J-IBMRYBIMDESrClT ATI AHTA SOUTHERN MEDICAL AND SURGICAL JOURNAL. EDITED BY I. P. GARVIN, M.D., PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS AND MEDICAL JURISPRUDENCE, IN THE MEDICAL COLLEGE OF GEORGIA. Medical College of Georgia. uJa prciuls le bicn oujc k Irouvc." VOL. VI. 1850. NEW SERIES. JAMES McCAFFERTY, PRINTER AND PUBLISHER. 18.r)0. TO THE READER. In the November number of the Southern Medical and Surgical Journal, the announcement was made, that after the completion of the current volume, Dr. P. F. Eve would retire from the Editorship, and that in future, the editorial department would be under the management of the undersigned. It is much to be regretted that the Journal should lose the benefit of Dr. Eve's supervision, under which it has acquired so high a character ; but circumstances, to which he has alluded in his valedictory remarks, have induced him to relinquish his post. Many medical gentlemen in various sections, have expressed an earnest wish that the Journal should be continued, and urged the Faculty of the Medical College of Georgia, under whose auspices the work was established, to make such arrange- ments as would secure its continuance. With this request they have complied, and have assigned to us its future management. "With this number, we enter upon the discharge of our duties, with much diffidence in our own abilities, but with a resolute determination to spare no effort to make the Journal useful to its patrons, and honorable to the South. But to effect these desirable ends, the co-operation of those who feel an interest in the advancement of the medical sciences, and in the character of the medical profession, will be requisite : for no one, though endowed with a capacity far beyond that to which we may lay claim, can carry on a work of the kind, without the aid of able collaborators. We would therefore respectfully yet earnestly, call upon our medical friends to aid us in our undertaking. The medical profession in the South, contains within its ranks as much intellect and scientific attainments as that of any other section, and an effort is all that is neces- sary to secure that place .in the public estimation to which it is justly entitled. Already many of the contributors to this Journal have made themselves favorably known to their brethren throughout our country, and we hope that many more, through the same agency, will obtain a like honorable distinction. If it were necessary, many reasons might be adduced to show why Southern physicians should make public the results of their observations. Causes are in con- tinued operation in our region which develope diseases peculiar in their character, and produce modifications in those which are more general in their prevalence. Moreover we have among us a large population whoso physical peculiarities mod- ify the features of many of their diseases. We arc aware that attempts havebeon made in certain quarters, to shew that as the principles of our science are the same every where, it matters but little, whether the physician be instructed by thoso N. S. VOL. VI. NO. I. 1 most familiar with the diseases of the region in which he is to practice his profes- sion, or not. The absurdity of such a position is manifest. What are the princi- ples of pathology but deductions from well ascertained facts, and to whom shall we go for these facts, but to those who have observed them. No one would ven- ture to assert that the physicians of Paris are as competent to determine the ques- tions connected with the origin, nature, symptoms and treatment of yellow fever, as the physicians of New Orleans. If, then, we have diseases peculiar to our region, and if important modifications are impressed by our climate, the physical pecu- liarities of a portion of our population, and other agencies, upon such as are common to all sections, it becomes the duty of every medical practitioner among us to report the results of his experience. Whilst the number of medical Journals in the South is very small, intelligent physicians are exceedingly numerous. If every one of these gentlemen would sus- tain at least one Southern medical periodical, by his subscription and by the con- tribution of important facts which may come under his observation, the number of such works might be largely increased. The field is sufficiently ample for many more laborers. The legitimate object of the medical press is not the advancement of pecuniary interests, or the gratification of personal ambition it has higher ends and nobler aims in view ; therefore, among them can be no rivalry , but rather a noble emulation to excel each other in efforts to advance the cause of medical science, and thus to promote the physical welfare of their fellow men. Communications intended for insertion in the Journal, should be addressed to the undersigned, at Augusta, Georgia. I. P. GARVIN, M. D. January 1st, 1850. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. 6.] NEW SERIES. JANUARY, 1S50. [No. 1. PART FIRST. r i g x n a I (Communications. ARTICLE I. Remarks on Typhoid Fever. By H. V. Wooten, M. t)., of Lowndesboro', Alabama. I do not propose to write a treatise on this fever, or to at- tempt a settlement of the controversial points of its character ; but simply to give some account of its history as it has occur- red under my own observation. This disease is becoming more and more prevalent in this particular region ; and from the reports of physicians,. I have no doubt that this is the case generally throughout our state ; and a remarkable circum- stance connected with it, is, that it appears more prevalent upon the more elevated portion of country, than on the lower and more miasmatic regions. My circle of practice compre- hends a high ridge, 200 feet above the level of the surrounding prairie plains and river low-crrounds. This ridge is about six miles long, by from one to three miles broad, and about one- third of the population of my circle resides upon the ridge, and two-thirds upon the low grounds : yet of Typhoid Fever, I meet with twenty cases upon the ridge, to one elsewhere. By some practitioners, this fever is considered as identical with the latter stages of obstinate or neglected remittent. But however similar the two fevers may be, in many of their symptoms, it seems to me, that a close examination will mark a very decided difference in the true characteristics of these 4 Wooten, on Typhoid Fever. [January, fevers. They do not prevail to an equal extent, in the same localities, or at the same season of the year. The Typhoid oc- curs frequently in spring and early summer, and even the winter months, whilst the remittent, or Bilious, as it is some- times called, almost invariably prevails in the latter months of summer, and in autumn. Remittent and intermittent fevers will prevail at once in the same neighborhood, and in the same families ; but it will be very rare that a case of genuine Ty- phoid will be found amongst them, while on the other hand, a prevalence of the typhoid, affords to an experienced observer, no grounds to fear the occurrence of remittents or intermit- tents. Prof. T. D. Mitchell has published the opinion, that all fevers are essentially remittent, or intermittent ; that the so- called Typhoid fever is nothing but a remittent, and ought to be cured by Quinine. I was one of the first to adopt, and have continued to be one of the most uniform in, the use of quinine in remittent fever, and I have tried its virtues in every form, stage, and condition of Typhoid, without the least benefit, except in some particular conditions hereafter mentioned, wherein its use was 'adapted to some of the minor and incidental symp- toms. I have seen, as elsewhere mentioned,* regular chills and exacerbations of fever occur periodically, upon a true typhoid fever; and have administered the quinine, so as effectually to arrest these paroxysms, and thoroughly impress the system with its peculiar powers, without, in the ieast degree, checking the course of the fever, but on the contrary, in some instances, it has aggravated some of the worst symptoms. In Typhoid, there are in many cases at least, remissions, as distinct, so far as febrile heat is concerned, as those of remittent fever, but a careful attention to the case, will discover a distinct difference. The remissions in Typhoid, do not recur at regular periods, and when the febrile heat abates, all the other symptoms, as fre- quency of pulse, oppression of the vital powers, head-ache, &c, do not abate as during the remissions of regular remittent. This difference in the remissions is more decided after the first few days. On the other hand, when the remissions of true Remittent occurs, it is at regular periods, the pulse lessens in force and frequency, the breathing is regular, thirst abates, * Bartlett, on Fevers of U. S. p. 127. 1850.] Wooten, on Typhoid Fever. patient feels decidedly better, and in fact it is more of a true and complete remission. When I have doubted concerning the true character of the case, I have found the quinine a very good test. If this medicine is freely given during the remission, it will prolong, and very probably perpetuate it in remittent, while in Typhoid, it will generally shorten the remission, and aggravate the exacerbation. I have almost uniformly found the indications afforded by this test, to be borne out by the subsequent course of the disease. But, without running a parallel with other fevers, a strict examination, of the particular and distinct characteristics of the Typhoid, will sufficiently establish its individuality. Much has been written, pro and con, upon the restriction of Typhoid fever, as a distinct disease, to a peculiarly diseased condition of the intestinal and mesenteric glands. Able rea- soners have appeared on both sides of the question, and it is not yet settled in a satisfactory manner. It is contended by the restrictionists that all cases of Typhoid fever that prove fatal, exhibit this particular intestinal lesion, and they have an impregnable argument by which to sustain the doctrine. For, if you give them ocular demonstration to the contrary, they will meet it by a denial that the case was typhoid fever, and prove it by your own evidence the absence of the peculiar lesion, even though they had pronounced it the genuine dis- ease, prior to death, and treated it accordingly. This occurred with M. Louis himself, who pronounced one of his own cases of Typhoid in life, not Typhoid post-mortem, because this es- sential lesion was not to be found. Then, those who deny that this lesion is essential to Typhoid fever, are forced, under the restriction which they deny, to yield the point. But the justice and propriety of the restriction still remains an unsettled ques- tion. We are told by these authorities, that, of a given num- ber of subjects who have died of genuine Typhoid making the peculiar intestinal disease the test a certain proportion will exhibit a diseased condition of the brain. Now, suppose we call this disease of the brain, Typhoid fever, and see what proportion of cases will exhibit the peculiar intestinal disease. Perhaps, under this restriction, the bowels would fall as far short, in their quota of distinction, as did the brain under the Wooten, 071 Typhoid Fever. [January, other. I am not prepared to make the comparison, but surely those who have had such ample, means of investigating the dis- ease, and have labored so assiduously in these investigations, ought to have tried it. But, admitting that this intestinal lesion is never wanting in Typhoid fever, every experienced observer knows, that it is often far from being the most important and dangerous portion of the disease ; and it is very rare that we see grave cases, in which diseased action is confined exclusively to the intestinal and mesenteric glands. According to my own observation, this peculiar intestinal lesion, although a common, perhaps in- variable, occurrence in the fever, is but one item, though a grave one frequently, in the group of morbid actions, which together, make up the disease called Typhoid fever. I have not attempted to argue, much less to settle this ques- tion of restriction, or even to take sides upon it ; but my object has been simply to notice it so far as was necessary to an un- derstanding of my own views in the premises, which are these: That Typhoid fever, as a disease, does not restrict the action of its destructive powers, to any organ or tissue of the system, but that all suffer under their influence, varying in their pro- portions in different cases ; while some organs may be uniform- ly diseased in a greater or less degree, none may be considered exempt. And, I will remark further, that I view this exclusive view of the disease, as very hurtful to the treatment; and it will, in a great degree, account for the discrepancy amongst physicians on this point, and also, in the results of the same treatment, in different hands, and at different times and places. I have found that in all cases of Typhoid fever, two great divisions of the system suffer in a greater or less degree, viz., the cerebro-spinal, or nervous, and the mucous surfaces ; and as either of these sub-systems exhibit the predominant amount of diseased action, I class the case as JServous or Mucous. It seems to me, that a classification, or division of this sort, is the most convenient plan for describing the course, symptoms and treatment of the disease; bearing in mind, however, that I do not mean to say, that in any case, either the nervous or mucous system is free from disorder or disease ; but merely to classify the case, according to the system that exhibits the greater amount of disease. 1850.] Wooten, on Typhoid Fever. 7 First, then, I will notice the nervous class, or those cases in which the nervous system exhibits the leading and most im- portant phenomena of the disease. For several days, perhaps a week or more, the patient feels a dizziness which gradually increases; vision grows daily weaker, and a disposition is no- ticed to draw the brows together, and to fix the eye upon objects of examination ; a dullness of hearing occurs, with a low but constant ringing in the ears ; there is a sense of tightness, sometimes, between the ears, as though a cord was drawn from one to the other ; with a feeling of oppression in the central portions of the brain. The senses of taste and smell, grow weak or become perverted : a strong desire is felt for such ar- ticles as have a very strong taste or odour. There is great and regularly increasing lassitude : the patient is continually disposed to drop the head, or lean it upon something for support. The head feels heavy, and a sort of indescribable numbness is about it. The countenance is expressive of great listlessness, and sometimes a drooping melancholy. There is great languor and a sense of general muscular weakness the patient is in- disposed to any kind of action or exertion, either mental or physical ; thought is weak, memory confused, and mental ap- plication, even for a short time, impossible. These symptoms gradually increase, until the patient finds that he is not dispo- sed to rise from his recumbent position, and when he does so, he cannot walk, without great dizziness and tremor of the ex- tremities. He is now found to have fever; stupor gradually steals on him; he rarely speaks, except wThen called with em- phasis, and answers questions in as few words as possible, gen- erally saying he feels better. His tongue is usually found clean, perhaps slightly furred, moist and flat, and greatly troubled with tremor, when he attempts to put it out. There is gener- ally no thirst ; pulse is usually from eighty to one hundred beats per minute, pretty full, but not very firm or quick ; tempera- ture moderately elevated, especially about the head and trunk, and there is often perspiration upon the forehead. He lies upon his back and appears to rest quite easy : raise him up and he will lie down at the earliest possible moment, and seem to prefer to be let alone. The slight spasmodic jerks or tremors of the extremities, set in and continue through the case, though Wooten, on Typhoid Fever. [January, they are not often troublesome, except when the patient moves the parts, or attempts to take hold of any thing. These symp- toms continue with great uniformity through at least the first stage of the disease, which usually last about nine or ten days. It is generally a day or two before the close of this stage, that the lenticular, rose-colored spots, make their appearance upon the surface, usually over the trunk and neck more particularly^ and continue through the second stage. In the second stage, the stupor runs into a sort of low, mut- tering delirium, with more restlessness; the irritation of the mucous surfaces is apt to become more decided; cough may become troublesome, but will remain dry and harsh : though this does not often occur in this variety. The tongue some- times becomes more pointed, dry and brown, though this is only in proportion as the case partakes of the mucous variety. Haemorrhage from the nose is most apt to occur in this stage. The perspiration about the face becomes more profuse and constant ; the stupor gradually increases ; patient gets more and more disposed to lie still ; and, if you can get his attention at all, he always says that he feels pretty well, or "right smart," but not another word. I have noticed that when cases of this class prove fatal, it is most apt to occur towards the close of this stage ; if, however, the patient should neither die or con- valesce at the end of the second stage, the stupor falls into decided coma, with great prostration of all the powers. Evac- uations from the bowels are involuntary ; there is either incon- tinence or suppression of urine, a hissing and hurried breathing and every symptom of exhaustion. This condition will gener- ally last from nine to twelve days, when the patient will be found to have rigid contractions of some of the muscles or this may exist throughout this stage and in this condition he will die. Should convalescence occur, it will be so gradual as to be scarcely perceptible for several days, but will be mani- fested by a relief of all the bad symptoms, and a return to the healthy functions. The mucous variety commences with the usual symptoms of slight fever; there is great lassitude, the appetite is variable, sometimes voracious, and again perhaps, in the same day, entire- ly wanting. The action of the bowels is irregular, sometimes 1850.] Wooten, on Typhoid Fever. constipated and again free, alternately ; the stools are copious and watery. If, during the constipation, a purgative is given, it will induce prostrating hyper catharsis, however mild its usual effects. Most generally there will be three or four watery evacuations a day, without pain. Febrile exacerbations are of short duration, and irregular recurrence. The skin is gener- ally dry; and there is frequently great soreness of the muscles and a sense of stiffness about the joints. There is frequently a pain, more or less severe, in the frontal region, which is contin- uous. The tongue is generally pointed, with edges and tip red, and very often a brown fur over the centre. The tendency to diarrhoea is generally not very hard to control, if desired, but purgatives of the mildest character are not tolerated. In this stage, the fever often runs very high : the pulse is apt to be quick, and from 100 to 130 per minute, in frequency; but less full and firm than in the nervous variety. The patient is more restless, than in the other variety, and if the mind is affected, it is a delirium instead of a stupor : watchfulness is apt to oc- cur, instead of somnolence. When the mucous coat of the stomach is disordered, there is thirst, and sometimes bilious vomiting; the conjunctiva is apt to exhibit turgescence, and there is often complaint of soreness about the tonsils, epiglottis, &c, so as often to produce some difficulty in swallowing; a dry, frequent cough, often troubles the patient, out as yet there is no expectoration. These symptoms continue from six to ten days, when we find them all more or less alleviated, and convalescence appears to be at hand. But, although the ten- dency now is evidently towards restoration, still, far the greatest number of cases, after a very short amelioration, fall into the second stage of the fever. The second stage is one of greater depression of the vital powers, more suffering to the patient, and more serious in every respect. The diarrhoea becomes more constant and persistent, and less under the control of remedies ; yet there is generally, no pain in the bowels. This, however, is not uniform ; I have sometimes seen patients suffer violent pain in the bowels : this will occur when there is peritonitis sometimes the large intes- tine becomes involved, which produces a griping and again, the patient may suffer neuralgic pains in the abdomen. I look 10 Wooten, 07i Typhoid Fever. [January, upon all these affections, or their symptoms, as mere complica- tions, and variations from the regular course of the fever, as it is most uniformly seen. In this stage, the abdomen is usually flat, and presents nothing remarkable, either in appearance or feeling. The stools are large, from five to ten a day, and have been aptly compared, in appearance, to new cider. In this stage, all the symptoms of the disease of the mucous surfaces are much increased. The eyes frequently become sensitive to the approach of light ; there is more cough, and not uncom- monly a bronchial rattle, with more or less tenacious expecto- ration. The lenticular eruption appears in this stage. In the commencement of the second stage, the tongue is frequently clean, and sometimes moist, presenting a florid, smooth surface. This "cleaning off" of the tongue, with other favorable changes, have very often deceived both patient and physician, into the belief that the " fever was broke." But soon, the tongue be- comes dry, dark brown, cracked and often bleeds, &c, as all the symptoms of this stage advance. The buccal membrane becomes spotted with aphthous eruptions, which often degener- ate into ulcers that bleed and are painful. These, with the soreness about the throat, frequently give the patient more an- noyance, and receive more of his attention, than all the other symptoms together. This stage, which may be called the eruptive, or inflammatory, usually continues from a week to ten days, when the third stage sets in. The patient now becomes greatly prostrated ; emaciation which in this variety, particularly, has been remarkably great, all along, now becomes extreme. The simple act of breathing seems to produce fatigue ; the tongue and extremities exhibit more tremor ; the eyes appear more sunken and open ; the features sharp and the complexion extremely palid, except in cases in which the stomach and duodenum are much involved, and those in which the bronchial surfaces have suffered much engorgement : in the former, the complexion is icteroid; in the latter, livid or bronzed. The stools change from a cider, to a dark, dirty color, which has been compared to pea-soup, and very offensive ; they are often streaked with mucous, some- times purulent matter and specks of blood, subsultus increases, and attempts at sleep result in a muttering delirium. The ul- 1850.] Wooten, on Typhoid Fever. 11 cerations of the mouth and throat become much more trou- blesome, and the act of deglutition becomes not only difficult, but distressing ; the pulse grows weaker, and sometimes inter- mittent ; watchfulness persists. There is now more tenderness upon the ileo-ccecal region than before, and often more fullness of the abdomen, even when tympanitis has not ensued, as it often does in this stage. There is a swelling of the sub-maxilary and sub-auricular glands which often occurs in this, or the pre- ceding stage, and sometimes it results in suppuration ; when this occurs, it is always in the latter part of the third stage. This third stage, might be termed the period, or stage of ulcera- tion, as I believe it never passes without that special patholo- gical condition. It generally runs its course in about the same length of time of the other stages, but it oftener transcends the limits than the others, particularly when the patient recovers. The first favorable indication of approaching convalescence, is a lessening of the frequency, and an increase in the consist- ency of the stools. It often happens, that at the commencement of improvement, the evacuations of the bowels cease altogether for several days, if not improperly interfered with, and when resumed, present very little departure from the healthful char- acter. It may be said that this division of stages is arbitrary, and so it is, to some extent ; yet its observance is very useful in describing the disease, particularly the mucous variety, and I think the three stages may well be characterized, as those of turgescence, inflammation, and ulceration. It is at the junction of these stages that a change of treatment is most frequently required, and at these points also, a prognosis is most easily made out, and most decisive. It is true, that many cases do not pass through all these stages, or the number of days as- signed them. Some die at the end of each stage, while many convalesce at the termination of the first, and second as well as the third. Again, the length of these stages cannot be any thing like definite. In many cases, the first and second stages are passed through in the time assigned to one, and sometimes they are all, and particularly the third, of twice the ordinary duration. But all these are variations from the general rule : as far the greatest number of unbroken cases observe their course with much regularity. 12 Wooten, on Typhoid Fever. [January, I have thus attempted a description of the course and symp- toms of the two classes of cases, (as I have observed them,) and I would add the remark, that in all cases of both classes, the symptoms of both exist to a greater or less degree, and it is in accordance with this degeee that each case is classified, as nervous or mucous. It must be admitted, that there are cases, in which both classes of symptoms are so nearly equal in num- ber and force, that they could not properly be assigned to either variety especially. These are usually very grave cases, and it is amongst them, that the greater proportionate amount of fatality is met with. A tall athletic negro man, aged 27, complained of great weakness, heaviness of head, inability to walk, or even sit up ; tongue covered with a thick whitish slime, and so tremulous as to be protruded with difficulty; no thirst or febrile heat. A dose of blue pills, followed in six hours by castor oil, produced copious and frequent watery evacuations ; these were checked by laudanum, and I was called to him. This was on the third day of the attack. I found him lying upon his back, with his legs extended, eyes closed, deep breathing ; temperature of the head and trunk a little elevated, that of the extremities natural ; pulse 112, rather full and quick, but soft ; complains of nothing when not questioned ; no pain in the abdomen, pressure over the ileac region produced the gurgling noise ; no tenderness, abdomen full, but not tense; tongue pointed, covered with brown fur, and dry, so tremulous that it could not be protruded ; said his throat was sore ; every attempt to use his hands, in- duced violent tremors, and sometimes spasmodic jerks ; could not sit up at all, even when supported ; troubled with a fre- quent, but not violent, dry cough. He continued in about the same condition, with from three to six of the cider evacuations per day, until the seventh day of his confinement, when he became decidedly comatose ; pupils dilated, hissing respiration, and cool extremities ; stools became of a dark colour, more copious, involuntary and very offensive. On the thirteenth day tympanitis ensued, with some signs of restlessness, which con- tinued, with a general decline of all his forces, until the 16th, when he died. Physical appearances, ten hours ^0s/-wor/em.-*-Pia-mater 1850.] Wooten, on Typhoid Yever. 13 highly vascular, moderate effusion between this, and the arach- noid coat, slight injection of the medullary portion of the brain; several ulcers upon the lining membrane of the throat, some mucus along the trachea, and bronchial tubes, with tumes- cence of the mucous membrane. The mucous membrane of the stomach appeared thickened, but presented no evidence of inflammation. The liver was pale, rather soft, and appeared to be somewhat enlarged. The mucous membrane of the small intestines was thickened and of a dark red color throughout ; the eliptical plates were generally decidedly elevated, and in the lower portion, near the ileo-ccecal valve, there were seve- ral jagged and uneven ulcers, some of them so deep as nearly to perforate the intestinal coats, others more superficial. The mucous surface of the large intestine was not diseased, but un- usually pale. In the contents of the bowels, there were found some small specks of blood, which had not been discovered in the evacuations. This examination was made merely to test the diagnosis, and was not so minute or comprehensive as it ought to have been, or the notes sufficiently full and exact for a report, which was not, at the time, contemplated. But the history of the case, as well as the post-mortem notes, may serve my present purpose, which is, merely to illustrate the double or complex variety of this fever. The prognosis of this fever is very difficult and uncertain: cases presenting some of the gravest symptoms will occasion- ally recover ; and again, those which exhibit no alarming symptom will sometimes disappoint us, and die. I attended once the case of a young man, who passed through all the stages, with some of the worst symptoms of both the nervous and mucous classes, and finally recovered. And I saw another who had gone through all the stages, with scarcely any symp- toms but those of the mucous class, and of a mild character even through the second stage, he could sit up a little and take light nourishment every day ; but late in the third stage, he grew suddenly worse, and I was sent for, for the first time. I found him suffering much pain^and distention of the abdomen, laborious breathing, delirium, &c. This was at 3 o'clock, p. m., and at 6 next morning he died. On examination, there were several plainly marked recent cicatrices on the mucous mem- 14 Wooten, on Typhoid Fever. [January, brane of the small intestines, near the coecum, and there was one ulcer, which when spread out, was about the size of a twenty-five cent piece. It was deepest in the centre, where it had perforated the peritoneal coat of the intestines, and much of the contents of the bowels had escaped into the cavity of the peritoneum the peritoneum exhibited marks of very high inflammation throughout. The amount of febrile excitement proper, affords of itself very little grounds of prognosis. The manner, especially the rapidity with which the disease manifests itself, affords some ground upon which to form an opinion as to its progress and termination. Those cases in which the system is violently as- sailed and rapidly prostrated, I have usually found to be more grave throughout ; and a far greater number of them prove fatal than of those which are more gradual in their first seizure, even though they grow severe eventually. But, in consider- ing the prognosis of this disease, it will be most convenient to continue the use of the classification heretofore adopted. In the nervous variety, I have found the degree of violence which the cerebral or nervous symptoms manifest, a good criterion by which to judge of the gravity and danger of the case. If the somnolence, or stupor, is great in the first stage, I view it as of serious portent, for it will be prone to increase in the se- cond stage, and if it does so, it will probably pass away no more. A drowsiness, from which the patient can be easily aroused, and drawn into connected and thoughtful conversation, is of no serious import. But that kind of stupor which will answer your most urgent and important enquiries with monosyllables, and without any appearance of thought, is a very different and much more grave affair, and more especially when it is found to increase from day to day. Dilatation of the pupil, when permanent, is unfavorable, as well as dryness and fixedness of the eye. Greater prostration of strength than the emaciation of the muscular system will account for, is unfavorable. The subsultus tendinum, or muscular agitation, I have not found to afford much indication as to the danger of the case, but a rigid contraction is very bad, and apt to be associated with other symptoms of evil augury. Profound and persisting coma is one of the very worst symptoms. Delirium of ordinary vio- 1850.] Wooten, on Typhoid Fever. 15 lence and remitting, I have usually found to pass off pretty well ; but when it is violent, continuous, and associated with unceasing watchfulness, I consider it very unfavorable. There is a kind of delirium to which patients are subject in the last stage of this fever which very much resembles some forms of hysteria : the patients imagine that they are, or have been at some distant place, most generally they either suppose that they are about to die, or that they are entirely well, and have not been sick 1 have seen several females take leave of their friends, and make all their arrangements to die, when in fact, they were really recovering and decidedly improved from a very threatening condition. This kind of delirium I do not consider unfavorable as to recovery; but such patients are apt to exert their powers more than they can bear, and on that account, they require very watchful management. In this class of cases, a pulse of over an hundred beats per minute is unfa- vorable, particularly if it continues to increase in frequency, and 130 is very alarming. An eminent practitioner and writer on this subject, has said, that be never lost a patient by this fever, in which the bowels remained constipated. My expe- rience satisfies me that he certainly never could have had many grave cases of the cerebral variety, or that he treated it under some other name ; for although I look upon violent diar- rhoea as a very bad symptom, still some of the worst cases that I have seen those which yielded least to remedies, and gave the most fatal indications from the beginning, and which died in the shortest time had not more than one evacuation per day, and some others had none except those which were indu- ced by medicine or the syringe. Yet, as exempt as these cases were from symptoms of diseased bowels, those which I have examined after death, (four in all) exhibited the same lesions of the intestinal glands only in a less advanced state as those which had suffered from profuse diarrhoea, though the disease generally covered a less extent of surface. The favorable indications in this class of cases are, an improv- ing clearness of the mind and an increasing power and inclina- tion to think. A lighting up of the countenance, so to speak ; the reappearance of intelligent expression, &c, are very fa- vorable. A lessening of the frequency of the pulse ; a more 16 Wooten, on Typhoid Fever. [January, regularly distributed temperature ; a return of tastes or senses, which have been suspended or perverted ; the ability to sleep soundly and awake clearly ; a returning muscular strength and steadiness; a desire for food, with a natural taste for it; are each very favorable, but when they occur together, I consider convalescence as begun. In cases of the mucous variety, early, copious and persisting diarrhoea is unfavorable. A diarrhoea of increasing violence with rapid decline of strength, at any stage, portends badly. A frequent pulse, over 120 in men, or 130 in women, without abatement, is very threatening, particularly in the second and third stages, and feebleness or intermittence adds to the gravity of the case. A hurried, or laborious breathing, is bad ; lividi- ity of the lips and cheeks is indicative of engorgement of the pulmonary mucous membrane, and is more or less unfavorable ; and the permanently bronzed cheek is very threatening; deaf- ness and blindness are unfavorable in proportion to their degree, but are only serious according to their association with other phenomena. I have seen only three cases of actual haemor- rhage from the bowels two of them recovered and one died; this one was associated with most of the very bad symptoms. Softness and bleeding of the gums, indicate, at best, a tedious case. The tongue is not a very good index in this disease I have noticed in several fatal cases, a very peculiar tongue which I have seen in no other disease : it is small, contracted in every aspect, dry, and of a pale dark brown, resembling in colour an old weather-dried oak leaf. I have observed this tongue only in fatal cases, and it occurs in the latter part of the second stage. Much ulceration of the throat, with difficulty of deglutition, is rather bad. Epistaxis, unaccompanied with other haemorrhage, is not serious. Vomiting in the second or third stage, if not easily controlled, is unfavorable. A jaun- diced conjunctiva, and surface generally, is rather a serious sign. Tympanitis is bad,' and accompanied with jactitation and delirium, it is amongst the worst of symptoms. Involun- tary discharges from the bowels or bladder denote an alarming state of things, and suppression of urine may be placed in the same class of symptoms. I view the prospect of recovery as good, when the pulse is 1850.] Wooten, on Typhoid Fever. 17 under 110 in men and 120 in women, and regular; tempera- ture Well distributed ; diarrhoea controllable, cough moderate, strength equal to muscular fullness, and the mind clear when awake. The taste and appetite returning, the stools lessening in frequency and increasing in consistency, and sleep refresh- ing, are indications of convalescence. It is unnecessary to remark, that cases of either class are the more grave and dangerous, in proportion as they exhibit the more serious symptoms of the other class ; or manifest the greater number of those of their own ; and further, the consti- tution of the patient must be taken into consideration, as a matter of no minor importance, in all such cases as are not de- terminate in their own characters, above all natural or medicinal influences. In my own practice, counting those cases which were well marked and decided, and which were fairly under treatment, there have died, of the nervous class, one in eighteen ; of the mucous class, one in twenty-four ; and of those which were strongly marked by the symptoms of both classes, so that they could not well be classified, one in four. A good number of these cases were negroes at * the quarter," and their general management was not under my control, as it ought to have been. The treatment of this fever is as difficult to systematise or specify, as the prognosis ; and my experience confirms the opinion expressed by Prof. Bartlett, that there can be no strictly systematic rule of treatment, that is of universal, or even gen- eral application. So far from it, that I think any routine or specific course, universally applied, will injure more cases than it will benefit. * When we approach the treatment of this fever, we must remember, that when once fairly established upon the system, it has a course to run, the various stages and incidents of which must be taken into account. The effect of a given treatment, upon a particular stage or state of things, is to be considered, not only in relation to that special state of the case, but its influence upon subsequent events which may be antici- pated, must also be looked to. I have found that in all varieties and stages of this fever, the age, habits, constitution, and par- ticular circumstances of the patient, are to be noted with as much circumspection as possible, because these things mnst n. s. VOL. VI. no. i. 2 18 Wooten, on Typhoid Fever. [January, have always a modifying, and often a controling influence in the treatment. In speaking of the treatment, it will be most convenient to continue the classification already used, and first to notice the nervous class. If, in the first stage, the pulse is full and pretty firm, with much fullness of the head, without diarrhoea, I bleed from the arm until I have made some impression upon the vas- cular force ; if, afterwards, relief is not decided or permanent, I resort to scarified cups to the back of the neck, and along the interscapular spine. In these cases, the hair should be closely trimmed, and the heat of the head kept down by cold applications. Under this state of things, I have known ice and cold water kept constantly to the whole scalp for three weeks ; for it was found to be effectual in controlling the distressing cerebral disturbance, and indispensible to that end, and was doubtless the chief agent in saving the patient. After the re- pletion of the vascular system has been sufficiently reduced, if stupor, or other evidence of cerebral engorgement exists, blis- ters to the cervical spine have been found very serviceable, and to continue their beneficial influence, it will often be neces- sary to repeat their application, in some cases several times. It is in this class of cases, that the repetition of purgatives is in many cases allowable, and in a smaller number, beneficial. The irritation of the mucous membrane and glands of the small intestines, is not so great, particularly in the first stage, as to require extreme caution in their disturbance, and when it is a mere turgescence, which involves the portal circle generally, I have found that twenty grains of blue-mass, administered in four doses, at intervals of three hours, and followed by seidlitz water, if necessary, or olive oil, according to indications, is of decidedly good service, both as a revulsive to the head, and in lessening the intestinal engorgement, thereby reducing its mischievous power in making lesions upon the surface. Further than this, I have learned to administer purgatives, even in the most appropriate cases, with great caution. Several years ago, I saw the case of a young man who was suffering under a ra- ther serious case of this variety, to whom purgative doses of calomel had been pretty freely administered, until late in the second stage ; when it was suspended on account of symptoms 1850.] Wooten, on Typhoid Fever, 19 of exhaustion. After several days had passed, without improve- ment, a distinguished practitioner was called in consultation .' he gave the case a slight examination, and told the attending physician that his favorite course of purgation, would " break the fever," with great certainty and promptness. He was the oldest and most distinguished physician, and his ptescription was agreed to, and put immediately into practice. Fifteen grains of calomel with half-grain of tartarized antimony, were given, and repeated at the end of two hours. Three hours after this, a dose of infusion of senna with epsom salts was given. This * course " was advised to be repeated at the expiration of twenty-four hours ; but before that time had half elapsed, the patient was in a most alarming collapse ; and so continu- ously were mustard, capsicum, brandy and morphine, in use, that the "second course," which was to give the finishing touch, Was never even mentioned, although its confident advo- cate was in attendance. After once clearing the alimentary canal of irritating mat- ters, I prefer, for the purpose of simple purgation, the use of the syringe, and avoiding, even in that way, the introduction of all irritating matters. During the first stage, or while febrile excitement runs pretty high, I have found good results from the use of the super-citrate of potash. Sometimes, it appears in the course of the first and second stages that the secretory functions are suspended, not for want of general vital power, but of organic secretory action. Under these circumstances, I have found alteratives of good service : two grains of calomel alone, or with the same of opium or ipecacuana, as the intesti- nal irritation may require, made into six doses, one to be admin- istered every three hours. This prescription I sometimes find it expedient to repeat, after an interval of twenty-four hours or more. In the latter stage of this variety of cases, the vital action sometimes becomes very weak, extremities cool, and all the functions which are not suspended, are sluggish and imperfectly performed. For this condition, I have used with benefit the nitric, or nitro-muriatic acid, three drops at intervals of four hours, in gum mucilage, and if there is restlessness or watch- fulness, it is advantageous to give it in hop-tea. In this state 20 Wooten, on Typhoid Fever. [January, of prostration, the subsultus frequently becomes very trouble- some, and as it is associated with symptoms of general nervous debility, I have resorted to the use of the ferro-cyanate of quinia with great benefit. I employ it in doses of four grains, once in four hours. I would suspend the use of the acids for this, only when the indications for such change were decided. As a more decided sedative to the nervous system, when no other effect is required, the valerianate of quinia is preferable, in doses of two grains once in three hours, simply dissolved in distilled water. I have repeatedly witnessed the most decidedly beneficial results from the use of these preparations of quinia, under proper indications. In this fever, there are occasionally many minor symptoms or compilations that have to be looked after, and amongst these, one of the most troublesome is neuralgic pain. This may occur in almost any part of the body, but I have most often found it in the extremities, about the joints ; frequently in the hip-joint ; sometimes in the ears. For this distressing complication, I find the best effects from the use of the extract of belladonna, applied externally in the form of plaster, and continued until the pain ceases. I have never seen any bad result from its use in this way. Sometimes, when the stupor is rapidly degenerating into coma, and the vital energies generally in a state of prostration, I have shaved the head and applied a blister over the scalp, and in two or three instances, the patient has recovered, and I have been disposed to attribute the good result to the blister ; but most frequently I have seen no appar- ent benefit from it : no doubt, I have generally applied it when the case was beyond the reach of remedies. In the treatment of the mucous class of cases, it is not often necessary to resort to general depletion, unless it is in cases which are complicated with some special organic inflammation. When we are first called to these cases, the diarrhoea is pointed out as the chief disorder requiring our attention ; and it is very often an important question, to what extent we may properly interfere to arrest it. The disturbing power is holding the physiological functions in check, and this leading symptom is often the result of nature's efforts to relieve herself of the ac- cumulated burthen, through unusual channels. If we can sue- 1850.] Wooten, on Typhoid Fever. 21 * ceed in arresting the discharge, while we make no provision for the relief of the engorged and oppressed organs, we have, at best, but smothered the flame, while the consuming fire is ready to break out again, and very rarely fails to do so, after a very short period. When first called to patients, I generally find that the diarrhoea has been checked, perhaps several times, by laudanum. A simple suppression of the discharge increases the cephalalgia and all the febrile symptoms, and no doubt in- creases and confirms the visceral engorgements. What we want to do, is to so far relieve the mucous coat of the small intestines, as to prevent or lessen as much as possible, the mis- chief there, while at the same time, we re-establish the natural secretory action and relieve the necessity for their morbid substitutes. Can we do this ? While we are bound to admit that we are liable to failure, we have well established thera- peutic principles to sustain the attempt, and we will very fre- quently succeed. For this purpose, I frequently employ with success, blue mass, 16 grs., opium, 2 grs., made into four pills, one to be given every third or fourth hour, as the urgency of the diarrhoea may indicate. Sometimes it is found necessary to increase the amount of opium, but most generally four of these pills will put a- check to the discharges for several hours, after which the re-establishment of the secretory functions will be manifest, to a greater or less degree. The urine becomes more copious and clear ; the skin, if not moist, is more pliant and soft, and ail the symptoms of general disturbance quieted. The stools become less frequent, are more consistent, and ex- hibit evidences of biliary secretion, and the tongue grows more moist and pliant. When the mucous irritations are de- cided or extensive, this amelioration will be but temporary, and it is frequently found necessary to repeat the pills several times during the first stage. Although this course may not often cure a case, it undoubtedly lessens visceral engorgements, by which means it often prevents some of the worst complica- tions of the fever, and I have witnessed its action in several cases in which I thought that it was the chief agent in prevent- ing structural lesions, and bringing on convalescence at the end of the first stage. While alterative medicines are being used, if the fever is high, soda water or the neutral mixture 22 Wooten, on Typhoid Fever, [January, may be given, as well as at other times when they are indicated. I believe it is decidedly beneficial to use a solution of gum arabic, as a constant drink. There are cases in which there is a sense of fullness in the bowels, stools frequent and scanty, evincing turgescence of the intestinal mucous membrane, of a primary character. When this occurs early in the first stage, saline purgatives may be administered with benefit, and repeat- ed, if necessary. It is sometimes found expedient to follow the alterative pills with a purgative of this class, when the evacuations are not resumed with sufficient freedom. The various states of the particular functions, &c, with their ac- companying visceral disorders, have given rise to the various contradictory modes of treatment which different authors in- sist upon with so much earnestness. One gives emetics, ano- ther cathartics, another bleeds, a fourth does about nothing at all, and each urges his own particular plan as the very best mode of curing the fever. These men have formed their opin- ions upon a number of cases which they have observed ; the cases of each being influenced by circumstances, and controlled by forces which had no influence whatever on the cases of the others ; remedies curing, or being tolerated at least, in one set of cases, which would have been pernicious in another. But the true and only rational p Ian is, to watch each case in- dividually, note well its extent, violence, and complications, and all the modifying agencies attending it ; and then apply the best remedies that medical science and watchful experience can furnish. Experience has taught me to employ purgatives with great caution in this class of cases I now, never resort to them after the first stage, and during that stage I rarely venture anything more than the mildest aperients I have observed this caution for ten years, and success has confirmed my opinion of its im- portance. Some of our best authorities advise that the bowels should be opened every day, by purgatives. There are many cases that will stand such a course of treatment, but even these would do much better under different management. In 1840, 1 knew the case of a young man who had passed through the second, and nearly the third stage, and was considered better in every symptom, although he was greatly emaciated and very 1850.] Wooten. on Typhoid Fever. 23 feeble ; a physician (there were several attending) called, and found that he had not had an evacuation of the bowels for forty hours, and there was fur on his tongue ; *he was almost shocked at the idea of a patient remaining so long without an action, and insisted that he should have fifteen grains of calomel, which was administered : active purging ensued, and the patient died in forty-eight hours. From many similar cases that I have seen and treated, I am convinced that this one was lost by in- judicious purging. In 1843, I had a very grave case, which exhibited most of the bad symptoms of both varieties, amongst them an offensive and persisting diarrhoea. He had almost reached the lowest point of exhaustion, when the stools lessen- ed to three per day, and in three days ceased altogether. The patient (a young negro man) lay in a semi-comatose state, completely prostrated, and had no motion of the bowels for nine days. During this time, a light liquid and stimulating nourishment was cautiously administered, and his strength very slightly and slowly improved; his taste and senses generally returned, his pulse increased in fullness and lessened in fre- quency, and all his symptoms were improved. Commencing two days before the lessening of the diarrhoea, I administered, #. Copaiba ol. Terebinth, a a 3ii. Acid nitric, 3i. Tine. opi. acet, 3 li.- Aqua menth. pip., q. s. to fill a $iv. vial, well shaken, a teaspoonful every fourth hour. After the fourth day of the suspended intestinal action, the opiate was left out of the prescription. A blister over the abdomen was kept running all the time. In 1844, I had another case that of a girl aged nineteen, very similar in every respect, and in which the evac- uations from the bowels were suspended seven days ; and a third in 1846, in a girl fifteen years old, in which the suspen- sion followed immediately upon checking an alarming haemor- rhage from the bowels in the third stage, and continued six days. In all these cases, these long suspensions of stools im- mediately preceded convalescence, and all were finally moved by mild enemata, but no purgative medicine was administered. It was difficult to persuade those interested, that it was best not to disturb the stomach and intestines with irritating agents, and continual appeals were made to " open the bowels." 24 Wooten, on Typhoid Fever. [January, In the latter stages of this fever, we know that the mucous coat of the intestines is inflamed, perhaps ulcerated, and the philosophy of curing this disease by continual action and irri- tation, is totally invisible to my conception. I have found it important to with-hold every thing of a solid nature, although, as nourishment, it may be as feeble and mild as possible. By this, we keep undigested and irritating remains from disturbing the inflamed mucous surface, and thereby keep this irritation much more under our control. As to the morbid secretions, whose effects upon the mucous disease of the bowels are so much dreaded by many, I have not found it necessary to assist its discharge by medicine, but I have often found it difficult to hold it sufficiently under restraint. When the symptoms of mucous inflammation are well es- tablished, as indicated by a pointed tongue, with edges red and dry brown centre, and in fact when the second stage has fairly set in, I use, with much confidence and success, the copaiba, with laudanum or black drop, as the state of the case may in* dicate: $. Copaib, ss. Acac. Gum. 3 ii, Tincopi. acet. 3i. Aqua menth. pip., q. s. to fill a 5 viii. vial. Mix well, and give a tablespoonful every fourth hour, varying the quantity of each ingredient, according to the particular in- dications of each case. If the diarrhoea persists, the opiate may be increased ; if the surface is cool, pulse feeble, &c, the spts. of turpentine may be substituted for the copaiba, or com- bined with it in suitable proportions. I use this prescription, modified according to indications, through both the second and third stages, with a success that gives me confidence in its vir- tues, as the most generally applicable of any that I have resort- ed to. I have sometimes resorted to mild alteratives, such as minute doses of calomel, blue mass, or hydr. cum creta, in ad- dition to the balsamic mixture, but only when especially indica- ted, and never to the extent of purging. Sometimes the pros- tration is so extreme, that almost every thing else has to give place to stimulants, and such agents as are intended to sustain the failing powers of life ; under these circumstances, the spts. of turpentine is preferable to the copaiba ; or if neither is toler- 1850.] Wooten, on Typhoid Fever. 25 ated well, and an alterative is indicated, the nitric acid may be resorted to with safety and benefit. Blisters, though condemned and discarded by high authority, (Louis,) in the treatment of this fever, I have found of the greatest value. There is no single agent of which I think more highly than blisters, in a large portion of cases. I have sometimes had cases presented to me, which I considered in the forming stage of this variety of the fever, and I gave a small dose of blue-mass, followed, when necessary, by seidlitz water; strict confinement and quiet, abstemious diet, allowing only the mildest liquids ; and by this course, I have several times, as I thought, succeeded in preventing an attack of fever. I men- tion this circumstance here, to say that in this abortive treat- ment, as it may be called, I have derived great benefit from blisters these I apply over the small intestines, in such cases as exhibit a tendency to much irritation there. I believe that if physicians could have an opportunity sufficiently early, more good might be done by medical treatment, in the forming stage, than any other ; for if the disease cannot be prevented, there is no doubt that it can, in almost every case, be greatly moderated. When the second stage has fairly set in, and the general febrile excitement is not very high, I view the indica- tion for the application of blisters as decided, and if there is tenderness of the bowels, imperative. Yet we must bear in mind, that the inflammatory action id this fever does not pro- duce pain and tenderness, so long as it is confined to the mucous coat of the small intestines, and we must look to other symp- toms for the evidences of its existence. To have the full ad- vantage of blisters, they should not be suffered to cure up entirely before the disease is removed. Here arises the error, as I esteem it, of those who condemn blisters as useless. In the first place, they may be applied too soon, in those cases in which there is high febrile excitement, and only add to the dis- turbance ; sometimes they are employed, while the internal disease is so violent that their revulsive efiect is scarcely ap- preciable, and they are neglected or discarded, just at the time that their beneficial powers are most needed. Again, they are sometimes applied, and afford relief while they are discharging, which relief ceases as they heal, and without noticing this rela- 26 Wooten, on Typhoid Fever. [January, tion of facts, they are dropped as a failure, or at best but a temporary remedy, and something else resorted to in the usual eagerness to " break the fever." 1 have made it a point of < interest to watch the effects of blisters in this form of disease, and I have almost invariably found, that as the blister healed or ceased to discharge, the evidences of internal disease increased, until the latter had itself abated to the healing point. My course is to apply, at the proper time, a large blister over the bowels, let it draw well, and whenever it heals, re-apply it, or sooner, if the symptoms demand the renewal. Haemorrhage from the bowels, I have usually been successful in arresting by the sugar of lead and opium : sometimes, when it did not succeed well by the mouth, I have given it by injections, with decided success, though my experience in this is very limited. I have several times found hiccup very troublesome, and have used musk, assafetida, and the usual list of antispasmodics, with variable success. In the last case of this troublesome symptom which I have treated, I found the valerianate of quinine in doses of two grains, repeated every hour, for six hours, to arrest it entirely, and it returned no more. In several cases that had reached an advanced point in the third stage, and the symp- toms of intestinal ulceration were obstinate, I have found great benefit from the nitrate of silver, in \ grain doses, every six hours ; and I may add, that from this course, I have never seen the least bad effect. Erysipelas, is a complication of this fever, that is sometimes very troublesome. I am at this time treating a case of the kind. It occurs upon any part of the body, but most generally upon the lower extremities. This occurrence makes, usually, no dif- ference in the general treatment of the fever, and the erysipelas should be treated locally, as if it were independent of the fever ; for this purpose, I find hop poultices very soothing; and when the cuticle has broken, and the surface presents abrasions, I find nothing so soothing and efficient as a liniment made of equal parts of liquor plumbi subacetatis, and olive oil, applied about once in eight hours. Stimulants and tonics, are sometimes required, though I be- lieve they are often used to a hurtful extent. I have not found 1850.] Wooten, on Typhoid Fever. 27 much satisfaction in the effects of any of the wines, for this purpose. If alcoholic stimulants are necessary, I prefer the French brandy, though I very rarely resort to it. When all the actions are very feeble, and a nourishing stimulus is indica- ted, I have found the brandy in the form of egg-nog, a good preparation, given in such quantities as the case may require, having regard to the powers and susceptibility of the stomach. I first learned the use of this preparation in my own case : it was given to me by a non- professional friend under the circum- stances here referred to, at first in very small quantities, and gradually increased it had a very happy effect. But purely as a stimulant, there is nothing which I have found to answer so good a purpose as the carbonate of ammonia, given with more or less freedom, according to its effects and the necessities of the case. Some authors recommend cinchona, and sulphate of quinine, in the latter stages of Typhoid fever, as tonics. I have given thes^ articles a full trial, with all my prejudices in their favor, and I would not give a cent for all their benefits as tonics, for I have seen none result from their use. There are, I am aware, many points in the treatment of this fever, which I have not noticed ; first, because it is my inten- tion only to speak of such points as my own experience presents prominently to view ; second, on all other matters, it is pre- sumed that the reader is as competent to form opinions as myself; and thirdly, I have, without going further into the matter, written as much as the limits of a journal article will admit. In fact, the treatment of this fever, depends so much upon the character of each individual case, that it is difficult to offer any thing on the subject of much real value, and my ob- ject has been simply, to suggest some of the chief remedial measures which I have found advantageous, and the principles and circumstances which guide me in their employment. A point of not the least importance in the treatment of this fever, is the dietetic management. The patient is much ema- ciated, very feeble ; -his complexion pale, and every exterior indication of a want of nourishment ; yet it is very doubtful whether or not nourishment, if he could properly appreciate it, would be of more benefit than injury, while the inflammatory disease exists. But the ability to digest, and appropriate nour- 28 Wooten, on Typhoid Fever. [January, ishment, and the effect of taking it into the stomach and bowels, while they are in a condition which forbids digestion, are questions of more importance. I do not believe that the patient ought to be nourished, while the inflammation and fever are going on with unsubdued power. It would but add to the force of morbid actions, and at least, counterpoise the relief which nature and well-directed medical art are striving to afford. Under the circumstances mentioned, I have not seen a patient that could digest any article of nour- ishment, except in some few cases, and then only of the mildest kind, and given in the most sparing quantities ; and I know, from sorrowful observation, that nothing is more pernicious than to throw upon the disordered and diseased organs, tasks which they cannot perform, and which leave upon their sensi- ' tive surfaces, agents that irritate and inflame. When I believe a patient is in need of nourishment, and able to digest and ap- propriate it at all, I allow it to him in very small quantities at a time, and of the lightest and most digestible liquids. I prefer liquids, because, under the same circumstances, they do not re- main so long on the stomach; and again, if they are not digest- ed, their presence in the alimentary canal is not so hurtful as solid substances. I have seen the very worst consequences from taking even mild solid food, when it could not be digested. Rice, is thought by many to be a very light diet, and easily digested, but observation has convinced me that it is not such. I have seen several patients who, after convalescence had fairly set in, had eaten rice in small quantities and well prepared, for several days, and thought that it was well disposed of, but an uneasiness of the bowels had gradually increased, until a cho- lera returned all the rice they had eaten, in much the same condition that they had last seen it. I prefer beginning with a weak animal soup, well seasoned with cayenne pepper. If there is still a disposition to diarrhoea, and no fever, boiled milk is a very good diet. When convalescence is established, a milk custard, or soft boiled egg, will be admissible; and if these are well digested, the appetite and other improving symp- toms increasing, a small piece of boiled bird, or something of that class may be taken. If, however, any of these things pro- duce a fullness of the stomach, dry mouth, or other indication 1850.] Eve, Case of Hydrocele. 29 of harm, they should be abandoned. But very little of any thing should be taken, without waiting to see the effect, before a repetition is allowed. These cautions may be carried to an erroneous extent, but it is best to err on the safe side of the question, if at all. At the end of the first stage of this fever, there is frequently a great tendency towards recovery : the fever abates, the patient feels better in every respect, and the appetite returns. It is difficult to convince the patient, under these circumstances, of the importance of abstemiousness, when that alone is the reme- dy that will secure a cure. But he indulges very moderately, as he considers it, and the inflammatory stage sets in, laying his body under siege for, perhaps, several weeks more. Of all the vexations and disappointments with which I have ever met in the treatment of Typhoid fever, far the larger portion have grown out of a disregard for my prescriptions in regard to diet. Influenced by the confidence they have in the physician, pa- tients will swallow physic, by the quantity, or by the hour, as he may direct ; while his prescription on the subject of diet, which is often much the most important, is not heeded half so much, as that of any sage femme who may happen to come along, and volunteer advice. ARTICLE II. A Hydrocele containing forty ounces. By Paul F. Eve, M.D., Professor of Surgery in the Medical College of Georgia. On the 23d of this month (November), I operated before the present Class of our College on a case of Hydrocele, which, from its size, may be deserving notice. Aaron, the patient, is a negro man aged 70, who some fifteen years ago. first noticed an increase of the left scrotum, and which has continued to enlarge to the present time. He has also some accumulation of fluid in the right tunica vaginalis, with a re- ducible inguinal hernia on the same side, which however does not descend into the scrotum. Through the kindness of a pro- 30 Transactions of the College of Physicians. [January, fessional friend in a neighboring county, he was directed to my Sursrical Infirmary. The scrotum was tapped by the trocar, and Dr. Means meas- ured forty ounces drawn off through the canula. Diluted tincture of iodine was then injected, and the patient since has been doing well, with a good prospect of cure. On a former occasion, I drew off thirty-seven ounces of fluid in a case of hydrocele, and permanently relieved the patient, by the same therapeutic agent. December 1st, 1849. PART II. U cox cm s an ft (Extracts. Summary of the Transactions of the College of Physicians of Philadelphia, from May 1st, to October 2d, 1849, inclusive. 8vo pp. 46. Associations of intelligent physicians, for a free interchange of opinion upon the various subjects connected with Medicine, are always profitable to those who are thus associated, and when they give to the public full histories of their transactions, the profession at large is benefitted, and becomes interested in their success. The College of Physicians of Philadelphia, composed of a number of able and accomplished medical men, are doing much in this way for the profession. The pamphlet before us completes a volume of 467 pages, in which much valuable information may be found. At the meeting in June, some discussion took place in rela- tion to the effect produced upon the healthfulness of the atmos- phere, by the practice of keeping the principal streets wet, during the summer, by frequent watering. Dr. Emerson ex- pressed opinions unfavorable to the practice, "He believed that frequent wetting the streets copiously, daily, during the hot season of the year, was calculated to ex- cite a morp active decomposition of the filth which is always present, to a greater or less extent, and in this manner, would tend to a greater vitiation of the atmosphere ; consequently, 1 S50.] Transactions of the College of Physicians. 3 1 that it should be suspended, particularly at a season when the city is threatened with the visitation of a fearful epidemic." Dr. Jackson gave a similar opinion, " Washing the streets, by allowing a plentiful stream of wa- ter to flow down them, at proper periods, would, in his opinion, be beneficial, by carrying away from their surface whatever decomposable materials they contained ; but to keep this filth in a constantly moist condition, under the influence of an in- tense noon-day sun, could not fail, he was convinced, to be productive of more or less deterioration of the atmosphere." Other gentlemen fully coincided in these views ; and we are informed that a majority of quite a number of physicians, to whom a circular had been addressed by a committee of the City Councils, soliciting their views in relation to the practice, had expressed opinions equally unfavorable. Dr. Wood, how- ever, seemed to have a greater dread of dust, than malaria : u Dr. Wood confessed that he was in favor of sprinkling the streets with water during the summer season. Every one, whether he walks or rides, must have experienced the incon- venience of dusty roads in windy weather. The annoyance resulting from this source to house-wives and store-keepers, along our principal thoroughfares, is far greater than can pos- sibly be produced by a judicious sprinkling of the streets. Independently of the inconvenience which the dust produces by entering our dwellings, and by the destruction of goods in stores, we are constantly forced to inhale a large portion of it, and thus a much greater quantity of decomposed vegetable matter is admitted into our bodies, than can be from the evap- oration of the water thrown upon the streets. It is doubtful whether any morbific emanations are produced by the practice of sprinkling our principal streets during the summer months. It is certainly not true that the inhabitants of these streets are more liable to disease than those who reside in the streets which are not sprinkled. A reference to the facts would shew, he believed, that less sickness actually occurred during the warm weather in the former, than in the latter. He would not wish, however, to be understood as attributing this difference entirely to wetting or non-wetting the streets ; whatever, how- ever, has a tendency to allay the intense heat of the atmosphere during the summer, will certainly remove one of the most fruitful sources of the bowel affections which usually prevail in our city during this season." A considerable portion of the summary is taken up withdis- 32 Transactions of the College of Physicians. [January, cussions upon the subject of Cholera. We have read them carefully, and do not find that they throw much light upon this vexed question. We shall therefore not attempt any analysis. At the October meeting, Dr. Hays made some interesting references to a case of intense irritability of the retinic coat of the eye, resulting from irritation of the dental branch of the fifth pair of nerves. This condition of the eye, in many in- stances, is produced by decayed teeth. Dr. Hays detailed the following case of this kind : " A gentleman, formerly a resident in this city, and devoted to chemical inquiries, became a sufferer from extreme photo- phobia, which he ascribed to having carried on very closely, for a long time, a series of chemical analyses over a bright charcoal fire. The affection of his eyes became so severe as to prevent him from following his usual pursuits. . The glare of the fire in his furnace became intolerable, and it was even im- possible for him to read or write without intense suffering. He was, at the same time, affected with neuralgic pains of the face and orbit. Upon examining his mouth, it was found that a number of his teeth were decayed ; the aconita ointment was tried, and afforded some relief to the neuralgic pains. After having, by Dr. H.'s advice, several of the most decayed teeth removed, he found his photophobia diminished considerably in intensity. He visited Baltimore on some business, and on his return his eyes were again affected, as they had been previous- ly. Dr. H. supposed that he had been too closely engaged whilst at Baltimore, in pursuits which had over-exercised his eyes, but this the patient declared was not the case ; he mentioned, however, the fact that some of the remaining teeth had begun to decay ; these the doctor advised him to have extracted, which was done, and his photophobia was again relieved. The gentleman's teeth decayed very rapidly, and others still became diseased ; but upon their removal, the affection was relieved as before. Many teeth were thus removed, and an artificial set substituted. Dr. H. has been informed that he still continues well." Dr. F. G. Smith, also mentioned a similar case which had fallen under his observation. His patient, a young lady, suf- fered from intense intolerance of light, with neuralgic pains over the brow and through the ball, and he supposed that a ten- dency to amaurosis existed : " After reading the cases related by Dr. Hays, as given in 1850.] Cod-liver Oil in Phthisis Pulmonalis. 33 the Summary of our Transactions, the suspicion arose that the affection of the eyes, in the young lady alluded to, might be caused by decayed teeth. A respectable dentist was requested to examine her teeth, but he declared, after a close inspection, that he could discover no defect in any of them. Dr. S. urged a second examination, and, on going carefully over the teeth, some degree of tenderness was detected in one of the bicuspids on the side corresponding with the eye most affected. This tooth was drawn, and an abscess was discovered to exist at its root. With the extraction of the tooth, the photophobia and pain ceased, and have not since returned, though several months have elapsed, during which the lady has been subjected to great mental distress from family afflictions. She can now read by artificial light without experiencing the least incon- venience, and has been enabled to resume her studies, which had been previously suspended in consequence of her great suffering." Dr. Condie presented an outline of a case of Hydrophobia, which is interesting, from the fact, that it was undoubtedly of spontaneous origin. On the use of Cod-Liver Oil in Phthisis Pulmonalis. By Dr. C. J. B. Williams, F. R. S., Prof, of Medicine in Uni- versity College. (Journ. of Medicine. Braithwaite.) The unvarying fatality of pulmonary consumption, under the usual modes of treatment, and its frequent occurrence, render the following remarks of Dr. Williams, highly interest- ing ; the more so, as his eminent professional standing entitles his observations to a most careful consideration. Dr. W. does not speak from a partial experience. His conclusions are based on the observation of 400 cases, of which 234 are recorded in his note book. Of these last, there were nine cases in which the oil disagreed ; 19 in which it did no good ; and 206 in which its use was followed by unequivocal improvement, varying in degree, from a mitigation of the distressing symptoms, up to an apparently complete restoration to health. The effect of the cod-liver oil in most of these cases was very remarkable. Even in a few days, the cough was mitiga- ted, the expectoration diminished in quantity and opacity ; the night-sweats ceased ; the pulse became slower and of better volume ; and the appetite, flesh, and strength were gradually n. s. VOL. VI. no. i. 3 34 Cod-liver Oil in' Phthisis Pulmonalis. [January, improved. The first change manifest in the physical signs was generally a diminution and gradual cessation of the crepitus ; the breath-sound becoming drier and clearer ; but the dulness, and tubular character of the breath and voice- sounds were much more persistent, and rarely exhibited a marked decrease, until after several weeks' use of this remedy, in conjunction with regular counter-irritation. The tubular sounds, in fact, frequently became louder at the first removal of the crepitus, which in phthisis as well as in pneumonia, tends to mask the signs of consolidation. In several instances, how- ever, in which I have had the opportunity of examining the patients under treatment, at several successive intervals of a month or six weeks, the gradual removal of the consolidations has been unequivocally proved, by the restoration of clearer vesicular breath and stroke-sounds to the affected spots. In several cases, in which the disease has existed long, the resto- ration has never been perfect ; even where the health has been completely re-established, and all common symptoms of disease have entirely disappeared, there have remained perceptible inequalities in the breath and stroke-sounds ; generally, with prolonged expiratory sound, which has more or less of a tubular note towards the root of the lung of the same side. These signs, if unaccompanied by decided dulness on percussion, I have learnt by the experience of many years, not to consider as exceptional against recovery, for they appear to be de- pendent on the puckering of the texture, often with pleural adhesions and old deposits in the bronchial glands, so frequently found after death at the summits and near the roots of the lungs of persons who have not for many years exhibited symptoms of any pectoral disease. As might be anticipated, a large number of the phthisical patients for whom I have been consulted, have been in the first stage of the disease, in which the tubercles or deposits are in the solid state. In these cases also, I have largely used the cod-liver oil, and, so far as I have ascertained them, with not less satisfactory results. The physical signs of improvement are precisely the same as those which take place tardily in the second stage after the removal of the humid rhonchi : and in truth, the treatment by the oil combined with counter-irritation, where successful, seems to bring back the lungs from the second stage, that of in- cipient softening, to the first stage, that of simple deposit, which is tardier in its changes of increase or diminution, and may remain long stationary without any obvious alteration. The same re- mark is applicable to the chronic products of inflammation of the lung, winch, as is known to the the profession, I consider to ap- proximate in nature to the higher class of tuberculous deposits. 1850."| Cod-liver Oil in Phthisis Pulmonalis. 35 The most striking instance of the beneficial operation of cod-liver oil in phthisis, is to be found in cases in the third stage, even those far advanced, where consumption has not only excavated the lungs, but is rapidly wasting the whole body, with copious purulent expectoration, hectic, night-sweats, colliquative diarrhoea, and other elements of that destructive process by which, in a few weeks, the finest and fairest of the human family may be sunk to the grave. The power of stay- ing the demon of destruction, sometimes displayed by the cod-liver oil is marvellous. [After relating several cases of tuberculous lung-disease in an advanced stage, in which the use of the oil combined with counter-irritation gave rise to the most decided improvement, Dr. Williams says :] The results above stated give to cod-liver oil, even as a tardative or palliative in phthisis, a rank far above any agent hitherto recommended, whether medicinal or regiminal. I have made extensive trials of several other medicines of reputed utility in this disease, and on a future occasion may lay before the profession the results of my experience, which prove some of these agents to be by no means inoperative or useless ; and f still consider them to be often salutary aids in the treatment of this formidable malady, but their utility and harmlessness fall so far short of those of the cod-liver oil, that I regard them now chiefly as subsidiary means, and the more likely to be useful, in proportion as they facilitate the exhibition or continuance of this superior agent. If the experience of the profession at large should accord with my own, and with that of those who have proceeded me in recommending the cod-liver oil, our prognosis with regard to phthisis must undergo some modification. To what extent this modification may reach, cannot be determined, until such cases as those which I have recorded have been tested by years of time ; but even now, when we repeatedly find forms and degrees of disease, that former experience had taught us to be utterly hopeless and speedily fatal, retarded, arrested, nay sometimes even removed and almost obliterated by various processes of restored health, we must pause ere we, in future, pass the terrible sentence of " no hope" on the consumptive in- valid. Mode of operation of cod-liver oil. It seems scarcely neces- sary to discuss the question, whether the oil owes its efficacy to the iodine which it contains. The amount of this element is so minute as hardly to admit of quantitative measurement ; and to ascribe virtue to such infinitesimal fractions, when or- dinary doses have no corresponding activity, is to adopt the 36 Cod-liver Oil in Phthisis Pulmonalis. [January, fanciful and mischevous speculations of the homoepathist, which cannot be too strongly deprecated by the scientific and con- scientious practitioner. Several of the patients whose cases are cited, and many more of whom I have records, had taken iodise in various combinations before taking the oil, but without any effects approaching to those which ensued on the change of treatment. I am by no means incredulous of the salutary opera- tion of iodine in some forms of tuberculous and scrofulous dis- ease ; indeed until I used the pure oil, I considered it to be the most useful remedy ; but in the last two years, the oil has so far surpassed it and every other medicine in beneficial operation, that I am convinced that it acts by a virtue peculiar to itself. A perusal of the foregoing cases, and of others on record, at once suggests that the cod-liver oil is a highly nutrient material ; and it is commonly admitted by all practitioners who have used it, that it possesses, in a pre-eminent degree, the property of fattening those who take it for any length of time. But its nourishing influence extends beyond the mere deposition of fat in the adipose tissue. The muscular strength and activity are sensibly and sometimes rapidly increased under its use ; whilst the improved colour of the cheeks and lips implies a filling of the vessels with more and better blood. Researches are wanted, to elucidate this subject more clearly ; but the analysis of the blood in one case of phthisis which had been under treatment by the oil, showed a most remarkable increase of the animal principles of the blood, especially the albumen, which amounted to thirteen per cent., being nearly double its usual amount, whilst the fat was not materially augmented ; and the fibrin, which is generally high in phthisis, was reduced below the'normal proportion. If these results should be con- firmed by further observation, there will be no difficulty in understanding that the cod-liver oil should prove a nutrient to all the textures ; although it may yet be a question, whether it does so by direct conversion into albumen or fibrin, or by pre- venting the waste of the albuminous principles by protecting it from the action of the oxygen absorbed in respiration. But there is much reason to believe that the oil itself proves serviceable in supplying the fat molecules which appear to be essential to healthy nutrition, as forming the nucleoli of the primary cells or rudiments of tissues. The important part which fat thus performs in the process of nutrition, was first pointed out by Ascherson of Berlin ; and that fat forms the central molecules of the elements of granules and cytoblasts of textures, is generally admitted though few agree with Ascherson in his opinion that the fat forms the cells by its power of coagulating albumen around it. It seems to have 1850.] Cod-liver Oil in Phthisis Pulmonalis. 37 been the opinion of Dr. Ascherson and of Dr. Hughes Bennett, who cites it, that in scrofulous diseases there is a want of this fat, and that the albumen derived from the food in digestion is liable to be precipitated in an unorganized condition, (as tubercle, etc.) for the lack of it. But it is now well ascertained that scrofulous and tuberculous deposits, so far from being deficient in fatty particles, contain them in greater quantity than exists in the blood, or in its plasma in a healthy state. The explanation which I have given of the chief salutary action of the cod-liver oil, is not that it supplies fat where it is wanting, but that it supplies fat of a better kind, more fluid, more divisible, less prone to change, and more capable of being absorbed into, and of pervading, the structures of the body ; thus affording a fine " molecular base" in the chyle, and there- in, a material for a better plasma ; and being conveyed into the blood distributed through capillaries and around deposits (in such quantity as to soften and dissolve the crystalline and irregularly concreted fat scattered through them), it renders them more amenable to the processes of reparation and absorption. Hence its beneficial operation is more marked in those stages of tuberculous disease in which the deposits abound in fat ; that is, at the period of maturation and softening ; although from the extent of mischief already done, both to the part and to the system, the benefit may not be so lasting as in the early stages of the disease. One of the most remarkable effects of the cod-liver oil, in some cases of the second and third case of phthisis, and in other forms of scrofulous disease with extensive suppuration, is the speedy removal of the sweats and other symptoms of hectic fever. This can hardly be ascribed to its direct nutrient powers ; but I think that it is due to its influence in diminishing the unhealthy suppuration which is excited around the softening and excavated tubercles. If my views of the chemical nature of suppuration, that it consists of a further oxydation, of the exu- dation corpuscle, be correct, then it is quite intelligible that the presence of so highly combustible a material as oil, must check this process of oxydation, and thus prevent the degeneration of the corpuscles into the aplastic pus globules. In fact, if it should prove to be correct, according to the analysis above quoted from Simon, that cod-liver oil removes the excess of fibrin e in the blood of phthisical patients this also equally accords with my notion, founded on the inferences of Mulder and others, that the formation of fibrine is due to a process of oxydation of the albumen (forming a deutoxide of protein, according to Mulder;) and that, by preventing this, the oil removes that tendency to cacoplastic inflammatory dc- 38 Cod-liver Oil in Phthisis Pulmonalis. [January, posits which largely contribute to increase the consolidation of the lungs and other organs in phthisical subjects. In making these surmises, I would not be supposed to adopt the idea of Liebig, that pulmonary consumption is the result of an excess of oxygen in the blood at large, consuming its ma- terials and those of the textures. Many of the symptoms, as well as the organic lesions of the disease, show that there is a great deficiency in the process of respiration by which oxy- gen is supplied to the blood ; and some of the most rapidly fatal cases, exhibiting speedy emaciation, are, throughout their course, in a condition bordering on asphyxia. Here is ob- viously a great want of oxygen in the blood nay I believe, the excess of fat in the liver, and in the tuberculous deposits, in these instances, to be caused by this very scanty supply of oxygen to the system. But although it is deficient in the system, enough oxygen comes into contact with the exudations from cavities in the lungs, and from the diseased bronchi in their vicinity, to effect the formation of much unhealthy pus ; and it is the formation and reabsorption of this that seems to excite the hectic of phthisis, as well as to keep up much har- rassing local irritation. Now, I believe it to be by diminishing these exudations, and checking their further oxydation into pus, that cod-liver oil acts so promptly in reducing the hectic sweats and purulent expectoration of phthisis, which accel- lerate and aggravate its destructive progress. The limits of this paper will allow me to notice but briefly one more point in regard to the action of cod-liver oil. Un- like other ods or fats, it rarely disorders the stomach or bowels, or disturbs the functions of the liver. If taken in any quantity, vegetable oils commonly purge, and animal oils turn rancid in the stomach, causing heartburn, bilious attacks, and even jaundice. On the contrary, cod-liver oil generally improves all the chylopoietic functions, and distinctly promotes the action of the liver ; so that, as in several of the cases above related, the appetite and power of digestion are restored, and patients are enabled to take an amount and variety of food be- yond what they were accustomed to, even in health. I can- not help thinking, that this peptic influence of the oil is due to its containing some biliary principle, which both favors its divisi- bility in the process of digestion, and promotes the natural secretions of the liver. The flow of bile, as indicated by the colour of the faeces, is generally free and uniform during its ex- hibition ; and I must not omit to notice another fact, which I believe to be connected with increased activity of the liver. I have in numerous instances remarked that the bulk of the liver (as determed by percussion) becomes augmented during its 1850.] Cod-liver Oil in Phthisis Pulmonalis. 30 use ; yet without tenderness or any other sign of disorder. In fact, this seems to be a kind of useful hypertrophy, induced by the oil augmenting the bulk and quantity of the hepatic cells, and supplying at once a material the more fitted for this secretion, because it has already within it some elements of biliary matter which served a similiar purpose in the liver of the fish, and this at a lower temperature, and less favourable to the activity of the process. The observation of this influence of cod-liver oil has led me to use it in several cases of function- al and structural disease of the liver, marked by defective or depraved secretion, and in some instances with most satisfacto- ry results, especially in one of habitual formation of gall-stones, which had resisted all kinds of treatment, and was rapidly destroying the health; the use of the oil has entirely stopped the attacks, and has restored the patient to good health. It appears probable, therefore, that although other oils might be equally influential in promoting nutrition, and in preventing and removing the cacoplastic and aplastic exudations of scrofulous subjects, the oil from the cod's liver, and perhaps those from the livers of other fish, have the advantage in point of digestibility, and in promoting the action of the digestive and biliary organs. In all instances I have prescribed oil as free from taste and smell as could be procured : and so little difficulty has been expe- rienced in its administration, that the proportion of cases in which it has decidedly disagreed has not amounted to four per cent. The inofTensiveness of the oil implies the use of no process by which it can be deprived of its proper qualities. All that is re- quired is, to obtain it pure and fresh, as it existed in the hepatic cells of the healthy fish when alive, without contamination by any process of putrefaction, roasting, boiling, or the like. My usual mode of administering cod-liver oil, is in doses of a teaspoonful, gradually increased (if the stomach bear it) to a table-spoonful, floating on some pleasant-flavored liquid, such as diluted orange-wine, or the infus. aurantii comp., with a little tinct. and syr. aurantii. The vehicle should be suited to the taste and stomach of the patient ; and much of our suc- cess in exhibiting the medicine will depend on our being able to keep the palate and stomach at peace with the oil. In numerous instances I have found that the addition of a little diluted nitric acid to the vehicle will make it more grateful to the palate, as wTell as serviceable to the stomach ; and we may often combine with it other medicines which are not disagreea- ble, and thus fulfil the indications of palliating symptoms by their means. The fittest time for taking the oTl is" from one to two hours after the three first meals of the da v. At this time 40 Treatment of Opacities of the Cornea. [January, the chyme is beginning to pass from the stomach into the duodenum; and it would appear that the oil passes quickly with it, for given at this time it causes none of those unpleas- ant eructations which are apt to occur when it is taken either before or with food. There is nothing in the oil for the stomach to digest ; and the less it is brought into contact with it, and the sooner it passes out of it, the better. When it mixes with bile and pancreatic juice in the duodenum, its division and absorption begin and proceed, as in the case of all fatty matters. Herein, too, we see a reason why the oil does not agree so well either with the palate or stomach, when mixed in an emulsion, or combined with liquor potassse, as re- commended by some practioners. In conclusion, I repeat, that further observations, and longer time, are requisite to determine with accuracy the extent to which this agent can control or remove tuberculous disease of the lung ; but I would state it as the result of extensive experi- ence, confirmed by a rational consideration of its mode of action, that the pure fresh oil from the liver of the cod, is more beneficial in the treatment of pulmonary consumption than any agent,medi- cinal, dietetic, or regiminal, that has yet been employed. Treatment of Opacities of the Cornea. By John Charles Hall, M. L). (London Lancet.) Simple nebula of the cornea can be removed without much trouble by the daily application of a solution of nitrate of silver in distilled water (distilled water, seven drachms; nitrate of silver, one to three grains ; wine of opium, without the aroma- tic, one drachm.) Or what is better still, in more severe cases, by the following drops, which I have now been in the habit of prescribing very frequently during the last ten years, and with much advantage : Take of the bichloride of mercury, two grains ; distilled water, an ounce : mix for a lotion, to be used once or twice a day. I would repeat, that whatever lotion be employed, it is far better not to drop it into the eye as we com- monly see, even in hospitals ; a camel-hair pencil should be dip- ped into the solution, and the opaque spot touched with it, by which means the remedy is at once brought into direct contact with the part to which you wish its operation to be confined, and that, too, without decomposition or dilutation from the tears, which must always be the case in the ordinary method. Whoever has had much experience in diseases of the eye, will have observed that when any of these drops are employed for the purpose of removing opacities of the cornea, after a few 1850.] Treatment of Opacities of the Cornea. 41 weeks they appear to lose their useful effect, the disease becom- ing, as it were, invincible to them ; I would, therefore, suggest that the nitrate of silver ointment, or drops, should be used for a week or ten days ; then a weak solution of the bichloride of mercury ; then the opium wine, and then the nitrate of silver a second time. This plan keeps up a continued state of im- provement, and the disease is removed in a much shorter space of time than if one of them only had been persisted in. When a patient comes before- us with the worst possible form of opacity, leucoma arising, as is too often the case, from the extensive ulceration, which has altogether changed the nature of the corneal surface, or with an extensive opacity, re- sulting from the application of a powerful escharotic, (which although it may not have destroyed the vitality of the part, appears to have produced some chemical change in its structure,) it is quite labour in vain to attempt the cure of such an affection, and truly dishonest, time after time, to pick the pocket of the unfortunate patient of fees, by exciting hopes which can never be realized hopes, the blighting of which, in the end, much increase his misery. Still, although this opacity cannot be destroyed by any means at our command, nor re- moved by the surgeon, this admission often only applies to the central portion of leucoma. In many cases, we have the hap- piness to find the edges becoming gradually less and less opaque ; a halo of hope surrounds this dimness of vision, and although it may not be within the compass of our art to im- prove the more dense central portion, something may yet be effected with the surrounding edges ; and I have been consulted in cases where a steady continuance in the applica- tion of remedies has most ceitainly produced very great benefit, and the results recorded in the archives of the profes- sion are doubtless such as to justify their employment in many of these unfortunate cases. According to my experience, the most useful remedy is the nitrate-of-silver ointment, of a strength proportioned to the condition of the affected eye. Counter irritation should also be kept up behind the ears or at the nape of the neck by blisters. Many advise certain ointments or liniments for pro- ducing irritation on the skin. I have little practical experience of their effects, but a very short trial of them most fully con- vinced me that they were very inferior to blisters. In the first place, several days must elapse before any useful influence can be exerted, and, in addition to this loss of time, which is often highly important, I am much mistaken if this St.-John-Long practice of applying plasters of tartarized antimony, &c, above the eyebrows, does not often produce permanently mischievous 42 Treatment of Opacities of the Cornea. [January, results ; and too much care cannot be exercised in daily watching their effects, more particularly when applied to the head and face of young persons, in whom, in some cases, their application has been followed by a state of inflammation and sloughing which has even threatened the loss of life. During certain stages of many inflammatory actions ex- isting in the eye, setons and issues can be most advantageously employed. They are easily made by the surgeon, cause little pain or trouble, can be enlarged or diminished at pleasure, and being perfectly manageable, combine, within any limits we may be inclined to mark out, the advantage of a moderate de- gree of counter-irritation with a most salutary discharge. The advantages connected with the use of blisters are many the convenience of their application the rapidity of their opera- tion the quick subsidence of their effects when no longer required.* There may, however, be cases in which, from peculiar irritability of the skin, from the liability of the patient to attacks of erysipelas, or from their having, on some former occasion, produced a violent effect on the urinary organs, some other form of counter-irritation must be used rather than blisters. The following is the form in which I have usually employed the nitrate-of-silver ointment : To take nitrate of silver, from three to ten grains ; solution of diacetate of lead, twenty drops ; lard, one drachm. This ointment must be used every night or every second night. A very small portion (not larger than a large shot- corn) being put into the eye, it always creates more or less ophthalmia, and its application must be regulated ac- cordingly. During the employment of this ointment, I would in many cases most strongly advise the internal exhibition of the bichloride of mercury. When there is nothing to counter- indicate its use, I have given it for six or eight weeks in the following form, without any severe affection of the gums, irritation of the bowels, or any other symptom requiring that the dose should either be intermitted or reduced. Ordered solution of the bichloride of mercury, one drachm ; tincture of bark, one drachm ; distilled water, seven drachms and a half. To be taken twice a day. As an alterative, the bichloride or oxymuriate of mercury, though doubtless more frequently prescribed than formerly in these cases, is not, I venture to think, so extensively used as it ought to be. It can be given in solution, which is of con- * With regard to the application of blisters in certain diseases of the eye, the situation most desirable for applying them is the nape of the neck, or behind the ears. 1850.] Treatment of Opacities of the Cornea. 43 siderable advantage, rendering its action much more certain, more equal, and by readier absorption probably more effectual in producing an alterative influence upon the whole system. Dr. Holland remarks that he has "seen its influence in augmenting the secretions, procuring the absorption of morbid growths, altering the state of the skin in many cutaneous dis- orders, and changing the character of morbid actions generally throughout the system, in cases where he believes no other medicine or combination of medicines would have had equal effect. Its combinations with bark, steel, sarsaparilla, &c, afford resources of the greatest value in the treatment of dis- ease ; and though otherwise held by common opinion he thinks it, on the whole, as safe a medicine as calomel in the hands of the practitioner, inasmuch as its distribution can be made as equal and determinate, and its effects, from being given in a state of solution, are much less likely to be interrupted by mechanical hindrances in the stomach and bowels."* I would add also, and it is worthy of note, that this medicine (bichloride of mercury) may be continued in uninterrupted use for a very considerable period, without obvious injury or in- convenience, and in certain cerebral and spinal affections, a long unbroken course of this preparation is of singular avail ; but to reap its fullest benefits, we must be watchful, patient, and decided in its use, for in cases in which, in the end, the hap- piest results follow the administration of the remedy, the changes are often the slowest, and not testified by those instant and obvious results which are sometimes desirable to fortify even the mind of the physician in the perservance proper to the practice, still more to convince the patient, his family and friends, that time is necessary for the development of the full and complete advantages of the means employed. Thus it fre- quently happens that the patient, alarmed, it may be, at the name of the medicine, and by the precautions taken as to its dose and effects, or tired by the little progress he appears to make, refuses after a time to go on with the remedy, very often at the moment when becoming most effective, and when there was every reason for thinking a dangerous or distressing malady would eventually yield by a further employment of it. I have many times seen the beneficial results arising from a long-continued use of small doses of the bichloride of mercury, in solution, in chronic iritis, and also in several cases of paraplegia, the slow progress of the disease giving full scope for its effects, and the great danger in prospect, justifying a long trial of the remedy. Of course in strumous children, mercury in any form can seldom be employed with ad van - * Medical Notes and Reflections. Second Edition, p. 242. 44 Bibliographical [January, tage, and in treating opacities of the cornea in them, in addition to appropriate remedies to the eye, it will be necessary to strengthen the system by attention to diet, shower-baths, sponging the body with cold water, the administration of the disulphate of quinine, and a residence of some months during the summer, when the circumstances of the parents will permit, at the sea-side. BIBLIOGRAPHICAL NOTICES. 1. The Practice of Surgery ; embracing Minor Surgery, and the Ap- plication of Dressings, Sun Rise. c Ther. Bar. 1 43 30 9-100 2 44 30 10-100 3 45 30 7-100 4 47 30 3-800 5 50 29 94-100 6 54 " 90-100i / 55 " 81-100 e 50 " 60-100 9 40 " 69-100 10 37 " 84-100 11 42 " 86-1 no 12 45 " 83-100 13 52 11 87-100 14 50 " 88-100 15 52 " 77-100 16 51 " 83-100 17 51 " 80-100 18 55 " 62-100: 19 53 " 59-l00i 20 46 " 56-l00i 21 >42 " 80-100 22 39 " 83-100 23 45 " 88-1001 24 52 " 95-100 25 61 , 86-100 96 62 " 73-100 27 42 " 91-1001 28 36 30 29 35 29 95-100 30 44 " 76-1001 72 71 77 71 76 61 64 64 64 66 2, P. M. Ther. Bar. 68 30 12-100 74 30 5-100 78 30 3-100 78 29 97-100 78 " 90-100 79 " 85 100 78 " 68-100 62 " 59-100 66 " 74-100 70 " 85-100; 62 ;t 82-100) 64 " 80-1001 75 " 89-100 73 " 83-100 74 " 76-1001! 70 " 83-100 i 67 " 72-100 58 " 57-100: 65 " 57-100 68 " 66-100 Wind. " 83-100 " 80-100 " 90-100 " 92-100 " 78-100; " 76-100 " 94-100 30 3-100 29 83-100 " 72-100 E. W. S. W. S. W. s. w. S. E. S. N. W. N. W. N. W. S. E. N. E. N. N. E. N. N. N. N. W. N W. N. W. s. w. s. w. s. s. w. w. w. s. w. s. w. Remarks. l|Fair. Fair. Fair. Fair. ' Fair. Fair some cl'ds in afternoon. 'Fair do. do. storm at 7 p.m., JFair blow, [rain 20-100. Fair. Fair. [Cloudy. Cloudy. Fair. Fair. Fair afternoon breeze. Fair breeze. Fair breeze. Drizzle. Cloudy. Drizzle at 7 a.m. fair afternoon. Fair. Fair. Fair. Cloudy. Cloudy. [90-100. Cloudy rain from 12 to 11 a.m. Fair. Fair ice, first this season. Fair. Cloudy. 19 Fair days. Quantity of Rain 1 inch 10-100 days. West of do. do. 17 days. Wind East of N. and S. 5 We are indebted to Dr. P. F. Eye, for our Meteorological tables. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. 6.] NEW SERIES. FEBRUARY, 1850. [No. t " .-- . . PART FIRST. Original dommunicatton*. ARTICLE III. Elephantiasis its History, Symptomatology, JEtiology and Pathology, with a Report of a Case and successful treat- ment. By James M. Gordon, M. D., of Lawrenceville, Gwinnett county, Ga. The appellation of " Elephantiasis," was anciently given to two distinct diseases of very dissimilar characters the one an enlargement of some portion of the body, the other a scaly, glossy, and tuberculated disease of the skin ; the former most frequently attacked the extremities, whilst the latter usually occupied the face and ears, and sometimes other portions of the cutaneous surface. These terms have been retained ; and for the purpose of preventing confusion, modern writers have formed of them two divisions : the first, distinguished by the epithet "Elephantiasis Arabium," or Arabic division the latter, " Elephantiasis Graccorum," or the Grecian variety. The re- marks in the present essay will be founded on the distinctive subject of Elephantiasis Arabica. History. The observations of some of the oldest writers on Medicine go to establish the truth of its being a disease of great antiquity. The earliest account that we have of it was by Rhazes, a celebrated Arabian physician, who, as early as A. D. 850, accurately described it. Since this period, many writers have given extended descriptions of the disorder : amongst n. s. VOL. VI. NO. II. 5 66 Gordon, on Elephantiasis. [February, them may be mentioned Morgagni, Chopart, Cheselden, Wal- ther, Dionis, and Larrey ; yet, more recently, the subject has engaged the attention and elicited the thorough investigation of Tilley, Dalton, Adams and Scott. The disease has received almost as many names as there have been writers engaged in the description, frequently assuming in part the name of the particular country, or place, in which it may be prevalent. Dr. Good has called it " Bucnemia Tropica," from the fact that it most generally occurs in tropical latitudes. In the Polyne- sian islands it has been termed " Yava Skin," from the suppo- sition that it originates from the use of a favorite beverage of those islanders, called "yava." On the peninsula of India, it is known as " Cochin leg." In Malabar, it has been called " Anay Kaal," which name it takes from its supposed resemblance to the elephants' leg. In Barbadoes, it is sometimes called "Bar- badoes leg," in others, the "glandular disease of Barbadoes" By some authors it has been termed " Yam leg," from its re- semblance to that vegetable. On the island of Ceylon, it is called "Galle leg," from its being most common in the vicinity of the principal town of that name. In France, it is known as " Lepra Elephantiasis," from the resemblance to the elephant's leg. The Arabian physicians applied to it the name of " dal til," which also means elephant's leg. It may, to the casual observer, appear a remarkable coinci- dence, that so many different authors, located in different parts of the globe, and all speaking different languages, should have, with such unanimity, compared this disease to one and the same object ; but it is only necessary for him to behold one solitary case, to forcibly impress his mind wTith the correctness of the simile. The enormous size of the part, with its clumsy, unsightly and misshapen appearance, are not the only points of resemblance to the leg of an elephant ; for at the same time the rugose and scaly appearance, together with the rough and uneven surface, bear close analogy to the skin of that animal. It is neither a contagious nor infectious disease, but, like many others, occurs endemically, exhibiting a strong predilection for particular localities in Southern latitudes. The countries in which this disease is in the most remarka- ble degree endemic, are the islands of Ceylon and Barbadoes, 1850.] Gordon, on Elephantiasis. 67 Egypt, Abyssinia, Japan, all of the West India islands, and some portions of South America and of Spain, the coast of Malabar, and also in many of the South-sea islands. Sporadic cases occasionally occur both in Europe and the United States* As has been previously remarked, it is chiefly confined to warm latitudes, prevailing most extensively in those particular low, humid, and unhealthy situations, where malaria in abund* ant quantities may be reasonably supposed to exist. Liability of persons to the disease. On the island of Ceylon it is wholly confined to the native inhabitants, including Creoles and half-breeds. Foreigners, from whatever quarter of the globe, are entirely exempt. In Barbadoes, it was confined to the black population alone, till about the year 1704, wrhen the first white inhabitant became its subject : since this period, it has become very frequent even among the white inhabitants* In Ceylon foreigners are not subject to it, until after having become thoroughly acclimated by a long residence on the island. In some other countries it is said to attack more fre- quently the lower classes. The young have also been represented as being more liable to it than those in advanced life. There are none, however, free from its dangers. It attacks all ages, both sexes, and indi- viduals in every condition in life : the opulent, surrounded by every comfort, and enjoying a life of luxury and ease, are equal- ly obnoxious to its influences, with the hardy and industrious peasant, who endures every privation in food and raiment, and in his daily toil is exposed to all the inclemencies of weather, and the greatest vicissitudes of temperature. There is no immunity from its attacks. Symptomatology. The onset of the attack is ushered in by the symptoms common to inflammatory or febrile diseases, such as rigors, with nausea, and sometimes vomiting, headache, and pain in the dorsal and lumbar regions, these are succeed- ed by considerable febrile excitement, with great thirst, and intense heat of surface, followed by profuse perspiration. In the mean time, the part destined to become the final seat of the disease becomes tumefied, with increased heat and great pain, particularly along the course of the lymphatics ; the skin pre* 68 Gordon, on Elephantiasis. [February, sents a tense, smooth, and shining appearance, frequently of a bright scarlet color, and in many respects resembles erysipela- tous inflammation. Subsequently, and in the early stage of the disease, it may possibly be mistaken for phlegmasia dolens, to which it bears a close resemblance, but by careful observation and minute investigation, the distinguishing marks betwixt the two diseases will be sufficiently obvious to the skilful in diag- nosis. The attack usually lasts for several days, (from three to five,) and generally yields to a mild course of antiphlogistic treatment, and indeed frequently without any treatment at all, for there appears to be a great proclivity to a spontaneous subsidence of all symptoms of the disease for the time present. The febrile symptoms gradually decline, and finally disappear ; the local symptoms also subside, and frequently with desquamation of the cuticle of the affected part, the patient being nearly restored to his ordinary health. The limb, or part affected, does not, however, return to the normal size, but remains somewhat enlarged. To an individual unacquainted with the nature and progress of the disease, it might reasonably be supposed that here the case would terminate; nor could his mind be brought to anticipate the horrible picture it may present, or the loath- someness it may attain. Attacks similar to the first, follow each other at earlier or later periods, the length of intermission between the attacks varying in different cases. It has been observed by a distinguished English author, that^a return of the paroxysm is generally preceded by a feeling of weariness along the course of the absorbents, with a benumbed sensation, as if the limb was asleep. Then follows the ordinary symp- toms attendant on a paroxysm : accelerated pulse, with general febrile symptoms ; furred tongue, with a renewal of the swol- len and painful condition of the limb or affected part. Similar attacks continue to succeed each other, observing rather mark- ed periodicity, each one leaving the part more swollen than the preceding, till it attains an enormous size. Thus the malady may gradually progress for months and years. After several attacks have been passed through, an habitual swelling remains about the ankle, dorsum of the foot, and toes, which is increased by exercise in either walking or standing. At first the swelling is 1850.] Gordon, on Elephantiasis. G9 soft, producing a doughy sensation to the touch, becoming gradually harder, till firm pressure produces only slight pitting; the lymphatic glands in the neighborhood of the parts become enlarged and indurated, especially those in the groin, if the lower extremity be the part affected. In process of time, the regular paroxysms of fever become less distinct, .and finally subside altogether; the glandular swellings are diminished, and there is much less pain along the course of the absorbents. It is very rare that these swellings advance to suppuration. The swelling up to this period has advanced slowly and regularly, commencing at the toes, (if the disease be located in the lower extremity,) and extending regularly up the foot and ]egf but it does not preserve uniformity, in consequence of the constriction about the ankle-joint ; the skin is formed into loose folds, which produce ridges more or less elevated, with intervening fissures, while the cuticle, becoming more rough and harder, interferes very much with the capillary circulation. In the most aggrava- ted cases, these folds of skin assume a fungous, tuberculated, rugose or warty appearance. These warts or projections are occasionally of such length and size, as to add very much to the deformity of the part, and have not been inaptly compared to a cock's spur. Appearances of this kind do not however attend every grave case, for in some instances the tumefaction arrives at a very great extent, with but little change in the appearance of the skin, the principal alteration the part has undergone be- ing in the sub-cutaneous structures, which seems to the touch rough, uneven and knotty ; the shape of the part becomes very much changed ; the foot acquires an enormous dimension and a square form in shape, the swelling overlapping and wholly hiding the toes from sight ; the shape of both the ankle and knee joints become very much altered, and in truth the whole extremity, from the tip of the toes, to above the knee, becomes one huge mass of shapeless flesh. From the great distension of the skin it cracks in many places, through which exudes a thin, serous fluid, discharged abundantly, of a very disagreea- ble odour, and so peculiar and remarkable that when once observed, will ever afterwards serve to distinguish the disease, even in the absence of other diagnostic symptoms. The lan- guid condition of the capillary circulation, in addition to the 70 Gordon, on Elephantiasis. [February, cracking of the skin, soon developes ulcers of a very unhealthy, indolent appearance, with elevated, hardened edges, and small, pale granulations, which never cease to discharge a fluid of such offensive odour as to be almost insupportable. After the appearance of ulceration, there is marked amelioration of the symptoms ; the attacks of pyrexia, which before have regularly recurred, no longer make their appearance ; the tumefaction, previously on the increase, either remains stationary, or sensi- bly diminishes ; pain, which has been a source of great annoy- ance to the patient throughout the whole course of the disease, is now materially modified, although not entirely absent its character is changed, from that constantly attendant on an increase of swelling, to the pain peculiar to this particular form of ulceration. When, in the progress of the case, the extent of ulcerated surface becomes greatly augmented, either by multiplying their number, or enlarging the extent of boundary to those already existing, alarming constitutional disturbance is manifested. As a matter of course, an increase of ulceration is attended by a corresponding increase in the quantity of ulcerous discharges ; to this succeeds general debility, with anorexia, mental imbecility, sleeplessness, pallid and anxious countenance, emaciation, and general wasting of the tissues of the body. Nature, accustomed to struggle against the ravages of the disease, overpowered and exhausted by the combined assaults, is no longer able to successfully contend with its adr versary, but calmly yields the victory, and the revolting scene is closed in death. The parts most liable to elephantiasis are those most pendu- lous, and in the neighborhood of a good supply of lymphatics and surrounded by considerable quantities of adipose and cel- lular tissues. The inferior extremity is the most common seat of the disease, and in that member it produces more frightful deformity than in any other location : it frequently attains a size equal to that of a man's body, or larger. The next most common position is the scrotum, and but for the testimony, upon the high- est authority, it would be incredible to narrate the immense magnitude that it has been known to reach, Mr. Liston reports a case in which he removed the scrotum, which weighed fifty-five pounds : it extended to the patient's knees. There is another 1850.] Gordon, 071 Elephantiasis. 71 report of the removal of the scrotum, which reached to the feet of the patient, and was in weight ninety-two pounds, and filled a pork barrel. The most extraordinary case of which we have any account, is that mentioned by Dr. Titley. The tumour rested upon the ground when the patient was in the erect position, and after removal from the body, was ascertain- ed to be of the astonishing weight of one hundred and sixty-jive pounds ! Many of the patients that have been operated upon have recovered. It is seldom that more than one portion of the body is affected at a time in the same individual. There have been a few exceptions to this rule. Dr. Scott* mentions the case of a schoolmaster, at Point de Galle, in Ceylon, who had both arms and bcth legs affected at the same time. The same author reports another case of a woman, at the same place, that had the disease in both legs at once. These are very rare cases, and constitute the exceptions to the general rule. In females, the vulva and mammary glands are occasionally the seats of the disease : the clitoris has been removed for this cause. Xext in frequency the arms become affected : then follows the scalp, neck, ears, tongue, and penis. Some of the internal organs have also been known thus diseased, as the ovaria, uterus, and liver. In fine, every part of the body ap- pears to be more or less liable to this malady. JEtiology. In treating of this division of our subject, it were better perhaps to adhere to custom, in sub-dividing the causes into predisposing and exciting, although it will readily be discovered that we have at our command no facts sufficient to give a satisfactory explanation for either. After a careful perusal of the most elaborate articles upon this subject, by some of the enfinent authors previously mentioned, we feel con- strained to say, that their remarks upon this particular division, so far from being satisfactory and conclusive, amount to no- thing more than mere hypothesis and vague speculation. Some of their theories are, however, not only ingenious, but also have the appearance of probability, as they are supported bv cor- roborative circumstantial testimony. In Demarara it is said to occur principally among the Creoles Encyclopaedia Practical Medicine, p. 7T1. 72 Gordon, on Elephantiasis, [February, (whether whites or Africans) and half-castes, while it rarely, if ever, attacks the aboriginal inhabitants, or Europeans. It is in this location, confined principally to the sea-coast. From these facts alone, it would appear that the amalgamation of the races predisposes to the disease. But in Ceylon, just the reverse is true, in two essential particulars, to that which obtains in Deme- rara. First, it scarcely, and perhaps never occurs except among the aborigines ; secondly, it prevails most extensively at a dis- tance of eighty miles from the sea-coast, where it is said that at least one-third, and probably one-half of the population, are affected with it. In every other respect, that portion of the island appears as healthy as any other, being remarkably free from intermittent or remittent fevers. It is in this part of the island only, that the disease is endemic, and persons who for a considerable length of time have been subject to its periodical attacks, upon removal to some other portion of the country, escape them, and not unfrequently perfectly recover. These facts tend to controvert the opinion, that an admixture of the races forms a predisposing cause to elephantiasis. But again, the present history of the disease in Barbadoes contributes in no small degree to confirm the correctness of the supposition, that it does amount to a predisposition of no mean importance. It has been previously observed, that on that island it was un- known, except among the blacks, till the year 1704, and it will be remembered that, prior to that period, the country was but sparsely settled by Europeans, and they of but recent residence. At that time, there were but few or no Creoles. Subsequent to that time, the number of whites largely increased, and at the present day, the whites and Creoles form a considerable por- tion of the population. During the past few years, elephantia- sis has there been of much greater frequency, and confined principally to the Creole and white inhabitants. No satisfac- tory explanation can be given of their greater liability, as there appears to have been no change in the climate, and in no other respect have diseases multiplied. The history of the disease, wherever it has prevailed most extensively, shows that Creoles and half-breeds, in proportion to number, have been the great- est sufferers. Among other predisposing causes may be enumerated 1850.] Gordon, on Elephantiasis. 73 peculiarity of habit. General constitutional derangement and debilitv, also favors an attack; food of improper qualities, or deficient in quantity ; an impoverished state of the blood, with languid circulation ; the lymphatic temperament ; absent or deficient transpiration all predispose to this affection. But if all the causes mentioned as prolific sources of this disease, there yet remains one, that has barely ever received even a passing notice by any author upon the subject, and one in our humble judgment of paramount importance to every other. We allude especially to atmospheric causes and climatic influences, or in other and less doubtful terms, to malaria. Were there no other arguments to offer in favor of this opinion than the analogy elephantiasis bears, from the very first prima- ry symptom of the disease, throughout its whole subsequent course, to our common forms of malarial fevers, it would be sufficient to establish the greater or less identity of the two dis- eases. The very first premonitory symptoms of elephantiasis, are those most common to our remittent and intermittent fevers, as regular exacerbations, attended with rigors, headache, nausea, and vomiting, accompanied by pain in the back and loins, and these symptoms being succeeded by a distinct inter- mission. As before remarked, the paroxysms recur with con- siderable periodicity, the only dissimilarity between this and a case of common intermittent fever, consisting in the different length of the period of intermission. Now we would not be understood to say that the exacerbations return with the same exactness as the chill in common intermittent fever. So far as we are at present informed, no writer upon the subject has given sufficient attention to determine the exact periods, as it not unfrequently occurs that the intermission embraces several weeks, and even months. We venture the prediction, that when this point shall have received the proper attention, it will be discovered that the paroxysms of the disease recur with much more regularity, than has generally been supposed. It may be said, however, that " out of the words of our own mouth shall we be condemned," in reference to our previous state- ment, that in Ceylon and Barbadoes intermittent and remittent fevers are almost entirely unknown. But in answer to this argument, we would suggest how readily it may be conceived, 74 Gordon, on Elephantiasis. [February, not only possible, but probable, that the same morbific cause, acting upon constitutions of peculiar susceptibilities, may and does modify and ehange the character or type of the common disease. Indeed, we know that this is true in regard to our malarial fevers in this country. Every practitioner has ob- served cases of entirely different types of fever, occurring not only in the same neighborhood, but even in the same family, the members of which had alike been exposed to the same influences. If this be a true statement in respect to the mala- rious diseases of this climate, certainly the same principles will hold good in Ceylon and Barbadoes. Although the common intermittent and remittent forms of fever may be unknown there, yet it may be that the inhabitants of those isles are scourged by the form of elephantiasis in lieu thereof. An additional argument in favor of the malarious origin of elephantiasis is, that our types of fever have been productive of a somewhat similar affection, by instituting inflammation, in the lymphatics, more particularly, of the inferior extremity. The writer has now in vivid recollection several cases of mark- ed phlegmasia dolens occurring in both sexes, and diversified ages, as an attendant of Typhoid fever. The cases, although not entirely analogous, are yet of sufficient similarity to throw some weight of evidence in favor of our supposition. A worthy member of the medical profession, in the West Indies, observes, that during attacks of fever there, there is a manifest predispo- sition to inflammation of the lymphatics, and a red line is fre- quently seen throughout the whole length of the lower extremi- ty marking the course of the lymphatic vessels. In conclusion, upon this part of the subject, we need only advert to the fact, that elephantiasis is most prevalent in warm latitudes, in the vicinity of low, marshy tracts of country, bordering on rivers and lakes, where malaria exists. In British Guiana, we have it upon the testimony of Dr. Dalton, that the disease not only resembles in many of its phases, but is also frequently associated with intermittent fever. The same obscurity veils a knowledge of the exciting, as of the predisposing or remote causes. By high authority it has been urged, that it is the result of vicissitudes of temperature; but that opinion has been controverted by showing that in 1850.] Gordon, on Elephantiasis. 73 localities where it is most prevalent the temperature is remark- ably uniform, the change not exceeding ten or twelve degrees during a whole annual period. It has been regarded by some authorities, entitled to confidence, as originally a local disease, produced by some local irritation, and the attendant febrile symptoms only the natural results of the local inflammation. This opinion cannot be sustained either by arguments or facts, and must, therefore, be untrue. If malaria be a predisposing cause, it also at the same time becomes one of the most import- ant exciting causes. The remarks upon that subject previously made under the head of predisposing causes, would apply here, but need no repetition. As previously intimated, we evidently regard this as a con- stitutional disease, and one that evinces a decided disposition to localize itself early in its course, and exhibits an obvious ten- dency to seize upon the lymphatic system. Upon post-mortem examinations of subjects who have died of this disease, the sub-cutaneous, cellular and adipose tissues, together with the muscular aponeurosis of the affected parts, are found hard, dense and tumefied. These changes appear as the result of the effusion of a quantity of aero-albuminous fluid into these several tissues, and which the absorbents are uimble to remove. The effusion in this case differs from ordinary dropsical effusions, in this, that it is always coagulated, and if left to the unaided powers of nature, is never absorbed. It appears to be a fluid sui generis in another particular, in that it never excites active inflammation or suppuration. The muscles are considerably atrophied and of a pale hue, and surrounded by much fatty matter and cellular tissue. The larger veins are increased, while the smaller are diminished in size, and many of them attire]/ obliterated. The arteries ard not materially changed in size, and are not very much enlarged, as from the hypertro- phied state of the parts they supply might he supposed. The nerves are a little flattened by the compression tl ey have sus- tained. In cases of long standing, the disease is not alone confined to the soft tissues, but the I 1 1 become di* The general contour of the part, in the most aLr'_ri*av;itrd c is frightful to behold, not only from its huge dimensions, hut from the unnatural appearance produced by the linn agglutina- 76 Gordon, on Elephantiasis. [February, tion of all the parts ; the skin being deprived cf all mobility and covered with scales. From the earliest notice of the disease, down to the present time, it has been generally considered as one of the opprobria medicorum, baffling the skill of the most scientific, and weary- ing the patience of the most earnest enquirers, who have sought to investigate its nature. * As in the history of all other diseases, much light has been thrown upon the subject by a gradual accumulation of facts, so that it is now not only no longer a mooted question, as to the possibility of ameliorating the condition of the patient, and even affecting a permanent cure. The treatment resolves itself into two divisions the consti- tutional and local. The former comprises all those means that have for their object the prevention of the successive returns of the febrile paroxysms. The latter includes those remedies calculated to diminish the hypertrophied part, by facilitating the absorption of the effused fluid, or, in other words, to the abortive and curative treatment The first indication, which is to prevent the return of the paroxysm, will be very much favored by a removal of the pa- tient from the locality where the disease has been contracted, and this should be the more imperative if it be endemic. If it be a disease of malarious origin, and subsequent experience and observation should prove its regular periodicity, then, in the great anti-periodic powers of Quinine, we have, as we doubt not, a most effectual remedy. Notwithstanding we know so little of the modus operandi of this great and heroic remedy for the largest class of diseases incident to southern climes, yet we do know, that its effects upon the animal economy are antagonistic to the periodicity of disease, and that it tends to counteract the pernicious influences of malaria. The removal of the effusion, and consequent reduction of the diseased part, will be attained by the administration of such remedies as will diminish the phlogistic predisposition of the system, and increase the activity of the absorbents. The pa- tient should be confined as much as possible to the recumbent position, and the affected member should at all times, during the course of treatment, be kept at perfect rest in the horizontal 1850.] Gordon, on Elephantiasis. 77 position. Mild meicurials, as pil. hydrarg., should be admin- istered pro re nala, and followed, at the commencement of the treatment, with a few brisk cathartics; but a continuance of active purgatives is not only unnecessary, but may prove hurt- ful. During the subsequent treatment, the more active cathar- tics should be dispensed with, and mild laxatives substituted in their stead, such as the supertart. potass, and the neutral salts : not omitting, however, the moderate use of mercurials, which should not be omitted, as they tend powerfully to increase the activity of absorption. Their use should be discontinued short of ptyalism. Particular care should be taken to sustain the strength of the system, and, if necessary, recourse should be had to stimulants, and tonics, combined with a generous diet. The preparations of iodine, especially the iodide of potassium, from their wrell known effects upon the glandular and absorbent systems, stand unrivalled as remedies effectual in the cure of this affection. A well directed system of compression by means of the roller-bandage, if practicable, will greatly facilitate the attain- ment of the desired results. The pressure of the bandage should be made from the toes upwards, and as firm as can be borne, without great discomfort, or as is consistent with the safety of the patient. The employment of severe friction, with a stimulating liniment, immediately preceding each application of the bandage, will tend greatly to accelerate the cure. The improvement for the first few weeks will be very rapid, and the re-application of the bandage often required, as it become* loosened on account of the subsidence of the swelling. Under such treatment, in the course of a month or two, there will be found a considerable diminution in the size of the limb, or af- fected part. The external appearances will also he very much changed for the better The hard protuberances and rough- ! of the skin become much ieai distinct, and in ewrv par- ticular, the part presents a much mora natural and healthy appearance. I>ut the bandage is not to be discontinued until long alter ever} vestige of the disease has subsided, and this may require many months : if the treatment be 100 early aban- doned, the disease rapidly returns. Tins unfortunate result actually occurred to the writer, in oonsequew iect 78 Gordon, on Elephantiasis. [February, of the attendant and nurse, in the interesting case herewith reported, as will be seen in the sequel of this article. In cases where ulceration exists, as in the advanced stages of the disease, if the ulcers be large, it will first be necessary, be- fore using the bandage, to diminish the size of the sores. The application of poultices, succeeded by stimulating and astrin- gent lotions, and then dressed with adhesive or Liston's plaster, so as to approximate the edges of the ulcer, will generally prove effectual. When the ulcers are small, they afford no objection to the employment of the bandage, but on the contra- ry, it is one of the most efficient remedies to promote their healing, as with the contraction of the skin, and other tissues, their edges become approximated and united. The use of the knife is rarely required ; but cases of severe ulceration of the leg, or insupportable pain, may demand amputation, and many cases have been followed by complete recovery. It should only be looked to as a resort when all other methods have fail- ed to afford relief. Case. We were requested on the morning of April 10th, 1847, to visit Peggy, a colored woman, belonging to Maj. Geo. M. Waters, a wealthy planter of this county. Upon our arri- val, we were absolutely startled and confounded at the huge, misshapen, and unsightly appearance of her left lower extremity, beginning at the toes, and extending to near the knee-joint. The foot presented an enormous mass of flesh of rather a square shape, the toes being almost entirely hidden from sight, by the overlapping of a large mass of skin and flesh ; about the flexure of the ankle-joint there appeared ridges of skin of considerable elevation, with intervening fissures of corresponding depths. The leg was of enormous dimensions, measuring about ten inches in diameter. The surface presented a rough, scaly ap^ pearance, with a few long hairs interspersed here and there. Upon the application of the touch, hardened protuberances were observed, with intervening depressions of comparative softness, which slightly pitted upon pressure. The entire limb, from the toes to the knee, appeared one shapeless mass, and the motion of the leg was very much impaired. In making out our diagnosis, wTe had no hesitancy in pronouncing it a case of 1850.] Gordon, on Elephantiasis. 79 Elephantiasis, though in an experience of several years' prac- tice, we had never previously met with one. Treatment. Absolute rest, in the recumbent position, was strictly enjoined, and she was directed to take pil. hydrarg. 6 grs., every other night, followed by an active cathartic on the following morning. This course of treatment was faithful- ly pursued for about ten days, when the pil. hydrarg. was directed to be continued, but a mild saline laxative was sub- stituted for the active cathartic on the morning following. Hydriodate of potash, in doses of 5 grains, gradually increased to 10, three times daily, was also added to the prescription, and regularly administered. The diet was restricted to a moderate allowance of bread and milk. A strong roller was applied from the toes upwards to the knee, as firmly as could be borne without pain, with directions to have it re-applied, as often as it becomes loosened. Previ- ous to the renewal of each application of the bandage, active and severe frictions, with a stimulating liniment, was ordered to be made over the whole extent of diseased surface. Under this plan of treatment, the improvement was rapid. The swel- ling diminished so rapidly that the bandage required to be re- applied at least once every twenty-four hours. This course of treatment, with but little variation, was rigidly pursued with the best effects, until the 1st of November following, during a space of seven months, at the end of which time, the member having been reduced to very nearly the nor- mal size, and presenting a natural appearance, the treatment was discontinued without our knowledge. After the discontinuance of treatment we lost sight of Peggy's case, and heard nothing more from her until about the 1st of November, 1848, just one year afterwards. Her owner then informed us that the limb had never been quite reduced to the size of the other, and had been occasionally painful ; that for the last few months both the swelling and painfulness had been rapidly on the increase, and that there appeared an evident predisposition to a return of the former aggravated condition. The method of cure previously adopted was again instituted, with only slight modification, and with the same beneficial re- sults. In the latter part of the treatment, the depletives were 80 Dugas, on Fractures. [February, abandoned, and the patient put upon a course of tonics, with a nutritious diet. The use of the stimulating frictions and the roller bandage was directed to be continued for at least two months, after every trace of the disease had disappeared. The remedies were again discontinued in the early part of the pre- sent year, since which, to the present time, she has remained perfectly well. We are enabled to give the following additional information in relation to Peggy, particularly as regards her early history, and the history of the disease in her case: She was born in the Cherokee Nation, on the Etowah river, and in wThat is now Cass county, and has been living at her present place of abode, on the Chatahoochie river, twenty-six years ; she is now about 46 years of age ; her father was a full blooded Mexican Indian, and her mother a mustee ; her health had been always previously good ; she is the mother of seven children. The first symptoms of the disease were developed a year before I saw her: she had been under the care of another practitioner, whose plan of treatment I was unable to learn. Menstruation ceased upon her one year prior to the attack. She is very fat, her weight being 330 lbs. Her master writes me, in answer to enquiry as to her present condition, dated October 29th, 1849, "that Peggy says, when she has walked about a great deal, during the day, the extremity is a little in- clined to swell, and is also slightly painful in the afternoon. She wears a shoe on that foot, and attends to her ordinary business with little or no inconvenience." ARTICLE IV Remarks on the Treatment of Fractures. By L. A. Dugas, M.D., Prof, of Physiology, &c, in the Medical College of Georgia. Although it may seem to be a work of supererogation to write upon a subject so trite and so familiar to every practi- tioner as that of Fractures, there are still some points upon which surgeons differ, and upon which they should therefore be heard. On the general principles of treatment all agree ; 1850.] Dugas, on Fractures. but such is not the case when we come to the details. For instance, the application of a roller bandage to the fractured Umb is recommended by many and condemned by others. Among the fornier, there are some who advise its immediate application, and others who defer it until the inflammatory stage shall have passed. In our country, the bandage is, I be- lieve, very generally used, and it is for this reason I propose to offer a few remarks against the propriety of such a course. What are the ends proposed to be attained by the application of the roller or other compressing bandage to a fractured limb? They are, I believe, three-fold viz : to aid in retaining the bones in their proper adaptation, to prevent the swelling of the limb, and to reduce this after it has occurred. A serious objec- tion to the bandage thus used, is that its application constitutes by far the most painful portion of the dressing, especially if the limb be held for the purpose by an unskilful aid. No one who has ever witnessed the application of the roller bandage, from the toes up to the pelvis, in fractures of the os femoris, when every turn of the roller however gently carried, imparts mo- tion and intense pain, can have failed to wish that it might be dispensed with. Such, at least, is the case with the patient, if not with the surgeon. This evil is aggravated by the necessi- ty, which very soon occurs, of removing and re-applying the bandage, as will be hereafter stated. Now, if the proper ap- position of the fractured ends can be secured without iht roller bandage, is not the difficulty and painfulness of its application a sufficient reason to abandon it ? But it is also proposed to prevent, by its use, the development of swelling. Let us see if this object is ever attained. Every one knows how difficult it is to apply the roller bandage to a whole limb in such a way that the compression will be perfectly uniform, and the circu- lation not impeded. Even expert surgeons sometimes fail in this, and the less experienced will, of course, do so still more frequently. Hut, however skillfully applied, the tendency to swelling at the seat of 'fmctitrr, will very soon make the band- age more ti^ht at this point than below it ; the venous circula- tion will become impeded ; pain will supervene and increase until the patient or his friends will be compelled to cut loose the bandage, in order to release the strict ure. The patient will n. s. VOL. VI. NO. II. 8 82 Dugas, on Fractures. [February, then have to remain with an imperfect adjustment of dressings until the physician can see him, which, in the country, may be, not only hours, but days. Cases also unfortunately occur oc- casionally in which, from the docility or fortitude of the patient, he does not demand and obtain timely relief from the com- pression, and suffers mortification to take place. One of the most distinguished surgeons of the North stated to the writer, a few months since, that he had been repeatedly called upon to perform amputation, in consequence of the tightness of the bandage occasioned by the supervention of swelling at the seat of fracture. There can be no doubt that such accidents are much more common than generally supposed, from the fact that few men are as fond of reporting their unfortunate cases as they are of heralding their successful achievements. The third object proposed to be attained by the roller band- age, is the reduction of the swelling or tumefaction usually occasioned by fractures. For this purpose, the bandage is ad- vised to be applied after the tumefaction shall have reached its maximum. At this stage of the case the bandage is unques- tionably less objectionable than it is at an earlier period ; yet its application, even now, is very painful ; it is still difficult ; and it may be so applied as to produce unequal pressure and conse- quent strangulation, with all its inconveniences and dangers. If it were absolutely necessary, these objections might be waived ; but, if not, they should have their full weight in deter- mining the practice to be adopted. It is certainly not abso- lutely necessary thus to reduce the swelling ; and the utility of the reduction by such means is extremely questionable. That any real evil arises from such tumefaction as usually follows fractures, has yet to be demonstrated. If left to the efforts of nature it will subside in due time, without the use of any com- pression whatever. If the bones can be maintained in apposition and the swelling be subdued without the roller bandage, and if this bandage cannot, without great danger, be depended upon for the preven- tion of tumefaction, the necessary inference is that it may be omitted without impropriety. If, again, it be true that the manipulations required for the application of the roller bandage are always painful, that they have almost invariably to be repeat- 1850.] Dugas, on Fractures. 83 ed once or more as the swelling progresses, that the compres- sion is generally the principal cause of pain in the treatment of fractures, and that it occasionally induces mortification when least expected, we should conclude, not only that it may be omitted without impropriety, but that its use ought to be aban- doned in general practice. The writer wishes not to be understood as alluding here to the starch bandage recommended by the distinguished surgeon of Brussels. The number of victims to its use when first sug- gested remains yet to be told. Suetin, however, no longer calls it the "immovable bandage," but the " movable and immovable bandage" and, so great is his apprehension that the roller bandage, which constitutes a part of it, may be applied with a view to compression, and therefore perhaps too tightly, that he advises a bit of tape to be placed longitudinally along the two sides of the limb before the roller bandage, and in such a man- ner that the ends will project above and below : the roller bandage is then to be applied with only as much tightness as may be required to keep it in place ; after which, the ends of the tape are to be drawn upon, for the purpose of ascertaining by their freedom of motion that the compression is neither too great nor unequal. If much swelling ensue, it will be manifest- ed, not only by pain and the appearance of the distal end of the limb, which is always to be left exposed for inspection, but also by the difficulty of moving the tapes beneath the bandage ; in which events he urges the bandage to be slit open and re- adjusted more loosely. With these abundant precautions, upon which Suetin now dwells with great earnestness, the plan is unquestionably the best that can be devised, whenever the pa- tient can have ready access to the surgeon or to an expert nurse as soon as it may become necessary to modify the dressing. In establishing rules of practice, whether in medicine or in surgery, authors do not sufficiently discriminate between the various circumstances in which both practitioners and patients may be situated. What may be easy and proper under certain circumstances, may prove difficult and injudicious under a dif- ferent state of things. A system of practice may be highly beneficial and unobjectionable in hospitals or cities, and be entirely unsuited to the camp or country. What may be 84 Eve's Introductory Lecture, [February, harmless in the hands of highly cultivated and experienced physicians, may cease to be so under the administration of practitioners less skillful. It is therefore important that the principles as well as the details of general practice, be plain, intelligible to all, and of easy execution. The safety of society demands that dangerous expedients be discountenanced by the profession, especially whenever more harmless procedures can be substituted for them. The indiscriminate use of the roller bandage in the treatment of fractures, has often occasioned the most serious accidents, and should give way to the simple use of splints and bandages applied in such a manner as to admit of being modified, according to the progress of tumefaction, by any person of ordinary intelligence. Let the more complica- ted and hazardous processes be confined to such cases as may be continually under the supervision of the surgeon. PART II. RetmtDS ctnir ., Secretary of the College of Physicians, &c, &c. Third Edition, revised and augmented, Philadelphia: Lea and Blanchard. 1850. 1 vol. 8vo., pp. 703. It can scarcely be necessary to express an opinion upon the merits of a work which has become generally known to the profession, and is so universally approved as to have reached a third edition. Our principal object in noticing this new edition of Dr. Condie's work is to call attention to the fact, that it is much improved, not only by the addition of a full and well digested article on epidemic Meningitis, but by the introduction of all the more important discoveries and im- provements which have been made in the nature, diagnosis, and treatment of the diseases of children. The work is what it professes to be, a practical treatise, and no one can fail to be benefitted by its perusal. After having named Messrs. Lea and Blanchard as the publishers of Dr. Condie's book, any commendation of its mechanical execution will be unnecessary. 2. On the Diseases of Infants and Children. By Fleetwood Churchill, M. D., M. R. J. A., Hon. Fellow of the College of Physicians, London; Hon. member of the Philadelphia Medical Society, etc., etc.,; author of the "Theory and Practice of Mid- wifery," " on the Diseases of Females," etc., etc. Philadelphia : Lea and Blanchard. 1850. 1 vol. 8vo., pp. 636. This work was written by Dr. Churchill, for the American press, at the request of his American publishers, and is now for the first time presented to the profession. The high reputation Dr. Churchill has acquired in Europe and the 1850.] Bibliographical. 116 United States, by his work on Obstetrics and the Diseases of Women, cannot fail to secure a favorable reception for the one now before us. We were very much gratified at the appearance of this publication, but still more on examining its valuable contents. In our estimate, some little modification may be required in the treatment of certain diseases, especially in the doses of certain medicines ; but with occa- sional variations and adaptations to Southern practice, which any physician of even moderate experience can readily make, its claims to merit, both as a scientific and practical work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe very few are equal to it, and none superior. j. a. e. 3. Principles of Human Physiology, with their chief applications to Pathology, Hygiene, and Forensic Medicine. By Wm. B. Car- pester, M. D., F. R. S., F. G. S.. &c, &c. Fourth American Edition. Philadelphia ; Lea and Blanchard. 1850. The Physiological works of Dr. Wm. B. Carpenter are so exten- sively and favorably known, that the mere announcement of a new edition of his most complete production, " with extensive additions and improvements by the author," is sufficient to secure for it a ready sale. The career of Dr. C. as an author has been most brilliant, both in Europe and in the United States. From the fact, however, that the demand for a new issue in this country has anticipated that in England, the author has had the opportunity of laying before his American readers his latest views upon several topics of considerable and growing interest, especially on the Nervous system and on Gen- eration. The treatise before us may therefore be now regarded as one of the most complete we have, and should be possessed by all who desire to keep pace with the rapid strides of this very interesting de- partment of medical knowledge, a correct acquaintance with which is indispensable in the appreciation of the morbid as well as normal phe- nomena of life. d. 4. Maclise Surgical Anatomy. Surgical Anatomy. By Joseph Maclise, Surgeon ; with colored plates. Part 1st to the 16th plate, inclusive. Large imperial quarto. Lea and Blanchard. Philadelphia : 1850. We have just received the first part of this beautiful work, contain- ing sixteen plates representing dissections of the Thoracic, Cervical, Axillary, Brachial, and anti-Brachial regions. The representations appear to have been made from original dissections, and are remarka- bly clear, and beautifully colored. 116 Bibliographical. [February, Although we are not prepared to admit that any thing can supply to the operator the place of actual dissections for it is only by this means that we acquire such a definite idea of the conditions and rela- tions of parts as will give confidence to our incisions still, to those who have dissected, this work will be found a most valuable remem- brancer of knowledge more thoroughly and laboriously acquired in the dissecting room. The plates are accompanied by references and explanations, and when the whole has been published, it will be a complete and beautiful system of Surgical Anatomy, having an ad- vantage which is important, and not possessed by colored plates gen- erally, viz : its cheapness, which places it within the reach of every one who may feel disposed to possess the work. Every practitioner, we think, should have a work of this kind within reach, as there are many operations requiring immediate performance in which a book of reference will prove most valuable. H. F. c. 5. Stanley on the Bones. A Treatise on Diseases of the Bones. By Edward Stanley, F. R. S., President of the Royal College of Surgeons of England, and Surgeon to St. Bartholomew's Hospital. Pp. 286. Lea and Blanchard, Philadelphia. 1849. We have examined this excellent work with much satisfaction. It is a concise and systematic treatise on the diseases of the Bones ; and supplies a want in medical literature that has been much felt by the p rofession. Heretofore we have been wholly dependant upon the few pages in works on Pathology and Surgery, for the history of the ob- scure, and often inscrutable diseases of this important part of our organism ; hence, the student's information concerning them is gene- rally imperfect, for want of more definite and elaborate treatises. The only works now extant that are devoted entirely to the diseases of the bones, are the Treatises of Petit, published in 1705, and of Boyer, in 1803. These are not accessible to the whole of the profes- sion ; and moreover are not of sufficiently modern date for the present state of our science. The present work seems to be the result of much study and patient investigation, under circumstances the most favora- ble for affording the best practical deductions. The author, from his position as Surgeon to St. Bartholomew's Hospital, has been enabled to produce a work of practical, as well as scientific excellence, and each of his chapters is well sustained and illustrated by cases which much enhance the value of his teachings. The work deserves a more extended notice than the limits of a monthly journal permits ; we therefore must content ourselves with giving it our unqualified recommendation. h. f. c. 1850.] Periscope. 117 PART III. lllontljlg periscope. On the Depuralive Action of the Bile. By Dr. Fauconneau-Du- fresne. (Brit, and For. Med. Rev. N. Y. Journ. Med.) Speaking of the function of the liver as auxiliary and vicarious to that of the lungs, the author observes : In intra-uterine life, the bile, in the ab- sence of respiration, purifies the blood by the removal of carbon. The meconium of the foetus is the carbon of the blood, extracted in a liquid form, which after birth will be eliminated in the gaseous form. If it is objected that the biliary secretion in the foetus is not manifested until towards the fourth month, it may be answered that, until this period, the liver is of very considerable proportionate size, and that it retains, for the purpose of its augmentation, materials, which, later, will serve for the secretion of this fluid. This function of the bile is not so appli- cable in extra-uterine life. In the different vertebrata, the develop- ment of the liver is generally found to be inversely to that of the lungs. This remarkable antagonism exists especially in fish, which respire by the bronchiae. In certain species of serpents the bile is very abundant, as if to compensate for their imperfect respiration. MM. Sandras and Bouchardat (Annuaire de Therapeut. 1845,) have established that, whatever be the nature of the aliment taken by an animal in good health, the quantity of fatty matters found in the blood is nearly the same, which gives rise to the supposition that they are eliminated as fast as they are introduced into it. According to the same authors, the fatty bodies which the liver separates from the blood have a constant point of fusion, and consist principally of choles- terine, which the blood of carnivora always contains, and of the mar- garic and oleic acids, united with soda. The fatty bodies of the blood are subjected to a series of successive oxidations, by which the solubili- ty of the sodaic compound which they form, is indefinitely increased. Cholesterine may result from the alteration of the fatty bodies ; for it is a neutral fat, the point of fusion of which is very high, and which, not having been burned in the blood, must necessarily become elimi- nated from the economy. Arsenic in Intermittent Fever. (Journ. des. Con. Med. Chirurg.) From the first of January, 1843, to the first of January, 1846, five hundred and seventy-four persons were admitted into the military hos- pital of Versailles with intermittent fever. Of this number, one hun- dred and forty -two had but slight fevers, and as their general health was not sensibly affected, they were treated with emetics, and simple hygienic means. The other cases in which the fever was well marked, and originated in marshy localities, were treated with the sulphate of quinine, or arsenious acid and emetics. Of the cases treated without either quinine or arsenic, there were eight relapses. One hundred 118 Periscope. [February, and eleven cases treated with the sulphate of quinine furnished four- teen relapses, whilst of three hundred and eleven treated with the arsenic, there were but ten. More than one -third of the cases sub- mittted to the arsenical treatment, had previously taken the quinine. The sojourn in the hospital of those who were treated with quinine averaged thirty days ; those who took arsenic averaged but twenty -two days. It is very evident that the intermittents of France are more obsti- nate than those of our region, or that our French brethren have yet much to learn in relation to the mode of employing quinine in such diseases. We hazard nothing in asserting that in the hands of the most inefficient of our practitioners, nay, even under the management of southern overseers, it would be a rare occurrence for any patient laboring under intermittent fever to remain on the sick list for one half of either of these average periods. Frictions of Oil of Turpentine in Intermittent Fever. (Journ. des Con. Med. Chir.) M, Maillier states that, since the year 1846, he has employed frictions with oil of turpentine with uniform success in cases of intermittent fever, even in such as had resisted the action of quinine in very large doses. He uses a liniment composed of the oil of turpentine, to which is added a small portion of laudanum, of which a couple of spoonsful are rubbed along night and morning dur- ing the apyrexia. Nitrate of Silver in Cholera. (Bulletin Gen. de Therap.) By N. Bakth.- The nitrate of silver was administered to hfty-three pa- tients of all ages, and all more or less seriously attacked. To some, it was administered only in enema, but in most instances it was also taken by the mouth. The ordinary dose was one grain, and in enema, five grains, and was administered one, two, or three successive days, rarely longer. In many cases the desired effect was produced in twenty-four hours ; when employed for three cr four days, without any good result, its use was abandoned. The principal effect of the nitrate of silver was to moderate the morbid secretions, and frequent- ly in eight or ten hours, the diarrhoea was arrested. In many cases the obstinate vomiting suddenly ceased after the first doses of the medicine had been taken. In no instance did the nitrate produce any inconvenience. In several instances, it produced no astringent effect, especially when given too late, but it never caused pain in the bowels or stomach, or was followed by any unpleasant consequences. 1850.] Periscope. 119 Combination of Mercurials and Chalybeaies in the treatment of Se- condary Syphilis. (Journ. des Con. Med. Chir.) Secondary Syphilis is often accompanied with a discoloration of the tissues with ansemic symptoms, against which it has been remarked that preparations of iron were very often efficient remedies, after the use of mercurials. The following is a formula for making Mercurial Ferruginous Pills, in imitation of those of M. Lagneau, which M. Bouchardat recommends to the employment of practitioners. R. Double Mercurial Oint., } Vallet's Pill mass, aa. > 5 grammes. Medicated Soap, ) Make 100 pills. Dose, from 2 to 6 per day, to be continued for the space of two months. Aloctic Febrifuge Elixir. (Journ. des. Con. Med. Chir.) A Jour- nal attributes to M. Recamier the following formula for avoiding the unpleasant consequences in the administration of Sulphate of Quinine; R. Aloes, soc. in powder, ) a i\r u \ 0 grammes. Mvrrh, aa. ) o Rheii, 150 ' " Alcohol, at 32 20 " Macerate for 24 hours, and filter. In this liquid, dissolve 6 grammes of sulphate quinine, agitate the whole with 25 or 30 drops sulph. acid, and add 2 grammes of Sydenham's laudanum. Dose, for an adult, 1 table-spoonful, and for a child, about a desert-spoonful. After each dose, the patient should keep warm, and remain at least two hours without drinking. By adding to this elixir 4 grammes of pulv. col- chici, it becomes, according to M. Recamier, a good remedy in rheu. matic affections. On the Nutritive Properties of Fish Oil. By Robert Druitt, F. R. C. S. (Med. Gaz. N. Y. Jour. Med.) Of the virtues of cod liver oil there can be now no question ; and it seems capable of doing two things. In the first place it fattens and adds to the bulk of the body ; and, in the second place, it gives nutrition a better turn, as it were ; it makes the fluids and solids healthier as well as bulkier, and enables them to throw off a variety of cachectic derangements. These useful qualities have been partially accounted for on the sup- position that they are due to a minute quantity of some biliary principal contained in the oil. This supposition seemed to me ex. tremely improbable, especially on considering the numerous adultera- tions to which the oil was liable ; and accordingly I determined on making a few experiments on the subject, the results of which I beg to forward to you. 120 Periscope. [February, For this purpose I applied to my oilman for some specimens of the purest and sweetest lamp oil, and procured several varieties of whale and seal oil, decidedly fishy and rank in flavor, but not rancid or oxy- dized or putrescent. In fact, the flavor of the oil commonly called " southern oil," the produce of the black whale, which I chiefly em- ployed, is not disagreeable to any one who is free from fancies on the subject ; and if mixed with three or four parts of almond oil, is not a whit more offensive to the taste than the common oleum jecoris asselli. Case I. and II. Two brothers, S., aged 3 and 5, flabby, pasty children, each suffering from pustular eruption on the head and face. A wound made on the head of one of them a week since had degen- erated into a flabby sore. No deficiency of food. Both took a teaspoonful of seal oil three times a day in lemonade. Their mother reports that they were excessively fond of their medicine ; they took it for a fortnight, when the skin of each was quite healthy, and com- plexion clear. III. J. W., a pale, unhealthy child, aged 2\ years, subject to pus- tular eruptions on the face. Cured by the same dose of southern oil, thrice daily for a week. Cured far more readily than on former occa- sions by calomel. Likes the oil extremely. IV. J. L., a miserable child; glands in neck, greatly enlarged ; purulent discharge ' from ears ; abdomen swelled and hard. This child got better under the use of seal oil, but did not take it regularly enough to make the case of any value. V. J. E., aged 2, subject to skin disease from birth ; his mother has had syphilis : his complexion peculiarly pasty and sallow. Took southern oil in the above doses for a month. Greatly improved in flesh and complexion ; but at the end of the course had an attack of eczema in the arms. VI W. aet. 30 ; subject to sciatica. Took the southern oil ; is certain that it has done him much good. VII. J. W., get. 36. Was largely bled for acute rheumatism a twelvemonth since. #Has never recovered flesh or strength, and is racked with pains in the back and shoulders. Took cod liver oil for a month with benefit last May ; left it off during the summer ; became thinner and weaker. Took southern oil in the dose of two drachms thrice daily for three weeks ; likes it much ; feels stronger, and looks as decidedly fatter and better in condition as he did from the cod liver oil. Mrs. P., suffered from puerperal mania whilst suckling last autumn ; has continued anaemic and despondent ; has taken every form of min- eral and vegetable tonic with temporary benefit. Took southern oil for three weeks, is unmistakeably plumper, clearer in complexion, and in better spirits. IX. J. M., a sallow child, aet. 4, took the southern oil for a week, for impetiginous eruptions on the face and legs. The improvement in flesh and clearness of complexion was extraordinary, and the eruption nearly disappeared. 1850.] Periscope. 121 These few cases do not prove much : out, so far as they go, are satisfactory. No one who had seen the children above mentioned be- fore and after their course of oil, could doubt that a most beneficial change had been wrought by something. The great delight which the little wretches took in their dose is another point worth noticing. I would therefore suggest, that it is well worth while to make a fair experiment on a large scale, to determine whether it is fish oil in gen- eral that does good, or only the oil of the cod's liver. If, as I believe, almost any kind offish oil will answer the purpose, then many of the poor will be able to use the cheaper kinds, who could not afford the nicer but more costly cod liver oil. Remarks on the good effects of the ointment of Nitrate of Silver, in the treatment of venereal buboes. By Dr. Robin, Sainte-Etienne, Loire. (Bui. Gen. de Therap.) Encouraged by the success of Dr. Lutens (of Anvers) in the treatment of venereal buboes, by nitrate of silver, I had recourse to its employment in my venereal practice, at the hospital of Sainte-Etienne, and employed it in more than twenty cases of double adenitis, and at all stages of inflammation. These are the results : In twelve cases the inguinal engorgement disappeared in eight or ten days, using the ointment morning and night ; in the remaining four, it was necessary to continue the fric- tions for a few days longer. In four cases I punctured the tumor, to allow the pus, which had collected, to escape, and to prevent a too great destruction of skin. Friction was continued on the remaining portions of the tumor, and a cure was quickly effected. The stage of suppuration was so far advanced in two other cases, at their entrance into the hospital, that I was obliged to confine myself to the knife and emollients. Such results should encourage practitioners in the use of this oint- ment in the treatment of syphilitic buboes, and in analogous cases. There is no doubt, but that indurated orchitis, bronchocele, parotitis, &c, might be successfully treated in this manner. This ointment does not occasion pustular eruptions, as mercurial, and other ointments do, but only an itching. The nitrate of silver should be first dissolved in a very small quantity of water, before mix- ing it with the adeps. The ointment used by Dr. Lutens consists of 4 gram, of the salt to 30 gram, of adeps, but that used by myself contained but 2 gram, of the salt, and the results were so satisfactory, that I deemed it unne- cessary to increase the strength. 122 Periscope. [February, New mode of Tamponning the Nasal Canals. By M. Merat. (Union Med., Sept. 1849. Bui. Gen. de Therap.) On examining the nasal cavities, they are found to be narrow, crooked canals, nar- rower behind than in front, and lined by a highly sensible mucous membrane. We know that the most frequent seat of nasal hemor- rhage is at the anterior and superior part of the canal. In considera- tion of this anatomical and pathological circumstance, and also the difficulty of the ordinary mode of operating, M. Merat thought that a more certain method might be adopted, which would also be less com- plicated and easier of performance, for arresting the hemorrhage. This consists in introducing, through the anterior opening of the nostril only, small balls of lint, pushing them back as far as possible, there being no danger of forcing through the posterior opening, since the canal diminishes as it proceeds backward, and the efforts at expecto- ration and coughing will tend to keep them forward. This method has, according to M. Merat, the advantage of being within the reach of every one, for cotton, paper, dec, may be substi- tuted for lint. This mode produces but little pain compared to Bellocq's, and it does not produce tumefaction and that fetid secretion from the mucous membrane, which the last named method sometimes does. And ano- ther advantage which M. Merat ascribes to it is, that it can be used immediately. Conclusions respecting Laryngotomy in Croup. By F. Churchill, M. D. 1. That the larynx is not mechanically closed by false mem- brane ; that in all cases, as Dr. Cheyne has remarked, there is suffi- cient space for the access of air; that if the larynx be closed, it must be by spasm in addition to the exudation ; and that, therefore, to at- tempt relief by a mechanical operation would be superfluous, to say the least of it. 2. That it is extremely difficult to say that exudation has taken place, and still more to fix the limits of it, and pronounce in any case that it has not extended below the larynx ; and yet upon this depends the utility of the operation ; for 3. If the false membranes have extended below our incision, the operation, being purely mechanical, can afford no relief, but may se- riously add to the danger. 4. Bronchitis or pneumonia may exist at the time of the operation, or may very likely arise very soon after, and render it altogether use- less. 5. The operation itself is not without danger, nor quite so easy as has been stated, especially with young infants. In addition to hemor- rhage and escape of blood into the trachea, the patient may be at- 1850.] Periscope. 123 tacked by prolonged syncope, asphyxia or convulsions, as occurred in M. Trousseau's practice, and occasionally either of them may prove fatal. 6. That the risk of inflammation and other accidents after the ope- ration is very considerable, and materially diminishes its value. 7. That the results of the operation hitherto, although successful to a considerable extent, are not sufficient to justify our having recourse to it under ordinary circumstances. .** If," says Mr. Porter, "it were possible to place a host of those cases in which bronchotomy had not proved serviceable, in array against those wherein it had seemed to be useful, it would scarcely be necessary to advance any further argu- ment in proof of its uncertainty. "? On Dis. of Inf. and Childhood. Reciprocal Influence of Pregnancy and Phthisis. ( Journ. des Con. Med. Chirurg,) The influence which pregnancy and phthisis exert reciprocally upon each other. In a memoir read by M. Grisolle, un- der this head, he states as his opinion that pregnancy does not arrest the progress of phthisis, as it is supposed, but on the contrary it rather increases the organic lesion. Here are the results of his observations in seventeen cases. 1. It is rare to see conception take place in confirmed phthisis ; but, on the contrary, the first symptoms of pulmonary tubercles often appear suddenly during pregnancy, and particularly during the first three or four months. 2. If unfavorable hygienic conditions, grief and misery, seem sometimes to explain the development of the organic affection, it is certain that in the greater number of instances pregnancy was the only observable change in the condition of the woman, and that it acted as the exciting cause. But pregnancy did not produce the dis- ease ; it only predisposed to it, as any other physiological or patholo- gical change would have done. 3. Pregnancy and phthisis appearing at or about the same time, ran their course without seeming to influence each other. 4. I have however observed, by comparison, that the organic lesion ran its course more rapidly than when pregnancy did not exist. 5. What proves, moreover, the evil effects of pregnancy, is that, as soon as parturition takes place the disease relents in its progress, or remains stationary, provided the disease was not too far advanced be- fore delivery. 6. Pulmonary tubercles do not modify pregnancy, at least in the majority of cases. This point has already been established by Desormeaux and M. P. Dubois. 124 Periscope. [February, Suppression of Uterine Hemorrhage. Machen. (Lancet.) More than three years ago, I wrote to a medical publication, suggesting an apparatus somewhat similar, but, I think, more applicable to those distressing cases haemorrhage after labour ; indeed, its simplicity is such, that an ordinary midwife could with ease make use of it ; for the greatest number of deaths occur in the practice of that class of obstetricians. Having provided a bullock's bladder of the largest size, and an ordinary enema apparatus, I fix the neck of the bladder to the enema- tube, softening it, however, before use, in warm water. The bladder is introduced into the uterus, and cold water pumped into it. The direct application of cold will soon cause the open orifices of the bleeding vessels to close, and the uterus to contract; and that the water might escape as the uterus contracts, I would have the tube double, and furnished with a stop-cock, which could be open to suffer the water already pumped in to run out, while the pump might con- tinue throwing in fresh cold water until the desired effect is fully ob- tained. Craniotomy ; the Child Born Alive. (Medical News.) We copy the following extraordinary case from the Pro v. Medical and Surgical Journal : " A remarkable case is narrated in the annals of the Medical So- ciety of Flanders, in which craniotomy was performed in consequence of deformed pelvis; but the child could not be extracted. As a last resource, the Caesarean section was performed, and, to the astonish- ment as well as horror of the surgeon, the infant was extracted alive, and exhibiting an immense lacerated wound of the skull. The brain was completely denuded, and appeared to be reduced to a complete pulp. The child survived, and suppuration was established, large quantities of brain coming away at intervals with the purulent matter. When exhibited to the Society, the child (a boy) was nine years old, and did not appear intellectually inferior to the average of boys of his age. The mother did well, and died some years afterwards of fever." Dysmenorrhea. (American Journal.) Dr. N. Ward, of Burling- ton, Vermont, reports that in several cases of menstruation, he has obtained the best results from the use of \ gr. of sulph, ferri, with a slightly laxative dose of sulph. magnesia, every day during the interval of the monthly periods, or for the last ten days of the interval. 1850.] Miscellany. 125 itUbual fHtsrellang. We have received a communication from Dr. J. D. Brooks, of Bellevue, Georgia, in reference to a singular epidemic which oc- curred in his neighborhood in August last, and to which the people assigned the name of " Bellows," the principal symptom being great difficulty of breathing, without cough or other indication of inflamma- tion of the respiratory organs. The cases generally yielded in a day or two to an emetic, a mercurial cathartic, and sinapisms to the breast and spine. It is to be regrettted that no post-mortem examination was made, by which more light might have been elicited in relation to the real pathology of these cases. Creosote to remove the Taste of Cod-liver Oil. (N. Y. Jour. Med.) One drop of Creosote added to each dose of half an ounce of Cod-liver oil, is said, by Dr. Barclay, to succeed in almost every instance in obviating the sickness which so generally follows the administration of this oil. Danger of using Gutta Percha Catheters. (London Med. Gaz.) Caesar Hawkins, Esq., Surgeon to St. George's hospital, says: Very soon after they were introduced, I was obliged to give up the use of catheters and bougies made of gutta percha, on account of the great irritation they generally excited in the urethra an irritation which is also found in many cases to prevent the employment of splints made of this substance in the treatment of fractures and diseased joints, for which it would otherwise be well adapted. The case of a man who this day leaves the hospital, induces me to point out the actual danger to life which may be occasioned by catheters of gutta percha, and is the necessary result of the mode in which they are construct- ed ; not of accidents or carelessness, which will occasionally lead to the breaking of the ordinary gum catheter also. The catheter is made, it would appear, of a slip of gutta percha nearly an inch wide, and of the necessary length for making the ca- theter, which is twisted round a stilette, so as to make the edges of the slip join together, in which position a moderate degree of heat makes them cohere to constitute a tube, when the stilette is withdrawn. Of course, if this slip is screwed up in one direction, the edges are pressed together ; but when twisted in the contrary direction, unless made to cohere very firmly, the catheter is readily untwisted into the original long narrow slip of the material employed, and probably the warmth of the body facilitates this separation of the edges of the slip. A second catheter, which my patient used on only one occasion, was thus opened at one point of junction, and was easily unrolled for its whole length ; others are not so easily broken up, but all must be dangerous. 126 Miscellany. [February, Death by Chloroform. The January number of the London Lancet contains the history of a casein which the inhalation of not more than one drachm of chloroform was followed by fatal consequences, in six or seven minutes. The case was one of a trifling character (onychia of the left great toe), and affords another striking illustration of the impropriety of resorting to so powerful an agent, except in the more serious surgical and obstetrical operations. Frequency of Poisoning by Arsenic. (London Lancet.) From the following table, drawn up by Messsrs. Chevallier and BoysdeLoury, the relative frequency of the use of arsenic (arsenious acid) for crimi- nal purposes in France will be seen at one glance. Arsenious Acid, .... 34 Acetate of Copper, . - - - 7 Cantharides, ... - . 5 Corrosive Sublimate, ... 5 Nux Vomica, 4 Fly Powder, ... - . 3 Nitric Acid, 2 Sulphur of Arsenic, - - - 1 Tartar Emetic, - - Opium, - - - - * Acetate of Lead, - - Cerussa, Sulphuric Acid, - - Sulphate of Zinc, - - Mercurial Ointment, - Undetermined nature of Poison, Inportant discovery in Ventilation. (Lit. Gaz. London Lancet). Dr. Chowne has enrolled a patent for improvements in Ventilating rooms and apartments, of the perfect efficacy of which, we believe, there cannot be a doubt, and on a principle at once most simple and unexpected. Without going into details at present, we may state that the improvements are based upon an action in the inverted syphon which had not previously attracted the notice of any experimenter viz., that if fixed with legs of unequal length, the air rushes down into the shorter leg, and circulates up, and discharges itself from the longer leg. It is easy to see how readily this can be applied to any chamber, in order to purify its atmosphere. Let the orifice of the shorter leg be disposed where it can receive the current, and lead it into the chimney (in mines, into the shaft.) so as to convert that chimney or shaft into the longer leg, and you have at once the cir- culation complete. A similiar air syphon can be employed in ships, and the lowest holds, where disease is generated in the close berths of the crowded seamen, be rendered as fresh as the upper decks. The curiosity of this discovery is, that air in a syphon reverses the action of water, or other liquid, which enters and descends or moves down in the longer leg, and rises up in the shorter leg ! This is now a demonstrable fact ; but how is the principle to be accounted for ? It puzzles our philosophy. That air in the bent tube is not to the sur- rounding atmosphere as water, or any heavier body, is evident ; and it must be from this relation that the updraft in the longer is caused, and the constant circulation and withdrawal of polluted gases carried 1850.] Miscellany. 127 on. But be this as it may, one thing is certain that a more useful and important discovery has never been made for the comfort and health of civilized man. We see no end to its application. There is not a sanitary measure suggested to which it may not form a most beneficial adjunct. There is not a hovel, a cellar, a crypt, or a black, close hole anywhere, that it may not cleanse and disinfect. We trust that no time will be lost in bringing it to the public test on a large scale, and we foresee no impediment to its being immediately and universally adopted for the public weal. We ought to remark that fires or heating apparatus are not at all necessary ; and that, as the specification expresses it, ' this action is not prevented by making the shorter leg hot while the longer leg remains cold, and no artificial heat is necessary to the longer leg of the air-syphon to cause this action to take place.' " Medical Education in Spain. (London Lancet.) We learn from an official return, that there are in Spain 290 professors belonging to the universities. Out of these, 86 give lectures on medicine and pharmacy. The number of medical professors is 75. There are, namely, 19 in Madrid, 14 in Barcelona, 14 at Valencia, 13 at Santiago, and 15 in Sevile. Of the 11 pharmaceutical professors, there are 6 in Madrid, and 4 in Barcelona. The 290 professors of the various universities of Spain cost the government 4,860,000 reals (52,488.) The medical professors have salaries varying from 130 to 220 a year, and the whole of the medical and pharmaceutical professors, taken together, cost the state about 17,971. A glance at the profession in actual practice, shows that there are in Spain 5500 physicians and medico-surgeons, more than 7000 surgeons and 3300 pharmaciens. It will therefore not appear surprising that the majority of practitioners are in great distress. Mortality in Cities. The deaths in the city of New-York during the year 1849, amounted to 22,374, or 1 in 20.11, estimating the popula- tion at 450,000. Of this number 3718 died of consumption, and 5072 of cholera. If the deaths from cholera are deducted, the mortality from other diseases would be in the proportion of 1 in 26. The deaths in Boston in 1849, are stated by the Boston Medical Journal at about 5300. The editor estimates the population at 130,000, which fixes the rate of mortality at 1 in 24.53. The deaths in Augusta, during the same period, amounted to 215, of which 107 were whites, and 108 blacks. If we estimate the popu- lation at 9000, which is certainly under the mark, the ratio of deaths is 1 in 41.86. Of these deaths, 55 were from cholera infantum, and other diseases ofthe bowels. 128 Meteorology. AUGUSTA, January 2, 1850. At a meeting of the Students of the Medical College of Georgia, Messrs. George Lumpkin, A. C. Hanson and W. S. Harden, were appointed a Com- mittee to report resolutions expressive of their regret at the decease of their friend and fellow student, Charles C. C. Williams, of Florida, which occurred this morning. At a subsequent meeting of the Faculty and Students, the Committee reported the following resolutions, which were unanimously adopted: Recolved, That by dispensation of Divine Providence we have been bereft of a companion, whose gentlemanly deportment and amiable character had se- cured to him the respect and affection of all who had made his acquaintance. Resolved, That we deeply deplore the loss we have thus sustained, but that our sorrow is mitigated by the fact that, although far from his cherished home, he received from the Faculty, from his fellow Students, and from his relatives, every kindness which true and heartfelt sympathy could dictate. Resolved, That we tender to the afflicted mother and relatives of the deceased our sincere condolence on this melancholy occasion. Resolved, That as a token of respect, we wear crape upon the left arm for thirty days. Resolved, That a copy of these proceedings and resolutions be forwarded to the mother of the deceased, and also presented to the Editors of the city papers and of the Southern Medical and Surgical Journal for publication. L. D. FORD, Chairman. ' METEOROLOGICAL OBSERVATIONS, Ga. Latitude 33 27' north Longitude 4 tide, 152 feet. By Dr. Paul F. Eve. for December, 1849, at Augusta, 32' west Wash. Altitude above 6 Sun Rise. 2, P. M. to c Ther. Bar. Ther. Bar. 1 56 29 67-100 60 29 58-100 s. 2 63 " 48-100 64 " 44-100, s. 3 46 " 65400 54 " 71-100, w. 4 45 " 87-100 48 " 87-100; N. W. 5 36 " 76-100 71 " 70-100; w. 6 43 " 72-100 72 " 74-100, s. w. 7 44 " 90-100 66 " 95-100, N. E. s 44 30 50 :< 94-100 N. E. 9 46 29 84-100 57 79-100 N. 10 55 " 74-100 73 " 67-100J S. 11 58 95-100 57 30 11-1001 N. W. 12 32 30 32-000 51 30 34-100 N. E. 13 39 30 14-100 39 29 92-100, K. 14 39 29 82-100 42 80-100; N. W. 15 43 " 90-100 45 " 93-100, E. lf 45 " 93-100 52 " 89-100 E. 17 54 " 89-100 73 " 92-100 W. 18 47 30 7-100 66 30 7-100 N. W. 19 52 30 10-100 68 30 3-100 S. 20 53 29 91-100 60 29 84-100 s. w. 21 54 " 80-100 60 " 77-100 s. 22 56 " 46-100 53 " 60-100 w. 33 43 " 69-100 52 " 63-100 s. w. 21 54 " 50-100 68 " 50-100 s. w. 25 34 " 77-100 52 " 85-100 w. 26 32 30 60 30 E. 27 35 30 68 30 3-100 N. W. 28 43 30 6-100 67 30 6-100 W. 29 48 29 95-100 70 29 87- 10C S. W. 30 53 " 84-100 61 " 80-100 E. 31 40 90-100 54 30 5-100 N. Remarks. tiny. ) tiny. 5 95-100-storm at 6 p. m. Rai Rail Cloudy.' Cloudy. Fair. Fair. Fair. Cloudy light rain. Cloudy light rain, ) all night, Cloudy rain, f 95-100. Fair-blow r. last night 35-100. Fair frost, first decided freeze. Rain, 70-100. Cloudy. Cloudy drizzle, ) 15-100. Cloudy drizzle, Fair afternoon. Fair. Fair morning. Rain, 50-100. [70-100. Cloudy rain storm all night, Fair blow. Cloudy. Fair afternoon blow. Fair. Fair. Tolerably fair. Fair morning. Cloudy shower at 7 p.m. Cloudy rain at night, 65-100. Fair. 9 Fair days. Quantity of Rain 4 inches 95-100. Wind East of N. and S. 7 days. West of do. do. 16 days. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. 6.] NEW SERIES MARCH, 1850. ~[i\o. 3. PART FIRST. Original dommtinicattons. ARTICLE V. Thoughts on the Modus Operandi and Therapeutic Properties of the Sulphate of Quinine in Malarial Fevers. By John Davis, M. D., of Abbeville, So. Ca. It is not designed, by the following observations, to enter into a labored attempt to reconcile the differences existing among medical men as to the modus operandi of the Sulphate of Quinine; but merely to bring before the readers of the Journal the results of our observations, with such views and deductions as seem to be most compatible with physiological science : and, for this, we conceive, there can be no apology necessary other than the fact, that many different and opposite views are set forth, upon this subject, by men equally entitled to credit. When the whole field is calmly and impartially surveyed, we are inclined to think that the greater differences of opinion depend more upon the importance attached to terms and technicalities, than upon facts and results. A long essay might be devoted to the questions, as to what is a sedative, and what is a stimulant, without shedding one ray of light upon the modus operandi, or therapeutic properties of the Sulphate of Quinine; for these terms, the former especial- ly, seem to aid but little in the explanation of the curative pro- perties of any individual article of the materia medica. The human system may be said to be in a sedative state or condition, when it is enjoying the most perfect health when it is free n. s. VOL. VI. NO. III. 9 130 Davis, on Action of Quinine in Malarial Fevers. [March, from all irritation and morbid action ; and any remedy, whate- ver, whose tendencies are to preserve or induce this healthy condition of the system, when diseased, is as much a sedative as any other, whether it be Calomel, Ipecac, Opium, Brandy, Quinine, Blisters, or Blood-letting. If this view of the subject be correct, then, the word sedative should not be applied to any one particular remedy or agent, rather than to another; since, in the main, they all tend, when properly administered, to restore the system to health to remove the existing morbid impres- sions, and thereby to induce a healthy, and consequently a seda- tive action of all the functions of the system. So, if the word sedative has any meaning at all, it can only mean, in physiolo- gical science, perfect health, in the general acceptation of that term, and cannot be applicable, strjctly speaking, to any remedy whose tendency is to induce that state, since, it must be con- fessed, that the remedy can only bring about the result by establishing a vital impression of its own, in the place of the one for which it was given. But, when we turn our attention to the word stimulant, we find it has a just claim to attention; for, as we have intimated, it is a law of nature, and especially exemplified in the animal system, that to remove an existing impression we must estab- lish, or substitute, another in its stead ; consequently a stimu- lant impression is a reality an effect not without a cause ; for when we look into the modus operandi and the therapeutic pro- perties of any and all of our medicinal agents, according to the generally received principles of physiological science, we are forced to the conclusion, that they all act by altering vital ac- tion, by means of impressions made upon the system. To say that any remedy (we care not what may be its name) can alter vital action, without at the same time producing a vital impres- sion, would be to claim an effect without a cause. It may, however, be said, that reputed sedatives diminish existing im- pressions, and, in this way, tend to cure disease. If so, they must also diminish, or suspend, existing action, and by the latter effect render null and void the former; for if the morbid im- pressions are not removed, by the substitution of others of their own kind, how can diseased action be removed, or vital action changed ? Hence, wTe conclude that all medicinal agents oper- 1850.] Davis, on Action of Quinine in Malarial Fevers. 131 ate upon the system by making impression, (the word impres- sion being only another term for stimulation.) and that different articles operate, as it seems, by predilection upon different organs: some upon the circulatory system, some upon the nervous and sensorial functions, and some upon the secreting and excreting functions ; all of which organs or systems are so intimately connected together as to render it impossible for any one of them to be materially impressed without, at the same time, the others partaking more or less of the impression. Alcohol may be said to act upon the circulatory system, prima- rily and chiefly ; opium, and its preparations, upon the brain and nervous system, primarily and chiefly, and calomel upon the secretions and excretions, and so on. It would be quite as proper to ask why the elements of water are oxygen and hy- drogen, as to ask why this difference in the modus operandi of medicines. We know the fact in the one case, and we only know it in the other : the why, or the wherefore, in either case, is equally sub luce, and beyond which it would be altogether futile to attempt an inquiry. From what we have said, it is obvious that we consider the Sulphate of Quinine a stimulant; and here it may not be amiss to state that we do not consider it an "antiperiodic" or atonic any more than opium, brandy, or calomel, unless it is designed to mean nothing more by the words antiperiodic and tonic, than that all medicines, when properly administered, tend to change, or remove the internal pathological conditions, upon which the external phenomena of disease depend. If this be the intended meaning of the words antiperiodic and tonic, we readily admit it as being quite applicable to the quinine, and not to quinine only, but to all other remedies, in an equal de- gree with their curative virtues. An individual is attacked, to-day, with a chill, and it assumes the intermittent type : he takes quinine, during the intermission, and gets well, without another chill. Now is it fair or just to conclude, from these circumstances, that the quinine is peculiarly tonic or antiperi- odic? The disease is, especially so far as the external phe- nomena are concerned, more or less periodic, (and so are all other diseases,) but this does not necessarily imply that the quinine, which cures it, or the remedy, or remedies, which cure 1 32 Davis, 07i Action of Quinine in Malarial Fevers, [March, other diseases, are antiperiodics or tonics, any more than that the patient was perfectly free from all disease, or morbid action, during the intermission ; for there must be in all cases, and at all stages of an intermittent, as well as in a remittent, however trivial the attack, more or less derangement of the nervous and sensorial functions, of the circulatory system, and of the secret- ing and excreting organs; though usually much less during the intermissions and remissions than during the stages of ex- citement. Now, to cut off the stages of excitement, all we have to do is to give the quinine, judiciously, during the inter- vals, and thus remove or change the nature of the existing morbid derangements, upon which the stages of excitement depend. Having much less to contend with during the inter- missions and remissions, the quinine will certainly more fully display its virtues, as a curative agent. It is in this way, as we conceive, that this remedy has secured the appellation of antiperiodic, and not from any peculiar or intrinsic virtue that it may possess in anticipating and wTarding off diseased action. It will not be pretended that there is, in any disease, a sepa- rate and distinct lesion for every seemingly different and dis- tinct symptom. This is especially true as to the periodic fevers of the Southern and South-western States. Climate, sex, age, manner of life, occupation, epidemic changes, and vicissitudes of weather, as well as temperament, to say nothing of the different intensities of affection, all tend to modify very materially the external symptoms, without at the same time affording, in the most of cases, any just ground for a change of remedies, if the remedies be properly selected at the outset. This leads us to believe that the leading principles of the pathology, and consequently of the practice in our malarial fevers are but few, and simple. We always find patients, laboring under the primary symptoms of fever, however mild the grade, to complain of weakness in the limbs, with more or less inability to exercise the mental faculties, in some instances for days, and even weeks, before they are said to be taken sick. It is not, reasonable to conclude that the weakness of body and mind, here, depend upon the excited state of the circulation, for this is but little, if at all, changed from the healthy standard, nor on a super-invigorated state of the brain and nerves. The 1850.] Davis, on Action of Quinine in Malarial Fevers. 133 patient is quite rational, and there is yet but little or no de- rangement of the secretions. Why all this weakness? Does it not seem evident that there is debility in. or a want of energy on the part of the brain and its appendages? We think this question can only be answered in the affirmative. In this state of thing?, if we give quinine, in moderate and repeated doses, the strength and vigor of both body and mind will be increased, the pulse become less frequent, softer and fuller; the peculiar febrile restlessness, anxiety and lassitude, subside* the skin be- come more moist and softer; the thirst less urgent; and, in short, the condition and feelings of the patient will undergo a radical change for the better. Xow if these are not the effects of the judicious administration of the quinine, in the forming stages of our autumnal fevers, we are ready to confess that it has no effect at all. But we go a step farther, and meet with cases presenting all the phenomena of our severest intermit- tens, where there is great anxiety and restlessness, the patient pitching and throwing himself from one side of the bed to the other, gasping, as it were, for fresh air, with great oppression and sickness at stomach, his extremities cold and clammy, whilst the temperature ofthe body is nearly or quite natural ; a quick, weak, and frequent pulse, numbering from 120 to 140; great difficulty of breathing, with a dark reddish tint ofthe surface, with watery evacuations from the bowels, and more or less derangement of the mind. Such cases as these are by no means of very uncom- mon occurrence in the Southern States, and to look upon them is to be convinced that much that threatens life is at work. Is all that we behold dependent upon the excessive derangement ofthe secretions and excretions? or does it depend upon the great derangement ofthe circulatory system, proper? or upon the disturbance of the nervous and sensorial functions? or, finally, does it depend upon violent and excessive functional disorder of all these systems of organs, in equal, or in different degrees? We would say that the first step in the morbid chain of diseased action in these cases is, (as we have intimated, was the case in the milder grades of our fevers.) derangement ofthe brain and nervous centres, and that this derangement consisted in debili- ty, or a loss of energy ; and that the next step, in the series of morbid action, was derangement of the circulatory system, and 134 Davis, on Action of Quinine in Malarial Fevers. [March, that this derangement consisted chiefly in congestions of the internal vital organs; and that the third step in the series of morbid actions was, derangement in the secreting and excreting organs; and that all these organs are more or less affected in all cases of malarial or other fevers : they are not, however, disordered in every case equally ; for we often find that the brain is more affected than any other organ, and again that the circulatory system, or it may be the secreting and excreting systems, suffer most; hence the diversity of symptoms, pre- sented by the different attacks of the same type of fever. Whilst some are mild, others are exceedingly violent, owing to the different degrees of disturbance of one, or more, or all the different systems of organs involved. Now, every practitioner who has had any experience in the management of the severer forms of intermittent, or " conges- tive fever " cannot have failed to notice that the patient had had one or two milder chills, previous to the severer ones, or, if not, had been, in the general understanding of the term, un- well for one, two, or three days, befote he was taken with the ('congestive') chill; and, further, that this previous ill health differed, in no essential particular, irom that preceeding con- finement to bed from other types of fever, viz : weakness of body and mind ; lassitude, with an aversion to both corporeal and mental effort, all denoting debility, or a want of energy, in the nervous and sensorial functions, in very many cases, long before the case became at all alarming, or there was any chill. Now, if these facts prove any thing, they shew that the first step, in the chain of morbid action (as has been intimated) manifests itself in the brain and nervous system ; for if we will take the trouble to observe closely the train of symptoms here, we will, in nine cases out of ten, find that a want of energy in the nervous and sensorial functions, invariably precedes any appreciable change in the vascular or circulatory system, even in those cases in which the patient may be carried off in ten or twenty hours after he is said to be first taken. In fact, we have made it a matter of particular observation, that patients invariably complain more or less of those feelings which indi- cate a want of nervous energy, for some time before the circu- lation becomes at all excited, or deranged, especially if the 1850.] Davis, on Action of Quinine in Malarial Fevers. 135 patient remained at rest. Finally, the chill comes on with a decided pain in the head, back and limbs ; excited pulse, inter- nal congestions, which are followed of necessity by more or less derangement in the secreting and excreting organs, as they are chiefly composed of the capillary extremities of the arte- ries. Now what are the legitimate deductions to be drawn, as to the practice? Here, according to the universally acknow- ledged principles of physiological science, we must not attempt a cure by drastic cathartics or emetics ; nor by regulating the action of the heart or arteries, by blood-letting. Neither can we expect a cure by the free use of brandy or alcohol, in any modification whatever. The reason is, (as we conceive,) that when we depend upon cathartics or emetics, or both, we only reach, and operate upon, the third morbid change in the suc- cession of diseased action derangement of the secreting and excreting organs, which depends upon the derangement of the circulation, and thus, instead of tending to effect the cure, we add fuel to the fire, by increasing the already existing gastric and intestinal irritation and debility, without, in the slightest degree, reaching and operating (favorably at least) upon the primary derangement the debility or depression of the ner- vous and sensorial functions. As to the blood-letting, the same principles hold good ; for by it we can only attempt the remo- val of the effect without removing the cause the debility or depression of the nervous energies. The same objection applies to the effects of the brandy or alcohol, in any of its modifica- tions; for these operate more directly upon the circulatory system than upon the nervous, and thereby tend to aggravate the already existing derangement and irritation, here, as well as that existing in the secreting and excreting organs, without at the same time operating, beneficially, upon the brain and nervous centres. If it be a fact that all medicines act, in curing disease, by changing vital action, and that this change can only take place by the remedy substituting an impression, and mode of action, of its own ; if it be a fact, that the difference, in the effects pro- duced by the different articles of the materia medica, are as great as their number, or as the organs and tissues, composing 136 Davis, on Action of Quinine in Malarial Fevers, [March, the human system, and that no two operate in every respect alike, and that some operate, as it would seem, by predilection upon one organ, or system of organs, and some upon others ; if it be a fact, (which we think cannot be denied with any show of truth,) that in all our malarial fevers, over which the quinine holds such universal sway, the first morbid derangement inva- riably is debility or depression of the nervous and sensorial functions ; that the next morbid change is in the circulatory system proper ; that the last, shows itself in the secretory and excretory organs, and that the first depends upon a particular cause, such as malaria, or a number of causes combined, and that the second depends upon the first, and the last upon the second, and that this is the invariable order of the succession of morbid action, in all our malarial fevers, from the most trivial to the most alarming cases, and that the diseased action is always the same, in kind, or quality, the external phenomena differing only in consequence of the different degrees of inten- sity of affection of any one or all the organs involved ; and still further, if it be a fact, that inflammation does not necessarily constitute a part of these fevers, and, further still, if it be true, as has been amply attested by experiment, and otherwise, that the effects of the sulphate of quinine, upon the brain and ner- vous system, when given in large doses, are very analogous to those of the alcoholic stimulants, without at the same time pro- ducing the same amount, of vascular action, then we think we can offer, at least an apology for our views upon the modus operandi and therapeutic properties of the Sulphate of Quinine, in our malarial fevers. Whilst we consider quinine a stimulant, we do not deem it a stimulant, whose modus operandi, or therapeutic properties, are similar to those of the alcoholic stimulants; for this very obvious reason, that whilst trie primary and almost the entire effects of the former are spent upon the nervous, the primary and almost entire effects of the latter are expended upon the circulatory system, especially when they are both administered in quantities not transcending the rational indications of physio- logical practice. This, when we take into consideration the indications, presented to our view, of the internal conditions of all the systems of vital organs, readily accounts for the differ- 1850.] Davis, on Action of Quinine in Malarial Fevers. 137 ence of their modes of operation. All things being equal, whilst the quinine gives vigor and a controling energy to the nervous functions, the brandy, or alcohol in any form, tends to increase and to aggravate the already too highly excited condi- tion of the circulatory functions, and thereby increases the existing derangement of the secreting and excreting organs whilst the quinine tends to remove the cause, the brandy tends to farther develope the sequent whilst the quinine will relieve internal congestions through the medium of the nervous system, the brandy will inflate, as it were, the vascular forces, and pro- duced a supee-excitatiox through the medium of the circulatory system. We freely admit that alcohol will excite and stimulate the nervous system, yet we deny that this is its proper field of ac- tion. We admit also that quinine will stimulate the circulatory system, more or less, when given to an undue extent; but we at the same time deny that this is its field of action. Why should we refuse to call quinine, with opium and its prepara- tions, stimulants, if their effects are different from those of the alcoholic class, or even from each other, especially, when we recollect that whilst the one class operates upon the nervous, the other acts upon the circulatory system. Might it not be anticipated, that whilst we admit all of them to be stimulants, their results upon the system would be quite different ? Thus it is seen that we are not only inclined to reject the notion of quinine being a sedative, but also to reject the notion of all sedatives, as well as antiperiodics and tonics, upon the same grounds, as without any foundation, either in observation or physiological science. What then is the conclusion ? It must be already fully anti- cipated. Apart from experiment and observation, the conclu- sion that forces itself upon us is, that quinine, in the proper and obvious sense of the term, is a stimulant, differing in many respects from all others; and that to realize the benefits of its proper and legitimate effects, as a curative agent, it should always be given, if possible, in exact proportion to the extent of the debility or depression of the nervous and sensorial func- tions. In the milder cases of our periodic fevers, from one to two grains every hour, or every two hours, will suffice; whilst 138 Garvin, on Internal Hemorrhoids. [March, in the more malignant attacks, from five to ten grains every hour, or oftener, may be required. In conclusion, we would state, that there may be many objections to the views advanced in this article ; but vve are confident that they will come with much more ease and plausi- bility in the shape of questions than answers, founded upon reason and observation, for it is much easier to ask questions, especially in medical philosophy, than to answer them. ARTICLE VI. Remarks on the Treatment of Internal Hemorrhoids. By I. P. Garvin, M. D. There is probably no disease of more frequent occurrence than Hemorrhoids, nor are there many in which the ordinary modes of treatment are usually less efficient. Comparatively few adults in our section, who reach the middle period of life, escape the annoyances produced by this troublesome com- plaint. In a large proportion of cases, the disease is slight, and is borne without any call for medical aid ; but the instances are not infrequent in which it is sufficiently severe to produce much suffering, and to impair seriously the general health. When such a state of things occurs, many physicians recom- mend the extirpation of the tumors by a surgical operation. That such advice is sometimes judicious, we are not disposed to deny, but such operations are not free from dangers, both of a primary and secondary character, and should therefore al- ways be avoided, when possible. We are fully persuaded that an operation would be rarely necessary if a proper treatment were adopted, and perseveringly followed for a sufficient length of time. Circumstances that need not be mentioned have induced us to give a considerable share of attention to this sub- ject, and as we have treated a very considerable number of cases, some of them very severe, and of long standing, with very general success, we have supposed that a brief account of the treatment adopted would not prove useless or unacceptable to the readers of the Journal. But we must premise that in 1850.] Garvin, on Internal Hemorrhoids. 139 this treatment there is nothing novel, for the remedy upon which we mainly rely is cold water, yet our mode of employ- ing it is not in general use. The application of cold topics to inflamed tumors is univer- sally known to be a very efficient treatment, but the incon- venience of such applications to such tumors as are internal, generally prevents a resort to this remedy. For many years we have been in the habit of employing enemata of cold water in every case of internal piles which we have been called to treat. We direct that about a gill of cold water be thrown into the rectum immediately before every attempt to evacuate the bowels, and that this enema be retained several minutes if pos- sible. This usually produces an evacuation of the fceces, which have been so far softened on their surface, as to permit their escape without the least straining or irritation. After every evacuation, it will be proper to use ablutions of the parts, more especially in such cases as are attended by some protrusion of the bowel. Though this treatment is a valuable palliative from the moment it is begun, it will do much more than palliate, if perseveringly continued. The length of time required will necessarily vary in each case. The proper course is to con- tinue this treatment until some days after all uneasiness is removed. In old or very severe cases, to effect such amend- ment, generally requires several weeks. It is highly important to impress upon the patient, the absolute necessity of perse- verance in the use of the cold water, even though he should be so far relieved as to feel almost well, for if it be suspended too soon, a very slight cause will bring on a relapse. So de- cided is the relief afforded by this treatment, that few persons would be disposed hastily to abandon it, but for the inconveni- ence of applying it daily. The ordinary apparatus for enemata are so unwieldy, that they cannot be carried about convenient- ly. All difficulty from this source may be obviated by the employment of a small pewter syringe with a ring handle to the piston. One which will hold two ounces is very conveni- ent, and may be carried in the pocket, when necessarv. When such enemata of cold water fail to procure sufficient alvine evacuations, the quantity of fluid may be increased to 140 Garvin, on Internal Hemorrhoids. [March, half a pint, or it may be necessary to resort to mild laxatives. Active purgation must be carefully avoided. The patient should be advised, never to aid the natural expulsive action of the bowels by straining. If an evacuation cannot be procured without such efforts, it is best to postpone it until aided by the action of a laxative. If the convenience of the patient will permit, it will prove advantageous to change the usual hour for the daily defecation, to a regular hour in the evening just be- fore retiring for the night. This will obviate the gravitation of blood consequent upon the erect position. This treatment will usually succeed equally well in hemor- rhoids attended by hemorrhage. In this form of the disease, cold water will be found a most efficient astringent. We have employed enemata composed of the vegetable astringents, and also of the acetate of lead, but have never found them to suc- ceed so well as the cold water. They are, moreover, liable to the objection of producing considerable pain, and disposition to strain, when they are evacuated. The effects of this simple mode of treatment are often surprising in some of the worst cases of hemorrhagic piles, especially when aided by such other treatment as the state of the general system may require. About two years ago we prescribed for a gentleman who had been a martyr to this form of the disease for several years. From having been remarkably fleshy, he had become very much emaciated. His skin had assumed a cadaverous hue, his nervous system was much disordered, and his strength greatly reduced. He at once began the use of the cold water enemata, and for the relief of the anaemic condition took five grains of the Citrate of Iron twice a-day. Such paliatives as the de- ranged state of his nervous system required, were given from time to time. In the course of two or three weeks, the amend- ment was very evident : the hemorrhage was sensibly dimin- ished his strength began to return, and the roses once more to bloom upon his cheek. The amendment was steadily pro- gressive, and after the lapse of a few weeks, the patient was restored to his former rotund dimensions, and the enjoyment of general good health. Since then, there have been occasional indications of relapse, which have been promptly removed by a return to the cold water enemata. 1850.] Eve Case of Hematocele. 141 In the summer of 1848, we prescribed this treatment for a gentleman who had labored under bleeding piles with consid- erable prolapsus of the bowel, for a long period, but whose general health had as yet suffered but little. We heard nothing of him for several months, when he informed us that he had left off the enemata because they had checked the discharges of blood so completely, as to induce a fear lest its sudden sup- pression should develop some other malady. We might cite a number of cases treated with similar results, but we deem it unnecessary, as we presume those referred to are sufficient to demonstrate the value of the treatment. Many cases are connected with chronic diarrhoea, hepatic derangement, etc., etc., and will require appropriate general treatment as well as the local. As it has not been our purpose to write an essay upon hemorrhoids, but merely to urge the employment of a very simple and at the same time a very effectual topical remedy, we have not noticed the general treat- ment required by those cases in which something more than local remedies is necessary. While we have no sympathy for Hydropathy, or any other of the empirical systems which have become so fashionable, we are free to admit that wre look upon cold water as an invaluable, yet too much neglected remedy in many diseases, and we are per- suaded that its simplicity has tended very much to cast its virtues in the shade. Whilst the medical profession very properly reject Hydropathy as a system, it certainly becomes them not to turn over to its followers, an agent so potent for good, as cold water. ARTICLE VII. Dissection of a large encysted Hcematocele from the Spermatic Cord. By Paul F. Eve, M. D., Professor of Surgery in the Medical College of Georgia. On the 24st January last, Col. G., of South Carolina, brought to me a negro man aged about 25, laboring under inguinal Her- nia of the right side, and a large Tumor in the spermatic cord of the same side. The rupture was of some years duration, was reducible, and a truss was worn for it. The tumor was of recent origin, dating back only five or six weeks, and was grad- 142 Uterine Displacements. [March, ually increasing in size. It was for this second affection that I was consulted. The patient said, in lifting a carriage ob- structed in the road, he felt something give way at the place where the tumor now exists, and he soon after detected a swel- ling there about the volume of a partridge egg. In operating the next day before the Class in the College, an encysted tumor of the spermatic cord, containing blood or wa- ter, was pronounced to be the diagnosis. It was quite evident that the hernia did not communicate with it. A careful dis- section was now commenced upon the tumor, dividing tissue after tissue, making some eight or ten laminae, opening the cord so as to expose its vessels, the veins particularly, and finally, a tumor the size of an orange was presented in the palm of the hand. It was almost perfectly round, as much so as any one I have ever seen; its cyst was laid open, and bloody serum was discharged with a coagulum, and the internal sur- face covered over by fibrine. The patient was under chloroform, which acted admirably. There has been considerable tumefaction in the scrotum since the operation, but the patient is now up and doing well. PART II. HXtvxzxos anir (ftxtvatis. The Causes, Effects and Treatment of Uterine Displacements. By M. Velfeau.* (Revue Med. Chir.) Causes of displacements. Arising from mechanical causes, deviations of the uterus seem at first to act only mechanically, and give rise alone to mechanical disorders. Among those who support the doctrine of uterine engorgement, there are An interesting discussion of the subject of uterine engorgements has re- cently taken place in the French Academy of Medicine, and has been protracted through several meetings. The remarks of M. Velpeau appear to have excited much attention and opposition, as his views are adverse to those held by most practitioners. The high professional rank and eminent ability of M. Velpeau, impart great interest to everything which emanates from his pen, and we there- fore have given his remarks at length. Should the views of other gentlemen opposed to him be written out, we will endeavor to present them to our readers. [Edt. 1850.] Uterine Displacements. 143. some who admit the existence of uterine deviations, but attribute them to engorgement. According to these, the uterus does not descend, does not deviate, nor is it inflected, but by its weight, when augmented by excess of volume at some point in a word, deviation, is not a primitive state ; it is only an effect, a consequence of engorgement. Nothing is exact in this doc- trine. I have proved in a number of instances, both upon the living and the dead, the existence of uterine deviations, without there being the least increase either in the size or weight of the organ. When there is hypertrophy with deviation (which I have occasionally observed, sometimes throughout, sometimes in the anterior or posterior portion only.) I am convinced that, so far from being the cause, the engorgement was the result of deviation. Once bent upon itself, the uterus is not as perme- able to the circulating fluids in certain portions as it was be- fore; hence the derangement in its functions, which might evidently produce hypertrophy. I will admit, on the other hand, that rigidity of a portion of the organ may favor one of the inflections of which I speak; but, at the same time, this etiology is only applicable in cases of deviation where there exists at the same time an excess either in volume or weight of the uterus ; and I repeat that these cases are by far the most rare. It is under the influence of chronic inflammations, old adhe- sions in the regions of the peri-uterine tissues, repeated pressure, &c, that uterine deviations are produced. Cough, vomiting, the act of lifting or carrying a weight, efforts at stool, every thing, in short, which compresses the viscera upon the body of the uterus, the neck being naturally more firmly fixed in front and behind, either by the utero-sacral or utero-vesical liga- ments, predispose to this kind of lesion. Any quick or sudden motion w7hen the uterus is relaxed to a certain degree, as at the approach of the menstrual period, abortion, or labour, is sufficient to produce inflection. I have frequently thus arrived at the origin of the disease in females who consult me, and I am convinced that by examining closely, it will be found that a large portion of deviations occur in this way. Effects of displacements. As I have said long since, (see my clinique, vol. ii, 1840), these deviations alone, are frequently 144 Uterine Displacements. [March, entirely inoffensive, and a number of women are affected with them without being aware of it. It is not impossible, however, for them to produce derangement, and these derangements are of three kinds 1st, the mechanical inconvenience which the displaced uterus occasions around it in the pelvis ; 2d, the pul- ling and stretching of the vascular and nervous filaments which come from the renal plexus and sides, which is produced by the descent of its fundus; 3d, to the narrowing of the uterine isthmus, that is to say, the internal orifice of the neck of the womb. Whenever the uterus deviates from its parallelism with the axis of the pelvis, the functions of the rectum, of the bladder, and of the nervous and circulatory systems, are in danger of being disturbed. When the patient complains of a weight about the fundament, tenesmus, constipation, frequent desire to urinate, &c, numbness of the whole pelvic cavity, to such a degree, that some believe that they are rather affect- ed with disease of the anus or intestine, than of the womb. Being depressed, the connections between the uterus and great sympathetic plexus naturally produce certain effects upon the whole digestive and nervous system ; hence those pains and uneasiness in the back, weakness, difficulty in walking, &c, and those thousand other inconveniences which torment both patient and physician. Free to descend a little lower in the pelvis, the intestinal mass plays its part in the production of like symptoms by reacting on the stomach, the liver, and the spleen. It is with such accidents that physicians have to contend in females said to labor under engorgement, but who really suffer from displacement. It must be evident to any one who will reflect for a moment, that the canal of a deviated womb must lose its dimensions at the place of the inflection, especially as this is almost always opposite the internal orifice, that is to say, the part of the uter- ine neck, naturally the most narrow. It will be seen at a glance, that an obstacle will be thus produced to the passage of the menstrual fluid, or any other matter to be expelled from the uterine cavity. From this cause, many females complain of acute pains and colics in the uterine or hypochondriac re- gions at the approach of the menses, and even during the whole 1850.] Uterine Displacements. 145 menstrual period. The passage of clots then gives rise to suf- ferings almost equal to those of labor, until they are discharged. I have seen many such cases. Some who have been in this condition for years have been relieved by dilatation of the nar- rowed neck, with bougies or sounds. Such cases point out the relation which exists between dysmenorrhea and uterine inflexions. The narrowing of the uterine canal, though it may arise from other causes, is equally a cause of sterility with uterine devia- tions. Besides the greater difficulty with which the seminal fluid reaches the orifice of the ostincae, this fluid when it has entered it, is again arrested by the constricted and changed direction of the uterine cavity, so that under such circumstances fecundation becomes very difficult. The subject of sterility is a very delicate one, and I shall there- fore make but few remarks upon it now. Guided by the pre- ceding etiology, I have treated a great many cases of sterility by dilatation of the narrowed uterine orifice : small bougies and sounds have opened the way for still larger instruments, which have permitted me to cleanse the uterine cavity by injections, and even to effect slight cauterisation. Young females who have been married for two, four, six, and even ten years, with- out having been impregnated, have conceived as soon as this treatment has been completed. Treatment of uterine displacements. The treatment of uterine displacements, notwithstanding its apparent richness in remedies, unfortunately leaves much to be desired. Without any good reason pledgets of various kinds, tonic, astringent, emollient, etc., introduced into the vagina, have been employed. For nearly thirty years I have used such applications made of saw-dust, of tan, or of powdered cinchona. Like others, I have resorted to sponge, either covered or not with fine silk, and impregnated with some medicated fluid. By these means, much relief has often been obtained, but such applications will not relieve all cases, and moreover they will not correct the dis- placement of the womb. I have tried all kinds of pessary, with but little success. It is easy to understand why they generally prove inefficient. The womb is so mobile, so slightly support- ed, that an instrument which will not hold it by the fundus will n. s. VOL. VI. NU. I If. 10 146 Uterine Displacements. [March, scarcely be able to fix it. When the case is one of anteversion or retroversion, a well adjusted pessary may possibly be useful. Once the neck of the womb is engaged in the cavity of the instrument, and is raised up, and placed in the axis of the cavity, it will in some instances remain there permanently, and give much relief. But in cases of inflexion, the value of pessaries is very questionable. In these cases, the neck of the womb being still in the centre of the pelvis may be engaged in the ring of the instrument, without in the least altering the position of the organ, and moreover is constantly escaping from it upon the least movement. Except in a few rare cases, pessaries made thicker on one side than the other, do not succeed much better, inasmuch as the organ and the instrument, rarely preserve their proper re- lations for more than a few moments. If they do give relief in some cases where there is inflexion, and not simple deviation, it is because they give support to the uterus, and not a better direction to the parts. Being discontented with all known pessaries, about twelve years ago I invented one which was intended to act directly on the deviation. It was armed with a stem of gum-elastic, from 5 to 8 centimetres in length, intended to pass up into the womb as an axis. It formed a portion of a disc, which I turned before in retroflexions, and behind in anteflexions. I used at the same time, as a rectifier, an articulated rod, similar to that proposed by M. M. Tanchou, Pravaz and Leroy d'EtioIIes, for straight- ening the prostatic region of the urethra. Carried bent, either through the stem of the pessary, or directly into the cavity of the uterus, the instrument was then straightened gradually by a few turns of the screw. Three or four women bore these attempts very well, but inasmuch as many others were threaten- ed with metritis or peritonitis, and as I feared ulceration or penetration of the uterine tissue by the stems of which I have spoken, I determined to abandon them. Would we be more successful by introducing foreign bodies in the anus? A bit of prepared sponge about the size of a finger, covered or not with fine silk or cloth, and carried dry to the neck of the womb in anteflexion, and even beyond the fundus in retroflexion, would produce a decided straightening as soon 1850.] Uterine Displacements. . 147 as it imbibed, and became distended with fluid. It is unfortu- nate that most females entertain great repugnance to such a remedy, which in fact is very difficult, and inconvenient in its application. I ought also to mention as another means, the introduction of an empty bladder into the bowel, which is then to be distended with some fluid injected into it. As all these means occasionally relieve, they may be tried ; but as none of them really cure, or rectify the inflected organ, it is clear that we have need of something more efficacious. The pressure of a pessary or other foreign body on the vagina, the womb, etc., is liable to so many inconveniences, that I asked myself twenty years ago, if certain kinds of belts would not answer better. At first I had one made by Madame Martin ; afterwards came those of M. Hall, Duvoir de Bechard, Madame Girard, etc. I did not expect by the aid of such means to rectify the position of the womb, even where there was only a simple deviation ; but with the hypogastric plate of some of these belts, particularly those of Duvoir de Bechard, we may raise up, and retain the abdominal viscera, whose weight, arrested above the pelvis, will cease to press upon, and weigh down the fundus of the womb ; the neighboring organs, the bladder, and rectum, thus relieved, will perform their functions better, and the whole abdominal nervous system being no longer irritated, the digestive functions will be restored, and all the general dis- turbance of the system obviated. Moreover, we may asso- ciate these belts with the employment of sponges, or vaginal pledgets, by means of a strap passing under the pelvis, pro- vided with a perineal pad. Sustained by this strap, the pad placed between the anus and vulva, presses up the perineum, and thus gives a very important support to the uterus. For twenty years I have prescribed these belts for many hun- dreds of females, who for the most part were benefitted. Some could not endure them, and of course were not relieved ; but in general, the patients who consented to wear them for at least a week, and who did not reject them on the first unpleasant sensation which they produced, soon experienced such relief, that they were neither able or willing to do without them. When the uterus is let down as well as deviated, the perineal pad is useful ; also in women who have a very large pelvis. 148 Uterine Displacements. [March, The belt alone will be sufficient in other cases, especially where it is employed to elevate a womb made voluminous by some tumor, or abnormal condition. The belts called hypogastric, are those which I have so far found best ; I cannot say, howe- ver, that we need no other remedy. It is well understood, that all I have said applies only to the mechanical or local treatment, and does not refer to the advan- tages that may be obtained from general medications in such cases. As I have announced at the beginning of this discussion, it is only of the body of the uterus that I have spoken in the pre- ceding argument, when it was a question of engorgement. It was not because I was disposed, as some appeared to think, to admit engorgements of the neck without dispute to admit especially the frequency of that pathological state in the neck, when I called in question its existence in the body of the organ. My design was simply not to discuss that which concerned the neck at first, because I wished to discuss separately, that which relates to maladies of this part of the organ. I have been asked if I comprehended engorgements of the neck in my denunciations. By answering no, but that I would reserve the question in relation to the neck, for another time, I did not intend to give my opponents a right to conclude that I readily admitted the existence of such engorgements. Now what shall I say of engorgements of the neck of the uterus? If I do not deny their existence, will it follow that I admit them ? By no means ; for a fact may not be admitted, the possibility of which cannot be denied. When chloroform was accused, I rejected the proofs that were offered, without denying that the thing was possible. More conclusive obser- vations have been submitted, and I have admitted the fact. So with uterine engorgement; tell me what it is let me see it, and I will admit it. Prove that there exists a chronic, persistent, pathological state, distinct from chronic phlegmasia, and hyper- trophy, which is neither the result, nor the complication of any other malady ; in fine, a pathological state which constitutes a distinct disease, primitively independent of any other affection already known under a special name, and I will admit engorge- ment. Until then, it appears to me logical to remain in doubt, 1850.] Uterine Displacements. 149 and to say, that in the neck, as well as in the body of the uterus, essential chronic engorgements are as rare, as they are thought to be frequent, even if they exist at all. If it is true that the neck is often enlarged, it is equally so that we may be easily deceived in this respect. The finger deceives less than the sight. The speculum is a source of errors which must be guarded against. By its vaginal extremi- ty, it tends to open the lips of the ostincse, and fully to uncov- er the apex of the uterus ; the neck often appears much more voluminous than it really is. Who does not know, moreover, how numerous are the varieties in the volume of the neck of the womb presented by different healthy females? Hard and flattened, or conical in some, soft and swollen in others, it is sometimes regular, sometimes uneven ; sometimes elongated in one direction, and shortened in another. It likewise pre- sents an almost infinite variety of colour, and of length, without being diseased. I have no desire to sustain the opinion, that the neck of the uterus is never more voluminous than it should be, or that dis- eases may not augment its dimensions ; I only deny, that the excess of volume, when it is pathological and persistent, merits the name of engorgement. Then there is either simple hyper- trophy, which constitutes a deformity rather than a disease, or a state of congestion, with heat, and even pain, which borders closely on irritation or sub-inflammation, a state always tran- sient ; or else, some affection more serious which ought to give a name to the disease, and should attract the principal attention of the physician. Shall we then give the name ef engorge- ment to the disease, merely because the volume of the organ is augmented, when there exists at the same time either cancer, tubercles, vegetations, fungosities, granulations, ulcers, etc.? Admitting, as has been done, that engorgement is a morbid entity, a distinct malady, you will have a special treatment for this supposed affection, as you have for pneumonia or intermit- tent fever. Now I ask, would it not be ridiculous to treat in the same manner, hypertrophy, sub-inflammation, granulations, fungosities, ulcerations, cancers, etc., of the neck of the uterus ? At least until the existence of a real disease, distinct from all those that I have indicated, shall be demonstrated, I persist in 150 Uterine Displacements. [March, declaring that it is useless, and even dangerous, to maintain in theory, or in practice, the idea of a special disease under the title of engorgement. One word more. To explain the pretended engorgements of the uterus, M. Robert has spoken of an affection which he seems to think new, and to have been discovered by M. Reca- mier. Jf I understand him correctly, this disease consists of fungosities, or vegetations of the size of a grain of sand, or the head of a pin, or even of a hemp or currant seed, which some- times stud the whole uterine cavity, and bleed upon the slightest contact, and even without any friction. In this case I must be permitted to express the same doubt as in cases of engorge- ment. Setting aside vegetations and cancerous fungosities, the description of M. Robert can only relate to those granula- tions that I demonstrate weekly at the Charite, observe daily, and have described, as well as other practitioners, very fre- quently during the last fifteen or twenty years. It is then perfectly useless to create anew designation, since this disease, which is quite common, is known to, and admitted by every one. This new name seems to me, moreover, to be danger- ous, for it has given birth to an operation wThich I believe to be useless, as well as highly objectionable. This abrasion, this scraping of the interior of the womb by means of a curette, a kind of small metalic spoon, of which M. Recamier speaks, will never be looked upon as an operation free from danger ; its inutility at least is so manifest, that M. Robert admits that it is not sufficient alone, but must be associated with injections and cauterisations. Now, numerous observations and experiments authorize me to declare, that, with a mop of lint, wet with the acid nitrate of mercury, and passed once a week into the uterine cavity, I have almost uniformly removed this granular and bleeding state of the genital cavities. I will add that some- times simple emollient, detersive, astringent, or tonic injections, are sufficient of themselves to effect a cure, or at least to com- plete it after the slight cauterisation to which I have referred. This, however, is a subject superadded to the discussion, and would lead us too far, if we were to examine it thoroughly at this moment. I will sum up my remarks. 1850.] Uterine Displacements. 151 1. Engorgement of the neck or body of the uterus as a distinct malady, a chronic and primitive state, is yet to be de- monstrated. 2. Supposing that engorgements do exist, they are at least extremely rare, as rare as they have been thought frequent. 3. This name has been given to a number of diseases which have an admitted existence, and of which it is but a symptom; we are especially liable to be deceived by deviations of the uterus. 4. The deviations which most frequently mislead in this case, are of two kinds: those with inflexion, and those without inflex- ion of the organ. 5. These inflexions deceive because in forming a diagnosis by touching through the vagina or rectum, the examination is too frequently made when the patient is in the erect position. 6. With the patient lying on her back, and the muscles re- laxed, we arrive at a correct diagnosis, in a certain sense mathematical, if the finger is passed into the rectum or vagina, and the other hand is applied to the hypogastrium, so as to grasp and force down the uterus, thus enabling us to appreciate cor- rectly its volume and consistence. 7. Inflexions of the uterus are as frequent, as they are sup- posed to be rare ; ordinarily simple, they are in general the cause, and not the effect of the hypertrophy which sometimes accompanies them. 8. They are not of themselves of a serious nature ; for many females are thus affected without suspecting it; and general and internal medications can only remedy their effects, or their complications. 9. Among the mechanical and palliative means, hypogastric belts are the most useful, and the least inconvenient. 10. Next to malignant and cancerous diseases, and tumors, the granular state, either of the os tincae, the neck, body, or cavity of the uterus is the most frequent affection. 11. The best topical treatment for this condition, is cauteri- sation with the nitrate of mercury, and nothing indicates that the method of abrasions are ever necessary for its removal. Such are my views on this important question, and to these I shall adhere, until my propositions have been demonstrated to be erroneous. 152 Mechanical Treatment of Sterility. [March, I am persuaded that this discussion . will not be useless. Those who think so, forget, that beyond these walls there is an immense number of our brethren, who hear us through the journals, and having no preconceived opinions, will examine anew in their practice, the questions which are agitated here. I feel assured that this discussion will dissipate more engorge- ments than all the iodides and imaginable discutients. It is scarcely necessary to say that the question of deviations has been but slightly touched upon, and I shall treat of them in de- tail elsewhere. On the Mechanical Treatment of Sterility. By Henry Oldham, M. D. (Guy's Hospital Reports. Amer. Journ.) There have been three plans of treatment of a mechanical kind, for the cure of dysmenorrhcea and sterility, recommended and practiced ; and it is impossible for any one in practice in this city [London] as an obstetrician, and who reads the weekly and monthly journals, to be blind to the fact, that these means have of late been unsparingly and boldly employed. They consist, first, of the dilatation by metallic bougies or sponge tents, or by section of the os uteri internum and externum ; secondly, of the removal of the front or back dis- placement of the womb by Dr. Simpson's uterine stem sup- porter; and, thirdly, by probing the Fallopian tubes. It is im- possible for me to omit the notice of these expedients ; although, if the womb be ascertained to be undersized, they would, I should hope, be abandonded in reference to it. No cutting, or dilating, or supporting, or probing, can make a small womb larger : and the amount of uterine stimulus which they would excite would be considered far too important to justify their use. I know, however, that the characters of the reduced womb (if I may so call it) are not always appreciated in their entirety ; and a source of error may arise from mistaking the natural and proportionate smallness of its orifice for a contrac- tion to be removed mechanically. The anteversion I have noticed would, by some, be regarded as an efficient cause of sterility and dysmenorrhcea, and the uterine supporter be ap- plied; while I suppose that Dr. Tyler Smith, if one or both these plans had been tried and failed, would, pa?* voie d'exclusion, consider it as coming within the undefined limits of tubal ca- theterism. The few remarks, however, which I shall make upon this subject, must be supposed to apply to the mechanical cure of sterility and dysmenorrhcea generally, without any 1850.] Mechanical Treatment of Sterility. 153 strict application to these disorders as connected with the un- developed womb. There are few cases which come before an obstetric practi- tioner which are so full of perplexity as those of sterility, especially where it is limited to those cases where the os, and cervix, and body of the uterus are free from any recognizable disease. Recent researches have afforded most valuable in- formation on the composition of the male and female generative elements, and the physiology of generation ; but our knowledge of the various causes by which impregnation is intercepted or prevented is very limited. One of these, no doubt, is any such partial or complete occlusion of the sexual canals as to prevent the transmission of the semen. Others are to be found in im- perfectly developed ova, within a shrunken ovary, or some defect in the semen, or a want of congruity between the two elements. These are subtle and concealed causes, difficult, and, with our present knowledge, almost impossible to detect, but of infinitely greater importance in their relation to primary sterility than the mechanical obstacles which have of late so exclusively engaged attention. It appears to me that the cases which justify the use of mechanical treatment require the greatest discrimination, not only on account of the facility with which they may be confounded with perfectly natural conditions, but also because these operations are not without danger. There is scarcely any amount of danger or pain that women will not go through to obtain the prospect of becoming mothers. They are notoriously credulous as to success, and are the ready, and often the costly victims of empiricism ; and I would venture to say, that obstetricians ought to be nicely scrupulous in encouraging a plan of treatment of a very doubt- ful efficacy, and dangerous to life. I cannot imagine a position more overwhelmingly distressing to any right-minded man than to have been the means of destroying the life of a woman in the endeavour to remove sterility. And yet I am sure that, in these operations, a hazard is run quite disproportioned to the amount of good accomplished; and I shall recount two fatal cases which have come to my knowledge: and I cannot but infer that others of a similar kind have occurred, but have not been recorded side by side with those of a more fortunate issue. I feel great confidence in saying that the true congenital stricture of the os uteri, externum or internum, or of the Fallo- pian tubes, sufficient to prevent impregnation, is very rarely to be met with ; and vet nothing is more easv, with the idea of a mechanical impediment in the mind, than to be self-persuaded into the belief that the natural orifice is too small. It is quite 154 Mechanical Treatment of Sterility . [March, impossible to fix a standard size for the inlet to the womb. It has often happened to me to feel the virgin os uteri extremely small, and yet pregnancy to take place. The sound, too, is a very insecure guide to the measurement of* the os internum ; and I think it is a most reprehensible practice to allow a neu- ralgic dysmenorrhcea, whose seat I believe is generally in the ovary, to be the indication for this meddlesome practice. The only cases, in my opinion, in which a mechanical dysmenor- rhcea with sterility can be said to exist, are those in which the tissue of the cervix is large and firm, and the os uteri is diminu- tive in comparison with the size of this body; a small, almost imperceptible, round aperture perforating a bulky cervix. When the tissue of the cervix is not so condensed, but has its normal, yielding feel, I doubt altogether the propriety of re- garding even a very small os uteri as a strictured one. I have myself successfully treated by dilatation some cases of the kind above cited, hut they are very few, compared with the large number which come under my care. I. I am indebted to my friend Dr. Golding Bird for the fol- lowing instructive case. On April 7th, 1849, I received from him the uterus and appendages of a lady w7ho died from perito- nitis, excited by attempts to cure sterility by mechanical dila- tation, whose history, as furnished to me by Dr. Bird, is as follows, and with whose concurrence 1 publish it: " A lady of dark complexion, aged 36, married several years, and never pregnant, resided in Jamaica. From youth she suf- fered intense dysmenorrhcea, and always had pains during sexual intercourse. She was nervous, hysterical, and excitable to the last degree, and was supposed to have suffered from every possible form of inflammation ; these attacks obviously being neuralgic, so common in hysterical women. In June last, by the advice of her physician in Jamaica, she came to Lon- don for the express purpose of having the os uteri dilated, which had already been attempted by wax dilators. The ob- stetric physician who was consulted in London coincided in this opinion, and thought the sterility and dysmenorrhcea depended on a stricture of the os uteri. He divided the os uteri with a cutting instrument, and introduced silver dila- tors. This produced horrible suffering; and, although at first she fancied the pains of menstruation wTere rather better, they soon became as bad as ever, and she did not experience the slightest relief. She left off the treatment for a time, but was soon again inclined to resume it ; and silver canulse were passed into the os, and left there. Again she suffered frightful- ly. On Saturday, March 31st, a gentleman, the assistanj of the physician, passed in another tube, but the distress was 1850.] Mechanical Treatment of Sterility. 155 intolerable; and sickness and shivering coming on, she urgent- ly begged her sister to try and remove it, which she succeeded in doing. Getting worse, a neighboring surgeon was summon- ed, and he found her laboring under what he regarded as peri- tonitis masked by hysteria. She had scarcely any fever, collapse coming on almost immediately, and she continued sinking until Tuesday, when I (Dr. G. Bird) was summoned to her. I found her at her sister's residence at T Park, pre- senting almost the collapse of cholera: pulse 200, and a mere thread ; distended abdomen ; vomiting of black fluid ; intense irritability. All treatment was useless, and she soon sunk. On examining the body, and raising the omentum, no appearance of disease of any kind was found above a line connecting the anterior superior spinous processes of the ilia. Below this line there was intense peritonitis; the convolutions of the intestines covered with butter-like lymph, and the pelvis filled with pus- like fluid ; the right ovary and broad ligament covered with the same butter-like lymph, but so feebly adherent that it wash- ed away by dipping it in Water; the cavity of the uterus was filled with bloody mucus. There was no other disease.'"' The uterus and appendages were examined by Dr. Oldham. The uterus had been opened by a single oblique division of the anterior wall, directed from the cervix to the left angle of the womb. The uterus was larger than usual for the virgin : it was rounded on its anterior surface, and a bulging convexity of the posterior wall, which, with the general softness of the tissue, showed it to have been the seat of recent engorgement. The blood-vessels over the entire surface of the uterus and appendages were injected with blood, especially the fimbriated extremity of the tubes, the ovaries, the broad and round liga- ments. On the anterior surface of the body of the uterus were two small projecting fibrous tumours, the size of a large and small pea; the serous investment of them was highly vascular, the blood-vessels rising over them just like the calyx of the ovarian ovum of the bird. There was a similar more flattened growth in the posterior wall. The divided surface of the anterior wall showed its proper structure to be much enlarged (it measured in the body eight lines) ; the muscular structure was soft, and the veins large, a probe easily ran through them. The length ef the united cav- ities was two inches and ten lines, the canal of the cervix being one inch five lines. The mucous membrane of the cavity of the body was soft, slightly raised, and of a vermilion hue. Agi- tation in the water was sufficient to loosen and separate it. At the os uteri internum, there was a zone of highly-injected blood-vessels, broken only at one point ; the circumference of 156 Mechanical Treatment of Sterility. [March, this aperture was eight lines. The os externum had a clean, smooth edge, without any break or mark of division; its cir- cumference measured one inch one line. The cervix had its characteristic markings, and the glands were empty of mucus. On the right side of the divided cervix, which would have form- ed the front wall, the ribbings were stretched upwards, enlarg- ing the mesh-like appearance; and, towards the os internum, some were lacerated transversely, and from this to the os exter- num the structure was more ragged than usual. The right tube. The extremity of this tube was almost en- tirely closed as a congenital formation, the aperture being very small. When opened, the fimbriated end showed its charac- teristic rich folds of mucous membrane, which were much injected, and were covered with bloody mucus. The remaining two-thirds of the tube was apparently healthy, not vascular, and pervious throughout. The right ovary, which was almost covered with lymph, soft and large. There was a cyst large enough to hold a small nut on the uterine end of the ovary. The stroma was gorged with blood. There was only one puckered Graafian follicle ; the surface of the ovary was thick and corrugated. The left ovary was irregular in its shape, a projecting mam- miliary portion coming out from its outer end. This, on being cut into, was hard and vascular, like the commencement of malignant disease ; the ovarian tunic was thick and wrinkled ; the stroma vascular ; a few remains of Graafian vesicles, with puckered tunics, and some clots of different colours, black and brownish. The left tube vascular at its fimbriae, healthy in its mucous membrane, and its canal pervious throughout. This tube pass- ed into the uterus more directly than its fellow, which was more curved. The veins healthy; arteries healthy; the right round ligament large and vascular ; vagina healthy. It is unnecessary to comment at length upon this case. It affords a most instructive example of the dangerous effects of dilatation, even in experienced hands, and the great caution with which it should be undertaken. It is important, too, as showing the difficulty of detecting the cause of stei ility. I am sure that there was no kind of morbid contraction in this case, and that the os and cervix uteri, which were alone treated, had nothing whatever to do with the dysmenorrhcea or sterility. Both of these, no doubt, were dependent on the atrophy of the ovary: and the congenital obliteration of the end of the right tube would have been sufficient to exclude the corresponding ovary from any share in the function of reproduction. II. Another presumed cause of sterility and dysmenorrhcea 1850.] Mechanical Treatment of Sterility. 157 is any deviation in the position of the uterus, and hence an indi- cation for the cure of these disorders is to replace this organ, and hold it in its proper axis in the pelvis, by means of Dr. Simpson's uterine supporter. Dr. Rigby and others have related cases of this kind. It is not necessary for me to reiter- ate the objections which I urged in the last number of the Reports upon this subject ; but I cannot avoid relating the fol- lowing case, which more than confirms my opinion of the dangers which may arise from this supporter. I am indebted to Mr. Bransby Cooper for this case, which, like the preceding one, ended fatally, and which he has given me his permission to publish : A young married lady, of great personal attractions, was at- tended by Mr. Cooper for a very painful fissure in the anus, which he divided and speedily cured. She then spoke to him of what had been to her a very distressing social trouble, name- ly, her sterility, which she associated with a perfect indifference to sexual intercourse. Mr. Cooper examined the sexual organs ; but, as he did not discover any defect which could be remedied by surgery, he referred her to a physician-accoucheur. This gentleman detected the uterus in a retroverted state, which he looked upon as the probable cause of the sterility. For the cure of this displacement, he introduced a uterine stem support- er, which set up peritonitis, of which she died in three days. It is much to be lamented that the warning which such a case as this imperatively suggests should not have been publish- ed by the obstetric physician in whose practice it occurrred. My own opinion is, that mere displacement forwards or back- wards, if the uterus be not diseased, does not commonly cause sterility; and I cannot but characterize the practice of fixing the womb in a definite position by means of a stem supporter, as rash and hazardous, causing severe irritation and pain, and even death, to the patient, with, at the best, a very questiona- ble amount of ultimate good. The anteversion or retroversion of a small uterus, without other complications, does not, in my experience, occasion any great distress ; and it is far better to leave it alone, and improve its tissue with the rest of the organs of the body, than to prop it up for a time under the feeble pre- tence of curing it. III. Dr. T. Smith's adventure of catheterizing the Fallopian tubes I know of only from his papers. I have the instrument by me, but at present I have no intention of using it. 158 Apoplexy of the South. [March, Apoplexy of the South, its pathology and treatment. By Samuel A. Cartwright, M. D. of New Orleans. (N. O. Medical and Surgical Journal.) The apophlegmatic treatment is the most successful in apoplexy, as met with in this valley ; it is not a disease peculiar to any climate or season, as it occurs in all the coldest and the hottest; being most rife in the greatest extremes of heat or cold, and excessive variations of the weather. The greatest number of cases occur at the summer solstice and at the equinoxes, in this country. In cold climates, it is not uncom- mon at the winter solstice. It would be a great mistake to suppose, that as apoplexy is found everywhere, and at all seasons, its treatment should everywhere be the same or even similiar. Pathologists coincide in the opinion, that every form and variety of the disease is attended with more or less pressure on the brain, interrupting the functions of the life of relation, sensation, muscular motion and intelligence. In a cold climate, the repletion of the cerebral vessels is often due to a surplus of arterial blood, and to an excessive action of the heart and arteries. The respiration of a cold, dense atmosphere tends to give a greater preponderance to the arterial over the venous system. Whereas, in a hot, damp climate the reverse is the case; a hot rarified atmosphere tending to accumulate the blood in the venous system. The treatment recommended by practitioners in high latitudes, from Cullen down to the present day, in apoplexy attended with cerebral pressure from arterial repletion and increased arterial action, is not the most success- ful in that form of the disease attended with coldness, torpor, and plethora of the venous system : Indeed, the standard works of the present day, in the hands of the profession, although con- taining many valuable improvements, are calculated to do more harm than good, as far as apoplexy and some other important diseases are concerned, to that portion of their readers who practise in a climate the very opposite of that where the books are written and the observations made ; because, by directing attention to the arterial system as the source of danger, the nervous, the digestive, the glandular, the venous and the respiratory systems are apt to be overlooked, or to have too little importance attached to them, in those complaints with us, where each is more implicated in the morbid actions than the heart and arteries. Apoplexy from venous repletion is noticed by the authorities, but many important pathological phenomena, which occur in other symptoms, both as causes and sequences of the venous repletion, are left unnoticed. The serous of or bloody extravasations, sometimes found in the brain, are 1850.] Apoplexy of the South. 159 only accessary ; because, in many apoplectic subjects, no ap- parent lesion whatever is detected in that organ. ' The effusions found in the brain are mere effects of the cerebral congestion, and are nothing more than evidences of misdirected efforts of nature to relieve the hyperemia of the cerebral vessels. But there are other very striking phenomena witnessed in apoplexy, in this latitude, of another expedient adopted by nature to re- lieve the congestion of the brain, unnoticed by modern authors ; consisting of copious exudations from the membrane lining the posterior nares, the tongue, cheeks, palate, uvula, pharynx, oesophagus, larynx, trachea, and the many cells, ducts and sinuosities into which the mucous tissue is reflected. In the healthy state, the pituitary portion of the membrane lining the internal nares. the maxillary, sphenoidal and frontal sinuses, and the ethmoid cells, throughout the greater part of its extent, is studded with glands and follicles, separating a mucilaginous lymph, called phlegm, or pituita, by the ancients; in apoplexy this fluid is poured out in much greater abundance than in health, and is more viscid and tenacious. Besides an increase of the mucosities, termed phlegm by the ancients, copious secretions or exudations take place from the glands and follicles, connected with the respiratory and digestive apparatus and its mucus lining ; these mucosities are often so abundant as to impede respiration and obstruct deglutition. The stertorous breathing is more the effect of collections of tenacious mucous, impeding respiration, than from paralysis of the muscles of the larynx, as has been supposed. This is proved by the fact, that the breathing ceases to be stertorous on its removal. As nature may be said to commit suicide in apoplexy, in relieving the cerebral hyperemia by an effusion of blood or serum, so also, she does the same thing in her efforts to remove the repletion by exciting so great, a flow of mucosities from the glands and follicles in the vicinity of the congested brain, and from the membrane lining the air passages, as actu- ally to obstruct respiration and hinder the transformation of venous into arterial blood, unless art be brought in aid, to clear those important avenues of the offending viscid fluids, by the proper apophlegmatic remedies. The abundance of mucosities blocking up those passages in apoplexy, is not a matter of spec- ulation or conjecture they can be seen and felt, and brought away, in the shape of tough, viscid ropes of agglutinated phlegm, by those measures and means called apophlegmatics. Paul of Agineta used a feather dipped in oil, to bring away the viscidities obstructing respiration, and assisted the removal with his fingers; as a preliminary measure to his ulterior treatment. Indeed, the viscid matter is often so tenacious as 160 Apoplexy of the South. [March, to admit of being laid hold of, and much of it extracted by mere manipulations. The celebrated remedy for apoplexy of the Dominican friars of Rouen, called " Elixir Antapoplexia" was nothing more than a combination of powerful apophlegm- atic ingredients, calculated to disembarrass the lining membrane of the trachea, larynx, fauces and posterior nares of the viscid mucus obstructing the air passages, and to excite the follicles, glands, and the membrane itself into active secretion, by direct medication to those surfaces on which many important nerves are expanded. The Friar's remedy won a high reputation for curing the disease; but not greater than its prototype, the ve- ratrum album, had won all over Southern Europe for curing the same complaint. In the Augustan acre, after four centuries of experience of the curative virtues of the veratrum album, in the treatment of apoplexy, we find Celsus, (lib. iii, chap. xxvi,)recommending the same powerful apophlegmatic in the same disease, in conjunc- tion with blood letting. The nauseous, bitter, acrid taste of the remedy, the burning sensation it occasions in the mouth and fauces, the tingling heat it excites in the nostrils, the nau- sea, vomiting and repeated retchings and the copious discharge of mucus attending its action, point it out as one of the most efficient apophlegmatics of the Materia Medica. Tne harsh- ness of its action led Aretaeus to substitute milder remedies to remove the obstructing mucosities. Subsequently, Fothergill introduced the use of the white vitriol, which he gave in doses of a scruple to half a drachm, to induce active vomiting Sy- denham, Pitcairn, and a great many eminent names in the profession, recommended emetics. A large portion of the phy- sicians of Southern Europe viewed emetics, conjoined with pungent stimulating substances, almost as specifics in apoplexy. It wns the high authority of Cullen, who discouraged the use of emetics and apophlegmatic remedies in the treatment of the disease. His objections were mostly theoretical, but as apoplexy, in the 56th parallel of latitude, is more owing to arterial excite- ment than to venous torpor, his ojections may be founded on practical observations, applicable to the disease in Scotland, but wholly inapplicable in Greece, Rome and the United States. Cullen's theory and practice in apoplexy and Cullen's prejudices against emetics and apophlegmatics in its treatment, pervade the works of nearly all the medical writers who have since treated the subject. The disease has been defined as a complete or partial sus- pension of the life of relation. The life of relation has two orders of functions, the one by which impressions from without reach the brain, the other by which the brain is exercised on 1850.] Apoplexy of the South. 161 the body. Both these orders of functions are suspended more or less completely. The brain can neither act nor be acted upon, except in a very imperfect manner in the complaint under consideration. Animal life, or the life of relation, is a mere abstraction, a subtle spirit with a body, when viewed separately from vegetative or organic life, on which it rests as a basis. Organic life has also two orders of functions. The one to assimilate substances to its nourishment by the processes of digestion, respiration and secretion ; the other to cnrry out of the* body the particles, which have become effete or noxious to the economy, by the processes of absorption, exhalation and secretion. Both these orders of functions, in the healthy state, are equivalent to each other, and both require a proper degree of activity in the circulating system for their due performance. The cause of apoplexy must be looked for, not in animal life, but in the two orders of functions of organic life ceasing to be equivalent ; in other words, in superabundant assimilation or in a delect of the excretory function. The first, constituting apoplexy from repletion of red and the latter of black blood, that connected with arterial reaction, as its most prominent feature, this, with venous congestion. When from defect of the secretory and excretory functions, as it generally is in warm weather and in warm climates, the safest and readiest method of cure is to awaken up all the absorbing, secretory and excretory organs from their torpor, into in- creased activity ; particularly those glands and follicles in the immediate vicinity of the congested brain: the congestion itself, being the effect of the want of action in the excretory system. This is the method of cure, which nature points out, as is evidenced by the copious excretions of viscid mucus that occur during the apoplectic fit. So abundant is the excretion of mucus in the nares, fauces, trachea and sesophagus, as to re- quire the assistance of art to expel it, or this very effort of cure would itself become the cause of death, by obstructing the due performance of the respiratory organs. On the other hand, in that form of the disease arising from a surplus of assimilated matter, introduced into the system by vigorous digestive powers, in a cold bracing atmosphere, depletion of the sanguiferous system by blood letting, would strike directly at the root of the evil, and restore the balance between the assimilating and excretory functions, by unloading the blood vessels, diminishing the morbid heat and quieting the excessive arterial excitement. Whereas, in apoplexy from venous congestion, with coldness and torpor, much loss of blood, or, indeed any, in many cases, would diminish the force of the circulation too much to be compatible with secretion, v. s. vol. vi. vo. in. 11 162 Apoplexy of the South. [March, exhalation and absorption, these requiring so much activity in the circulatoiy system for their proper performance, as oftener to need stimulating substances, to excite that system, than the lancet to quell it. There is pressure on the brain in venous congestion, equally as in the other form of the disease from arterial fulness and reaction ; but unloading the larger venous trunks will not unload the distention of the smaller vessels of the congested brain, where the danger lies, or do the good it does in the other form of the disease. Although blood letting is often serviceable, sooner or later, the main dependence is in giving energy to the absorbent, excretory and secretory actions, by addressing remedies directly to as large a surface of the sensative, nervous expansions as can be reached. Stimu- lating applications to the cutaneous surface, as mustard, for instance, to the extremities and over the epigastrium, have great power in awakening the torpid nervous system ; yet they are feeble remedial agents in comparison to stimulating applica- tions to the mucous surface. One of the most effective remedies for the latter purpose, is a combination of mustard flour, table salt, ipecac, and tincture of assafcetida. When patients are utterly unable to swallow water, or the most bland substance, the mere presence of this combination in contact with the ner- vous expansions in the mucous membrane (lining the mouth, tongue, palate, posterior nares and fauces,) will detach the viscid mucus, which is choaking and suffocating the patient, restore diglutition and give free egress to the atmospheric air, so essential to the respiratory system, and to vitality itself. It not only detaches and throws off the viscid phlegm, already formed by that low grade of vital action, termed passive exudation, but by its stimulus on the net work of nerves, it brings to the rescue of the patient a higher grade of vital ac- tion in the absorbent and secretory organs of the digestive and respiratory apparatus ; and thereby unloads as if by enchant- ment, the repletion of the smaller vessels compressing the brain. Even the regurgitation of this powerful apophlegmatic into the posterior nares, when it cannot be swallowed, is not without its benefit. Its direct application to the membranes on which the entire olfactory pair of nerves and some important branches of the fifth are distributed, is well calculated to make a strong impression upon the sensorium. On the tongue, it lies in contact with the expansions of the lingual branch of the fifth, the glossopharyngeal portion of the eighth, and nearly the whole of the ninth pair. Deep in the throat, it comes in con- tact with the superior laryngeal and recurrent nerves, branches of the pneumo-gastric ; awakening the torpid and paralyzed nervous system into life and promoting absorption, excretion 1850.] Apoplexy of the South. 163 and secretion in the broad expansion of the mucous surfaces, and the subjacent, as well as the distant organs, subservient to the important processes of elimination. When it is remem- bered that a large portion of the mucous membrane acts as a kind of periosteum, on one of its faces to the bones of the head, and on the other as an eliminating surface, it can readily be perceived, how important the mucosities thrown off by it must be in diminishing the plethora of the cerebral vessels. In children, whose heads are large, the secretions and excretions thrown off from the lining membrane of the mouth, throat and nares are in much greater quantities than in the adult ; thus proving the importance of such evacuations in preventing cerebral plethora, by an eliminating process or local depletion, constantly going on in the healthy state of childhood. In apoplexy" besides the beneficial efforts of the mere presence of apophlegmatics in contact with the mucous surface of the mouth and throat, further advantages are to be derived from their deglutition, in doses sufficient to cause vomiting. Indeed vomiting without reference to the substances exciting it, does some good, but much less than when the substance employed is both emetic and apo phlegmatic. In substituting simple emetics, devoid of apophlegmatic properties, for such articles as the veratum album, possessing both properties in a high degree, the profession, instead of making progress, made a retrogade movement, and finally abandoned emetics almost entirely in the treatment of the disease. Some attention to the patholo- gical phenomena observed in apoplexy and some other diseases, from venous congestion, will show the reason why apophleg- matic remedies cannot be dispensed with in their treatment. Observations prove that in such affections, the mucous mem- brane, even into the stomach, intestines, and lungs, is covered with mucosities of so tenacious a nature, as actually to form, over a great or less extent of its surface, an additional tunic, rendering the portion thus coated almost insensible to the or- dinary medicines. In the lungs, the tenacious mucus obstructs the inflation of the cellular substance surrounding each of the extreme ramifications of the bronchial tubes, by stopping up the small air conduits, opening into the cells, and rilling the cells themselves, which are lined by a delicate mucous tissue, with morbid exudations. In the human subject the bronchias end in cells exceedingly small, scarcely perceptible to the naked eye. In the alligator, however, Dr. bowler's dissections (witnessed by the author) show that they are large bladders, equal in size to the urinary bladder of man. Their inflation brought the animal to life, after it had been apparently dead for nearly an hour, and the viscera of the thorax and abdomen had been laid 164 Apoplexy of the South. [March, open to view by a careful dissection ; so perfect was the re- storation of \itality, from the simple process of inflating the air cells of the lungs, that the partially dissected carcass had to be tied with strong cords to prevent its doing mischief. On suspending the inflating process, the air cells become flacid, and a corresponding suspension of animation again occurred, and was again revived by renewing the inflation. No better demonstration of the great inportance of the free expansion of the air cells of the lungs with atmospheric air, could be desired An emetic, or some remedy capable of dis- embarrassing the air cells, and the bronchial tubes opening into them, of all obstructing mucosities, must be of essential service in the treatment of such a formidable complaint as the one un- der consideration. But to derive much benefit from it, its ac- tion should extend further than a mere evacuation of the. contents of the larger cavities; it should be capable of loosen- ing and throwing off* the tenncious phlegm coating the mucous surfaces, and filling the cells and smaller cavities. In other words, it should be apophlegmatic, a remedy possessing the virtue of detaching and throwing off phlegm. The preceding remarks have been deemed necessary to throw some light on the rationale of the treatment contained in the following abstract. The merits of the treatment do not, however, rest on the imperfect reasons above given in support of it. The theory may be ever so imperfect or erroneous, and the practice good. The latter was derived from the school of observation and experience; the former was subsequently pre- fixed to the practice, and not the practice to the theory. If it be not a satisfactory explanation, the merits of the practice re- main the same, wanting nothing but a writer better able to elucidate and explain it. The truths of a long and extensive experience, in the treatment of apoplexy, as met with in this valley, declare the practice to be successful. Col. Wiley P. Harris, some 20 years ago, in the hot weather of mid summer, fell in a deep apoplectic fit in the streets of Natchez, and was among the first triumphs of the practice in the author's hands a practice which he had derived from the late Dr. J. A. McPheeters, who himself, recently died of the disease, but not under the treatment, which he himself had successfully used for 25 years in Natchez, and had pre- viously been eminently successful in his hands in the same disease in St. Louis and vicinity. Thus proving, that the good results of the treatment are not confined to the southern portion of the Mississippi Valley. Dr. McPheeters never pub- lished his experience, and when stricken downby the disease himself, he derived no benefit from it, but was treated secundum 1850.] Apoplexy of the South. 165 artem, as recommended by northern writers and teachers. In the hands of the author of this paper, the practice recom- mended in the following abstract, triumphed over a severe apoplectic attack in the person of the hero of Chapultepec and the first American governor of the city of Montezumas, Major Gen. John A. Quitman, long before he triumphed over the Mexicans. It cured the historian of the Mississippi Valley, Dr. J. W. Monett, of a severe attack, connected with hemi- plegia. It cured both in a very short time. In Capt. Coarse's family, of Concordia, La., a case occurred, where the first immediate relief, from impending death, was procured by extracting the inspissated mucus, obstructing respiration, with the fingers. In the case of the commander of the Round Islanders, last summer, Col. W , who fell in his door, in this city, in a stertorous apoplelic fit, entirely insensible and mo- tionless, strong and pungent apoplegmatic medicines, conjoined with a mercurial, (omitting emetic substances.) succeeded in effecting a prompt cure: camphor, assafcetida, capsicum, quin- ine, laudanum and mercury, each in a full dose, were mixed together and inserted into the mouth. The combination was in part regurgitated into the nares ; deglutition being impossible, until after the medicine had disencumbered the throat and fauces of the obstructing mucosities. In this case, death was so close at hand, that the sphincters were relaxed. The emetic substances were omitted in conse- quence of the copious alvine evacuations. Recovery took place without bleeding, cupping, leeching, vomiting or purging, by the mere force of apophlegmatics, assisted only by the mercury to emulge the liver. The same happy result, from the same combination, used in the Col.'s case, (with the addi- tion of blood-letting, after re-action took place,) was witnessed in a case of apoplexy, in a very large, plethoric lady, a native of the Sandwich Islands, in the prime of life, attacked in the very hottest weather of last Julv, in this city, at the Planter's Hotel. These recent cases, with some others that might be men- tioned, go to show that the virtues of the following treatment depend, probably, less upon the emesis occasioned by the remedies used, and more upon their simple apophlegmatic action, than was hiterto supposed. The treatment, however, is given, woid for word, as originally written, a long time ago, but not until now published to the world. Treatment of Apoplexy. TwV> teaspoonsful of table salt, two teaspoonsful of mustard flour, one teaspoonful of ipecac, and one teaspoonful of tincture of assafaetida, in a tumbler of warm or cold water. 166 Apoplexy of the South. [March, The more disgusting the medicine the better, because it loosens the tenacious phlegm adhering to the throat and air passages. The pungency of the mustard is all important for the same purpose. The throat is so choaked up with mucus and phlegm, that the swallowing of any thing is almost impos- sible. This mixture does great good without being swallowed. Its mere presence in the mouth and throat loosens the tenacious phlegm adhering to the fauces, causes it to pour out of the mouth, and arrests the stertorous breathing, caused by the phlegm in the throat, enables the patient to breathe easier, rouses him in some degree from the stupor, and enables him to swallow that, or other things. He had better swallow the mixture, however, until he vomits. It should be forced upon him until he does vomit, or act on the bowels. The whole tumbler full should be given in the space of ten or fifteen minutes, unless it vomits. A second tumbler full is sometimes necessary, but if it does not vomit, or cannot be got down, the white vitriol is the best remedy : a teaspoonful in a tumbler of water, half at one dose, and small portions afterwards The salt, mustard, ipecac, etc., make the best remedy to begin with, because it is the best to loosen the phlegm, which is suffocating the patient ; it should be forced into the throat, by prizing the mouth open with a spoon, and into this spoon the mixture should be poured by another spoon ; when it falls down to the root of the tongue, it causes a heaving, strangling kind of motion to be made by the patient ; then, he should be turned a little on his side, to enable the loosen phlegm to run out of the mouth, but soon replaced on his back again, with head a little elevated, to get more of the medicine. While this is doing, hot water, with mustard in it, should be poured, time after time, on his feet and hands, and a flannel shirt, wrung out of very hot water, doubled up in a large ball and wrapped in a dry flannel, should be applied over the stomach and bowels, and frequently renewed, as hot as the hands can bear it. A great deal of phlegm, a ropy white-of-egg looking substance, will be thrown up, and the patient will get relieved. Chamomile tea may be given to encourage the vomiting. If the head is hot and the face red, the head and face should be frequently wet with cold water. When the skin gets hot, and the pulse rises and face flushed, bleeding from the arm should be resorted to ; but it is a very dangerous expedient in the opposite state of the system. After the vomiting, a twenty grain dose of calomel, floating on a spoonful of water, and a stimulating enema, to move the bowels, if they have not been already moved. The subsequent treatment consists of but little more than a light gruel diet, a little salts, and very small doses of sweet spirits of nitre, to act on the kidnevs. 1850.] Scrofula. 167 If the patient can be made to vomit, he almost invariably re- gains his faculties directly. Some physicians have theoretical fears of vomiting ; it never does mischief to the head in any case, except where there is great heat of the whole surface, strong circulation and flushed face ; and not then, if the head be wet before and at the time of vomiting. Jn the state just mentioned, bleeding and vomiting at the same time do well together. Prompt action is as necessary in this complaint, as in any other kind of strangling or suffocation. The means to be used should be well fixed in, the mind before hand, and all the means mentioned should be made act together at the proper time the vomiting, the hot applications to the extremities and stomach, and hot or cold to the head. The Scrofulous Constitution the signs by which it is known the causes in which it originates its effects upon families and individuals. By Dr. King. (Prov. Med. Jour. Am. Jour. Med. Sciences.) ' The scrofulous constitution may be called a defective and abnormal one, consisting in an imperfect state of the vital pow- ers ; "the principle of vitality" (whatever that is) causing an imperfect development of the physical structure, both in form and substance. There is an imperfect deposit of bony matter to form the skeleton, and too great a proportion of animal mat- ter. The bones are therefore too soft to hold their contents, when that is required, as in the head; and too soft to support weight and endure force, when that is their office, as in the rest of the body, the spine, ribs, pelvis, and extremities. All the cartilaginous parts are increased in size : the extremities of the long bones are large and soft, and the interstices filled with serum and jelly instead of earthy matter : and the bones are either longer or shorter than the average. The head bones being soft, give way to the pressure of the brain, which is affected more by the influence of gravity than its own vitality, and becomes misshapen. When fluid collects within, the shape is still more affected, and in those who recov- er, the disfigurement remains for life. The malar bones are often too prominent, and the lower jaw too large : the palate is often imperfect, and the dentition is tar- dy, difficult and irritating: (he teeth imperfectly formed, dis- coloured, friable, only one half enamelled, and readily decay : the two middle upper incisors are often unnaturally large and prominent ; the upper lip partakes of the imperfection of the palate, and is often fissured. Frequently the ears are deficient, 168 Scrofula. [March, the cochlea being wanting, and sometimes the internal meatus: the thorax is deficient in size and deformed in shape: the ribs bent in, the sternum protruding, and its divisions imperfectly united. The abdomen is too large and protuberant, from the flabbiness of internal parts and abnormal size of organs and mesenterical enlargement. The bones of the spine, partaking of the deficiency of earthy matter, particularly of the phos- phates, are too soft to support the head and chest, and yield as well as their ligaments. The sacrum is often pushed towards the pubes, producing a narrow, pelvis, and consequently in fe- males, difficult or impossible parturition: the ilia are often twisted : the arms too long or too short for the body, the wrists too swollen, and the hands misshapen. The lower extremities are too long ox too short, badly supporting the trunk : the knees larger, the bones badly fitted to each other, forming the knock- knee, or the reverse; the tibia, sometimes the femur, bending beneath its weight, and the feet splay-footed, or club-footed, in various degrees. The soft, parts partake of the same want of vitality. The brain is too large or too small, too soft, pulpy, and heavy in its functions, and liable to effusion from vascular debility : though sometimes its intellectual functions are more active than com- mon, this being the exception, not the rule. The nerves are not so defective in carrying sensations or motions, as the brain is in its functions. The vascular system is generally relaxed and weak, and what used to be called (for want of a better theory) leucophlegmatic : the muscular fibre is weak and relax- ed, and wanting in tone and vigour; the hair is generally of a light colour or reddish, and thin in texture, and scanty, and liable to fall ofi> independent of disease, from a low vitality : the eye has a peculiar expression, generally heavy, languid, inexpres- sive; whilst sometimes it has an animated expression of a pe- culiar kind, known to medical men, and may be called the scro- fulous eye; at others, it foretells consumption, of itself. As a contrast to other signs of imperfection, the eyelashes are often long and beautiful. The stature varies from the dwarf to the apparent giant, when a boy may be six feet high at fifteen years of age ; but such excess in height is never accompanied with corresponding muscular strength and well-developed limbs and features; they are always puerile and almost effemi- nate. The appearance of the child is often that of the little old man : while the appearance of the man is often that of youth and boyhood without its vigour. Sometimes the child is fresh and plump, with embonpoint, and to the artist beautiful; but this hypertrophy of the cellular membrane is delusive and morbid and often accompanied with organic infirmities, fore- telling future disease. 1350.] , Scrofula. 169 The deposit of tuberculous matter, from imperfect assimila- tion, is one of the most obvious and leading erlects of the scro- fulous constitution, to which some writers have improperly confined their notion of scrofula. It is only one effect or dis- ease among many which arises from a common constitution. Scrofula not only produces specific diseases, but modifies all which happen in the body in which it exists. Thus, hooping- cough, small- pox, measles, scarlet fever may he fatal in a scro- fulous constitution, and harmless in an unscrofulous one. The specific diseases to which the scrofulous diathesis gives rise, are hydrocephalus, tumours of the brain, tubercle, abscess, fungus, epilepsy, insanity, hysteria, amaurosis, cataract, deaf- ness, otorrhcea, conjunctivitis, lippitudo, lupus, ozsena, coryza; tubercular glands in the neck ; diseases of the heart and lungs, of the abdomen, oesophagus, stomach, bowels, pancreas, liver, kidneys, bladder, uterus, mesentery, scalp, skin, joints. Many forms of indigestion, dyspepsia, mal-assimilation, anorexia, general debility, want of tone and power, nervous debility without organic disease, are modifications of the scrofulous di- athesis : so is gout. Scrofula is supposed to affect one-fifth of mankind : of those who are born scrofulous, one-half perish in infancy; of scrofu- lous foetuses, one-quarter die in utero. Few scrofulous persons live to he married : this seems to be the provision of nature to get rid of the imperfect part of her works. Louis calls phthisis the most relentless enemy of the human race; but he forgets that it is the means of preserving purity of blood and vigour of constitution. Nature does not allow the direct transmission of scrofula to proceed, as a general rule, beyond three or four gen- erations. It is then cut short by phthisis, or some other organic form of scrofula, or by abortion, or by non-conception. The following principles may belaid down, as true and fundamental in scrofula, the cases on which they are founded being omitted for brevity ; but probably every medical man's experience will assent to their truth 1. The grand source of the scrofulous constitution is the direct hereditary principle. 2. Scrofula is hereditary in collateral branches, when latent in the direct line. 3. When second marriages take place, if both parents are healthy, the children will be healthy; if either parent be scro- fulous, the children will be scrofulous. 4. Persons who may have been scrofulous in youth may ap- pear to have been cured, and to have grown into good health, but the constitutional taint remains, and the children will be scrofulous. 170 Scrofula. , [March, 5. Phthisis is the most fatal form of the scrofulous constitu- tion. Sydenham called it "scrofula of the lungs." Portal con- sidered that congenital phthisis was scrofulous. Bayle and Laennec the same. All cachexia is a form of scrofula. 6. Scrofula and phthisis co-exist in the same family. More than half the scrofulous patients have parents or ancestors who died of phthisis. Of eighty-four cases of scrofula in the hos- pital of St. Louis, at Paris, more than half had phthisical parents ; all the patients in that hospital who died of various forms of scrofula, had tubercles in the lungs. 7. Persons who are scrofulous in childhood sometimes be- come stronger after puberty ; but the taint remains, and the children are scrofulous. The parents try to conceal the scro- fula of their youth, which makes it difficult for the physician to trace the constitution of the child, unless he is clear in his general principles. 8. Parents who do not appear to be scrofulous themselves, but whose brothers or sisters are so, have scrofulous children. The family taint passes through them to the children. .Thus, scrofula, like gout, is said sometimes to skip a generation. The scrofulous constitution may be originated independent of hereditary taint. 1. Syphilis is a cause of scrofula. Astruc says, when scro- fula is not hereditary, it is invariably caused by syphilis. Scro- fula attacked the nurse children (foundlings) of Montmorenci, in France; all the nurses had syphilis; as they were cured the children got well. Another originating cause of scrofula is ex- cessive indulgence and abuse of the sexual instinct. The children of such parents are generally scrofulous. The parent verifies the expression in Job xx. 2, 11 : " His bones are full of the sin of his youth." This power of early self-indulgence is one of the curses of hereditary wealth. 3. Another originating cause of scrofula \s premature indul- gence of the sexual instinct, and premature marriage. If the offspring are to be healthy, strong, and vigorous, no man ought to marry before the age of twenty-five, or woman before the age of twenty-two or twenty-three. The secretion of the seminal fluid, like all other secretions, must be subject to laws which decide its health and vigour. It should not take place too early or be too frequent, and it should be spontaneous i.e. the natural result of a healthy organism, not of a mere mental action, or effort of imagination ; there is a period of life during which these conditions are complied with, but before and after which they are not. The ancient Germans held it disgraceful to indulge the passion before the age of twenty. The laws of Moses contained particular restrictions on the subject ; and it 1850.] Scrofula, 171 is almost needless to state that the law of Christ inculates puritv of mind as the grand safeguard against the abuse of this faculty. If premature marriages have been preceded by in- dulgence, they are still more unfavourable to the offspring ; and if by syphilis, still more so. The gradual extinction of the higher and aristocratic classes, by the want of direct heirs, is perhaps partly owing to these causes, engendering a scrofulous, and therefore perishable constitution. On the other hand, the lower classes marry early, not only from instinct, but also to obtain the services of a wife and companion ; the physical strength has been deterioated by low diet and hard labour, and the premature marriage completes the inability to produce a healthy, strong, and robust offspring. The labour of the peasantry is said to be two-thirds too much, and their food two- thirds too little ; their food, clothing, and habitations are calcu- culated to a minimum of sufficiency. 4. Another originating cause of scrofula is marriage too late in life. Debility in early life may, in some degree, be correc- ted ; .that of old age cannot. The generative power begins to decline about the age of forty-five. Those who marry late in life may have one or two children strong, but every child is weaker than the preceding one, and the youngest are the weakest. The child of the old man is become a proverb for visible debility stamped upon its physiognomy. Many of them die at birth. Some are precocious in childhood, and then sud- denly fade and become effete and stunted, like the withering and dropping of fresh fruit in autuman ; they are born out of due season. The period of weak fecundity in women com- mences about the age of forty. After this time pregnancy is often a delusion, or there is an imperfect conception or mis- carriage, or the child perishes at birth, or, if reared, it is delicate and scrofulous. When marriage has not been followed by chidren till after several years, they are generally weak and scrofulous, agreeing with the age of the parents at the time of birth. Children born after the expectation of farther increase of family has ceased, are general scrofulous. 5. Another cause originating scrofula is disproportionate age and unequal vigour. When the father is younger than the mother, it may be a cause of scrofula. In all animals, power is the privilege of the male. The relative superiority of the man ought to be the foundation of marriage. Upon it depend all domestic felicity, and often its morality. The constitution of the children follows that of the father more than that of the mother. This is the law in the brute creation. The breeders of cattle set more value upon the male than the female. 6, Another originating cause o^ scrofula is paralysis, and also epilepsy, lunacy, and other diseases of the brain. 172 Scrofula. [March, It may be observed that parents may be scrofulous without apparent signs ; the scrofula may be latent, and the children scrofulous. Parents may show no signs of scrofula till after they have had children, when it may begin to appear. In this way it may be said to skip a generation, when it is latent. Du- ring the wars of the French Revolution, when the conscription was at its height, France was so depopulated that every man capable of bearing arms was enlisted, and even many who were incapable. None were left at home but the sick, the in- firm and those who had married at nineteen or earlier, in order to avoid the conscription. Hence the population was kept up by persons too infirm and sickly for military service, and too young to produce strong children. Thus, at the Restoration in 1814, it was found difficult, out of a levy of 80,000 men, to find 25,000 to term a corps d* elite, and it was necessary for this purpose to lower the standard of height. After the peace of 1814, when the conscription was less rigorous, the men were more robust. But the conscripts of 1836 were an exception, for they were born in 1816, in which year nine-tenths of the population suffered severely from famine. These facts are ob- tained from the reports of the French Secretary at war. The end of marriage is domestic happiness, and the procreation of healthy children ; and the former depends much upon the latter. The law is very particular about the forms of marriage, but very indifferent about the results. Rational marriages must rest with the parties themselves. Ignorance of the laws of constitutional health is one great cause of irrational mar- riages. The great motives to marriage are rank, property, fancy ; to these ought to be added, morals, intellect, health, which are more important for happiness. The moralist has hitherto been too liitle of a physiologist. Physiology is the basis of morals as well as of health. The educator ought to be a physiologist as well as a moralist. It is only by the union of the two that the young can be judiciously trained, and prepared for real life. However persons may despise physiological warnings before marriage, they are too sensible of their value afterwards. Constitutional diseases not only produce unheal- thy children, but often also disgust, aversion, and misery be- tween the parties themselves. Marriage will not strengthen a weak constitution, as some suppose, but debilitate it still more. It is a common observation of females, " I have never been well since I married." Child-bearing and nursing demand more than a delicate and tainted constitution can bear. The strength gives way under the heat and burden of the day. I have* thus endeavored, though too briefly for the importance of the subject, to trace the history of the scrofulous constitution 1850.] Stricture of the Urethra. 173 in its hereditary principles, direct and indirect, proximate and remote. Where it exists, it cannot be entirely eradicated. Where it does not exist, it may be originated by the vices and follies of men. I have considered it as the source of many dis- eases not hitherto attributed to it; and that its best antidote would be a judicious education and training upon physiological principles. These principles it is the aim and merit of medi- cine to diffuse among society. The medical voice reaches the highest and lowest ranks. Her useful and practical truths are of daily application, and daily disseminated by her faithful dis- ciples, who in the lower walks of the profession, ever ready by day or night at the call of distress, find their chief and often their only reward in the conscious exercise of the duties of humanity, the mens sibi conscia recti. Finally, the greatest compliment which has yet been paid to the medical profession, and its humane and scientific principles, is to see the whole legislature, and every populous city in the kingdom, resolve to adopt them as a basis of civil polity, and to carry them out for the health, benefit, and happiness, of the poorest and largest class of our fellow-creatures. Cases of Permanent Stricture of the Urethra, cured by Cutting. By James Bryan, M. D., of Philadelphia, Professor of Sur- gery in Geneva Medical College, N. Y. (N. Y. Jour. Med.) It is well known, that the common modes (dilatation and caustic) of treating permanent strictures, are to the last degree unsatisfactory. Patients are relieved temporarily by the forci- ble introduction of bougies, especially conical ones; by the judicious use of caustic, &c, but the disease generally remains, and the patient either returns to the surgeon, or goes to ano- ther for further temporary relief. Years pass on, and the stricture becomes gradually worse, until the patient, especially in cold weather, is in daily danger of a rupture of the bladder, from retention of the urine, and the impossibility of passing any instrument through the urethra into the bladder. In other cases, the patient is doomed to carry with him at all times, a number of bougies and catheters of "assorted sizes," in order to relieve himself under the almost certain emergencv. I can- not, perhaps, better detail my mode of treating these hard cases, than by referring to one which came under my care several years ago, with three others which followed. It was that of Mr. S., a young married man, who had for nine years suffered from stricture in its worst form. We had gone through the usual dilating and caustic treatment, with temporary relief 174 Stricture of the Urethra, [March, from time to time, until the canal had, as far as the introduction of any instrument went, entirely closed. A very small stream, or rather dropping of urine, which of course demanded a long time to evacuate the bladder, was the extent of his power of urination. He had in fact, several times been in danger of rupture of the bladder from retention. Having tried a large number of our most respectable surgeons without permanent benefit, he despaired of relief. On examination I could dis- tinctly perceive from without, commencing about h\ inches from the mouth of the urethra a large cartilaginous stricture, which seemed to extend 1| or 2 inches along the passage. On reflection, I came to the conclusion that nothing but a com- plete division of the strictured part would be of any avail. I called upon our surgical instrument makers, but found nothing that I could use, but got Mr. Shively to make me a flexible metallic catheter, with a stylet, on the distant end of which was fixed a blade. With this instrument (a full account of which will be found in the Medical Examiner of 1847), 1 suc- ceeded in a few sittings in entirely dividing the stricture ; since when, he has had no difficulty in urination or symptoms of the disease. The following cases have occurred since that time. Mr. B., a respectable merchant, from a town in the western part of New- York, came to Geneva, while I was lecturing there on surgery ; and consulted me about his case. In my notes, I find that he applied on the 15th of June, 1849. The stric- ture was of 12 years' standing. He had consulted many eminent surgeons in the state and city of New- York ; had had caustic, dilatation and scarifications tried. In reference to the latter mode of treatment, my opinion is that, at best, in the cartilaginous form of the disease, they can but palliate. Mr. B. supposes there are two strictures, one 5| inches, and the other 7 from the mouth of the urethra. June 16th. On examination, I find that the first stricture is cartilaginous, and at least an inch long. The second is longer, and in the membranous portion of the passage. Two incisions were made to-day ; one at 12| o'clock, and the other at 3| P. M. The instrument advanced more than a quarter of an inch ; the stricture, after the incision, was distinctly felt to give way before the point of the instrument. 17th. Two incisions have been made to-day; one at 9, and the second at 3 o'clock. Mr. B. says that no blood follow- ed the first incision yesterday, and only a few drops after the second. That the stream of urine is much freer and larger. This morning's operation excited a little pain, and produced a little blood. The afternoon's incision was followed by about fifteen drops of blood, but very little pain, and an advance of the instrument of about one inch. 1850.] Steicture of the Ueethra. 175 18th. One incision a few drops of blood no pain. 20th. The bougie passes one and a half inch further. The first stricture is fully divided and passed. Some soreness, and a little pus to apply cold water to the perineum, and take a dose of salts. A good stream of urine. 22d. Quite comfortable ; no discharge of blood or pus ; continual rest and low diet. 26th. Made an incision, and gained an advance of one- quarter of an inch on the last. 27th. Advanced another quarter of an inch after an in- cision. 28th. Made another incision, which was repeated on the 29th and 30th, when the passage was clear to the mouth of the bladder no difficulty in inducing an ordinary sized ca- theter. Having left Geneva the next day, I became anxious to hear from my patient, but did not until one day last week Novem- ber 23d. The treatment was successful, and a gentleman from a neighboring district, who has suffered the disease about three years, has just been treated in the same way, and discharged. The gentleman came to Philadelphia to consult me. Nov. 19th, 1849. Mr. P., aged 23. This stricture was passable with a small conical bougie, and was located a lit- tle beyond the curve of the urethra. An incision was made, and a free cathartic recommended. 20th. A little soreness on passing a small metallic sound at the point where the incision was made. 21st. An incision made ; the instrument advancing about half an inch beyond the first point. 22d. No incision thinks the urine flows better than it has for years. 23d. Cut gained an inch. The operation was repeated on the 24th and 25th, when the passage was perfectly clear. A large sized metallic catheter passes readily to the bladder. The patient remained a few days longer, taking cathartics several times during the treatment, and living on a vegetable diet. He was perfectly relieved, and I hope cured. Case 3. Mr. I., from Georgia, aet. 35, with a stricture of nine years' standing, having used bougies and caustic again and again, came to consult me. The first incision was made October 22d, and repeated five times, the instrument each time advancing from one-eighth to a quarter of an inch. No other treatment was resorted to. Only a few drops of blood were lost and the stream of urine was restored to its natural size. A full sized bougie can be introduced with the the greatest facility. The particulars of this case are so much like those of the first, that it is needless to repeat them. 176 Periscope. [March, It will be remembered that Civiale has adopted the catting mode of treating stricture, but that a fatal objection lies against his instrument, inasmuch as, like those of Amusatand Lallemand. it must pass the stricture before it can be made to operate, and then only scarifies. He tells us that he has long been in the habit of cutting through strictures near the mouth of the urethra, and that now he cuts them beyond the curve. Mercier's ideas, in our opinion, are the nearest correct ; viz., that the stricture must be entirely divided, in each direction. I think that the use of bougies and dilators of any kind are prejudicial, and tend to develop strictures rather than cure them. I recommend no dilatation after cutting, but rely upon the urine itself keeping the incisions open, and the sides of the stricture from adhering. PART III. JH o n 1 1) I b Periscope. Movements of the Respiratory Organs in Disease. (Prov. Med. and Surg. Jour. American Journal.) Dr. Sibson gave an account, illustrated by diagrams, at the meeting of the South-Eastern Branch of the "Provincial Med. and Surg. Association," in July last, of his investigation into the movements of the respiratory organs in dis- ease : Tn health, the inspiratory movement of the walls of the chest, du- ring tranquil breathing, is only from two to six hundredths of an inch; while that of the abdomen is about three-tenths of an inch. During a deep inspiration, the expansive motion of the walls of the chest is, in front, about one inch; and at the side, about-two thirds of an inch ; and that of the abdomen is about one inch. The expansion of the two sides of the chest is nearly equal ; the left side does not, however, expand quite so much as the right side, over the lower two thirds of the chest, owing to the position of the heart. In those cases in which there is great obstruction to the entrance of air, during inspiration, through the outer air passages, as in cases of extreme narrowing of the larynx or trachea, the walls of the chest, to a greater or less extent in proportion to the obstruction, instead of advancing during inspiration, actually fall backwards. The cause of this remarkable phenomenon is evident: the diaphragm acts with great power, and lengthens the lung, and, as air can only rush into the lengthened lung through the larynx, with great difficulty, the lungs collapse, just as a half-filled bladder collapses when it is length- ened, and the pressure of the atmosphere forces backwards the anterior walls of the chest. In emphysema and bronchitis, in those cases where there is an 1850.] Periscope. 177 obstruction to the entrance of air into the air-cells through the smaller air tubes, the lower end of the sternum and the adjoining cartilages fall backwards during inspiration, while the upper part of the chest, ex- pands, and the diaphragm descends with great power. In pleuritis, with pleuritic effusion, the inspiratory expansion of the whole of the affected side of the chest is diminished, abolished, or, in some cases, even reverse, while that of the opposite side is throughout exaggerated. The inspiratory motion of the abdomen is also lessened or abolished in the affected side, while on the opposite side it is in- creased. When the whole of the lung is consolidated from gray hepatization, or tuberculous deposit, or condensed from firm tendinous adhesions fol- lowing pleuritis, then the expansion of the whole of the affected side is diminished, arrested, or reversed ; while that of the healthy side is exaggerated. When the upper lobe is affected with phthisis, or pneumonia, or any- other local disease, the expansion of that lobe is interfered with, and the inspiratory motion of the ribs over the affected lobe is diminished ; while that of the ribs over the opposite lobe is usually increased. It is not, however, alone in diseases of the upper lobe, that the motion of the ribs over that lobe, namely, the five superior ribs, is diminished, as the respiratory motion is lessened, or even arrested, when those ribs are injured or diseased, or when the intercostal muscles moving them are inflamed, or affected with pleurodynia, or when the motion of those ribs would produce pain or injury in the ad- joining scapula, shoulder joint, or arm, when they are injured or in- flamed. When the lower lobe is the seat of pneumonia, or any other dis- ease, the motion of the ribs over thnt lobe is usually, but not in every case, diminished ; and the motion of the abdomen just below the ribs, on the affected side, is always diminished in these cases. When the heart is enlarged, and still more when it is adherent, there is diminished motion of all the ribs on the left side, with the ex- ception usually of the second and third. If there be pericarditis, the motion is still more interfered with, and the motion of the abdomen just below the xiphoid cartilage is also much affected, being in all cases lessened, and, in some extreme cases, quite interrupted. While the motion of the centre of the abdomen is diminished, that of the ab- dominal walls at each side is usually not affected. In peritonitis, if the disease be general, the abdominal motion is universally diminished ; if it be partial, the diminution of respiratory motion is most marked over the immediate seat of the inflammation. Dr. Sibson concluded by calling attention to the value of the signs afforded by the modification of the respiratory movements in disease, and to the aid which those signs give in arriving at an accurate diagnosis. The nature of the disease cannot be detected by the ob- servation of the signs just indicated, but its seat is at once pointed out. In those persons who are really healthy, but who imagine themselves to be the subjects of chest-disease, the observation of the movements .v. s. VOL. vi. no. in. 12 178 Periscope. [March, of respiration will almost always give the satisfactory, conclusive, and very comfortable knowledge, that the chest is healthy. In general, the information as to the respiratory movements afforded by touch and sight is quite sufficient, but, in cases of difficulty, the ob- servations may be rendered minute and accurate by the aid of the chest measurer. On the Comparative Pathology of the Different Races of Men, (Annales d'Hygiene. Med. Chir. Rev.) M. Boudi^ has for some considerable time been engaged in furnishing statistical proof of the erroneousness of the doctrines of acclimatization, which suppose that long residence habituates men to climates otherwise unfitted tor them. He has brought forward, in his various communications, of which this forms one, ample proof of the little success and the great mortal- ity that have attended the attempts at the colonization of Algeria. In the same way, the European has always failed in fixing himself in Egypt, and the French cannot propagate their race in Coisica. He pays a well-deserved compliment to the British government for having availed itself of a knowledge of these deleterious influences, in the more judicious distribution of its troops in recent times. Thus, by adding to the British troops auxiliaries recruited among races whose physiological and political aptitudes suited them to the respective cli- mates, by selecting for the European troops serving in warm climates the most elevated regions, and by shortening the time of service abroad, it has effected a remarkable diminution of mortality a diminution which, in the most unhealthy possessions, has amounted even to fifty per cent. He contrasts this with the large mortality which still pre- vails among the French troops serving in analogous regions. The differences of the comparative mortality of the different races placed under different circumstances, is seen by examining that of the white and the negro population. Thus, while at Philadelphia the mortality of the whites is 24 per 1000, that of the negroes is 47 ; that of the whites 10 years old and upwards being, at New York, 15 per 1000, that of the negroes 26. At the Eastern Penitentiary, 20 per 1000 whites and 70 blacks die ; while at Weathersfield, the numbers are 28 and 100 respectively ; and the same enormous disproportion is observed in other prisons. The great mortality is especially due in the negro tribes to phthisis and typhus; while the negro is so proof against malaria, which carries off so many whites, that a due observa- tion of this fact has enabled the British government to diminish won- derfully the mortality of their troops employed in the East and West Indies. In the West Indies, the mortality of the negro soldier, com- pared to the white one, is but as 40 to 78 per 1000; and in Sierra Leone, it is 16 times less than that of the white. The latter are 160 times more fatally affected by fevers than the negro ; and it is only in diseases of the chest that they enjoy a somewhat greater immunity (4.9 to 6.3 per 1000). Even in the most southern station in Europe, Gibraltar, however, the negro mortality (62) greatly exceeds that of the white soldiers (21.4), though these are also strangers to the soil the diseases of the chest in the negro amounting to 43 per 1000. 1850.] Periscope. 179 In respect to the Sepoys, their mortality, at the different stations, is three or four times less than that of the English soldier; and they en- joy a remarkable immunity from diseases of the chest and liver, but are more prone to dropsies, owing to the endemic prevalence of the beriberi. The mortality of the Hotientot soldier at the Cape is very small, half of the deaths arising from diseases of the digestive organs. They, too, are more prone to diseases of the chest than the white sol- dier. Many facts tend to show that the Jews, even amidst wide-spread- ing pestilences, have enjoyed great immunities ; and that they pre- eminently possess the power of acclimatization. M. Boudin concludes the present paper with some observations on the diseases and mortality of the icar-horse. In 1645, of an effective force of 33,6 IS horses, the French cavalry lost by death 2603, and by discharge 2511. Of an effective force of 41,793, in 1646, 2679 died, and 3314 were discharged. While the general loss by death and dismissal, in France, was 143 per 1000, it was in Algeria 240. In 1636, the mean annual mortality was 197 per 1000 ; 126r in 1841 ; 108 in 1-42: 71 in 18 13: 76 in 1644: 77 in 1645 ; and 66 in 1646 a diminution constituting one of the greatest triumphs achieved by the application of sound hygienic and administrative measures. How much yet remains to be done, however, is shown by the fact that the Prussian cavalry only loses 20 per 1000, and the French gendarmerie 14 per 1000. The largest mortality takes place in the finest quarter of the year from April to October : while the smallest corresponds to the cold season of the year a fact chiefly attributable to the sus- pension of mancevres during the latter period. The most frequent causes of death, both in France and Algeria, are glanders and dis- eases of the respiratory organs. The glanders gives rise to ten times the mortality in Algeria to that produced in France a difference, If* Boudin thinks, that may be in part explained by the fact of so many mules (5695, in a force of 16.538) being employed in the former country the disease almost always attacking these animals in the acute form. In 1646, the Minister of War consulted 136 army vete- rinary surgeons, as to whether this disease is contagious. No answer was returned by 12 : 24 were uncertain ; 36 were non-contagionists ; and 64 contagionists. Cases of Inveterate Sciatica, treated by the actual cautery. By Dr. Payan, of Aix. (Gaz. Medicale.) Case I. A plasterer, 34 years of age, was admitted to the Hotel-Dieu of Aix, affected with sciatica of 15 years standing. Bearing his pain with great fortitude, he had but seldom been compelled to relinquish his avocation. The attack which brought him to the hospital was, however, more severe than heretofore, and had now lasted six month-. Meet of the usual remedies had been tried without success. During the day the limb would be pain- ful and benumbed, but during the night tin.- pain would become in- tense and lacerating, extending along the entire course of the nerve 180 Periscope. [March, and its subdivisions, but especially behind the trochanter, in the ham, and upon the dorsum of the foot. Fifty leeches were twice applied, followed by turpentine enemata, and blisters and morphine to the de- nuded surface. The patient was so far relieved as to be able to re- sume his occupations in 18 days. The pains, however, very soon returned with increased intensity, and the patient returned to the hos- pital. Two moxas applied along the course of the nerve near the trochanter, and frictions with anodyne liniments produced some relief, yet the pain in the hip and back of the leg remained undiminished. M. Payan now applied the cautery with a white heat (about 3 centi- metres long) between the metatarsal bones sustaining the little toe and that next to it. The relief was complete. The patient slept well the following night and experienced no more pain whatever. The burn healed in 28 days. The patient has been frequently seen since and continues perfectly well. The case wras treated towards the close of 1847. Case II. A man 45 years of age, had suffered with sciatica six years, when (in 1848) the pain being increased, he consulted M. Payan. The pain was located principally along the nerve and its branches, from the hip to the toes. Cauterization was made between the metatarsal bones (as in the above case), the wound healed in 31 days, and the cure was complete. The patient had suffered no re- turn 18 months after the treatment. Case III. This patient, aged 46 years, had suffered with sciatica five years. M. Payan saw him on the 22d Nov., 1848, in an attack of 10 days standing. The pain was seated in the left thigh and leg. 40 leeches were applied behind the trochanter and morphine admin- istered, with slight relief, which soon subsided. On the 24th Nov., the sufferings were as great as ever. Cauterization was now resorted to as in the above cases. The pains ceased on the instant of its ap- plication, and had not returned a year after the treatment. This was 35 days in healing. Case IV. A female, aged 35 years, entered the hospital the 6th Nov., 1848, with sciatica of the left limb, which had existed since the January preceding. The pain was felt principally along the external and posterior surface of the leg, and extended to the toes. Although somewhat relieved by blisters, it was still very intense. Cauterization between the metatarsal bones was here also completely successful. It remains to be determined whether a similar treatment wTould be successful in cases in which the pain did got extend to the foot or toes. 1850.] Periscope. 181 Treatment, of Insanity. (Gaz. Medicale.) Mi Brierre-de-Boismont, of Paris, manager of the Insane Asylum, has just published a memoir the object of which is to demonstrate from clinical observations, that all varieties of acute insanity and mania may be cured, in from one to two weeks, by the use of protracted baths and continued irrigations. On Nervous or Convulsive Cough. By M. Sandras. (Bulletin de Therap. Med. Chir. Rev.) There are several species of this : 1. The patient can receive no physical or moral impression, without suffering from a cough almost convulsive in its character. In exam- ining the chest of such a person, the physician may be led into griev- ous error, and the unnecessary fear of incipient phthisis, unless he examines it on various occasions and under different circumstances. Patients with incipient phthisis also cough from the slightest cause ; but it will be generally found that in those cases the impression is physical, while in those we are alluding to it is oftener moral. 2. Another form of cough, having some analogy to this, is observ- ed whenever certain functions are brought into play, or when they are more actively exerted than usual. Thus, it is found in some whose meals have been too long delayed ; in others, as soon as they have eaten, especially if rather fully. Other persons cannot take a little extra-muscular exertion without bringing on a tormenting cough of this kind. In both this and the preceding form, the cough is dry and capricious, exhibiting very inconstant physical signs; but this latter form is somewhat more fixed in character than the first, inasmuch as, in the same person, it is always when the same function is fulfilled that it is produced ; and it seems, too, to be more dependent upon dis- order of the organs in connection with the exercise of whose functions it appears ; and this should be our chief guide for its treatment. 3. Another cough is observed upon the slightest irritation of the bronchi being produced ; so that the least cold brings on a convulsive cough nearly as bad as that of pertussis. Sometimes, and especially in children and very young adults, it takes on this form at the very commencement of the cold, and retains it until coction is produced. Each paroxysm is accompanied by a dry, raucous sound, and attempts at vomiting. Sometimes it is periodical, the disease only gradually assuming the characters of an ordinary ripening catarrh. In other cases, the spasmodic character is only observed as the cough is draw- ing towards an end. Instead, however, of coction taking place, the expectoration continues frothy and transparent, and is only ejected by convulsive efforts and vomiting the paroxysm being brought on by the slightest cause, and a state of spasmodic suffocation being almost induced, until a little transparent and frothy matter is expectorated, when all becomes quiet and normal until a new paroxysm. In some cases, the cough suddenly ceases, without the expectoration having undergone any change ; but this is rare. The causes of this pertus- soid cough are not of easy appreciation. At the commencement, all is like a common cold ; and it is the reiterated catching cold in an 182 Periscope. [March, eminently neuropathic subject that seems to induce the aggravation. The prognosis, as regards immediate danger, is favourable ; but is more serious in respect to future consequences, owing to the various evil consequences which may ensue upon the congestions the parox- ysms give rise to. The destruction of sleep and disturbance of digestion which it causes are other important circumstances. Among the more serous results, is the production of hernias and emphysema pulmonum. The irritation of the glottis and larynx should be re- lieved by tepid aqueous or narcotic vapours, and by the use of demulcent emulsions with laurel- water. When the expectoration is difficult, syrup of poppies, with small doses of tartar emetic, should be given, the antimony, whether it causes vomiting or not, affording great relief. So, too, small doses of extract of belladonna every night, or night and morning, should be given when the expectoration is somewhat modified, and in a few days the convulsive character of the cough usually abates. When this drug disagrees with the patient, it should be used endermically. 4. This variety may be called hysterical, from its occurring in hysterical patients. In a subject whose respiratory organs are habit- ually in a good condition, all at once an irregularly paroxysmal cough comes on, occurring at frequent intervals, and sometimes almost with- out intermission. It does not terminate with the expulsion of mucosi- tes, but is either dry and objectless, or is accompanied by a true phlegmorrhagia. Hysterical phenomena sometimes precede or ac- company the cough ; while at others it ceases instantly that these ap- pear. The cough is found to get worse and worse, in proportion to the development of the hysteria ; and this without any physical expla- nation of its intensity. The pulse is not febrile, but may be irregu- lar, and such a one as is found in nervous subjects. The prognosis is favourable, unless the cough is mistaken for a phlegmasia, and ag- gravated by maltreatment. The treatment is, in fact, that which is proper for hysteria; but two means are especially indicated the use of belladonna, and the employment, of baths." Belladonna, given in doses of one-seventh of a grain every half hour, is highly efficacious: and it is rare for five or six doses to be given before improvement is visible. Baths at from 84 to 89 act as if by enchantment ; but sometimes it is useful to give them at from 75 to 82 ; and this is the temperature which will in most cases prove the best, after the patient has already employed the higher. Treatment of Nervous Cough with a gargarism of Sal. Ammoniac and Spirits of Mindererus. (Annales Soc. Med. d'Emulation. Jour, des Con. Med. Chir.) At the close of catarrhal affections, and especially of the grippe, there is often a dry and purely nervous cough, excited by a tickling sensation in the larynx or throat. This cough, in some instances, ceases for a time, but soon returns with increased intensity. In such cases, Lceffler advises the frequent application of gargles of 1850.] Periscope. 183 sal. ammoniac dissolved in spirits of mindererus, as a very successful treatment. Its efficacy was exhibited in the case of a young man, who, at the close of an intense bronchitis, was troubled with a dry, fatiguing cough, which resisted both narcotics and derivatives. The gargarism of Loeffler, with the addition of laudanum, in two days re- moved this cough which had continued for three weeks. The follow- ing is the formula : ft Distilled water, 360 grammes. Hydro-chlorate of Ammoniac . 15 " Spirits of Mindererus, ... 24 " Sydenham's Laudanum, . . 12 " Syrup of Diacodium, ... 30 " Make a gargarism. Conclusions in relation to Angina Pectoris. By Samuel Kneeland, Jr. (Amer. Jour. Med. Sciences.) 1. From the symptoms and morbid appearances, angina pectoris is not a disease of the lungs, heart and its vessels-, or stomach ; but an affection of the nerves sup- plying these organs. 2. Anatomy, physiology, and pathology would lead us to place the seat of angina pectoris in the par vagum, and not in the sympathetic system of nerves. 3. Like other nerves, the par vagum maybe affected with neuralgia and rheumatism ; with inflammation ; it may be compressed by mor- bid growths ; its spinal origin may be compressed by hemorrhage, accidental wounds, and various irritations all of which may cause the symptoms of angina pectoris. 4. Angina pectoris and asthma are intimately related ; the former being an affection more especially of the sensitive filaments of the par vagum ; and the latter an affection of its motor filaments. Both are generally more or less combined in the same case. 5. Angina pectoris is a disease not necessarily fatal, especially in young persons, if accurately diagnosticated, and properly treated. 6. In addition to the remedies of the books, special attention should be given to the inhalation of oxygen, and to the use of electricity. 7. In cases of angina pectoris, attention should be directed to the examination of the par vagum, from its origin to its terminations, which, doubtless, on careful examination, \vill exhibit lesions sufficient to account for a fatal result. Chronic Articular Rheumatism treated with Applications of the Tinc- ture of Iodine. (Theses de Strasbourg. Bulletin-Gen. de Therap.) M. M. Held and Gros, have called the attention of physicians to the beneficial effects of the application of tincture of iodine to the affected joints in all stages of chronic rheumatism. The tincture they employ 184 Periscope. [March, contains one part of Iodine, to ten parts of Alcohol at 33. They re- port a number of cases in which this treatment was most beneficial. They state that the local action of the Iodine much resembles that of vesicatories, tartar emetic, or nitrate of silver. It seems to act on several elements of the articular affection ; it promptly mitigates the pain and hastens the absorption of the fluids effused into the articula- tion, or infiltrated into the adjacent tissues. Moreover this application produces no pain, but only a slight sense of warmth in the parts upon which it is made. The first applications sometimes produce some sen- sation of the integuments, which causes a merely temporary incon- venience. In some few subjects, vesicles similar to those pro pounds, was then placed upon the part, with the effect of 220 Transactions of American Medical Association. [April, subduing the pulsation completely. After five days this was replaced by another, weighing two pounds, which was continu- ed for two days. Complete success crowned this expedient." Some other cases of interest are referred to, but we must refer our readers to the Transactions for them. The commit- tee conclude their report with the declaration that, " in this department of medicine, the spirit of improvement is abroad in our country, and that the inventive genius which we claim as a national characteristic,- is being exercised with signal success in whatever relates to the science and art of surgery." Report on Obstetrics. This report was prepared by Dr. Gilman, owing to the illness of the chairman, Dr. B. R. Wel- ford, of Virginia. It is quite an able paper, extending to near twenty pages. It refers to the improvements in our means of diagnosis, by the speculum and other means, by which many of the opprobria medicorum among the diseases of females are now accurately distinguished, and subjected to modes of treat- ment very generally successful. The subject of retroversion engages the attention of the committee, and they have brought to notice the sound, and the stem pessary, proposed by Prof. Simpson, as means to be employed in such cases. Of the sound they speak favorably. The employment of the sound as a means of diagnosis has been denounced by some English ob- stetricians; but whilst admitting, that in the hands of the igno- rant and careless it will probably do harm, the committee asserts that " it can be used without danger." In relation to the use of the stem pessary, they pronounce no opinion. We -feel no hesitation in expressing the opinion that the stem pessary should be entirely proscribed. It may be true, that the evidence brought forward by Prof. Simpson abundantly proves that the presence of the stem or shaft, in the uterine cavity, does not always produce as high a degree of irritation as we might have expected, yet the observations of others conclusively demon- strate that it does frequently produce the most alarming effects. Velpeau, after a fair trial, was forced to abandon its use. Dr. Meigs approves of the sound, " but condemns the pessary most unequivocally." Reference is made to an instrument invented by Dr. Bond, of Philadelphia, for the replacement of the retro- verted uterus, which has been employed with success in a case 1850.] Transactions of American Medical Association. 221 where Simpson's sound could not be introduced. The commit- tee are of the opinion that this instrument will " prove a valua- ble addition to our armamentum obstetricum." The report refers to some attempts made by Dr. Van Buren, of Bellevue Hospital, to cure prolapsus uteri, by destroying some strips of the vaginal wall with the actual cautery, a mode of treatment originally suggested by Dr. Marshall Hall. These operations were not perfectly successful, yet the results were very encouraging, and the committee express the opinion that the operation deserves more frequent and extended trials than it has yet received. The report notices the modification latterly proposed, in the management of cases of placenta prsevia, which consists in the detachment of the placenta from the uterine wall, and gives the grounds upon which the practice is advocated. ( " 1st. The old plan of rupturing the membranes and turning the child, has been, according to recorded experience, singularly unsuccessful, one in three of the mothers perishing, and the proportion of children saved being inconsiderable. 2d. In not a few cases the rigidity of the os and cervix uteri renders the operation of turning exceedingly difficult indeed almost impossible ; and when performed under such circum- stances, it is nearly always, and of necessity, fatal. 3d. The detachment of the placenta, will, in a vast majority of cases, immediately and effectually check the hemorrhage." The committee give the principal arguments which have been adduced in the support of these propositions, and whilst admitting that the detachment of the placenta is practicable, and that such detachment will materially check the hemor- rhage, they look upon it " only as a resource when turning is impossible, or from the state of extreme exhaustion, likely to destroy life. In the former category will be found the so-called cases of rigidity of the os, but in which, as the committee be- lieve, the difficulty really depends on an undeveloped cervix ; in such cases the operation is valuable, and iosuch the commit- tee are disposed to confine it." A large portion of the report is devoted to the use of anaes- thetic agents in obstetrical practice. The facts with which the journals have been teeming for many months have generally 222 Transactions of American Medical Association. [April, impressed the medical public favorably with regard to the em- ployment of these agents in midwifery. The committee state that the practice is gaining ground every where, and that of the thousands of parturient females who have been subjected to the influence of anaesthetic agents, no one has lost her life in con- sequence of the pains of labor having been controlled by ether- ization. For a solution of the question, why chloroform, which has been used in obstetrics more frequently than in surgery, is sometimes followed by fatal consequences in the latter, but ne- ver in the former, the committee refer to the explanation pro- posed by Prof. Channing. " In surgical cases, the agent is used as a preparation to the operation, to prevent pain ; pain is not present, it has as yet exerted no influence on the nervous sys- tem, that system as yet has not been exhausted by suffering ; it is in its integrity, and has of course its greatest capacity of impression, the greatest amount of sensibility, with the least power of resistance. The whole nervous power is brought into relation with the cause affecting it, and yields to the im- pression. For the most part the mind consents to the same- thing, and no moral resistance is made. How is it in labor? Here pain is present, and has been for a long time ; the nervous system has been greatly taxed ; its power, so to speak, been used up. Impressions upon it are weaker than they would be under other circumstances, the system comes rapidly under the anaesthetic influence, very little ether or chloroform is necessa- ry, the consciousness need not be destroyed, sensibility need never be abolished ; neither of these states is desired or aimed at by the judicious accoucher." The report invites attention to the reputed prophylactic powers of Quinine in puerperal fever. This article has been tried by M. Londet of Rouen, in the endemics of the Hotel Dieu, in the years 1843, 4, 5 and 6. Of one hundred and four patients who took no medicine, forty were attacked by the fever while of forty who took quinine, only two had the dis- ease. To this report are appended the history of two cases of retro-flexion of the uterus, one by Dr. A. C. Post, of N. York, and the other by B. W. McCready, of New York. Report on Medical Education. This report examines the general condition of Medical Education in the United States v 1850.] Transactions of American Medical Association. 223 compares it with the state of Medical Education in Great Bri- tain, France, Germany, and other enlightened European na- tions ; notices the requirements in the U. S. Army and Navy? and the legal requirements exacted by the different States of the Union. Some measures, prospective and established, in reference to medical education, and the reputable standing of the profession, and certain matters specially referred to the committee, are also considered. The length of this report, and the variety of topics which are introduced, renders it impossible to do justice to it by any synopsis which our limits will allow. It appears that the sub- jects taught in the European schools of medicine, are much greater than in this country ; the time devoted to their study is much longer; and the subjects are so arranged, that they follow each other in a regular order. In the European schools, satisfactory testimonials of a suitable preliminary education are required, and examinations are more numerous and compre- hensive than in this country. In Scotland alone, is punctual attendance exacted. ' The report gives its approval to the sys- tem which requires a larger number of teachers, and of subjects to be taught, but does not deem it essential or expedient, to adopt the numerous subdivisions which exist in some of the European schools. From this report, we learn that in the States of the Union generally, no legal requirements are ex- acted of medical practitioners. The only exceptions are, New Jersey, Louisiana, Michigan, and the District of Columbia. Among the measures of reform in the system of medical education, the committee recommends that a certain degree of preparatory education should be required of those who engage in the study of medicine: they refer approvingly to the action of the Medical Society of New York, which provides that, " to be admitted to the offices, of any of the members of the society, it shall be required that the applicant shall, in addition to a good English academic education, have made respectable attain- ments in the Latin and Greek languages.'' They urge the importance of hospital clinical instruction, and of making at- tendance upon it, obligatory upon pupils: They condemn what are called "College clinics," and "concur unanimously in the opinion, that they present no adequate equivalent to the 224 Transactions of American Medical Association. [April? student, when resorted to as a substitute for actual hospital attendance." They also object to the private examination of students, and recommend that, if not public, they " should be conducted in the presence of at least a majority of the profes- sors, and should be in writing, as well as vita voce." The committee think much would be gained by a division of the subjects taught, into two classes, and propose that at the end of each course, the student should be examined, and a certificate of acquirement given. They also reiterate the recommenda- tion of the Medical Convention of 1847, that the collegiate courses should be extended to six months. Other matters of interest are brought forward which we cannot now notice. To this report is appended the " views of the Medical Faculty of Harvard University, relative to the extension of the Lecture Term," which are adverse to such extension. This paper is ably written, and some idea may be formed of its character from the fact that the Association appointed a special commit- tee to reply to it. This reply is also appended. If our limits permitted, we would notice these two articles at length. Report on Medical Literature. The subjects embraced in this report are 1st. The general character of the Periodical Medical publications of the United States ; 2d. The more im- portant articles therein presented to the profession ; 3d. Origin- al American Medical publications ; 4th. Medical compilations and compounds by American writers ; 5th. American re-prints of Foreign Medical works ; and 6th. All such measures as may be deemed advisable for encouraging and maintaining a national literature of our own. a The present aspect presented by medical journalism in our country is full of auspicious omens of the future progress of medical science. The first minds of the profession are engaged both in their editorial management, and in the making up their original, and review matter. A wise and liberal spirit general- ly pervades and animates the editorship. No personal abuse or vindictive feelings are allowed to stain their pages, and dis- parage the dignity of the science, to the promotion of which they are devoted." At the time this report was prepared, there were published in the United States, twenty original, or native, and four for- 1850.] Transactions of American Medical Aosociation. 225 eign or re-published medical periodicals. Of the former, five are published quarterly ; six bi-monthly ; six monthly ; one semi- monthly ; one weekly, and one irregularly, (the Transactions of the Philadelphia College of Physicians.) We must pass over the other subjects of this excellent report, and will only bring to the notice of our readers a measure it proposes, which we doubt not will receive the approbation of the profession : " it is the appointment of a Committee or Board of Publication, at Philadelphia or New York, whose duty it should be to receive, and carefully read the original 01 transla- ted works which American writers might offer, and to have them published under the superintendance of the board or com- mittee." " This board or committee of publication should have funds raised by subscription, after the manner of the Sydenham Society in England, placed in its hands." Report on Public Hygiene. This report, with its appen- dices, occupies over 200 pages. It notices the subjects of drainage, street cleansing, water, building, and ventilation, nuisances and disinfectants. To the report are appended sani- tory reports from many of our large cities ; a communication from Dr. Fenner on the Yellow Fever quarantine at New Or- leans ; one from Prof. Jackson on the influence upon health produced by the introduction of Tea and Coffee in large pro- portion into the Dietary of children and the laboring classes; one from Prof. Johnson on the introduction of water and gas into cities ; and one from Dr. Harris on the use of disinfectants in the Navy. Report on Adulterated and Sophisticated Drugs. This re- port is quite short, but it contains many interesting facts, and some valuable suggestions which we may notice hereafter. Report on Indigenous Medical Botany. This report is also short, and is mainly devoted to an examination of two articles, the Sarracenia, or side-saddle flower, and the Cornus Florida. Of the former article the report says, "from its physiological effects, we should confidently expect the remedy to be of very great value in all those morbid conditions characterized by de- pression of organic actions, loss of appetite, and deranged diges- tion, unaccompanied by inflammatory action." In speaking of the Cornus Florida, the report pays a deserved compliment to n. s. VOL. VI. no. iv. 15 226 Therapeutic Effects of Aconite. [April, the article of our esteemed young friend, Dr. D. C. O'Keeflfe, which originally appeared in this Journal, and draws largely from it, to illustrate the properties, &c, of this indigenous medicine. To this report is appended a long and elaborate report by Dr. F. P. Porcher, of South Carolina, on the Medicinal plants of that State, indigenous and introduced, and one by Dr. Ste- phen W. Williams, of Mass., on the indigenous Medical Botany of that State. We hope that the foregoing brief and imperfect synopsis of the transactions of the American Medical Association, will induce our readers to purchase the volume. It contains a large amount of interesting and instructive matter to which we have not even alluded, and will fully repay any one for its cost, and the time expended in its careful perusal. A copy may be pro- cured by remitting to Dr. Issac Hays, Philadelphia, three dollars in par funds and free of postage. Therapeutic Effects of Aconite. By Dr. Teissier, of Lyons. Condensed and translated for this Journal, by J. A. S. Milligan, M. D. We find in the Revue Medico-Chirurgicale an article on this subject by Dr. Teissier, of Lyons. After alluding to the dis- crepancy in the published opinions of different authors on the therapeutic value of the preparations of aconite, and explaining this discrepancy by a want of similarity of cases in which the remedy was employed, he proceeds to record the results of his researches, undertaken for the purpose of defining in which diseases this medicine was indicated. Dr. T. has examined aconite with reference to its narcotic and antiphlogistic actions the two modes of action usually ascribed to it. That this remedy possesses narcotic properties, he thinks there can be no doubt. Its power, however, was found to be more feeble than that of opium, belladonna, or the datura, and the field of its applicability more circumscribed. It afforded no relief to patients affected with exostosis, cancer, nephritis, paronychia, etc., but was very efficacious in assuaging the pains of diseases recognizing for their cause a derangement 1850.] Therapeutic .Effects of Aconite. 2V7 of the functions of the skin, as, for example, rheumatism, angina, odontalgia caused by cold, etc. Dr. T. concludes, therefore, that aconite may be of 'ieat service to practitioners as a nar- cotic, but that this is not its chief property. He has administer- ed aconite in many diseases for the cure of which blood-letting is deemed by all practitioners indispensable, such as peritonitis, apoplexy, and hypertrophy of the heart ; but he has never met with a single case in which he was convinced that this medi- cine acted as a useful substitute for venesection, or as a directly antiphlogistic remedy. He does not wish to be understood as affirming, however, that aconite never acts as an antiphlogistic ; for he will show hereafter, that in certain diseases, a in mea- sles, scarlatina, etc., it may exert a depressive influence on the circulation : he thinks that it produces this effect, however, indirectly, and by regulating another function, the derange- ments of which had caused the disease. According to Dr. Teissier the action of aconite is directed chiefly to the skin. Its special property is to eliminate from the cutaneous tissue all noxious principles, and to re-establish the disordered functions of this organ. He recommends the preparations of aconite, therefore, in all diseases caused by a "derangement of the cutaneous secretion, and consecutively by a catarrhal j tee on the articulations (articular rheumatism), on the muscles (muscular rheumatism, lumbago), on the nerves, (sciatica, odontalgia), on the mucous membranes, (coryza, angina, bronchitis, grippe, catarrhal fever, etc.)" Dr. T. re- commends aconite also at the commencement of all eruptive fevers. We will notice briefly some of the diseases in which he has found aconite particularly useful. Qourbature. This mild disease, caused by a suppression of perspiration, and characterized by pains in the limbs, shivering, lassitude, headache, and general aching, says Dr. T., may serve as a type for the administration of aconite. In this affection he prescribed from 5 to 10 drops of the tincture during the day. Catarrhal Fever. Dr. T. found aconite equally serviceable in catarrhal lever. The therapeutic indications in this lever are: 1. Tore-establish the functions of the skin ; 2. Tocombat the local irritation of the nose, throat or bronchi. He affirms 228 Therapeutic Effects, of Aconite. [April, that aconite fulfils perfectly the former of these indications; but that in carrying out the latter, it requires the assistance of other means, such as opiates, vesicatories, etc. Angina, Acute Bronchitis. " With MM. Tessier (of Paris) and Gabalda, we have frequently known aconite," says the wri- ter, "to exert a happy influence in simple angina, and in acute pulmonary catarrh, mitigating readily the pains of deglutition in the former, and quieting the severe cough of the latter. We have found it only necessary in these cases to administer from 5 to 10 drops of the tincture every day." Grippe. Dr. T. states that in this disease, which bears a striking resemblance to courbature and catarrhal fever, aconite is very serviceable: it restores the healthy action of the skin, relieves the painful sensations of the disease, and abridges its duration. He considers it worthy of remark, too, that those patients who made use of this medicine did not retain so long the feeling of depression and general aching, which so frequent- ly follows an attack of grippe. Rheumatism. Dr. T. has not found aconite equally useful in all cases of rheumatism. He derived the most decided benefit from it in cases of recent origin, attended neither by swelling nor fever, or in which these symptoms were but slightly devel- oped. In these cases he thinks it preferable to blood-letting, to morphine, and to belladonna: to blood-letting, which only combats the pain, which does not remove the rheumatic princi- ple, and which frequently predisposes the part affected to stiff- ness, swelling, and a recurrence of the evil: to morphine and belladonna, because they are not so well tolerated by the stomach, and because they too are merely palliatives. In acute articular rheumatism, with fever and decided tumefac- tion, the writer has found aconite less effectual than in the cases just mentioned. But even in these cases it may be administer- ed at the commencement, in order to diminish the fluxion to the joints. In chronic rheumatism, aconite did not prove so serviceable as in cases of recent origin. Dr. Teissier has known instances* however, where obstinate rheumatic pains of several years du- ration were overcome by the persevering employment of this remedy. He states, further, that aconite is undoubtedly eflica- 1850.] Therapeutic Effects of Aconite. 229 cious, when its use is continued for several months, in subduing predispositions to rheumatism. This result it produces by re- storing the functions of the skin, especially by promoting the insensible perspiration, and by neutralizing the influence of atmospheric moisture and of the rheumatic principle. The dose of aconite, the writer observes, must be much larger in rheumatism, than in the diseases previously noticed. We should begin, he says, by giving from 10 to 20 drops of the tincture, and increase the dose gradually to 4, 6, or even 8 grammes a-day. Eruptive Fevers. Dr. T. has employed this remedy very successfully in exanthematous fevers, in rubeola, variola, scar- latina, urticaria, miliaria, erysipelas, etc. He affirms that in all these diseases, but especially in the measles of children, aconite exerted a happy influence on the fever and on the eruption, which came out with readiness, and ran its course with remark- able regularity. "But," he adds, " if complications occur, it will be necessary to combat them by the other means which experience has sanctioned." Erysipelas. In this section, the writer treats of the action of aconite in erysipelas complicating wounds. He has known aconite to afford very prompt relief in traumatic erysipelas, attended with fever, rigors, inclination to vomit, temporary delirium, etc. He remembers, particularly, two patients, who were affected very seriously with this disease, but who were relieved, in a manner really surprising, in twenty-four hours. He recommends very highly the employment of this remedy in hospitals where traumatic erysipelas is so common. Pneumonia. Dr. T. has administered aconite in a great many cases of pneumonia. " On the success which has follow- ed the employment of aconite in this disease," says he, "the homceopathists base their assertion, that this medicine may be usefully substituted for blood-letting." He has found aconite serviceable in the early stages of pneumonia, before the inflam- mation had become decided; but when once auscultation had proved that the tissue of the lung was gorged with blood and denser than in the normal state, he has found this medicine insufficient, and has been obliged to resort to antimonials. He does not think, therefore, that it follows as a natural conse- 230 Therapeutic Effects of Aconite. [April, quence, because aconite contributes to the moderating of the febrile symptoms at the commencement of the disease, that it is for this reason an antiphlogistic remedy, and that it acts like venesection. He says, further, that he does not believe blood- letting to be indispensable in the treatment of pneumonia ; that in fact we may do without it in the majority of cases, excepting those very rare instances where the oppression is very great. The writer remarks, that all that he has said respecting pneumonia, is applicable also to pleurisy. " Aconite," says he, "may be useful at the commencement of the disease, but when the effusion is pretty considerable, it becomes only an accessory element in the treatment, and it then becomes necessary to join with it purgatives, diuretics, and blisters." Dr. T. has used the preparations of aconite in typhus, and in inflammatory fevers, but without success. He is induced to believe that aconite would be a useful remedy in syphilitic erup- tions ; but having never administered it in these diseases he is unable to bring any facts to the support of his opinion. He cannot say anything of the value of this medicine in chronic psoric affections. Dr. T. has had a great desire to try the administration of aconite, in accordance with the advice of M. Tessier (of Paris), in the purulent diathesis. He would state, however, that the purulent diathesis is a disease so terrible, and which carries oft* patients so rapidly, that he would hardly dare to trust to the action of aconite, except as an adjuvant, to arrest its progress. Beside the diseases already enumerated, Dr. T. thinks that there are many, in the therapeutics of which aconite may enter as an accessory. As a general rule, he observes, we may de- rive benefit from its employment whenever we are called upon to treat a disease, in which the cutaneous action is abnormally performed. Mode of Administration. In rheumatism, neuralgia, or in any other painful disease, where the anodyne effect of aconite is desired, Dr. T. gives from 10 to 20 drops of the tincture, increasing the dose gradually to 3, 4, 5, and even 8 grammes a-day. In courbature, or catarrhal fever, he gives only from 5 to 10 drops of the tincture in the 24 hours : by this means he reduces the pulse, and lowers all other febrile symptoms, with- 1850.] Ttierapeutic Effects of Aconite. 231 out producing any of the phenomena of intoxication. He recommends that the medicine be taken some time either before or after a meal. * Of course," says he, " it must be used with more reserve in the cases of children, than in those of adults." Dr. T. prefers the alcoholic tincture of aconite to the other preparations of this medicine, considering it as being more relia- ble than the extract. The dose of the extract, he says, is from 5 to 10 centigrammes, increasing it to 50 centigrammes, or even to 1 gramme a-day. We give here the recapitulation of Dr. TVs conclusions. 1. Aconite is a very useful medicine, and is applicable to a great number of diseases. 2. It is a narcotic less active than opium, belladonna, and the datura, but which nevertheless may be of great service in pain- ful diseases, especially in those which recognize for their cause a serous, catarrhal, or rheumatic fluxion. It is less successful in the treatment of pains proceeding from diseases decidedly inflammatorv. 3. The characteristic property of aconite is, to act on the functions of the skin. It exerts a special eliminatory influence on this membrane, that renders it useful, either as a principal or adjuvant remedy in all diseases where disorder of the cuta- neous action constitutes a prominent part, especially in courba- ture, catarrhal fever, grippe, angina, and acute pulmonary catarrh, articular and muscular rheumatism, especially those cases attended with but little fever, and slightly marked inflam- matory symptoms, rheumatic neuralgia, etc. ; and in all affec- tions where a morbific principle is retained in the meshes of the cutaneous tissue, and alters its normal organization, as in all the exanthemata (rubeola, variola, scarlatina, miliaria, urti- caria, erysipelas, etc.) 4. Aconite is never directly antiphlogistic. It cannot re- place blood-letting. It simply diminishes, in many diseases, the frequency of the pulse by quieting the pains which occa- sioned the fever, or by facilitating the elimination of the morbid principles which kept it up, as in erysipelas and measles. 283 Extraction of Foreign Bodies. [April, On the Extraction of Foreign Bodies. By Johann Frederich Dieffenbach. (Excerpta from his Operative Surgery. Ranking's Abstract.) I. Removal of foreign bodies from natural cavities, within reach of the surgeon. II. Removal of foreign bodies which have penetrated the textures. I. The Removal of Foreign Bodies from Natural Cavities, within reach of the Surgeon. 1st. The removal of foreign bodies from the nasal cavity. Foreign bodies in this locality are met with most frequently in children of from three to six years old. Their abstraction is often very difficult, especially when they have caused swelling, are firmly fixed, and situate high up. The most common are leguminous seeds, peas, beans, little stones, glass beads, bits of wood, pipe-stalks ; in the instance of adults, ends of pipes, buttons of foils, fragments of pincers, silver wire left behind after attempts to remove polypus, dossils of lint, blotting-paper, and compressed sponge, which may have served as plugs, to check hemorrhage. In the first place, it is requisite to ascertain the nature of the foreign body, and also the nostril in which it is lodged. For this purpose, the patient being seated facing a window, the surgeon gently introduces a blunt silver probe, curved at the end, and moistened. The substance, if small, and not wedged in, may be directly extracted with the probe, insinuating the concave side of the instrument behind it, and securing it in a favourable position. Sometimes the irritation excites sneezing and whenever this can be foreseen from the grimaces of the patient, sudden pressure is to be made on the opposite nostril, whereby the body will be expelled through the current of air and the concussion. This will occasionally follow a pinch of snuff. Should the first attempt fail, and the surgeon be aware of the situation of the foreign body, the head is to be thrown back, supported by an assistant, while with the left hand he presses upwards the tip of the nose. If the subject be a child, he takes a strong silver director, bent at the end like a flat hook, passes it from below upwards round the extraneous substance, lowers his hand in order to elevate the point, and withdraws it in that direction. For infants, an oculist's curette will be found suita- ble. When the substance is firmly fixed, and cannot be got away with the above instrument, a small pincer may be em- ployed, in the manner of a polypus-forceps, one blade being di- 1850.] Extraction of Foreign Bodies. 233 rected upwards, the other downwards. The expanded blades being made to grasp the body, a few gentle to and fro move- ments are performed, and the extraction achieved. It is not sale to exercise much pressure in the instance of glass beads, lest they break, or even with regard to swollen beans or peas, lest they be crushed. Residuary fragments often create more mischief than the original mass. These are best removed with an ordinary forceps. The dislodgment of firmly impacted hard substances from the nostril is frequently difficult. I generally use a straight polypus-forceps. The manipulations here are the same as for the torsion or extraction of solid nasal polypus. The hemor- rharge is oft times considerable ; to be arrrested only by cold injections and cold applications to the forehead and nose. Where the foreign body is too large to pass the nasal orifice, or to be pushed into the throat, it it is necessary to divide the ala nasi. Bulky substances alone ought to be propelled into the gullet, because, if small, there is the risk of danger of their dropping into the windpipe. Bits of sponge, lint, and other kinds of plugs, are readily withdrawn by the aid of polypus- forceps, after water has been previously squirted up. To allay pain and inflammation, tepid injections of decoction of mallows may be thrown into the nostrils. 2d. The extraction of foreign bodies from the external auditory passage. This is'often indispensable in the instance of children who have stuck peas, beads, berries, portions of chalk or stone in the ears. These are most readily scooped out with a curved director or a curette ; if in the anterior part of the auditory tube, with forceps. In adults, the meatus is sometimes blocked up with dead insects, plugs of cotton, and other things incrusted with cerumen, or with indurated cerumen itself. These, the cause of continued deafness for years, are best extracted with moderate sized polypus-forceps. It is advisable to drop in beforehand a little almond oil, and allow the patient to recline upon the opposite side of the head. Great caution is to be observed, so as not to injure the walls of the meatus, or the tympanum. Should violent bleeding supervene, and there be no likelihood of completing the operation at one sitting, cold, and afterwards warm, applications are to be re- sorted to, so as to favour suppuration. Subsequently, when the parts are relaxed, the substance may be extracted. Fa- bricius Hildanus witnessed hemicrania, debility of the entire half of the body, obstinate cough, amenorrhcea, epilepsy, and wasting of the arm ensue from the circumstance of a bead having been forced into the ear. Restoration to health followed its abstraction. Sabatier saw typhus fever and death conse- 234 Extraction of Foreign Bodies. [April, quent upon the pressure of a pellet of paper in this situation. Power observed protracted salivation and atrophy result from a dossil of wood. I have noticed, after the removal of foreign bodies, long impacted in the ear, that the hearing became so acutely sensitive, as to require the ears to be stopped with cot- ton. Should a living insect create any distressing symptoms, it may be picked out by the aid of a tuft of cotton fastened to the end of a match ; or killed with a drop of oil, and then readily extricated. Solution of acetate of lead, dilute cherry-laurel water, and a weak solution of corrosive sublimate have been used for the same purpose. Comperat destroyed an insect larva in the meatus auditorius by means of tincture of opium. Andry states that a round worm crept along the Eustachian tube into the ear. 3d. The extraction of foreign bodies from betwixt the eyelids and the eyeball. These are of every variety, mostly grains of sand, particles of lime, insects, seeds, and the like. They either lie free between the lids and ball of the eye, or are imbedded in the surface of the cornea or sclerotica, for ex- ample, splinters of steel. Foreign bodies, situate beneath the eyelids, are easily removed, provided these are not inflamed and can be held apart. If situate, under the lower lid, this is to be depressed with the left index-finger, held firmly upon the skin. If under the upper lid, the central eyelashes are to be seized with the fingers, and the lid gently dragged from the globe ; then, upon the patient throwing his head backwards, the operator keeping his eye fixed on the intervening space, withdraws the mote by the help of a blunt forceps. The curette answers well when the substance is round ; dust, sand, and the like are got rid of by a hair pencil, together with aqueous injections ; acrid matters, as gun-powder, salt, pep- per, by means of a pencil soaked in almond oil. Irritant chemical substances are neutralized by appropriate liquids, and their effects counteracted by a strict antiphlogistic after-treat- ment ; if the eyelids are greatly swollen, they must be care- fullv opened, and then syringed with warm milk. Foreign bodies, which penetrate, and are firmly fixed within the inner membranes of the lids, are not easily reached, especially when the eyeball is much inflamed and the eyelids are closed from inflammatory swelling. When such is the case, previous resort must be had to local or general blood-let- ting, cold applications, and, where the substance has remained a considerable time, to tepid, mucilaginous, and narcotic applica- tions. The speculum is seldom admissible from the risk of irritating the eyelids. If the penetrant body is sharp, angular, and firmly imbedded, 1850.] Extraction of Foreign Bodies. it must be removed at all hazards, for fear of its perforating the eyeball. Where it connot be picked out with forceps, and is endangering sight, the external commissure of the lids ought to be snipped. The section of the conjunctiva is generally re- quired from its elimination. For the removal of minute bodies projected into the mem- branes of the globe, as tiny splinters of metal, glass, flint, or points of needles, the forceps of Professor Von Ammon is con- venient, the eyelids being held asunder with the ordinary speculum. Very small splinters are most readily extracted with a cataract needle. The surgeon may occasionally avail himself of the hooks employed in strabismus operations, for the purpose of fixing the eye. In the instance of seeds of corn, which do not perforate the eye, it is generally necessary to dilate the minute aperature wTith a fine cutting instrument, ere they can be withdrawn with the forceps. When the foreign body has remained so long as to have got incased in a capsule, a slight incision is to be made, after which it may be picked out with the point of the knife or with forceps. 4th. The extraction of foreign bodies from the larynx or air- tubes. (See also some remarks on this subject in our Report on Surgery, vol. ix.) The extraction of foreign bodies from the air-tubes is an impracticable operation, partly owing to the physiological structure of the parts, and partly to the coincident irritation. The slightest attempt of the kind augments the jeopardy to life. If it be a pointed body, as a needle or fish- bone, there is always a chance of its having stuck in the superior portion of the windpipe. Here, after depressing the tongue with a spatula, it may be seized with a long forceps. Small round substances are apt to fall into the windwipe, and occasion by their ascent and descent, during the act of respira- tion, the most alarming symptoms. How are they to be secured? With forceps ? Death would inevitably follow the experiment. Desault alone proposed the passing of an elastic catheter from the nostril into the trachea. As a general rule, the foreign body, if of small dimensions, as a pea or little bean, after having lodged for a while in the trachea, drops into bronchus, commonly the right, because that is shorter and wider than the other. After careful dis- section, I have always found it in the right, and never in the left bronchus. It will seldom be evacuated by sneezing, provoked artificially, by coughing, vomiting, or by inclination of the head forwards. Only by prompt opening of the larynx or the trachea can life be saved. All other means are fruitless. Its exact position can be rarely ascertained by percussion, in- 36 Extraction of Foreign Bodies. [April, asmuch as it is constantly shifting to and fro during the first period after the accident, through the movements of respiration and cough. 5th. The extraction of forign bodies from the cavity of the mouth and gullet. Foreign bodies become fixed in the mouth only after having penetrated the mucous membrane, and are easily removed. When situate in the fauces or gullet, they create intolerable irritation, and eventually inflammation, if of a sharp or acrid description. Their immediate removal is therefore indispensable. Where there is a prospect of this being accomplished without operative interference, an en- deavour may be made to provoke vomiting, by thrusting down the end of a feather, dipped in oil ; if the patient has the power of swallowing, an emetic may be exhibited by the mouth, or, under urgent circumstances, injected into a vein. This treat- ment can apply only to small substances, for. if large and firmly impacted, the gullet may be ruptured. In all examina- tions with instruments, the tongue ought to be depressed to the utmost. The body in question must either be withdrawn, or hurried into the stomach. The first course is the best, the last often dangerous. Venesection is occasionally indicated. Should everything fail, oesophagotomy is the sole alternative. The substances which in the fauces are generally small and pointed, such as fish-bones and needles, most frequently the former. The patient being seated, is directed to gape and make a deep inspiration, whereby the velum is elevated, and the surgeon enabled to detect and extract the bone with a forceps. A lady, after eating some cake, suddenly shrieked with pain. I could perceive nothing about the neck, but, on carrying my forefinger to the back of the tongue, brought away a long thick bristle, which lay archwise across. Foreign bodies observe, in their transit, certain stations at which they halt; thus, in the pharynx, behind the thyroid and cricoid cartilages, in the begining of the gullet, or at its lower end, close to the diaphragm or cardia. They seldom stop at the middle of the gullet. If very large, they may cause suffocation ; thus, a large piece of meat, a hard-boiled egg, a pear, a chestnut, have each proved fatal. Guattani witnessed the most frightful death ensue from a chestnut ; the part of the gullet at which it stuck was gangrenous. Spiritus saw the same result follow the swallowing of a five-franc piece, which perforated the gullet above the cardiac orifice. Needles, in- advertently swallowed, pierce sometimes the gullet or stomach, advance by the aid of suppuration, or otherwise, towards the surface, and either escape spontaneously or through incision. 1850.] Extraction of Foreign Bodies, 237 Lyson observed a case where three needles, that went in at the mouth, came out at the shoulder ; I have known one issue at the arm. The procedure must be modified according to the nature of the substance. None but a bungler would attempt to disgorge a piece of meat sticking at the cardiac opening, or urge on a fragment of glass from the gullet into the stomach. External pressure will suffice for potatoes or plums when stuck in the throat. For the withdrawal of needles, fish-bones, and the like, there is no better implement than a large goose or swan quill-feather, with the barbed portion ruffled, and imbued with oil. The patient sits, with his head leaning upon the breast of an assis- tant, while the surgeon lowers the tongue, then introduces the feather, with its concave side downwards, into the throat, turns it rapidly round, and draws it out. The popular practice of swallowing a crust of bread is sometimes availing, but may also increase the peril when arrested above the bone. A sud- den slap on the back is by no means a bad plan, when the substance is large and obtuse. It is preferable to that of setting the patient on his head, as was done in the instance of Mr. Brunei, to promote the expulsion of the half-sovereign piece. The principal instruments employed for the present pur- pose are of the description of forceps. Dupuytren advises, as a preliminary step, the introduction of a gum elastic tube, sur- mounted with a silver ball, in order to ascertain the position of the foreign body. This, however, is superfluous, and will tend, moreover, to augment irritation. Cooper recommends the forceps of Weiss. The so-called leaden hammer of earlier writers consisted of a lead ball attached to a string, which was let down the throat, and pulled up again. Mesnier's lead hammer was of an olive shape; Petit's was equipped with a wire instead of a string. Petit used, besides, a metal noose fastened to a whalebone stem ; Fabricius Hildanus, a many- holed silver tube, provided below with a sponge. The double ring of Graefe, attached to the end of a rod of whalebone, with a steel spring, is very convenient for taking pieces of money out of the throat. The customary instrument, termed repous- soir, or probang, namely, a bit of sponge, as big as a walnut, stuck to the end of a whalebone rod, is generally useful, either for entangling fish-bones and the like, or propelling large round substances. My own procedure is as follows; if the body be small and sharp, I employ the oiled feather, as above described. An oiled wax taper, passed down to the cardiac orifice, has proved serviceable ; for, as soon as withdrawn, the body has been rejected. If the body be large, as a portion of flesh-meat 238 Extraction of Foreign Bodies. [April, adherent to a fragment of bone, I use a lithotrite with an imperforate scoop, and rather straight. The instrument is introduced with the blades closed, until, it arrives at its destina- tion, when these are to be separated sufficiently to grasp the substance, and, after a few gentle turns, withdrawn. When there is impending suffocation, from the presence of very large bodies impacted in the throat, Habicot enjoins tracheotomy before resorting to opening the oesophagus. I have never been compelled to this extreme measure. The most difficult thing to deal with are sets of false teeth when swallowed. I once relieved an old lady in this predicament by means of my fingers. On several occasions, I have removed, with curved polypus-forceps, from three to four teeth attached to a gold plate, and which got accidentally into the throat ; once, by the aid of an emetic, as a last resort, a seat of four teeth, very deeply located. In all these operations, the patient is to be in a sitting posture, the head properly supported, the mouth rinsed with tepid water, tepid water mixed with white of egg taken as a drink, and the instrument smeared with white of egg rather than with oil. 6th. Of foreign bodies in the stomach and intestines. For- eign bodies may accumulate to enormous loads in the stomach before they endanger life. Fournier mentions a galley-slave who, after swallowing for years all sorts of extraneous sub- stances, ultimately died of ileus. In his stomach were amassed twenty-eight bits of wood, a few small pewter spoons, several nails, buckles, weighing altogether one pound ten ounces. Bjerlander relates the instance of a man who swallowed a great many copper coins, a pocket-knife, and a steel for striking fire, all of which were, however, rejected. Needles, bones offish, and of small poultry, are sometimes voided with impunity ; at other times retained, perforate the tunics of the stomach or the in- testines, and migrate towards the surface, the track which they permeate, being progressively closed as they advance. Small pointed bodies are found in the most unaccountable localities. Heim, the younger, records several instances of fragments of bone, grains of corn, and the like, which he detected in the appendix cceci vermiformis. I once met with a fish-bone, half an inch long, in that situation, while examining the dead body of an aged female. I have not unfrequently seen fish bones and sharp osseous spicuise discharged from fistulous openings about the verge of the anus, which had evidently perforated the rectum posteriorly to the sphincter, and given rise to fistula. Leeches occasionally find their way into the stomach, and fasten themselves to its inner membrane. Numerous minute 1850.] Extraction of Foreign Bodies. 239 leeches were discovered in Egypt by Larrey in the stomachs of soldiers, who had died in consequence. When this happens, the patient ought to drink a quantity of strong solution of com- mon salt to destroy the annelid, and afterwards an aperient dose of sulphate of magnesia to bring it away from the bowels. When the substance remains, even after free vomiting has been induced, large quantities of white of egg ought to be ad- ministered either directly by the mouth or the stomach-pump, aided by clysters of the same, anodynes, venesection, and leeches. Should death not ensue, or the body not pass by the anus, nature, in some rare cases, favours its escape by the formation of abscess, and art by incision through the stomach or intestine. 7th. The extraction oj foreign bodies from the rectum. These have either traversed the whole intestinal canal, or originated from hardened feces in the rectum, or entered from without. The most appropriate instruments for their removal, are bullet-forceps, polypus-forceps, small lithotomy-forceps, smooth blunt hooks of the breadth of the finger, and scoops with long handles. Before operating, the rectum is to be filled with gruel mixed with one-fourth of olive oil, in order to prevent its coats from getting into contact with the foreign substance, or dam- aged by the forceps. The patient is made to lean over the back of a chair and grasp its front edge, the buttocks being held apart by an assistant standing to the left side. The anus is then closed with the left hand, and the forceps, well oiled and shut, introduced by a gentle movement betwixt the fingers. The blades are next separated, carried upwards, and then approxi- mated. The surgeon will soon be sensible whether he has secured the object of his search: if not, he directs the blades upwards and downward till he has ; he then drags it out by a slight rotatory motion, as in the extraction of a stone during lithotomy. An irresistible call to stool seizes the patient, the liquid contents gush forth in a full stream, and at that moment the foreign body is evacuated. I have thus more than once taken away a mass of incrusted excrement which had been for years accumulating in the gut. I succeeded, by the aid of a silver spoon, in relieving an old gentleman throughly of an infirmity which had troubled him for a long period of time. He had previously been treated for stricture of the rectum by means of bougies, and once by dilatation through inpision. He had annually resorted to Carlsbad to drink the waters, the radical evil having been overlooked. All loose stools uniformly swept by the incrusted feces. The extracted lumps possessed a calcareous crust, and were very voluminous. Leber failed in removing, by the forceps, a piece of wood 240 Extraction of Foreign Bodies. [April, one foot long, and one inch thick ; he at length bored it through, and pulled it out. Marchetti extracted a dried sow's tail by passing some membrane over it, so as to hinder the short pickly bristles from irritating the mucous lining. Von Walther drew away with the forceps, from the rectum of a peas- ant, a piece of the root of a tree, which measured seven inches; Von Graefe, in like manner, the end of a stick ; and myself a shoemaker's pliers from a lad. Wherever the foreign body, either on account of its magni- tude, or its being obliquely wedged in, cannot be got away without violence, it will be expedient to enlarge the orifice of the anus with a probe- pointed bistoury. In order to insure a clean incision, the left index-finger, smeared with oil, is to be inserted with the volar aspect towards the sacrum, as a guide for the knife, which is made to cut for about an inch in the di- rection of the os coccygis. This facilitates the extraction, and the wound readily heals under cold applications, and injections of gruel into the rectum. 8th. The extraction of foreign bodies from the female parts of generation. For this purpose the surgeon may commonly use his fingers or a polypus-forceps ; but if the foreign body be bulky and wedged in, then bullet or lithotomy-forceps and broad hooks. The patient being seated upon the edge of a table, facing the light, with the thighs held widely apart by two assistants, the surgeon squirts a little oil into the vagina, ex- amines the nature of the body with the fingers and speculum, then passes up the forceps, previously oiled, gradually opens them, insinuating one blade behind the body, and finally with- draws it in the line of the pelvic axis. This is nowise difficult, when the body is not very irregular in shape, and the parts are not inflamed or swollen. Where, on the contrary, the vagina is contracted, and deprived of elasticity through inflammation and puriform secretion, and the substance large, it must be broken up into fragments and taken away piecemeal. After its removal, the vagina ought to be well syringed, and the patient put into a warm bath. Mucilaginous decoctions may be subsequently injected, and the parts fomented with in- fusion of chamomile and Goulard lotion. Foreign bodies in this situation are of every variety. If allowed to remain long, they determine inflammation, suppura- tion, and napture of the vagina, either into the rectum or the bladder. Thus communication with these cavities, and effusion of their contents into the vagina, is the obvious result. Foreign bodies, if sharp and angular, occasion, now and then, danger- ous lesions. I once had to remove from a young lady a number of different sized fragments of a porcelain urinal which 1850.] Foreign Body in the Windpipe. 241 had broken under her. The labia were severely wounded, and the vagina completely filled with the shred. The hemorrhage was so excessive as to have caused fainting. I extracted the whole by means of a polypus-forceps, and inserted a few fine sutures. The wounds healed promptly. Large, incrusted, and firmly-adherent sponges were removed by me with lithotomy-forceps, as also a variety of full-sized wooden pes- saries, all in like manner covered with a crust. Some of these 1 was obliged to break, using several forceps, wTith the aid of assistants, or else cut them in half with Liston's bone- scissors. Morand withdrew from a lady a silver pessary through the openings, in which bridles had shot across, and held it fast. Dupuytren extracted from a nymphomaniac a poma- tum-pot; on another occasion, an old ring-pessary, which was wedged in, and caused most urgent symptoms. A girl intro- duced the cone of a pine into the vagina. The sharp imbricated scales got lodged in the mucous membrane, and were picked out one by one after the cone had been cut in pieces. The vagina was excessively turgid. The remainder of this article devoted to the subject of " the removal of foreign bodies which have penetrated the textures," will appear in our next number. A Case of Foreign Body in the Windpipe, By John Popiiam, A. B., M. B. (Dublin Journal.) The subject of the present case was a little boy, named John Casey, aged 4, who was brought to the infirmary to be treated for supposed croup. His respiration was stridulous, voice hoarse and at times almost inaudible, and cough dry and hard, occurring in paroxysms, which threatened suffocation. Du- ring the fits of coughing, the inspirations, assumed a peculiar character, becoming shrill and whistling, not, however, so dis- tinctly sonorous as in hooping-cough ; the expirations were without any appreciable sound. When the paroxysms ceased, the child appeared comparatively free from distress, and the sharp sound of the inspirations became less audible, but did not quite lose the sibilant character. A circumstance which early attracted notice in the case was a want of accordance between the pectoral signs and constitutional symptoms. Thus, the child suffered very little pain, complaining chiefly of soreness at the hollow of the neck from constant coughing, the tongue was clean, the deglutition not affected, there was but little thirst or heat of skin, and the pulse ranged from 90 to 102 in x. s. VOL. VI. no. iv. 10 242 Foreign Body in the Windpipe. [April, the intervals of cough, being slightly intermittent ; the face, however, was pale, swollen, and anxious, the head thrown back, so as to extend the larynx; the jugular veins were turgid, and the child was particularly fidgety and restless. On re- marking these circumstances to the mother, she stated that on the previous day the child had been seen playing with a little ring of brass, an eyelet or stay-eye which he said he had swallowed, but, from his extreme youth, she did not attach much importance to the child's assertion; she admitted, how- ever, that the piece of brass had been sought for and could not be found. She also observed that a slight cough which the child had, became suddenly and alarmingly aggravated ac- companied by a choking sensation so urgent that she took him to an apothecary in the neighbourhood, who told her that the child had quinsy, and administered an emetic with temporary relief. On examination of the chest, the sound on percussion was found everywhere normal. The respiratory murmur was heard distinctly in both lungs, and was not accompanied in the early stage of the case by any rhonchus ; but, though perfect- ly veiscular all over the lungs, yet it was not as loud as is usually heard in a child of his age. There was no perceptible difference in the respiration of the right lung, as is observed to occur when a foreign body becomes impacted in the right bronchus or its subdivision. We could thus gather only the negative evidence that the bronchi were not directly obstruct- ed, nor the parenchyma of the lungs inflamed. The examina- tion of the larynx was less conclusive. It was difficult to apply the stethoscope to the short and uneven neck of the child, and he was constantly crying and shifting his position. We could, nevertheless, collect that no evidence of a moveable body ex- isted either upon coughing or change of posture, even on inverting the child ; the distress, howTever, produced by this position, was so great that we did not attempt to repeat it. The diagnosis of the above case was embarrassing. Wre had, on the one side, the testimony of the little patient himself that he had swallowed the piece of brass, but so far dubious, that when he was pressed further, he got frightened, and de- nied all knowledge of it ; we had also the sudden appearance of the suffocation cough and dyspnoea, and the paroxysms of great distress, alternating with intervals of comparative ease and remission of febrile symptoms ; these circumstances, taken in combination with the existing physical signs, rendered the supposition of a foreign body in the windpipe extremely probable; on the other hand, cases of croup were at the time of almost daily occurrence at the infirmary, and, in the present instance, the signs of temporary or permanent pulmonary ob- 1850.] Foreign Body in the Windpipe. 243 struction were absent. As, however, the evidence in favour of the presence of a foreign body in the air-tubes predomina- ted, and the child, in such an event, incurred hourly risk of suffocation, if not relieved by an operation, it was resolved to admit him into the hospital with the view of operating upon the first emergency. On explaining, however, to the friends the probability of the operation being required, they at once demurred, and even refused to allow the little patient into the infirmary, unless a pledge was given that no operation should be performed. Under these circumstances, nothing remained but to carry out the medical treatment, explaining to the parents the risk of failure; accordingly the trachea was freely leeched, and powders of calomel and ipecacuanha were given, with the apparent effect of improving all the symptoms, except the stridulous breathing. The cough lost much of its hard character, and its exacerbrations were less frequent ; the expectoration became more free, the only change in the respira- tion being the addition of slight bronchial murmurs. On the twenty-first day, from the date of the severe symptoms, the child after a night of unusual dyspnoea and spasmodic cough, while sitting up in his mother's arms, where, indeed, he had continued nearly all the time of his illness, from inability to lie in bed brought up the piece of brass by a strong expiratory effort without cough. The little patient was the first to notice its escape. Upon examination of his chest a short time after, we found the stridulous breathing and signs of oppressed cir- culation gone, and the vesicular respiration decidedly louder over both lungs. In a few days all traces of irritation had dis- appeared, and the child in the month following passed through a severe attack of measles without any untoward result. The piece of brass proved to be, as was suspected, one of those small rings, with a groved edge and central orifice, used by stay-makers; it weighed three grains, and its diameter somewhat exceeded three-tenths of an inch, no doubt greater than that of a bronchus in so young a person. Hence, and from the absence of the physical signs of obstruction of the air passages of either lung, it seems almost certain that the sub- stance was not impacted in any of the bronchi ; that it was fixed seems probable, from the absence of pain and of the signs usually denoting the motion of a foreign body in the trachea; the weight of the brass and its sharp, jagged edges would also dispose to this result, but whether it was fixed in the trachea or in one of the ventricles of the larynx we can only conjec- ture. The central opening in the eyelet, by affording a facility for the transit of nir, certainly lessened the danger which would be incurred from a solid body of equal diameter, and to 244 Periscope. [April, this was probably owing the feeble vesicular murmur heard equally in both lungs, as if from a cause common to both. Per- haps, also, the central orifice in the brass had some connexion with the whistling sound of the inspiration noticed above, simi- lar to that which occurred in the case recorded by Professor Macnamara in the Dublin Hospital Reports, where a distinct musical note was produced from a perforated cherry-stone impacted transversely in a boy's larynx. It is probable that the aggravation of the symptoms upon the night previous to the expectoration of the eyelet, was oc- casioned by the loosening or dislodgment of it. Certainly the happy escape of a body of dimensions so disproportionate to the opening of the glottis of a child of his age, is a lesson to us not to despair when, as in the present case, an operation, though strongly urged, will not be permitted. PART III. Jttontljlp ^izvistoyc. On the Physiological Anatomy of the Spleen. (Medical Times. American Journal.) Dr. VV. R. Sanders arrives at the following conclusions, which he gives at present without any details : I. The Malpighian glandular or sacculi, and the pulp of the spleen, constitute a true secreting apparatus. A. The Malpighian sacculi are hollow, spherical membranous bags, completely closed, and filled with organized contents ; they are at- tached to the trabecular by an arterial pedicle, and are imbedded in the pulp. Saccular membranes. The outer membrane of the sacculi is fibrous, and contains arterial remifications and numerous capillaries ; their inner membrane is granular. Saccular Contents. On the inner surface of the membrane is applied a complete layer of nucleated cells ; which are clear (not granular) of about 1.1200th inch diameter, and of a light yellowish colour, when not altered by the action of water. The rest of the inte- rior of the sacculus is filled up by free corpuscles (containing nucleoli) of a light grayish colour, and of about l-4000th inch diameter, corres- ponding precisely with the nuclei of the cells, and by a homogeneous or slightly granular plasma. The perfection of the forms, the constancy and uniformity of appear- ance of these corpuscular elements, together with their reactions under water, acetic acid, &c, are extremely characteristic, so that they are easily and distinctly recognized. There is also evidence of the growth and maturation of the sacculi. This part, therefore, of the glandular anatomy of the spleen exhibits characters as perfect and as truly dis- tinctive as the glandular elements of the liver, kidneys, salivary glands, &c. 1850.] Periscope. 245 The sacculus is the formative secreting organ, analogous to the acini of known secreting glands. B. The splenic pulp consists, like the contents of the sacculi, of plasma and corpuscles; but the nucleated cells are extremely few, and mostly glanular hence the reason why they were not detected by observers who did not examine the sacculi apart from the pulp with sufficient care the plasma is full of granules, which are distinct, and infinitely mors abundant, than within the sacculi ; and the cor- puscles, instead of a regular uniform shape, are mostly angular, de- formed, with great variety of shape and appearance, and breaking up into granules. These corpuscles are often, also, of a reddish colour ; and, besides them, coloured semi-crystalline particles, of a deep red or yellow hue, and whose true relation is not yet perfectly made out, are found in the pulp. The pulp is, therefore, that part of the glandular apparatus where the corpuscles of the spleen become disintegrated and dissolved into granules and plasma; and, if the sacculi are analogous to acini, it is probable that they burst and effuse their contents into the pulp, where they undergo degenerating changes, becoming thus fit for absorption : the pulp being a reservoir or duct, in which the secreted product is lodged for a time, and undergoes the ulterior changes of maturition and solution. II. The veins are the absorbent elements of the spleen, and carry away its secretion. This is rendered probable by their extraordinary number and size; by their abundant ramifications in the pulp (while the arteries are spread over the secreting sacculi) ; by evidence derived from the com- position of the splenic venous blood, as shewn in Beclard's recent comparative analysis of splenic and other venous blood (Archives Generales de Medecine, Oct., Nov., Dec, 1848) ; and by general analogy in the nature, functions, and relations of the portal circulation in the adult and in the foetus. III. The blood circulation within the spleen is peculiar, but the peculiarities are not confined to the venous circulation, as has been generally supposed, but are common to it with the arterial. Its gen- eral principle is, " the sudden and immediate transition from very- large to very small vessels," which renders the circuit of the blood- current extremely short. This general rule does away with all the minor differences of vascular distribution found in the spleens of man, the horse, dog, &c, compared with those of the sheep, bullock, &c. The venous cells of the spleen, though, under certain circumstan- ces, an undoubted appearance, are entirely artificial, and always produced by methods of preparation, on which no reliance should be placed. There is no satisfactory evidence that the lymphatics are the ex- cretory ducts of the spleen ; nor that its fibrous tunic or tabeculce are muscular, or anything more than very elastic. Conclusion. The spleen is a true secreting gland ; and its product, which is some organized or organizablc albuminous compound, is ab- 246 Periscope. [April, sorbed into the venous blood of the portal system, and contributes, but is not essential to nutrition. The elements here mentioned are constant : they are easily made out in the spleens of the bullock, sheep, &c, tvhen quite fresh. In the human spleen, they are in general less easily analyzed ; but the microscope shows them to be identical, and, further, thus affords the means of recognizing and establishing the existence of the Malpighian sacculi, when (as not unfrequently happens in the human spleen) they are not visible to the naked eye, or, at least, not distinguishable from the pulp. Cod lAver Oil in Phthisis. The First Medical Report of the Hospital for Consumption and Diseases of the Chest, by the Physi- cians of the Institution. London. (American Journal.) The earliest trials of this remedy, made on a large scale, were those instituted at the Brompton Hospital ; where it has now been given in many hun- dred cases. The results of all these are not given, but its effects are shown in 542 cases. Of these 542 cases, 293 were in the first stage of the disease, and 249 in the second and third, or those stages subsequent to softening. Of those in the first stage, 190 were males, and 103 females ; 72 per cent, of the males, and 62 per cent, of the females, had their symp- toms materially improved : in nearly 18 per cent, of the males, and in 28 per cent, of the females, the disease was arrested (the term arrest implies that all, or nearly all, the symptoms of the disease had disap- peared, the patients felt themselves well, and able to pursue their ordinary occupations) ; in 10 per cent, of the males, and in nearly 10 percent, of the females, the disease progressed unchecked. Of the 249 patients in the second stage of the disease, 139 were males, and 110 females ; in 53 per cent, of the males, the symptoms were mate- rially improved, and in nearly 61 percent, of the females; in a little more than 14 per cent, of the males, and in nearly 14 per cent, of the females, the disease was arrested, In a little more than 32 per cent, of the males, and in 25^ per cent, of the females, the disease was not arrested. Viewing these results collectively, we find, in about 63 per cent., the symptoms improved; in 18 per cent., the disease was ar- rested ; and in 19 per cent., it went on unchecked. When it is recollected that, of the whole number treated at this hospital, the dis- ease was arrested in only 5 per cent., the value of this remedy, under the use of which the disease appears to have been arrested in 18 per cent, of the cases, must be considered very great. Different qualities of oil were tried, without exhibiting any marked difference in their remedial effects; but the offensiveness of some of the darker kinds rendered their general use impracticable. The oil now used is straw-coloured, transparent, and free from offensive smell. Patients in general take it without repugnance. The dose, at first, is 1 drachm three times a-day, for an adult; but it is gradually increas- ed, in some few cases, to l| oz. for a dose. It is usually administered in camphor-water, any aromatic water, bitter infusions, milk, or any 1850.] Periscope. 247 other agreeable fluid. When there is great irritability of stomach, it has been given in mucilage of gum with a few drops of hydrocyanic acid. In cases where there existed great anaemia and debility, and in those where the effect of the oil seemed slight, preparations of quinine and iron, especially the iodide, have been conjoined with advantage. It has appeared advantageous to intermit its use for a few days, when nausea and feverishness, from whatever cause produced, are present. In certain cases, the use of the oil has been continued during the ex- istence of slight haemoptysis, without producing any injurious results. Other animal oils (not derived from the liver), and vegetable oils, were tried with a view of ascertaining how far their operation resem- bled that of cod-liver oil. The experiments hitherto made have not shown them to possess the same powers; but they have not been as yet sufficiently often repeated to warrant decided conclusions. One of the most striking effects of the use of cod liver oil is an in- crease in the patient's weight ; with a view of showing the frequency with which this occurs, the gain or loss of weight was ascertained in 219 cases of consumption treated with the oil. Taking both stages of the disease, and the sexes collectively, a gain of weight occurred in 70 percent., a loss of weight in only 21 per cent., and in about 8 percent, the weight remained stationary. The amount of the increase varied, being in some patients little more than one or two pounds during several months ; whilst, in many, the aver- age increase was from a pound to two pounds weekly, during several weeks. Some very remarkable instances of great increase of weight presented themselves thus, in one instance, 41 pounds were gained in 16 weeks ; in another, 19 pounds were gained in 23 days, and 10 pounds in the succeeding 10 days; in another case, 29 pounds were added to the patients weight in 31 days. It must be observed, that an amelioration of the symptoms did not invariably follow an increase of weight, though the exceptions were rare. An aggravation of the symptoms and a diminution of weight were almost invariable coinci- dences. In a few cases, the symptoms improved, though the weight remained stationary, or even became slightly diminished. In other cases, where the amelioration was still more considerable, and the progress of the disease appeared to have been stayed, relapse occur- red, and was followed by a rapid progress to a fatal issue. That such cases do occur, requires to be remembered, in order to restrain too sanguine expectations, and to prevent the remedy from falling into the discredit which disappointment, after an unlimited confidence, may induce. On the other hand, without entering into a description of the successive steps of amelioration experienced by patients, it will suffice to say, that many of the cases included in the 18 per cent., in whom the disease is marked arrested, felt themselves as well as they had been before the attack of the disease. From these facts, no other conclusion can be drawn than that cod liver oil possesses the property of controlling the symptoms of pulmo- nary consumption, if not of arresting the disease, to a greater extent than any other agent hitherto tried. 248 Periscope. [April, Treatment of Scarlatina. By Dr. G. W. Brown. (Medical Ex- aminer.) In the commencement of the epidemic I adopted the treat- ment usually recommended in the books, viz. : an emetic followed by calomel, pepper gargles, laxatives, diaphoretics, tepid sponging and counter-irritation, to the throat ; but this I soon found to be lamenta- bly deficient, for I lost fully one-half of my cases. About that time, in conversation with Dr. J. S. Capenter, of Poltsville, I was speaking of the fatal nature of the epidemic, and of the inefficiency of our, present mode of treatment, when he suggested a strong solution of the nitrate of silver to the throat internally by means of zprobang. I adopted it immediately, with the most happy results, in all of my cases. Of the last fifty cases treated by it, I scarce lost a patient. I sometimes used a strong solution of the sulphate of copper, especially where I desired to vomit the patient at the same time, as was often the case where the throat was filled with shreds of membrane, foetid mat- ter, &c,; but I think the nit. argent, preferable in all cases. The strength of the solution was Si. to the g of water. I applied the nit, arg. in all my cases as soon as I was called, whether there was ulceration or not, and repeated it once or twice daily till the patient was convalescent. In malignant cases I also used the chloride of soda internally, besides using it as a gargle, and I thought with decided benefit. Blisters, with few exceptions, did no good, but, on the con- trary, I thought they did harm by increasing irritation. Liniments, particularly of iodine, answered better, especially where there was enlargement of the absorbent glands. My treatment then consisted in an emetic at the commencement, followed by calomel in doses of two or three grains every two hours till the .bowels were freely moved ; then laxatives, to keep up a gentle action on the bowels, sufficient to remove morbid secretions. A mixture of equal parts of the syrup of ipecac, and spir. nit. dulc, to keep a gentle action on the surface, and at any time that it was indicated, pushed snfnciently to produce full vomiting. Nit. arg. to the throat internally, once or twice daily, with gargles of the chloride of soda, and internal adminis- tration of the same, when indicated by malignant symptoms. Lini- ments to the neck, and tepid affusion to the whole body. Cool air and cold applications to the head in the shape of evaporating lotions, so long as the fever continued. I sometimes made use of venesection with decided benefit, but only in vigorous constitutions, and in the very early stage of the disease. Dropsy was treated by bleeding freely and purging, with diuretics and counter-irritation in the latter stages. Pericarditis was treated by the same means as the dropsical effusion, only more promptly. Squill, nitre, digitalis and calomel, in combina- tion, I found to be almost a specific in the second stage of pericarditis, especially if it purged freely. Strychnine in Chorea. (L 'Union Med. Ranking's Abstract.) M. Trosseau treats chorea by the use of a preparation of the sulphate of strychnine. Of this, they prepare a syrup in the proportion of four- fifths of a grain of strychnine to three ounces of simple syrup. In 1850.] Periscope. 249 children from six to twelve years of age, he commences with six tea- spoonfuls during the day ; in more advanced age, the dose is a desert- spoonful six times a day. The doses are equivalent in the first case to thirty, and in the second to fifty grammes of the syrup, twenty grammes of which contain one-seventh of a grain of strychnine. These doses were increased or diminished according to the effects produced. Under the use of the remedy, a distinct rigidity of the jaws, neck, and limbs is produced ; but the author has found that these physiological symptoms are the forerunners of the yielding of the the disease, and they therefore advise the continuance of the medicine until they are induced. Therapeutic Effects of Gamboge administered in large doses. (Gaz. des Hop. Bui. Gen. de Therap.) Hitherto regarded as a drastic purgative, gamboge has been recommended in dropsy, and classed by the Italians among their contra-stimulants. We, in truth, know but little in relation to its physiological and therapeutic effects. It has been recently subjected to experimentation by M. Rayer, who, with- out determining its precise mode of action, has established its good effects in Bright's disease. We now have new facts, published by Dr. Abeille, physician of the Val-de-Graee, which tend to demonstrate that, like many other substances, this may be given in very large doses, and be tolerated in certain cases so far as to lose entirely its cathartic properties and to acquire new ones as the dose is increased. We will subjoin, briefly, a few of these facts. Case 1. A. female, 40 years of age, had been eleven months affected with ascites, which had resisted a great variety of means, and which must, have been connected with disease of the kidneys. She was tapped ; then subjected to mercurial frictions, to salivation, and the internal use of gamboge, beginning with a dose of 30 centigrammes, which was daily increased 1 decigramme, so that on the eighth day the patient took 1 gramme. The first two doses provoked numerous stools, attended with griping ; as the doses were increased, the num- ber of stools were diminished, and the griping ceased. When the dose reached 80 centigrammes there were but two stools per day. During the two first days the swelling of the inferior extremities disappeared, but the collection in the peritoneal cavity was increased. From the seventh to the eighteenth day the gamboge was carried to 14 deci- grammes per day, which occasioned but one stool. From the sixteenth to the eighteenth day, a real urinary crisis took place, upwards of fifteen litres being evacuated in forty-eight hours, when the ascites en- tirely disappeared. Case 2, A young soldier entered the military hospital of Givet, 250 Periscope. [April, affected anasarca about ten days, and which M. Abeille attributes to the existence of pulmonary tubercles, and to a pericarditic effusion. A large blister was applied to the pericardium, and gamloge pre- scribed in increasing doses. The first doses, being from 30 to 40 centigrammes, produced brisk catharsis. As the dose was subsequent- ly increased and tolerance established, the purgative effect diminished, and finally ceased. In eight days, the gamboge being perfectly toler- ated in doses of 1 gramme was prescribed only every second day. On the fifteenth day, when the patient was taking 15 decigrammes per day, in broken doses, the urine became more abundant. From the fifteenth to the twenty-second day, the secretion of urine became so abundant, that on the last mentioned day the patient was reduced to a mere skeleton by the disappearance of the anasarca. Case 3. This was a case of Bright's disease. Four issues by caustic potassa were established over the kidneys, and gamboge ad- ministered in increasing doses. On the fourth day the remedy was tolerated, the patient taking 80 centigrammes. The dose was in- creased gradually to 15 decigrammes. The secretion of urine be- came abundant, although still albuminous, and gradually lost its acidity and became alkaline. On the fifteenth day the ascities had disappeared, and the oedema of the legs was diminished. A repug- nance to the gamboge compelled its suspension for three weeks, at the end of which time the ascites had relurned with pain in the pericardial region an effusion in the pericardium was detected. The gamboge was again administered in the same way, and a blister applied to the pericardium. The use of the gamboge was again attended with a disappearance of the ascites in seventeen or eighteen days. The urine was still albuminous, though but slightly so. The use of the gamboge was again suspended for a month, when it was resumed, the ascites having reappeared. This third time the gamboge provoked more griping and catharsis: it was never completely tolerated, the patient having of late two or three stools per day. The secretion of urine was, nevertheless, increased, and the ascites dissipated for the third time in twenty-one days. Case 4. This was a case of ascites consequent upon hypertrophy and degeneration of the spleen. The patient had been several times tapped, and the peritonium would fill up again in a few days the tappings, however, being made at intervals of two months or two and a half months. The patient was now put on the use of gamboge, which produced numerous stools during the first days. These di- minished when the dose was carried to a gramme or more, and tho 1850.] Periscope. 251 secretion of urine became more active than it had ever been. The abdomen remained three months without being much distended, and seven months elapsed before it was again necessary to resort to tap- ping. If it be borne in mind that gamboge was never prescribed in doses exceeding from 6 to 12 grains, incorporated with some substance capable of mitigating its action lest it might give rise to serious gastro- intestinal irritations, it will be seen, not without surprise, that the dose has been carried as high as one gramme and a half, not only without producing emesis nor intestinal inflammation, but even with very little purgative effect. This is therefore one more fact in evidence of the modification which large doses produce upon the dynamic action of certain remedies, and which should lead us to class, in this respect, gamboge with tartarized antimony, nitrate of potash, &c. It will be remarked that the gamboge seems to exert its principal influence upon the kidneys. As to its therapeutic effects, we are 4ed to believe that they are confined to the elimination of serous collections, without otherwise influencing the organic lesions which occasion these collec- tions. But even if the effect of gamboge be thus restricted, it is still an important remedy, whose effect should be studied by further ex- periments to determine its real therapeutic value and degree of its tolerance. Poisoning with Strychnia relieved by Chloroform. A case of poison- ing with strychnine in which chloroform was employed with advan- tage, has been communicated by Dr. Dresbach, in the February numberofthe Western Lancet. A servant, in the employment of Dr. D., mistaking a solution of strychnine for brandy, took three ounces of the strength of one grain to the ounce : twenty minutes after the ingestion of the poison, the whole muscular system was rigid ; the muscles of the back and legs so rigidly contracted that it was with extreme difficulty the patient was able to walk ; face drawn awry, and articulation extremely difficult ; sense of burning about the stom- ach ; tightness about the chest, with vertigo and dimness of vision ; lower extremities cold, and perspiration flowing in a stream from the head and chest; pulse small and frequent, but regular. None of the ordinary antidotes being at hand, the chloroform was resorted to in the dose of two drachms. A few minutes after the administration of the medicine, the patient said that he felt its effects " to the end of his toe," and in less than fifteen minutes he was completely relieved of all symptoms of the poisoning. Although an isolated case like this is not 252 Periscope. [April, sufficiont to establish the character of chloroform as an antidote to strychnine, the happy results in this instance, should lead to further trials in similar cases. Conclusions of the Committee on Surgery in relation to Chloroform, (Trans. Amer. Med. Assoc.) 1st. The means of generally render- ing patients insensible to the pain of surgical operations, so long a desideratum, have at length been furnished in the anaesthetic agents sulphuric, ether, chloroform, and chloric ether. 2d. The employment of these agents for obviating pain in most severe surgical operations is now not only justifiable, but the impera- tive duty of surgeons ; and, indeed, we may almost adopt the language of Prof. Miller, before the Medico- Chirurg. Soc. of Edinburgh, that " no one among his surgical friends, would deem himself justified, morally or professionally, in now operating upon a patient in a waking and sensitive state." 3d. Of the anaesthetic agents, chloroform is decidedly the most efficient and facile of respiration ; but, being most powerful, is, at the same time, most dangerous, when incautiously employed. 4th. In formidable and painful operations, chloroform not only obviates pain, but contributes to the safety of the patient, by prevent- ing shock, and the irritation which is the antecedent, and to a certain extent, the cause of inflammation. 5th. The use of Chloroform is inadmissible in trivial cases, because the danger from its use is greater than that from the operation. All must admit that, of the two objects to be held in view in a surgical operation, safety and immunity from pain, the former is the more im- portant. 6th. In regard to circumstances under which chloroform should be employed, we adopt the conclusions of the French Academy. "It should not be used when there exists any disease of the heart, any aneurism near the heart, any threatening dyspnoea, any tendency to engorgement of lungs or brain. Care must be taken that, during the inhalation, atmospheric air be sufficiently mixed with the vapour of chloroform, and that respiration be carried on freely. The inhalation should be suspended as soon as insensibility is obtained." 7th. The best vehicle for the administration of chloroform or ether, is a handkerchief or sponge of loose texture, through which the at- mosphere may be copiously inhaled. Dr. Smith's mode of Reducing Dislocation of the Shoulder. (Ibid.) Its peculiarity chiefly consists in the application of the counter-exten- sion to the opposite wrist, extension being made from the wrist of the dislocated member. Steady traction from the two wrists, in the hori- zontal direction, will be observed immediately to erect the head, neck, and chest, and to restore the symmetry of the two sides of the body. This at once calls to our aid the action of numerous muscles. The object of counter-extension is, of course, to fix the scapula of the injur- ed side. Traction from the opposite side most effectually does this, 1850.] Periscope. 253 first, by erecting the spine, which otherwise yields to the extension, and, more directly, by communicating support to it through the clavi- cles which in front fixed the two scapuke together, and behind through the muscles and tendons, which effect the same on the back. Support one scapula and you necessarily sustain the other. We accomplish reduction, in many instances of dislocation into the axilla, by simple traction, for a few minutes, from the two wrists. In difficult cases we place the patient on a chair, pass a band (sheet or towel) over the top of the scapula and tie it beneath the chair. The knee of the surgeon is then placed in the axilla, and traction is made steadily from the two wrists, till the muscles are observed to yield, and the head to be disengaged. Then the surgeon directs the arm to be depressed, while at the same moment he urges his knee into the axilla by extending his foot. We have succeeded thus in cases of two months' standing, and where other methods in judicious hands have failed. Indeed, we now practice no other method. A new Operation superseding that of Removal of the Testicle. By Charles Taylor, Esq., Alfreton, Derbyshire. (London Lancet.) The castration of animals is an operation which the interests and necessities of society require, and in the very earliest pages of human history, we read of the perpetration of the art ; it becomes, therefore, no longer a question of premediated cruelty, but a possitive necessity, and which must be generally adopted, so long as man continues to be carnivorous. The epicure's dainty taste is satiated with the savoury flesh of the ox, while the capon forms one of the most exquisite dishes of the wealthy farmer. The horse, rejoicing in his strength, defying restraint in his search after females, is tamed down to the useful, docile, noble animal which we now use, and which forms an important means of commerce, business, or pleasure ; but it is to be regretted that the operation which renders the horse subservient to our purposes, should be cruel in the extreme, and should not only deprive him of his sexual desires, but also of a great portion of strength and power of en- durance, and should spoil his shape, rendering him, in comparison with our noble stallions, a sorry piece of horse-flesh ; indeed, so undeniable is this fact, that the principal draymen in London employ stallions alone to transmit their burdens, regardless of the extra expense, care, and attention they require to restrain their penchant for the opposite sex. On studying the anatomy of the testicle and spermatic cord, it struck me that an operation might be performed, which would ob- viate the undesirable effects of the removal of so important an organ, and which would still destroy desire without affecting the seminal secretion, and by this means avoid depriving the animal of his mascu- line characteristics, which, unfortunately, is done by the present operation, I find that when sows in this neighbourhood, are what is popularly termed cut, the operation consists, not in the removal of the ovaries, but in simply dividing the Fallopian tubes, thus preventing sexual heat, which would otherwise come on in certain months of the year, and destroying, not only all desire, but all capability of procrea- 254 Periscope. [April, tion, without unsexing the animal. Now I humble opine that a similiar division of the vas deferens in the male would, on the same principle, deprive the animal of desire ; and as the testicle would be still effectually nourished and retained in situ, it is fair to suppose that the semen would be secreted as before, and be taken up by the ab- sorbents into the blood, by this means retaining all the masculine characteristics of the animal ; but it may be averred by some, that this operation would not deprive the patient of sexual inclination. Allowing, as physiologists do, that desire is caused by the irritation of the semen in the vesiculoe seminales, I believe that this operation would be quite as effectual as the total removal of the testicle ; as it is a well acknowledged fact amongst horse-dealers and others, that a horse old enough for procreation will, after castration, have desire and power to impregnate one female with the semen which then fills the vesiculce seminales, though of course not more than one. This, I think, is a full proof that desire is created by the irritation of the semen, in the vesiculae seminales, and that division of the vas deferens would be quite as effectual, far less cruel, and attended with much better effects, than the ordinary removal of the testicle. Acting un- der this impression, I placed a dog under the influence of chloroform, dissected the vas with a ligature, removing an interspace of about three quarters of an inch ; the animal recovered perfectly ; the wounds healed by the first intention, and I took the first occasion that occurred to place him with a bitch in use, when his conduct plainly showed that all tendency to perpeutate his species was gone. Preservation of Defective Teeth. (Boston Med. and Surg. Jour.) Dr. Harwood, a dental operator of celebrity in Boston, is practising a method in regard to the management of diseased, sensitive, aching teeth, which promises to revolutionize the whole modern art and mys- tery of operative dentistry, while the benefit likely to accrue to those so unfortunate as to suffer from diseased teeth is of incalculable im- portance. The idea was first suggested by his partner, Dr. Parker. The old practice consisted, in regard to a carious tooth, too sensitive to bear gold filling at once, in destroying the vitality of the nerve by the application of arsenic, nitro-muriatic acid, or even the actual cautery by introducing into the cavity a red-hot wire. When that had been accomplished, pressure could be borne and the hollow completely occupied with gold. In that case, however, the tooth became, by the laws of chemistry, a foreign substance. It had no longer any vital- ized connection with the living system, and consequently soon became partially if not wholly discarded, and gradually rose from the socket nature never relaxing her efforts to throw off the dead material. To save the tooth, without severing its connection with the jaw, by the destruction of the nerve, was the ambition of Dr. Harwood. Those familiar with the anatomy of the region will appreciate the ingenuity and success of his plan. With a simply constructed instrument, the shape and use of which are no secret, the nerve is severed. Instantly the patient is relieved from the acute and distracting pain sometimes 1850.] Miscellany, 255 characteristic of some kinds of pulp-exposed teeth. Having carefully removed every speck and point of decayed bone, the tooth is then plugged artistically, without the least disturbance to the patient. In the meanwhile a conservative principle is at work. The diseased up- per and exposed surface of the nerve is divided from the healthy mass below; but little or no inflammation follows, the air bein? excluded, as in subcutaneous division of the tendons, and the wound speedily heals. Nourished, as it always had been, by the arteries at the roots, and the body of the tooth retaining all its original vital endowments, no discoloration ensues, and a tooth subjected to this truly philosophi- cal treatment, may perhaps remain the most enduring and useful of any in the jaw through life. We consider this a triumphant achievement of American dental science, deserving the marked consideratinn of dental surgeons, and the most extended publicity of the press. fHeirical fUtscdlang. Prof. Le Conte and Dr. Bennett Homier. The March number of the New York Journal of Medicine contains a letter from Prof. Le Conte, of the University of Georgia, asserting his claim to priority in the experiments, and the conclusions deduced from them, which have been published by Dr. Dowler in his "Contributions to Physiology." Prof. L. very justly expresses his surprise that Dr. Dowler should have made no allusion to these experiments in his recent article, more especially as Dr. D., in a review of Solly's work on the brain, published in the New Orleans Medical and Surgical Journal for July, 1848, quotes them in full, and acknowledges their physiological bearings. Prof. Le Conte's experiments were published in the New York Journal of Medicine for November, 1845, in an article entitled "Ex- periments illustrating the seat of volition in the Alligator or Crocodilus Lucius of Cuvier." The Bulletin General de Therapeutique states, that the French Government, acting upon the advice of the Council of health and of a special committee composed of savans and architects, has recently or- dered the white oxide of zinc to be substituted for the white lead in painting the public buildings. We omitted to notice in our last number the receipt of Ranking'* semi-annual Abstract, richly laden, as usual, with the fruits of the labor of our transatlantic brethren. No one who desires to keep fullv ^56 Miscellany. Meteorology, "posted up" in European Medical literature, should be without this work, and Braithwaite's Retrospect. Medical College of Georgia. The Annual Commencement of the Medical College of Georgia was held in this city on Tuesday, March 5th, 1850, on which occasion the degree of M. D. was conferred on forty-four approved candidates. The honorary degree of M. D. was conferred upon the Rev. Dr. Boring, now a. missionary to California, and on Dr. Dudley W. Hammond. A very able and eloquent address to the Graduating Class was delivered by Dr. Miller, of Rome, and an interesting valedictory, by Dr. R. B. Nisbet, one of the graduating class. The Class, during the course which has just terminated, numbered one hundred and seventy-nine. METEOROLOGICAL OBSERVATIONS, Ga. Latitude 33 27' north Longitude 4 tide, 152 feet. By Dr. Paul F. Eve. lor February, 1850, at Augusta, 32' west Wash. Altitude above En Sun Ther. Rise. Bar. 2, 1 Ther. \ M. Bar. Wind. Remarks. 1 46 30 21-100 72 30 10-100' s. w. Cloudy sprinkle. 9 58 29 93-100 63 29 58-100, s. lain, 60-100. 9 54 " 65-100 53 " 76-100, N. W. Cloudy blow. 4 26 30 12-100 37 30 25-1001 N.W. 'air blow. 8 24 30 30-000 44 30 37-100 N. E. ?air. 6 24 30 29-100 52 30 40-100. N. E. ?air. r. 30 30 28-100 60 30 12- 100 N. E. ?air. 8 42 30 3-100, 68 29 89-100! s. Jloudy. 9 58 29 46-100 62 " 29-100! s. lain, 60-100. 10 38 " 52-100: 57 " 50-l00| s. w. ^air afternoon. ll 36 " 82-100 59 " 92-100; w. ?air. 12 32 30 63 :< 98-100 E. Fair. 13 48 29 64-100 55 46-100 E. lain, 55-100. 14 43 " 25-100 40 " 26-100 s. w. Sprinkle-flakes of snow-storm. 15 38 " 44-100: 46 " 55 100 w. Cloudy storm. 1G 31 " 85-100 53 <: 95-100 N. W. Fair. 17 32 " 96-100 56 " 90-100! s. Fa i r. 18 36 " 62-100 43 " 45-100' s. w. Rain storm, 20-1G0. 19 . 35 " 76-100 52 " 86-100 w. Fair. 20 3D " 91-100 65 " 90-100 s. Fair. 21 43 " 83-100 73 " 81-100 s. w. Fair. 22 57 " 78-100 49 93-100 N. E. Cloudy drizzle. 23 36 30 10-100 60 30 10-100 N. E. Fair. 24 45 29 93-100 52 29 75-100 S. E. Drizzly rain, 30-100. [&65-100. 25 56 " 62-100 76 " 63-100 S. W. Some cl'ds rain at 8 p.m., 1 in. 26, 58 " 59-100 78 " 63-100 s. w. Rain at 7 a.m., 10-100. 27j 57 " 70-100 78 " 66-100 s. w. Cloudy drizzle. 28 56 " 70-100 71 " 58-100 s. Cloudy. 12 Fair days. Quantity of Rain 4 inches. Wind East of N. and S. 8 days. West of do. do. 14 days. Another very disagreeable month; frequent changes and much wet weather. We have had but one fair Sunday during the winter. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Yol. 6.] NEW SERIES MAY, 1850. [Xo. 5. PART FIRST. Original Communications. ARTICLE XII. Report of the Surgical Clinic in the Medical College of Geor- gia, during the Session of 1849-50. By Paul F. Eve, M.D., Professor of Surgery. Having been requested to furnish a report for the Journal of the cases and operations presented to the Class during the course of Lectures just terminated, I do so in the order in which they occurred, adding just such details of each, as may make them more satisfactory and of some interest to all. Case I. Operation for separating the Jaws. This was a boy, aged 8 years, coming from South Carolina. Cause, pro- fuse salivation. Anchylosis, apparently complete. Operation : inhalation of chloroform through the mouth ; effects only par- tial then free incisions transverse and parallel to both maxil- lary bones. Some eight or ten teeth, wTith portions of the alveoli, were removed. Results, fcetor of mouth corrected, and with Mott's Dilator perseveringly used, patient can now open the mouth about three-quarters of an inch between the incisors, the only teeth he has. II. Removal of foreign body from the Cornea. A negro man from Elbert Co., has had a portion of fodder blade thrust through the cornea into the anterior chamber of the eve, where it has sojourned for two years. It was removed with a cata- ract needle. III. Fractured Lc?. A white child, 4 years old. Applied the immovable or starch apparatus. Cured without deformity. n. s. VOL. VI. no. v, 17 258 Eve's Report on Surgical Clinic, [May, IV. Excision of female mamma. Patient from Hall county, 26 years old. Decided schirrous tumor. Under chloroform, removed by elliptical incisions. She returned home on the thirteenth day after the operation. Tumors are re-developing within five months. I have never yet operated upon a schirrous or cancerous breast, where the diagnosis was unequivocal, that the affection did not return. V. Amputation of toe. Cause, ground itch. VI. Excision of Tumor lipoma. An aged and lean negro woman. Situated upon left shoulder. Its removal was fol- lowed by hemorrhage, after the dressings were applied, which was arrested by pressure with compress and bandage. VII. Dislocation of Humerus. Cause, hemiplegia; no treat- ment. VIII. Hydrocele 40 ounces. Reported in this Journal, (see vol. vi., p. 29.) IX. Incised Wound of Hand with Fracture of Phalanges. White carpenter ; injuries the result of circular saw moved by steam power. Portion of thumb cut off and lost, fore-finger divided through distal articulation, and all the others more or less incised. Result, a good and useful hand. X. Fracture of Thigh. An active boat-hand, on our river, aged about 35 years, fell off the upper on to the lower wharf at night. Called to him immediately ; no fracture was detected, but there existed some tumefaction over the anterior middle of the right thigh. We are positive the trocanter major turned with the foot and leg, wThen they were rotated, and no crepita- tion nor artificial mobility could be produced at the seat of injury ; neither was there any shortening. Moreover the pa- tient insisted the bone was not broken, and sustained the ex- tremity upon the heel, the member being drawn up, while lying upon his back. And yet a fracture must then have existed. This was made evident in a few days, when he attempted to walk. Without entering upon the question of the best position and treatment of fractured thigh, we simply remark here that, for what we consider obvious reasons, the bent is selected for frac- tures of the upper or lower third of this bone, and the straight for the solutions of the bone occurring in the middle. 1850.] Eve's Report on Surgical Clinic. 259 In the treatment, we apply/oar well padded splints the length of the thigh, and then place the patient in Prof. Gibson's appa- ratus. This latter alone will answer in some cases, but when we consider the very great liability to deformity in all cases of fractures of the femur, especially in the careless, we make surer work by applying the two at the same time. We give prefer- ence to Dr. Gibson's spints over all others for fractures in the middle of this bone, and for all patients: in the adult it over- comes the muscles in the child, the hands can be secured to the foot-piece or inferior extremity of the apparatus. For fifty cents we have had the two long crutch-like splints with the foot-piece made, and they can be padded with some four to six pounds of cotton. The reason for using the short spint when four are applied, the one to the outer side of the thigh in addition to Dr. Gib- son's, is to prevent the angular deformity outwards, so com- monly met with in the treatment of these fractures. XI. Excision of Tumor lipoma weighing about 4 pounds. Patient a fat old lady from South Carolina. She supposed the tumor was the result of a fall received several years ago. It was situated over the left false ribs. Placed under chloroform, it was removed by elliptical incisions. The recovery was good. XII. Whitlow. Opened. XIII. Large Abdominal Tumors. Case of a negro woman about 45 years old. Large tuberculous masses originating in the abdomen had at last ulcerated and protruded at the umbili- cus. These had^been removed by the knife, and now there existed new projecting tumors of a fibrous nature. No opera- tion was proposed. XIV. General Exostoses. This wras the case of a boy 5 years old, son of Rev. Mr. C , who likewise presents some nodosities in certain of his bones. This little patient has osse- ous tumors, varying in size, in different parts of the system, but particularly on the tibia, femur, humerus, &c, of both sides. These enlargements in the bones amount to considerable de- formity, and are situated near the joints. When the patient was only three months old he had a convulsion, and these peri- osteal exostoses were then first noticed. Prescription general invigoration of the system by hygienic and remedial agents ; 260 Eve's Report on Surgical Clinic. [May, alteratives, chiefly of iodic preparations the same for local application, with blistering and firing. XV. General Anasarca. Presented on account of its im- mense size, and occurring in a boy : rapidly relieved by the vapour bath, brisk purgation with cremor tartar and jalap, and the acetate of iron, made by adding rusty nails to sour cider. XVI. Large Polypus of the Nose extracted through the Pha- rynx. This was removed from a young girl of Scriven county, who had presented symptoms of nasal polypus for two years. The foreign growth could now be seen projecting in the pha- rynx, around which a tape was secured, and the mass removed. In a few days she returned home well, with the senses of smell and taste completely restored. XVII. Ankyloblepharon and Symblepharon. This patient was also a young girl from Scriven county, aged about 13 years. When overheated by work six months ago, she waded into a pond, which produced inflammation of the skin of the face, &c. The nature of this could not be ascertained, but she now has the eye-lids closely agglutinated and the lids adherent to the ball on both sides. Under chloroform, the eye-lids were separated and then detached freely from the orbits. Without great care there is danger of a recurrence of the symblepharon, if not also of the ankyloblepharon, to some extent. XVIIL Ulcer of Cornea. Cured by caustic solution. XIX. Scrofulous Ulcer of Cornea. Cured by hydriodate of potash with comp. tr. gentian, and caustic to ulcer. XX. Fractured Thigh. Cause, a fall : direction, transverse, in a boy 6 years old. Gibson's apparatus cured without de- formity. XXI. Ligature to Primitive Carotid. Patient, a negro man from Putnam county, aged 26. Fell, six years ago, upon a rock, striking the back of his head, followed by hemorrhage from the nose and slight delirium. In the course of a short time epilepsy supervened, and within the past six months total blindness. Although his master was told the case was exceed- ingly unpromising, and in all probability nothing could be done for the man, he insisted that both medical and surgical treat- ment should be tried. Having exhausted the first, with no other benefit than to arrest the epilepsy, ligature of the primi- 1850.] Eve's Report on Surgical Clinic. 261 tive carotid to the side (right) most affected of the head was suggested and acceded to. The ligature came away on the seventeenth day after its application, and up to the time of his return home, more than a month afterwards, there had been no improvement in vision. XXII. Operation for Artificial Pupil. Failure. XXIII. " for Cataract. Couching. Result good. XXIV. " for Pterygium. XXV. Exsection of three inches of Inferior Maxilla for Spina Ventosa. This operation was performed on a young lady from Randolph county, aged 18 years. The cause of the disease was unknown, probably it was owing to defect of a molar tooth. It was of six years existence ; the deformity was great, and pain at times quite acute. Operation: patient under the effects of chloroform, an incision from beyond the angle of the inferior maxillary of the right side over the tumor to a central point under the chin, was then made, and the bone care- fully denuded. The stomach tooth of the same side extracted, the bone sawed in two, turned outwards, and again divided be- yond its angle. Considerable hemorrhage occurred during the operation ; the patient nevertheless had a good recovery the line of cicatrix being under the chin is scarcely perceived. The portion of bone removed included one of its angles, was greatly enlarged, and when sawed in two presented a central cavity about the size of a pullet's egg, the walls of it moreover were more than half an inch thick. XXVI. Amputation of Thigh. Fungus Haimatodes. Ne- gro man from South Carolina, aged 50. Had observed a small round tumor on internal side of knee-joint, more than ten years ago, which has now acquired the size of the two fists, and has bled freely, spontaneous and repeatedly from a small projecting tubercle. The probe here enters without resistance, encoun- tering nothing solid, but gives pain, and its withdrawal is followed by hemorrhage. Fungus haematodes is suspected. Operation : patient under chloroform, tumor laid open by en- larging the issue at the tubercle, when a large quantity of brain-like substance, mixed with blood, was turned out. The thigh was now amputated by the circular method. The pa- tient had a good recovery, and has yet no return or development of this malignant disease, five months since the operation. 262 Eve's Report on Surgical Clinic. [May, XXVII. Compound complicated Fracture of fourth and fifth Ribs death in nineteen hours. This was the result of an acci- dent on the rail-road, to a stout, athletic negro man, aged 21, by a collision of cars loaded with wood. The fourth and fifth ribs, about their centre, were fractured one in two places, and both dislocated from the spine ; the intercostal arteries were ruptured and the thorax laid open, the lung of that side and the pericardium being fully exposed. There was besides these injuries a compound fracture of the left tibia. The wounds were closed, but the oppression and difficulty of breathing were so great that the patient removed all applications to the chest, and besides laudanum and hot brandy toddy to produce reac- tion, he drank large quantities of water. Death put an end to his sufferings in nineteen hours after the accident. XXVIII. Fracture of both Malleoli. XXIX. Compound Fracture of fourth Metacarpal, and other injury to right hand. XXX. Concussion of Brain. Case recovered. XXXI. Compound Fracture of Tibia. Passed into hands of other physicians. XXXII. Incised Wound of Scalp, XXXIII. Amaurosis from blow to head. All treatment failed. XXXIV. Lacerated Wound to scrotum. XXXV. Exsection of Female Mamma. In a young negro woman for schirrous degeneration from neglected milk abscess. Operation performed under chloroform. Patient well in two weeks. XXXVI. Amputation of Leg. This was in a patient who had served as a volunteer in Mexico, and had returned home with chronic diarrhoea. Pie had now sustained a compound fracture of both bones of the left leg at the ankle-joint, from a loaded wagon passing over it. Amputated just below the knee, under chloroform. XXXVII. Operation for Radical cure of Hernia. In a boy 10 years old, with congenital inguinal hernia on the right side. Performed Bonnet's operation with pins patient under chlo- roform. Result, a failure. XXXVIII. Keloidal Tumor in a cicatrix over a Ventral Hernia. A negro boy, 10 years old, and very unmanageable, 1850.] Eve's Report on Surgical Clinic. 263 had been gored by a cow eighteen months ago in the right inguinal region. The intestines protruded, a ventral hernia, size of a turkey egg, has been gradually increasing, and upon the cicatrix of the skin an oblong keloidal tumor is growing. While the patient was under chloroform, in cutting out this tumor, (the hernia having been reduced, as was believed,) the intestine proved to be adherent to the cicatrix, and was pretty freely laid open. An artificial anus was the result of this ope- ration, but which has gradually diminished to a small orifice, over which the pad of truss is now placed, and the patient is walking about the Infirmary. May not this case throw some light on the causation of keloi- dal or cancroidal tumors, from the fact of the close proximity of fecal matter to the cicatrix? May. not the want of cleanli- ness in the skin of the negro account for the frequency with which this affection is met with in the black, without referring its production in them exclusively to the peculiar organization of the cutaneous structure itself? XXXIX. Necrosis of Femur. XL. Cancer of Face. In an old man, and of several years' duration. Chloroform, and excision of the ulceration. Not cured. XLI. Hematocele of the Cord. Case reported in the Jour- nal, vol. vi., p. 114. XLII. Caries of the Tibia. Patient a negro man in the prime of life. Cause, obscure, probably scrofulous cachexia. Under chloroform, the diseased bone was exposed, the crown of the trephine applied, and the chisel and mallet completed the remo- val of it. By the use of hydriodate of potash and comp. tinct. gentian, and then Fowler's solution, the patient has greatly improved, and seems to be now nearly well. XLIII. Excision of part of both Tonsils. XLIV. Radical cure for Hernia. Second attempt in case referred to (No. xxxvii.), by Mayor's method of invaginatinga portion of the scrotum. The boy now wears one of Chase's trusses, and hopes are entertained that the operation will be successful. Doing now well. XLV. Amputation partial of the Foot. In a free negro wo- man, from neglect and filth, resulting in extensive ulceration and repeated hemorrhage patient under chloroform. 264 Eve's Report on Surgical Clinic. L^ay XL VI. Excision of Bleeding Tumor from head and neck. This was an old man from South Carolina, having a large tumor of a mixed character over the occipital region of the head, and extending to the neck. While under chloroform, it was ex- cised by elliptical incisions. The hemorrhage was profuse, and six arteries were secured. The tumor was not aneurismal, but had a central hardened portion. It was fibrous, but very- vascular. XLVII. Amputation of the Thigh. Case of a negro man, aged 55, having been burnt on the right knee in infancy. The cicatrix has now taken on a keloidal degeneration, and bleeds from slight causes acting upon its large exposed ulceration, which is very rough, hard, and at times dry. Under chloro- form, the circular amputation was performed, and the patient . was out of bed in two weeks, with the stump nearly healed. XLVIII. Fracture of Thigh. In a boy, 7 years old, pro- duced by a bale of cotton falling upon him. Treatment, four spints with Gibson's apparatus. Besides these cases and operations, there were several pa- tients presented to the Class with ulcers, hernia, &c. Classi- fied, we have Of Fractures of the Thigh, ... 3 ' " Leg, .... 3 Of all other Bones, 3 Total, . 9 2 - 1 1 1 Total, . 5 Of Tumors. Lipoma, .... 2 u u Schirrous, Cancer, and Malignant, 5 Other Tumors, 6 Total, . 13 Of the 39 cases operated upon, not one died. Of the whole number presented, but one only had a fatal termination, and that within twelve hours after entering the Surgical Infirmary. Of u II Amputations u a of the M U ( Thigh, Leg, Foot, h M i. Toe, 1850.] Hammond, on the Calycanthus. 265 ARTICLE XIII. Calycanthus Floridus its properties and nses. By Dudley W. Hammond, M. D., of Cullodens, Georgia. The Calycanthus, or sweet scented shrub, as it is familiarly called, derives its name from the Greek words xaXug, calyx, and avdo$, an anther or flower, in reference to the calyx being co- lored, and appearing like a carolla. It is a shrub from three to seven feet high, erect, virgate, stoloniferous, the young branches pubescent, leaves opposite, sometimes acuminate, entire, on short petioles ; flowers solitary, axillary and terminal, on short branches ; the petaloid segments of the calyx disposed in two series, filaments minutely pubescent, the anterior generally without anthers ; capsule turbinate, seeds oval and large. It grows in fertile soils, along rivulets, in the upper districts of South Carolina and Georgia, and is rare in the lower. It flow- ers in April. There is a remarkable fact in regard to the Calycanthus, originally noticed by Mirbel. In the stems of this plant, there is the usual deposit of concentric circles of wood around the pith, and in addition four very imperfect centres of deposition on the outside, next the bark, a very unusual structure. A good figure of this interesting fact has been given by Mirbel, in the Annates des Sciences Naturalles, vol. xiv., p. 367. It is also described by Lindley, Don, de Candolle, and Prof. Darby, &c. Lemaire has given a description of the Calycan- thus Floridus in Dictionaire Universel D'Historie Naturelle, at page 78, and states that Buchoz, in consequence of the de- lightful aroma exhaled from its branches, being so agreeable and attractive, or for some other reason, has made it a genus, dedicated to the "very famous madam Pompadour. At my particular request, Prof. Darby, of Cullodens, has analyzed this shrub. He says " I have subjected to analysis the twigs of the Calycanthus Floridus which you presented to me, and have obtained the following results. I took 2000 grains for experiment, and obtained in the various products 98 grains. This amount of products would vary very much de- pending upon the parts of the plant taken. All the essential products lie in the interior bark, and buds. The wood contains scarcely any of the following products. 266 Hammond, on the Calycanthus. [May, Green coloring matter with a resinous substance, . 5.5 Volatile oil, colorless, and highly inflamable, . . 10.4 grs. Bitter substance, soluble in ether and alcohol, . . 14.6 " Gummy extract, soluble in water, but not in alcohol or ether, 57.3 " A volatile oil, readily miscible in water, with a great- er specific gravity than the preceding, . . . 2.4 Tannic acid, gallic acid, and a free organic acid, starch, nitrogenized substances, probably, albumen and fibrine, 6.8 98.0 The juice does not take on the vinous fermentation, and of course contains no sugar. It undergoes putrefaction and liber- ates ammonia." Out of the 28,000 species of plants in the vegetable kingdom, we have not more than 1 or 2,000 capable of making sanative impressions upon the human system; and many of these which now hold a place in the Materia Medica, if properly tested, would probably be found so feebly endowed with curative vir- tues, that on a revision of the Pharmacopoeia many of them would be discarded. But, on the other hand, there are doubt- less many, possessing inestimable medicinal qualities, which are hidden and unknown. It should then be the great and para- mount duty of every physician to explore the great and inex- haustible store-house of nature, in search of those hidden treasures which have been kindly provided for the alleviation of the innumerable maladies to which flesh is heir. Man is a constant prey to the ravages of disease in every clime and place upon the "habitable globe ;" and it is almost a truism in medical science, that in every inhabited region of the earth there are to be found medicinal plants, capable of alle- viating the diseases peculiar to it. As a proof of this, the inhabitants of warm countries are bountifully supplied with plants possessing acescent and febrifuge qualities, and others having virtues suited to the diseases incident to this clime. Who can contemplate the discovery of the Cinchona without the most heart-felt gratitude to Him who brought it into exist- ence. We find also in all the malarious districts of the South 1850.] Hammond, on the Calycanthus. 267 the Cornus Florida and the Liriodendron Tulipifera. And in the cold and bleak regions of the North, plants grow and flour- ish suited to its diseases, such as the uva ursi, Lichen, etc., etc. From these considerations we cannot resist the conclusion, that, in this, our delightful country, there are, no doubt, hun- dreds of plants, highly medicinal and whose virtues have not yet been discovered. It is then the imperative duty of every medical practitioner, so far as it may be in his power, to use such p r udent and safe means as may lead to the discovery and development of those great natural resources of the healing art. I am not aware that any notice of the medicinal properties of the Calycanthus has been taken by any writer. I was in- duced to believe that it was medicinal from its highly pungent and agreeable odor, its mild and pleasant bitter taste, and its peculiar effects upon some constitutions. Flowers* and other odoriferous substances are generally agreeable to the great majority of mankind. Prof. Dunglison, however, at p. 39 of his general Therapeutics, states that, the smell of the Calycanthus Floridus is so disagreeable to some persons as to be almost intolerable. I also knew a lady who could not inhale its fra- grance, without being thrown into a violent paroxysm of spas- modic asthma, often lasting for hours together. I have found the Calycanthus to be endowed with the follow- ing medicinal properties : Slightly stimulant, diaphoretic, tonic, carminative, diuretic, and perhaps anodyne. In the form of infusion, it is a mild stimulant and diaphoretic, and may be given in dyspeptic conditions of the stomach, at- tended with flatulence, cardialgia, griping pains of the stomach and bowels, neuralgia, etc. When first taken, it soon produces a slight exaltation of the vital forces, the heart's action is aroused, and the pulse soon feels the impulse ; the excitation is quite agreeable, but is evanescent, unless the dose is frequently repeated. In torpor of the general system, with depression of the sensorium, I have found it a mild and efficacious remedv. In abnormal conditions of the stomach, consequent upon an atonic state, attended with flatulence, and a dry and harsh skin, it often produces the happiest effects. From the analysis of the Calycanthus, its modus operandi * 1 allude to those which exhale a pleasant smell. 268 Hammond, on the Calycanthus. [May, upon this pathological state of the system is readily compre- hended. The "bitter substance," acts as a tonic upon the muscular tissue of this organ, whilst the " volatile oil" exerts a gentle stimulating effect upon the sentient extremities of the nervous filaments of its inner coat, bringing into vigorous ac- tion the great central organ of sympathetic action. The stom- ach, before painful, has new vigor imparted to it, and soon becomes quiescent from the expulsion of flatus ; the skin also is relaxed, and a general diaphoresis follows, together with an enlivened state of mind, which is generally succeeded by a calm and quiet slumber. I have long been in the habit of prescribing a tincture of the Calycanthus in colicy affections of infants. I consider it supe- rior to the camphorated tincture of opium, so universally used both by nurses and physicians. It readily acts as a carmina- tive, removing the cause of these distressing ailments. It does not constipate the bowels, as does the camph. tinct. of opium ; neither does it produce the starting, often caused by this popu- lar remedy. In Arthrodynia, it deserves notice. I am well acquainted with an elderly gentleman in this vicinity, who is in the habit of drinking a strong; hot infusion of it for Podagra, and he as- sures me that it is the best remedy he ever tried. Another affection might be mentioned, in which I have used it with signal success. In those violent nervous headaches, to which some females are subject immediately preceding the regular return of the catamenia, a cup full or two of the infu- sion, drank warm, soon alleviates the pain, and in many instan- ces, I am persuaded, hastens the return of the flux. Although the Calycanthus is a mild stimulant, I have found its administration contra-indicated in an inflamed condition of the gastro-enteritic mucous membrane. Is it not wTorthy of trial in adynamic fevers, attended with asthenic hyperaemia of the encephalon, when a slight exaltation of the vital powers is required ? The Calycanthus is a tonic, very mild in its operation, and may be properly classed with the sub-tonics. As a general rule, vegetable tonics are bitter, and disagreeable to the taste, and sometimes nauseating to the stomach. In this respect, the 1850.] Hammond, on the Cahjcanthus. 269 Calycanthus claims a decided preference over most of them, as it is not very bitter, neither is it disagreeable to the taste. When prescribed as a tonic, I direct the cold infusion to be made strong, and to be drank in small quantities, frequently re- peated during the day. As a remedy in Dyspepsia, the great protean malady of the nineteenth century, whether idiopathic, or the sequence of some acute disease, it, in a few cases, had no substitute. From my limited observation of its effects in this distressing disease, I most respectfully commend it to the favorable consideration of the profession. As a remedy in Bilious Remittent and Intermittent fevers, it is often valuable, especially after the primce vice have been well cleansed, and the liver emulged by calomel. During the apyrexia, I direct a strong infusion of the cortical portion to be drank, which, in most cases, arrests the next paroxysm of fever. Large draughts of it taken in anticipation of a chill, in intermittent fever, very often as effectually destroys its periodi- city, as most other vegetable tonics, the cinchona excepted. Analysis shows it to contain a large amount of a bitter prin- ciple, for which I would propose the name of Calycanthine ! Judging from its modus operandi upon the system, I would suggest it to the profession as a suitable remedy in Leucorrhasa, a disease which has troubled me more than all others with which I have had to contend. When the discharge is exces- sive, the constitution becomes extremely weak and nervous ; the skin cold and clammy ; stomach feeble and flatulent ; and the mind, too, sooner or later, becomes involved in this morbid catenation. The patient often looks upon her case as hopeless ; "she pines away," and "void of counsel," she becomes "timer- ous, fearful, and sad." In this pathological state of the system, I would recommend a trial to be made of the Calycanthus, with other suitable remedies. There is one fact in regard to the Calycanthus which it might be well to mention. I have known it in two instances to produce ptyalism, after having been used for a few days: the flow of saliva was immoderate in one of them. j\o soreness of the gums in either. It is an anodyne, but not in the same sense, perhaps, in which opium is anodyne. Any remedy which 270 Hammond, on the Calycanthus. [May, equalizes the circulation, or that excites the stomach, thereby expelling the flatus, will relieve pain. The Calycanthus, acting in this way, often produces ease and quiet. I, however, have frequently observed, that aftei giving a warm draught of the tea, that the patient soon became sleepy ; and those to whom I have prescribed it as atonic and alterative, have frequently re- marked its tendency to produce drowsiness. I consider its anodyne operation to be the result of its action upon the brain and nervous system, in the same way that camphor and the nepeta cataria are anodyne. As a Diuretic, I have for several years prescribed an infu- sion of the Calycanthus in dropsical affections, with marked benefit. I direct a strong, cold infusion of the bark, to be drank in large quantities, say from 2 to 3 quarts per day; and should it appear to be tardy in exciting the secretory functions of the kidneys, I generally give 10 or 15 grs. of the nitrate of potass., or a drachm of the super-tartrite, two or three times in the day, in a half tea-cupful of the infusion. This combination generally brings off large quantities of urine in the course of thirty-six or forty hours. Notwithstanding it requires, in some cases, the aid of the nitrate or sup. tart. pot. to direct its action to the renal apparatus, it is nevertheless a diuretic per se, almost in every instance causing more or less diuresis; and this circumstance cannot be considered an exception to the general rule. Squills, for example, produce more or less diu- retic action, but its virtues in this respect are greatly heightened by the addition of the proto-chloride of mercury. Other exam- ples might be given. After the kidneys have been aroused to vigorous secretion from the infusion of the potash the latter may often be discontinued without diminishing the urinary secretion the infusion alone, being sufficient to keep up a copious discharge, when once established by this combination. I have generally found it necessary to discontinue it after eight or ten days, in consequence of the anorexia it produces. This ts caused in part, I imagine, by over-distention of the longitudinal and cir- cular fibres of the muscular coat of the stomach, and a dilution of the gastric juice. It will be recollected, when speaking of it as a tonic, that I recommended it for dyspepsia ; but in that 1850.] Hammond, on the Calycanthus. 211 case, to be drank in small quantities, its action upon the stom- ach being'governed by the quantity taken into it, and the length of time it is continued. After suspending it a few days, for the stomach to regain its tone, it may be resumed again, and in this way continued throughout the whole course of treatment. To recommend a remedy for dropsy, without stating what kind, or without explaining the pathological state of the system, to which such remedy is applicable, would most certainly be con- sidered unsatisfactory to the profession, if I had not already sufficiently explained its modus operandi, and given in detail the analysis of the remedy under consideration. It will then be only necessary for me to say, that in all cases where the hydropic accumulation or diathesis is the result of asthenia, this remedy may be safely and beneficially prescribed. When the assimilative process is deranged from a morbid condition of the stomach and chylopoietic vicera, emaciation and debility ensue, thereby laying the foundation of dropsy, by destroying the proper balance between the exhalent and ab- sorbent systems. It may then be assumed, that in this patholo- gical state of the organism that " the common predisponent cause is debility." In such cases, a mild, stimulating sub-tonic would be proper, and at the same time, some article would be necessary to carry off the serous effusion. The Calycanthus will fill every indication in such a case, or as nearly so as any remedy with which I am acquainted. But for fear of extending this essay too far, I might very ap- propriately detail the history of three cases of dropsy I have recorded in my note-book, which would more clearly show the great powers of this remedy in hydropic accumulations. It must suffice on this occasion to notice them cursorily. One was a married lady, 22 years of age, who had extensive anasarca of the whole subcutaneous cellular tissue, produced by irregular and painful menstruation : she had been afflicted with it for years, and she had undergone the usual routine of medical treatment. I put her upon the infusion of the Caly- canthus, and in two months she was cured. In the meantime, to the great satisfaction of herself and friends, encyesis took place for the first time; she carried the lectus to the full period 272 Hammond, on the Calycanthus. [May, of utero-gestation, and on the first day of October last, was delivered of a fine healthy male child, since which time she has been entirely free from any appearance of dropsy. I will here mention that the patient took, in conjunction with the infusion, for two or three weeks, the muriated tinct* ferri, but she had repeatedly taken chalybeates before, with only tem- porary relief. The second case, was oedema of the feet and legs in a child 5 years of age, occurring as the sequel of chronic diarrhoea. The child had been treated with the common remedies without any abatement of the symptoms. The cold infusion, aided by a few doses of hydrarg. cum creta, dispelled the disease in fif- teen days. The third case, was a lad 14 years of age, in whom extensive anasarca supervened after the operation of lithotomy, com- mencing on the seventh day after the extraction of the calcu- lus.* I prescribed a hydragogue cathartic, which operated well, causing some diminution of the swelling, and directed Port wine to be given freely. One bottle was consumed with but little benefit. I ordered the infusion to be taken every three or four hours, and in eight days he was convalescent. The wound healed readily, and the patient had a tedious but com- plete recovery. The hot infusion is made by pouring a pint of boiling water upon an ounce of the bark and buds, covering the vessel for twenty or thirty minutes. Of this, from two to four fluid ounces may be administered at one time. The cold infusion is prepared by adding two ounces to a pint of water, and suffer- ing it to remain six or eight hours. Dose, from one to two fluid ounces, three or four times per day. The Tincture is made, by taking of the bark and tender twigs, two ounces, bruised ; diluted alcohol, one pint macerate for seven days, and filter through paper. This tincture pos- sesses the active properties of the Calycanthus Floridus. The dose is from one to four fluid drachms. * The calculus is now in the hands of Prof. A. Means for analysis. 1850.] Production of Sugar in the Human System. 273 ARTICLE XIV. Experiments and Conclusions of M. Bernard in relation to the normal and abnormal production of Sugar in the Human System. By Juriah Harriss, M. D., of Georgia now in Paris. Phenomena. Amylaceous materials being the only substan- ces from which the chemist can manufacture sugar, it might be inferred that it is also from them that sugar is produced in the system, or at least in the digestive apparatus. It is indeed now well established, that sugar is formed during digestion, by the action of the pancreatic juice upon starchy substances. This can be easily proved by placing starch in a tube with this secretion. Saliva will produce the same effect in a tube, but does not do so in the stomach ; for the acidity of the gastric juice prevents its action. The pancreatic juice has not an acid fluid to contend against hence it is unchecked in its action, and when the aliment containing starch comes in contact with it in the intestines, sugar is formed. This sugar is called glucose, or unchrystalizable sugar, resembling very much the sugar found in grapes. The glucose thus formed in the diges- tive tube from starchy aliment is absorbed by the veins and carried into the circulation through the portal system. If, then, an animal be fed upon food containing starch, sugar will be found in the blood, which sugar was manufactured in the diges- tive canal. But will this source alone account for the amount ordinarily found in the economy ? If so, it will certainly not account for the enormous amount frequently found in the blood, urine, and other secretions, during diabetes. It could not be well imagined that a man could eat sufficiently of starchy food to supply the excessive quantity of sugar found in the economy of a diabetic patient. There is an experiment made by M. Bernard, which furnishes conclusive proof that digestion is not the only process by which is produced the sugar found in the circulation. He has frequently taken two dogs, and fed one indiscriminately upon azotic and non-azotic food, (meat and bread,) and the other upon azotics alone for months together. At the end of this time he has taken the blood from the right auricle of each dog, and found it in each to contain sugar. The x. s. VOL. vi. no. v. 18 274 Production of Sugar in the Human System, [May, blood may be taken from the right auricle by passing a cathe- ter down the jugular vein, taking care, however, that do air may pass into the circulation. The opinion that aliments are the only source of sugar, would lead us to believe that no sugar ought to be present in the blood of the animal that was fed upon azotics alone ; yet the experiment proved that as much sugar existed in the blood of one, as in that of the other. One would suppose that if sugar was derived exclusively from starchy food, that no sugar ought to be found in the blood of the animal that had eaten no such food ; but the experiment proves conclusive- ly that the blood of animals will contain sugar, independently of the character of their food, whether azotic or non-azotic. Bernard, seeing this, concluded that sugar must be formed by some other action, as well as by digestion. He accordingly instituted a series of experiments, to determine where the sugar originated. Having ascertained that sugar existed in the blood taken from the right auricle of animals, it was clear that it came from above, through the superior vena cava, or from below, through the inferior cava. He examined the blood contained in the superior, but found no sugar ; he then examined the blood of the inferior cava, and detected it here on its way to the heart. The conclusion was then plain, that it was formed by some organ or portion of the body, whose venous blood was carried into the inferior cava. The crural veins were next ex- amined, and their blood contained no sugar, nor did any exist in the inferior vena cava, below the liver or below the joint at which the hepatic veins empty into it. The probability seemed then that it was formed by some of the abdominal viscera. This could be determined readily by examining the blood of the veins of each of these organs. Each vein was examined in succession, but sugar existed in none of them the viscera themselves did not escape ; a decoction was made of them by maceration in boiling water. The search for sugar in their tissues was equally unsuccessful, save in the liver sugar was found in abundance in the decoction of its tissue. The result of the experiments is then, this: that sugar, or glucose, was found in none of the veins, save in the inferior cava, above the opening of the hepatic veins. None existed in this vein below the point at which the hepatic veins open into it, nor in the vena porta as it enters the liver. 1850.] Production of Sugar in the Human System, 275 In making this experiment, a small opening should first be made in the abdomen, and the vena porta tied ; for if the abdo- men be largely opened without this precaution the blood of the liver will regurgitate and carry the sugar in this vein, be- cause the pressure of the abdominal walls are obstructed. A neglect of this precaution might tend to the error that sugar exists always in the vena porta. This abdominal regurgitation is seen in paracentisis for ascites. Sugar was found only in the blood that made its exit from the liver, and in none of the viscera save this organ. The con- clusion then, that this substance was formed in the liver was highly justified by experiments, thus giving to this organ a dou- ble secretory function, resulting in the production of both bile and sugar. Bernard believes sugar to be a veritable secretion. It is manifestly formed under the influence of the nervous system. A simple irritation of the pneumogastric nerve, as pinching, will increase its secretion. If this nerve be cut, the secretion is immediately arrested. Besides, if in a rabbit, the origin of the pneumogastric, which is near the fourth ventricle and calamus scriptorius, be pricked, the increase in the quantity of sugar formed will be so great as to constitute a real diabetes ; and sugar will be found in abundance in his blood and urine. The origin of this nerve may be reached by passing a pointed instrument between the occiput and the atlas. This artificial diabetes will cease as soon as the irritation has passed away : it never lasts over three days in a rabbit, nor more than seven in the dog. The opinion that it is a secretion, has been combatted by some. The objectors urge that the sugar may be manufactured in digestion, absorbed by the veins and deposited in the liver, this organ serving as a reservoir. This is by no means a serious objection, for dogs have been fed for months upon azotised food alone, and yet sugar existed in their blood. It cannot be easily imagined that a sufficient quantity could collect in the liver to supply the purposes of the economy for such a length of time. The influence of the nervous system is a sufficient answer to this objection. There is, however, this difference between this secretion and the others that it has no duct, but is emptied directly into, or is rather absorbed by the hepatic veins. 276 Production of Sugar in the Human System. |^ay> Bernard having proved that sugar was manufactured in the economy and thrown into the circulation, then attempted to ascertain what becomes of it. He traced it from the liver up the inferior cava, to the right auricle and ventricle of the heart, and up the pulmonary arteries to the lungs. But in these or- gans it disappeared, for none could be found in the pulmonary veins as they returned the blood from the lungs to the heart. It was evidently then destroyed in the lungs. How and by what process? was the next question to be solved. It has been long known that caustic potash placed in contact with sugar of glucose would destroy it, disengage carbonic acid, and leave in the vessel a brown acid. Hence it has been supposed that the alkalies of the blood destroyed the sugar, and that when they were not in sufficient quantity to destroy this sub- stance, it accumulated in the economy and constituted diabetes. Although glucose may be destroyed in a tube by a strong alkali, this action certainly does not take place in the economy, for the chemical action would be so powerful as to destroy the vitality of the tissues, even admitting that the alkalies were sufficiently strong, (which is not the case). A simple experi- ment will prove that its destruction is not due to the alkalies of the blood. If this fluid be heated to 100 Reaumur, it will no longer possess the property of destroying sugar, although the alkalies are not altered by this elevation of temperature. The blood of a diabetic is no less alkaline than that of a healthy person ; hence there is no more reason why one person should be affected with this disease than another. M. Bernard does not believe its destruction to be effected by the alkalies, but by a peculiar organic ferment that the blood contains. This fer- mentation and destruction of the sugar takes place only in the lungs, because there it meets, or comes in contact with the air, which is the great promoter of fermentation. The ferment of the blood is, like all organic ferments, destroyed by concentra- ted acids and heat. If the blood, as before mentioned, be heated to 100 R. it can no longer destroy sugar, because the fermenta- tive principle is rendered inactive, and not because of any alterations in the alkalies. By this fermentation lactic acid is formed, which unites with the soda of the blood to form the lactate of soda, which passes into the circulation, and carbonic 1850.] Production of Sugar in the Human System. 277 acid gas is given off. When the lactic acid unites with the soda, heat is produced, and this is one of the sources of animal heat. Sugar then serves two purposes to the economy 1st, production of animal heat, and 2d, the elimination of carbonic acid gas. It serves no purpose of nutrition, but is simply a respiratory aliment. In animals whose liver secretes but little sugar, their temperature is very low. When the secretion of sugar is arrested by cutting the pneumogastric nerve, the animal heat gradually, but very sensibly, diminishes. These two cir- cumstances add strength to the opinion that sugar assists in the production of animal heat. Sugar being secreted by the liver, and destroyed by the lungs, it may be conceived in what manner diabetes is produced. This must be done in one of two ways either by a diminution of the quantity of the fermentative principle of the blood, the agent of the destruction of the sugar, thereby allowing an ac- cumulation to take place in the economy, and to pass out through the secretions; or else the accumulation arises from a super-secretion of this substance by the liver, to such an amount that the ferment cannot destroy it. The first opinion, though admissible, is not at all appreciable, for an estimate of the in- crease or decrease of this principle cannot be made. M. Ber- nard inclines to the latter belief that it is the result of a super- secretion of the liver : he thinks that it is at least the most frequent cause of this disease. McGregor's experiments (in Glasgow) would seem to oppose the opinion that it is a result of the super-secretion of this organ. He gave only meat to a healthy man, and to a diabetic, and a short time after eating, he made them both vomit. In the matters vomited by the healthy person no sugar could be found ; but those of the dia- betic contained it. He concluded therefore that in this disease the gastric juice possessed the abnormal property of changing food into sugar. The presence of sugar in the matters vomit- ed by the diabetic patient can be easily accounted for ; the blood of this man was saturated with sugar, and it passed into the stomach with the gastric juice, where it was secreted, as it does in the urine. All foreign substances placed in the blood, the prussiate of potash, for example, will pass into the stomach with the gastric juice. The frequent association of diseases of 278 Production of Sugar in the Human System. [May, the lungs with diabetes, can be readily explained by admitting that the latter is caused by an excessive secretion of the liver. The secretion being increased, the lungs are forced to take on an increased action to destroy it and prevent its accumulation in the economy. Hence the air expired by a diabetic contains more carbonic acid than that of a healthy person. The lungs, containing this abnormal activity, gradually becomes fatigued, exhausted, and finally diseased. Any acute disease supervening upon diabetes, will arrest its progress until the acute malady be cured. M. Andral notices a singular example of this. A diabetic patient, whilst under his care, was frequently attacked with diarrhoea, and at each attack the diabetic symptoms were relieved temporarily. It has been observed, that the blood of a diabetic contained little or no sugar after death. This is a singular fact, but is doubt- less owing to the lingering existence and gradual exhaustion of the nervous system before death. If a person laboring under diabetes be at the same time affected with phthisis, but little sugar will be found in his blood after death. If, however, the patient dies suddenly, sugar will be abundant in his blood. M. Bernard has as yet proposed no treatment for this disease. He, however, advises the physician to direct his attention to the nervous system, and not exclusively to the digestive canal, as has heretofore been done. Sugar is evidently secreted under the nervous influence, and diabetes may be styled a nervous disease ; for any powerful agent that will modify the nervous system will mitigate this affection. Hence it is that so many remedies have been proposed, nearly all of which will diminish its intensity temporarily. 1850.] Influence of the Foetus in Utero, \>* by inhalation ; not producing the desired effect, through imperfect application of the napkin to her mouth; the dose was repeated. In a few moments, as soon as the pulse indicated the influence of the chloroform; she fell asleep, and awoke perfectly cm VI. v 306 Periscope. [May, PART HI. ill o n 1 1) 1 g IjizxxstQyG. Effects of Bloodletting and Mercury' in Pericarditis. By Dr. lorn* Taylor. (Med. Gazette. Braithwaite's Retros.) I. Bloodletting. The conclusions arrived at are the following. I. The duration of pericarditis increases in proportion as the time is longer between the commencement of the disease and the first bleeding. 2. The duration of the cases bled' after the first four days is greater by one-half than of those bled within the first four days from the invasion of the' disease. 3. The influence of bleeding was more marked in the case in which it was copiously and repeatedly, as well as early, practised,- than in those in which blood was drawn less fre- quently and more sparingly. 4. Pericarditis is never extinguished at once by bleeding, however early er however copiously practised.- 5. In several cases the pericarditis was suspended for a limited time* The suspension in every instance wras immediately consequent upon the local abstraction of blood. 6. It is probable that renal has a long- er duration than rheumatic pericarditis. 7. Bloodletting must be less- copious, and is more frequently inadmissible, in renal, than in rheu- matic pericarditis. 8. Bloodletting probably lessens the mortality,, inasmuch as it lessens the duration of pericarditis ; but direct proof of the reduction of mortality is not to be obtained from these cases. 9. The abstraction of blood by venesection, cupping or leeches, al- most invariably relieved the pain at once, but not permanently. There is no reason to believe that any one form of bleeding relieved pain more effectually than another. 10. Bloodletting never lessened the frequency of the pulse, except when there were signs of the inflamma- tion having abated. 11. The tendency to syncope in some cases of pericarditis, renders it necessary to be very careful in abstracting blood by venesection. 12. Free venesection for pericarditis does not always prevent the subsequent appearance of serious inflammation in< other internal organs. II. Mercury. 1. The cases in which mercury was given within the first four day s$ had an average duration less by five days than those in which it was given later. 2. The cases- in which salivation was produced within the first four days had an average duration less by two days than those in which it had occurred later. 3'. Iris difficult to determine how much of the benefit was due to the mercury, because all the patients who took mercury were likewise bled,, and in almost every instance the two remedies were first employed on the same day. 4. The au- thor is inclined to the conclusion, that the benefit' was due in greater measure to the bleeding than to the mercury partly because the du- ration of the disease was more abbreviated in those who simply began' to take mercury than in those in whom salivation was produced with* in the first four days. The administration of mercury coincided with vhe bleeding, but the salivation did' not, and the results are just wha 1850. \ Periscope. $0i might be looked for upon the supposition that the benefit was due to the bleeding, and not to the mercury. 5. If the production of saliva- tion had anything like the marked influence in arresting inflammation, arid in promoting the removal of its products, which it is currently believed to possess, the duration of the cases of pericarditis after sali- vation ought to have been much less than it really was. This is proved by a detail of the cases, (a.) Salivation was not followed by ariv speedy abatement of pericarditis in sixteen cases, (b.) Salivation was followed by pericarditis in five cases, (c.) Salivation was follow- ed by an increase in the extent and intensity of the pericarditis in three cases, (d.) Friction-sound ceased two days before the mouth became sore in two cases, (e.) Salivation was followed by a speedy diminu- tion of the friction-sound in two cases; it did not cease, however, for some days after, (f.) The pericarditis ceased soon after salivation in two cases; in one of them, however, it had been declining for some days before, (g.) Mercury was given, Ink no salivation was produced in seven cases. (/*.)' No' mercury was given, nor other treatment adopted in eight cases, (i.) Cases are detailed exhibiting the occur- rence of various internal inflammations during the time that salivation was proceeding. The cases comprise examples of endocarditis, pleuro- pneumonia, pneumonia, pleuritis, erysipelas, and rheumatism. A conclusion rather adverse to the antiphlogistic powers of mercury having been drawn from the facts narrated, the author next examines the evidence upon which the contrary and more prevalent opinions is based,* and infers that the evidence is not satisfaetorv. Treatment of Scarlatina by hot-water applications. By F. A. Bul- ley, Esq. (Med. Times. Braithwaite's Retros.) Mr. Bulley de- scribes a mode of treatment which he has adopted and found successful not only in scarlatina, but in every instance of febrile disturbance that has come under his observation within the last few years. He gives as an illustration the case of a farmer, who, after several days of pre- monitory symptoms, became covered with a rash. The next day Mr.- Bulley was sent for, and found his patient labouring under an attack' of scarlatina, which he (Mr. B.) believed would prove a very severe one. The following treatment was adopted : The patient was placed upon a bed, on which, the sheets having been removed, two blankets had been laid, tiicn a flannel pad, compos- ed of four thicknesses of coarse household flannel, sixteen inches long by ten inches wide, stitcl>ed round the margin to keep it together, and wrung out of hot water till almost dry, was laid as hot as he could bear it upon the pit of the stomach and over the region' of the heart ; and while it was still warm, the blankets, one by one, were carefully folded round his body, so' as to completely confine the perspiration and heat, which might be generated by this process ; at the same time, another pad of two thicknesses only of the course flannel, wrung out of boiling vinegar and water, was placed round the throat for the relief of the local inflammation. After he had remained enveloped in the Wrappings a little more than half an hour, during which time the & 308 Periscope. [May, brile excitement had been somewhat increasing, he burst into a pro- fuse and general perspiration, in which he was allowed to remain for two or three hours longer, with an evident abatement of the symptoms, when the blankets were carefully removed, and the flannel pad with- drawn ; after this, he had some refreshing sleep, and but little return of the burning fever; he was now ordered to take half a drachm of Dr. Stevens's saline powder in a mixture every four hours, and to use the following gargle to the throat : R. Armenian bole ; burnt alum powdered, aa. gr. 40; brown sugar, gr. 60; water 3 viij. Mix. This plan of treatment was so successful that on the seventh day from the first appearance of the eruption, the patient was going about h^s farm. Mr. Bulley makes the following remarks upon the treat- ment: I have had the satisfaction to observe, that the simple method which I have adopted in the treatment of fever, and which I practised in the foregoing case, has never, in any trial which I have made of it, failed in its object. I have now used it in a great number of cases, some of them of the worst description, and in every instance where the process has been judiciously managed, it has either at once annihilated the fever, mitigated its severity, or diminished its duration. I have also found it extremely useful in cases of small-pox, in constitutions where the circulating power has been naturally so feeble as to be insufficient of itself to throw out the morbid elements from the blood by the skin. Employment of Manganese in Ancemic and other affections. By M. Hannon. (London Jour, of Med. Braithwaite's Retros.) Manga- nese and iron are almost constantly found united in the same minerals, and can be separated with difficulty. Again, iron is not always efficacious in chlorosis, and fails in curing anaemia arising from can- cers, from tubercles, from prolonged and abundant suppuration, &e. In these cases, it cannot be the iron that is deficient in the blood, but some other ingredient ; and it is probable that iron is united to man- ganese in the blood ; and that cases of anaemia, unsuccessfully treated by iron, might be cured by manganese. M. Hannon first tried the effects of this agent on himself. He took at first a grain of the car- bonate of manganese daily, increasing the dose to four grains by the end of the first week, and to eight grains by the end of the second. At the end of a fortnight, he experienced symptoms of plethora ; tho appetite increased, the pulse became stronger, and the colour of the interior of the eyelids was heightened. He then administered man- ganese to some anaemic patients ; some of them experienced nausea for two or three days, after which the medicine was tolerated. In a short time, its beneficial effects became manifest in the increase of colour, in the fuller and more frequent pulse, in the energetic move- ments and general improvement of the functions. The presence of manganese in the blood was discovered by M. Millon, who presented a memoir on the subject to the Academic des Sciences of Paris. His observations have been confirmed by M, Hannon. 1850.] Periscope. 309 Several illustrative cases arc given. The first mentioned is one of extreme chlorosis, in which the patient was sent into country air, and took iron for some time, without benefit. We are told that The patient was then directed to take one of the following pills daily before breakfast, and another before dinner: Extract of cinchona, carbonate of manganese, of each a drachm. Mix and divide into four grain pills. After she had used these pills for a fortnight, the cheeks and conjunctiva? regained their colour, and the swelling of the feet disappeared. The following pills were then ordered. Sulphate of manganese, carbonate of soda, of each a drachm; fresh charcoal, ho- ney, of each a sufficient quantity to make a mass, to be divided into four-grain pills. A fortnight after the employment of this medicine, the bellows-sound had disappeared; the pulsations of the heart were strong and loud ; and an energetic impulse was felt on applying the hand. There was no syncope ; and the appetite had returned. The dose of the pills was increased; and a month after, menstruation oc- curred, and the patient became plump, and able to bear much exertion. She digested and slept well in a word, was cured. Another case is that of a young lady affected with phthisis : Iron with opium was prescribed ; but it increased the cough, and brought on obstinate constipation. Syrup of the phosphate of manga- nese was then given, with cod-liver oil ; the latter being added rather to prevent the contact of air with the manganese, than from any ex- pectation of its producing good effects. The constipation ceased ; and the cou^h became more bearable, and ceased in a fortnight. The patient then began to recover embonpoint. A month after the knuc- kles assumed a very remarkable brick-red colour, which has continued up to the present time a period of nearly a year and half. This patient took three gros (216 grains) of phosphate of manganese, in doses of three grains daily. Madame R. was affected with cancer of the uterus. She complain- ed of remittent pain in the hypogastric region, and suffered much while at stool. In the evening, she was troubled with severe lancin- ating pains, which often continued through the night. She was ex- cessively weak, and of a pale yellow hue. She was troubled with palpitation, and a hruit was heard in the carotid. The feet frequent- ly swelled. Syrup of the iodide of manganese was given with syrup of horse-radish, for several months. The pains did not leave her, but the amemic appearance completely disappeared. To calm the pains, opium, with extract of hemlock, was prescribed; and the patient be- came apparently cured. Mademoiselle M., aged 14, of a scrofulous constitution, had glandu- lar enlargement in the neck, ulceration of the transparent cornea of the left eye, and caries of the first phalangeal bone of the index finger of the right hand. Being the dau^htcrof a peasant, she had lived ex- clusively on vegetable fo< id ; bul was ordered to take meat, and to drink beer. Syrup of the iodide of manganese was given in doses-oCa spoonful two or three times a-day. Under the influence of this, and her improved diet, she became lesa lean; soon alter, the cornea re. $1Q Periscope. [May, gained its transparency, having been washed with a lotion containing gr. ss. of nitrate of silver to an ounce of distilled water. The suppu- ration of the carious bone ceased, and the finger was cured. M. G. B., aged 28, had been treated with mercury for some years, for constitutional syphilis. The bones were sound ; the skin was af- fected with all kinds of eruptions; the tongue had long been the seat of an obstinate tumour ; and there were syphilitic ophthalmia and iritis. Fumigation and iodide of potassium were persevered in for several months, but without effect. Iodide of manganese was then given, with syrup of sarsaparilla ; and in a month, the patient was completely healed. He was directed to continue the use of the jnan- ganese ; and, as he has not since applied for relief, it is probable that he has had no relapse. These cases have been selected from a number of similar ones, and shew the efficacy of the new remedy proposed. Manganese has in all cases produced a more rapid effect than iron, in cases of simple anaemia. In the forms of anaemia cited, all the cases had resisted iron, and all yielded to manganese. The other cases are respective- ly of phthisis, cancer, scrofula, and syphilis:- all inducing almost jrremidiable cachexia, and all rapidly alleviated by manganese. The effects of the manganese, as observed in one case, (phthisis) are re- markable. Iron seldom produces a similar result; if it improves the state of the blood, it increases the cough; so much so, that many practitioners abstain from its use in phthisical cases. In all the scro- fulous cases, the iodide of manganese, by its salutary and rapid influence, was proved superior to the iodide of potassium? The per- sistence of the cures obtained by manganese, in comparison with those produced by iron, is very remarkable: no cases of relapse have tjeen observed by M. Hannon. The quantity required to be taken, in or- der to produce the desired result, is far from being so great as that of iron. Qn the Treatment of Hooping Cough. By M. 'J'bousseau. (Journ. ties Connais. Medico-Chirurg.) M. Trousseau thinks favorably of the emetic treatment recommended by Lsennec for the commencement of the disease; but for its subsequent stages he prefers belladonna to all other remedies. We give his views on this subject. The belladonna should be given from the first in full doses, M. Bretonneau, says he, has remarked that a large dose of cinphona acts much more energetically when given at one time, than when double the quantity is taken in five or six doses. The same is true of bella- donna. Experience has shown, moreover, that, as is the case with the datura, digitalis, etc., the powder of this plant is preferable to both the tincture and extract, even when these latter are prepared in the best manner. The powder of the root should be employed therefore, or if that cannot be obtained, the powder of the flowers, in the dose qf i-850. J Periscope. 31 1 one centigramme, to a child from two to six years of age, according to the following formula: Powder of the root, or .flowers, of belladonna, 1 centigramme. Pulverised sugar, '... 25 " Triturate carefully. This dose is to be administered at one time, morning or evening, according as the cough is observed to be most troublesome in the night or during the day. After having kept up this treatment for two or three days, if there is any marked amend- ment, the belladonna is to be continued in the same dose ; but if there is no improvement, the dose is to be doubled, and two centigrammes are to be given during three days. The dose may be even increased to three centigrammes, to be given always at one time. Moreover, the belladonna should fee continued for twelve or fifteen days at least after the cessation of the cough ; otherwise it might return with des- perate obstinacy, and then the remedy, after having been suspended, would ot yield the same advantages as in the first instance. Here opium sometimes succeeds where the belladonna has failed. One drop of Rousseau's laudanum every day for three days might then be found serviceable. After opium, digitalis may be used, in the dcse of one centigramme of the powder, or one milligramme of digitalin. It will seldom be ne- cessary to quintreple these doses ; if these means fail, recourse must be had to antispasmodics, such as gum ammoniac, the sub-nitrate of bismuth, and the oxide of zinc. A blister, or frictions, with croton oil, may be of service during the latter stages of the disease, or when it is protracted in duration. Hemorrhages constitute a frequent and sometimes a very serious complication of hooping-cough. M. Trousseau has lately seen a child with hGoping-cough sink under haemoptysis : this is of rare occur- rence ; but epistaxis, and sub-cutaneous and sub-mucous ecchymosis are more common. Children have been known to weep tears o blood. Epistaxis may be repeated so frequently as to cause in the little patient a state of anaemia. There is no better remedy in these eases than the Peruvian bark, given in doses of two or three grammes &-day. This remedy is equally successful in the epistaxis of adult?. Rhatany is far from being equally useful. We may also use the dry extract of this article topically, or we may inject into the nostrils a solution of the sulphate of zinc or of copper. We may begin with a solution of five centigrammes of the salt to thirty grammes of distilled water, and increase the former gradually to ademigramme or even to one gramme. 312 Periscope. [May. Sulphate of Iron in Diabetes of Children. (Joum. des Connais. Med. Chirurg.) Dr. Heine, of Berlin, reports two cases of diabetes mellitus in young children, treated successfully with the sulphate of iron. The first case was a child of nine years. At the age of four years he had measles, and from that time was unhealthy. He was badly fed and clothed ; feeble, emaciated, and melancholy. His ap- petite was irregular, and his bowels costive. He was attacked with fever every night, but received no medical treatment until the diabetes made its appearance, when his step-mother, annoyed by his urinating ten times in the night, applied to Dr. H., who detected sugar in a con- siderable quantity in his urine. Small doses of calomel, rhubarb, and magnesia, were given, and in the intervals, phosphate of soda, com- bined with ipecacuanha. All the symptoms were mitigated with the exception of the excessive secretion of urine. The calomel wTas dis- continued, and the patient put upon the use of the sulphate of iron. He had not taken this medicine more than two days, when a decided improvement was observed. He urinated but twice in the night, and the urine presented no traces of sugar. The sulphate was continued five or six weeks, and the health of the child was completely restored. The other case was a child of seven years, who had been in a state of utter destitution. He was much emaciated, his bowels constipated, without appetite, and a prey to continued fever. He also labored under a profuse saccharine diabetes. Dr. H. gave him the sulphate of iron in half grain doses, combined with rhubarb. A rapid ameliora- tion took place. In about five days the urine was much diminished, and at the end of eight days, it contained no sugar. The cure was perfected in four weeks. Sulphuric Ether topically applied to atonic ulcers. (Bulletin do Therap.) Prof. Bouisson recommends the topical application of sul- phuric ether as a valuable means in the treatment of atonic ulcers. Employed in this mode, the ether, independently of its sedative pro- perties, produces a tonic effect, due to the refrigeration which results from its rapid evaporation ; it also dries the humid surfaces with which it is brought into contact. Prof. B. has recently treated two cases, the one for an ulcer of the thigh, resulting from a bruise, and of two months standing the other from an ulcer in the abdominal region, primitively of a venereal origin, which had resisted all external and internal treatment. The application of lint wet with the sulphuric ether, three times a-day, effected a cure in fifteen days. This treat- ment is very simple, raid should be tried when the ordinary treatment p-roves unsuccessful. 1^50.] Periscope. 318 The Bark of the Khaya Senegalensis as a substitute for Cinchona. The Journal des Connaissanccs Mc-dico-Chirurgicales, for January, contains the following description of the Khaya Senegalensis, com- monly known as the Cinchona of Senegal, by M. Cavento. The Khaya Senegalensis, (Switenia Senegalensis,) one of the largest and most beautiful of the trees which adorn the banks of the Gambia, and the Peninsula of Cape Verde, belongs to the family of Meliacex. The febrifuge properties of the bark of this tree, noticed some time ago by MM. Merat and De Lens, and also by M. Guibourt, have ob- tained for it the name of the Cinchona of the Senegal. The bark of the Khaya Senegalensis is about 15 millimetres in thickness; grayish, rough and hard, externally; under the epidermis it is o^ reddish, yellow colour, which becomes lighter in proceeding from without inwards. It developes, when chewed, a decided bitter- ness, has a clean fracture, is close grained, and presents in its longi- tudinal direction white lines, which become more close and numerous as we proceed from the bark toward the centre. M. Cavcntou has analyzed this bark, and has obtained .from it a new organic principle to which he has given the name of cail-cedrin. This is a yellowish, opaque, non-chrystalline body, of a resinous ap- pearance, of a bitter aromatic taste, and is but slightly soluble in water. A trial of this article, made at the Hotel-Dieu, by MM. Moutard, Martin and Chomel, seemed favorable to its employment in intermit- tent fcver. M. Caventou himself admits, however, that it demands further examination. But as those who live on the banks of the Senegal cure themselves when most violently attacked with fever, by using the decoction of Khaya bark, it is to this that the first clinical researches should be directed. Vegetable Charcoal. (Journ. des Connais. Med. Chir.) M. Patis- sier, oil the part of MM. Becamicr, Caventou, and for himself, read the following additional conclusions of a report previously communicated to the Academy on a memoir concerning the use of vegetable carbon in gastro-intestinal nervous affections, both idiopathic and symptoma- tic, by Dr. Belloc, surgeon-major to the 6th regiment of hussars. These results, said he, from the chemical facts mentioned in the memoir of M. Belloc, and from those which your committee have been able to gather, arc : 1st. That pulverised charcoal prepared from the common poplar, 314 Periscope. \ [May, may be used with advantage in the treatment of nervous affections of the stomach and intestines ; that its therapeutic effects do not differ materially from those of charcoal obtained from light and porous wood (white willow, fir, larch, etc). 2d. That these powders are only really valuable when administered in large doses, four or five tea-spoonsful a-day, to be taken before or after meals. The committee think that M. Belloc has rendered a service to prac- tical medicine, by directing the attention of physicians to the thera- peutic value of vegetable charcoal. Your committee propose that you address a letter of thanks to this excellent brother, and place this memoir in the archives. Anti-asthmatic pills de M. D'Avonie. (Journ. de Med, Connais. Med. Chirurg.) M. D'Avonie recommends pills made according to the following formula, as uniformly efficacious in asthma, whether idiopathic or symptomatic: ft. Venice soap, , , , 4 grammes. Gum ammoniac, i Fresh squills, > Socatorine aloes, ) aa 2 grammes. Bals. copaiba, q. s. Make into pills of four grains each. One pill to be taken every two hours. For Alopecia. (Bulletin de Therap.) Ointment of cocoa, (cocoa butter 2 parts, olive oil 1 part,) 60 grammes. Tannin, ,..,,, 80 centigr. Quinine, ..,,,,, 40 " Dissolve in aromatic alcohol, (alcoolat aromatique,) . 8 grammes. Make an ointment. To be used night and morning. New Febrifuge Pills. (Journ. de Med. de Toulouse. Bulletin de Therap.) ft. Willow bark, .,,..,.... 10 parts. Capsules of common lilac (syringa vul.) "j ?entian' , I each 2 Lesser centaury, j Wild endive, J Exhaust by means of boiling water, concentrate the liquors, reduce to the consistence of an extract ; and add, one half-part of crude 1850.] Periscope. 315 quinine, dissolved in three times its weight of lactic acid. Incorpo- rate intimately, thicken with a sufficient quantity of powdered Colombo root, and divide the mass into pills of 15 centigrammes, (3 grs.) From one to three pills to be given a-day, and to be continued some days after the cessation of febrile symptoms. Position of the Foetus in Utero, and the causes of Preternatural Pre- sentations. By Dr. J. Y. Simpson, Edinburgh. (Monthly Journal. JSraithwaite's Retros.) Dr. Simpson endeavors to establish the follow- ing propositions relative to the common or natural position of the foetus jji utero : 1. The usual position of the fostus, with the head lowest, and pre- senting over the os uteri, is not assumed till about the sixth month of intra-uterine life, and becomes more frequent and rnore certain from that time onwards to the full term of utero-gestatiqn. 2. Both the assumption and maintenance of this position, are vital and not physical acts, for they are found to be dependent on the exist- ence and continuance of vitality in the child : concurring with its life, but being lost by its death. 3. In human physiology we do not know or recognize any vital power or actk>Q, except muscular action, .capable of producing mo- tions calculated to alter or regulate the position, either of the body, or any of its parts ; and further, the motory muscular actions of the fcetus are not spontaneous or voluntary, but reflex or excito-mstory in their nature, causation, and effects. 4. The position of the foetus, with the head placed over the os uteri, is that position in which the physical shape of the normal and fully developed foetus is best, adapted to the physical shape of the normal and fully developed cavity of the uterus. 5. This adaptive position of the contained body to the containing cavity is l.be aggregate resuli of reflex or excito-motory movements on the part of the foetus, by which it keeps its cutaneous surface with- drawn as far as possible from the causes of irritation that may act upon it as excitants, or that happen to restrain its freedom of position or motion, Proceeding to speak of preternatural positions and presentations of the foetus, as originating in the derangement of one or other of these normal conditions, Dr. Simpson states them to be referrible to the fol- lowing causes: First. Prematurity of the labour; parturition occurring before the natural position of the foetus is established. Secondly. Death of the child in utero; or in other words, the loss of the adaptive vital reflex actions of the foetus. Thirdly. Causes altering the normal shape of the foetus or contain- ed body, or causes altering the normal shape of the uterus or containing body, and thus forcing the foetus to assume, in its reflex movements, an unusual position in order to adapt itself to the unusual circum- stances in which it happens to be placed. 316 Periscope. [May, And, lastly. Preternatural presentations are occasionally the result of causes physically displacing either the whole foetus or its presenting part, during the latter periods of utero-gestatiou, or at the commence- ment of labour. Prematurity of the labour is a cause of mal-presentation in this re- stricted sense, that the position of the fcetus with the head lowest, and presenting over the os uteri, is not generally assumed till the sixth month ; and that from this period such position is taken and kept with a certainty and frequency which increase in proportion to the dura- tion of the pregnancy. Thus, Dr. Simpson states, that while the per- centage of head presentations in children born at the end of the sixth month is only about 52 in 100, it increases during the seventh month to 68 in 100, and to 76 in 100 during the eighth and ninth months ; and rises at the full period, as high as 96 or 97 in 100. He says : It is hence evident that if, from any causes, parturition happens to come on prematurely, the child is much more liable to present preter- naturally, than if pregnancy had gone on to the full time ; or, in other words, the prematurity of the labour, is, in this sense, a cause of the malpresentation of the fcetus. From an examination of statistics published by various authors, Dr. Simpson adduces also the following conclusions : 1. That while presentations of the head occur in 96 per-cent. in common obstetric practice at the full time, the same presentations oc- cur only in 70 per-cent. among premature labours ; 2. that pelvic presentations* are nearly eight times more frequent among prema- ture labours than among labours at the full time; and, 3. That transverse presentations are nearly ten times more frequent among premature labours than among labours at the end of the usual time of pregnancy. On the subject of the death of a child, as a cause of abnormal pre- sentation, Dr. Simpson says : The child not unfrequently dies in utero, and before labour begins. In cases in which the death of the fcetus is induced from any cause, during its intra-uterine life, the child, when labour at last supervenes, is apt to be found presenting pretcrnaturally. The maintenance as well as the assumption of the usual position of the fcetus with the head downwards and over the os uteri, is an excito-motory, and consequent- ly a vital act ; and hence, when the vitality of the fcetus is lost, its position, as a result of that vitality, is liable to be lost also. In other words, the death of the child thus becomes a cause of* its malpresenta- tion at the time of birth. The difference between the liability to cephalic, pelvic, and trans- verse presentations between children who have died before labour, and those bom alive, may be expressed as follows: 1. Head pre- sentations are 16 per-cent. less frequent among dead than among living infants ; 2. Pelvic presentations are five times more frequent among dead than among living children ; and 3. Transverse presentations are four times more frequent among the former than the latter. 1850.] Periscope. Miscellany. 317 Chlorosis in Pregnant Females. (Gazette Medicale.) It a meeting of the Academy of Medicine of Paris on the 19th of February, M. Cazeaux read an essay, the object of which was to show that the functional derangements so common among pregnant females, such as cephalalgia, vertigo, tinnitus aurium, palpitations, dyspncea, &c, gen- erally attributed to plethora, are more frequently the results of chloro- anemia. In pregnant women sanguine plethora is rare, but serous plethora is quite common. M. Cazeaux founds his opinions upon a chemical analysis of the blood, upon the symptoms, and upon the hap- py effects of the ferruginous preparations : he concludes, from the chemical results, that the principal elements of the blood, during preg- nancy, undergo modifications analogous to those of chlorosis. The functional disorders are also similar. Moreover, an animal diet, and the administration of chalybeates, have always been found equally efficacious in the treatment of the functional disorders of pregnancy, as in chlorosis. He now does not resort to bloodletting for the relief of palpitations, and he has never found them to resist the employment of chalybeates when continued for some days. ill t it i c a I ill i s c 1 1 a n jj . Medical Society of the State of Georgia. An accident which hap- pened to the train on the Macon Rail-road prevented the attendance of our delegates at the late meeting of the State Society. But we have been favored with an account of some of the proceedings of the late meeting, in the following letter from the Recording Secretary, Dr. Nottingham : Macon, Ga, April 18th, 1850. Dr. I. P. Garvin, Editor, &c. Dear Sir, Pursuant to a resolution adopted at the last annual meeting, the Medical Society of the State of Georgia assembled in Macon, on Wednesday, the 10th inst., and continued in session two days. The meeting, although not a full one, was sufficiently numer- ous for the transaction of business. Many important subjects con- nected with the advancement and elevation of the Profession, were deliberated upon in a spirit of harmony, high toned feeling and liberal sentiment, that augurs well for the future usefulness of the Institution. The officers elected lor the present year, were Charles West, M. 1). of Houston, President ; R. D. Aknold, M. D., of Chatham, 1st Vice-President ; I. E. Dupbee, M. D., of Twiggs, 2d Vice-President ; 318 Miscellany. [May, J. M. Green, M. D., Of Bibb, Correspond'g Secretary ; C. B. Nottingham, M. D., of Bibb, Record'ng Secretary ; S. W. Burney, M. D., of Monroe, 'Treasurer. The following gentlemen were duly elected Delegates to the next meeting of the "American Medical Association," which will convene in Cincinnati, on the 2d Tuesday in May, viz : s L. D. Ford, M. Dm of Richmond; l^- W. M. F'rasier, M, D., of Pulaski ; I. E. Dupree, M. D., of Twiggs ; T. F. Green, M. D., of Baldwin ; Charles Thompson, M. D., of Bibb ; T. L. Rives, M. D., of Troup; J. N. Simmons, M. D., of Butts ; R. L. Roddey, M. D., of Monroe ; J. H. Oliver, M. D., of Laurens. A number of committees, composed of much of the medical talent of the State", were appointed to prepare Essays and Reports, upon various subjects pertaining to Medical Science, to be presented af the next annual meeting of the Society which will be held at Atlanta, Dr. Arnold of Chatham, with Dr. LeConte of Bibb, as his alternate, was selected as Orator for the occasion. A summary of the Proceedings will be published in pamphlet form at as early a day as practicable. Very respectfully, C. B. Nottingham. New Orleans Medical and Surgical Journal.-^-We were much grati- fied a few days since, to receive the March number of our valued New Orleans COtemporary, which has been delayed by the disastrous fire that consumed the office, with all its books, printing material, etc., and' reduced to ashes* all the profits which had accrued from several years' incessant labors. Whilst we deeply sympathize with our esteemed- brother, we can but admire the indomitable spirit which he exhibits. "If we have heen unfortunate," he says,- "we are not despondent ; but gathering additional energy from our recent losses, we shall push for- ward the work with all that zeal and resolution which can alone guar- antee ultimate success in any undertaking." Fortuna opes auferre, iwn animum, potest. Extract of a Letter from James H. Oliver, #1.D., of Laurens Co., Ga. I was, on 22d January, 1849, called to see a gentleman whom 1 found it necessary to cup. His wife, who was some four months ad- 1850. J Miscellany. 319 vanced in pregnancy, was sitting near me whilst 1 was operating upon his temples. Nothing worth noticing transpired at the time of oper- ating or daring the latter months of pregnancy. At the expiration of the usual term, she was delivered of a fine, and apparently healthy child. There were found twelve scars in each temple of the child, arranged so uniformly that they resembled the cicatrices made by the action of the scarificator in actual cupping. These cicatrices, as I term them, gradually disappeared as the child advanced in life. The last time that I examined the temporal region they were entirely invisible. How the impressions made upon the mother caused this physical evo- lution to take place upon the foetus whilst in utero, is wonderfully mysterious. I had always doubted that any such impressions could be made, but I am now constrained to believe it possible. Percussion. (Gaz. Medicale.) M. Poirson, Interne at la Saltpe- triere, has communicated a new mode of percussion, that consists in striking after the usual manner, without a plessimeter, and with the index or middle finger furnished with a polished thimble, adjusted in such a manner as to confine a certain quantity of air between its upper extremity and the end of the finger. This instrument without alter- ing in anywise the character of the sounds, communicates to them, according to the author, a remarkable clearness and intensity which enables the physician to perform the percussion, and yet to spare the patient almost entirely the suffering occasioned by a shock that is often very painful. Northern Lancet, and Gazette of Legal Medicine. A new Medical Journal, under this title,- has been received. It is published ai Pitts- burgh, N. Y., in monthly numbers of 32 pages each, and is edited by Drs. Francis J. D' Avignon and Horace Nelson. A considerable por- tion of the work will be devoted to Legal Medicine, a subject which has hitherto been too much neglected by the profession. We wish the enterprising editors great success in t'heir honorable undertaking. A Foetus discharged by tlic mouth. We find in the Gazette Medicale of the 23d February, a very singular case (if true), derived from the Spanish journals. Maria de la Cruz, aged 18 years, in the second- stage of yellow fever, was attacked with vomiting, during which she threw up, with much difficulty, a substance which proved to be a per- &cily developed fcetus of four months. The female died next Jv-. 320 Miscellany. Meteorology. On an examination of the body, the uterus was found augmented in vo- lume, and between that organ and the vagina, an abnormal cavity communicating with the intestine by an opening four inches in diameter. Mortality of Providence, R. I. We learn from a communication, made by Charles W. Parsons, M. D., to the Boston Medical and Sur- gical Journal, that the deaths in Providence for the last eight years, among the white population, including the still-born, amounted to 6146, or 1 in 39.42. During the same period, among the black population, which numbers 1476, the deaths were 457, or 1 in 25.89. METEOROLOGICAL OBSERVATIONS, for March, 1850, at Augusta, Ga. Latitude 33 27' north Longitude 4 32' west Wash. Altitude above tide, 152 feet. By Dr. Paul F. Eve. , P.M. Sun Rise. Ther. Bar. 70 53 62 48 48 57 51 42 47 56 51 37 54 65 59 60 57 57 44 49 46 46 52 36 43 45 56 38 35 49 45 2, Ther. 29 43-100 " 72-100 " 54-100 " 97-100 30 12-000 29 79-100 " 41-100 86-100 " 92-100, " 84-100 " 91-100 11 97-400 " 94-100 " 74-100 " 82-100 " 85-100 " 77-100 " 59-100 " 85-100 30 10-100 29 35-100 " 70-100 " 41-100 91-100 " 76-100 " 53-100 " 32-100 " 52-100: " 87-100 " 74-100 " 72-100 Bar. (*) From E. to N. E, 29 47-100 67-100 58-100 30 5-100 30 5-100 29 31-100 50-100 91-100 94-100 83-100 92-100 30 29 84-100 :' 77-100 " 74-100 " 78-100 65-100! " 62-100 " 90-100 ;o lo-ioo 29 88-100 60-100 59-100 88-100 69-100 44-100 31-100 63-100 82-100 66-100 79-100 all around the Wind. w. S. E. E. S. w. w. s. w. w. N. E. N. E. E. W. w. () s. s. w. w. E. S. E. S. E. N. W. N. W. S. S. N. E. N. E. E. N. W. compass. Remarks. Fair Wow. Cloudy. Fair afternoon gale. Fair. Cloudy. [85-100. Cloud)' violent storm rain, Fair. Fair. Cloudy. Fair afternoon. Rainy hail breeze. Fair afternoon. |Rain all night, 1 inch 10-100. Fair afternoon. Storm at 2 p.m., 90-100. Storm all afternoon 1 in. 30-100. Storm at 4 p.m. \ two nights, 1 Cloudy. $ inch 30-100. Fair. Cloudy rainy. Rain, "l inch i. 3-1 00. Cloudy rain, 95-100. Fair heavy blow. Fair. Cloudy. Somewhat hazy rain at 8 p.m. IRain, 25-100. !Fair afternoon blow. 'Some clouds. ,Cloudy rain at 3 p.m., 55-100. Fair breeze. 8 Fair days. Quantity of Rain 11 days. West of do. do. 13 days. Another most disagreeable month- inches 35-100. Wind East of N. and S. cold, wet. and tempestuous SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. 6.] NEW SERIES. JUNE, 1850. [No. 6. PART FIRST. r i 3 1 n a I (ttotrurutntcattons. ARTICLE XV. An Essay on the Influence of Dentition in producing Disease. By Henry F. Campbell, M.D., Demonstrator of Anatomy in the Medical College of Georgia. The period of Dentition has ever been regarded one of pecu- liar interest, as well to the pathologist as to the practitioner. That certain diseases are more apt to occur during this season, few pretend to deny ; but the amount of the symptoms, due to the irritation of teething, has been variously estimated, some attributing to this cause nearly all the ills to which infancy is liable, while others ridicule the idea that a process .in itself so purely physiological and natural should be regarded ever a cause of disease. The object of our essay is to investigate impartially this important subject with the view of determining, as nearly as possible, to what extent the organism is affected by the evolu- tion of the teeth. In doing so, it appears to us most rational, as a primary step in the investigation, to review briefly the phenomena of both normal and anormal dentition, with the view of finding the foundation of the pathogenic theory, if such exists, in the physiology of this process. The phenomena observed during easy or normal dentition may be briefly summed up as follows : The salivary secretion is increased, the gums are swollen, the mouth hot, and the child evinces a disposition to press every substance within its reach N. 3. VCL. VI. no. vi. 21 322 Campbell, on the Influence of Dentition [June, upon the gums, in order to relieve the irritation it here suffers. Later the gums become more swollen and softer, the irritation more distressing, and, under certain circumstances, the mouth dry and slightly inflamed. The child becomes fretful; its sleep is disturbed and feverish, its bowels become loose, which latter symptom we frequently observe accompanied by nausea and vomiting. There is also described by some authors an irritation of the schneiderian membrane, with increased secre- tion, marked by the child's rubbing its nose. Cases of anormal dentition are brought more frequently under the cognizance of physicians, and their phenomena are hence familiar to every one. The above symptoms become exagger- ated some, which in normal dentition were of trivial import- ance, becoming so severe as to threaten the life of the patient. Thus the gently relaxed condition of the bowels, which in easy dentition was even beneficial, is now changed to diarrhoea with distressing tormina and alarming emaciation. The salivary glands, which in easy dentition manifested their implication only by increased secretion, now become inflamed and swollen till finally their secretion is altogether arrested, leaving the mouth and tongue dry, parched and painful ; and the nervous fretfulness of the normal process is often replaced by actual fever, sometimes attended by the most terrific convulsions. We have here sketched hastily some of the more prominent phenomena of both easy and severe dentition, as we each daily observe in practice, and find reported by authors, and we do not adduce them at present as the direct results or consequen- ces of the process, but only as its pretty constant concomitants. In referring to those symptoms hereafter in the course of our essay, we will necessarily enlarge upon and develope more fully some of their characteristics. Let us now, with a little atten- tion, enter into an analysis of these concomitants of dentition, and endeavor to ascertain whether or not their origin may be found in the process itself. To this end, we will consider briefly the anatomy and physiology of the parts concerned in this im- portant and often perilous process of evolution. Dentition begins early in foetal life by the formation of minute pulps in the maxillae, the deposition of calcareous matter upon these pulps afterwards occurs, and finally these rudimentary bodies, becom- 1850.] in producing Disease. 823 ing more and more perfect, emerge from the fibrous capsules that envelope them, and finally by the absorptive process make their appearance through the gum, and the child is said to have cut its teeth. This process is not at once uninterruptedly completed, but is from time to time resumed with but short intermissions, till, successively, all the teeth are through, the whole process occupying a period varying from fifteen to thirty months. The parts in which this slow and tedious evolution takes place soon become better supplied with blood, the vessels enlarging for this purpose, and moreover it is not unimportant to recollect they are supplied by sensitive branches of the trifacial or fifth nerve, a nerve the irritation of which is ever made evident% the most painful manifestations. Add to the above the inordinate development of the nervous system, par- ticularly the spinal, at this period, and we have the most import- ant physiological peculiarities which bear upon the question under consideration. That pain frequently exists during dentition is a fact that needs no argument to substantiate ; the uneasiness, fretfulness, biting and other symptoms, are all unmistakable manifestations of pain in the child, and further, we know that in the adult the appearance of the wisdom teeth is often attended with pain of the most acute character. The following case will illustrate this fact : Some time since we were requested to extract a tooth, the young man complaining of intense pain in the lower jaw ; on examination no decayed tooth could be discovered to which to refer his distress, but behind the last molar tooth on the right side there were much tumefaction and tenderness; on scarifying the part deeply the wisdom tooth was felt to grate under the lancet. He was instantly relieved of the pain, which did not return, and the tooth has since made its appearance without causing further trouble. His pain had been caused, no doubt, by the pressure of the growing tooth upon the branches of the fifth nerve distributed to the gum in which it was embed- ded ; and in the same manner does the emergence of each successive tooth in the infant cause pain, varying in degree according to the susceptibility of the subject and number of the teeth simultaneously emerging. Ill children* as in the above adult case, we constantly observe 324 Campbell, on the Influence of Dentition [June, instant relief from free incision of the gums ; indeed, we could report many cases wherein the relief was so marked that the children seemed aware of it themselves, and would make no resistance whatever to the operation, but would bear up against the cutting edge of the lancet, the pressure of it affording relief. In addition to the local results of pressure upon the nerves, as pain, heat, tumefaction, and other symptoms of inflammation in the mouth and its vicinity, we have general symptoms of a graver and more important bearing upon the welfare of the individual, a train of phenomena denominated by some authors the sympathetic disorders of dentition, and by others denied, as having little or nothing to do with the process, but treated of as merely coincident diseases, occurring at this period be- cause the system is more irritable, and consequently more liable to disease, thus we may say evading the question and virtually acknowledging their true origin. Thus Dr. West, in his recent admirable course of " lectures on the Diseases of Infancy and Childhood," writes, " the time of teething is in reality one of more than ordinary peril to the child, though why ft should be so, is not always rightly understood." And he goes on to ac- count for it. by saying that "it rs a time of the most active development of the organism a time of transition from one mode of being to another, in respect of all those important functions by whose performance the body is nourished and built up. Statistics embracing the largest numbers, prove the dangers of this period, and warrant us in regarding the comple- tion of this process as a fair subject of congratulation."" Among the diseases to which the system is at this time liable, we will enumerate as most important, first, those of a convul- sive or spasmodic nature, and secondly, and almost as im- portant and dangerous, those that affect the gastro-intestinal canal. That the convulsions occurring during dentition de- pend upon the irritation of the process for their production, we have every reason to believe, that high authority, ob- servation and careful induction can afford. We are all aware that irritation occurring in one portion of the nervous system, is adequate to the production of sympathetic irritation in ano- ther portion, sometimes indeed very remote from the exciting cause. Thus an irritation of the nervous plexuses supplying 3850.] in producing Disease. 32o the womb, often gives rise to puerperal convulsions, by the reflex action of the nerves transmitting this irritation through a nervous centre, the spinal marrow, to certain muscles, many of them very distant from the primary seat of the irritation. Or, as another familiar illustration, we adduce the irritation of the fauces in the production of vomition : here the irritation, being made in the branches of an exciter nerve, the glossopha- ryngeal, distributed upon the mucous membrane of this region, is transmitted to the medulla oblongata, the nervous centre common to this and a motor nerve, the pneumogastric supply- ing certain muscles of the pharynx, oesophagus and stomach, and vomiting is produced. That this is true, there can be no doubt ; for whenever the fauces are in a condition to obtund the sensibility of the glossopharyngeal nerve, whether from tumefaction or the deposition of false membranes, it is with great difficulty that vomition is effected, because then we are deprived of the action of the chief excitor to the act. Since, then, we must admit that dentition gives rise to much local irritation, and also that local irritations can, under certain cir- cumstances, be productive of sympathetic phenomena, through the reflex agency of the nervous system, the conclusion is inevitable that some at least of the convulsions occurring during this period are directly referable to such local irritation, for here the analogy is as perfect and entire as could reasonably be required for such a deduction. Here the sensitive branches of the fifth pair of nerves itself almost a spinal nerve, become excitor to the motor filaments of the spinal nerves, by transmit- ting to the medulla oblongata the irritation caused by the pres- sure of the growing tooth, this irritation is thence reflected through the spinal marrow and motor nerves arising therefrom to the muscles, and the convulsions are thus produced.* This theory of the origin of this irritation receives further corrobora- tion, if we observe that the reflected irritation is first transmit- ted through the nerves that arise successively from the nervous centre, thus, first the motor branches of the fifth nerve itself are excited, and those muscles moving the inferior maxilla are convulsed; then the sixth, and the eye is rolled outward in its orbit; thirdly, the seventh is excited, and the superficial mus- * Todd's article on Sympathy, in the Encyclopedia of Anat. and Phys. 326 Campbell, on the Influence of Dentition [June, cles of the face, the muscles of expression, distract the features by their convulsive actions. Then in rapid succession the other nerves ; the pneumogastric causing dyspnoea by closure of the glottis from spasm. Then the hypoglossal protruding the tongue ; and we think it is owing to the position of the origin of this nerve that this organ is so frequently lacerated, the mascatory muscles are already in action, and on the excita- tion of the ninth pair the tongue is thrust between the teeth before the patient has made noise enough \o attract the atten- tion of the attendants, for it is only after the excitation of the phrenic nerve, which arises much lower down, that the dia- phragm is convulsed, and the crowing inspirations are pro- duced. But to resume : shortly after the ninth, we observe the action of the spinal accessory nerve of Willis is excited through the common nervous centre, and the head is drawn forcibly backwards upon the neck by the action of the sterno-mastoid and trapezius. Now in rapid succession all the spinal motor nerves are excited and the convulsion is general. The above, with very little variation, will be found to con- stitute the order of phenomena of those convulsions that occur during dentition. The successive excitation of the nerves above-mentioned is so rapid that it is difficult to mark the exact time of its recurrence, but that it is successive is plain and per- fectly observable to any one who has awaited in dread, as we have done, the advent or return of this most terrific of the many scourges that affect mild and innocent, yet too fragile childhood. From the above considerations we are induced to conclude that convulsions are often produced by the irritation of denti- tion, and can be directly referred to this as the sole cause. We arrive now at a point in this somewhat obscure and much disputed question which perhaps affords more ground for doubt than any of the foregoing, viz., a consideration of the pathogenic influence of dentition in the cholera infantum or diarrhoea so uniformly co-existant with this process. Unlike the convulsions, the analogy between which and certain known and established phenomena of the excito-motory system, which it is only necessary to refer to, and their operation is plain and intelligible, this new set of symptoms, if we refer them to the process of dentition, requires us to look yet deeper into the 1850.] in producing Disease. 327 mysteries of our nervous organization, and to venture still one step further on the terra incerta of sympathetic interpretation. In order to apply our arguments, let us hastily review the foregoing investigation, that they may bear more fully upon this part of our question; and, firstly, we have seen that in- flammation, pain, and irritation are produced locally by the process of dentition, evinced by restlessness, biting, &c. Se- condly, we have seen that this local irritation can be transmitted by excito-motory influence to other and distant parts of the body manifested by convulsions. We have also endeavored to corroborate this latter opinion by a reference to the order of succession in the nerves in which this irritation occurs, and also by a comparison of these phenomena with other well under- stood and established analogous phenomena. Heretofore we have had to deal entirely with functions of the cerebro-spinal system of nerves ; but to account for this second and more ob- scure part of our problem, we must look in vain to any direct anatomical connection between the fifth pair and the rest of this system of nerves. We are forced to seek out other con- nections, indeed somewhat more intricate and indirect, but fortunately no less legitimate and definable. We have now to consider a sett of organs that, unlike the voluntary muscles, have no connection, or rather, we would say, emphatically, they have a connection, though indirectly, with the cerebro-spinal system. We mean the abdominal viscera, which we know are almost altogether supplied from the great sympathetic system of nerves. Now, in the prosecution of our inquiry it becomes necessary, to the elucidation of the question, to trace out the same connection between the fifth pair and the sympathetic or secretory, as we did between the fifth pair and the cerebro-spinal or motory nerves, and then, should we succeed, we will briefly inquire into the bearing which this connection and its possible results may have upon our question. The connections between the fifth pair, the rest of the cere- bro-spinal system of nerves and the great sympathetic, are so abundant and universal that it is only necessary to enumerate a few of them to illustrate the fact. Firstly, we have a con- nection in the ophthalmic or first division, by its nasal branch communicating with the ciliary ganglion ; then in the superior *J28 Campbell, on the Influence of Dentition [June, maxillary, or second division, are branches of communication with Meckels ganglion ; again, in the sub-maxillary ganglion, with the inferior maxillary or third division. So much for the fifth itself. Then we know that every one of the spinal nerves throughout the entire chord are connected to each sympathetic ganglion of the system, thus establishing communications the most abundant and intimate between these two systems of nerves. We know also that these ganglia distribute numerous branches to all the splanchnic viscera by plexuses which ac- company the arterial trunks into the minute structure of these organs. Thus connected and distributed, this nerve presides over the important functions of nutrition and secretion, which office so characterizes it as to give it the name of the secretory system. In the physiology of the nervous system, there is no fact bet- ter established by anatomy and pathology, as well as by ex- periments on the lower animals, than this, that the sympathetic nerve, whatever else may be its functions, always forms a necessary element in the nutrient and secretory apparatus of all the splanchnic viscera ; and further, that upon its sanity depends the due administration of these two great functions. It is the nerve for the bloodvessels ; '' and," remarks Todd and Bowman, "as secretion is mainly dependant on the normal nutrition of glands, it is reasonable to suppose that that func- tion would be to a certain extent controlled by these nerves." And as early as the year 1732, Pourfour du Petit found that the division of the trunk of the sympathetic, opposite the fourth or fifth cervical vertebra in dogs, was followed very rapidly by great disturbance of the circulation of the eye-ball, producing inflammation, flattening of the cornea, and finally destruction of this organ. The experiments of Dupuy upen the horse, wherein he severed this nerve at the superior cervical ganglion, also cor- roborate this statement ; general emaciation here ensued, with an anasarcous condition of the limbs and an eruption over the whole cutaneous surface. In some experiments made by Dr. J. Reid, and reported by Todd & Bowman, in reference to the sympathetic branches supplying the eye, it was found that a section of this nerve was I860.] in producing Disease. SUM to produce an immediate injection of the conjunctiva. In one case, he observes, the redness of the conjunctiva took place in a few minutes after the section. It has been already stated, continue these great authors, that a section of the branches of the fifth nerve which supply the eye, is followed by ulceration and other signs of impaired nutrition in the eye-ball. But these changes do not take place for some time after the section of the nerve generally many days elapse and they are attributa- ble to the presence of irritating particles which, owing to the insensible state of the conjunctiva, are suffered to remain in contact with the surface of the eye, giving rise to inflammation and ulceration of its textures. The effects of section of the sympathetic are immediate, and are probably due to a change produced in the blood-vessels, in consequence of the with- drawal of the accustomed nervous influence.* We have now glanced sufficiently, we think, at the anatomy and physiology of the sympathetic system of nerves, to make the application of such points as are pertinent in the solution of our pathological problem. In its anatomy, we have seen its connections with all three of the divisions of the fifth nerve by ganglia, the connexion of these various ganglia with each other, as well as with the cerebro-spinal axis ; and lastly, the distribu- * In the Medico-Chirurgical Review for January, 1845, this view of the func- tion of the sympathetic nerve is ably elucidated in an article by Dr. T. Proctor. " After alluding to the proofs derived from the experiments of Philip, Flourens, and others, oi the non-dependence ot the circulation upon the cerebro-spinal system, Dr. P., in another part of his work, thus expresses himself. -' 'It is self-evident, then, that it is to the sympathetic, and that alone, that we must look for regulating the arterial system. And it will be observed that, in all parts of the animal body, where large and sudden supplies of blood are required, such as the heart, stomach, bowels, and organs of generation, we have the gan- glionic or sympathetic system very fully developed, and, as far as I can judge, in ratio to the amount of blood supplied to the several organs: on the contrary, in some parts of the body, and in the extremities where the flow of blood is more regular, and not subjected to those sudden calls for large supplies of blood at irregular periods, we find this nerve manifestly decreasing in size: and, indeed, as far as we can judge with the naked eye, ceasing altogether in some parts. Still I perfectly agree with Sir Charles Bell that it is distributed all over the bo- dy; but whether its influence is confined to regulating the small arteries which supply the coats of the vessels, or whether the same influence is continued by it over the whole circulating medium of the extremities and other parts that it manifestly has over the abdominal viscera, must, I fear, be left to a more en- larged enquiry.' " The whole article is full of interest and valuable suggestions, and its perusal will add much to the clearness of our pathology in many points that have here- tofore been exceedingly embarrassing to practitioners. 330 Campbell, on the Influence of Dentition [June, tion of branches from these ganglia, which are conducted by the arteries into every part of every one of the splanchnic viscera. In its physiology, we find it in entire charge of the important functions of nutrition and secretion, and that where ever these processes are effected it is by the agency of this nerve alone upon the blood-vessels. And further, we have seen that pathology and experiments on lower animals establish its indispensableness to the due performance of these functions, and that whenever the supply of its innervation has been cut off from a particular part of the organism, that part immediate- ly manifests symptoms of impaired nutrition and altered secre- tion. Now we are all aware that nearly the whole of the intestinal canal, or rather that portion between the stomach and lower part of the colon, receives no direct innervation from the cere- brospinal axis, but is entirely dependant upon the sympathetic nerve for its supply of nervous influence of whatever kind it may enjoy, whether motory, sensory, or secretory, and conse-* quently an impairment of the function of this nerve must neces- sarily correspondently alter its condition so far as regards all those functions with which this nerve endows it. The altera- tion in these functions would, of course, depend, in a great degree, upon the amount of impairment in the source of irrita- tion ; thus, as we have seen, if the supply is entirely cut off, the functions of the arteries seem in a great measure to cease, pas- sive congestions occur, and the parts inflame and ulcerate. Now we can also very naturally conceive of a condition of these nerves somewhat analogous to the above, yet intermedi- ate between the entire interruption caused by section, and perfect health: a condition of embarrassed or of exalted innervation. Now this intermediate condition is exactly the state which, from the developments of the foregoing investiga- tion, we feel that we are authorized to affirm is that which occurs in severe dentition, and that upon it is dependant the whole train of intestinal morbid phenomena observable during this process. That this, so far, is legitimately inferable, we do not think any one will deny. Now let us enquire how far these phe- nomena are dependant upon dentition; and analogy with the 1850.] in producing Disease. 331 excito-motary system will much assist us in our argument. We have seen that local irritations can, through this system, produce convulsions by the reflex function of the nerves, the sensitive branches of the fifth pair becoming excitor to the motory spinal nerves ; and so may we justly infer do these same branches, under certain circumstances, become excitor to the secretory filaments of the sympathetic, distributed so abund- antly to the intestinal canal, by a transmission of this irritation through the various ganglia with which it is connected. Thus the irritation at first produces simply an exaltation of the inner- vation of these secretory surfaces, and consequently secretion is more active than normal, producing simple diarrhcea. A continuance of the irritation, alters the character of the secre- tion, and we have the various morbid discharges observable during this period. This increase and change in the secretion are effected by the agency of the altered function of the nerve upon the arteries from which these secretions are eliminated. Now when the innervation of these arteries is still further em- barrassed by the long continuance of the reflected irritation, the state of things nearly approaches that observed in Dupuy's, Reids's and Pourfour du Petit's experiments of actual destruc- tion of the nerve, and we have ulceration of the intestinal mucous membrane: all these phenomena being the result of various degrees of injury sustained by the sympathetic nerve. It may here be asked, why should the branches supplying the intestinal mucous membrane become more implicated than any other portion of the sympathetic system? and why do not similar irritations of the fifth nerve produce like results in the adult ? To the first of these questions we answer, that most probably the other portions are implicated, but the manifesta- tions of such, implication are greater and graver here than elsewhere, because these are the sole sources of innervation to the viscus. The other branches are in all probability implica- ted, but receiving a certain amount of innervation from other sources, most of their functions not being entirely secretory, are still, though imperfectly, carried on. But in the intestinal canal the case is far different ; the requisitions made upon \i are of a nature that it has need for no other innervation than that of the sympathetic system. Its functions are secretion and 332 Campbell, on the Influence of Dentition [June, nutrition for the whole animal organism, and when these are impaired, its primary, indeed its only intents are altered or completely nullified. The second question is answered by the greater development of this system in the growing than in the adult individual, for the purpose of supplying the more active nutrition and secretion at that time necessary. We know that disease is more apt to occur in many parts of the body during this period; this is the general admission. Thus, according to many authors, among whom are West, Churchill, &c, pneumo- nia and bronchitis are more apt to attack children during dentition, than at any previous or subsequent period. Cutane- ous eruptions, and many other aberrations of secretion occur- ring during this period, but serve to corroborate our theory of the origin of the morbid intestinal secretion. The increased vermicular action and tormina attending this affection, find a ready explanation in the fact, now well established, that the sympathetic receives both motor and sensitive filaments from the anterior and posterior roots of the spinal nerves, endowing the organs of their distribution, to a certain degree, with cor- responding susceptibilities. In conclusion, let us define the position which, at the end of our investigation, we feel warranted in assuming. They are the following: that in the anatomy and physiology, as well as in the dependant analogies of the process of dentition, we find ample ground for the opinion that the diseases pertaining to this period, may be dependant, and in many instances are en- tirely so, upon the local irritation attending the process being transmitted through either the cerebro-spinal system of nerves, producing convulsive diseases in the motory apparatus, or through the sympathetic, causing derangements in the secreto- ry organs, particularly the alimentary canal, by the sway which it exercises over the arterial system, from which these secre- tions are eliminated. And the practical deductions to be drawn from these conclusions are, that we should not be remiss in taking every measure to arrest or lessen this local irritation, either by free and repeated incisions of the gums, or by the judicious administration of appropriate remedies, among which we have found opiates to prove most safe and efficient. It would indeed be an improving, and not an unpleasing ex- 1850.] in producing Disease. 333 ercise, to trace out more fully the connexions between the local irritation and the various diseases occurring during the period of dentition, to take more extended views of the abundant analogies and comparisons afforded by this truly prolific sub- ject ; but time and the special object of our essay, do not war- rant the indulgence in speculations so general and discursive. Our object has been to trace the connexion between this process and diseases in general, only in so far as it has a bearing upon the establishment of one principal question in reference to the diarrhoea of this period. The subject has been only glanced at, and deserves a fuller and more extended treatise ; wherein all the concomitant diseases of dentition, as dropsy, eruptions, and the many infantile neuroses, should be fully and carefully discussed. Such views, we would earnestly invite from some abler and more philosophic member of the profession. ARTICLE XVI. Veratrum Viride. By Wesley C. Norwood, ofCokesbury, S.C. American Hellebore. There is no science or art that suffers more, for want of reflection and investigation, than the science of medicine and the art of administering remedial agents to diseased animal bodies. When we reflect on the important responsibility that rests on the physician, this fact is truly a source of profound regret. It is truly surprising, how little is known and understood of the powers and properties of many remedial agents, to say nothing of the same want and deficien- cy in much that pertains to the grand circle of medical science in its most general and extensive import or widest range. The circumstances leading to this much to be deplored condition, would afford abundant matter for a dissertation, alone. The powers and properties of Veratrum Viride are but little known, and the little that is known is rather taken for granted or supposed from analogy : it is certainly a powerful and efficient agent, and can be as easily and as safely managed as any other equally active and energetic remedy. We have first employed it in July, 1841. It was in the case of Mrs. T.,that 334 Norwood, on Veratrum Viride. [June, our attention was more particularly called to some of its pecu- liarly striking effects. She was ordered full doses in the morn- ing. In the afternoon we were sent for in haste, as it was operating drastically: we found the skin cold; considerable moisture of the surface ; paleness extreme ; vomiting every fifteen minutes or oftener ; the pulse beating not more than sixty, but full and distinct. The pulse in the morning, before the administration of the veratrum viride, was one hundred and thirty in the minute. The emesis, coldness and extreme pale- ness of the surface, great despondency, or sense of sinking and dissolution, and the great reduction in the frequency of the heart's action, led us to observe more carefully its effects from that period. The disease in which we have used it most fre- quently is Pneumonitis, and its varieties. Its remedial proper- ties or powers are acrid, narcotic, expectorant, diaphoretic, emet- ic, and lastly, sedative, eminently reducing the frequency of the pulse, and rendering it slow, full and distinct. Its occasional effects are slight and pleasant delirium, hysteria or symptoms approximating hysteria, preternatural wakefulness, &c. We have enumerated its powers, beginning with that which is least prominent, and so on till we have reached the last, and as we believe the most energetic and valuable. It possesses a suffi- ciency of the powers called Acrid to relieve very moderate cases of torpor and where not sufficient for extreme cases, it renders a much less quantity necessary of such articles as gin- ger, grains of paradise and capsicum, than would be requisite, if veratrum viride was not administered, and by virtue of this property, it obviates any torpor that might be the result or follow from its own narcotic powers, and also counteracts some of the troublesome effects of Papaver, such as general torpor of the whole system, or of the bladder in particular. The next property in order, is its Narcotic, or if we had any appro- priate term between a nervine and narcotic, we would use it ; but as it is not a pure nervine, nor an intense narcotic, but more of the latter than the former, we must retain it. We have found a much smaller quantity of opium and its prepara- tions necessary, and many of its inconvenient effects obviated, under the administration of this article, such as, starting, fright- ful dreams, and a continual muttering while dosing or sleeping, 1850.] Norwood, on Veratrum Yiride. 335 which symptoms or effects are distressing to the patient, and sometimes alarming to the friends. By allaying pain, inducing more or less quiet, or even sleep, and not being accompanied with the above named disagreeable symptoms or effects, it proves itself a valuable agent in the treatment of disease. In the third place, it is Expectorant, and as decidedly so as any article with which we are acquainted, not only increasing, but materially changing the matter expectorated. When adminis- tering it we rarely find any other expectorant indicated. Under its ordinary effects, the surface is nearly always sufficiently soft or moist, and at times drenched with perspiration or if there is no moisture, the heat is reduced sufficiently low to render any additional remedy for its diaphoretic effects unnecessary. This brings us to the more active powers of the article; and, first, it is actively and drastically emetic, when administered in single full doses, but sufficiently mild and moderate in its operation when given in small doses at short intervals, for the young, delicate or feeble to take it with perfect safety. It operates on the stomach, and produces but a small discharge of bile, but a considerable quantity of mucous or watery fluid, or perhaps both. It excites a great degree of nausea, and an un- usual paleness or a contraction of the capillaries, thereby pro- ducing more or less coolness of the surface, with a feeling of sinking or exhaustion. It alone answers all the purposes that can be obtained from emetics in pneumonitis. The last and most prominent effect is a certain extensive and permanent reduction of the frequency of the pulse. It is the only article with which we are acquainted, that certainly and invariably lessens the frequency of the pulsations of the heart and arteries, and it possesses this power in a greater degree than any one, and perhaps all the articles combined for which this quality or effect is claimed. It so constantly produces this effect, that it may be administered without any fear or dread of disappoint- ment. In Pneumonitis Typhoides the frequency and rapidity with which the blood is sent through the lungs is certainly one of the most difficult circumstances belonging to the disease to control permanently. This frequency of action or pulsation of the heart and arteries aggravates, and is more liable to keep up persistent pain and inflammation than perhaps all others em- 336 Norwood, on Veratrum Viride. [June, bodied and combined. The hurried^motion of the lungs, from the rapid circulation through them, must be detrimental to an organ whose functions are so essential, and whose office is so important to the animal economy. From the great variety of remedies recommended, the conclusion is forced on us, that these motions and actions are of difficult control, or the state and condition of the system exciting them, are not counteract- ed by ordinary agents. But to be able to control these morbid actions and motions, or to manage or change the morbid state or condition from which they result, with a single article, that can be administered without difficulty that is not inconvenient from bulk, nor disagreeable to the taste, nor of offensive odour or smell, is certainly not a minor consideration, and should be taken into strict account in healing this scourge of the human race. If a multitude of remedies have been found absolutely necessary to control and subdue the above motions and actions, under the usual and ordinary mode of treatment, upon what does the cure depend? Does it rest on the fact of their controlling the action of the heart and arteries and the mo- tions of the lungs, thereby giving the vis medicatrix an oppor- tunity of relieving the state or condition on which they depend ? Or does it result from their counteracting this state and condition, the motions and actions ceasing, as a necessa- ry consequence of this counter-agency ? Or do they unitedly effect this desirable object ? We know that calomel, emetics, blisters, expectorants, are resorted to in the treatment of this disease ; and notwithstanding the powerand activity of many of these articles, we often find it absolutely pecessary to call into full requisition the whole catalogue, and after using them as skilfully and efficiently as we may, we often get along badly with many cases. But further, as all reme- dial agents are more or less poisonous and detrimental to a purely physiological state of the system, and if administered in health, will destroy that nicely adjusted balance of action in the various organs so essentially necessary to health, their suc- cess or power of removing disease must depend on their ex- citing a new disease, or a series of impressions and actions of an opposite character to the disease, and as their actions and effects are not persistent, unless frequently repeated, we have 1850.] Norwood, on Veratrum Viride. 337 often to continue them for some time to subdue the disease: or perhaps while the disease proper, and the disease incident, or the effects of the remedies are contending for the mastery, the great principle vitality, or instinct, if you please, resumes its place, and health is restored. By vital principle, instinct, nature, or the vis medicatrix naturse, we understand that state, condi- tion, or principle, as expressed by Dr. Good, which tends to preserve, perpetuate and re-produce a part or parts, or a being of like powers and properties. We believe that the veratrum viride embodies as many or more powers than any one, and perhaps all the other articles used in pneumonitis, combined ; and that it is superior to all others, from the fact that it not only counteracts and excites a new series of actions, but from its possessing, in an eminent degree, the peculiar power of les- sening the frequency of the pulse, and consequently the motion of the lungs and frequency of respiration, thereby giving time and opportunity to the diseased organ to restore itself. We wish to call the attention of the profession, particularly, to this peculiarity in the effects of this article. In inflamma- tion, there are all the symptoms that go to make up fever, and in addition, there is pain in the organ or part inflamed, and congestion and relaxation in the capillaries of the diseased part. That a cure may be consummated, the pyrectic symptoms must be subdued the pain, with other inflammatory attendants, re- lieved. To effect this object, that is, to subdue pain, to remove the heat or pyrectic symptoms, to control the frequency of the action of the heart and arteries, to relieve the hurried and laborious respiration, to moderate the continued motion of the lungs, and to assist the relaxed and congested capillaries in unloading themselves, are the great ends sought to be accom- plished in the cure of pneumonitis. The great duty of the physician is to subdue all diseased action speedily and with safety to the patient. We know of no article capable of meet- ing these indications with so much ease, certainty and safety to the patient, as the veratrum viride. By its narcotic powers, the pain and irritability are greatly moderated, if not relieved ; by virtue of its emetic powers a sudden shock and impression is made on the system, and if a resolution or crisis is not produced the pyrectic symptoms are greatly abated, and in addition n. s. VOL. VI. NO. vi. 22 338 Norwood, on Veratrum Viride. [June to the general shock, there is a series of new actions and im- pressions excited which are of great service in counteracting the disease and changing the secretions and excretions. It is powerfully nauseant, thereby aiding expectoration, which, in an eminent degree, assists the capillaries in relieving them- selves of their engorged condition. But, as has been already stated, its power of reducing the frequency of the dilitations and contractions of the heart and arteries, and consequently lessen- ing the frequency of inspiration and expiration, and the con- tinued motion of the lungs, which effects being accomplished, gives an opportunity to the relaxed and engorged capillaries to unload themselves of the unusual quantity of blood they contain, and gives, justly, to veratrum viride, the prominent position it is justly entitled to in the list of remedial agents. It does not possess the properties of colchicum. Colchicum is a chylo- gogue cathartic, more or less emetic, and possesses very con- siderable nervine powers. Veratrum Album is an emetic, and hydragogue cathartic. It usually produces more or less of a burning glow of the surface and flush of the face. The active principle of the colchicum and veratrum album, therefore, seem to differ from each other; but however unlike they may be, it does not follow that they are not adapted to, and useful, in over- coming the same disease. We will now repeat, or give, rather, a condensed description of some of the leading powers of veratrum viride ; and as its powers and properties are, or have been supposed to be, the same as those of veratrum album, we will contrast their effects, that others may judge of the similarity of their powers. It is actively emetic, but does not occasion a great secretion of bile, but produces free mucous or serous discharges. It induces an unusual degree of paleness and coolness, or, strictly speaking, coldness ; more or less moisture of the surface ; a sense of great exhaustion and dissolution; occasionally a slight and pleasant delirium ; occasionally a paroxysm of hysteria, or an approximation to hysteria. During all this emesis, nausea, coldness, paleness, and delirium or hysteria, the pulse is slow, full, and distinct, and so far as it is concerned, the person would be considered in good health, if it were not for other accompa- nying symptoms. 1830.] Norwood,, on Veratrum Viride. 339 We will contrast the effects of Veratrum Album and Vera- trum Viride. The V. album is emetic and cathartic, whilst the V. viride is emetic, but never cathartic. The V. album excites a peculiar burning glow and flush of the face, but the V. viride produces no such symptoms. The V. album does not produce a sense or feeling of dissolution, nor delirium, nor paroxysms of hysteria, nor an approximation to it under its ordinary operative effects, whilst the V. viride does produce these symptoms in its ordinary operation. The effects of the V. album do not excite in the minds of bystanders a belief in the rapid and speedy dissolution of the patient, but the action of the V. viride usually creates such an impression. The V. album does not lessen materially and permanently the frequen- cy of the pulse, but the V. viride does produce this change in the heart's action. The V. album does not produce paleness and coldness, nor diaphoresis, whilst the V. viride produces such symptoms in an unusual degree. The difference in the effects produced by these articles prove that they are each entitled to a separate and distinct place. We trust enough has been said,' to satisfy any reasonable mind that the powers and properties of the article under con-' sideration are but little known, and that, instead of possessing powers and properties similar to other articles, as stated in the books, that it possesses properties and principles quite dissimilar and peculiar. Its virtues should therefore be more fully tested. As already stated, we have used it mostly in pneumonitis of the typhoid type ; but we would also use it in other tvpes, pre- mising venesection. Once for all, we state that we would feel as awkwardly situated and as much unprovided for the treat- ment of pneumonitis without this article, as we would if we were deprived of cinchona and its preparations in the treatment of intermittent and remittent fevers. We are of opinion that it will prove to be a valuable agent in the treatment of many inflammatory affections, as gout, rheumatism, peritonitis, 6cc. It may be prepared for use, by digesting eight ounces ef the bruised root in one pint of alcohol. We generally commence with ten drops, and increase the portion from one to five drops each time, repeating the dose every two or three hours, until nausea, emesis, or a reduction in the frequency of the pulse 340 Dugas, on Quinine in Singultus and Tetanus, [Jane, takes place. We then lessen the quantity, or extend the inter- val, so that nausea and emesis are not excited ; but take care that sufficient is given to maintain the required redaction in the frequency of the pulse. We often omit the article for the space of one day, when the pulsations fall in number under fifty or sixty per minute. For a child, from three to five years of age, we begin with two or three drops every three hours, but do not increase it at each dose beyond one or two drops, unless the symptoms are or should become so urgent as to require that the system be brought more speedily under its influence. A tea-spoonful will often operate drastically, and will scarcely have need, at farthest, to be repeated beyond the second or third portion every half hour, before its full effects will be ex- perienced. The small dose, gradually increased, and often repeated, we have found the most efficacious. To relieve its unpleasant efFects, a mustard plaster to the spine and extremi- ties, and a little syrup of morphine and tincture of ginger or seeds of paradise, together with a suspension of the article, will be all that is necessary. We have not exaggerated the effects produced by veratrum viride, and wTe are confident that we can demonstrate them at the bedside to the satisfaction of any and every one. We could extend this article much further, but we have already spun it out much beyond what we intended, ARTICLE XVII. Observations on the use of the Sulphate of Quinine in Singultus and Tetanus. By L. A. Dug as, M. D., Professor in the Medical College of Georgia. Aware of the evil consequences of generalizing from isolated facts, and also of the tendency to over-estimate the value of new remedial agents, the cases now submitted have been thus long withheld from the press in the hope that other opportuni- ties might be presented for repeating the treatment detailed. The writer has not since had the management of similar cases, and feels it a duty no longer to remain silent, but to lay before the profession the following facts in relation to two forms of 1850.] Dugas, on Quinine in Singultus and Tetanus. SHI disease, whose usual obstinacy and fatality should plead his apology for suggesting a fair trial of the plan of treatment which in these two instances proved successful. Case of Singultus. On the 17th of February. 1848, Judith, a negro woman of apparently good constitution and about 25 years of age, (the property of Mr. J. R.,) was taken with labour and placed in charge of a midwife. The pains pro- gressed regularly, and seemed to be effective ; yet after the lapse of twenty-four hours without delivery, I was requested to see her. Finding that the head presented, but was still in the superior strait, no active measures were recommended. On the 19th, however, the same state of things continuing, the pains having lost their intensity, and the patient being much fatigued, wine of ergot was administered, with the effect of bringing the head to the inferior strait. The patient during this day suffered occasionally with hiccough, without any other symptom of prostration. During the night the singultus be- came persistent, and continued so without intermission, even during sleep, for seven days and nights. On the 20th, the child's head being firmly fixed in the inferior strait and the prostration of the mother being imminent, the forceps were used in vain, and delivery was finally effected by emptying the cranium. The child had hydrocephalus. Puerperal peritonitis very soon ensued with great intensity ; the posterior walls of the vagina sloughed away with a portion of the rectum, giving a free passage to the faeces through the vagina ; the pulse was reduced to a mere thread ; the surface was bathed in a cold, clammy sweat ; the abdomen was very much enlarged, and the case presented every appearance of utter hopelessness. The patient, however, recovered ! The peritonitis was principally treated by extensive blister- ing over the abdomen and large doses of spirits of turpentine. As this affection yielded, attention was directed to the persistent hiccough. The usual antispasmodics, opium, camphor, assa- fcetida, brandy, &c, were used ineffectually; chloroform was inhaled repeatedly until the induction of coma and insensibility, without arresting the hiccough for a moment. The precipita- ted carbonate of iron, which I had used in several other cases 342 Dugas, on Quinine in Singultus and Tetanus. [June. of obstinate singultus with marked success, was unavailing here. On the fifth and sixth days after delivery the pulse had become full and of good character; the patient seemed to be doing well, with the exception of the hiccough and a daily ex- acerbation of the febrile symptoms. Despairing of being able to arrest by remedial agents the hiccough, I prescribed, on the 25th February, quinine for the purpose of averting the next febrile exacerbation, directing 10 grs. to be given at once, and 5 grs. more two hours afterwards. The first dose had been taken only half an hour, when the hiccough ceased entirely : nor did it return until the following morning, when another dose of 10 grs. promptly arrested it again, and permanently. The suggestion naturally presents itself, that there was per- haps a mere accidental coincidence between the administration of the quinine and the cessation of the spasmodic affection. But the repetition of the same circumstances would incline us to a different conclusion. The result was as unexpected as it was gratifying, for the prescription was made for another end. The fact, however, is valuable, and may incite others to test the same remedy more directly. Case of Tetanus. Sophia, a negro girl about 10 years of age, (the property of Mr. J. B. C.,) became affected with tetanic symptoms on the 10th of April, 1848, some eight or nine days after having stuck a nail in her heel. Having been called to see the case about twelve hours after its invasion, I found it in charge of Dr. Hammond, who had examined and opened the wound without giving issue to any pus ordered an alkaline poultice to it, and morphine internally. The jaws were not " locked," for the mouth could be opened about half the usual extent ; the head was drawn back ; there existed a fixed rigidi- ty of the muscles back of the neck, along the spinal column and over the abdomen, which were attended with distinct spas- modic jerks at intervals of about five or ten minutes. The ex- pression of the countenance was anxious and the pulse some- what accelerated. The use of morphine was ordered to be carried as far as possible, and extensive counter-irritation ap- plied to the spine. She was kept in a state of narcotic sleep . during the remainder cf the day and night, and until noon 1850.] Prevention of Constipation. 343 following (11th April). The symptoms still progressing, not- withstanding our efforts to control them by counter-irritants and narcosis, I stated to Dr. H. the effect produced by quinine id the case of singultus first related, and suggested its use in the present instance. Not feeling warranted in omitting the morphine, we combined the quinine with it, so as to administer every three, four or five hours, according to effect, 10 grs. sulphate quinine with \ gr. sulph. morphine, in solution. This treatment was soon attended with a prolongation of the inter- vals between the paroxysmal spasms, and a diminution in their violence. The cold sweat usually induced by excessive doses of quinine showed itself several times to a moderate degree, and in the course of forty-eight hours the spasms had entirely ceased, although the rigidity persisted and gradually wore away in the course of a week. The doses of quinine and morphine were now gradually lessened and finally entirely omitted. On the 21st of April the patient was dismissed, entirely restored. Inasmuch as the treatment did not modify the disease until the use of quinine, we may without impropriety attribute to this agent a very important part in the successful termination of the case. If upon trial in other cases it be found entitled to confidence in the management of so formidable a disease as tetanus, it is hoped that the fact will be made known. PART II. UtvxtvoB ft n i he N. s. VOL. VI. no. vi. 26 402 Dr. Drake's New Work. [July, maritime belt east of the mountains;* and about twenty years afterward, M. Volney,f on returning from his travels through this country, adopted the same conclusion. In 1815, I endea- vored to show,J that the opinion to which those distinguished writers had given currency was erroneous. At that time, the number of reliable observations was small, compared with the present ; yet the error into which Mr. Jefferson had fallen, by a premature generalization, was correctly pointed out ; as nu- merous observations on both sides of the mountains, have since shown. As it is not in the plan of this work to institute com- parisons between the climate and diseases of the Interior Val- ley, and the regions beyond the mountains, which bound it to the east and west, I shall limit myself to the assertion which has been made, leaving it with others to compare the observations, which show that in the same latitudes the temperature of the climates on the opposite sides of the Appalachian range, is sub- stantially the same. The physician, then, of Maryland or Pennsylvania, who would advise his patient to emigrate to a milder climate, must not point out the State of Ohio ; nor must the invalid of Virginia, expect a warmer climate by removing to Kentucky. Much of the popular perpetuation of this error, has come from the direction of the great current of immigration into the the middle latitudes of the Mexican, and the southern portion of the St. Lawrence Basin. It has been largely from higher to lower latitudes, and yet it was all, in the phraseology of the people and the profession, to the West. They reached a warmer climate, by going south, and without investigation pro- nounced it the consequence of travelling westwardly." (p. 476.) The variations of season in different latitudes are thus summed up. "In the equatorial regions, the seasons present but little varia- tion ; and the difference between winter and summer, is not as great, as that between one hour and the next, in the temperate zone. In advancing to the north, the curves which indicate the temperatures of those seasons, immediately begin to diverge, and continue to separate wider from each other, until we reach the fifty-third parallel of latitude. This divergence another expression for the difference between winter and summer proceeds pari passu with the decrease of mean annual heat; so that the individual who travels from south to north, is con- stantly subjected to a climate of less mean heat, and greater extremes of summer and winter temperature, than that he left behind. He cannot anywhere in the Valley enjoy a temperate * Notes on Virginia. t View of the Soil and Climate of the TJ. S. t Picture of Cincinnati, by Daniel Drake. 1815. 1850.] Dr. Drake's New Work. 403 summer, without encountering a rigorous winter and a low annual heat ; nor a mild winter, without a hot summer, and high annual heat." (p. 491.) In the Table (p. 588) representing the average quantity of rain and snow per annum at 52 places, we find it to be At New Orleans, 51.204 inches. Mobile, 66.915 " Natchez, 60.120 St. Louis, - 39.670 " Huntsville, Ala. - . 54.878 " Nashville - 55.002 Cincinnati, - 35.332 * Rochester, N. Y. 34.920 " Toronto, 32.798 " The author, after dwelling upon the heterogeneous charac- ter of the population of the great valley, derived as it is from the various nations of Europe, from the Atlantic States of the Union, from the African and from the Aboriginal tribes, all of which are undergoing a regular process of amalgamation, ar- rives at the conclusion that we cannot as yet define any physio- logical peculiarities as characteristic of this vast region. He thinks it probable, however, that as the population assumes a fixed character, u Autumnal fever will decrease, and typhus and typhoid fevers become more prevalent ; gout will occur oftener than at present ; the diseases produced by the intem- perate use of ardent spirits will diminish ; consumption and scrofula will increase; apoplexy, palsy, and epilepsy will be- come more frequent ; diseases of the liver will become less, and those of the mucous membrane of the bowels, more prevalent ; and lastly, mental alienation will be more frequent." We regret that, from the statistical nature of the work, we cannot furnish even a summary of the facts so industriously and judiciously accumulated. We must therefore be content with recommending their attentive perusal to all who may wish to study the subject. The portion of the volume devoted to spe- cial diseases comprehends about 165 pages, in which we find treated Intermittent and Remittent fevers, each being subdi- vided into simple, inflammatory, and malignant. The remarks, 404 Dr. Drake's New Work. [July, upon their geographical limits and causes are exceedingly judi- cious and instructive, and, we think, conclusively demonstrate the futility of any attempt to discover a special morbific agent, instead of regarding (as we have done for many years) a varie- ty of circumstances connected with soil, temperature, moisture, electricity, animal and vegetable decomposition, the growth of forests and agricultural products, the evolution of animalculae and fungi, &c, as concurring in greater or less numbers in the causation of autumnal fevers. Yet the author concludes the subject by stating that, " Ignorant, however, of any definite, efficient cause for autumal fever, I am a full believer in its ex- istence, and shall speak of it as a specific agent, known only by its effects on the living body." The treatment recommended by Prof. Drake for " Simple Intermittent fever," is very much the same as that formerly in vogue on the atlantic slope. Whether or no this form of fever differs upon the eastern and western declivities of the Appala- chian heights, we are not able positively to determine, as we have not had an opportunity to make personal observations. Were we left, however, to form an opinion from the work be- fore us, we would acknowledge that we can perceive no differ- ence. We therefore feel confident that the vast improvements made in this section of the country in the treatment of, not only * Simple Intermittent," but also of every other form of Inter- mittent and Remittent fever, might be adopted with advantage in the great " Interior Valley." Those amongst us who have so long adopted the plan of never permitting the patient to have another paroxysm after seeing him, would feel restive under a system of "preparative treatment," consisting of " blood-let- ting," " emetics," and " cathartics." Desiring to do full justice to the author, we quote his own words. "Bloodletting. In the beginning of simple intermittents, we often find much vascular fullness, and during the hot stage, a considerable resistance in the pulse, with great heat, thirst, jactation, headache, backache, and pains in the perios- teum of the long bones. Such a concourse of symptoms, would seem to indicate a phlogistic diathesis ; but in reality they are the expression of a febrile condition only, and in a few hours will entirely cease, to be renewed the next day, or the next but one. Shall we admit that in this condition 1850.] Dr. Drake's New Work. 403 the lancet is demanded ? The answer, I think, should be, that whenever the constitution is vigorous, and the physician is called to an early paroxysm, bloodletting is not only safe, but will both mitigate the symptoms, and prepare the system of the patient for other remedies ; which, in many cases fail, or succeed but imperfectly, from the tone and fullness of the vascular system, (p. 743.) " My own experience, with that of many others, leads me to commend emetics in this form of fever. When the circum- stances already recognized as suggesting venesection exist, let it be first employed when they do not, an emetic may be the first remedy. A free and full evacuation of the stomach is followed by a decided improvement in its condition, by a ten- dency to sleep, and an abatement of the dryness of the skin, if not an actual perspiration. The emetic may be given during the hot stage, if the arterial system should not be plethoric ; or it may be administered in the intermission, or at the access of the chill, which it often shortens, and sometimes averts. In fact, when the disease has lasted for a while, a powerful vomit just before the shake, is one of the successful modes which the people adopt, for arresting the disease. It carries into the sys- tem a perturbation, in which the paroxysmal tendency is lost. As a preparatory remedy, an emetic empties the stomach of undigested food, and the acids resulting from indigestion or morbid secretion. Very commonly, however, instead of acids, a liberal quantity of regurgitated bile is thrown up, from the beginning, or at the close of the operation. Great comfort, and much abatement of all manifestations of disease, generally follow such an operation, and the stomach is prepared for the favorable action of other remedies. "Cathartics. In the commencement of simple intermittent fever, the bowels are generally sluggish, if not torpid, and charged with feculent matters and bile. A cathartic is, there- fore, indispensable, whether an emetic be first administered or not. Of this cathartic calomel should always be an ingredient, as a complete emulgence of the hepatic ducts, is a desideratum. The old-fashioned dose of ten grains of calomel with ten of jalap, with or without one grain of tartarized antimony, is equal to any other formula ; but calomel, in a dose of ten, fif- teen, or twenty grains may be given alone; and after its alterant action has been exerted on the liver, its cathartic effect may be quickened by an infusion of senna, with or with- out sulphate of magnesia. The best time for the operation to take place is in the decline of the hot stage. If that stage should be intense or prolonged, the bowels may not be obedient 406 Dr. Drake's New Work. - [July, to the impress of the medicine, when a liberal bleeding will bring on free and full purging. Jn some cases the liver is in a high state of functional excitement ; and there is an un- common development of the elements of the bile. Such a condition is indicated by yellowness of the eyes, a sallow complexion, and a tongue covered with a heavy yellowish fur, large quantities of bile being at the same time brought away by the operation of cathartic medicines. It is quite possible, how- ever to attach too much importance to the removal of these symptoms, and to be over anxious for a clear and healthy tongue before proceeding to other measures. In short, I can see no sufficient reason, for a continuance, through many days, of a treatment which, carried to any extent, will seldom arrest the disease. Indeed, I suppose it would be better to leave the patient to himself, than by the daily repetition of drastic evacuants, to reduce his strength, and irritate, if not inflame, the mucous membrane of his stomach and bowels; for, if brought into such a condition, he would not be prepared, but rendered unfit, for the treatment which is essentially remedial.*' (p. 744.) It is manifest from the following paragraph that the author is acquainted with our plan of treatment and pathological views : "Omission of Preparatory Treatment. At the outset it may be asked, whether the sulphate of quinine will cure inter- mittent fever without the preparatory treatment which has been recommended ? The answer must be that it will ; for in the south, it has of late, been frequently administered, as the first medicine, and found successful. This may seem incredi- ble to those, who, adhering rigorously to old ideas, regard evacuation, revulsion, and time, as curative; and the sulphate as a tonic, maintaining and carrying on what they had com- menced ; but those who see in that medicine, a power of es- tablishing in the system a peculiar action, incompatible with the febrile will have little difficulty in believing the report that it has often succeeded, without preparative treatment. Re- garding the morbid state of the secretions, as the effect and not the cause of the disease, they will consistently suppose, that the best corrective for that state must be the agent which can supersede the febrile action by one of its own. Nevertheless, I believe the preliminary treatment, which has been pointed out, generally advisable, and in many cases indispensable. This remark, however, applies chiefly to the early stages of the disease ; for in relapses, no treatment preparatory to the ad- ministration of the sulphate, is in general required." (p. 747.) 1850.] Dr. Drake's New Work. 407 Arsenious acid, although once famous in intermittents, has lost much of its celebrity since the introduction of Quinine. It is still however a valuable remedy, and may enable us very often to dispense with the use of the more costly interloper. The following formula is that recommended by Dr. Drake : " Ff . Arsenious acid, grs. j. Finely powdered opium, grs.iv. Mix intimately, and divide into sixteen pillls. Three or four of these pills, in the course of twenty-four hours, are as much as can be long borne. If the disease should not yield, by the time the stomach becomes irritable, with some degree of epigastric tenderness, or the face exhibits an incipient oedema, it is not advisable to continue the medicine any longer. Sixteen grains of sulphate of quine, added to this formula, will make it as effective in obstinate agues, as any other remedy with which I am acquainted." (p. 751.) We cannot refrain from re-producing a passage well calcu- lated to account for the popular tendency in favor of homoeopa- thy. We do not think that any practitioner in our section of country has ever used such rash medication ; but it cannot be denied that our people have taken, and still take much more physic of all kinds than can be necessary or useful. "The Purging Practice (in Remittent fevers). At all times, and with all our physicians (except those who adopted the opinions of Broussais,) purging, as we have seen, has been an important part of our methodus medendi ; but it required a peculiar hypothesis, to resolve the whole treatment into that operation. This was at length supplied, in congestion of the portal circle and the vena cava ascendens. The removal of this congestion constituted the sole indication of cure, and was to be accomplished, by increasing secretion from the liver, and the mucous membrane of the stomach and bowels. Those who adopted this hypothesis, as simple as the gastro-enteritis of the French school (but suggesting in the opinion of its ad- vocates, a totally different practice), built their hopes on drastic purging, and, consistently made calomel the governing article of their prescriptions. Thus the mercurial and cathartic treat- ment became united into one method, which in its application substituted, for the discriminating skill of the physician, the relentless punctuality of the apothecary and the nurse. Calo- mel, in doses which the world had not hitherto known, was given to excite the liver and mucous membrane into increased secretion, and drastics, in corresponding doses, to drain the 408 Dr. Drake's New Work. [July, bowels, as fast as those fluids were poured into them. The object was not to supersede the febrile action, by a mercurial irritation of the general system ; but to rouse the liver and gastro-enteric membrane into secretory excitement ; and thus transform the blood of the portal viscera into bile and liquor- intestinalis. To this end, scruple doses of calomel were regarded as sufficient for the mildest cases only; and drachm doses, at short intervals, became a familiar prescription, in or- dinary epidemics ; while, in those of greater violence, portions of half an ounce, an ounce, or an ounce and a half, were swal- lowed by the patient several times a day ; till in some instances, a pound, or a pound and a half, was administered to a single pa- tient, and gave to his excretions the appearance of chalk ! I am not at liberty to doubt the testimony collected in the south, on which I make this statement. In the State of Mississippi, a physician assured me, that he had given a patient, one thousand grains for three successive days ! As the purgative effects of calomel do not increase wTith the dose, and yet purging was an essential part of the cure, medicines better calculated to excite it, were either alternated or combined with the calomel ; and these were very commonly given in vast doses. A respecta- planter, in the same state, assured me, that he had given, by order of his physician, such quantities as I thought incredible ; till I met with a neighboring physician, who declared that he had administered, in a single case, six hundred grains of a triple compound of aloes, rhubarb, and calomel, in equal quanti- ties, for six consecutive days! Such instances, I am happy to think, embrace the extremest abuses of this method ; and the number who reached these criminal limits, was perhaps not very great. It cannot be denied, however, that the practice, here reprobated, was for several years, that on which numer- ous physicians of the west and south rested their hopes; and although in general they stopped short of the recklessness of a few, they carried their single idea to an excess, which at length produced a revulsion in the public mind ; and in numerous in- stances led to their being superseded by empiricsjwho declaimed equally against the judicious, and the headlong administration of calomel. Under this reaction, it became, at least, difficult to exhibit that medicine in any dose, and the blue pill is now often substituted, when calomel would be preferable."* (p. 785.) * Some years before the visits of which I have spoken, a physician of Louis- iana, flippantly andhyperbolically, wrote me, that in a certain epidemic, he had drawn " blood enough to float, and given calomel enough to freight, the steam- boat General Jackson !" During my first visit, another who had given it by the ounce, said his object was. to load dmen the irritable stomach, so as to prevent vomiting! "While multitudes believed, that when they did not obtain bilious discharges, by ounce doses, it was because they were too timid in the adminis* tration ! (p. 804.) 1850.] Southern Medical Reports. 409 In the treatment of the malignant forms of fever, our author is in advance of those who have preceded him in systematic treatises, although he does not insist sufficiently npon the jugu- lating method to meet our entire approbation. In conclusion, we cheerfully accord to Prof. Drake the credit of having furnished the profession with a work entirely original, containing a vast store of useful information, and written wifh a simplicity of style characteristic of good scholarship and cor- rect taste. The diction is chaste, to the point, and entirely devoid of that redundancy so common in the light literature of the day, and so much out of place in works of science. We earnestly hope that the learned author may soon be able to complete a work so successfully commenced. D. Southern Medical Reports ; consisting of general and special reports on the Medical Topograghy, Meteorology, and preva- lent diseases of the following States: Louisiana, Alabama, Georgia, Mississippi, South Carolina, Florida, Texas, Ar- kansas and Tennessee ; to be published annually. Edited by E. D. Fewer. M. D., of New Orleans, Visiting Physician to the Charity Hospital, &c., &c. Vol. 1. 1849. New Or- leans : B. M. Norman, 16 Camp-street ; New York : Samuel S. and William Wood, 261 Pearl-street. 1849. 1 vol. 8vo., pp. 448. We have been kindly furnished, by the Editor, with the sheets of this work, which is now passing through the press, and their perusal has afforded us much pleasure as well as pro- fit. The volume contains a large collection of facts bearing upon many subjects of great interest to the medical profession, and especially to those who practice in the South. The work, as its title imports, is made up of reports from physicians in several of the States upon the topography, diseases, &c., of their sections. We propose to bring some of these reports to the notice of our readers, premising that, from the character of such a work, it will be impossible for us to do more tban give a brief summary of some of its most important contents. A large portion of the volume (255 pages) is occupied bv reports from Louisiana. The first of these is on the Medical Topography and Meteorology of New Orleans, with an account 410 Southern Medical Reports. U^Y* of the prevalent diseases during the year 1849, by Dr. Fermer. We learn from this report that there are two rainy seasons in New Orleans, and the adjacent country ; one in summer, and the other in winter; and that the quantity of rain which falls in each season is about the same. The annual average of rain for the last ten years was 69.632. The mean annual tempera- ture during the same period was 70.6. There are some interesting remarks on the subject of accli- mation. The views of Dr. Fenner are embodied in the following extract: * 1. That persons coming from more northern latitudes to this, have to undergo an acclimation or seasoning, before they become secure in the enjoyment of good health. "2. That this acclimation may be attained without sickness ; but that, most generally, it requires the endurance of one or more spells of the customary endemic fevers. " 3. That an attack of the endemic yellow fever effects great- er security against subsequent attacks, than any form of fever seen in the country ; but that the remark is applicable, in some degree, to all of them, excepting the ordinary mild intermit- tents. "4. That persons may have yellow fever more than once, though it is evident that those who have had one plain attack, usually have little or nothing to dread from subsequent attacks. " 5. That Creoles, or natives of New Orleans., may have yellow fever though generally, they have it in very mild form." Cholera made its appearance in New Orleans in the latter part of the year 1848, but soon subsided. In the early part of 1849, the city was visited by a second epidemic of Cholera, which continued its ravages with more or less severity until July. During the first six months of the year, the deaths from Cholera were 2608, and of all other diseases 2794. In the month of May, the back part of the city was inundated by the Mississippi, and remained under water until the 18th of June, a period of about forty days. Many persons felt much alarm, lest the subsidence of the flood should be followed by a sickly season. The remainder of the year, however, was unusually healthy. This, we learn from Article Second, on the subject of the inundation in 1816, was the case during that year, as 1850.] Southern Medical Reports. 411 also after the inundations in 1785 and 1791. During the sum- mer it is true that a few cases of yellow fever occurred, but it is worthy of remark, that the deaths from this disease were almost exclusively confined to the cases in the Charity Hospi- tal, those occurring in private practice almost all recovering. Dr. F. attributes this fact to the mildness cf the disease which led the laboring class, who are usually ignorant or reckless, to neglect their cases, under the belief that the fever under which they labored was not of a serious character. During the lat- ter part of the year, diarrhea and dysenteries were somewhat prevalent. The dysenteries were easily relieved, if taken in time, by a combination of quinine, blue mass and morphine. Article Third is devoted to the Hydrography of the Missis- sippi river. It has been carefully prepared by Caleb G. Forshay, A. M., Civil Engineer, and is accompanied by a diagram exhib- iting the rise and fall of the river during the year 1849, and also its mean height for thirty years in groups of ten years. Article Fourth, is an elaborate report of the Board of Health of New Orleans, prepared by Dr. Barton. The first part is devoted to "the condition of the city as to health during the year 1849," and the remaining part to "the suggestion of such means as are advisable for improving the same." The report complains of the imperfection of the data in relation to fevers, and indeed all special diseases, yet it expresses a belief that fevers have diminished "in numbers, intensity and mortality,"' owing probably to the improvements which have been made, and particularly to draining in the rear of the city. The num- ber of deaths from Phthisis is remarkably small, especially if we take into account the number of consumptives from north- ern regions, who resort to New Orleans during the winter months, and die there. The proportion which the deaths from Consumption bore to the whole mortality for 1849, was only 9.37 per cent., whilst in Havanna it was 19.50, and in Charles- ton, 18.27. Exclusive of the deaths from Cholera, and causes other than disease, the mortality in New Orleans for 1849, amounted to 6314, being at the ratio of 1 in 16.67, the stationa- ry population being estimated at about 105,000. A very con- siderable portion of this heavy mortality was of course derived from the floating population, which is very large during a part 412 . Southern Medical Reports. [Juty> of the year, and is made up of persons not only unacclimated, but many of them of broken down constitutions, and given to various kinds of excess. That a large part of the mortality is thus derived, is proven by the fact that of the deaths by fevers, 870 were foreigners, and but 85 citizens of the United States. Notwithstanding that a part of the great annual mortality of New Orleans can thus be accounted for, it cannot be denied that until a great sanitary reform is effected, the chances of human life are much less in that city than in most other cities of the Union. Appended to this report are several mortuary and meteorological tables, which sustain the various positions of the writer. The fifth Article is "a special report on the fevers of New Orleans, particularly the Yellow fever of 1849, by Dr. Fenner. This is an interesting paper, though some of its positions will not be generally admitted : we allude more particularly to the writer's opinions on the nature of Yellow fever. He advocates the opinion that this disease is but a modification of the ordina- ry remittent and intermittent fevers of that locality. But we will let him speak for himself. He says, " Cases are seen every sickly year, commencing as intermittent or mild remittent, and wanting those strongly marked diagnostic symptoms which have been said to distinguish yellow fever ; yet which, if neg- lected or maltreated, terminate in hemorrhage and black vomit. In these cases, the advocates of the specific character of yellow fever contend that the patients contract a new and different dis* ease; but we think improperly. We believe it is all the same disease ; differing only in grade and stage." He further goes on to say, "A vast majority of cases in their mild forms, and the early stages of the more grave, are just such as are seen all over the southern country. The more malignant forms, and the advanced stages of the mild, have a decided tendency to terminate by hemorrhage. This makes what is called yellow fever, and is the main feature that distinguishes it from the endemic fevers of the country. Physicians may say what they please about being able to distinguish a case of yellow fever as soon as they examine it : we don't believe it possible, ac- cording to their ideas." We are not prepared to give our assent to these views. Our opportunities for observing inter- 1850.] Southern Medical Reports. 413 mittent and remittent fevers have been by no means inconsid- erable, and the frightful epidemic Yellow fever which ravaged our city in 1839, gave us ample opportunity to learn something of the character of the latter disease, and we feel no hesitation in expressing the firm conviction that these do differ in some- thing more than " grade and stage." And this we believe is the opinion generally entertained by those who have had op- portunities for clinical observation of these diseases. In our own section we sometimes meet with remittent or "bilious fevers," as fierce, and as rapidly fatal as yellow fever, but never presenting the peculiar features of this latter disease. In some sections of Georgia and South Carolina, the mortality from febrile diseases, among unacclimated individuals, will exceed that of New Orleans. In some localities, to sleep one night is almost certain death. Yet in such places we hear of no yel- low fever. Besides, it is known that second attacks from yellow fever are comparatively rare, indeed so rare that by many, persons who have once passed through the disease, are deemed almost as secure from its future visitations, as small-pox sub- jects are from a second attack of variola. This we know is not the fact in relation to our ordinary malarious fevers. An at- tack of intermittent fever renders an individual more liable to be re-attacked ; and remittents, though not so apt to be followed by a severe return, often attack the same individual frequently during a period of years, though usually in a mitigated form. But we are not disposed to discuss the question, and will leave it for those whose familiarity with yellow fever will enable them to speak more reliably upon this subject. It appears from this report that there were admitted into the Charity Hospital during the year 1849, 7575 cases of fever, of which number 4439 were intermittents; 10G0 yellow fever; 824 remittents ; 891 typhus ; and 130 " bilious/' The remain- der were cases af typhoid, continued, &c, &c. In the treat- ment of yellow fever, Dr. Fenner recommends the " abortive method by quinine." He states, that when called to a case within twenty-four to thirty-six hours after the attack, he sel- dom failed to cut short the disease by large doses of quinine in combination with opium or morphine, frequently followed by a little blue mass or calomel. He says : " Our usual mode of pro* 414 Southern Medical Reports. July, ceeding in this stage is, to order at first a hot, mustard foot-bath and a purgative enema then give to an adult 20 or 30 grains of quinine with 25 or 30 drops of laudanum, or 1 or 2 grains of opium, or the fourth of a grain of sulphate morphiae, at one dose. This would generally reduce the vascular and nervous excite- ment completely in the course of a few hours, throw the patient into a profuse perspiration, relieve all pain and produce sleep. The bowels were kept open by some gentle means, and more or less quinine was repeated as occasion required. We recol- lected but one fever patient that required cupping, and we did not have a single one bled from the arm." Dr. Fenner looks upon blood-letting as of great value in persons of a plethoric habit. He deems it applicable to that stage in which the quin- ine is so useful. Dr. Fenner's views of the treatment of yellow fever have found many advocates among them was the late Prof. Harrison. Article Sixth, contains statistics of Yellow fever, and of all diseases in the Charity Hospital of New Orleans, for thirty years, from 1820 to 1849, inclusive, prepared by J. C. Simonds, M. D. During this period, 130,000 patients have been admit- ted, of whom nearly 13,000 were laboring under yellow fever. From the manner in which the records have been kept, no very important conclusions can be drawn from them. Article Seventh, is a report on epidemic Cholera in the city of New Orleans, 1848-'49, by Dr. Fenner. It contains many facts in relation to the epidemic, but we do not find any which throw new light upon the subject. In relation to the conta- giousness of the disease, Dr. Fenner says, "although there are on record some well authenticated, and apparently indubitable instances in which cholera was conveyed and communicated from person to person, yet this is neither its only, nor its prin- cipal method of extension." Dr. Fenner defends the profession against the charge so often made by the unprofessional, and strengthened by the admission of some physicians, that medi- cal men "know nothing about cholera or its remedies." He very justly contends that we do know a great deal about both. He says : " There can be but little doubt that at least eight- tenths of the victims of cholera in New Orleans have died unne- cessarily ; i. e.} they have been lost on account of their neglect 1850.] Southern Medical Reports. 415 of the plainest dictates of prudence and common sense. Ought this to be charged to the discredit of the medical faculty? Or ought we to confess that so many people have died of cholera because we did not know how to treat the disease ? Certainly not. We do know how to treat it ; and as the best evidence of the fact, we have seldom failed to cure our patients, if called in before they are beyond the curable stage. We had as well be expected to raise the dead as to cure patients in articulo mortis. " A remarkable feature in the history of the year 1849, was the prevalence in New Orleans of an epidemic Colic after the subsidence of the cholera in the spring. The eighth Article is on this subject, and is from Dr. Fenner. This disease has gen- erally been seen every summer, and on one or two occasions prevailed to some extent. During the past year it prevailed during the months of July, August and September, chiefly amongst the laboring class of whites, but to some extent among the negroes. " The prominent symptoms of the complaint were a constant and severe griping pain in the abdomen, at- tended with but little tenderness and no fulness, eructations, vomiting of bile, and obstinate costiveness." Prof. Hunt and Dr. Stone look upon the disease as a neuralgic affection. The treatment generally consisted in the use of mercury, purgatives, anodynes, &c, &c, and was generally successful. Dr. Fen- ner saw one fatal case in the Charity Hospital, and was told of three others that occurred in private practice. We have neither time nor space to notice the remaining re- ports contained in the volume, further than to recite their titles, and thereby give our readers some idea of the character of the remaining part of the work. Article Ninth, is by James B. Duncan, M. D., on the Topography, Climate, and Diseases of the parish of St. Mary's, La. Article Tenth, by Wm. A. Booth M. D., on the Cholera of Lafourche Interior. Article Eleventh, is a report on the origin and sanitary condition of the Orphan Asylums of New Orleans and Lafayette, by J. Rhodes, M. D., O. Carey, M. D., and U. P. Sunderland, M. D. Article Twelfth, gives a number of interesting statistics of the New Orleans Charity Hospital. From Alabama, there are four reports : the first on the To- pography, Climate, and Diseases of Madison county, by J. Y. 41 G Southern Medical Reports. [July, Bassett, M. D., of Huntsville. This is quite an interesting arti- cle, written with considerable spirit and humor, and will doubt- less be appreciated by all who peruse it. Article Second, consists of contributions to the vital statistics of Mobile, by George A. Ketchum, M. D. Article Third, is an abstract of the proceedings of the Mobile Medical Society, which contains a number of interesting facts which have been brought to the notice of the society by its members. The last Article from Alabama is by T. A. Bates, M. D., on the prevailing diseases of a part of Dallas county, originally read before the Alabama State Medical Association in May, 1849. From Georgia, there are two reports one on the Topogra- phy, Climate, and Diseases of Middle Georgia, by E. M. Pen- dleton, M. D. This is a well written article which will repay the time spent in its perusal. A portion of it has heretofore appeared in the Southern Medical and Surgical Journal. The other Article is a case of Insanity, by J. C. C. Blackburn, M. D. From Mississippi, we have five reports : the first on the To- pography, Climate, and Diseases of Jackson, the Gapital of Mississippi, by S. C. Farrar, M. D. ; the second, on epidemic Cholera in the vicinity of Natchez, by C. H. Stone, M. D. ; the third, from C. S. Magoun, M. D., of Natchez, on epidemic Cho- lera and its preventive treatment ; the fourth, a case of Disar- ticulation and removal of one half of the inferior Maxilla for Osteo-sarcoma, by A. M. Clemens, M. D. ; and the fifth, on the Medicinal Waters of Mississippi the Artesian springs of Madi- son county. From Tennessee, there is a report on the commencement, prevalence, treatment, &c, of pestilential Cholera in Memphis and its vicinity; with the prominent facts bearing upon the unsettled question of its imported or domestic origin, by Lewis Shanks, M. D. From South Carolina, there is an Article by Thos. T. Simons, M. D., on the fever which is developed in the city of Charleston, after exposure to the country air during the summer and autumn, and known there as Country fever ; an Article on the Yellow fever of 1849, by the Editor of the Charleston Medical Journal, and extracted from that journal ;' and some cases in private practice, by W. F. Holmes, M. D. 1850-1 Identity of Erysipelas and Puerperal fever. 417 From Texas, there are two reports, both mainly devoted to the subject of Cholera, the one by J. J. B. Wright, M. D., Sur- geon U. S. A., and the other by N. S. Jarvis, M. D., of the U. S. A. We have now given our readers a brief and imperfect out- line of Dr. Fenner's work, but sufficient, we hope, to impress them favorably with its character. It is a new undertaking, and has cost the Editor much labor and expense, which we trust will not go unrewarded. We hope our readers will mani- fest their appreciation of Dr. Fenner's efforts in the cause of medical science by purchasing a copy of his work, and giving to it a careful perusal. By so doing, they will reap profit for themselves, and will enable him to prosecute his laudable un- dertaking with energy and success. Upon the patronage which the work receives its continuance depends. On the Identity of Erysipelas and a certain form of Puerperal Fever, and its Contagiousness. By Ezra P. Bennett, M.D., of Danbury, Conn. (American Journal of Med. Sciences.) On this subject there appears to be, at the present time, great diversity of opinion. Some maintain I think correctly that the two diseases are identical in their character, and that both under certain circumstances, are contagious ; and that the mor- bid principle of either may, under favorable circumstances, produce the other. Others contend that they are totally and essentially distinct, and incapable of producing and reproducing each other, under any possible conditions. In view of this divided state of the profession in regard to a disease of so much importance, I have thought it might be use- ful, or at least interesting, to send you for publication the histo- ry of eleven cases of puerperal disease, which occurred in my practice in the winter of 1847-8, extending into the summer months ; giving, at the same time, my own opinion in regard to its true nature, its identity with erysipelas, its communica- bility from one patient to another, by the accoucheur, and by other modes of propagation. In doing this, I am well aware that I am arraying myself in opposition to some of the profes- sion in this country, whose opinions, in consequence of age, experience, talents, and position, are entitled to the utmost re- spect and deference. But after all, facts are facts, no matter by whom observed. Facts make up all that is useful in medical n. s. VOL. VI. NO. VI. '27 418 Identity of Erysipelas and Puerperal fever. [July, science. We know, for instance, that it is a fact that cinchona will cure an ague and mercury syphilis, yet no theorizing could ever have arrived at these facts, and no theorizing can make them any thing less than facts. In the fall of J 847 and 1848, a disease of a new character made its appearance among us. It appeared to break out simultaneously in both parishes of the town, viz., Danbury pro- per and Bethel, which proved to be an epidemic erysipelas of a wide-spread and fatal character: Previous to this time, cases of ordinary erysipelas had become much more than usually prevalent, so much so that, from being a very rare, it had be- come a very common complaint. Many of the cases were severe, but none were fatal. In November, it assumed an epidemic character, of a malignant grade. This form of the disease has been well described by my nephew, Dr. H. N. Ben- nett, of Bethel, in the New York Journal of Medicine. A very accurate account of it has also been given by Dr. Charles Hall, of Burlington, Vt., and Dr. George Dexter, of Lancaster, N. H., in the American Journal of the Medical Sciences for January, 1844. The disease, as it occurred here, was, with a very few and slight exceptions, a fac simile of the complaint as it occur- red in the above-mentioned places. My object in this paper is to prove the connection and iden- tity of this disease with a peculiar form of puerperal inflamma- tion, which commenced in January, 1848, when the erysipelas was at its height, and which went hand in hand with it during its stay in this place. I think I shall be able to prove that the two diseases are not mere coincidences, but that they were identically and specifically the same ; differing only in their location and the peculiarities of the child-bed state. In the first place, I became perfectly satisfied, during the prevalence of this epidemic, both by observation during the life of the patient, and by post-mortem examinations, that erysipelas is not exclu- sively a dermoid disease. The evidence was indubitable, that not only the skin, but the mucous membranes, cellular tissue (primarily, and not by extension), and the serous tissues of the pleura and peritoneum, were the seat of this disease. The very first case of this affection to which I was called, was an erysipelatous inflammation of the pleura. It commenced (as I was informed by the friends) with sore throat, which was treated for a few days by a Thompsonian. When I saw the patient, she had a train of symptoms which were of an entirely different character from any thing I had ever seen in a practice of over twenty years. She had no pain in the side, or catching in respiration, but her breathing was excessively hurried, as was, of course, the circulation; her face was cadaverous; look 1850.] Identity of Erysipelas and Puerperal fever. 419 anxious ; said she was in no pain, but was very tired ; no rale ; chest sounded clear ; she died within twenty-four hours ; and left rne perplexed in regard to the true nature of her case. Two or three days after this, I was called to see a precisely similar case of disease, in a patient of my nephew, in Bethel. This case was a fac simile of the other in symptoms, and ter- minated fatally in about three days; when a post-mortem examination revealed a case of erysipelatous pleuritis, of a most unmistakable character. The whole pleura costalis and pulmo- nalis of both sides was affected with a diffuse inflammation ; on one side there was an effusion of a sero-purulent character, with some few albuminous flocculi, on the other there was scarcely any effusion, but some very slight adhesions. The parenchy- matous texture of the lungs, together with their lining mem- brane, was free from disease. Now this was not an ordinary case of pleuritis ; there was not the pulse of pleuritis ; there was no pain in the side in fact, there was no pain anywhere ; her only complaint was of being tired; the effusion was not sufficient to cause death, and that effusion was not of a sero-albuminous character, as is the case in pleuritis. Death was produced by excessive irritation of the nervous system. Again, in many cases this disease commenced in, and was in a great measure confined to, the cellular tissue (the skin suffer- ing but slightly and secondarily), producing diffuse cellular inflammation of a most virulent and extensive character; in one instance, affecting the whole trunk from the pelvis to the chin. This was the case of a young physician, of much prom- ise, and terminated fatally, of course. In another case, that of a robust mechanic, the whole cellular tissue of the thigh was affected, which terminated in gangrene and death. In a small boy, the cellular tissue of the thigh also was affected, without the skin participating in the affection in the least. He was treated with poultices ; translation to the brain took place, and he died of meningitis. Jn some cases, again, the disease attack- ed the stomach and bowels, producing gastritis or peritonitis ; and, in many cases, it attacked the womb and its peritoneal covering, producing metritis and puerperal peritonitis. I am aware that this view of the disease is directly opposed to that of Dr. jViiigs and others. Dr. Meigs says that it is as impossi- ble for a woman to have erysipelatous inflammation of the peri- toneum, as to have iritis in the pylorus; a very strange remark, by the way, and one the force of which I am totally unable to perceive. So far as my experience goes, the same kinds of inflammation may occur in tissues wholly different, and that it is the effects 420 Identity of Erysipelas and Puerperal fever. [July, of the inflammation, which are so much modified by difference of structure. Now inflammation may take place in the iris or in the pylorus, and that inflammation may be of the ordinary or diffuse character ; and this is all I contend for in the present case. A woman may have inflammation of the skin, of the cellular tissue, of the mucous membrane, of the pleura, or of the peritoneum, and that inflammation maybe ordinary healthy inflammation, the disposition of which is to limit itself by con- densation of surrounding cellular tissue, and by its disposition to form pus in cellular textures, or in the serous tissues, by an effusion of sero-albuminous fluid with a tendency to adhesion ; or it may be of an unhealthy inflammation of a diffuse charac- ter, with a disposition to spread and disorganize, according to the cause which produced it, or the state of constitution and general health of the patient in whom the disease occurs. Dr. M. admits the cellular tissue may become the seat of erysipelas. Now, if this is so, then why may not the serous tissues, as the one is but a modification and condensation of the other? One thing certainly must be admitted, and that is this, that erysipe- las is not a local, but a general disease, produced by a morbid state of the fluids, and that these diseased fluid's may produce this peculiar form of puerperal inflammation when brought in contact with an absorbing surface of a female recently deliver- ed. Very many cases of a reliable character are on record, where practitioners have communicated the disease to puerpe- ral females, after dressing erysipelas ulcers, when due attention has not been paid to cleanliness. Now is it not a general rule that, when vitiated animal fluids are capable of producing dis- ease in a healthy person, I say is it not a fact that the disease produced is of a similar character to the one which produced it? Most certainly it is: there may be slight modifications, but the general characters of the disease remain the same. Variola never produces rubeola, nor syphilis variola ; but like produces like. Now is it at all probable that the disease in question is an exception to this general rule ? Is it to be sup- posed that inoculation of a puerperal patient with the morbid matter of erysipelas, should produce any thing but erysipelas? Certainly not. Again, it is a well established and acknowledged fact that, when any malignant disease is prevailing epidemically in a cer- tain portion of country, all the diseases of that district are more or less modified by and assimilated to the prevailing epidemic. Now, if this is so (and I trust there are very few who will deny it), what effect would an epidemic erysipelas be likely to pro- duce on an inflammation of the peritoneum in a. child-bed wo- man"? Would it not so modify it as to produce an erysipelatous 1850.] Identity of Erysipelas and Puerperal fever. 421 instead of an ordinary inflammation? This certainly cannot be denied. Thus it is that the same miasmatic state of atmos- phere may produce erysipelas of the skin in one, of the cellular tissue in another, of the mucous membrane in another, of the pleura in another, and, most of all, would it be likely to pro- duce metritis or peritonitis in a woman recently delivered, as her situation would be such as particularly to invite the disease to locate in that region. When erysipelas prevails in hospitals, wounded patients, from accidents or operations, are always sure to be attacked with it. Xow a woman just delivered is in a similar condition to a wounded man, in more respects than one. She may have lost an undue quantity of blood, which renders the system- peculiarly liable to this kind of disease ; besides, that portion of the wornb from which the placenta has been separated, is not in a very dissimilar condition from that of a wounded person from other causes. I do not pretend to say that it is exactly similar, but there certainly is something analo- gous in the two conditions. If the disease attacks the mucous membrane of the uterus, and spreads from thence to the perito- neum, it proves just as conclusively that the peritoneum is sus- ceptible to this kind of disease as if it had originally commenced there. All I want to prove is that the peritoneum may take on erysipelatous inflammation, of which fact I myself have not the least doubt. When this is once fairly established, the con- troversy in regard to the identity of the two diseases is at an end, and the point established that they are identically one and the same disease. Again, if it can be proved that the mucous membrane of the uterus may be, and sometimes is, the seat of erysipelas (a fact which I believe is conceded by Dr. Meigs himself), then what objection in saying that a certain form of puerperal fever is identical with erysipelas ? yea, more, that it is erysipelas itself? In most of the cases which occurred here, the disease evidently commenced in the uterus, and sometimes confined its ravages entirely to that organ ; in other cases, it evidently extended to the peritoneum in a gradual and progressive manner: its progress could be traced as easily up the peritoneum as it could be traced upon the external surface. Another powerful reason for considering this affection as erysipelatous, is the fact that many of the children born of these women died within a few days with erysipelas of the scalp. Now if these females did not die with erysipelas, how happens it that so many of their children should happen to be attacked, whilst no other infant born at the same time suffered? To say the least of it, it is a remarkable coincidence. Remote Cause. The remote cause of this complaint was 422 Identity of Erysipelas and Puerperal fever. [July* undoubtedly a vitiated, miasmatic state of atmosphere. What the peculiar poison contained in the atmosphere at this time was, no one can say with any degree of certainty. It was pro- bably of such a character as to produce a defibrinating effect upon the blood to a certain degree, but its greatest influence was exerted upon the brain and nervous system, prostrating the vital energies and preventing healthy reaction. Predisposing Causes. There seemed to be but one predis- posing cause, and that was a want of stamina in the constitution. It was confined almost exclusively to the anemic ; so much so was this the case, that I could generally predict with certainty who would be attacked and who would not. Not one healthy, red-faced woman was attacked. If my patient was florid in the face, and did not flood, I usually felt that she was secure ; if, on the contrary, she was pale and weak, or flooded much, my apprehensions were always excited. Exciting Causes. These were the peculiar condition of the system induced by labour, exposure to cold, and the abuse of stimulating drinks, and, in some cases, excessive purgation. Prevention. There are only two modes of prevention ; one is to give the patient, before parturition, such a hygienic and therapeutic course as to improve her general health to such a degree as to enable her to resist the poisonous influence of the disease. She should take regularly as much exercise in the open air as she can possibly bear without fatigue ; her diet should consist principally of bread and lean meat, with oysters, eggs, &c, and with her meals she should take moderately of good, sound porter, or good wTine ; her bowels should be moved, if costive, by enemata of moderately cool water, to which, if necessary, a little salt may be added. Purgatives should be sedulously avoided. The body should be sponged daily with water, not cold or warm, but of such a temperature as to feel slightly cool, after which it should be well rubbed with a coarse towel. In regard to medicines, I should place the most reliance upon some of the acidulated preparations of iron and cinchona ; they should be used for at least two months, if possible, before delivery, and continued after delivery until the danger is past. The only sure preventive, however, is removal from the infect- ed district; this I believe will never fail; every woman who went abroad to be confined did well. To write out the history of the eleven cases in detail, would extend this communication too far ; I shall therefore give a brief synopsis of the symptoms, treatment, peculiarities, ter- minations, &c, from which as correct deductions can be drawn as from a detail of each case separately. Of the eleven cases attacked, ten died ; nine were attacked in just about forty-eight 1850.] Identity of "Erysipelas and Puerperal fever. 423 hours after delivery ; two were attacked in twenty-four hours after delivery. The disease commenced invariably with a chill, which was usually slight ; there was pain in the head and hack, and, in ahout half the cases, pain also in the bowels ; but this was not constant, and, except in two cases, was slight. The most that they complained of was a sense of weariness; they were very tired, was the usual reply, I feel quite comfortable if I was not so tired. In the commencement, in every case, the uterus could be felt just above the pubis a little enlarged and tender, but this tenderness did not extend beyond the uterus. The belly was soft and flaccid ; the milk was usually suppressed, but not always the lochia, but its character was changed to a dirty sanies. By degrees, in some cases, the bowels became gradu- ally distended and resonant, but not to that degree that we ob- serve in ordinary peritonitis ; they wrere not hard and rigid, but had a soft and doughy feel ; but in the majority of the cases the bowels were not distended during any part of the disease, but remained soft and flaccid to the last. Immediately after the chill, the pulse rose rapidly up to 160, which was its maxi- mum ; it was weak and easily compressed. The tongue was covered with a thin, white coat ; the urine scanty and high colored ; skin cool, preternaturally moist and sticky ; counten- ance leaden, look anxious ; slight disposition to diarrhoea, so that purgatives operated quickly, powerfully, and, in most cases, injuriously prostrating the powers of the patient without at all relieving the disease. The intellect could hardly be said to be clear, although there was no delirium, except in the last stage of the disease ; yet there was this peculiar hebetude of mind and peculiar indifference to their condition, which we often see in fatal disease of the bowels. In only two cases did the patients seem to be fully aware of their real condition; they did not generally consider themselves as very sick, or that there was danger of death ; towards the close'ofthe disease the mind usually wandered. Two cases only terminated in gangrene ; the rest died from the exhausting effects of the disease, or the poison of the disease acting on the nervous system. In regard to treatment various plans were adopted. The first cases which occurred, were treated with calomel and opium, fomentations and blisters to abdomen, with saline diaphoretics and mercurial inunctions, with a view, if possible, to produce a very gentle mercurializa- tion ; then, as the cases continued to prove fatal, other remedies were given either separately or conjointly, as spirits of turpen- tine, externally and internally, camphor, serpentaria, nitre, quinine, ammonia, &c. Toward the close of the epidemic, I 424 Identity of Erysipelas and Puerperal fever. [July, bled three ; the loss of blood was soon followed by symptoms of syncope, so that in neither case was there taken more than eight ounces of blood, and this was not repeated ; the blood was buffy and cupped. I bled at the very outset of the disease, as soon as the chill was felt ; one of these cases recovered, one lived about two weeks, and at one time her pulse fell to 110 ; she had had mercurial injection rubbed into the abdomen and thighs, and was slightly mercurialized. This produced, in my opinion, the mitigation of the symptoms as they occurred simul- taneously, but a change for the worse soon took place and she died. In one case (the last case which occurred), the bleeding did not appear to have any effect. In the patient which recov- ered, in addition to the bleeding, I put her upon full doses of opium and digitalis, and blistered the abdomen; purgatives were invariably hurtful. Moving the bowels by injections, was productive of the most benefit. The time of death varied in different cases, from twenty-two hours to fourteen days; mean duration of the disease was about five days ; those who were bled survived the longest. Can this disease be communicated from one person to another by the practitioner ? This is a very important question, a correct answer to which would be exceedingly desirable, as it affects seriously both practitioner and patient. That it can be conveyed from one patient to another, is probably correct, where due attention to cleanliness is not observed ; but if ordinary attention be paid to person and clothes, I do not believe it will ever be thus pro- pagated. In this epidemic, I am quite sure that it was not thus caused in a single instance ; for had it been so caused, it would not have attacked one and then passed over five or six to ano- ther ; but it would have attacked in succession, all the females where I attended, wrhich was by no means the case. Only one out of five were sufferers from it. Moreover, in three or four of the cases, before attending them, I washed my whole person with soap and water, then with a solution of chloride of lime, and then with alcohol, changing every article of dress, and putting on clothes which were entirely clean. Yet, notwith- standing this precaution, they were attacked and died. I did this in the last case that occurred ; I then was satisfied that the disease was not propagated by the hands or clothes of the phy- sician ; and I went from her dying bed and attended two ladies, without using any precaution, and they both escaped. My nephew in Bethel had three or four scattered cases ; he took no precaution, but had no more cases. The next question is, can the practitioner convey it in his own system, and communicate it by his breath, or by his cuta- 1850.] Puerperal Convulsions. 425 neous transpiration? This question I will not attempt to an- swer. I was constantly in the erysipelas from its beginning, was very much fatigued and worn down by constant riding and attendance on the sick, and in May, I had an attack of erysipelas of the face, which confined me for two weeks and over. Now about half of these cases occurred before I was taken with the disease and about half after I recovered and resumed my professional labours. Every case of this disease occurred in my practice ; however, it must be born in mind that, at the time of its commencement, I was doing nearly all of the obstetrical practice of the town, being the oldest and only married physician in the place. Pueperal Convulsions succsssfully treated by Chloroform. By John Senior Turner, Esq., M.R.C.S., Mansfield. (London Lancet.) I was called, about eight P. M., on the 25th of September last, to attend Elizabeth F , aged twenty -two, who was in labour of her first child. I found everything natural, and a living child was born about half-past nine, the placenta follow- ing in a few minutes. Having left an anodyne draught, with orders for its being given when- the patient was in bed, I re- turned home. At three A. M. of the 26th, I was summoned in great haste to the patient, whom I found labouring under puerperal con- vulsions. She having already had three fits, I immediately pro- posed bleeding. As the friends strongly opposed this step, I reluctantly consented to defer it for a short time, and mustard plasters were applied to the legs and feet; but another fit supervening, I determined to wait no longer, and I bled the patient to twenty ounces, without any alleviation of the attacks, either in intensity or duration. She continued insensible be- tween the fits. I then ordered a turpentine injection ; the head to be shaved, and cold applied to it ; and a mixture con- taining sulphuric ether, ticture of cardamom, and camphor julep, to be taken every hour. I also gave two* drops ofcroton oil, which operated freely in about an hour. The pupils were generally dilated, and the retina showed very slight sensibility ; the eyelids were half-closed ; the breathing was stertorous, ex- cept just previously to the accession of a fit. Matters con- tinued in this way the fits coming on about every fifteen or twenty minutes till twelve o'clock, when a consultation was proposed. I felt a strong desire to administer chloroform, from having 426 Puerperal Convulsions. [July, read of its good effects in some cases of tetanus and hydro- phobia, and believing that there was some analogy between the cases: but feeling the responsibility of trying so powerful an agent without a second opinion, my friend Mr. Cooper was sent for. He not being at home, I waited until half-past two o'clock, but the attacks continuing with the same frequency, and each successive fit leaving the patient in a more profoundly comatose state, I resolved on applying the chloroform. A few minutes before the usual time for the accession of a fit, I put her under the influence of this agent, and repeated its application when any restlessness (which always preceded a fit) was apparent. No fits recurred after the application, till after three o'clock, when the period for three attacks having elapsed, I resolved to discontinue the remedy, and await the result. At a quarter past three a fit again came on. I then resumed the use of the chloroform, with the same results as be- fore. On one occasion, the patient not having been brought under its influence with sufficient promptitude, a slight convul- sive movement of the right hand was visible, but of no other part of the body. Mr. Cooper arrived about half-past four, and coincided with me in the propriety of continuing the treatment. Another fit, as violent as before, and attended witb episthotonos, occurred just at this juncture, I having again omitted the use of the remedy. The next fit came on at half-past six, our chloro- form being exhausted, and a fresh supply not arriving in time. About this time a full dose (seventy drops) of laudanum was given. The cloroform was again assiduously applied as before, till half-past eight, when, not expecting any return, and having neglected to watch the premonitory symptoms, another fit occurred, and I am happy to say, that from that time there was no recurrence of the fits. I left the house soon after, but visit- ed the patient again about eleven, when I found her in a com- fortable sleep, and perspiring freely. Sept. 27th. At our visit this morning we found conscious- ness had partially returned. The patient had passed a quiet night, without any convulsions. She was sufficiently sensible to put out her tongue when requested to do so. She continu- ed to improve during the day, and convalescence was gradual and uninterrupted. She is at this time in good health. The only subject of complaint afterwards was some pain in the head, which was relieved by anodyne medicine. The lochial discharge had continued unaffected from the first. I think it is evident, that in the above well-marked case of puerperal convulsions, the administration of chloroform had a powerful effect in controlling and postponing the fits, and I also think that its influence was manifestly beneficial in conducting 1850,] Remarks on Vermifuges. 427 to a favourable termination one of the most formidable diseases with which we have to contend. Doubtless the bleeding, and probably the full dose of opium, were of service, but neither had so obvious a good effect in arresting the convulsions as the chloroform, which succeeded in the direct ratio of its digilent employment. Remarks on Vermifuges. By M. Cazin. (Dublin Journal, from Jour, de Med. et de Chir.) Dr. Cazin, of Boulogne-sur-Mer, having had the opportunity of treating a large number of worm cases, has published the following interesting account of his experience. He states that he has frequently employed the common Spigelia or worm- grass. He administers it in the form of decoction, prepared by boiling two drachms of the herb in a quart of water to one half. The decoction is then expressed, strained, and flavored with a little lemon-juice and a sufficient quantity of sugar. The dose for an adult is two wine-glassfuls, followed by a wine-glassful every six hours until the desired effect is produced. To chil- dren and delicate persons a smaller quantity is to be given. Wormwood (Absinthium) is an excellent indigenous anthel- mintic; it is also a powerful tonic and stimulant, the use of which, continued after the expulsion of the worms, prevents their reproduction. M. Cazin often uses a wine prepared by digesting an ounce of wormwood, with an equal quantity of garlic, in a bottle of white wine, of which he gives from one to three ounces every morning. This wine is well adapted for poor lymphatic subjects, wasted by wretchedness, and suffering from the influence of a marshy soil. The Absinthium mariti- mum is likewise a very good anthelmintic. M. Cazin gives it to the extent of one or two drachms boiled in four or five ounces of water, with the addition of some white sugar, or of any an- thelmintic syrup. This is quite a popular remedy in the mari- time districts, and almost always succeeds with children affected with worms. Although a case of poisoning by Cevadilla has been reported, M. Cazin has administered this vermifuge with success in cases in which ordinary anthelmintics had but little effect; but he has always commenced with a very small dose, in order to ascertain how far it would be borne by the digestive organs. For children the dose of this plant is from a grain and a half to four or five grains of the powder of the seeds, mixed with syrup of rhubarb; for adults eight or nine grains, with the addition of a little sugar and a few drops of oil of fennel. In each case the 428 Remarks on Vermifuges. [July, dose is to be repeated daily for four days, after which the infu- sion of chamomile is to be given. Assafcetida possesses acknowledged anthelmintic properties, and is suitable for cases of sympathetic nervous affections pro- duced by the existence of worms. It thus, like valerian, fulfils a twofold indication. In a case of nervous affection, which M. Cazin believed to be idiopathic, the administration of assafcetida both determined the disease and revealed its true cause, by effecting the expulsion of a number of lumbrici. This result has, in three cases of chorea and in two of epilepsy, enabled him to recognise that sympathetic irritation, depending on the presence of intestinal worms, was the sole cause of disease in these in- stances. Under ordinary circumstances M. Cazin frequently combines assafcetida with calomel in pills. This combination, of all those that he has employed, succeeds best in expelling lumbrici. He has also combined it with black oxide of iron, particularly in anemic patients. Assafcetida may be given in powder, in doses of from four grains to half a drachm. The essential oil of turpentine is jiot merely useful in cases of taenia, it is also decidedly efficacious in expelling the lum- brici. M. Cazin has sometimes, in cases of lumbrici and ascarides, administered with advantage turpentine enemata, prepared by suspending, by means of yolk of egg, from one drachm to half an ounce of the oil in decoction of tansy, absin- thium worm-seed, (semen-contra), or Corsican moss. Common salt is very destructive to worms ; it is given alone in large doses dissolved in water ; it should be taken on an empty stomach. M. Cazin also frequently administers it in the form of enema, with brown sugar, linseed or poppy oil, and a sufficient quantity of water. With children it almost always succeeds. Like all tonics, iron has the advantage of destroying worms, at the same time that, by imparting tone to the intestines, it prevents their reproduction. From six to eight grains of iron filings, mixed with an equal quantity of rhubarb, and taken twice or three times a day, have often been sufficient to expel the worms contained in the intestines. M. Cazin succeeded in rapidly curing a boy nine years of age, emaciated and pale, whose sleep was disturbed, and who was suffering from spas- modic movements similar to those which characterize chorea, by the exhibition of pills of sulphate of iron, combined, accord- ing to Fuller's formula, with aloes, senna, &c, under which treatment he voided twenty-three lumbrici in four days. He has also used with remarkable success Bosen's mixture, con- taining extract of black hellebore and sulphate of iron. But what he chiefly gives to children, as well as to adults, is the 1850.] Remarks on Vermifuges. 429 syrup of citrate of iron (four parts of citrate to sixty of simple syrup, and one of essence of lemon), in doses of from two drachms to half an ounce to children, and from half an ounce to two ounces to adults. M. Cazin remarks that calomel, so efficacious as an anthel- mintic, ought never to be combined with an alkaline chloride, as the formation of corrosive sublimate would probably ensue from their admixture. In like manner, the combination of calomel with cherry-laurel water, or emulsion of bitter almonds, would give rise to the development of two formidable poisons, corrosive sublimate and cyanide of mercury. The effects of the male fern, tin, pomegranate bark, hellebore, &c, require merely to be noticed ; and the properties of the pomegranate root bark are so well known that they need not be dwelt upon. M. Cazin has remarked nothing particular re- specting other anthelmintics. He merely says that cod-liver oil has succeeded with him in the cases of two females, one of whom passed twelve lumbrici the same day that she had taken in the morning three table-spoonfuls at intervals of an hour. But, whatever be the medicine selected, we must not, like routine practitioners, be content, when the worms are killed and dislodged, with this merely palliative cure. A very im- portant indication remains to be fulfilled, viz., to prevent their reproduction. This object is attained, according to M. Cazin, by the adoption of a tonic and stimulant regimen, which must be long continued, and, above all, by the employment of bitter and chalybeate preparations. He has found the ferruginous chocolate to be sufficient, in the case of children, to prevent the relapses which are for many years very apt to occur. Wine taken while fasting has succeeded with the poor inhabit- ants of the marshes, accustomed to live only on vegetables and milk ; and he has also remarked its efficacy as a preventive of worn affections in other instances. To these observations of M. Cazin, the editor of the Journal de Medicine has appended the following practical remarks. The number of experiments tried by M. Cazin leaves no room for doubt respecting the enormous amount of worm affections which he must have met with. Such a result may appear strange to Parisian physicians, who attribute to the presence of worms in the intestines only a very trifling influence over the symptoms formerly ascribed to them. But if worm affec- tions are rare among the inhabitants of large towns, the\ are frequent and generally more serious among the peasantry, and particularly among those who are poor and placed in unfavora- ble hygienic circumstances. We shall, therefore, take the present opportunity of mentioning the efficacy of brown sunto- 430 Remarks on Vermifuges. [July, nine, lately brought under the notice of the readers of the Bulletin de Therapeutique, by M. Gaffard, an apothecary at Au- r iliac. The difficulty experienced in procuring pure santonine, both on account of its high price, and for other reasons, has induced M. Gaffard to endeavor to obtain from worm-seed, a product which may possess the advantages of the former, and at the same time be free from the objections to the use of the latter. This product he calls brown or impure santonine ; it is obtain- ed in the following manner :. Take of Aleppo worm-seed, three ounces ; carbonate of pot- ash, one ounce ; slacked lime, sifted, half an ounce ; water, from three pints to three pints and a half. Place the mixture on the fire, stirring occasionally with a wooden spatula; let it boil for an hour ; on removing it from the fire pass it with expression through a linen cloth, let it settle, decant, and add hydrochloric or nitric acid until it reddens litmus without being sensibly acid to the tongue. Allow it to rest, pass it through a filter previous- ly moistened, or through apiece of close canvass, and allow the product which remains on the filter to dry in the open air until it acquires the consistence of firm butter. This product, which is a mixture of santonine, resin, and essential oil, will answer for the various pharmaceutic forms in which the practitioner may wish to exhibit it. M. Gaffard gives it in the form of loz- enges composed as follows: Brown santonine, three drachms ; powdered sugar, thirteen ounces ; powdered gum, one ounce and a half, essential oil of lemon, twenty-five drops. Place the brown santonine in a mar- ble mortar ; add by degrees, and with constant trituration, the sugar mixed wTith the essential oil and the gum, so as to make a homogeneous powder. Form with a sufficient quantity of water a mass of the desired consistence, and divide it into loz- enges, each of which shall weigh, when dried, fifteen grains; each lozenge will then contain somewhat more than one-third of a grain of brown santonine. For infants under six months the dose will be one lozenge night and morning; from six months to a year, two lozenges night and morning ; from one to two years, three, and from two to four years, four night and morning ; for children of five years and upwards a lozenge for each year of the child's age should be given night and morning. The medicine to be continued until the desired effects are no longer produced. A remedy for tape-worm, which has been for some time em- ployed in France under the name of kousso, has been recently tried in King's College Hospital, London, with marked success. It is an infusion of the dried flowers of Bravera anthelmintics, 1850.] Urethral Hemorrhage. 431 a native of Abyssinia, in which country it is a popular remedy for this worm, which is very prevalent amongst the inhabitants. A single dose, which is prepared by macerating for a quarter of an hour half an ounce of the dried flowers powdered in half a pint of hike-warm water, is taken at a draught, the suspended powder being all swallowed. Lemon juice may be taken be- fore and after the dose. It usually brings away the worm in an hour or two after it has been taken. Those who have tried this remedy state that it is equally safe as effectual; and the only objection to its employment is its high price at present. Clinical Observations on the Treatment of Urethral Hemor- rhage. By James S. Hughes, M. D., F. R. C. S. I., Surgeon to Jervais-street Hospital. (Dublin Journal.) There is, perhaps, no form of hemorrhage, which, when profuse, causes more alarm to the patient, or proves more trou- blesome to the surgeon, than that arising from the urethra, especially if it resist the ordinary modes of treatment; and as great difficulty is at times experienced in arresting the bleeding, when it springs from a part of the urethra beyond the influence of pressure, we cannot be too well prepared to meet such cases by prompt and effectual treatment. The causes of hemorrhage from the urethra are very numer- ous ; amongst the most, frequent, however, may be mentioned those arising from the acute stage of gonorrhoea, rupture of the urethra from falls on the perineum, and the improper use of instruments. When the hemorrhage does not arise from any distinct accidental cause, it may be difficult to find out from whence it proceeds; but experience tells us that, under these circumstances it is occasionally the consequence of malignant disease of either the kidney or bladder. Of all the sources of obstinate bleeding from the urethra, the most fruitful, perhaps, is that caused by the rough handling of the catheter, either by the patient himself or by an inexperi- enced practitioner, in cases of diseased prostate gland ; examples of which most surgeons have met with, and which, unfortunate- ly, often tend to shorten life. But the most alarming form of urethral hemorrhage I ever saw, occurred lately in the person of a man who presented himself at Jervis-street Hospital, caused by the giving way of some vessels in the urethra during the venereal orgasm. As it is a rare and complicated case, I shall give it in detail. - Mullens, a3t. .35, a very delicate looking man, a hatter by trade, presented himself at the Dispensary of the Hospital 432 Urethral Hemorrhage. [July, on May 8th, 1849. The patient was perfectly anemic in ap- pearance, being quite blanched in the face ; his pulse was rapid and feeble, and the extremilies were cold. He stated that at 4 o'clock on that morning, immediately after sexual intercourse, he felt the lower part of his night-dress quite wet, and that on inspection he observed a stream of florid blood flowing from the urethra. He left his bed, and, having dressed himself, attempted to stop the bleeding with cloths wrung out of cold water, but without effect, the blood continuing to pour out until his arrival at the Hospital at nine o'clock, A. M. On examination, I found his shirt and several folds of rags saturated with blood ; I then removed some clots of blood from the penis, when a stream of florid blood poured out from the orifice of the urethra. The fraenum exhibited no appearance of injury, and there was no- thing external to account for the hemorrhage ; there was neither fulness nor pain on pressure along the penis, or in the perineum ; and the patient had passed water three or four times since the accident. On questioning him he stated that he had been married for the last eight years, but that previously to his marriage he had suffered several times from gonorrhoea, and that he had been labouring under a frequency of calls, and difficulty in expelling his urine, for about ten years, for which he had not consulted any surgeon. A middle-sized catheter was now passed four inches and a half into the urethra, where it met with an obstruction ; a smaller- sized gum-elastic catheter was then, with some difficulty, passed through a long cartilaginous stricture, a distance about seven inches, when it was suddenly arrested in its course. Other instruments were then cautiously tried, and as they appar- ently took the direction of a breach in the canal, as the patient had passed water seveial times since the accident, and as there was no evidence of extravasation, it was not deemed advisable by Dr. Power (my colleague on duty) or myself to have re- course to violence in attempting to introduce an instrument into the bladder. A full-sized catheter was then passed down to the obstruction, the patient was put to bed, and proper pres- sure was applied to both the perineum and penis ; but although the pressure was assiduously kept up for a considerable time, the bleeding evidently continued, flowing backwards into the bladder, the patient having frequent and urgent calls to make water, which contained much blood and some coagula. Ex- perience having taught me the value of gallic acid as a styptic in affections of the urinary organs,* I ordered in the following In the the third volume of the New Series of this Journal I have published a case illustrating its effects in hematuria from injury. 1850.] Urethral Hemorrhage. 433 form : Gallic acid, eighteen grains, and extract of gentian, eight grains : to be divided into six pills, one to be taken every second hour. Before the patient had taken more than twelve doses of the gallic acid, the hemorrhage had completely ceased, at which time the presence of the acid in the urine was detected by the addition of the tincture of the muriate of iron. The patient left the hospital of his own accord on the second day, there being no return of the bleeding ; and he promised to return in a few days in order to have an instrument passed. Laceration of the urethra, followed by profuse hemorrhage, as a result of the venereal orgasm is a very rare occurrence, there being few cases of the kind on record, but, although rare it may lead to very serious results, as we learn from the follow- ing case, related by South, in his edition of Chelius' Surgery, f " I may here mention, that I once saw a case under my colleague, Mr. M'Murdo's, care, in which there was enormous extravasation of blood from the bursting of some vessels in the penis during the act of coition, and the result of which was, that the penis especially, and the perineum, were greatly dis- tended, and he was unable to pass his urine without extreme pain, in consequence of which a catheter was introduced. In the course of two or three days extravasation of urine ensued, and the bladder was punctured through the rectum. Conside- rable sloughing, not only in the perineum, but also up into the groins, took place, into which incisions were made as needed and he ultimately, though slowly, recovered." With regard to the application of pressure to the perineum in cases of hemorrhage from the urethra, there does not now exist in the minds of surgeons that prejudice against it, which Sir Everard Home and others improperly entertained on the subject. Sir Everard Home's objection to it was, that, although it arrested the flow of blood externally, it directed it backwards into the bladder, thereby converting, as he said, a case of sim- ple bleeding into one of danger, by the filling up of the bladder with coagulated blood, and probably inducing retention of urine. No doubt the filling up of the bladder with coagula- ted blood in these cases is a most unpleasant complication ; and numerous cases of urethral hemorrhage have been publish- ed by Guthrie, Brodie, and others, in which pressure on the perineum, whilst it arrested the bleeding from the orifice of the urethra, appeared to have directed it backwards into the bladder, yet the filling up of which viscus, although attended with much annoyance to both patient and medical attendant, was not, m itself \ productive of serious consequences. The proper mode ~ t Vol. i. \\ 1 J7. N. I. VOL. VI. NO. VI. 38 434 Reconstruction of an Entire Phalanx. [July, of treatment to be adopted, in cases of profuse hemorrhage, when it proceeds from the urethra anterior to the triangular ligament, is obviously that by pressure ; and if the rules iaid down so clearly by the best authorities on the subject especial- ly those by Mr." Guthrie, be strictly followed, the bleeding point will be soon arrived at, and hemorrhage, either anteriorly, or backwards into the bladder, will be, in most cases, complete- ly arrested. But, on the other hand, in cases of profuse hemorrhage springing from the membraneous or prostatic portions of the urethra, posterior to the triangular ligament, where pressure can exert but little, if any, beneficial influence, the surgeon should, I think, rely chiefly on the immediate exhibition of gallic acid internally. In it he may place the greatest confidence, its rapid and powerfully styptic action on the urinary organs rendering it peculiarly suitable to such cases. Its timely administration will, in all probability, pre- vent the distention of the bladder with blood, the necessity for having recourse to instruments for the purpose of withdrawing the contents of the bladder, and the subsequent injection of that viscus with tepid water, with the intention of breaking up the coagula; which operations must, in all cases, tend more or less to induce a recurrence of the hemorrhage by the additional infliction of mechanical violence or irritation thereby. The gallic acid may be administered, in these cases, in doses of from three to ten grains, but my experience has led me to prefer giving it in three-grain doses every second hour, to giving it in maximum doses at long periods. The stomach will, in some cases, reject the large doses, when frequently repeated, whereas I have never known it to disagree in three or four grain doses repeated at short intervals, by which means its influence on the urinary organs is steadily maintained. The acid may be or- dered either in the form of pill, or suspended in water by means ofmucilafre. 'O Reconstruction of an Entire Phalanx. Reported by Frank H. Hamilton, one of the atending Surgeons of the Buffalo Hospital of the Sisters of Charity. (Buffalo Journal.) Catharine Dolen, aged 24 ; admitted Dec. 25, 1849. Thumb : The bone was necrosed, and on the 29th I extracted the phalanx entire. The inflammation having considerably sub- sided by the third of January, five days after the operation, I applied a tape roller the whole length of the thumb, and mod- erately tight. This was continued with occasional intermissions during two months, when a new phalanx was found to have 1850.] Periscope. 435 been formed, of the same length and breadth, and form, as the original phalanx ; the articulating snrface was also re- formed, and the flexor and exterior tendons so attached as that the motions of the joint were perfect. This result is not now the first time discovered. More than a )Tear since, Prof. Dudley, of Lexington, informed me in a private communication, that he had been able to reconstruct a phalanx, where the bone had been entirely removed, by the continued application of the roller. To Dr. Dudley, therefore, is the profession indebted for this interesting pathological dis- covery. We have many times seen the bone reconstructed, where a portion only of the whole was removed ; as when the bone was partially destroyed by necrosis or caries and exfoliated, the deficiency has sooon been supplied, so that the form, size, and functions were again restored. Especially has this happened when the process of necrosis was slow. Nor ought we to have been surprised to find the entire phalanx reformed after a slow destruction of the original, since the new phalanx might have been commenced before the complete death of the old, and thus serve as a nucleus for a reformation. This may have happened often, and may have been noticed, but it is the com- plete reconstruction of a bone when it has been removed in its totality by extraction, that excites our surprise, and which we have marked as a novelty, for I am not informed that after Dr. Dudley, any one except mvself has demonstrated its practica- bility. PART III. ill o n 1 1) hj Periscope. On Blood-Jetting in the Pneumonia of Children, By Dr. Mauth- ner, (Monthly Jour. Osterreich. Med. Wochen. Amer. Jour.) It is only in the genuine lobar pneumonia of children that Mauthner re- commend venesection. This form of disease usually occurs without any lengthened premonitory stage, after alternate exposure to extreme heat or cold, sometimes apparently in connexion with depraved digestion, often as one of the sequela of scarlatina, measles, or small- pox. Its prominent symptoms are, difficult breathing, with oppression at the chest, short sharp cough, (a symptom which, in the severe forms of the disease, is at first wanting.) heat of surface, i^cver, head affec- tions, and sometimes vomiting. Over the seat of the disease, which is usually the back of the right lung, the j>ercussion sound becomes dull ; and, on auscutlation in the 436 Periscope. [J^ty"? early state, fine dry crepitation is audible ; afterwards bronchial re- spiration. The child usually lies on the right side ; and, if it can speak, complains of pain in the chest ; the pulse is small, hard, and frequent; the secretions and excretions are dimished in quantity. These severe attacks are most common in children above a year old, but infants are not exempt from them. The anatomical characters of the first stage consist in extensive congestion (stasis) of the pulmonary parenchyma; of the second, in alteration of structure, with effusion of plastic exudation in the form of red hepatization ; of the third (the so-called suppurative stage), in effusion of pus, sometimes diffused throughout the parenchyma, more rarely in children constituting true abscesses. In the cases treated during the first stage, Mauthner has obtained the very best effects from blood-letting. He has often bled the little patients who have been brought for his advice to the hospital, permit- ted them to be carried home, had been subsequently astonished to find how completely this single remedy had obviated the urgent symptoms. On the other hand, he has too often seen the bad effects of neglecting this heroic remedy at the outset of the inflammation. In using the lancet, re- gard must be had to the age and constitution of the patient, and to the intensity of the disease. The depletion should not stop till the child turns pale, becomes sick, vomits, or seems exhausted. When the operation is properly performed, Mauthner thinks all other remedies, such as leeches, cataplasms, and internal physic, may be dispensed with, and in a few days the child is well. In cases in which the disease has reached its second stage, the im- mediate effect of venesection is not so remarkable ; but some benefit is usually speedily experienced, and within three days the bronchial re- spiration ceases, and the morbid process is removed, usually upon the appearance of some critical evacuation from the skin or kidneys. Even when there was reason to suspect suppuration, Mauthner has often let blood after mature deliberation, and has had no occasion to repent the adoption of the practice. Thus, he believes that he suc- ceeded in saving a boy six years of age, who, after a neglected pneu- monia of three weeks' standing, fell under his care, suffering from hectic fever, emaciation, and purulent expectoration. After in vain attempting a cure with digitalis and acetat. plumbr, Mauthner ordered venesection, and the boy recovered. Where, however, as is often the case, an unresolved pneumonia seems to have gone on to tuberculosis, bleeding can do no good. The indications for venesection are derived, first, from an accurate physical exploration of the chest. It must, however, be noted, that, when the cough and general symptoms indicate the existence of pneumonia, the absence of physical signs does not justify the neglect of proper remedies. For, even when extensive congestion of the pul- monary tissue is present, if a certain quantity of air be still included in its interstices, the percussion sound and respiratory murmur may not be sensibly affected. Besides, the inflammation may be situated in a part of the lung which cannot be satisfactorily explored ; or the 1850.] Periscope. 437 child may be so restless and timid as to render the use of the stetho- scope impossible. The second indication is derived from the age and individual con- stitution of the child. Strong plump children above a year old may be bled without scruple ; those who are delicate will still bear depletion, if it be ascertained that their previous health has been good ; even in- fants under one year of age, labouring under severe pneumonia, suffer less from venesection than from the application of three or four leeches. The stage of the disease affords the third indication. In the con- gestive period, the remedy is quick and sure. When hepatization has already taken place, the detraction of blood is never hurtful ; but, when the suppurative period has arrived, the lancet must be used cautiously and seldom. The operation of opening a vein in the arm of a fat restless child is not easy, and for its proper performance requires some previous experience for the feel of the vein must, more than the eye, guide the lancet. The ribbon must at first be drawn rather tightly, until the vein be felt and opened, when it must immediately be slackened again. While the blood trickles out (a full jet is seldom obtained from a child), the arm should be left quite still, for, on the slightest movement, the fat mobile integuments lap over and close the orifice. There is no difficulty in stopping the bleeding, either with a cross of sticking plaster, or by a single turn of a bandage. The amount of blood drawn must be chiefly regulated by the age of the child. Considerable effect may be expected in infants, from the detraction of a single ounce. Children from two to three years of of age require a blood-letting of from two to three ounces, and older children more in proportion. The usual relative proportion of serum and cruor in cases of pneumonia, in children, Mauthner states to be one part of the former to two of the latter. He has not unfrequently observed the buffy coat, but attaches very little importance, in a therapeutic point of view, to its presence or absence. In the case of a boy, two years old, whom he had occasioned to bleed to three ounces for severe pneu- monia, which had been in vain treated by leeching, he found a bufTy coat of two lines in thickness upon the blood, after it had stood for some time in a conical-shaped vessel. In this case, there was no oc- casion to repeat the operation, but rapid convalescence followed. Treatment of Chorea. (London Lancet.) M. Faivre d'Esnans mentions in the Journal de Medecine et de Chirurgie Pratiques, that he has obtained the happiest results from the prussiate of iron in chorea and epilepsy, and he gives several cases where the cure was obtained in between four and eight days. He uses the following formula: Prussiate of iron, fifteen grains ; extract of valerian, forty- five grains ; make twenty-four pills. One pill to be taken three times a day, at six hours' interval, each pill to be iollowed by a wine-glass of infusion of valerian. The author was induced to try the prussiate of iron, from having seen M. Jourdes use it, at the Military Hospital 438 Periscope. . [July, of Strasburg, for intermittent fever. Ashe considers that both dis- eases (chorea and ague) have their seat in the medullary spinals, he thought that the same remedies would prove efficacious in both com- plaints, in which supposition, according to his statements, he was not deceived. On AncEsthesia hy Inhalation of Ether or Chloroform. (Ibid) M. Velpeau read, at the annual meeting of the Academy of Sciences, a paper on the Inhalation of Ether or Chloroform, in which he embo- dies the history of anaesthetic agents, their introduction into practice, the results obtained, and his own opinions on the subject. In the historical sketch we find the following passages. The so-called Memphis-stone, dissolved in vinegar, after having been reduced to powder, was used as an anesthetic agent amongst the Greeks and Romans, and mandrake was extensively known as possessing anaesthe- tic properties. Dodonaeus says, in his history of plants, that the vinous decoction of mandragora causes sleep, and allays pain ; and that it was therefore administered to those who were to have part of their body burnt or sawn off. The surgeons of the middle ages were well acquainted with the employment of certain anaesthetic agents. Hugh, of Lucca, a celebrated practitioner of the thirteenth century, speaks very distinctly on the subject. A sponge dipped in the juice of morel, or nightshade, hyoscyamus, cicuta, lactuca, mandragora, or opium, was put under the nose of patients, and made them sleep during operations ; they were then roused by being presented another sponge soaked with vinegar, or by putting the juice of rue into their ears. From M. Jullien's communication to the Academy of Sciences, it may be seen that the Chinese, some centuries ago, were aware of means for rendering patients insensible during operations. Boccaccio men- tions, in the Decamerone, 39th tale, that Mazet de la Montagne used to operate on his patients after having put them to sleep with a water of his composition. Formulae have been transmitted from father to son among malefactors, by which their intended victims might be plunged into sleep. Prisoners, towards the revival of letters, knew how to procure certain drugs with which they could bear torture without feeling the pain. Is it not likewise said that the Turks pos- sess the means of plunging into anaesthesia those upon whom circum- cision is to be performed ? In our own times we find Sir Humphrey Davy stating, after having used the nitrous oxide gas upon himself to allay toothache, that this gas might probably be of use in surgical operations. Mr. Wells, of Hartford, used this gas in 1842, for ex- tracting teeth without pain. Mr. Hickman announced in Paris, in 1821, that he was able to render patients insensible to pain by making them breathe a gaseous substance, the name of which he did not make public. Messrs. Orfila and Christison had found that animals might be rendered insensible by giving ether internally. M. Merat used ether inhalations for allaying pain, and Mr. Faraday observes {Quarterly Journal of Sciences, 1818) that ether acts upon man like the nitrous oxide gas, and that the action of the former, at first exhilarating, soon becomes stupefying. 1850.] Periscope. 430 M. Velpeau, after refuting the objections of those who represent the inhalations of ether or chloroform as dangerous, says: The use of these agents does not seem prudent in operations to be performed on the mouth or throat, in the nasal fossae, the larynx, or trachea, on ac- count of the necessity for patients to expel, by coughing, the blood which tends to invade the bronchi. Without proscribing chloform, I however do not advise it when operations are to be performed on the eyes, lids, or lips, when in aneurism an artery is sought for, or in oper- ations upon individuals much enfeebled, either by disease or old age. It is a mistake to believe that chloroform facilitates the surgeon's task, for it would be often advantageous to make the patient change his posi- tion, answer questions, &c ; and the operator is likely to get nervous and flushed when the chloroform is kept on for a long time, as fears of ultimate unpleasant results will disturb his mind. Yet painless opera- tions by means of chloroform must be reckoned among the most bril- liant discoveries of the nineteenth century; and so great is the desire to tike advantage of it among the public, that the surgeon is more frequently obliged to refuse giving the chloroform than to induce the patients to inhale it. Many people who would have gone to their grave without even disclosing the nature of their affection, from their horror of operations, will now have a chance of a prolonged life. Finally, M. Velpeau thinks that the administration of anaesthetic agents ought to be regulated more by the nervousness and fear of the patient than by the importance of the operation. Terror and dread are very detrimental, and though the cases be slight, anaesthetics should be had recourse to when the patient's mind is disturbed by lively apprehensions of pain. Intercostal Neuralgia as a sign of Phthisis. By M. Beau. (L'Union Medicale. Braithwaite's Retrospect.) Intercostal neuritis is an affection which habitually coincides with inflammation of the .pleura, whether simple or combined with pulmonary inflammation. The explanation of this coincidence is found in the anatomical rela- tions of the pleura and intercostal nerves which are in immediate contact at the posterior part of the thorax. According to the author, the stitch in the side, which attends affections of the pleurae, and most' severe pulmonary affections in which the pleurae are involved, is owing to inflammation of the intercostal nerves, which are found en- larged to two or three times their normal size, adherent to the pleurae or to the cellular tissue in which they lie, and, in acute cases, much injected. The degree to which the nerves are affected bears an exact relation to the amount of affection of the pleurae, and is therefore evidently secondary to it. When the lung is attacked by tubercles, it almost invariably hap- pens that adhesions of the pleurae take place in their neighborhood. The adhesions, like that tubercles, are at first confined to the summit of the lung, and are attended by the same change in the intercostal nerves as in the case of acute affections, only that the lesion is chronic in its development, and not generally characterized by in- creased vascularity. 440 Periscope. [July, Thus the author explains the dull pains which occur at the summit of the thorax in phthisical persons. Sometimes these pains are suffi- ciently distinctly marked, and even neuralgic in character; they radiate into the neck and supra spinous fossa, or even along the arm, as in angina pectoris ; this divergence being due to the inosculations between the intercostal nerves and those of the cervical and brachial plexuses. But it is not always so, nor can these pains be said to be an habitual symptom of phthisis. Nevertheless the lesion of the in- tercostal nerves is almost always found after death from this disease. In seeking to explain this contradiction, M. Beau has discovered a symptom, to which he attaches considerable importance in the diagnosis of doubtful cases of phthisis. Even where no pain is mani- fested under ordinary circumstances, he finds that this symptom may be almost constantly produced by moderate pressure with the finger on the anterior or sternal extremity of the intercostal spaces. In early cases it is limited to the upper part of the chest, and is, generally speaking, more severe in the first space than in the second, in the second than in the third, &c. It varies in intensity, but sometimes is so considerable as to cause an involuntary shrinking on the part of the patient. It is more severe and effects the greatest number of spaces, on the side in which the tuberculization has advanced farthest. This symptom is almost constant in phthisis pulmonalis. Among fifteen causes under M. Beau's observation at the time of writing, it was not absent in more than one ; and only one of these cases pre- sented the symptom of one spontaneous pain. The author, therefore, thinks it will prove a useful diagnostic mark in cases where the physi- cal signs of phthisis are marked by bronchitis. "The predominance of the pain in the anterior part of the spaces, where the alteration of the nerves is least considerable, is ascribed by M. Beau to the circum- stance that, when a nerve is diseased, in any part of its course, the morbid sensibility is always referred to its peripheric extremity. Another form of the intercostal neuralgia of phthisical patients is the pain between the shoulders which has been so frequently described as characteristic of phthisis. In these cases the author has always found that the pain may be traced along the intercostal spaces to the anterior part of the chest. M. Beau had previously endeavoured to demonstrate the connection between intercostal neuralgia and dys- pepsia : he now considers both these symptoms as related to phthisis, of which disease dyspepsia, as is well known, is a frequent accom- paniment. Use of Coffee in Hooping -Covgh. (Lon. Jour. Med. Braithwaite's Retrospect.) Various medicines have from time to time been brought forward as specifics in hooping-cough ; and some of them we have tried. To quinine, salicine, arsenic, and oxide of silver, we have given a fair trial in a considerable number of cases ; and the result of this ex- perience is, our belief that all of them, except the last named, possesses some power in checking the disease, when it has gone on for some time, and is marked by periodicity. When the hour of the recurrence 1850."| PefHscope. 441 of the fits comes to be accurately foretold, all of the above-named drugs given in full doses in anticipation of the attack, postpone, or entirely prevent it. In the early stages or latter, where there is some amount of bronchitis, the free use of stimulating embrocations, with occasional expectorants, 4and stomachics, and alteratives, (such as a powder composed of cusparia, trisnitrate of bismuth, and rhubarb, are the means we trust to. When the cough assumes a distinctly periodic character, we recommend a trial of antiperiodic remedies and chauge of air, both of which measures, in many cases, prove of signal and speedy benefit. From Pereira's summary of the therapeutic uses of coffee, it is not unlikely, however, to exercise some control in hooping-cough. " It has," says Pereira, "been employed as a febrifuge in intennittents ; as a stomachic in some forms of dyspepsia ; as an astringent in diarrhoea ; and as a stimulant to the cerebro-spinal system in some nervous disorders." Floyer, Dr. Percival, and others, have used it in spasmodic asthma ; and Laennec says, " I have seen several cases in which coffee was really useful." The recommendation of coffee, in hooping-cough, seems decidedly to merit attention. Dr. Jules Guyot, who advocates the use of the reme- dy, writes thus in the Union Medicale for 24th April, 1849 : " Cafe a Veau, hot, and well sugared, in suitable doses, taken four times or oftener, daily, will cure, in from two to four days, the most obstinate cases. For a child of two years, the dose is a teaspoonful ; for a child of four years, a desert spoonful ; and for an elder patient a tablespoonfuh To obtain a rapid and permanent cure, it is necessary to conjoin with the coffee treatment a diet of fried and roast meat, taking care to mince it, if the child cannot masticate it sufficiently. The quantity of milk used, ought' to be diminished ; and farinaceous food, confectionaries, and fruits, must be entirely prohibited." The alledged specific power of coffee in hooping-cough, was ac- cidentally discovered by observing the following case : A child of four years old, under rigid dietetic treatment for measles, was seized with congestion of the lungs, against which energetic anti- phlogistict treatment was put in force. When Dr. Guyot was called in, death seemed imminent from violent paroxysms of cough, which in- duced such alarming suffocation and syncope, as to cause the patient to appear to be actually dead. Some spoonfuls of strong beef-tea, with some spoonfuls of sweet and hot infusion of the lime-tree, were pre- scribed. The child passed the night without tainting. On the fol- lowing day, the same infusions were continued, and in addition, there was given a little bit of grilled and finely minced mutton, with the view of restoring strength as rapidly as possible : but a severe fit of coughing came on, which terminating in vomiting, caused ejection of the food ; recourse was again had to to the beef-tea, which provoked a similiar fit of coughing, and was ejected. In these circumstances, with death apparently impending, a tea-spoonful of coffee was given after each tea-spoonful of beef-tea. Not only was the beef-tea retained; but, to my great surprise, the cough likewise ceased. Two 412 Periscope. [July, hours afterwards, the child took with relish, a little bit of hashed cutlet, followed by a teaspoonfulof the coffee; the food was not. ejected, digestion went on naturally, the night was passed in comfortable sleep, there was no more cough : and in truth the child was saved. On the following day, the treatment was continued, and there was a continuance of a like satisfactory state. On the third day, however, the relations omitted the coffee, when the cough returned after the first meal, with all the characteristic violence of well-formed hooping- cough ; and this state continued during the day. On the fourth day when the coffee was resumed, the cou^h disappeared. During forty- seven days the coffee was persisted in, when the cure was distinctly complete. The little patient was the only daughter of M. Haquin, a master boot-maker of Argenteuil. This case was furnishing subject of serious reflection, when Dr. Guyot met in a public conveyance M. Bouju, ex-notary of Francon- ville, he told him that he had been obliged to have double doors for his study, to keep out the terrible and incessant noise caused by his two children with the hooping-cough. Dr. Guyot detailed the case above narrated : and he cured both his children in four days by means of coffee. He has since tried the remedy successfully in above sixty cases. The efficacy of coffee in hooping-cough seems to show that the seat of the disease is not in the bronchial tubes or larynx nor in their vascular or nervous network but exclusively in the digestive organs, and especially in the pharynx and stomach. The cough and convulsive movements ofthelarjnx are excited by a pruriginous irritation of the pharynx; which, again, probably depends on some special affection of the stomach. Formula employed by M. Ricohd in the Treatment of the various forms of Syphilis. (Gaz. des Hop. Dublin Journal.) Non-malignant Varieties. 1. Inflammation of the glans penis and prepuce : Injections of the following solution are to be made three times a day between the prepuce and the glans : Nitrate of silver, twelve grains ; distilled water, one ounce. 2. Abortive treatment of gonorrhoea : A single injection is to be made with the following solu- tion : distilled water, one ounce; nitrate of silver, eight grains ; and this powder to be taken three times daily : cubebs, two drachms and a-half, and powdered alum fifteen grains; mix. 3. Injection for gon- orrhoea when the period for the abortive treatment is past : Rose water, six ounces ; sulphate of zinc and acetate of lead, of each twelve grains ; to be used three times a-day. 4. Internal treatment of gon- orrhoea : Balsam of copaiba, syrup of tolu, syrup of poppies, of each one ounce ; mint water, two ounces ; gum Arabic, as much as may be sufficient ; orange-flower water, half an ounce; to be made into an emulsion, of which a table-spoonful is to be taken three times a-day. 5. Acute stage of gonorrhoea: Twenty leeches to the perineum, fol- lowed by a warm bath, cooling drinks, confinement to bed, low diet ; to use a suspensory bandage, and to take four times a day one of the following pills : Lactucarium and camphor, of each two scruples, to 1850.] Periscope. 443 be made into twenty pills. 6. Gleet (goutte militaire) : The following injection to be used three times daily : Rose water and red wine, of each six ounces ; alum and tannin, of each eight grains. Malignant Varieties. Primary Symptoms. 1. Abortive treat- ment of chancre : During the first five days after contagion, destroy the chancre with Vienna paste. 2. True chancre not indurated : Frequent dressings with aromatic wine ; extreme cleanliness ; occa- sional light cauterization with nitrate of silver ; rest ; emollient drinks. When inflammation exists, antiphlogistics, purgatives, emollient ap- plications. (No mercury). 3. Phagedenic chancre : complete cau- terization with nitrate of silver, acid nitrate of mercury, potassa cum calce, or the actual cautery, according to circumstances. In a more advanced stage, lotions composed of aromatic wine, three ounces and a-half, and extract of opium, two grains and a-half ; or aromatic wine, eight ounces, and tannin, twenty-four grains; or, in the scrofulous diathesis, distilled water, three ounces and a-half, and tincture of iodine, one drachm ; or the application of sulphur ointment, and the use of sulphurous baths. Internally : Tartrate of iron and potash, one ounce dissolved in eight ounces of distilled water, of which one ounce is to be taken three times a-day. 4. Indurated chancre : Three dress- ings daily with the following ointment ; Calomel, one drachm, and lard, one ounce ; mercury to be given internally. 5. Abortive treat- ment of bubo consequent on the absorption of the virus of a non-indu- rated chancre : Deep cauterization with potassa cum calce, to be continued for ten minutes ; the separation of the eschar is to be pro- moted. 6. Bubo consequent on indurated chancre : Antiphlogistics are to be employed according to circumstances, and vents must be given to the purulent matter by cauterization with caustic potash ; the glandular mass situated at the bottom of the opened bubo is subse- quently to be gradually destroyed by caustics ; an ointment composed of equal parts of extract of belladonna and mercurial ointment may be added to the poultices after cauterization. 7. Horse-shoe bubo, and gangrene : For the former the same treatment is to be adopted : for gangrene, lotions with the following mixture : Chloride of lime, one ounce ; distilled water, three ounces and a-half; or the application of a powder composed of equal parts of prepared charcoal and powdered cinchona bark. Secondary Syphilitic Symptoms. A spoonful of compound syrup of sarsaparilla to be taken three times a-day in a glass of decoction of soapwort leaves ; one of the following pills to be taken daily : Proto- iodide of mercury and lactucarium, of each thirty-five grains; extract of opium, twelve grains ; extract of hemlock, one drachm and a-half; to be divided into sixty pills. Tertiary Syphilitic Symptoms. A spoonful of the following syrup to be taken three times a-day, in a glass of decoction of soapwort: Syrup of sarsaparilla, thirty ounces, and iodide of potassium, one ounce. Scrofulous Complications. The following emulsion is to be giv- en in three doses : Iodine, two grains and a-half; oil of sweet almonds, 444 Periscope, [July, one ounce; gum Arabic as much as may be sufficient; almond emul- sion, three ounces and a-half. Mercurial Stomatitis. Decoction of lactuca sativa, five ounces; honey, half an ounce ; hydrochloric acid, fifteen drops ; to be made into a gargle to be used three times a-day. Salivation. One drachm of flowers of sulphur, mixed with honey, to be taken daily ; water acidified with nitric acid, and sweetened, to be used as ordinary drink. The following gargle to be used three times a-day : Decoction of lactuca sativa, five ounces; honey, one ounce ; and hydrochloric acid, fifteen drops. Aphtha ix the Mouth. Decoction of hemlock, six ounces and a-half, and bichloride of mercury, two grains and a-half; to be used as a gargle three times a-day Warts are to be sprinkled twice a-day with a powder composed of equal parts of savin, oxide of iron, and burned alum. Sumbul (London Lancet.) In recently attending the medical wards of this (King's College) hospital, we perceived that Dr. Todd was pre- scribing, in a case of epilepsy, a medicine, the name of which we heard for the first time. On inquiry, we find that this root, called Sumbul, is being introduced into practice as an anti-spasmodic by Mr. Savory, of Bond street. It appears that Dr. Granville, on a recent return from the Continent, mentioned sumbul to Mr. Savory as a root employed with great success in Germany and Russia, against cholera : wondering that it had not yet found its way into this country. Mr. Savory immediately set about procuring it, but his correspondent in Russia had much trouble in getting this root ; he, however, sent over specimens of it. A little later, another parcel of the sumbul was ob- tained, by the same house, from Hamburg ; and on comparing the two samples, Mr. Savory came to the conclusion that the German one was decidedly the firmest, least damaged, and in the best condition of the two. We were shown these specimens, and find that they resem- ble much the circular pieces in which calumba is generally seen, ex. cept that they are considerably larger, of a more spongy texture, and resembling huge bungs. They are of a yellowish grey, whitish in the centre, with a thin, pellicular bark surrounding them. The most striking feature of the root is its very strong odour, which very much approaches that of musk, being almost as pleasant and powerful. The pieces are very light, and seem to be formed of a condensed and har- dened pithy substance. From this imperfect description, it may at once be gathered that the sumbul promised to be useful as an anti- spasmodic, and Mr. Savory first thought of combining it with the coty- ledon umbilicus, and using it. against epilepsy. It is, however, being tried by itself, and though Dr. Todd cannot as yet state anything posi- tive as to results, we were told that the little boy who is taking ten minims of the tincture thrice a day, and who, when admitted, had an epileptic fit once or twice a week, has had no attack since he has been in the hospital. Mr. Savory has likewise prepared on extract of the root, and further trials are of course necessary to judge of the efficacy 1850.] Miscellany, 115 of the medicine. Musk being, however, very expensive, it would be a great boon to the public were this root found as efficacious. No- thing is yet known of the botanical origin of the plant; efforts are, however, being made to ascertain its natural history, and we shall have much pleasure in communicating to our readers the details which may transpire both in the latter respect, and with regard to the trials which are being made as to the therapeutical virtues of the root. Supplementary Mamma. (Archives Generales.) M. Marotte read the notice of a case of supplementary mammee, occurring in a young woman 17 years of age. The glands of the axilla were the seat, every month, of painful sensations at the menstrual periods. This sensation began to be experienced at the age of 12, during menstrua- tion. These two tumours, especially the one on the left side, attained, in this young woman, a considerable development during pregnancy, and two days after her delivery they discharged spontaneously a fluid having all the appearances of milk. The normal breasts were devel- oped, but were not of unusual size. Vicarious Menstruation. In the June number of the Western Lan- cet, Dr. B. F. Richardson, of Cincinnati, reports a case in which at each regular menstrual period the discharge takes place from the anus instead of the vagina, and continues about as long, and in quantity is about the same as the normal menstrual discharge. The fluid does not coagulate. Its discharge is usually preceded by pain and uneasi- ness in the lower part of the bowels. From careful and minute enquiry, Dr. R. is satisfied that the discharge was not hemorrhoidal, and that there was no reason to suspect a recto-vaginal communication. A very singular case of vicarious menstruation was brought to the notice of the Westminster Medical Society by Dr. Rogers, last year, in which blood oozed from the tips of the fingers. itUMcal ill i s c c 1 1 a n tj - Compensation of Physicians for Post-mortem examinations hefore Coroner's Inquests. Until a short time since, we have had no oppor- tunity to examine the Act, passed at the last session of the Legislature of Georgia, whicli provides for the compensation of medical men who may be required to attend professionally upon Coroner's inquests. This act provides that " it shall be lawful for every Physician or Sur- geon who shall be summoned by the Coroner or Sheriff of the county to make a post-mortem examination for the information of juries of 446 Miscellany. [July, inquest, to charge and receive from the Treasurer of the county, the sums following, to wit : For each post-mortem examination, when death has resulted from external violence, where no dissection is re- quired, the sum of Ten dollars ; for the same, where dissection is necessary, and where no interment of the body has been made, Twen- ty dollars ; for the same, after one or more days interment, Thirty dollars ; for the same, when any chemical analysis is required, the sum of Fifty dollars, and the expense of such analysis : Provided, that the compensation allowed in this act, shall not extend to more than one physician, for each post-mortem examination." We are pleased that this tardy act of justice to the medical profes- sion has been done ; but at the same time we are constrained to say that the compensation for post-mortem examinations, where chemical analysis is required, is entirely inadequate. In almost every case of this kind, the entire responsibility is thrown upon the physician. Upon the correctness of his analysis, the reputation and life of the accused depends. His opinion alone determines the question whe- ther or not a crime has been committed. To place a man under such a weight of responsibility, and then to offer to compensate him for fifty dollars, shows a very low appreciation of the profession, or a very extravagant estimate of the value of money. We hope that this part of the law will be hereafter amended, and a more adequate compen- sation allowed. We are, however, much gratified that the obligation of the community to compensate physicians for services rendered the public has been thus recognised. This recognition is doubtless due to the organization of the profession which has been going on throughout this country for the last three or four years. The same means, if properly used, will procure a further recognition of the obligations which the public are under to physicians. Medical Society in Cobb county. We learn from a medical friend that a Medical Society has been formed in Cobb county, Georgia, and that Dr. Elliott has been elected its President, Dr. Quintard, Vice- President, and Dr. Dun woody, Secretary. The next meeting of the Society will be held on the first Saturday in August, at which time an address is expected from Dr. Slaughter, of Marietta. The Postmaster-General has decided that the " African Reposito- ry, a monthly periodical of 32 pages, printed in Washington and stitched in a cover, is entitled to pass through the mails at newspaper postage. The Boston Medical and Surgical Journal, an unstitched 1850.] Miscellany. 447 weekly journal, is charged with pamphlet postage. Is it that the af- fairs of Africa, and the interests of the African race, are deemed of more importance than the physical welfare of our own people ? University of Pennsylvania. Prof. George B. Wood, has been transferred to the Chair of Practice, vacated by the resignation of the venerable Professor Chapman, and Joseph Carson, M. D., has been elected to the Chair of Materia Medica and Therapeutics. American Medical Association. The following resolution, append- ed to the Report of the Committee on Medical Literature, was adopted by the Association at the meeting at Cincinnati in May last. Resolved, That the sum of one hundred dollars, raised by voluntary contribution, be offered by this Association for the best experimental essay on a subject connected either with physiology, or medical chemistry, and that a committee of seven be appointed to carry out the objects of this resolution : said committee to receive the competing memoirs until the first day of March, 1851 ; the authors' names to be concealed from the committee ; and the name of the suc- cessful competitor alone to be announced after the publication of the decision. Dr. Francis G. Smith, Philada., Chairman. " Alfred StillS, Philadelphia. " Franklin Bache, " " L. P. Yandell, Louisville, Ky. " James Moultrie, Charleston, S. C. " Robert Bridges, Philadelphia. " Washington L. Atlee, Philadelphia. In accordance with the above resolution, the Chairman gives notice that the sum of one hundred dollars is secured, and will be paid over to the successful competitor, or, if preferred, a gold medal of equal value, bearing a suitable inscription. The competing memoirs must be transmitted to the Chairman, free of expense, and should be designated by some appropriate motto ; the author's name accompanying it in a sealed packet, designated in like manner. The successful essay will become the property of the Asso- ciation, and in case no paper of sufficient merit is offered, the time will be extended for another year. After the decision of the committee, the sealed packet containing the author's name will be opened in the presence of the Association. Medical Journals throughout the country are requested to give pub- icity to the above Notice, and to aid in furthering the wishes of the Association in this respect. Francis G. Smith, M. D., Philada., Chairman. 418 Miscellany. Meteorology. Great Longevity. The Boston Medical and Surgical Journal states that among the members of a religious congregation in Suffolk county, Long Island, N. Y., there are five persons over one hundred years old ; eighteen over ninety j fifty-one over eighty ; and forty-five over seventy. If this report is correct, it speaks well for the morality of the congregation, for " a conscience void of offence1' is certainly one of the most important means of procuring long life. Deaths. M. Makjolin, one of the oldest and ablest of the surgeons of France, died on the 4th March, in the seventieth year of his age. A large concourse of medical men, students, deputations from hospi- tals, &c, followed his remains to the tomb. Doctor Capurox, a distinguished professor of Midwifery, died re- cently in Paris, at the advanced age of eighty-three years. METEOROLOGICAL OBSERVATIONS, Ga. Latitude 33 27' north Longitude 4 tide, 152 feet. By Dr. Paul F. Eve. for May, 1850, at Augusta, 32' west Wash. Altitude above < Sun Ther. Rise. II Bar. j 3, I Ther. \ M. ! Bar. Wind. Remarks. 1 58 29 91-100' 85 29 87-100 s. w. Fair. 2 60 t: 95-100 84 " 90-100 w. Fair. 3 62 " 95-100 75 " 87-100 S. E. Cloud)' breeze. 4 68 " 80-100 81 " 65-100 E. Cloudy. 5 70 " 47-100 82 " 61-100 S. E. Fair. 6 60 " G3-100 76 " 74-100 W. Fair. 7 56 " 90-100 75 " 96-100 E. Fair. 8 62 " 74-100 77 " 51-100 S. E. Rain, stormy, hail, I in. 25-100, 0 60 " 55-100 76 65-100 W. Fair. 10 56 " 70-100 81 " 64-100 S. E. Fair. 11 66 " 62-400 81 " 56-100 s. w. Fair. 1-2 58 " 72-100 73 " 76-100 z. Fair. 13 50 80-100 77 M 80-100 E. Fair. 14 68 " 50-100 78 " 44-100 s. w. St0rm~rain'l 5(M00' 15 65 " 38-100 74 " 35-100 S. E. If, 64 " 39-100 76 54-100 s. w. Fair. 17 63 " 40-100 78 a 51-100 s. w. Fair. 18 66 " 62-100 73 " 62-100 S. W. Cloudy, 19 57 " 70-100 77 72-100 w. Fair. 20 57 " 80-100 76 " 79-100 w. Fair. 21 60 !( 80-100 80 " 80-100 N. W. Fair. 2-3 63 " 91-100 81 " 91-100 s w. Fair. 23 69 " 93-100 80 91-100 w. Fair. 21 66 83-100 72 " 81-100 E. Cloudy. 25 87 '' 76-100 76 " 76-100; E. Cloudy all the morning. or. 60 " 75-100 86 " 74-100 N.W. Fair. 37 63 " 75-100 90 " 74-100 N. \V. Fair blow sprinkle at 7 p.5'< 28 68 " 72-100 91 " 68-100 X. w. Fair storm w wind at 8 p.m. 29 68 " 64-100 95 58-100 w. Fair morning blow at 8 p.m. 30 71 58-100 79 " 58-100 N.W. Cloudy rain, 80-100. 31 67 " 56-100 70 " 51-100i N. E. Rain, 45-100. 20 Fair days. Quantity of Rain 3 inches Wind East of N. and S. 12 dayc West of do. do. 19 days. SOUTHERN MEDICAL AND SURGICAL JOURNAL. Vol. 6.] NEW SERIES AUGUST, 1550. LNo. 8. PART FIRST, rtginal am muni cat ions. ARTICLE XX. Counter-irritants. By T. C. Quixtard, M. X)., of RosWell, Ga. Although our subject may seem to be "hackney'd and worn out to the last faint thread," it is nevertheless one of too great importance to be passed heedlessly over by the medical prac- titioner. Speculation' in philosophy, particularly in medical philosophy, is carried to such an extent that it amounts to a positive evil, in our times : it frequently takes the place of scientific facts which bear directly upon natural phenomena, and leads the mind from the contemplation of mere agents, to the grander subject of systems and laws. It is pleasanter to give loose reins to the imagination, to study the poetry of science, to deal in the abstract conditions of matter, of the principles of natural bodies, or of the motion, place, and time of natural bodies, than to curb the fancy down to the stern reality of fact and experience, or the consideration of those things which lie before us in daily life. We do not hope to present any thing new, probably nothing that has not been known since the days of Hippocrates, and yet we hope our subject will find favor from its intrinsic importance. Aristotle has said, "they who demonstrate plain things, light a candle to see the sun." This is very true ; but there are some fnen who would never know the sun rose at all unless they were told it, and there are some men of exuberant intellects who like to have common subjects brought before them without the bother of thinking. Jf. 8, VOL. VI. NO. VII!. CD 450 Quintard, on Counter-Irritants. [August, Counter-irritants may be defined agents, whether natural, mechanical or medicinal, by which we endeavor to remove or diminish the morbid condition of a particular structure by pro- ducing an abnormal state in some part more or less remote from the seat of disease. Counter-irritants have two distinct modes of operation, the one derivative, the other stimulant t'o the general system or to some susceptible organ in particular ; and a knowledge of this distinction must guide us in their ap- plication. The principal object to be gained by the use of counter-irritants, is the withdrawal of morbid action from an inaccessible and more or less vital organ, to a part immediately within our power of control. In their application, both skill and judgment are needed ; for in the hands of the inexperienced they may work mischief. About the middle of the last century, when epispastics were far more popular than at present, coun- ter-irritation was the pet practice in the treatment of gout. Hillary gives us a case of " gout at the stomach, with some pain in the head, for which a large vesicatory was applied to the head, which soon brought the gouty humor thither, and caused it to swell in an extraordinary manner,, and killed the patient in thirty hours; whereas," he continues, " if it had been applied to the feet or ancles, and other proper methods used at the same time, it would have drawn the gout thither, and have saved the life of the patient/'* The experience of every man who has seen much of disease, might be introduced to prove the necessity of discrimination iu the use of counter-irritants, especially in those diseases affecting the respiratory organs. Mr. Porter protests against the use of blisters in acute laryngitis, especially in the earlier stages.f A case is also related where, in acute pneumonia, the application of a blister was followed by an aggravation of the symptoms, and death was the consequence. On dissection, a portion of the surface of the lung, exactly cor- responding to the size and shape of the blister, was found in a more advanced stage of inflammation than the remaining pul- monary tissue. So, also, tartar-emetic may become so violent in its action as to increase rather than remove the difficulty for * Hil. Med. Knowl., p. 353. See also Boerhaave, Aphorisms, Febris and Bagliv de Usu et Abusu vesicant. t Surg. Obs. on Dis. of the Larynx and Trachea 1850.] Quintard, on Counter- Irritants. 451 which it is applied, and a case will be given, when we come to speak of croton oil, in which twelve drops of that article appli- ed over the chest for a bronchial affection, produced an eruption over the surface of the whole body. Counter-irritants have been more or less popular with the profession from a very- early period in the history of medicine, and were doubtless first "suggested to the attentive observer by the occurrence of spon- taneous translations of disease from one part to another, and by the obvious and frequent relief afforded by them: as, for exam- ple, in the subsidence of pulmonary and gastric irritation on the appearance of a cutaneous eruption." It is this simple process of enquiring into the causes of natural or morbid appearances, which has assisted materially in placing medicine among the certain sciences; and it is by accurate observation, after all our reading, with true inductive reasoning, from certain estab- lished facts, that we are enabled to perfect the ars divina. Such observation and reasoning will conduct us right and prove truly satisfactory to the judicious physician. With these few desultory remarks, we proceed to the consideration of Cantharides. Cantharides, cantharis vesicatoria Geoffroy ; meloe vesica-' toria Lin. ; lytta vesicatoria-~Fab. ; belonging to the family of the trachelides. They are common in Spain, Italy and France, where they are found in great numbers on the ash, lilac, viburnum, &c. Their body is from six to eight lines long; the feelers are black, retaceous, composed of twelve articula- tions ; the elytra, long, flexible, of a shining golden green, and the tarses of a deep brown. Their odour is strong, penetrating, peculiar and unpleasant; their taste extremely acrid; their powder is of a brownish gray, intermixed with shining particles of a metallic green color.* According to Robiquet, they con- tain, with several other ingredients, a peculiar substance, called cantharadin. They were first used internally, as a diuretic, by Hippocrates,f while to AretaeusCappadox, who lived probably about the time of Domitian, towards the latter end of the first century, is due to the credit of first applying them externally as vesicatories. * Encyc. Am. et Gen. crust, et Insect., torn, ii., p, 220. (Latreille.) i Hippoc. de Intern, affeciionibus. 452 Quintard, on Counter-irritants. [August, By the application of cantharides to the surface of the body, the extreme vessels take on an inflammatory action, the inten- sity of which depends on the strength of the plaster and the length of its application. It follows, therefore, that the benefit derived is by different modes of operation. As a rubefacient it is advantageously applied in low fevers to increase the vigor of the circulation and to impart tone to the nervous system ; as evacuants, by getting up a determination to the surface, and by withdrawing blood from the engorged capillaries to supply the discharge of serum or pus; as derivatives, by producing a diversion of the circulation from the neighboring organs; as antispasmodics, relieving pain through the medium of sympa- thy. " A blistered surface may be considered in the light of a new excretory organ, the fomentation of which requires the establishment of a new current of blood."* In whatever way blisters may operate whether as evacuants, rubefacients, de- rivatives, or direct stimulants, whether as " cordial and exhilira- ting" remedies or depletories, as in erysipelas, experience has proved their utility in a great variety of cases, in affections differing as widely in their anatomical character, as in their location. The effect of a blister on the cuticle is worthy of notice. It at once destroys its connection with the cutis, and the perspira- tory apparatus is broken up. If a blister be applied to a sweat- ing surface, so soon as it produces sufficient inflammation to bring on effusion of serum, the cuticle separates from the cutis,, and becomes impervious. Whether, therefore, this be a dis- tinct papillary structure, as Gaultier contends, or possessed of an infinite number of minute pores or, as M. Chevalier thought, permeable by means of a velaminous structure, its vitality is at once destroyed by being separated from the parent cutis, and is never again reunited to that structure. The more powerful rubefacients will produce vesication ; but of them and their effects we shall speak hereafter. If a plaster of canthari- des here be applied for two or three hours only, its effect is merely rubefacient ; but if allowed to remain on the surface of the body from five to ten hours, as the circumstances of indi- vidual cases will indicate, a quantity of yellowish serum will be Eb. Therap., v. 2, p. 216. 1850.] Quintard, on Counter-irritants. 453 found beneath the cuticle, which, being poured out more pro- fusely after the removal of the plaster, fills the. separated cuticle. Unless local depletion is used, cantharides has a stimulating effect, until vesication is completed, or rather until the engorg- ed capillaries are about to throw out serum, when their evacu- ant power is developed, and frequently to such a degree as to decrease the frequency of the pulse, and having thus an indirect sedative action, induce sleep. Frequently the active property, the cantharadin, is absorbed into the system, causing a considerable degree of general irrita- tion, producing priapism, strangury, bloody urine, &c. This is more peculiarly liable to occur where the system is uncom- monly irritable, where the blister is large, or where it is appli- ed to a newly abraded surface, as to the head, when recently shaved. (Murray.) It was once contended that the canthari- des contained an "alkaline semi-volatile salt," "which passing into the blood, attenuated, dissolved, and hastened and increas- ed its putrefaction," and this conclusion was confirmed by "the putrid alkaline acrimony which it produced in the urine."* Modern research has given us a clearer and .more satisfactory explanation of the modus operandi of this agent, and the man- ner in which strangury arises.f An analysis of cantharides was attempted, by Thonvenal, in 1773, and by Dr. Beaupoil, in 1803, but no result of value was obtained until 1810, when Robiquet discovered in them a crystalline substance, which ap- pears to be the vesicating principle. It is owing to the absorp- tion of this active principle, which is one of the most troublesome attendants upon their operation, that many practitioners hesi- tate in prescribing them where they are indicated. To prevent the occurrence of strangury, as well as unnecessary irritation from the adhesion of particles of fly to the surface, it is well to adopt the expedient recommended by M. Bretonneau, that of interposing a piece of thin gauze, or paper, well soaked in oil, between the blister and the skin. The oil, according to the experiments of M. Robiquet, being a solvent of the vesicatory * Hiliary Med Know]., p. 35G. t The student should consult Marshall Hall's Memoirs on the Nervous Sys- tem. (Lond., 1837.) 454 Quintard, on Counter-irritants. [August, principle,* transfers its effects, without any diminution to the skin. (Paris.) When strangury does occur, it is better to have recourse to small injections of oil and laudanum, rather than to allow the patient to drink freely of mucillaginous com- pounds as is often recommended ; for there are instances in which the quantity of fluid taken has entirely desti oyed the influence of the blister. Liquids must be absorbed in the cir- culating fluids, and thus may counterbalance the evacuant power of the vesicatory and render it a simple counter-irritant. Dr. Williams says, " we are convinced, by experience, of the advantages of abstinence from any bulk of liquids, and would, therefore, look for other means to avoid the irritating effects of absorption from a blister."f As all local diseases are more or less connected with the general health, wre should beware, lest, in applying blisters for slight local diseases, we produce too great general disturbance. Abernethy, in speaking of this subject, says, "You need not apply a blister a foot square in order to derive benefit from it. Oh ! no. But blister a small part of the surface of a large swelling at a time. Quiz it as they like, it is a very useful pro- cedure." Again,. in speaking of counter-irritants generally, he says, ' Blisters may be considered one of the mildest of them ; yet a blister, oh! a blister is a horrible thing in an irritable system, and disturbs the general health more than you would suppose.rJ The powerful impression made by blisters on the system is sufficient, in many instances, to destroy morbid action : hence their use in the treatment of remittent and intermittent fevers. In those cases of intermittent fever, where quinine will " break the chill" for a while, by giving tone to the vis nervosa, with- out a corresponding effect on the muscular fibre, a blister ap- plied to the spine will generally break up the morbid action completely, when so employed as to be in full operation at the * This fact shows how erroneous was the opinion formerly entertained viz.. that oil was an antidote in cases of poisoning by canth. It assists its action. Emetics should be employed, and afterwards draughts containing camphor or opium, with mucillaginous injections into the bladder. t Cyc. Prac. Med. t Vide Marshall Hall, on the true spinal marrow and excito-motory system of nerves. 1850.] Quintard, on Counter-irritants. 455 period for the recurrence of the paroxysm. By carefully guarding against too great arterial excitement, blisters may be used in nearly every disease attended with irritation or inflam- mation of internal organs. Substituting their own action in the part to which they are applied for one of a morbid nature, they are useful in tinea capitis, herpes, and a variety of cutane- ous eruptions. As local stimulants, they are of use in cases of threatened gangrene, partial paralysis, &c. Some five year* since, the writer was attacked with paralysis of the portio-duraB on the right side. The most delicate, and the most powerful remedies were applied, without success, by Prof. Pattison, of New York. The use of an electro-magnet was persevered in for a length of time; but all agents, both internal and external, failed, except cantharides. Blisters were applied repeatedly, as stimulants, and so soon as the effect of one wore off, the application was renewed, each application producing a marked benefit in giving tone to the muscles of the face. The serous discharge they produce renders them useful in cases of local inflammation, where they can be applied in the vicinity of the disease, as in erysipelas, &c. On some constitutions canthari- des produces a poisonous impression, when externally applied, attended with dryness of the fauces, subsultus tendinum, and even convulsions : the instances are, however, rare, and should not deter a physician from prescribing the remedy as often as his judgment dictates. It is impossible to determine what is the condition of the system, or peculiarity of constitution in which this is liable to occur. Few authors recommend a more general adoption of blisters than Broussais, and although his treatment was based upon his favorite theory of disease, the student will find very much valuable information in his writings, with reference to the sub- ject of blisters. There is one point, too often lost sight of in the management of pleurisy, viz., after the application of a blister to a case of pleuritic phlogosis, the pain being removed, and a partial cessation of the fever, and other general symp- toms, the uneasiness and slight dyspnoea are regarded as the effect of a disease removed, rather than symptoms of a disease continuing. On this point, M. Broussais, after noticing the universality and appropriateness af the application of blisters in 450 Le Conte, on the Science of Medicine, tyc. [August, this disease, remarks : " We usually observe, in fact, that the pain disappears in consequence of their action ; but I have several times noticed that this disappearance did not offer the physician a guarantee sufficient to remove all his fears as to the sequelae of the phlegmasia. I have seen several pleuritic patients die, previously to the term assigned to acute diseases, in whom the blister had removed the pain from the first day, and dissection proved that the inflammation of the pleura had not been dissipated." In hospital practice, where, from multi- plicity of engagements, the physician is unable to give the requisite attention to all his cases, this is more apt to occur than in private. It often happens that a pleuritic patient will, in common parlance, "get well." The physician, losing sight of his patient, has no opportunity of judging of the after effects of the disease. Says the distinguished author just quoted, " I lay great stress on this point, being intimately persuaded that a host of practitioners have habitually under their care, consumptions arising from pleurisies, the formation of which they have seen and misunderstood. Brown,'in his system, condemns the use of blisters, without reserve, in all sthenic diseases. The humoralists use them to evacuate "the humors;" the vitalists propose to establish by them an innocent external phlogosis in place of an internal one so that as system succeeds system, this remedy is adopted by each, for various reasons and explanations, differing widely in theory and fact, given to justify their use. With this imperfect sketch of our subject we are obliged to close for the present. In our next we shall take up Tartar- emetic and Croton oil, as counter-irritants. ARTICLE XXI. On the Science of Medicine and the causes which have retarded its progress. By Joseph LeCont, M. D Macon, Ga. It is the remark of one of the most profound writers and thinkers of the present day, that the prevalance of quacks and quackery in any age marks the decay of old institutions and the loss of public confidence in existing formulae and modes of 1850.] Le Conte, on the Science of Medicine, fyc. 457 thought; and that affairs can in no wise progress or improve, until some radical change is effected and a new basis of faith established. Let us apply this truth to the existing state of medicine. Never in the whole history of our science did quackery abound to the same extent as it now does. The variety and speciousness of its forms are so great as to elude the vigil- ance and deceive the judgment of the most penetrating. Now, if we seek the- cause of this growing evil, is it not evident that it takes its rise in the want of entire public confidence in the so-called orthodox system of medicine, and the notorious fact that the frequency of recoveries from disease is nearly the same under every system of treatment? Is it not because, while general intelligence, civilization and science in every other department, is advancing with a rapid and constantly increasing rate of progression ; medicine is slowly halting after, at an almost telescopic distance. The public are not to blame. The origin as well as the cure of this disease rests with ourselves. The evil will continue to increase, acts of legislation and reso- lutions of medical societies to the contrary not withstanding, unless we shake off the lethargy which has seized upon the pro- fession, and with it all orthodoxy or prejudice in favor of existing systems, all petty jealousies and selfishness, and ap- proach the subject with an open, candid mind, full of the love of truth, fired with zeal and confidence, but tempered with the awe which should characterize the true devotee at the shrine of nature. If, then, we have rightly stated the origin of the evil of which so much complaint is heard (as we think every candid mind must admit we have), it behoves us to waste no more time in vainly attempting to put down quackery, by memorials to the Legislature or any other forcible means. As the science now exists, the evil is necessarily and inseparably connected with the practice of medicine under every system, and the only possible way of eradicating it, is to direct all our energies to the accomplishment of two objects, vjz., the advancement of the science of medicine and a proper system of medical educa- tion. Of these two grand objects of medical organization, we pro- 458 Le Conte, on the Science of Medicine, fyc. [August, pose on the present occasion, to speak only of the former, particularly as the latter is now engaging the attention of medical societies throughout the country. And here, lest we should be charged with presumption, we would premise by remarking, that it is not our intention to attempt a complete solution of the problem of medical advancement to point out the best plan of medical organization. to show the means to be used, and the manner in which they must be used in other words, to construct the whole complicated machinery by which the principles of Inductive Philosophy may be best applied to medicine ; but simply by glancing slightly into the philosophy of our science and pointing out the causes which have retarded its progress, to show that statistics are the most direct and powerful means of fulfilling the object which, it is hoped, we all have in view that it is indeed the only means of applying induction to a large portion of our science. Among the causes which have retarded the progress of the science, we might mention its necessary connection with, and consequent dependence upon, the profession of medicine. The result of this connection is, that petty selfishness is often opposed to the best interests of truth. Hence, when we look for union and concerted action, we find disunion, wrangling and jealousy, until the very word "physician" is proverbially as- sociated with illiberality and prejudice. But, we will not dwell upon these humiliating facts, for the existence of medical asso- ciations in every part of the country, and the increasing interest which is felt in them, are evidences, not to be mistaken, of the dawn of a better state of things. Another, and perhaps more important, cause, is the great prevalence, both in, and out of, the profession, of the belief that there is a natural antagonism between profound scientific knowledge and great practical skill that there is a practical knowledge and a practical skill found thereupon, which is vastly superior to, and has no connection with, theoretical knowledge that, in short, the study of the science, unfits a man for the practice, of medicine. Now, although there is probably a germ of truth in this notion, yet it is evident that those who entertain it, take but a superficial view of the subject and by hasty and unphilosophical generalization strike a blow at the very life of medicine as a science. 1650.] LeConte, on the Science of Medicine, tj-c. 4f>9 It is readily admitted that there is a knowledge which cannot be learned from books which science has not yet attempted to brin^ under her dominion a knowledge which is essentially unscientific in its character which is more or less vague and indefinite, and which therefore can only be expressed vaguely and indefinitely ; but which is nevertheless of the utmost importance in the practice of medicine. It is to be learned by close observation and constant attendance at the bedside of the sick. It requires the exquisite sense of touch, the keen ear, and, above all, that delicate constitution of the perceptive pow- ers which quickly and accurately responds to the senses, the strong intuitive mind which easily look through the external features or physiognomy of a disease and sees its true nature and tendency, and the decision, promptness and energy necessa- ry to overcome the foe whose nature and place of concealment we have discovered. It is also admitted that there are many profoundly versed in the science of medicine, as it now exists, and who, for the want of knowledge of which we have spoken or perhaps of the proper constitution of mind and body, are nevertheless unsuccessful in practice, and others who are comparatively successful and yet trust so evidently to the delicacy of their senses, the intuitive quickness of their per- ceptive powers and the promptness and accuracy of their judg- ments, as to affect a contempt of the science of medicine. But it is evidently a " non sequilur" to conclude that the superiority of the latter is due to his want of scientific or theoretical know- ledge. All practice, however strictly practical it may be, is founded upon general notions or theories of some kind. Even in the most common acts of practical life, we are invariably (when we act rationally) guided by such general notions. Indeed this faculty of theorizing and forming general rules of conduct seems to be one of the most important of those which separate us from the brute creation. The only difference then between the so-called practical and the scientific physician, is that the rules by which the former is guided are based upon crude ill- constructed theories drawn from hasty observation and limited experience, and wanting in scientific distinctness and accuracy, and therefore can only be applied with more or less vagueness 460 Le Conte, on the Science of Medicine,