevers uncomplicated with true phlegmasia or inflammation, it is pro-
per that I say a few words in relation to cases we occasionally en-
counter, in which genuine phlegmasia? are complicated with remit-
tent fever or the paroxysmal peculiarity. I allude now specially to
the form of Pneumonia and Pleuro-pneumonia which has prevailed
more extensively in Georgia and South Carolina, (and perhaps in
other southern states) during the last year or two than formerly, and
which has been attended with an extraordinary degree of mortality.
From what I have seen of such cases, and learnt from my professional
brethren here, and elsewhere, I am satisfied that whilst the most
striking element of the disease is an inflammation t)f the pulmonary
organs, this is complicated with remittent fever. Indeed they pre-
sent regular diurnal or tertian exacerbations and remissions of such
decided character as to mislead the friends of the patient, and even
his physician, into a degree of security which has often proved fatal.
Seized with a violent attack of pneumonia, the patient finds himself
at once quite ill, but is soon relieved from anxiety by an apparent
amelioration of his condition. This continues until the next day, or
perhaps the third, when another exacerbation supervenes and rapidly
aggravates the condition of the lungs ; but the intensity of the symp-
toms again abates, and the patient is flattered with the hope af ap-
proaching convalescence, until a repetition of the paroxysmal affec-
tion places his life in imminent peril, if not beyond the reach of
remedial means and all this notwithstanding a vigorous antiphlo-
gistic course of treatment. This disease has been particularly fatal
on our plantations, where the daily or tertian amendments of the
patient have induced the owners or overseers not to call in medical
aid as early as they would have otherwise done.

10 Calomel in Dysentery and Cholera Morbus. [January,

In all the cases of pneumonia, complicated as above stated, that
liave come under my observation, I have not hesitated to combine
the use of quinine with that of the lancet, antimonials and opiates,
and have uniformly had every reason to be entirely satisfied with the
result. They do not require, nor can they bear, the same amount
of depletion usually regarded as necessary in common pneumonia
and pleurisy, and they very rarely yield to antiphlogistics alone. In
furnishing my own testimony to the efficacy of the suggested com-
bination, I might add that of other practitioners of distinction, who,
entertaining the same views with myself, have met with similar suc-
cess. It is scarcely necessary to add that the quinine should be given
during the periods of remission, and as liberally as though there
were no organ in a state of inflammation.

I have now freely and without reserve, given my views in relation
to the use of quinine in our remittent fevers and in lauding, as I
have done, its efficacy, I cannot but apprehend that the charge of
ultraism will be preferred against me by those who are still unac-
quainted with its properties. Be this as it may, I fear nothing from
the test of time and experience, and will be amply compensated for
the temporary odium, if this article will induce any who may have
been backward in the use of quinine to give it a fair trial under the
circumstances here recommended. It should be borne in mind, how-
ever, that we occasionally meet, even in this latitude, cases of typhoid
fever, or of enterkic fever, in which quinine possesses no peculiar
efficacy. But these fevers do not present the paroxysmal type, and
can therefore be easily distinguished from those in which it is useful.

ARTICLE II.

The propriety of large doses of Calomel in Dysentery and Cholera
Morbus. By W. F. Barr, M. D., of Greenville, Tennessee.

If we examine the standard works upon practice, in the treatment
for dysentery and cholera morbus, we find small doses of calomel, in
combination with opium, recommended. For reasons which will be
made known, I have been induced to depart from this mode of
treatment.

In endeavoring to give the reasons for this deviation from a system,
recommended by some of the first men in the profession, it will be-

1947.] Calomel in Dysentery and Cholera Morbus. IX

come necessary to speak first, of the influence of the bile upon the
intestines; secondly, of the pathology of these diseases.

The influence of ike Bile upon the Intestines. From time immemo-
rial to the present period, the opinion has been entertained that the
bile acts as a stimulant upon the intestines, and thereby keeps up
regular peristaltic motion. A denial of this opinion may appear, to-
the minds of many, as heterodoxical ; but fair reasoning, founded
upon truth, ought to satisfy the most sceptical.

The bile is not a stimulant, but a sedative; and to its sedative
influence the intestines owe their healthy action and regular peristal-
tic motion.

Although many contend that the bile is a stimulant, and that it is
to an increased quantity in the intestines, which causes them to be-
come excited, yet we find many others, equally as learned and expe-
rienced, asserting that such a condition is owing to a deficiency of
bile. This, then, is our opinion : from sudden suppression of perspi-
ration, the influence of malaria, cold, vicissitudes of weather, &c,
the liver becomes torpid, and, consequently, there is a deficiency in
the quantity of bile. The intestines thus being deprived of an accus-
tomed sedative, are excited, and irregular and diseased action are
the consequence.

This is proven from the fact, that in the early stages of the diseases
spoken of, the stools are not of a bilious color, but white, pale, &c. ;
and that in the treatment dark, or bilious discharges are hailed as
ominous of improvement. Now, if this excited condition of the in-
testines be owing to too great a quantity of bile, why are dark, or
bilious colored discharges looked for with such anxiety ? To believe
that the bile acts as a stimulant, and that it is owing to the presence
of too great a quantity of this stimulant, and then use medicines to
make the discharges of a bilious color, seems too much like curing a
burn by placing the person injured in the fire !

In those diseases in which the intestines are in an excited condi-
tion, and the stools are of a pale or white color, their recovery to a
dark or bilious cotor, (at which time there will be an improvement,)
proves, incontestibly, this excited condition is owing to the absence
of the bile, and that when restored, its action as a sedative allays the
irritability and excitement. From these facts, we contend that the
bile is a sedative.

Pathology of Dysentery and Cholera Morbus. Believing that the
bile is a sedative, we contend that the excited condition of the intes-

12 Calomel in Dysentery and Cholera Morbus. [January,

tines in these diseases is owing to the absence of the bile to the
abstraction of an accustomed sedative.

Treatment. Entertaining the views advanced in relation to the
influence of the bile, and the pathology of dysentery and cholera
morbus, the main and important indication to be fulfilled, is to pro-
cure, or increase the secretion of bile, in order to have its sedative
influence to allay the excitement of the intestines. To accomplish
this object we give calomel in large doses. We know there is no
remedy which acts so certainly and powerfully upon the liver as calo-
mel. If, then, we wish to increase the quantity of bile, shall small or
large doses of the article which we know will accomplish our object,
be given ! Although Dr. Eberle, in his system of practice, contends
that in cholera morbus there is a deficiency of bile, yet he recom-
mends calomel in two grain doses. But, under this opinion, is such
practice correct? This can be answered, by referring to efforts to
excite any secretion. If, for instance, we desire to increase the flow
of saliva, will a small or a large quantity of an article be taken in the
mouth ? Would not every one use a large quantity ? Upon this
principle of reasoning, we argue, in these diseases we wish to in-
crease the secretion from the liver, then, of course, we would not
recommend a small dose of the remedy we know will do so, but rather
a large one. Therefore, in dysentery and cholera morbus, where
there is deficiency in the quantity of bile, we wish to increase it,
for which purpose we give large doses of calomel. In those cases
which I have attended, I have administered it not in larger doses
than 20 grains, though the quantity should be modified, or increased,
according to circumstances. I give 20 grains every six hours, until
the stools become dark and fetid.

Case. Mr. M. had been confined some ten or twelve days with
dysentery. When I saw him he was very pale, pulse small and weak,
tongue furred, disagreeable taste in the mouth; the discharges were
frequent and painful. I prescribed calomel in 20 grain doses every
six hours until the discharges were dark and fetid. He took but two
doses, which had the desired effect, and in two days he was able to
attend to his business.

Other cases of both diseases could be given, but it is deemed un-
necessary, as the treatment and results were the same as the one
given.

I hare endeavored to be brief but it is thought enough has been
said to convince anv one.

1847. Mechanical Obstruction in the Bowels. 13

It is due to the learned and talented professor to say, that for the
above views I am principally indebted to Dr. Cross, formerly Profes-
sor of Institutes in Transylvania University, but now of Memphis
Medical College. Although Dr. Dick, in his treatise M On the Organs
of Digestion," advances the opinion that the bile " has a sedative
effect on the intestines," yet to Dr. Cross is the credit to be given for
having first advanced the opinion and taught the doctrine, and also
having recommended the practice which should be pursued under
this theory.

ARTICLE III.

A Fatal Case of Mechanical Obstruction in the Bowels, (conglom-
eration and adhesion of the ileum above a reducible hernia,) with
the 'post-mortem appearances. By Paul F. Eve, M. D., Professor
of Surgery in the Medical College of Georgia.

The frequent occurrence of obstinate constipation, and too often
unfavorable termination in such cases, give an importance and inter-
est to the subject, which should lead every honest and candid physi-
cian to record and publish every thing he may meet with in his
practice bearing upon this point. The writer is aware there is
nothing very peculiar in the case he is about to report, but it will be
adding another fact to the many causes producing obstruction to the
bowels, and even to a fatal extent ; and it may besides possess some
novelty and interest.

Thomas Newell, aged 30 years, entered the Augusta Hospital on
the 14th November, for constipation of the bowels; having had no
evacuation from them since the 10th. He was a laborer on the Au-
gusta canal, had had intermittent fever during the fall, and some
time ago was attended by a physician for some difficulty in urinating.
From his wife I learn, since his death, he was ruptured, but had
never worn a truss. In his last sickness, catheters or bougies, or
probably both, were used. From sickness in my own family, Dr.
Garvin visited this patient for me the afternoon of the day he enter-
ed the hospital, and prescribed 15 grs. calomel, to be taken at bed
time.

Sunday, 15th. Had, in addition to the calomel, taken a dose of
castor oil before visited. Complains of soreness and pain over the
abdomen, has no fever, borborygmus, considerable tympanites, with

14 Mechanical Obstruction in the Bowels. [January,

eructations and anorexia. Prescribed a large warm mustard poultice
over the abdomen, and salt-w\trr injections, to be administered at
once. In the evening, no relief being obtained, the long stomach
tube was added to the glyster pipe,

16 th. Was called to patient. Has now copious stercoraceous
vomiting; indeed the quantity ejected was enormous. Has had
little or no evacuation downwards from the intestines. A concealed
inguinal hernia of the right side was now detected, but it was reduci-
ble, and had no symptoms of ii flammation or strangulation. The
patient though asked, never located his sufferings in this part of the
abdominal contents. The finger in the rectum, pushed high up, met
with resistance towards the bladder, offered apparently by the intes-
tines impacted in the pelvis. Difficulty being experienced in pass-
ing the tube into the colon, the patient was placed upon' his elbowV
and knees, and it then entered much easier. Cold water was freely
injected, with a view to condense the flatus. It was returned with but
little faecal matter. Melted lard was now freely given in half pint
closes, and was retained for some hours. At the evening visit, a
blister to cover the abdomen was put on, and when it acts, a drop of
croton oil is to be given every hour.

17th. Patient is worse. Took eight drops of the croton oil with-
out any relief. Dr. Ford called in consultation. Table-spoonful
doses of pulverized charcoal were given. Injections still continued*
Wine and good nourishment ordered.

18th. Vomits still occasionally is much weaker has hiccups at
times. The blister has acted well. No increase, but diminution of
tympanites. The hernia descends whenever he assumes the position
to evacuate the enemata, but is restored by pressure. Recommended
still to use the long injecting tube with warm water or stimulating,
fluids, and such nourisment as the stomach would bear.

19th. Died at 4, P. M.

Post-mortem at 8, A. M., on the 20th, by Dr. Campbell, Demon-
strator of Anatomy, and in the presence of the medical class.

No great emaciation. Blistered surface over the entire abdomen.
No great distention of it. Removed the anterior abdominal wall.
The small intestines, particularly the ileum, were distended and were
very red, near the ccecum of a dark, approaching to a black color,
and seen through the peritoneum. The hernial sac was laid open,
and a small knuckle of intestine found occupying it. This sac was
quite thick, much condensed tissue forming its parietes. The pro-

1S47.] Mechanical Obstruction in the Boirels. 15

truding viscus was loosely attached to its internal surface by recent
exudation of plastic matter or fibrin. These attachments were readi-
ly broken up, and the hernia was reduced. The sac was of ancient
formation, but the agglutination of the intestine to its internal face
was recent. The hernial tumor was a portion of the ileum, about
four inches above its termination at the ileo-ccecal'vale. It was
gangrenous, and the same condition continued up for several inches
in this intestine, which was found convoluted and agglutinated, and
formed an irregular tumor as large as a common sized apple pressed
down into the pelvis. The adhesions of this portion of the ileum were
firm, and required the knife for separation. They were evidently
ancient, and not the result of the attack from which the patient died.
There were neither recent affusions of much serum or of any fibrin,
(except that mentioned in the hernial sac,) or other symptoms of
peritonitis. Some eight to twelve inches of the ileum constituted
this mass or ball. The internal surface of the obstructed portion
was gangrenous, and its mucous membrane detached at places by
ulceration or mortification. Its calibre could not well be judged of,
as the adhesions had previously been divided, before laying open the
intestine, but their conglomeration amounted to a perfect stricture,
judging from the accumulation of flatus and fluids above it. The
ileum contained a muddy, semi-fsecal or semi-purulent matter, be-
sides flatus. The rectum and colon were much contracted, emptied
by the injections.

This patient then evidently died from an obstruction in the bowels
existing above the reducible hernia. The adhesions of the ileum
may have occurred at the time of the difficulty he experienced in his
urinary apparatus, for they were situated just above, if not upon the
bladder, and the complete stricture of which he died on the 19th, was
superinduced upon this condition of the parts on or about the 10th,
probably by some imprudence. The hernia of itself had nothing to
do with his death directly.

Knowing a hernia existed in this case, the operation of Callisen or
Littre, recently revived, and one of them performed successfully by
Amussat, was not proposed.

10 Researches upon the Blood. [January,1

PART II. REVIEWS AND EXTRACTS.

ARTICLE IV.

Researches vpon the Blood. By M. Doias. (Translated for this
Journal, from the August number of the Annales de Chimie et de
Physique : by J^o. M. B. Harden, M. D., of Liberty Co., Ga.)

The blood contains three nitrogenized organic principles which
are essential to its nature and its functions, viz., fibrine, albumen,
and the red globules. Their abundance in the blood or the import-
ance of their offices has long drawn to them the special attention of
chemists and physiologists.

But if it has been a very easy matter to separate the fibrine from
the blood by the simple process of beating (battage) after obtaining it
from the vein ; or no less easy to procure the albumen by allowing
its serum to separate by spontaneous coagulation ; this is not the
case when we wish to obtain the red globules free from all fibrine
and albumen.

Recently, however, a peculiar process first pointed out by Berzeli-
us, and afterwards more fully developed by M. Muller, has suggested
to MM. Lecanu and Fisuier* a method of obtaining the globules-
free from all mixture. This method is founded upon a modification
which the blood undergoes, by its admixture with certain salts, in its
transmissibility through the pores of our filtering paper. If we pour
some blood, which has been beaten and deprived of fibrine and con-
sequently fluid upon a filter made of Joseph paper, we see the glo-
bules of this blood pass through the filter, and the filtered fluid will
be of a deep red color. The filtration, which in such a case is slow
and tedious, leaves upon the filter nothing but a residue of globules,
altered in appearance and so small in quantity as to render it impos-
sible to study their properties.

But if, before filtering the blood, we mix it with three or four times
its volume of a saturated solution of sulphate of soda, this mixture
will so modify the properties of the liquid in which the globules float
that it passes through the pores of the paper, leaving behind all the
globules upon the filter. It drains off completely colorless and alto-
gether limpid, and as the process is generally rapid the globules may
be collected in a satisfactory state of purity and integrity.

The application of this process, however, is not devoid entirely of
some difficulties, which are worthy of attention, because of some cir-
cumstances connected with the nature and office of the red globules
which they make manifest.

For example, if we take blood deprived of fibrine, but kept for many
hours, and attempt to filter it after the addition of even an increased

* An interesting paper upon this subject, from the pen of M. Figuier, may
be found in the 11th vol. of the Ann. de Chimie et de Phys., page 503.

1347.] Researches upon the Blood. 17

quantity of sulphate of soda, the fluid passes with difficulty and is
always colored.

It is necessary, therefore, that we operate upon blood recently
drawn from the animal. As soon as it has been well beaten *nd all
the fibrine is coagulated, we should pass ft through a line piece of
linen and receive the fluid into a solution of the sulphate of soda.
The mixture bein^ bow thrown upon a filter, we obtain a fluid per-
fectly limpid with a slightly yellowish tint, and all the globules will
remain upon the filter.

But soon, however, the liquid which has been drained offbeing re-
placed by a fresh solution of the sulphate of soda for the purpose of
washing the globules, we see it pass through colored, feebly at first,
afterwards a little more so, and, at last, the color becomes so deep
that we cannot doubt that the globules have been greatly altered in
their properties.

Yet it is necessary, in order to obtain the globules pure, to wash
them many times with the solution of the sulphate of soda without
which they will remain impregnated with the serum of the blood, that
is to say, with an albuminous fluid whose presence will entirely con-
ceal their true characters.

After a good many useless attempts, I have found in the globules
of the blood a remarkable property by means of which this difficulty
may be avoided.

As long as the globules of the blood are in contact with air or aera-
ted water ; as long as, in one word, they are in the arterial state the
solution which contains them passes colorless through the filters and
leaves them all behind.

But, on the contrary, as soon as these same globules have taken
the violet color which characterizes venous blood, the filtered fluid
becomes colored.

It is necessary, therefore, to maintain the globules in the arterial
state during the continuance of the filtration and the washings.
This I have been able to do in a satisfactory manner, by plunging
into the filter a slender tube, by means of which I direct a constant
and rapid current of air through the fluid.

Thus treated, the globules are deposited with some difficulty from
the fluid, which is now maintained in a state of aeration favorable to
the permanence of the arterial condition.

I throw, therefore, upon a large filter moistened beforehand with a
solution of sulph. sodae, the blood just after its passage out of the
vein, but deprived of its fibrine, and diluted with a solution of sulph.
of soda a continual current of air passes through the liquid which
is contained in the filter a tube connected with a solution of the
sulphate of soda supplies continually the loss of the fluid which is
drained off.

By means of the^e precautions, the globules of the blood may be
completely separated from the serum. Nevertheless, when we wish

2

18 Researches upon the Blood. [January,

the operation to succeed, it is necessary to neglect nothing that can
ensure its rapid execution.

As soon as the globules have had time to be deposited upon the
sides of the filter, and form there a layer of sensible thickness, those
which are in contact witn the surface of the paper cannot be longer
acted upon by the air and pass immediately to the violet, whilst those
which make up the exterior layer preserve the arterial state, and evi-
dently arrest all the air contained in the washings.

In consequence of this the fluid passes colored, and if we do not
immediately remedy this difficulty, its increasing coloration will soon
demonstrate that the globules have undergone a great alteration.

Under these different circumstances the globules of the blood be-
have as if they were truly living beings, capable of resisting the
solvent action of the sulphate of soda, as long as their vitality contin-
ues, but yielding to the action as soon as they become asphyxiated,
which results in this case from a deprivation of air, and which is
manifested with singular rapidity, either by a change of color, or
by their prompt solution.

Hence the object of the chemist must be to preserve the vitality of
the globules, and among the means which present themselves to the
mind we may mention the agitation of the fluid, its constant aeiation,
and lastly, the keeping of the blood at the same degree of tempera-
ture at which it was found in the body of the animal.

All these precautions being followed, we are furnished in a few
hours with pure globules, provided we do not undertake to prepare
more than five to six grammes at one time.

This rapid alteration of the globules, as soon as they are deprived
of the direct contact of air, or of aerated water ; the extreme energy
with which, in a layer of globules, those which occupy the surface
appropriate to themselves the whole of the oxygen, causing a fluid to
pass to those below, which is entirely unfit to arterialize them, are
circumstances well calculated to fix the attention of physiologists.

In the discussions in which the respiration has been the object of
our inquiries, the blood has always been regarded as a homogeneous
fluid, receiving the contents of the air in the lungs, and undergoing
there more or less rapid alterations.

Doubtless the serum of the blood does constitute such a fluid, nor
will I dispute the part which it may take in the phenomenon of res-
piration ; but the globules of the blood compose so many vesicles
floating in this serum, having a respiration peculiar to themselves,
whose effects, connected with those resulting from the respiration of
the serum, produce by their ensemble the general phenomenon of the
respiration of the blood.

We may say, therefore, laying aside for the present the proper ac-
tion of the serum upon the air, that the respiration of one of the
superior animals, and particularly of man, has for its object the con-
tact of oxygen with the globules of the blood and the expulsion of the
products into which they are converted.

1847.] Researches upon the Blood. VJ

Hence, if we wish to calculate the effects of respiration, we must
take into consideration the membranes which form the envelope of
these glohules, for we know how very different from a pure and sim-
ple solution of a gas are those strange phenomena of endosmose which
take place through membranes which separate two reservoirs filled
"with different gases, or with fluids saturated with these gases.

Respiration, in order to be well understood, must therefore be stu-
died in these vesicles or blood-globules, the principal seat of those
phenomena which it is destined to produce, and whose organization
complicates so strongly the physical laws which govern it.

The manner in which these blood-globules act upon the surround-
ing or dissolved air, and the conditions under which they preserve
their normal character, become, when thus regarded, subjects of the
highest interest.

To determine the integrity of the globules and the existence of their
fundamental property, we have two means, both of which are equally
exact, the microscope and the agitation of them with oxygen as
long as the globules are entire the microscope will indicate it: as
long as they may be arterialized they will redden in contact with
oxygen.

Now every body knows that the blood possesses these two charac-
ters whilst it is circulating; nor does it lose them after its escape
from the animal. The beating of the blood, by which the fibrine is
separated, does not injure the globules nor deprive them in any way
of the property of becoming arterialized.

In this phenomenon the albumen is no more needed than the fibrine.
When we gradually replace the serum in which the globules are
suspended, by a solution of sulphate of soda, they preserve no less
their integrity, and they become no less reddened by being agitated
with oxygen.

Thus the faculty of assuming the brilliant color of arterial blood
belongs to the globules ; it is independent of the albumen, of the se-
rum, of the fibrine of the blood, and of the vital action of the animal.

But if the sulphate of soda preserves this property of the globules,
will this be the case with all the alcaline salts? By no means ex-
periment proves this.

The common phosphate of soda which exists in the blood, may,
like the sulphate, saturate the blood without in the least destroving
in it the property of becoming arterialized. Blood saturated with
phosphate of soda, when agitated with oxygen, receives a brighter
arterial tint than it would have done without it.

In regard, therefore, to this property at least, the blood may with-
out inconvenience have added to it much larger quantities of the
sulphate or phosphate of soda than it naturally contains.

The salts formed from the organic acids, such as the salt of Seig-
nette, are similar in their effects, which leads us to believe that the
lactate of soda may exist in the blood, even in large proportion, with-
out producing any ill effects in this respect.

20 Researches upon the Blood, [January,

Bnt is this the caso with common salt or chloride of potassium ?
Experiment shows that these salts are altogether different in their
effects.

If we saturate blood deprived of fibrine, although fresh, with com-
mon salt, and agitate it immediately with oxygen gas, it remains of a
sombre violet hue. Sal ammoniac produces the same effect.

Does there not exist an iutimate connection between these phe-
nomena and the supposed injurious effects of salted meats in the
production of scurvy ? Must we not also find some agreement be-
tween the action of sal ammoniac, upon the blood, and the poisonous
properties of this and other ammoniacal salts upon the body ?

But however this may be, it is certain that there are some salts
which leave the blood the property of becoming arterialized, whilst
there are others which entirely destroy this property. The sulphate
and phosphate of soda and the salt of Seignette belong to the first
division ; the chlorides of potassium, sodium, and ammonium to the
second.

With these results, there is one circumstance connected which
cannot fail to arrest our attention. Those salts which maintain in
the blood the property of becoming arterialized, are at the same time
the best adapted to preserve the integrity of the globules, and they
give it the property of furnishing a colorless serum by filtration. On
the contrary, those which take away this property cause the filtered
serum to be more readily colored.

The whole of these experiments lead us to believe that the coloring
matter of the blood is peculiarly fitted to take on the characteristic
tint of arterial blood, when it is connected with the globules them-
selves, of which it forms a part. This character is modified, or lost,
when by the alteration or destruction of the globules, the coloring
matter enters truly into solution.

By comparing with great care specimens of the same blood, brought
into contact with alcaline salts, and allowed to be saturated with
these salts in the cold it appears to me that generally these saline
solutions, agitated with oxygen, act in the following manner :

Those salts containing complex organic acids, as the tartaric and
citric, preserve the integrity of the globules much better than the salts
formed from the mineral acids.

Those salts which have soda for a base, are better fitted to main-
tain this integrity than those with potash or ammonia as the base.

There appears, therefore, to exist an unexpected relationship be-
tween the integrity of the globules, the arterial state cfthe blood, the
phenomena of respiration, and the nature or the proportion of salts
dissolved in the blood.

It requires only a few experiments of this kind to be convinced that
asphyxia may be induced in the midst of air, or of oxygen gas, with-
out any apparent change in the phenomena of respiration, by the
simple introduction into the blood of those salts which modify the
action of the oxygen upon the red globules.

1S47.] Researches upon the Blood. 21

We cannot but call the attention of physicians to this order of
phenomena. At a time when the analysis of the blood attracts with
bo much reason their regards, it is to be hoped that the study of the
^lobules, in certain well understood diseases, should become the ob-
ject of peculiar investigation.

Every thing leads us to believe that, in their less or greater, and
slower or quicker alterability, there exist degrees which may be ascer-
tained and measured by receiving the blood from a vein into a solu-
tion of sulphate of soda, for the -purpose of subjecting it to different
trials, or even after defibrinization, by attempting to alter it by grad-
uaied doses of well chosen salts, such as common salt (chloride of
sodium), or sal ammoniac (chloride of ammonium).

The greater or less resistance of the globules to the alterative
operation of these salts, would furnish indices which nothing could
replace at present in our diagnosis of Diseases of the Blood.

The elementary analysis of the blood globules, when once they arp
isolated, is so easy that I have been ante to go through it with full
confidence in the results. The globules of the blood, deprived of
serum and collected on a nat d:-h, placed in the vacuum of an air-
pump on which is pure sulphuric acid, yield in a short time a residuum
perfectly dried. This, treated by ether and alcohol, at the boiling
points, becomes insoluble in water which may now be used to remove
any sulphate of soda remaining in the globules. It is after this pre-
liminary treatment that I have made an elementary analysis. The
following are the results, neglecting the ashes :

GLOEULES OF BLOOD,

Of

a Female.

Of a

Dos.

Of a Rabbit

Carbon,

55-1

55-1

55-4

51-1

Hydrogen,

7-1

7-2

7-1

7-1

Nitrogen,

17-2

17-3

17-3

17-5

Oxygen,

20-6

20-4

20-2

21-3

100-0 100-0 100-0 100-0

It appears evident from these analyses, as we may have concluded
from their properties, that the red globules belong to the family of
aibumenoid bodies. If the carbon whieh they contain is a little great-
er than that of caseine and albumen, it is because in the red globules
there exists a coloring matter which accounts for this excess.

I will examine, however, in a subsequent memoir, the question,
whether the matter of the red globules may be confounded with albu-
men or caseine, or whither, as appears probable, it may not be distin-
guished from these substances altogether, as well as the fibrine itself.

22 Seven Cases of Traumatic Tetanus cured. [January,

History of Seven Cases of Traumatic Tetanus, treated successfully
by Strychnine. By J. W. Fell, of New, York. (New York
Journal of Medicine.)

Dear Sir :

In compliance with your request, I herewith furnish you
with the histories of seven cases of tetanus (six of them certainly
traumatic, and most probably the seventh), which have been treated
by strychnine with success. The first two were published in the New
York Medical and Surgical Reporter, but as they will be more inter-
esting in connection I send them to you. The 6th case was furnished
me by Dr. Botsford, the 7th by Dr. Vanderpool, of Fourth-street.

You will observe that in every case, as soon as the specific twitch-
ing was produced, the tetanic spasms abated, and they convalesced
rapidly. I have found this distress over the diaphragm (caused, no
doubt, by its spasmodic contraction) the most troublesome symptom
in all the cases.

I would, from the experience I have now had, administer the
strychnine as follows. I should at once give an eighth or tenth of a
grain, then, in two hours, the sixteenth, then reducing the dose just
sufficient lo produce its effect after each one. The great object is to
produce the twitchings as soon as possible, they can then be kept up
by a much smaller dose than the one which first produced them.
Hoping they will meet your approbation,

I remain yours very trulv,
New York, Oct. 9th, 1845. j'. WELDON FELL, M. D.

Doctor Lee.

On the use of Strychnine in Tetanus.

Case I. Aug. 1st, 1845. Visited William Ellsworth, aged 7
years, living with his parents, in Hudson county, New Jersey. Found
him in a kind of stupor, but upon his father's taking hold of him, he
was thrown into a violent spasm which lasted a few minutes, during
which his body was curved backwards, jaws set, countenance distort-
ed, and his body resting entirely upon his head and heels. After the
spasm ceased, he complained of pain and distress over the diaphragm,
jaws stifT, and almost closed, difficulty in swallowing, pain along the
spine, and soreness in the left groin. The spasms were excited by
touching him, or by his attempting to swallow. During the spasms
the muscles were so rigidly contracted that he could be raised by his
head alone.

About ten days ago he injured his left knee with a thorn. While
playing a few days after, it commenced swelling, and to be painful;
but by the application of some domestic remedies, the swelling was
reduced, and the pain allayed. Soon after he became restless and
uneasy, complained of distress about the precordial region, pain in
the masseter and temporal muscles ; his voice changed, he had diffi-
culty in swallowing, and these symptoms were attended with slight

1847.] Seven Cases of Traumatic Tetanus cured. 23

fever. These symptoms increased until yesterday, when the charac-
teristic spasms of tetanus set in. His mother immediately applied a
blister to the knee and one to the spine. The glands in the left
groin were enlarged and tender.

The case was evidently one of traumatic tetanus, well developed
and rapidly advancing, and demanding the most vigorous treatment.
Iat once determined to administer someone remedy, and tocontinue
its use until some decided effect was produced by it. I reviewed in
my mind the many remedies heretofore used, viz., opium, alcohol,
turpentine, iron, digitalis, tobacco, aconite, &c. &c, and knowing
they had all failed, in the majority of cases in which they had been
used, I, from a suggestion of Professor Mott's, during the previous
winter, determined to use the strychnine, and at once prescribed it in
doses of the fourteenth of a grain, every two hours. I also ordered
a poultice to the knee, and the spine to be rubbed with ung. tart, anti-
moni. The strychnine produced its peculiar twitching effects after
the fifth dose. It was given as above for two days, each dose after
the fifth producing the specific effect. The intervals between the
doses were now increased, until, on the sixth day, he only took it
three times. He had no spasm after the second day ; he convalesced
slowly, until the sixteenth day, when the strychnine was discontinued,
as he had entirely recovered.

I have frequently seen his father since, and he informs me the boy
lias enjoyed perfect health.

Case "II. Oct. 4, 1S46, 10 o'clock, P. M. Was called in haste

to see 3Iiss M , of Sullivan street, aged 25 years, under the care

of Dr. E. Vanderpool. Found her in a spasm ; the muscles of the
left side only being in a contracted state ; jaws set, left leg and arm
stiff, body bent to the left side, extremities cold, pulse feeble, and
left side of the face distorted. Ordered some wine, as soon as the
spasm passed off, and she could swallow. Dr. Vanderpool having
been at once sent for, now arrived, and gave me the. following history
of the case. Miss M. had been suffering for several months with a
bad toe, the nail of the great toe of the left foot having grown under
the flesh. She had not been out of the house for months, she refusing
to have the nail removed. A few cays ago, however, she consented,
and Dr. Vanderpool removed a part of the nail; the next day she
went out riding, and directly after her return, the toe commenced
swelling, and to be very painful, the pain extending up the ieg, side,
arm, and soon affecting the temporal and masseter muscles of the
left side.

Dr. Vanderpool and myself examined and found the toe and foot
much swollen and tender, the lymphatic glands of the left groin en-
larged and painful, the muscles of the left side contracted, jaws stiff,
but not entirely closed, difficulty in swallowing, masseter and tem-
poral muscles contracted and painful, and uneasiness about the pre-
cordial region ; during the spasm the diaphragm was powerfully
contracted. Considering this also a case of traumatic tetanus, I

24 Sev?n Casen> of Traumatic Tetanus cired. [January,

suggested to Dr. V. the use of strychnine in this case ; he preferred,

however, waiting until morning. He made a free incision upon the

toe, and prescribed the following:

R Tinct. Assafcetidee ) c , ,

n r\ \ a teaspoonful every two hours.

Oct. 5, 10 A. M. Upon visiting the patient this morning, we found
her much worse. Spasms more severe and frequent, jaws nearer
closed, and the difficulty of swallowing greater. We gave her

R Strvchnin. gr. jss. ) c, ,, . ,

E." , 7 f i -, T > it. pill no. xvi. one every two hours,
xtract. JuglandisC, 3ss. $ v J J

10 P. M. Was called in haste to see the patient, as her friends
thought her dying. We found her under the specific effect of the
strychnine. Ordered the pills discontinued until morning.

Oct. 6, 10 A. M. The patient slept well from 12 to 4 o'clock this
morning, being the first sleep she ha:; bad i.i some days. She is much
improved ordered one pill every three hours.

7 P. M. Has had some slight spasms during the day ; jaws a little
relaxed ; gave her wine whey, to be continued as above.

Oct. 7. Miss M. slept well during the night, and the irritability
which had been so marked, has in a great measure disappeared. The
twitching is produced by each pill : it commencing about twenty
minutes after taking the pill, and hasting about fifteen.

Oct. 8. No spasm since yesterday ; ordered one pill every six
hours ; continue the wine whey.

Oct. 10. Discontinued the pills, as the tetanic symptoms have all
disappeared.

Oct. 16. Miss M. is going out as usual, quite well.

The only peculiarity about this case, was the contraction being
confined to the left side, making it a case of Pleurosthotonos.

Case III. Nov. 15. Visited Mrs. J., of Thompson street, aged
27 years. About ten days ago she ran a needle into the palm of her
hand ; it breaking, a piece was left in the wound. This was remov-
ed by a barber in the vicinity within a few days; but the hand and
arm continued sore and painful. Yesterday she complained of hav-
ing taken cold, as her jaws were stiffand deglutition painful. During
last night she had hot flushes and chills. I found her complaining of
difficulty of swallowing : jaws very stiff, and nearly closed : pain and
distress in the diaphragm, and some slight spasms. Ordered the
following :

v ? t i ' ? ," tit i in pill nos. xiv one every two hours,

liXt. Juglandis 3ss. M. $ * J '

the hand to be bathed frequently in hot water and ashes.

Nov. 16, 9 A. M. The third pill produced the twitching. This so
much alarmed the family, that they have discontinued them since.
I immediately ordered them to be given again. They produced the
twitching in about ten minutes, it lasting sometimes as long as half
an hour.

4, P. M. Patient some better, still slight spasm.

1847.] Seven Cases of Traumatic Tetanus cured. 25

Nov. 17. Has had no spasm since yesterday : the swelling in the
hand and arm is much rediced : still painful. Ordered a pill every
Jour hours, and a poultice to the hand.

Nov. 18. Thj patient slept well last night for the first time since
she has been unwell. Jaws relaxed. One pill every six hours.

Nov. 19. Patient about the house as usual. Arm stiff*. Ordered
two pills per day.

Nov. 21. Each pill produces the twitching; but as the patient has
completely recovered, 1 ordered them discontinued.

The hand now did well, and healed rapidly.

Case IV. May 9, 1846, 8 o'clock, P. M. Thomas Brown, of
Hoboken, New Jersey, called at my office, and requested me to visit
his sister-in-law, Miss Jane Savage, aged lfi years, then at his house,
suffering with lock-jaw. On my arrival at his house, I learned that
Dr. Julien had been in attendance. I at once had him sent for, and
upon his arrival we visited the patient. Upon our entering the room
she was thrown into a violent spasm, which lasted about a minute,
during which her body was bent backward, resting upon her head
and heels, her countenance distorted, and her pulse quick and irregu-
lar. After the spasm passed off, we found her jaws were entirely
closed and set : pain along the spine, and over the region of the
diaphragm: difficulty of deglutition and respiration, and her pulse
still quick. Learned the following history: Some days since she
ran a carpet-tack into her right thumb; soon after she took a cold in
it while washing. It commenced swelling and to be painful. It
grew worse until about forty-eight hours since, when she was seized
with the tetanic spasm. Dr. Julien was then sent for : he bled her,
and ordered counter-irritation to the spine. This morning she was
worse, the spasm more frequent and severe. He ordered an injec-
tion, and invited Dr. Hosack to see her. They visited her at 12 M.,
and at once ordered her to take large quantities of Sherry wine and
arrow-root, and a poultice of herbs to the spine, but as she has a very
regular set of teeth, and her jaws being set, and as it is very difficu-t
for her to swaliow, it was almost impossible to give it, up to the
present time, and about nine o'clock P. M., her mother informs me
that she has taken about a wine-glassful of the wine and arrow-root.
The patient is evidently growing worse. I informed Dr. Julien of the
result of the three preceding cases, and advised the use of the strych-
nine in this. After due consideration he wrote as follows : R Strych-
nin, gr. j., Spts. Yin. Rectf. I]. M. : Of this 30 drops to be given
every two hours. The strychnine was procured and the first dose
given, at half-past ten, P. 31. In about fifteen minutes the twitching
commenced : it lasted about twenty : the patient then fell asleep.
At half-past twelve she took the second dose, with about the same
effect, again falling asleep. She continued to take the drops every
two hours, until twelve o'clock M., Sunday.

Sunday, May 10. The patient, at eight o'clock this morning, sat
up in the bed and fed herself with a tea-spocn, her jaws having re-

28 Seven Cases of Traumatic Tetanus cured. [January,

laxed very much, and the spasms almost ceased. A 12 M., Drs.
Julien and Hosack called, and from some cause, carried the strych-
nine away with them, giving as a reason to the family that it would
injure her health ever after, if she continued to take it. They then
ordered her (now she could swallow) to take a gallon of Sherry wine
a day ; and said she would certainly recover. At 9 P. M., Mr. Brown
called at my office, and communicated the above to me; he also said
Jane had eaten a piece of beef-steak just before he left home. He
asked me to give him a prescription for another bottle of the strych-
nine, as he was satisfied it had produced the great change in the
patient. I did so, with directions to give it as before, if there was a
return of the spasms. But as they did not return, the drops were
not given.

Dr. Julien continued to visit the patient, and ordered the wine to
be given in large quantities for some days.

May 16. 1 visited ?Jiss S. to-day, and found her in a state of in-
toxication. I at once advised the wine to be discontinued.

June 10. Mrs. Savage and her daughter Jane called at my office
to-day. Jane is in a complete state of fatuity. Dr. Julien has been
treating her for some days without any benefit. Mrs. S. now wished
me to prescribe for this difficulty. I, with the advice of Professor
Mott, put her upon a course of Sub. Mur. Kvdrarg., and applied
counter-irritation to the hack of the neck. This course was pursued
until it produced gentle ptyalism : this was kept up for about two
weeks, with decided improvement.

June 28th. Mrs. S. and daughter called to-day. Jane has en-
tirely recovered. She continued perfectly well, and was married
September 20, 1846.

This was undoubtedly a case of traumatic tetanus from a punctured
wound, yielding at once to the strychnine ; but whether the wine or
the strychnine produced the fatuity, I leave for others to decide.
Why Dr. Julien carried away the strychnine (without consulting me)
while the patient was improving under its use, I also leave.

Case V. May 10, 1846. Visited Mrs. Andrews, of Robinson
street, aged 55, under the care of Dr. Condit. Dr. Conger, Sen.,
having been called in consultation yesterday, found her suffering
with completely developed tetanic spasms, occurring every few min-
utes, during which her body was bent backward, countenance dis-
torted, violent contractions of the diaphragm, and jaws set during the
remissions, her jaws were nearly closed, deglutition very painful and
invariably exciting a spasm, pain and rigidity of the right temporal
and masseter muscles : the head was drawn to the right side, and the
right arm and shoulder painful, the glands in the right axilla swollen
and tender. The patient, some time since, bruised her right elbow,
but the pain ceased in a day or two and was forgotten. A few days
since the right elbow and arm commenced to be painful, the pain ex-
tending up to the shoulder and side of the neck. She thought she
had taken cold, and did not feel alarmed until the spasm commenced.

1847.] Seven Cases of Traumatic Tetanus cured.

This patient had been bled, and had taken tincture opii, &c, &c.
She however continued to grow worse to the present time. I sug-
gested to the above named gentlemen the use of the strychnine.
They at once gave their assent, and it was given in dose* of one-
twelfth of a grain every two hours. It produced its peculiar effect
after each dose. She was also ordered injections from time to time,
as her bowels would not move without it. On the next day the dose
was somewhat diminished, as its effects were very powerful. The
spasms ceased after the fourth day. This patient convalesced very
slowly, her arm being weak and painful for some time : this, however,
may have depended upon her age.

August 21. Called and found Mrs. A. had just returned from th<^
country ; she has quite recovered. I have called several times since,
and she continues quite well.

Case VI. This case occurred in the practice of a gentleman in
Sullivan Co., X. Y., and as he has kindly furnished me with a history
of it, I will insert it here.

"Dear Sir: Miss , of this village, aged 14 years, robust and

healthy, ran a piecg of bone in the sole of her foot, about the last of
October. There was a little irritation about the foot for three or four
weeks after the reception of the injury, and two or three times during
the period there was slight ulceration; but little pain was felt by the
patient until about the time she was attacked by the tetanic symp-
toms.

"She had, however, from time to time, after the injury and previ-
ous to the tetanic attack, more or less ' stiffness and numbness' in the
injured leg. She states, also, that at different times during this peri-
od, 'her leg was hot and had red streaks upon it ;' these lasted a day
or two and then disappeared. She lirel nothing buf some slight do-
mestic remedies applied, until her case became alarming by the spas-
modic action.

"It had been my determination ever since reading the result of
your cases published in the 'Reporter,' if calied to a case of tetanus,
to treat it with strychnine. When my attention was called to this
case, I was destitute of this medicine, and none could be obtained in
the vicinity; accordingly the case progressed for forty-eight hours
before the remedy was obtained and administered.

"In the meantime. I pursued the following course : There were
violent pain and spasms at intervals, commencing in the affected leg,
and extending along the muscles on either side of the spine to the
head and jaws, violent distress about the diaphragm, with consider-
able sympathetic fever.

"My first effort towards subduing the disease was making an in-
cision with a bistoury, about an inch and a half in length, and of
sufficient depth to thoroughly divide the plantar aponeurosis, which
was wounded by the piece of bone. I then filled the incision with lint
saturated with ol. terebinth, and a bread and milk poultice to be ap-
plied over it. I then used V. S. gx.xvj. on the leg, and administered

S8 Sevan Cases of Traumatic Tetanus cured. [January,

the following : ft Calomel, grs. xx., Jalap, xv., to be followed by sal.
Epsom in two hours. After this had operated briskly and freely, I
gave her a teasponful of Tinct. Opii every hour, with a view to sub-
due the* spasms. After she had taken two or three doses, the spasms
were somewhat relieved nnd the pain less. This truce lasted four or
five hours. She became worse, although the Tinet. Opii was con-
tinued as above; her btidy curved more backwards, her joints were
set and the spasms more severe. The dose of Tinct. Opii was in-
creased, but it failed to subdue the disease. By this time, I obtained
the strychnine, and administered it with complete success ; so soon
as it produced its peculiar twitching effect, the spasm abated and the
patient rapidly recovered : in a few days she was about as usual.
The dose given was T\ of a grain every two hours, at first, gradually
increasing the intervals.

"Dear Sir: I send you above a history of a case of traumatic
tetanus I lately treated with strychnine. You are at liberty to make
what use you please of it.

"In great haste, yours, &c,
" To J. Weldon Fell, M. D. (signed) CifeMENT Botsfoed.

" Bloomingburgk, Sullivan Co., N. Y."

Case VII. This case was furnished me by my friend, Dr. E.
Yanderpool, and although it was not so well marked as some, still I
think that there can be no doubt of its having been an incipient case
of traumatic tetanus.
" Dr. Fell :

"Dear Sir: The case of tetanic rigidity you request a history
of, though only partially developed, is, I think, sufficiently interesting
to be published,. as tending to commend the use oi'strychnine in this
most alarming malady.

"The 2d of Sept., 1846, I excised an elliptical piece of the cutis,

on the radial side of the metacarpal joint of the thumb of Mrs. ,

in view of removing a cicatrix from the point of a scissors with which
it had been punctured some three months previously, in hope of
curing a neuralgic condition of the arm, which had been thus pro-
duced.

"On the 10th Sept., 1846, just eight days after the operation, the
wound having healed, a slight but permanent contraction of the arm
was noticed, with rigidity of the flexor muscles, particularly the biceps,
which was painful upon pressure. That night she was unable to
&kep, from the uneasiness and increase of this rigidity involving the
muscles of the neck and jaws, accompanied by a 'violent cramp or
drawing' in the region of the diaphragm on the affected side. These
symptoms all became aggravated by attempting to extend the arm,
or by any motion of the body, and produced great general distress,,
with nervous tremors, 'shuddering and shaking' of the whole body.

"The arm fell on the inner side, as she expressed it, corded in its
whole length. Next day there was a little abatement of the a Dove
symptoms, hut on (he 12th she became decidedly worse, the ( cramp
and drawings' being more severe.

1847.] Insensibility during Surgical -Operations. 29

" Sept. 13th. I was sent for at 3, P. M. I found her sitting up ;
said she could not sleep on account of general uneasiness and a dis-
position to move the arm. which brought on an increase of the symp-
toms enumerated. On examining the arm, [ found it a little, but
firmly flexed; the biceps was contracted, cord-like, and hardened,
and somewhat tender upon pressure. Slight rigidity of the muscles
of the neck on the affected side, also a feeling of 'tightness' extend-
ing from her hand to her head. From the tetanic character of the
symptoms, I at once prescribed strychnine in doses of y1^ of a grain,
in solution, every two hours (when awake) with a sinapism to the
biceps.

"Sept. 14, 10 A. M. Patient has slept well through the. night for
the first in some time, arm a little relaxed, otherwise as yesterday;
continued the strychnine as above.

"7, P. 31. Xo improvement ; ordered T]T of a grain of the strych-
nine.

" Sept. 15, 10, A. M. Patient has slept but little during the night ;
complains of the 'rigidity, tightness, and drawing' of her arm;
her head is drawn down towards the shoulder of the affected side,
with inability to extend the jaws to the full extent, and distress over
the diaphragm; ordered her to take strychnine T1^ of a grain every
two hours.

"7, P. M. Has had a few twitches, characteristic of the effects
of the strychnine ; a little yielding of the tetanic symptoms ; con-
tinued the strychnine as above.

"Sept. 16, 10, A. 31. Patient has slept well, general improvement,
contracted muscles relaxing; has taken considerable nourishment,
having been unable to do so for some days.

"17. Dicontinued the strychnine, as the tetanic symptoms have
all disappeared.

"From this time forward, the patient continued to mend rapidly,
and bythe 21st was perfectly well.

" Respectfully yours, &c.

New York, Oct. 1, 1846. "Edw. Vaxperpool."

Insensibility during Surgical Operations produced by Inhalation.

In a recent Xo. of the Boston Medical and Surgical Journal,
(Xov. 18th, 1846,) Dr. H. J. Bigelow drew the attention of the pro-
fession to the fact, that the leading surgeons connected with the
Massachusetts General Hospital, had operated upon a few patients
while in a state of insensibility produced by inhaling a new gas, said
to be discovered, or invented, by Dr. Charles T. Jackson, a chemist,
and Dr. Morton, a dentist of Boston. On the reception of this intel-

30 Insensibility during Surgical Operations. [January,

ligence here, a letter was addressed to Dr. Smith, editor of the above
journal, offering to test the article before the profession and medical
class of this city, upon patients in the Augusta Hospital. The follow-
ing is the reply :

"Boston, Dec. 2, 1846.
Dr. Paul F. Eve :

Dear Sir Dr. J. V. C. Smith has kindly shown to Dr. W. T. G.
Morton, of this city, your letter of Nov. 23. It will afford Dr. Morton
much pleasure to permit you to make trial of his discovery. He has-
written a letter to Dr. John C. Warren, of this city, requesting him to
name theTnost respectable and charitable hospitals of the United
States, and it is Dr. M.'s intention to give to such the free use of his
discovery for the benefit of the poor. As soon as measures can be
taken, such hospitals will be licensed. In order to use the article
employed, it is necessary to have a proper apparatus which costs,
with a quart bottle of the preparation, $25. If the hospital you
mention desires such, and will render the above amount in a letter, it
can have it to use for the poor, and you can employ it, to test the
same to your satisfaction. We hope soon to effect arrangements
whereby all the surgeons can avail themselves of its use. The dis-
covery is of great value to the world. If you desire to use the same
in your practice, I have no doubt Dr. 3Iorton will give you an appa-
ratus and license to do so for five years, for $100.

Yours, respectfully, R. H. EDDY,

Attorney for Dr. Morion."

Surgical Operations with the aid of the " New Gas."
To the Editor of the Boston Medical and Surgical Journal :

Dear Sir The two following cases, occurring in my practice
during the past week, are of interest as supporting the claims to con-
fidence of Dr. Morton's anodyne compound.

Case I. Nov. 19th. An Irish girl, under 20 years of age, in at-
tempting to step into the cars at Hamilton, while they were in motion,
fell, with her arm upon the track, and had a compound, comminuted
fracture at the elbow, from the wheel of the car. At about 9 in the
evening, I amputated in the middle of the humerus. The operation
lasted a little longer than if done by daylight, although it was a flap
operation and quickly executed. Three vessels were tied. Dr. Fisk,
dentist, of this city, accompanied me and caused the patient to inhale
the vapor of the compound, about three minutes before the operation
commenced. By this time she appeared to have yielded entirely to
its influence, and became pale, silent, and perfectly passive and man-
ageable, whereas she had before exhibited evidence of great physical
suffering and uncontrollable grief. Before the arteries were all tied
she appeared to be returning to consciousness, when, on offering the
apparatus to her mouth, she seized it with avidity, respired rapidly,

1847.] Insensibility during Surgical Operations. 31

and soon seemed to relapse into the unconscious state. It was thus
renewed four or five times before she was placed in bed. Her own
statement is that she suffered no pain during the operation, that she
was asleep, and when she awoke she breathed again of what was
offered to her and fell asleep again that she remembers to have
done this three times. She says she did not know what we were
doing to her, but in her sleep she thought she had got a reaping hook
in her arm, and that she heard the noise 6f sawing wood. She says
she was not sensible of any thing till she was laid in bed, when she
became quite talkative, and evidently somewhat excited. She slept
some hours during the night. On dressing the stump on the third
day, she made a violent outcry at the slightest pain. I was convin-
ced that her statements with regard to her freedom from pain during
the operation, were to be believed.

II. Nov. 21st. An intelligent tanner, about 30 years old, had,
with a fracture of both bones in the middle of the left leg, his ancle
crushed by the cars engaged in building the Salem and Methuen
Railroad. I amputated the leg just below the knee. The patient
respired the vapor under Dr. Fisk's directions. He says he was not
conscious of feeling any pain and after the operation was finished
and the ligatures applied, his consciousness returned, and, with great
apparent sincerity, he asked if his limb was taken off. He says,
though he felt no pain, he was conscious of the presence of those
around him, and he was obedient to the directions given him. The
operation was performed at about 3, P. M., and the stump was dress-
ed at about 9, when, he says, the pain of a few sutures far exceeded
that of the operation.

In both these cases the pulse became somewhat accelerated after
the operation, the countenance assumed a vacant expression, although
in the first case there was working of the brows, and the pupils were
dilated. They both appear to be doing well, and exhibit no symptoms
worthy of note. Respectfully, yours,

Salem, Nov. 24th, 1846. A. L. Pijirsox.

Postscript. Xoiwnber 25//*, 1845. Yesterday, I made further
trial of the ethereal vapor, upon a middle-aged female, from whom I
removed an adipose tumor, by an incision four inches long over the
clavicle and scapula. She was an unimpressible subject, and was
less perfectly under the influence of the vapor than the others, but she
was entirely bewildered and not able to realize the nature of what
we were doing to her. She was much more quiet than patients
usually are. although the dissection was somewhat protracted, by the
dipping down of the tumor into the supra spinal fossa of the clavicle,
and confinement by fascia. She says she felt no pain, and did not
evince any perception of the puncture of the needle in dressing the
wound a sensation which usually calls forth complaint, as it is com-
monly unexpected.

It needs, no doubt, still further careful observation of its effects, to

32 Insensibility during Surgical Operations. [January,

establish medical confidence in the new remedy, a confidence which
must be of slow growth. From the results I have seen at the
Massachusetts General Hospital, and in my own practice, I am led
to expect the following advantages from its exhibition :

1st. Uniformity of its effects, unlike any mode of intoxication by
stimulants in the stomach, or respiration of nitrous-oxide gas. My
three patients were as unlike in age, temperament and habits, as
could well be imagined, yet all exhibited the same appearance of pas-
sive endurance.

2d. There was no instinctive or voluntary resistance, which is so
embarrassing to an operator. This, next to its power of preventing
the perception of pain, is the greatest merit claimed for it.

3d. The securing the patent from the severity of the great shock
which a capital operation inflicts on the sufferer. It was quite
noticeable, in all the patients I have seen, that there was none of that
extreme depression which sometimes follows a severely painful im-
pression on the nervous system.

4th. Its effects pass off rapidly, and, as far as I know, no bad results
follow.

5th. It can be repeated several times during the operation, except
the mouth or jaws are the parts to be operated on. The repetition
of the close is always sought by the patients with avidity.

6th. The last and most important of its effects, is, that it either
wholly annuls pain, or destroys the consciousness of it, so that it is
not remembered ; and thus the sentiment of fear is wholly obliterated.
The patient appears to have been dreaming, and in the second case
said that "he was in a distinct existence" (i.e., distinct from his for-
mer experience), thus illustrating the theory of double consciousness.

These are recommendations enough to ensure it a fair trial among
the humane and enlightened members of our profession, and for their
decision we must wait, and by it be governed in its future use. Dr.
Morton and Dr. Jackson, at least, are entitled to the hearty thanks
of the profession for their discovery, and the liberal manner in which
they have offered it to all the subjects of surgical operations, both in
and out of the Hospital. If some hunter up of obsolute theories
should prove that such a thing had before been thought of, or tried,
still these gentlemen are entitled to the credit of having made it, for
the first time, perfectly available to the suffering, and submitted it to
the test of those competent to decide on its merits, without being
content to rest its pretensions on non-professional credulity or popular
notoriety. A. L. Peirson.

Salem, Nov. 2Qth, 1846.

The Inhalation of an Ethereal Vapor to prevent senibility to pain

during Surgical Operations.
To the Editor of the Boston Medical and Surgical Journal :

Sir, That which has always been a desideratum in surgery,
seems, at length, to have been discovered. And if the effects of the

1847.] Insensibility during Surgical Operations,

agent or agents be such as has been reported, of which there is little
room to doubt since the appearance of the article in a late No. of your
Journal, by Dr. Bigelovv, Jr., every one who has any sympathy for
human suffering must rejoice in the discovery ; and all who are called
upon professionally to perform painful operations must feel desirous
to avail themselves of the means of diminishing or destroying that
state of consciousness which recognizes all violence done to the sen-
sitive tissues of the body, while such operations are in process.

But it appears, from numerous statements, and through your cor-
respondent, Dr. B., who speaks with much authority on the subject,
that the article used is a secret, or patented affair.

Now the enlightened and regular medical faculty of Massachusetts
(as well as of other parts of our country), are associated and have
arrayed themselves against all secret remedies, or patent medicines,
and this for the just and laudable purpose of protecting the commu-
nity, as far as might be, from imposition, and of preserving the integer
rity and standing of the profession ; they cannot, therefore, feel
themselves at liberty, as I judge, to seek aid for their patients through
the adoption of such articles and means.

If I wish to furnish those by whom I am called upon to operate in
painful cases with the relief which this new discovery may afford, I
am told I must obtain it and use it as a secret, or purchase the
patented article and employ it as such. But I ask why? It is said
to be, by those who really do, or who assume to know what it is, the
vapor of sulphuric ether only. This was judged to be the agent by
several who witnessed some of its earliest public exhibitions under the
hands of Mr. W. T. G. Morton. Dr. E. R. Smilie, of this city, with
all due candor and liberality, has given, in your Journal for Oct. 28th,
an account of his experience with sulphuric ether and opium, the
effects of which he says are similar to those* produced by the "new
gas."

The free use of the article has been ceded to the surgeons of the
Massachusetts General Hospital, and these gentlemen would receive
it or adopt its use, on no other condition, of course, than that of know-
ing what it was, and having the full and free control of it for that
institution. Hence, I ask, why, if I wish to avail myself of any of
the possible effects of an article of our materia medica an article
which I have administered to patients hundreds of times, which I
have often swallowed, and have inhaled till I was all but lost in sleep
why I must now purchase the right to use it, and use it as a patent
medicine. %

But we are still told that it is patented. What is patented? A
power? A principle? A natural effect ? The operation of a well-
known medicinal agent? I doubt the validity of such letters patent.
It would seem to me like patent sun-light or patent moon-shine.

To my mind it seems unfortunate, to say the least, that the dis-
covery has not been brought to public notice in a ditferent manner
and under different circumstances. And I am sorry that Dr. Bige-

3

34 Insensibility during Surgical Operations, [January,

low, in his article above mentioned, has attempted to apologize for
the arrangements which he says have been made by Dr. C. T. Jackson
as one of the parties, to secure by patent the control of a medicinal
agent like the one in question. The doctor seems to feel very fully
his position in relation to this point, when he says,

" For various reasons, discoveries in high science have been usually
rewarded, indirectly by fame, honor, position, and occasionally, in
other countries, by funds appropriated for the purpose. Discoveries
in medical science, whose domain approaches so nearly that of
philanthropy, have been generally ranked with them ; and many will
assent with reluctance to the propriety of restricting by letters patent
the use of an agent capable of mitigating human suffering."

Of the three reasons which he offers as worthy of consideration in
this behalf, two are, to my mind, entirely without force sufficient to
be any excuse for such a measure ; and the total incorrectness of the
,Amain part of the third, must be apparent to all who are at all acquaint-
ed with the subjects on which it is made to bear.

"1st. It is capable of abuse, and can readily be applied to nefari-
ous ends."

If, however, the right is to be sold, and every opportunity is to be
improved to make money of it, and all may buy who please, I do not
see how the abuses to which it may possibly be put by evil-minded
persons are to be restricted by a patent. And any one vile enough
to use such an agent for nefarious purposes, would not stop to ask
about his right to do so.

" 2d. Its action is not yet thoroughly understood, and its use should
be restricted to responsible persons."

Who are the most responsible persons to be trusted with this
agent? All will assent, no doubt, that they are such as are most
likely to be acquainted .with the properties of the article, with the
nature of those unpleasant symptoms which may occur from the use
of it, and have occurred in certain constitutions, and with such anti-
dotes or remedies as should be used if required ; or, in three words,
regular physicians, surgeons and dentists. And I am at a loss to see
why the use of the discovery would not be as safe in such hands as in
those of " the proprietor" so called.

"3d. One of its greatest fields is the mechanical art of dentistry,
many of whose processes arc by convention, secret, or protected by
patent rights."

Who is there that bestows a thought on the subject, who will not
see at once, that this narcotizing process of inhaling the ether has
nothing to do with the mechanical operations of dentistry, but only
with those which are strictly surgical, those which Dr. B., in speak-
ing of the importance of this process, couples with amputations.

As to that part of this third apology, which charges dentistry or its
professors with holding secrets, by convention, or by the security of
patent, I must view the writer as being entirely in error ; for if there
is truth in the charge, I cannot find it. I do not know of anything

1847.] Observations on Croup.

which is practised in dentistry, in our own country, even relating to
the mechanical department, which is kept secret by or from the duly
educated dentists. [How this is with the host of ignorant pretenders,
and advertising impostere, I know not.] And with regard to a
patent for any process in the art, or even for an instrument, I do not
know that such a thing exists, nor am I willing to believe, without
greater evidence than the doctor's assertion, that a patent can be
found that has any especial bearing on the subject of dentistry.

I have been asked, by a member of the Massachusetts Medical
Society a respectable and excellent dentist of this city, what I in-
tended to do about using the M new gas," stating that he had used
it and knew what it was, and when questioned by me directly, did
not hesitate to say, M it is simply sulphuric ether " ; but added, "the
discovery is patented." My reply to him was, ul shall not obtain
and use it as a secret medicine I shall not purchase and use it as a
patent medicine. If it is simple sulphuric ether, and it will produce
the desired effect, I shall use it, and so will others who wish to do so."
If it is a compound, as stiil advertised to be by Mr. Morton, it is said
to be ceded to the surgeons of the Massachusetts General Hospital.
These gentlemen, it is to be presumed, will not consent to hold it as a
secret or patent medicine ; and if known to the medical students who
are privilodged to attend that institution for the purpose of acquiring
information and obtaining instruction in all that is clone there pertain,
ing to their profession, no one, as I judge, can rightfully restrict them
from using what is there used for the relief of suffering humanity ;
and it will become, as it ought to be, free to all who should be trusted
to do good with it, or who can receive relief from suffering by it. To
patent it would be, what it would have been for the immortal philan-
thropist Jenner to have patented vaccination.

These, Mr. Editor, are some of my thoughts on the subject; and if
I am in error for holding them, or for thus giving them to the public,
you are able, no doubt, and will be ready, to set rne right.

J. F. Flagg.

Xo. 31 Winter sired, Boston, Xov. 23d, 1846.

Observations on Croup : a paper read before the Fellows of the Col-
lege of Physicians and Surgeons. By Alexander H. Stevens,
M. D., President of the College. (The Annalist.)

The frequent occurrence of croup, and its not unfrequent fatality in
the northern and maritime regions, especially those of the United
States, render important every addition to our knowledge of the na-
ture and treatment of this formidable disease. Up to the time of Dr.
Bayley, of New York, no modern writer appears to have entertained
correct pathological notions of this malady. It had previously been
confounded with anginose affections of the fauces. It was, however,

36 Observations on Croup, [January,

known to Hippocrates, who describes it in these remarkable words:
" Ab angina homo suffocalur oculi affecti sunt, ac velut strangulatis
prominent ; facies et fauces incendunter, imo etiam collum intumesci-
tur vero nihil mali habere videtur"

We owe to the late Dr. Hosack of this city, the best description of
the various stages of croup, and, probably, the best practical direc-
tions for the treatment of it. Yet there are important points, both of
pathology and practice, which he leaves wholly untouched; and
others in which, if I am not mistaken, he is inaccurate.

It is usual among the medical men of this city, to speak of genuine
croup, meaning that in which a membrane is formed in the trachea
and of spasmodic croup, many of them believing that inflammation
either does not exist at all in the latter species, or that it is not the
prior or primary morbid condition. These views I hold to be erro-
neous; and, if carried out in practice, highly dangerous.

Professor Ware, of Boston, (the most recent writer on croup,) has
recently presented another view of the subject, in a well-reasoned
paper, wherein he records numerous cases and dissections, knowing
how little that is truly valuable to American physicians, in relation to
croup, is to be found in European publications, more especially among
the continental writers ; or, rather, how far they fall short in estab-
lishing those rules of practice, by which alone the American physician
can successfully contend with the formidable malady. I am led to
infer that it may present itself under different aspects in different
regions. Be this as it may, the division of croup proposed by Profes-
sor Ware into four species viz., catarrhal, membranous, inflamma-
tory and spasmodic, does not accord with my own experience, or with
that of the most sagacious and experienced practitioners of this city,
with whom I have conversed on this subject.

The forms under which croup has presented itself to my observa-
tion in this city, during a period of more than thirty years, are the
following :

1. A child with coryza and occasional cough of the ordinary char-
acter, as in bronchitis, is playing about without sore throat, or redness
of the fauces, or glandular swelling. He appears more than usually
animated his countenance, especially his eye, is unusually bright,
and his mind exhilarated. His skin, at this time, is not heated during
the day, but rather harsh to the feel and dryer than natural. To an
acute observer, with a nice ear, his voice will be a little sharper than
usual ; and if he cries for a time, the peculiar inspiration will excite
alarm. On the second or third night the attack of croup commonly
comes on, after a few hours sleep, the symptoms being a ringing
cough, hoarse inspiration and great roughness of the voice. If the
patient dies, a membranous formation is found in the trachea, and,
more or less, in the bronchial lubes. This is what all admit to be
genuine inflammatory croup.

2. Without any noticeable illness whatever, a child suddenly wakes
up in the night with spasmodic suffocating cough, of the peculiar

1847.] Observations on Croup.

croupy sound, the same inspiration as in the former case and the
same hoarseness. A drink of some kind is given : the next cough is
less sonorous, but the croupy symptoms as before described remain.
The case is usually relieved by an emetic and some stimulating appli-
cation to the throat, both of which are kept for that purpose in almost
every well regulated family in the city, where there are many children
under eight years of age. If not so relieved, the patient may die
within twenty-four hours or less, or after a lapse of two or three days,
or even a week. Where the disease terminates quickly in death, no
well-formed false membrane is seen, but only mucus in the trachea,
more or less thick, and redness about the glottis. This is the form
to which the term spasmodic croup has been given. Spasm of what ?
Of the glottis, undoubtedly! And from what cause? From the
presence of vitiated secretions and undigested decomposed food in the
stomach, it is answered. And how does this act? By sympathy?
Now, this cannot be either proved, or even rendered probable. It is
true, when the stomach empties itself by vomiting, the symptoms, for
a time, at least, and often permanently, are relieved. But vomiting
does more than unload the stomach : it relaxes the system, reduces
the action of the heart, determines the fluids to the skin, which pos-
sesses so remarkable an antagonism to the mucous surfaces: above
all, it induces a copious secretion from the fauces, and thereby un-
loads the congested vessels of the glottis. It is admitted, that an
acid state of the stomach ofien causes irritation in the pharynx, which
thence extends to the posterior part of the upper portion of the
larynx. In adults this is beyond all doubt, and in children it is every
way probable. Is the impression of these acrid matters, eructated
from the stomach or secreted in the pharynx under particular circum-
stances, upon the larynx the cause of the sudden occurrence of croup ?
It would be difficult absolutely to disprove these propositions. In my
mind they are not improbable ; but, on the other hand, admitting the
connection between disordered stomach and croup (established, as it
is, by the most extended observation), may it not be attributable, in
part, at least, to the fact that continued coldness of the surface is pre-
cisely the condition which fits the system, as well in childhood as in
age, for the action of cold and moisture in producing inflammatory
diseases ?

But, stating aside these considerations, and, under any view of the
subject, what is the morbid condition of the glottis, which gives rise
to the croupy symptoms? If from cold, it is inflammation ; if from
acrid secretions acting for more than a few minutes, it is. and can be,
nothing else. There is, therefore, no spasmodic croup, if, by spasm,
it is intended to exclude inflammation as a cause of that spasm.

But, I am asked again, how are the two kinds of croup above de-
scribed, to Ihj explained pathologically. The itn&wer to this query
will appear in the classification of the forms of croup now proponed.

Under t he term croup, properly so called, are included two atfec-
tions, which may exist cither separately or together.

88 Observations on Croup. [January,

1. The cynanche tracheal is, or trachitis, in which membranous
exudation is more or less former! in the trachea, before any affection
of the larynx, and, more especially of the glottis, takes place.

2. The cynanche laryngea, or laryngitis, or glnttitis, in which the
laryngeal, or spasmodic symptoms occur first or exteriorly.

3. Between these two, there are varieties of combination, and these
constitute the great majority of the cases met with in actual practice.
In the most pure case of the so-called spasmodic croup, no practitioner
can say beforehand that no fatal inflammation of the glottis will occur,
or that no obstruction of the trachea, by false membrane, or solid
mucus, is to be apprehended.

Is the disease, croup, a specific disease? Is there any peculiarity
in the inflammation which gives rise to that secretion in the trachea?
Let us look to anatomy and physiology, and the observation of disease,
and to dissections, for answers to this question.

In the first place, between the most firm tubular form of false mem-
brane and inspissated mucus, and mucus of an ordinary consistence,
we see, in dissection of croup, every grade and variety. If specific,
its character should be more marked.

When a child attempts to swallow hot water, the membranous exu-
dation is produced in the posterior fauces and upper part of the larynx.
Here, then, is an ordinary cause of inflammation producing what
some consider a peculiar and specific secretion.

This question has a bearing upon practice, because it is contended
by some that the specific effect of mercury is the proper remedy for
this specific secretion.

It remains f>r those who deny the specific character of the tracheal
secretion, to account for its existence there, rather than in'the larynx
and trachea. In the larynx it is more rarely met with ; in the trachea
it gradually becomes less tenacious, and more rrscmbles*ordinary or
inspissated mucus. May it not be merely inspissated mucus in all
cases? mucus, inspissated by rapid desiccation? If a portion of
mucus is left in the trachea, the increased rapidity of respiration, and
the narrowed calibre of the tube, must necessarily remove its watery
particles in a doubly augmented ratio ; less so in the trachea, because
the same volume of air in proportion to surface does not pass by, and
the air, also, is more charged with the moisture, in its previous pas-
sage through the trachea less so in the larynx, becar.se that tube is
larger. Rarely is the membrane seen upon the glottis, because death
arises from spasms, ere it has time to form on that irritable part.
Rarely in adults, because in them the trachea is double the size it is
even in advanced childhood, and because they exert a stronger
volition to detach by hawking the first tenacious mucus that is ad-
herent to the trachea.

The surface of the trachea is very unirrifable. Where foreign
bodies enter by accident, as when a tube is forced into it from an
artificial opening, no coughing is induced, unless, by its rising up. the
glottis is touched. A email foreign body has been known to remain

1847.] Observations on Croup. 89

for years quietly lodged in one of (he ventricles of the larynx. The
trachea, and the comparatively unim table parts, are those in which
inflammation may be going on for a considerable length of time, with-
out exciting any very marked symptoms. This constitutes the truo
explanation of the two modes of invasion in croup.

Besides these three foims of idiopathic, primary, or true croup
the laryngeal, the tracheal and the mixed there are forms of secon-
dary croup, such as occur in measles, scarlet fever, and, more
especially, in the malignant ulcerated sore throat, the diphtherite of
Bretonneau. This last occasionally occurs sporadically with us, and
is, I apprehend, very generally, the disease, which, under the term
croup, carries off, in quick succession, two or more children in the
same family. I .have treated it successfully with calomel and opium,
followed hy wine whey, in conjunction with nitrate of silver, to the
throat :but my experience is too limited, for me to assume to instruct
others in regard to its nature and treatment. The French writers do
not appear to discriminate between this affection and croup, as known
here and in Great Britain.

Before speaking of the proper medical treatment, I will say a few
words on a point of Ilygeine.

1st. What is the best method of bringing up children, with a view
to their exemption from this disease?

Two systems are adopted for this purpose one is to allow free
exposure and exercise in the open air, except in the very worst
weather. The children, being well guarded with warm clothing, are
not suffered to cease their exercise until they re-enter the house.
The second is to confine them within doors, during the whole of the
winter and the early part of the spring. My observation leads me to
think that, although the first plan, if it is followed with great care, is
the best, yet the second is more easily pursued, and, upon the whole,
is the safest.

2d. Under what circumstances should especial precautions bo
taken, with a view to ward off the attack?

A child, between the ages of two and five years, with catarrh and
cough, however slight and unfrequent, is a fit subject fjr croup: and,
if that disease is prevailing at the time, an attack, after any exposure
to cold and moisture, or any excess in eating, is almost probable.
The child should be confined to the house an

The treatment of croup should be prompt and decided ; for, left to
itself, the disease would probably, in genera!, prove fata!. But, al-
though prompt and decided treatment is necessary, it does not follow
that the heroic treatment is always, or omen gem-rally, required.
But the existing symptoms must always be met by remedies adequate
to subdue them. The great skill of an oxprs ionr-ed practitioner is
shown in determining what amount of active I it is tssentihtxn

any given case ; how much is requisite to remove the tlircatehin*
symptoms, and to induce a favorable clianre, an 1 hnwaoon ho mrtst
recur to I he more severe remedies, after Iho i has been lor a

time meliorated.

40 Cancer of the Stomach, [January,

Cancer of the Stomach. By Professor W. H. H. Walshe, M. D.

(British and Foreign Medical Review.)

The mortality from cancer of the stomach is very considerable.
In this respect it yields to no organ but the uterus. Of the 8289 deaths
in Paris, 2303 are referred to the stomach. In 67 cases, MM. Her-
rick and Popp found this organ diseased in 19. Cancer of the stom-
ach may exist alone, but is usually associated with similar affections
of other organs, more especially of the liver. It is almost invariably
primary. All the varieties of the three species of carcinoma occur
in this organ ; it is the special site of colloid cancer; and the milt-
like variety of encephaloid is more common here than elsewhere.
Infiltration is essentially the mode of deposition in this place, and,
indeed, throughout the alimentary canal ; and the seat of the deposit
is the submucous cellular tissue, though the mucous membrane, par-
ticularly when hypertrophied, may become a nidus of formation.
The pylorus is the part most commonly affected ; next the cardiac
orifice; then the greater, and, lastly, the lesser curvature. Dr.
Walshe has not met with an instance in which the disease was limited
to the fundus a fact of importance as bearing upon the supposed
origin of the disease from the ingestion of irritants. Three-fourths,
or even more, of the organ may be disorganized ; and this is particu-
larly the case when colloid is the species.

The mucous membrane long resists the disease, and its chief ten-
dency is to become irregularly hyperlrophous, giving rise to the
apparent formations of vegetations, &c. The cellular structure
undergoes very marked thickening, and this occurring between the
muscular fibres produces the striated appearance so commonly ob-
served. The muscular coat of the sound parts of the organ is often
enormously hypertrophied. The peritoneal coat is seldom affected,
excepting in cases of colloid.

The size of the organ varies extremely. When the pylorus is af-
fected it is often greatly enlarged; when the cardiac orifice, it is
contracted ; when the body of the organ is alone diseased, the gene-
ral bulk commonly remains unchanged. It is a curious and unex-
plained fact, that, where the pyloric orifice undergoes dilatation, the
walls of the stomach become hypertrophous.

The progress of the disease presents nothing peculiar. Ulceration
is slow to commence ; but when once begun, its ravages are extensive.
In most cases, adhesions, especially to the liver and pancreas, take
place before the peritoneum gives way.

The disease is more common in males than in females, and between
the ages of 35 and 60. It is often hereditary, and has apparently, in
many cases, been induced by mental distress.

Cancer ofthe stomach, in the early stages especially, may be con-
founded with other affections; the most practically important of which
are gastrodynia and chronic gastritis. We subjoin the following
sketch of the chief points of distinction :

1847.]

Cancer of the Stomach.

41

Gastrodynia.

Tongue variable, but
often pale, and pitted at
the edges.

Eructation frequent of
air, without disagreeable
smell.

Appetite depraved, ir-
regular, capricious.

Sensations, sometimes
of heat, sometimes of cold
in stomach; thirst not
common.

Solids more easily di-
gested than liquids.

Digestion completed,
though with much labour
and suffering.

Pain variable, occurs
in irregular paroxysms;
is often relieved by inges-
tion of food or pressure.

Epigastric pulsation not
uncommon.

Never runs a complete-
ly latent course.

Chronic vomiting is
most frequent in females,
and is almost confined to
persons affected with hys-
teria.

Chronic Gastritis.

Tongue dry, red, con-
tracted, smooth, shining,
or saburral.

Eructation not a promi-
nent symptom.

Sensation of heat in sto-
mach; thirst.

Gastric Cancer (early period.)

Tongue pale or natu-
ral.

Eructation of air more
or less fetid, sometime^
horribly so, a prominent
symptom.

Appetite diminished, or
even totally suppressed.

These symptoms not
observed.

Digestion imperfectly
completed.

Epigastric pain not ve-
ry severe, and scarcely
ever felt when the stom-
ach is empty ; increased
by pressure.

It is not observed.

Never completely lat-
ent.

Vomiting of sudden and
severe character some-
times the very first symp-
tom; occurs irregularly
before or after eating.

Vomiting of coffee-
ground-looking matter
does not occur, unless
from accidental and rare
haematemesis.

Bowels generally con-
stipated, but not obstinate-
ly so.

Febrile action acciden-
tal and rare.

In females the chlorotic
tint is often present.

Often accompanied with
various nervous or hys-
terical symptoms.

Hypochondria occa-
sionally present.

Is more frequent than
the other two.

Is more common in wo-
men than men.

May exist in very young
persons (e. g. act. 15.)

Coffee-ground-looking
matter sometimes vomit-
ed ; but this is rare and
exceptional.

Irritation, colic, and di-
arrhoea irequent, from ex-
tension of inflammation
to intestine.

Evening fever not un-
common.

Violet discoloration of
the lips,conjunctivse, face,
&c, often present.

Not so attended.

Liquids more easily di-
gested than solids.

Digestion not properly
effected.

Epigastric pain maybe
agonizing; the lancina-
ting character sometimes
marked ; often increased
by pressure.

It is not observed.

May for a va riable time
be completely latent.

Vomiting of sudden and
severe character is never
the first symptom ; it oc-
curs generally early in
the morning, subsequent-
ly at variable periods af-
ter eating, or at periodical
intervals.

The matters vomited
are a first glairy, then
half-digested food, then
coffee-ground or soot-like.

Bowels habitually and
obstinately constipated ;
occasional severe diar-
rhoea.

Fever absent.

Straw-coloured tinge of
skin may be obvious.

Not so attended.

Hypochondria not cau-
sed by chronic gastritis.

Is rarer even than can-
cer.

Is probably equally fre-
quent in both sexes.

Occurs at all a<rcs.

Hypochondria not an
effect ofgastriecancer.(])

[8 much rarer than gas-
trodynia.

Occurs more frequently
in men than women.

is excessively rare be-
fore art. 30.

42 Treatment of Orchitis. [January,

Gastrodynia. Chronic Gastritis. Gastric Cancer (early period,)

Is often hereditary. Is not hereditary. Occasionally runs in

families.

Is rarely referrible to Is often referrible to :- Is rarely, if ever, refer-
any distinct local exciting some distinct local exci- rible to local agencies,
frause. - ting cause.

Is relieved or cured by Is relieved or cured by Is not cured, but is re-
stimulant, tonic, and an o- antiphlogistic treatment. lieved by special treat-
dyne treatment. ment.

As the disease advances the diagnosis becomes Jess obscure, but
cases do now and then occur which present all the ordinary combina-
tions of symptoms, and yet are not cancerous; so (hat the detection
of tumour is the only absolutely certain sign. This is most easily
discovered when seated in the pylorus or great curvature : it is much
more difficult to detect when occupying the lesser curvature or the
cardiac orifice. It must be remembered that the situation of the
tumour changes continually; and it is of the last importance to
bear in mind that the whole course of the disease maybe of an inter;
mittent character.

In regard to treatment but little can be said. Conium is the only
supposed specific which is applicable. Dr. Walshe has derived bene-
fit from a combination of trisnitrate of bismuth and extracts of hop,
.stramonium, and conium, in pil! ; and he believes that the treatment
generally should be such as is applied to nervous, rather than inflam-
matory affections. Leeches and blisters may be used to relieve oc-
casional local irritation. Opium is contraindicated by the constipa-
tion ; but the Indian hemp may be tried. A drop or two of oil of
cajeput on sugar is the safest carminative. Cold applications or a
blister sometimes also relieve the flatulence, and a dose of morphia
has been found useful id the same way. But most is to be done by
regulating the diet, observing what agrees with the patient, making
the quantity taken at each meal small, securing perfect regularity in
the hours, and complete mastication of each morsel. Sickness ma)r
lie relieved by effervescing draughts, prussic acid, blisters, rough ice
allowed to melt in the mouth, the application of ice in bladders to the
epigastrium, or an occasional dose of creosote. The bowels are best
kept open by encmata : drastic purges are quite inadmissible.

M. Recamier narrates a case of pyloric tumour, "possibly cancer-
ous," which was reduced in bulk by pressure, applied by means of a
folded napkin secured by a bandage round the body. It may be well
to try some such plan as this.

On the Treatment of Orchitis hy division of the fibrous tunic of the
Testicle. [Gazette des Hopitaux, from St. Louis Medical and
Surgical Journal.]

M. Vidal de Cassis is a partisan of division of the fibrous tunic of
the testis in some forms of orchitis, attended with severe suffering

1647.] Treatment of Orchids. 43

The following is a resume of M. Vidal'sl opinions, for which we are
indebted to his interne, M. Bouteiliier.

J)efinitions and Complications. Parenchymatous orchitis, which
may likewise be designated as orchitis properly so called, is inflam-
mation of the testis itself. It exists, according to M. Mica rd, scarcely
ever without affection of the epididymis. This last inflammation
precedes orchitis properly so called. In fact, \n order to extend
itself to the testis, the inflammation must affect the epididymis. Let
it be well understood, that we are speaking of affections of the testis
consequent on gonorrhoea. In casus following blows on the organ,
or of wounds of its structure, the reverse may happen that is to say,,
we may meet with parenchymatous orchitis before we have epididy-
mitis. We can easily conceive the existence of the first inflammation
in such cases as these, without the coincidence of the second.

Parenchymatous orchitis often accompanies effusion into the tunica
vaginalis, the consequence of inflammation ; hut in all these cases
we are not to conclude there is inflammation of the serous membrane:,
we believe the inflammation has more frequently a passive rather
than an active character.

Lastly, sometimes we may find in the same person, parenchymatous
orchitis, epididymitis, effusion into the tunica vaginalis, inflammation
of the subcutaneous cellular tissue, or even of the skin of the scrotum.
Frequency. Orchitis, properly so called, is much more frequent
than is generally believed, and merits a description in our noso-
graphical chart. If M. Vidal has observed more than any other
surgeon, one ought not to be so much surprised when acquainted with
the large number of patients who apply for admission at the Hopital
du Midi. Each surgeon can there make his selection. While one
receives a large number of patients affected with diseases of the
scrotum, in order to confirm his views on those affeations, another
admits cases which bear most on syphilis. So that it cannot be said
that parenchymatous orchitis is only met with in the wards of M.
Vidal. Or:e case presented itself in the service of M. Ricord, in the
commencement of this year.

Causes. Parenchymatous orchitis, like epididymitis, recognizes
as its cause, most frequently, an existing gonorrhoea, or one that has
recently disappeared ; in fact, it is most frequently gonorrhoea!. We
have attempted to push our inquiries further, and aseertain why. in
certain individuals, gonorrhoea induces the affection of tile epididymis,
and in others (hut much less frequently), orchitis, properly so called.
To this end we have most minutely interrogated our patients on the
circumstances of the gonorrhecal affection. But we have been una-
ble to find any aggravating cause constant in all.

Local Symptoms. The tumor formed by the inflamed testis is less
voluminous than when caused by the epididymis. We have already
stated that Dupuytren was wrong, when he advanced an opposite
opinion. In the general sw< lling, I he enlarged epididymis forms the
larger portion, next the testis and, lastly* the ( {fusion into the tunica

44 Treatment of Orchitis, [January,

vaginalis. The form of the partial tumor we are speaking of, is that
of the testis, exagerated, it is true. The inflamed organ presents a
swelling in front ofthe epididymis, behind the serous effusion ; neither
elasticity nor resistance remains; the swelling is as if containing
coagulated fluid. When the tunica vaginalis is emptied, the testis
appears to occupy the place ofthe liquid ; and the general swelling,
previously pear-shaped, assumes a rounder form. The pain and
local heat are of the most violent description. The pain has this
peculiarity, that it spreads upwards and downwards, extending to the
kidneys, and to a corresponding point below. The color of the skin
is slightly modified ; but in some cases it is exceedingly red, or even
of a violet color. It has been remarked, that the cord is less liable
to be affected in cases of parenchymatous orchitis, than in instances
of simple epipidymitis.

General Symptoms. Fever is generally ofthe most violent form ;
there is sleeplessness, nausea, colic; and vomiting comes on, adding
considerably to the suffering of the patient, so as to induce him to
call for treatment which silences him at once.

Prognosis. The prognosis is not severe, when we destroy that
which gives it a particular character namely, the strangulation ; but
is very severe, on the contrary, when the disease is allowed to run its
own course. In that case, suppuration or mortification speedily
comes on in the parenchymatous structure ofthe testis.

Treatment. Local and general bleeding, poultices made with
laudanum, narcotic embrocations, purgatives lastly, puncture of the
tunica vaginalis, produce but slight amelioration of the symptoms of
the patient. It is necessary, in many cases, after having recourse to
all these remedies, to have recourse to the division ofthe tunica albu-
ginea, and it is better to perform it early.

This little operation presents nothing very alarming to the patient ;
hitherto, it has never been followed by an untoward event. Never-
theless, before resorting to it, it may be as well to puncture the tunica
vaginalis, when that membrane contains fluid, and, if that allays pain,
allow the patient to remain quiet; but we are obliged to admit that
temporising in such cases has too much danger to be long excusable*
We have always remarked that pain, after the division, ceases imme-
diately ; the fever decreases, and the patient Hills asleep in a quarter
of an hour, although he may have been unable to rest for several days.

After the division of the membrane, no further application is ne-
cessary other than a laudanum poultice applied to the scrotum, which
should be kept in its place by means of a loose bandage. In the seven
cases of division, which we have collected, the cure was rapid ; in
the instance ofthe patient operated on by M. Cullerier, the recovery
took place in eighteen days ; in a case we have seen this year, a cure
was^ffected in ten days, in one instance in sixteen, in another.

The division ofthe tunica albuginea should not be more than a
centimetre or a centimetre and a half; cicatrisation sometimes takes
place by union ofthe skin, tunica vaginalis, and albuguinea, to this

1847.] Hydropathy, or the Cold Water Cure. 45

extent; but very often this adherent point which is in no respect
injurious completely disappears, and the testis recovers its freedom,
its ordinary volume, and normal consistence ; its functions are sub-
sequently in no respect altered.

Hydropathy, or the Cold Water Cure.

The following conclusions on thissuhject, we meet with in Forbes'
British and Foreign Review :

1. We should be glad to see Dr. Currie's practice revived (for the
sake of experiment, at least) in all its boldness, for the suppression of
the general febrile paroxysm. On carefully looking over the evidence
published by Dr. Currie and his cotemporaries, it is impossible to deny
that they attained a larger amount of success in treating fever by*
water than other practitioners have done by other means. We have
already pointed out how their practice can be misunderstood by mo-
dern writers. But. while we regard this practice as well adapted
for treating general fever, we find no proof that it is competent to
meet the dangerous local complications with which fever is so often
accompanied. These complications may reasonably be expected
less frequently, when the early treatment of fever is rendered more
efficacious. But when they do occur, we find nothing in hydropa-
thic writers to show that lancets, leeches, blisters, &c., can be dis-
pensed with.

2. In a large proportion of cases of gout and rheumatism the water-
cure seems to be extremely efficacious. After the evidence in its
favour accessible to every body, we think medical men can hardly be
justified in omitting in a certain proportion of cases, at least a full
trial of it. No evidence exists of any special risk from the water-
practice in such cases.

3. In that very large class of cases of complex disease, usually
known under the name of chronic dyspepsia, in which other modes
of treatment have failed or been only partially successful, the prac-
tice of Preissnitz is well deserving of trial.

4. In many chronic nervous affections and general debility we
should anticipate great benefit from this system.

"). In chronic diarrhoea, dvsenfery and hemorrhoids, the sitz-bath
appears to be frequently an effectual rem* dy.

G. We find nothing to forbid a cautious use of drugs in combina-
tion with hydropathic measures. On the contrary, we are convinced
that a judicious combination of the two is the best means of obtain-
ing the full benefit of each. The water cure contains no substitute
for the lancet, active purging, and many other means necessary for
the relief of sudden and dangerous local maladies. The banishment
of drugs from his practice was necessary, and perhaps natural, on the

46 Hydropathy, or the Cold Water Cure. [January,

part of Preissnitz : the like proceeding on the part of qualified medical
men superintending water-establishments in this country, evinces
ignorance or charlatanry, or both.

7. With careful and discreet management, in the hands of a pro-
perly qualified medical practitioner, the water-cure is very rarely
attended with danger.

8. Many of the principal advantages of hydropathy may be ob-
tained in a private residence, with the assistance of ordinary movea-
ble baths. Therefore, it can easily be brought under the direction of
Ihe regular medical practitioner.

9. In many cases, however, it is evident that what may be termed
the mere accessories of the water-cure, are of extreme importance in
bringing about a favorable result; and these accessories are frequent'
ly not available or available in a very inferior degree inordinary
practice. Among the more important of these accessories we may
mention the following as having relation to most of the chronic cases
treated in hydropathic establishments: 1, relief from mental labours
of an exhausting or irritating kind, from the anxieties and responsi-
bilities of business, from domestic irritations of various kinds, from
mental inaction or ennui, &c. ; 2, change of locality, air, scene, so-
ciety, diet, &c. ; 3, the fresh mental stimulus involved in the almost
constant occupation of the patient's time, in the performance of the
numerous and various dabblings, paddlings, sweatings, washings,
drinkiugs, rubbings, &c, imposed by the water treatment; 4, the
frequent and regu